Effect of different forms of coconut on the lipid profile in normal free-living healthy subjects: A randomized controlled trial (Phase II)

Background

It has been postulated that the lipid effects of coconut could be mediated by its fatty acids, fiber and lysine/arginine ratio. Hence, the lipid effects of coconut oil could be different from the effects of the kernel flakes or milk extract because the constituents could be different in each coconut preparation. The present research investigated the lipid effects of different modes of coconut used in food preparation.

Methods

This study involved a total of 190 participants, randomized into four groups, which received coconut oil supplement (30 ml) (n = 53), kernel flakes (30 g) (n = 52) or coconut milk powder (30 g) (n = 44) for a period of 8 weeks. The control group (n = 41) received no supplement. Lipid assays were performed at baseline and at the end of the 4th and 8th weeks. The generalized estimating equations (GEE), ANOVA, and paired and independent t-tests were used in the analysis.

Result

The age range of the participants was 25-60 years, and 52.6% of them (n = 100) were men. Coconut milk supplementation induced beneficial changes in the lipid profile in that the LDL and non-HDL levels decreased while the HDL levels increased. The subgroup whose baseline LDL level was elevated appeared to benefit most from coconut milk supplementation. Coconut oil and kernel flakes failed to induce favorable lipid changes comparable to coconut milk supplementation.

Conclusion

Differing concentrations of protein, fat and fiber in coconut preparations could possibly explain the dissimilar effects on the lipid profile caused by the different coconut preparations. The benefits of coconut milk seen in the high basal LDL subgroup warrant a detailed study.

A real-time PCR for quantification of parasite burden and its correlations with clinical characteristics and anti-rKRP42 IgG level in cutaneous leishmaniasis in Sri Lanka

In visceral and mucocutaneous leishmaniasis, humoral immune response can reflect disease severity and parasite burden. Cutaneous leishmaniasis (CL) in Sri Lanka is caused by a usually visceralizing parasite, Leishmania donovani. We assessed the parasite burden (relative quantity-RQ) in 190 CL patients using quantitative real-time PCR (qPCR-with primers designed for this study) and smear microscopy, then correlated it with clinical parameters and IgG response. RQ of parasite DNA was determined with human-specific glyceraldehyde 3-phosphate dehydrogenase (GAPDH) as the internal control. The qPCR sensitivity was tested with serially diluted DNA from cultured L. donovani parasites. Smears were assigned a score based on number of parasites per high power field. Data from previous studies were used for comparison and correlation; nested Internal Transcribed Spacer 1 (ITS1) PCR as reference standard (RS) and IgG antibody titers to the Leishmania rKRp42 antigen as the immune response. The qPCR amplified and quantified 86.8% of the samples while demonstrating a fair and significant agreement with ITS1-PCR and microscopy. Parasite burden by qPCR and microscopy were highly correlated (r = 0.76; p = 0.01) but showed no correlation with the IgG response (r = 0.056; p = 0.48). Corresponding mean RQs of IgG titers grouped by percentiles, showed no significant difference (p = 0.93). Mean RQ was higher in early lesions (p = 0.04), decreased with lesion size (p = 0.12) and slightly higher among papules, nodules and wet ulcers (p = 0.72). Our study established qPCR's efficacy in quantifying parasite burden in Sri Lankan CL lesions but no significant correlation was observed between the parasite burden and host IgG response to the Leishmania rKRP42 antigen.

Environmental fluoride exposure and implications on potential pediatric kidney health risks: an approach with urinary biomarkers

BACKGROUND

Environmental fluoride exposure at elevated levels is potentially linked to kidney injury, and may contribute to chronic kidney disease of uncertain etiology (CKDu) as a risk factor. However, this link remains unclear, and examining the risk of kidney damage from early life fluoride exposure may provide important insights. Hence, this study aimed to investigate associations of fluoride exposure with pediatric kidney health in CKDu impacted and unimpacted communities in Sri Lanka.

METHODS

Considering the geographical variations in environmental fluoride, climate, and prevalence of CKDu, four study groups were established within selected education zones in CKDu-endemic dry zone regions (D-En), and CKDu-nonendemic regions within the dry (D-NE), wet (W-NE), and intermediate (I-NE) climatic zones. The study population included 922 school students (11-18 years of age). Participants in each group were divided into four subgroups based on quartiles of respective urinary fluoride (UF) distribution for comparison of urinary kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and albumin-creatinine ratio (ACR).

RESULTS

UF levels in participants particularly in CKDu endemic dry zone regions were significantly high compared to the other regions. Significantly high median urinary NGAL (in D-NE) and ACR (in D-EN, and W-NE) levels were observed in subgroups of higher UF quartiles. Albuminuria was not particularly identified in subjects with high UF excretion. Urinary KIM-1 showed no significant variation across the UF quartile subgroups. Linear regression identified weak associations of UF with kidney injury biomarkers.

CONCLUSIONS

Fluoride exposure is particularly high in CKDu-endemic dry zone communities. As implied by kidney injury biomarkers, a strong link between fluoride exposure and pediatric kidney health was not evident at the observed exposure levels in the study regions.

Nursing students' experience of bullying and/or harassment during clinical placement

PROBLEM OR BACKGROUND

Bullying is a recognised problem in nursing. Nursing students are particularly vulnerable. Bullying and harassment of nursing students can be detrimental to both students and recipients of care.

AIM

This study aims to identify the incidence and nature of bullying and/or harassment experienced by nursing students in Sri Lanka.

METHODS

A cross-sectional survey consisting of eight demographic questions and 15 items specific to the experience of bullying and harassment was administered to nursing students online.

FINDINGS

A total of 656 students from 26 nursing education institutions in Sri Lanka participated. The majority were female with a mean age of 24.4 years. More than a quarter of respondents reported that they had experienced bullying and/or harassment while on clinical placement, with a further 16.7 % being unsure. Most bullying or harassment (55 %) occurred in hospitals with 29 % experienced in community settings. Registered nurses, including nurse managers and clinical facilitators were the most common perpetrators. Verbal abuse was the most frequent type of behaviour reported.

DISCUSSION

These findings support existing literature that indicates that bullying of nursing students is an international phenomenon. The context of this study provides clues as to how culture may influence the problem. There is a need to better understand bullying and harassment in the environments in which it occurs, in order to identify strategies that can bridge cultures and settings.

CONCLUSION

The incidence of bullying and harassment of nursing students in Sri Lanka is concerning. Further research is needed to identify and evaluate targeted strategies to help prevent negative outcomes in all nursing contexts.

The genetic identity of the Vedda: A language isolate of South Asia

Linguistic data from South Asia identified several language isolates in the subcontinent. The Vedda, an indigenous population of Sri Lanka, are the least studied amongst them. Therefore, to understand the initial peopling of Sri Lanka and the genetic affinity of the Vedda with other populations in Eurasia, we extensively studied the high-resolution autosomal and mitogenomes from the Vedda population of Sri Lanka. Our autosomal analyses suggest a close genetic link of Vedda with the tribal populations of India despite no evidence of close linguistic affinity, thus suggesting a deep genetic link of the Vedda with these populations. The mitogenomic analysis supports this association by pointing to an ancient link with Indian populations. We suggest that the Vedda population is a genetically drifted group with limited gene flow from neighbouring Sinhalese and Sri Lankan Tamil populations. Interestingly, the genetic ancestry sharing of Vedda neglects the isolation-by-distance model. Collectively, the demography of Sri Lanka is unique, where Sinhalese and Sri Lankan Tamil populations excessively admixed, whilst Vedda largely preserved their isolation and deep genetic association with India.

Ocular Dirofilariasis in Migrant from Sri Lanka, Australia

We describe a case of imported ocular dirofilariasis in Australia, linked to the Hong Kong genotype of Dirofilaria sp., in a migrant from Sri Lanka. Surgical extraction and mitochondrial sequences analyses confirmed this filarioid nematode as the causative agent and a Dirofilaria sp. not previously reported in Australia.

Effect of Soil Temperature on Canine Soil-Transmitted Nematodes in Kandy District with the First Record of Hookworm, Ancylostoma tubaeforme from Sri Lanka

PURPOSE

Soil-transmitted nematodes (STNs) are widespread in tropical and subtropical regions, particularly where the communities are socio-economically challenged. We investigated the effect of soil temperature on the prevalence and intensity of STN infection in free-roaming dogs.

METHODS

Fresh faecal samples collected from free-roaming dogs in Digana and Pussellawa town areas in the Kandy District, Sri Lanka, were microscopically analysed for canine STNs. Soil temperature was measured at each sampling site. Highly prevalent canine hookworm Ancylostoma, was further studied using PCR and sequencing, followed by phylogenetic analysis.

RESULTS

The soil temperature ranged between 28 and 31 °C (mean = 29.79 °C) and 18-21 °C (mean = 19.52 °C) in Digana and Pussellawa, respectively, showing a significant difference in the two sites (Students t-test t = 1.68, p < 0.0001). Of the total 44 dogs sampled, 41 (93.2%) were positive for STNs. During microscopic analysis, five nematodes: Ancylostoma spp., Capillaria sp., Strongyloides sp., Toxocara canis, and Trichuris sp., were identified. Ancylostoma species (93.2%) were the most prevalent, followed by Strongyloides sp. (22.7%) and Toxocara canis (15.9%). Infection prevalence of Strongyloides sp. was higher in Digana (40.9%) compared to that in Pussellawa (4.5%; Chi-square test, χ2 = 8.28, p = 0.004) and also the infection intensity from Digana (EPG = 8.02 ± 20.2) compared to that from Pussellawa (0.45 ± 2.1; Mann Whitney U test, p = 0.006). Amplicons (ITS1-5.8S-ITS2) of the expected size for A. caninum, and A. tubaeforme were produced. An A. caninum sequence reported here (OQ101719) illustrated the highest similarity of 99.2% to one of the local sequences (MZ707153) upon pairwise comparison.

CONCLUSION

Digana, with a higher soil temperature than Pussellawa, had a significantly higher prevalence and infection intensity, particularly Strongyloides sp. This study also signifies the first molecular identification of hookworm species A. tubaeforme in Sri Lanka.

Lived experiences of Sri Lankan Tamil refugees in the UK: Migration and identity

Sri Lankan Tamil refugees (SLTRs) have lived in the United Kingdom in substantial numbers for about three decades. However, they remain under-represented in academic and public discourse, and little is known about their migration experiences. This study examined first-hand accounts of such experiences, with special attention paid to identity and acculturation. Data were collected through four semi-structured interviews and analysed using interpretative phenomenological analysis (IPA). The results suggest that SLTRs' experience of conflict as an imposed life disruption continues to shape their adaptation, identity, and meaning-making ("Afflicted life"). Changing social identities mediate protection from, as well as risk of, trauma. SLTRs try to remedy the socio-economic and emotional losses suffered in the conflict, but achieve only a partial compensation. Consequently their repair efforts are a source not only of positive emotions but also of dissatisfaction ("Living past"). Finally, participants' sense of belonging and quest for home represent a challenging socio-emotional process in which they continue to engage even decades after migration ("Continuing quest for home"). This nuanced analysis of how the past continues to shape lived experience, contributes to the under-developed literature on qualitative psychological investigations of acculturation, research on forced migration, and the establishment of IPA in social psychology.

Fluoride exposure and pediatric kidney health in dry, wet and intermediate climatic zone communities in Sri Lanka: Implications from urinary Cystatin-C, and albumin-creatinine ratio

BACKGROUND

High fluoride exposure is increasingly discussed attributing to kidney injury as a causative factor. Depending on geochemistry, differential fluoride levels in drinking water are identified in different regions in Sri Lanka. However, the levels of fluoride exposure, and associations with kidney health has not been adequately studied in Sri Lanka, particularly in pediatric communities. Hence, the present study aimed to assess fluoride exposure in selected pediatric communities in the dry, wet and intermediate climatic zones in Sri Lanka, along with an assessment of renal health using urinary Cystatin-C (uCys-C), and albumin-creatinine ratio (uACR).

METHODS

We conducted a cross-sectional study with school students in selected education zones representing dry (N = 331), wet (N = 152), and intermediate (N = 292) climatic zones in Sri Lanka. Fluoride contents in urine and drinking water were assessed as measures of fluoride exposure.

RESULTS

The median (interquartile distance) urinary fluoride levels of participants in the dry, wet and intermediate zones were 1.63(1.04-2.85), 1.29(0.85-2.21), and 1.07(0.61-1.98) mg/gCr while the fluoride contents of drinking water samples were 1.76(1.36-2.30), 0.25(0.18-0.37), and 0.43(0.26-0.63) ppm respectively with significant differences among the three groups. Median uCys-C level (ng/mgCr) of the participants in intermediate zone [30.26(8.49-71.44)] was significantly low (p < 0.05) compared to that of the participants in dry zone [56.19(7.08-211.8)], and wet zone [66.29(30.43-125.20)]. The incidences of elevated uCys-C levels above reference intervals in participants of dry zone (47.7%), and wet zone (50.0%) were significantly high (p < 0.001) compared to the intermediate zone (26.4%).

CONCLUSION

Relatively high fluoride exposure is likely in dry and wet zone communities compared to the intermediate zone along with significantly higher incidence of uCys-C levels above reference intervals in study groups with higher fluoride exposure. However, to conclude a clear link between fluoride exposure and kidney health we need in-depth studies.

Assessment of knowledge, attitude, and practice on self-care with over-the-counter medicines among pregnant women

Background

Self-care during pregnancy is a crucial topic to be discussed due to its effects on both the mother and fetus. In Sri Lanka, specifically regarding self-care with over-the-counter (OTC) medicines, usage among the pregnant population is scarce.

Objective

This study assessed knowledge, attitudes, and practices (KAP) on self-care with OTC medicine usage among pregnant women attending maternity clinics in the Colombo Medical Officer of Health (MOH) areas, Sri Lanka.

Method

A cross-sectional study was conducted among 399 pregnant women enrolled through simple random sampling using a self-administered questionnaire. Data were collected on knowledge, attitudes, practices, and sociodemographic characteristics. SPSS version 27 was used for descriptive statistical analysis.

Results

There were satisfactory levels of KAP on self-care with OTC medicines identified among participants. The Mean ± SD for knowledge was 4.38 ± 0.873, and for attitude and practice, 27.56 ± 3.752 and 20.35 ± 4.235, respectively. Significant positive linear correlation between knowledge and attitude (r = 0.375, p < 0.001), attitude and practice (r = 0.518, p < 0.001), and knowledge and practice (r = 0.224, p < 0.001) were observed. It refers to participants with higher levels of knowledge being more likely to exhibit certain attitudes and engage in good practice regarding self-care. However, 93% of the participants had a wrong intention that any medicine could be used at any stage of pregnancy, and 26.3% of the participants didn't know that the medications taken during pregnancy could impact the fetus. Surprisingly, 87% had misperceived that antibiotics can be purchased as OTC medicines. Additionally, the majority of the participants (96%) believed that they could use old prescriptions to purchase medicines during pregnancy.

Conclusion

Greater awareness regarding self-care with OTC medication usage is suggested to be provided during pregnancy.

Human papillomavirus (HPV) vaccination program in Sri Lanka: Ongoing costs and operational context of a routinized program

Existing evidence on the cost of human papillomavirus (HPV) vaccination programs has focused on pilot and demonstration projects or initial introductions, which resulted in a perceived high cost. We aimed to study the ongoing cost and operational context of an established HPV vaccination program in Sri Lanka. We conducted a retrospective operational research and microcosting study focusing on 2019. We collected data from 30 divisional health units, 10 districts, and the central level. We then evaluated financial and economic costs, reported by level of the health system, program activity, cost types, and per dose delivered. In 2019, Sri Lanka delivered a total of 314,815 doses of HPV vaccine. In our study sample, 95 % of the HPV vaccination sessions took place at schools, with peaks of delivery in February-March and September-October. The weighted mean financial cost per dose delivered was $0.27 (95 % confidence interval [CI]: $0.15-$0.39) and the economic cost per dose was $3.88 (95 % CI: $2.67-$5.10), excluding the cost of vaccines and supplies. Most of the cost was borne by the divisional health unit level. Service delivery and social mobilization were major contributors to overall costs at the divisional health unit level, and vaccine collection or distribution and storage were the most costly activities at the district and central levels. Cost drivers included the opportunity cost of health worker and non-health worker time at the divisional health unit level and capital costs for vehicles and equipment, along with fuel, maintenance, and energy, at the district and central levels. This study provides new evidence on the cost and cost drivers of a routinized HPV vaccination program. Results can be used for financial planning purposes in Sri Lanka and may inform other countries as they consider use of HPV vaccines.

Disease burden of cardiovascular conditions complicating pregnancy in Sri Lanka: a protocol

Background

Cardiovascular diseases (CVD) are the commonest indirect medical cause of maternal deaths worldwide, both in high-income and low and middle-income countries. To minimize the effects of CVD in pregnancy, proper risk assessment and appropriate referral is required. In Sri Lanka, cardiovascular disease complicating pregnancy is a significant cause of maternal mortality, second only to postpartum hemorrhage. Screening for CVD in pregnancy in Sri Lanka is limited to a routine clinical assessment. Evidence-based guidelines are yet to be developed, and this deficit may have resulted in a substantial underestimation of the CVD burden. This study aims to determine the burden of CVD in early pregnancy and develop a risk prediction model to be used in field pregnancy clinics in Sri Lanka to reduce CVD effects in pregnancy.

Methods

A prospective cohort study was carried out in the Anuradhapura district, Sri Lanka. Following registration to the antenatal care, pregnant women fulfilling the eligibility criteria were invited to attend a special clinic at their relevant Medical Officer of Health (MOH) area. Risk assessment was done through history and a clinical examination, and suspected/probable cases were referred for an echocardiogram by a consultant cardiologist. All the recruited participants in the first trimester were prospectively followed up and screened again between 24-28 weeks of the period of amenorrhoea (POA). Antenatal ward admissions with CVD complicating pregnancy will be extracted, and a telephone interview will be carried out between 6-12 weeks after the expected delivery date to cover postpartum morbidities.

Discussion

This proposed study will be the largest of its kind carried out in the local setting. The study's findings will be beneficial for policymakers to develop guidelines to reduce maternal cardiovascular disease morbidities and mortalities in Sri Lanka.

What Women Want: Mental Health in the Context of Violence Against Women in Sri Lanka-A Qualitative Study of Priorities and Capacities for Care

Insufficient evidence guides mental health service development for survivors of violence against women in Sri Lanka. Provider and survivor perspectives on (1) what constitutes mental health, (2) quality of care, and (3) priority areas and stakeholders for intervention were identified through framework analysis of 53 in-depth interviews. Desired care is chiefly psychosocial-not psychological-prioritizing socioeconomic, parenting, and safe environment needs in non-clinical community settings. Our evidence points strongly to the need to strengthen non-mental health community-based providers as "first contacts" and reassessment of health system-centric interventions which neglect preferred community responses and more holistic approaches accounting for women's full circumstances.

Queens of hearts: Exploring the lived experiences of mothers caring for infants with complex congenital heart disease in Sri Lanka

This qualitative study explored the lived experiences of eight Sri Lankan mothers of infants with complex congenital heart disease (CCHD) using semi-structured interviews. Four themes were generated as: illness perception, communication with medical staff, challenges faced, and coping mechanisms. These provided insight into the multi-faceted nature of mothers' experiences, importance of medical-caregiver communications and their need for psychosocial services. The findings enhance the limited knowledge of South-Asian primary CCHD caregiver experiences and will help in improving psychosocial support services in Sri Lanka.

Future of medical research in Sri Lanka: amidst economic chaos

Sri Lanka is facing an economic crisis and medical research is significantly affected at present with researchers facing many obstacles. Urgent remedial measures are required to overcome the current situation if medical research is to continue in Sri Lanka.

Disability-adjusted life years due to leptospirosis in Monaragala District of Sri Lanka

Leptospirosis is a zoonotic infection with significant morbidity and mortality. As an occupational disease, it has become a global concern due to its disease burden in endemic countries and rural areas. The aim of this study was to assess disease burden in terms of Disability-adjusted life years (DALYs) of leptospirosis.A hospital-based descriptive cross-sectional study was conducted using 450 clinically diagnosed leptospirosis patients admitted to base and above hospitals in Monaragala District, Sri Lanka, using a pre-tested interviewer-administered questionnaire. The patients were followed up until normal day-to-day life after discharge. Estimation of DALYs was done using laboratory-confirmed leptospirosis patients. Leptospirosis disease burden in Monaragala District was 44.9 DALYs per 100,000 population, which includes 33.18 Years of life losts and 10.9 YLDs. The incidence of leptospirosis in Monaragala District during the study period was 59.8 per 100,000 population, and the case fatality rate (CFR) was 1.5% and 75% of deaths were among males.The disease burden of leptospirosis in Monaragala District was significantly high and urgent efforts to control and prevent leptospirosis should be a priority.

Antibiotic resistance through the lens of One Health: A study from an urban and a rural area in Sri Lanka

This study aimed to investigate and compare the proportion of AMR Escherichia coli (E. coli) between urban (Dompe in the Western province) and rural (Dambana in the Sabaragamuwa province) areas in Sri Lanka. The overall hypothesis of the study is that there is a difference in the proportion of AMR E. coli between the urban and the rural areas. Faecal samples were collected from healthy humans (n = 109), dairy animals (n = 103), poultry (n = 35), wild mammals (n = 81), wild birds (n = 76), soil (n = 80) and water (n = 80) from both areas. A total of 908 E. coli isolates were tested for susceptibility to 12 antimicrobials. Overall, E. coli isolated from urban area was significantly more likely to be resistant than those isolated from rural area. The human domain of the area had a significantly higher prevalence of AMR E. coli, but it was not significantly different in urban (98%) and rural (97%) areas. AMR E. coli isolated from dairy animals, wild animals and water was significantly higher in the urban area compared with the rural area. There was no significant difference in the proportion of multidrug resistance (MDR) E. coli isolated from humans, wild animals and water between the two study sites. Resistant isolates found from water and wild animals suggest contamination of the environment. A multi-sectorial One Health approach is urgently needed to control the spread of AMR and prevent the occurrences of AMR in Sri Lanka.

Whole genome sequencing data of Leptospira weilii and Leptospira kirschneri isolated from human subjects of Sri Lanka

Leptospirosis is a re-emerging zoonotic disease. This article reports the complete genome sequences of three novel strains of Genus Leptospira: two from the species Leptospira weilii (FMAS_RT1, FMAS_PD2) and one from Leptospira kirschneri (FMAS_PN5). These isolates were recovered from the blood samples of acute febrile patients in different geographical and climatic zones of Sri Lanka. High-quality genomic DNA was extracted from the three isolates in mid-log phase cultures. Whole genome sequencing was conducted using the PacBio Single Molecule Real-Time (SMRT) platform to identify the species, genome features, and novelty of the strains. The annotation was conducted using RAST (Rapid Annotation Using Subsystem Technology version 2.0) and the NCBI Prokaryotic Genome Annotation Pipeline. The genome sequences of three isolates have been deposited in the Mendeley data repository and the National Center for Biotechnology Information (NCBI) repository. This data will be useful for future researchers when conducting comparative genomic analysis, revealing the exact mechanism of pathogenesis of leptospirosis and developing molecular diagnostic tools for early detection.

Challenges faced in establishing a pediatric liver transplant program in a lower-middle-income country with free healthcare service

BACKGROUND

Liver transplant is the cure for children with liver failure. Sri Lanka is a lower-middle-income country with a predominant free, state health system. Pediatric liver transplant program in Sri Lanka is still in the budding state where the initial experience of the program is yet to be documented.

METHODS

A retrospective review was performed including the clinical characteristics of all pediatric liver transplant recipients of Colombo North Centre for Liver Diseases since the inception of the program from June 2020 to May 2023.

RESULTS

There were 14 PLT performed in 3 years. The median recipient age and weight were 8 years (6 months-15 years) and 23.3 kg (6.4-49.2), respectively. The majority were boys (64%). All were from low-income backgrounds. Indications for LT were acute liver failure (5/14), decompensated chronic liver disease (5/14), and acute on chronic liver failure (4/14). Underlying liver diseases were Wilson disease (6/14), autoimmune liver disease (3/14), biliary atresia (2/14) and progressive familial intrahepatic cholestasis type 3 (1/14), and unknown etiology (2/14). The majority were living donor liver transplants (86%). Of the living donors, 42% (5/12) were Buddhist priests. There were three immediate deaths and two late deaths. The 3-month survival was 78%, and overall survival was 64%. Living donor transplants carried a higher success rate (92%) compared to diseased donor transplants (0%; 2/2).

CONCLUSIONS

Initial experience of pediatric liver transplant program of Sri Lanka is promising despite being established in a free healthcare system amidst the crisis circumstances.

Prevalence and associated factors of depression in Sri Lanka: a systematic review and meta-analysis

PURPOSE

Epidemiological data on depression are required to inform policies and service planning in mental health in Sri Lanka. This review aimed to synthesise data from existing studies to calculate the pooled prevalence of depression in Sri Lanka, assess its variability across subgroups, and identify associated factors within each subgroup.

METHODS

PubMed, Embase, PsycINFO, Science Direct, Google Scholar and local journals were searched to identify peer-reviewed studies reporting the prevalence of depression among non-clinical adult, young, older, and maternal populations in Sri Lanka. A meta-analysis was performed using a random-effects model to calculate pooled prevalence estimates. Subgroup, sensitivity and moderator analyses were performed. A qualitative synthesis of factors associated with depression was conducted.

RESULTS

A total of 33 studies representing a total of 52,778 participants were included. Overall, the pooled prevalence of depression was 19.4% [14.44-25.54%]. Among subpopulations, the highest prevalence was reported among young persons (39%); the rates in adults, older persons and maternal populations were 8.7%, 18.4% and 16.9%, respectively. Prevalence estimates were higher when based on screening instruments (21.2%) compared to diagnostic interviews (4.3%). A high degree of heterogeneity (I2 = 99.2) was observed. A qualitative synthesis of factors associated with depression, including individual attributes and behaviours, socio-economic circumstances and broader environmental factors, is reported for each age group.

CONCLUSION

Approximately one-fifth of the population was detected to have depression. Notable variations in prevalence were observed across age groups. The heterogeneity of studies limits the inferences drawn from this review.

Quality of care as perceived by caregivers and residents in aged care homes in Sri Lanka: a qualitative study

OBJECTIVE

Quality of care determines the physical and psychological wellbeing of aged care residents. The study aims to explore barriers and facilitators of quality of care in aged care homes (ACHs) in Sri Lanka from the perspective of older adults and caregivers.

METHODS

This qualitative descriptive exploratory study was conducted in selected five ACHs in Galle District, Sri Lanka, from May 2021 to January 2022. We recruited a purposive sample of residents and caregivers and conducted ten in-depth interviews with ten caregivers and nine focus group discussions with forty-five residents. The data were analysed using the thematic analysis.

RESULTS

The majority of caregivers and residents were females. Caregivers and residents were aged 25-35 years and 70-80 years, respectively. Two major themes emerged: (a) barriers of quality of care and (b) facilitators of quality of care. Both residents and caregivers reported a lack of referring system facilities; a lack of financial support on the infrastructure; a lack of financial support in supplying medication and employing human resources; insufficient knowledge of gerontological care and geriatric syndromes for both caregivers and residents; and lack of interest in being a caregiver at the ACHs as barriers in providing quality care. Moreover, caregivers and older people reported donations by philanthropists; supportive leadership; and welfare benefits from the government authorities as facilitators of quality care. Additionally, caregivers reported a lack of in-service programmes for caregivers as a barrier and positive institutional values as a facilitator for providing quality care.

CONCLUSION

The available human and physical resources are insufficient to address the demanding needs of residents in ACHs, apart from the received donations. There is a simultaneous need for healthcare policymakers' and social welfare authorities' attention to implementing necessary measures to uplift the quality of care for residents in ACHs to enhance their quality of life.

Perceptions of the importance of sports nutrition knowledge and barriers in implementing them: a qualitative study among track and field stakeholders in Sri Lanka

BACKGROUND

Integrating the core aspects of sports nutrition knowledge [SNK] into the multidisciplinary team is critical to improving an athlete's performance and well-being. Conducting in-depth interviews with members of the sports-related team is a comprehensive method of gathering information on various aspects of SNK. This qualitative study aimed to examine the opinions and beliefs of stakeholders in athletics regarding the importance of SNK.

METHODS

Fifteen professional track and field athletes and stakeholders were recruited into the study. Separate in-depth interviews were conducted to collect information within four key themes. Practical difficulties in getting an appropriate meal were included in an additional theme. Thematic analysis was performed using NVIVO v10.0.

RESULTS

All participants were mindful of the importance of proper food habits for overall athletic outcomes and reported different opinions on meal timing and composition. The opinions on supplements were heterogeneous and both positive and negative claims were reported. Beliefs regarding hydration demonstrated that the cohort was well aware of the significance of adequate hydration plus the signs and consequences of dehydration with many reporting experiences of the negative consequences of dehydration. All respondents reported that both alcohol and smoking may have an adverse impact on performance and health.

CONCLUSIONS

All respondents emphasized the importance of proper food habits for sports performance and well-being, but also identified barriers to optimizing nutrition.

Fine-scale monitoring of insecticide resistance in Aedes aegypti (Diptera: Culicidae) from Sri Lanka and modeling the phenotypic resistance using rational approximation

BACKGROUND

The unplanned and intensified use of insecticides to control mosquito-borne diseases has led to an upsurge of resistance to commonly used insecticides. Aedes aegypti, the main vector of dengue, chikungunya, and Zika virus, is primarily controlled through the application of adulticides (pyrethroid insecticides) and larvicides (temephos). Fine spatial-scale analysis of resistance may reveal important resistance-related patterns, and the application of mathematical models to determine the phenotypic resistance status lessens the cost and usage of resources, thus resulting in an enhanced and successful control program.

METHODS

The phenotypic resistance for permethrin, deltamethrin, and malathion was monitored in the Ae. aegypti populations using the World Health Organization (WHO) adult bioassay method. Mosquitoes' resistance to permethrin and deltamethrin was evaluated for the commonly occurring base substitutions in the voltage-gated sodium channel (vgsc) gene. Rational functions were used to determine the relationship between the kdr alleles and the phenotypic resistant percentage of Ae. aegypti in Sri Lanka.

RESULTS

The results of the bioassays revealed highly resistant Ae. aegypti populations for the two pyrethroid insecticides (permethrin and deltamethrin) tested. All populations were susceptible to 5% malathion insecticide. The study also revealed high frequencies of C1534 and G1016 in all the populations studied. The highest haplotype frequency was detected for the haplotype CC/VV, followed by FC/VV and CC/VG. Of the seven models obtained, this study suggests the prediction models using rational approximation considering the C allele frequencies and the total of C, G, and P allele frequencies and phenotypic resistance as the best fits for the area concerned.

CONCLUSIONS

This is the first study to our knowledge to provide a model to predict phenotypic resistance using rational functions considering kdr alleles. The flexible nature of the rational functions has revealed the most suitable association among them. Thus, a general evaluation of kdr alleles prior to insecticide applications would unveil the phenotypic resistance percentage of the wild mosquito population. A site-specific strategy is recommended for monitoring resistance with a mathematical approach and management of insecticide applications for the vector population.

Recalibration of Framingham risk for a local population of Sri Lanka

BACKGROUND

Cardiovascular Diseases (CVD) account for the highest number of deaths and disability globally and within Sri Lanka. A CVD risk prediction tool is a simple means of early identification of high-risk groups which is a cost-effective preventive strategy, especially for resource-poor countries. Distribution of risk factor levels varies in different regions even within the same country, thus a common risk estimation tool for the country may give false local predictions. Since there are few published data related to Sri Lanka the aim of this study was to recalibrate the Framingham equation according to the local risk factor profile of a population in the Kurunegala region in Sri Lanka.

METHOD

A cross-sectional study was conducted with the participation of 1 102 persons from the Kurunegala Regional Director of Health Services area and the data was collected using an interviewer-administered questionnaire, anthropometric, blood pressure, and biochemical measurements. CVD risk was estimated using Framingham original and recalibrated CVD risk assessment methods. Current CVD mortality and morbidity data and the recalibration method conducted by the method described by Wilson and colleagues were used for calculations.

RESULTS

Original and recalibrated Framingham CVD risk scores predicted 55.5% (N = 612) and 62.3% (N = 687) to be having less than 10% CVD risk respectively. Further, the original and recalibrated CVD Risk Scores predicted 2.2% (N = 24) and 1.8% (N = 20) to be having CVD risk more than 40% respectively.

CONCLUSION

These findings show an over prediction of the CVD risk with the original Framingham risk calculations which signifies the importance of development of a region-specific risk prediction tool using local risk factor data in Sri Lanka which will prevent unnecessary expenditure to manage people without risk of CVD.

Knowledge, perceptions, and consumption behaviour of cosmetics among undergraduates of Sri Lanka: a descriptive cross-sectional study

Background

Despite the increasing usage of personal care products among young adolescents in Sri Lanka, limited studies have been conducted to understand the behaviour of cosmetic users and associated health complications. Therefore, the current study was conducted to evaluate the cosmetic consumption related behaviour of the undergraduate community in Sri Lanka and to identify the driving factors behind the incidences of cosmetic related adverse health effects.

Method

An analytical cross-sectional study was conducted by recruiting 421 undergraduates from five state universities in Sri Lanka through stratified random sampling, as the study population. Information on socio-demographic factors and cosmetic consumption behaviour of the participants were acquired through a self-administrated structured questionnaire, along with Knowledge, Attitudes and Practices (KAP) relevant for cosmetic usage. The Binary Logistic Regression model was used to determine the significant socio-demographic driving factors on cosmetic usage among the undergraduate community in Sri Lanka at a confidence level of 95%.

Results

Around 96.4% of the study population used one or more cosmetic products (77%) out of which, 75.3% experienced cosmetic related adverse health effects. Skin dryness (24%), acne (21%), allergies (20.5%) and rashes (19.8%), were identified as the most dominant adverse health effects, related to cosmetic usage. Perfumes (65.6%), face cream (63.2%) and body lotion/hand cream (60.6%), were the mostly used cosmetic products. Even though half of the study population exhibited higher levels of good practices during purchase (54.9%) and application (52%) of cosmetics, around 47.5% were characterized with a low level of knowledge on cosmetics. Gender, academic year, knowledge on cosmetics, monthly expenditure on cosmetics, source of recommendation for cosmetics, practices related to purchase and consumption of cosmetics and preference to receive medical care in case of cosmetic related emergency were recognized as significant risk factors (p < 0.05) associated with the incidence of cosmetic related adverse health effects among undergraduate students.

Conclusion

Given the high prevalence of cosmetic related adverse health effects, the health authorities of Sri Lanka should pay more attention towards the wellbeing and responsible cosmetic usage among undergraduates. Designing of effective tools and regulations to monitor the cosmetic market and improving the knowledge on cosmetics are recommended to ensure safe cosmetic usage within the country in general and of adolescent users in particular.

The Colombo Twin and Singleton Study (COTASS): Piloting the Feasibility of Collecting Nutritional Data and Extension of the Sample to Include Children of Twins

Nutrition and diet are key modifiable risk factors for the rising burden of non-communicable diseases like cardio-vascular diseases and diabetes in low- and middle- income countries (LMICs). The nutritional transition in dietary behaviours in LMICs has most likely contributed to this problem. Although traditionally assumed to be environmental, dietary choices are also genetically influenced. Twin study designs can be used to investigate the relative influence of genes and environment on nutrition intake, eating behaviours and associated psychological health. The overall aim of this project is to: provide proof-of-concept for the feasibility of using dietary (biomarker) data within the Children-of-Twin design in nutrition studies, develop laboratory skills and statistical genetic skills and establish a Sri Lankan-specific food composition database. Currently, a pilot study is being conducted with 304 individuals (38 Monozygotic twin pairs, 38 Dizygotic twin pairs and their male or female adult offspring). Questionnaire data on nutritional intake, eating behaviours, psychological well-being, physical health, and bio-specimens are being collected. A Sri Lankan-specific food composition database was developed, training sessions on macro and micro element analysis in biological samples and statistical genetics skills development were conducted and Community Engagement and Involvement programs were carried out in two districts of Sri Lanka.

Frequency of Consumption of Food Groups and Cardio-Metabolic Risk Factors: A Genetically Informative Twin Study in Sri Lanka

Low- and middle-income countries (LMICs) globally have undergone rapid urbanisation, and changes in demography and health behaviours. In Sri Lanka, cardio-vascular disease and diabetes are now leading causes of mortality. High prevalence of their risk factors, including hypertension, dysglycaemia and obesity have also been observed. Diet is a key modifiable risk factor for both cardio-vascular disease and diabetes as well as their risk factors. Although typically thought of as an environmental risk factor, dietary choice has been shown to be genetically influenced, and genes associated with this behaviour correlate with metabolic risk indicators. We used Structural Equation Model fitting to investigate the aetiology of dietary choices and cardio-metabolic phenotypes in COTASS, a population-based twin and singleton sample in Colombo, Sri Lanka. Participants completed a Food Frequency Questionnaire (N = 3934) which assessed frequency of intake of 14 food groups including meat, vegetables and dessert or sweet snacks. Anthropometric (N = 3675) and cardio-metabolic (N = 3477) phenotypes were also collected including weight, blood pressure, cholesterol, fasting plasma glucose and triglycerides. Frequency of consumption of most food items was found to be largely environmental in origin with both the shared and non-shared environmental influences indicated. Modest genetic influences were observed for some food groups (e.g. fruits and leafy greens). Cardio-metabolic phenotypes showed moderate genetic influences with some shared environmental influence for Body Mass Index, blood pressure and triglycerides. Overall, it seemed that shared environmental effects were more important for both dietary choices and cardio-metabolic phenotypes compared to populations in the Global North.

Body mass index and implications for pediatric kidney health: a cross-sectional study with urinary biomarkers

BACKGROUND

Extremes of unhealthy body weight, particularly obesity, are known to increase the risk of chronic kidney diseases. However, the current knowledge of kidney health outcomes associated with unhealthy body weight remains incomprehensive, especially in pediatrics. Therefore, the present study aimed to evaluate body mass index (BMI) and its potential associations with kidney health in a selected subset of school students in Sri Lanka.

METHODS

This cross-sectional study was conducted among students of both sexes in the range of 11-18 years of age (N = 1078) in education zones with no reported cases of chronic kidney disease of uncertain etiology. Based on sex- and age-specific BMI percentiles (LMS method), the participants were classified into five BMI groups (severely thin, thin, healthy, overweight, and obese) for measurement of urinary biomarkers of kidney injury: kidney injury molecule (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and albumin creatinine ratio (ACR).

RESULTS

The median urinary levels of NGAL, ACR, and particularly KIM-1, which is a more sensitive indicator of kidney injury, showed no significant differences across the BMI strata. Importantly, moderate correlations of BMI with KIM-1 and NGAL were identified in severely thin girls.

CONCLUSIONS

According to the present study, these findings do not produce plausibly strong evidence to establish a potential association of BMI with altered kidney function in the studied pediatric communities. Particularly, a likelihood of abnormal kidney health outcomes associated with undernutrition is apparent in severely thin girls. However, in-depth studies are warranted to develop a comprehensive understanding of the associations of nutritional status with pediatric kidney health in Sri Lanka. A higher resolution version of the Graphical abstract is available as Supplementary information.

Generalisability of and lessons learned from a mixed-methods study conducted in three low- and middle-income countries to identify care pathways for atrial fibrillation

BACKGROUND

Identifying existing care pathways is the first step for understanding how services can be improved to enable early diagnosis and effective follow-up care for non-communicable diseases (NCDs); however, evidence on how care pathways can and should be identified in low- and middle-income countries (LMICs) is lacking.

OBJECTIVE

To describe generalisability and lessons learned from recruitment and data collection for the quantitative component of a mixed methods study designed to determine the care pathway for atrial fibrillation (AF) in Brazil, China and Sri Lanka.

METHODS

Adults (≥18 years) that spoke the local language and with an AF diagnosis were eligible. We excluded anyone with a hearing or cognitive impairment or ineligible address. Eligible participants were identified using electronic records in Brazil and China; in Sri Lanka, researchers attended the outpatient clinics to identify eligible participants. Data were collected using two quantitative questionnaires administered at least 2-months apart. A minimum sample size of 238 was required for each country.

RESULTS

The required sample size was met in Brazil (n = 267) and China (n = 298), but a large proportion of AF patients could not be contacted (47% and 27%, respectively) or refused to participate (36% and 38%, respectively). In Sri Lanka, recruitment was challenging, resulting in a reduced sample (n = 151). Mean age of participants from Brazil, China and Sri Lanka was 69 (SD = 11.3), 65 (SD = 12.8) and 58 (SD = 11.7), respectively. Females accounted for 49% of the Brazil sample, 62% in China and 70% in Sri Lanka.

CONCLUSIONS

Generalisability was an issue in Brazil and China, as was selection bias. Recruitment bias was highlighted in Sri Lanka. Additional or alternative recruitment methods may be required to ensure generalisability and reduce bias in future studies aimed at identifying NCD care pathways in LMICs.

Exploring the diversity of CFTR gene mutations in cystic fibrosis individuals of South Asia

OBJECTIVE

Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CFTR gene. This study aimed to identify the spectrum of CFTR variants reported in individuals with CF from South Asia (ISA).

DATA SOURCES AND STUDY SELECTION

We conducted a PubMed search for CFTR variants reported in ISA. Full text of original articles and case reports was read to compile data on reported variants. To gather additional data, we independently cross-referenced each variant with the CFTR Mutation Database and ClinVar.

RESULTS

Our investigation identified a total of 92 CFTR variants reported across 30 articles. The most frequently tested, and reported variant was ΔF508 with a global frequency of 69.74%. Notably, we found 14 pathogenic CFTR mutations shared among ISA, originating from more than one South Asian country: ΔF508, 1525-1 G > A, G542X, S549N, R117H, S549R, R709X, V456A, Y569D, L1077P, 1161delC, 1898 + 1 G > T, G551D, and 2184insA.

CONCLUSION

In summary, the higher prevalence of consanguinity and the limited availability of CF diagnostic resources in South Asia considerably contribute to the prevalence of genetic disorders like CF. The spectrum of CFTR mutations exhibits noticeable variations within South Asian and other populations. The inclusion of current study-enlisted CFTR gene variants is highly recommended for CF disease genetic testing in South Asia which may aid in achieving a precise diagnosis, enhancing disease management, and discovering drugs for currently untreatable genetic variants. It is also imperative to conduct a comprehensive study in this region, especially in previously unexplored countries such as Nepal, Bhutan, Maldives, and Bangladesh.

Knowledge, perceptions and practices on healthcare waste management and associated occupational health hazards among healthcare professionals in the Colombo District, Sri Lanka: a cross-sectional study

Background

Proper Healthcare Waste (HW) management is directly influenced by the knowledge and attitudes of Healthcare Professionals (HCP). However, studies that characterize the knowledge and practices of HCP on HW management are limited in Sri Lanka. This study was conducted to characterize the knowledge, perceptions and practices of HCP on the management of HW and to determine the risk factors influencing HW related occupational health hazards in the Colombo District of Sri Lanka.

Methods

A total of 407 HCP were recruited as the study population from selected hospitals in the Colombo District. Information on socio-demographic factors, knowledge, attitudes and practices on HW management were gathered using an interviewer-administrated questionnaire. The Binary Logistic Regression (BLR) was used to determine the socio-economic risk factors associated with the occurrence of HW related health issues among the respondents.

Results

The majority of respondents were characterized with a high knowledge level (76.9%) and positive attitudes (53.8%) on HW management. Incineration (82.6%) was recognized as the most widely used HW treatment method. Personal Protective Equipment (PPE) was used at a satisfactory level (85.5%), while liquid waste treatment was limited (57.5%). The occupational designation, level of training received in HW management, professional experience, vaccination status for tetanus, degree of knowledge and attitudes on HW management were recognized as significant risk factors (p < 0.05) associated with the occurrence of HW related occupational hazards.

Conclusion

Even though, the treatment of HW was satisfactory, strengthening the existing mechanisms for monitoring of HW management, provisioning more resources and organizing training and awareness programmes on HW management for HCP are recommended.

Exploring health information system resilience during COVID-19 pandemic: case studies from Norway, Sri Lanka & Rwanda

The study aims at exploring health system resilience by defining the scope on health information systems, one of the six building blocks of the health system. The empirical evidence is derived using qualitative data collection and analysis in the context of Norway, Sri Lanka and Rwanda during the COVID-19 pandemic. The case studies elicit bounce back and bounce forward properties as well as the agility as major attributes of resilience present across the countries. Existing local capacity, networking and collaborations, flexible digital platforms and enabling antecedent conditions are identified as socio-technical determinants of information system resilience based on the case studies across the countries.

Plasmodium ovale infection in Sri Lanka: distant exposure and incidental detection of hyperparasitemia: a case report

BACKGROUND

Plasmodium ovale malaria, which was previously endemic to tropical Africa and the Southwest Pacific islands is now being reported from parts of Asia. In Sri Lanka, the indigenous transmission of malaria has not been documented since October 2012. Since then, there have been several imported cases of malaria, including P. ovale, which have been detected sporadically. The reporting case of P. ovale was imported and detected incidentally in 2021, with several atypical presentations.

CASE PRESENTATION

A 40-year-old Sri Lankan medical doctor developed continuous fever with chills, rigors, and dysuria a day following removal of a large lipoma at the root of the neck under general anaesthesia. When the fever has been responding to antibiotics, on the 4th postoperative day a mild thrombocytopenia on complete blood count was detected. A blood smear which was done on the 5th postoperative day incidentally found a malaria parasite and confirmed as Plasmodium ovale with a density of 6535 parasites/microliter on the same day. He never had malaria in the past, but he had worked in South Sudan 1 year ago and visited India six months ago. On the 6th postoperative day, he was treated with chloroquine, and hyperparasitemia reduced rapidly by the next day. As the fever recurred with clinical deterioration, he was treated with different antibiotics. During the course of the illness, he did not develop pallor, or icterus except for a palpable soft spleen. The parasite count was zero on the 9th postoperative day and his fever subsided on the next day. Further, he was treated with primaquine to prevent future relapse and transmission.

CONCLUSION

A long incubation period, incidental detection of P ovale in a blood smear, and hyperparasitaemia are the atypical presentations of this case. Postoperative bacterial infection and stress may have reactivated the dormant malaria (hyponozoites) in this patient with an unusual picture. Coinfection of malaria with bacterial sepsis is a challenge in the management of the patient. As the Anopheles mosquito vector exists in Sri Lanka, the risk of indigenous transmission is high from such imported cases of P. ovale.

Development of a risk prediction model to predict the risk of hospitalization due to exacerbated asthma among adult asthma patients in a lower middle-income country

BACKGROUND

Asthma patients experience higher rates of hospitalizations due to exacerbations leaving a considerable clinical and economic burden on the healthcare system. The use of a simple, risk prediction tool offers a low-cost mechanism to identify these high-risk asthma patients for specialized care. The study aimed to develop and validate a risk prediction model to identify high-risk asthma patients for hospitalization due to exacerbations.

METHODS

Hospital-based, case-control study was carried out among 466 asthma patients aged ≥ 20 years recruited from four tertiary care hospitals in a district of Sri Lanka to identify risk factors for asthma-related hospitalizations. Patients (n = 116) hospitalized due to an exacerbation with respiratory rate > 30/min, pulse rate > 120 bpm, O2 saturation (on air) < 90% on admission, selected consecutively from medical wards; controls (n = 350;1:3 ratio) randomly selected from asthma/medical clinics. Data was collected via a pre-tested Interviewer-Administered Questionnaire (IAQ). Logistic Regression (LR) analyses were performed to develop the model with consensus from an expert panel. A second case-control study was carried out to assess the criterion validity of the new model recruiting 158 cases and 101 controls from the same hospitals. Data was collected using an IAQ based on the newly developed risk prediction model.

RESULTS

The developed model consisted of ten predictors with an Area Under the Curve (AUC) of 0.83 (95% CI: 0.78 to 0.88, P < 0.001), sensitivity 69.0%, specificity 86.1%, positive predictive value (PPV) 88.6%, negative predictive value (NPV) 63.9%. Positive and negative likelihood ratios were 4.9 and 0.3, respectively.

CONCLUSIONS

The newly developed model was proven valid to identify adult asthma patients who are at risk of hospitalization due to exacerbations. It is recommended as a simple, low-cost tool for identifying and prioritizing high-risk asthma patients for specialized care.

Lessons learned from the COVID-19 response in Sri Lankan hospitals: an interview of frontline healthcare professionals

Introduction

The COVID-19 pandemic revealed the lack of preparedness in health systems, even in developed countries. Studies published on COVID-19 management experiences in developing countries, including Sri Lanka, are significantly low. Therefore, lessons learned from pandemic management would be immensely helpful in improving health systems for future disaster situations. This study aimed to identify enablers and barriers to COVID-19 management in Sri Lankan hospitals through healthcare workers' perceptions.

Methods

Frontline doctors and nurses from different levels of public hospitals were interviewed online. Both inductive and deductive coding and thematic analysis were performed on the transcribed data.

Result and discussion

This study identified four themes under enablers: preparing for surge, teamwork, helping hands and less hospital-acquired infections. Seven themes were identified as barriers: lack of information sharing, lack of testing facilities, issues with emergency equipment, substandard donations, overwhelmed morgues, funding issues and psychological impact. These preparedness gaps were more prominent in smaller hospitals compared with larger hospitals. Recommendations were provided based on the identified gaps.

Conclusion

The insights from this study will allow health administrators and policymakers to build upon their hospital's resources and capabilities. These findings may be used to provide sustainable solutions, strengthening the resilience of the local Sri Lankan health system as well as the health systems of other countries.

The effect of financial development on environmental quality: a developing country evidence

Financial development is vital to enhance the inclusive growth of a country in the modern world, and environmental quality, affected by financial development, is also a highly debated topic. Thus, this study attempts to investigate the role of financial development in determining environmental quality in Sri Lanka considering other variables namely economic growth, energy consumption, trade openness, and foreign direct investments. The key econometric tool used for the purpose is the Autoregressive Distributed Lag (ARDL) approach with the data from 1992 to 2021. As per the findings, financial development, economic growth, energy consumption, and foreign direct investments adversely impact environmental quality both in the long-run and short-run. Additionally, trade openness established a negative impact in the short-run only. Importantly, the Environmental Kuznets' Curve (EKC) hypothesis and Pollution Haven Hypothesis are established. Finally, all variables except trade openness confirmed a unidirectional causal relationship with environmental quality. This study recommends that all the modelled variables are vital to enrich the environmental quality in Sri Lanka.

Is violence against men a problem in Sri Lanka?

BACKGROUND

Gender-based violence (GBV) among men is a universally present phenomenon that is mostly unacknowledged. The relative lack of research in this area leads to a deficiency of evidence ascribing due recognition to GBV among men. This, in turn, leads to not identifying it as a social problem, hence, poor development of resources for victims as well as poor help-seeking behaviour patterns are prevalent, especially in Southeast Asia.

AIMS

We aimed to determine the prevalence of GBV among men in Colombo, Sri Lanka.

METHOD

A descriptive cross-sectional analytical community survey was conducted to explore GBV against 1280 Sinhala-speaking men, selected using a multistage cluster sampling method in Colombo district, Sri Lanka. The GBV among men questionnaire (GBVMQ) was developed and culturally validated. A multiple logistic regression model was developed and nine correlates of GBV were identified and adjusted odds ratios estimated.

RESULTS

The prevalence of GBV was 35.8% (95% CI 33.1 -38.6). The prevalence of Verbal GBV was 34.7% (95% CI 32.1 -37.5). Childhood sexual abuse was 7.6% (95% CI 6.2 -9.2). Being subjected to ridicule as cowardly or unmanly (AOR = 25.3, 95% CI 5.58 -114.7, P<0.0010), Childhood sexual abuse (AOR = 4.4, 95% CI 1.73 -11.09, P = 0.002) showed positive associations with statistical significance.

CONCLUSION

The results highlight the importance of having services for men as well as women. Enabling inclusiveness of men in mandates of state and private institutions catering for GBV would be a strategy in moving forward for Sri Lanka.

Differences in the characteristics of people who purchase pesticides from shops for self-harm versus those who use pesticides available in the domestic environment in Sri Lanka

OBJECTIVE

Data from South Asia indicate that for 15%-20% of suicide attempts, pesticides are purchased from shops; otherwise, pesticides are obtained from an individual's house or nearby environment. We aimed to investigate the difference between individuals who directly purchase pesticides from shops for suicide attempts and suicide deaths versus those related to accessing the pesticides from an individual's house or nearby environment.

METHODS

We conducted two comparative studies in rural Sri Lanka: (1) non-fatal shop cases (n = 50) were survivors of self-poisoning with pesticides who ingested the pesticides after purchasing them from a shop; non-fatal domestic cases (n = 192) were survivors who accessed pesticides from their house or nearby environment. (2) fatal shop cases (n = 50) were individuals who died after ingesting pesticides they purchased for the act; fatal domestic cases (n = 102) were patients who died after ingesting pesticides they accessed at house or nearby environment. Logistic regression analysis was used to assess the characteristics which distinguished between the shop and domestic cases.

RESULTS

Data indicate that 20.7% and 32.9% of individuals who used pesticides for suicide attempts and suicide deaths had purchased them from shops, respectively. Being a non-farmer was the main distinguishing characteristic of shop cases: adjusted odds ratios (AOR) 8.9, 95% confidence intervals (CI) 3.2-24.4 for non-fatal shop cases, and AOR 4.0, 95% CI 1.5-10.6 for fatal shop cases. Non-fatal shop cases also had higher suicide intent (AOR 3.0, CI 1.0-8.9), and ingesting an insecticide (AOR 4.8, CI 1.8-1.0-8.9) than non-fatal domestic cases.

CONCLUSION

A high suicide intent of individuals who purchase pesticides for the event explains the high proportion of such fatal cases. Such high suicide intent makes the prevention implications difficult to spell out for those individuals who purchase pesticides for self-poisoning. However, our findings are valuable for clinicians to assess pesticide poisoning cases in hospitals.

Phenotypic and genotypic characterization of antibiotic-resistant Salmonella isolated from humans, aquaculture, and poultry in Sri Lanka: A retrospective study

BACKGROUND

In Sri Lanka, foodborne diseases caused by nontyphoidal Salmonella are of increasing concern. We therefore aimed to characterize the dominant Salmonella serovars in humans, poultry, and aquaculture through a One Health approach.

METHODS

We collected isolates from different sectors, confirmed their identities using PCR, screened their antibiotic resistance profiles, and determined their antibiotic resistance genes based on whole-genome sequencing.

RESULTS

Of the 75 Salmonella isolates identified, the majority of serotypes were unidentified. Both Salmonella enterica serovar Enteritidis (S. Enteritidis) and Salmonella enterica serovar Typhimurium (S. Typhimurium) could be isolated from human sources and were also found prevalent in the poultry sector. ST36, ST11 and ST1541 were the dominant serotypes of S. Typhimurium and S. Enteritidis, respectively. Alarmingly, 4% (1/25) of poultry Salmonella isolates were resistant to ciprofloxacin, suggesting an emergence of this phenotype. Moreover, virulence genes were very diverse among S. Enteritidis and S. Typhimurium isolates.

CONCLUSIONS

With the diversity of unidentified serotypes found and the detection of emerging resistances, our study highlights the importance of a One Health approach to monitoring antibiotic resistance. For public health initiatives in Sri Lanka to be successful in mitigating salmonellosis, all three sectors - humans, aquaculture, and poultry - must be tackled concomitantly in a coordinated manner under the One Health approach because antibiotic resistance genes, and even specific sequence types, may be able to spread across the aforementioned sectors. We anticipate that our results will inform public health policies in Sri Lanka to tackle foodborne illnesses.

The impact of the Sri Lankan economic crisis on medication adherence: An online cross-sectional survey

Background

The economic crisis in Sri Lanka has disarrayed the country's healthcare services, posing a challenge to people with chronic diseases on routine care. This study investigated the changes in medication adherence during the economic crisis.

Methods

A web-based cross-sectional survey was undertaken in July-August 2022. It assessed socio-demographics, diseases, medication adherence, and reasons for changes in compliance of respondents and their family members during the economic crisis. Descriptive statistics and multivariable logistic regression analysis were used.

Findings

A total of 1214 respondents, aged ≥18 years were included in the survey. The majority were females (60%). The main finding was that 39%, 41%, and 37% of participants, their family members, or children respectively have changed medication use during the crisis. Among those who changed their medication practices, the most significant change was the change in the brand, reported by 44.7% of the respondents. A similar pattern was observed among other family members, with 61.3% of adults and 53.8% of children switching brands. Respondents who lived outside the Colombo district had a significantly increased risk of changing medication (OR = 1.425, 95% CI = 1.020-1.992, P = 0.038). Respondents with monthly incomes of less than 100,000 LKR had a twofold greater risk of medication nonadherence compared to participants who earned more than 100,000 LKR per month (OR = 2.278, 95% CI = 1.37-3.78, P = 0.001). The most stated reason for changing medication among adults was the high cost of drugs, whereas among, children, the lack of access to drugs in the public or private sector was the leading cause of non-compliance.

Interpretation

The population's adherence to medication is negatively impacted by the economic crisis in Sri Lanka.

The politics of glyphosate regulation: lessons from Sri Lanka's short-lived ban

BACKGROUND

Glyphosate is the world's most used herbicide and a central component of modern industrial agriculture. It has also been linked to a variety of negative health and environmental effects. For instance, the International Agency for Research on Cancer classified glyphosate as "probably carcinogenic to humans" in 2015. This has motivated widespread political demands for stricter glyphosate regulation but so far few governments have followed through.

METHODS

We conduct a case study of Sri Lanka, which in 2015 became the first and so far only country in the world to adopt and implement a complete glyphosate ban. But this ban proved to be short-lived, as it was partially reversed in 2018 (and later fully revoked in 2022). To explain the political causes of Sri Lanka's pioneering glyphosate ban and its subsequent reversal, we employ process tracing methods drawing on publicly available documents. Our analysis is theoretically guided by the multiple streams framework and the concept of self-undermining policy feedback.

RESULTS

Glyphosate regulation rose to the top of the Sri Lankan political agenda in 2014 when a local scientist linked glyphosate exposure to an epidemic of Chronic Kidney Disease of Unknown Origin (CKDu). A glyphosate ban was eventually adopted in June 2015 by the newly elected government of Maithripala Sirisena. The ban was a political commitment made to the Buddhist monk Rathana Thero and his party, which had supported Sirisena during his presidential campaign. The ban's partial reversal in 2018, implemented through sectoral exceptions, was the result of continued lobbying by export-oriented plantation industries and increased political concerns about potential negative effects on the large and structurally powerful tea sector. The reversal was further aided by the scientific community's failure to corroborate the hypothesized link between glyphosate and CKDu.

CONCLUSIONS

The case of Sri Lanka suggests that strict glyphosate regulation becomes more likely when coupled with locally salient health risks and when decision-making authority is de-delegated from regulatory agencies back to the political executive. Meanwhile, the short-lived nature of the Sri Lankan ban suggests that strict glyphosate regulation faces political sustainability threats, as the apparent lack of cost-effective alternative herbicides motivates persistent business lobbying for regulatory reversal.

RB1 screening of retinoblastoma patients in Sri Lanka using targeted next generation sequencing (NGS) and gene ratio analysis copy enumeration PCR (GRACE-PCR)

BACKGROUND

Retinoblastoma (RB) a tumour affecting those under 5 years, has a prevalence of 1 in 20,000, with around twenty new diagnoses per year in Sri Lanka. Unilateral and bilateral RB presents around 24 and 15 months respectively. Approximately 10% are familial. Systematic genetic testing for germline pathogenic variants of RB1, the only gene associated with an inherited risk of RB, is unavailable in Sri Lanka. Genetic testing optimizes management of affected children and at-risk siblings. This study aimed to develop accessible genetic testing to identify children with a germline pathogenic variant of RB1 in Sri Lanka.

METHODS

Targeted next generation sequencing (NGS) for detecting pathogenic sequence variants and Gene Ratio Analysis Copy Enumeration PCR (GRACE-PCR) for detecting RB1 copy number variations (CNVs) were performed for 49 consecutive RB patients treated between 2016 and 2020 at the designated RB care unit, Lady Ridgway hospital, Colombo. Patients (bilateral RB (n = 18; 37%), unilateral n = 31) were recruited following ethical clearance and informed consent.

RESULTS

There were 26 (53%) females. Mean age at diagnosis was 18 months. Thirty-five patients (71%) had undergone enucleation. Germline pathogenic variants of RB1 identified in 22/49 (45%) patients including 18 (37%; 12 bilateral and 6 unilateral) detected by targeted NGS (2 missense, 7 stop gained, 1 splice donor, 8 frameshift variants). Six were previously undescribed, likely pathogenic frameshift variants. Four bilateral RB patients had GRACE-PCR detected CNVs including one whole RB1, two intragenic deletions (exon 12/13; exon 11 and 23) and a partial duplication of exon 27. The only familial case (affected mother and child) shared the duplication. Only 2 of 4 CNVs and 10 of 18 pathogenic variants were confirmed by whole exome sequencing and Sanger sequencing respectively, due to funding limitations.

CONCLUSIONS

The study identified pathogenic or likely pathogenic germline RB1 sequence variants and copy number variants in 16/18 (89%) bilateral and 6/31(19%) unilateral cases, which is comparable to worldwide data (10-15% unilateral, 80-85% bilateral). Targeted NGS combined with GRACE-PCR significantly reduce the cost of RB1 testing in Sri Lanka, and may widen access for genetic diagnosis of RB patients in other low and middle income countries.

(Kothala Himbutu)

BACKGROUND

Decoctions of the root and stem of the medicinal plant Salacia reticulata is an indigenous remedy for diabetics and its complications in Sri Lanka. In diabetics, the formation of advanced glycation end products (AGEs) leads to many pathologies. Nevertheless, the anti-protein-glycation property of this plant is poorly documented. This study reports the anti-protein-glycation and radical scavenging potential of various plant parts of S. reticulata.

METHODS

Hot water extracts (2g dried powder/50 ml) of root, stem, leaf, twigs, and fruits at various concentrations (15.6 to 500.0 µg/ml) were subjected to anti-glycation and glycation reversing assays in vitro. 1,1-diphenyl-2-picrylhydrazyl (DPPH) assay was used for free radical scavenging property.

RESULTS

Various plant parts of S. reticulata showed anti-protein-glycation and free-radical scavenging activities. IC50 for the anti-glycation activity of root, stem, leaf, twigs, and fruit extracts were 11.92 ± 1.14, 35.18 ± 2.79, 113.3 ± 1.91, 149.59 ± 1.06, and 1120.37 ± 229.48 µg/ml respectively. IC50 of Rutin was 21.88 ± 2.82 µg/ml. EC50 of the root, stem, twigs, and leaf extracts for glycation reversing was 102.09 ± 6.23, 116.99 ± 5.82, 154.45 ± 5.79, and 278.78 ± 14.19 µg/ml respectively. The EC50 values for the radical scavenging activity of leaf, stem, and roots were 26.4±4.7, 9.0±1.2, and 9.1±1.3 respectively. Root had significantly (p<0.05) high activity for all the parameters tested.

CONCLUSION

Salacia reticulata possess anti-glycation, glycation-reversing, and free radical scavenging activities. Other than root and stem, the leaves and twigs too may be a useful source for anti-diabetic bioactive molecules.

Symptoms of depression and anxiety and stress among postgraduate trainees in Sri Lanka: Risk factors and implications for practice

High workload, long working hours, and the need to study and work simultaneously put postgraduate trainee doctors at a high risk of depression, anxiety, and stress. A cross-sectional descriptive study was conducted among all postgraduate trainees registered at the Postgraduate Institute of Medicine (PGIM), Sri Lanka, using the 21-item Depression Anxiety Stress Scale (DASS-21). Eleven-point two percent (11.2%) had depressive symptoms, 8.9% had anxiety symptoms, and 1.9% had high levels of stress. Being female, having a past or current mental illness, not being supported by the trainers, being unfairly treated by trainers, dissatisfaction with the work environment, difficulty in coping with long working hours, and poor peer support were significantly associated with symptoms of depression and anxiety, and stress (P < 0.01). Given the association between psychological distress and the characteristics of training and work environment, the postgraduate training programs should be reviewed to ensure the psychological well-being of trainees.

Associations between socioeconomic factors and depression in Sri Lanka: The role of gene-environment interplay

BACKGROUND

Low socioeconomic status is a risk factor for depression. The nature and magnitude of associations can differ cross-culturally and is influenced by a range of contextual factors. We examined the aetiology of socioeconomic indicators and depression symptoms and investigated whether socioeconomic indicators moderate genetic and environmental influences on depression symptoms in a Sri Lankan population.

METHODS

Data were from a population-based sample of twins (N = 2934) and singletons (N = 1035) in Colombo, Sri Lanka. Standard of living, educational attainment, and financial strain were used to index socioeconomic status. Depression symptoms were assessed using the Revised Beck Depression Inventory. Structural equation modelling explored genetic and environmental influences on socioeconomic indicators and depression symptoms and moderation of aetiological influences on depression symptoms by socioeconomic status.

RESULTS

Depression symptoms were associated with lower standard of living, lower educational attainment, and financial strain. Sex differences were evident in the aetiology of standard of living, with a small contribution of genetic influences in females. Educational attainment was moderately heritable in both males and females. Total variance in depression was greater among less socioeconomically advantaged individuals. Modest evidence of moderation of the aetiology of depression by standard of living and education was observed.

LIMITATIONS

While the sample is representative of individuals living in Colombo District, it may not be representative of different regions of Sri Lanka.

CONCLUSIONS

The aetiology of depression varies across socioeconomic contexts, suggesting a potential mechanism through which socioeconomic disadvantage increases the risk for depression in Sri Lanka. Findings have implications for cross-cultural investigations of the role of socioeconomic factors in depression and for identifying targets for social interventions.

Experience from Eastern Province of Sri Lanka

BACKGROUND

According to the World Breastfeeding Trends Initiative, Sri Lanka ranked as number one and only country to achieve green status. Exclusive breastfeeding (EBF) for six months is current practice with a rate of 75.5% among 0-5 months.

AIM

Identify factors contributing early cessation of breastfeeding in a single centre of Eastern province Sri Lanka.

METHODS

A descriptive cross-sectional study conducted in Sammanthurai Medical officer of Health area. Consecutive mother-infant days with the infant ageing < 6 months were included from 25 public health midwife areas using an interviewer administered questionnaire. Missing values imputed using 'missForest' algorithm.

RESULTS

The mean age of the sample was 28.4(SD ± 5.6). Of the 257 mothers recruited, 15(5.8%) were teenagers and 42(16.3%) > 35 years. 251(97.6%) had children 1-5 and 86(33.5%) were first born. 140 (54.5%) had tertiary education, 28 (10.9%).31(12.1%) were employed. EBF rates 0-6 months was 79.8% (n = 205). 239(93.0%) started breastfeeding within an hour. EBF was not associated with maternal age, birth order or income. 18 employed mothers and 186 unemployed mothers continued EBF. Regarding the factors associated with EBF, having a tertiary education (p < .001), being employed (p = .004) and having less than 3 children (p = .03) were associated with non-exclusive breastfeeding. Tertiary education was the significant predictor of non-exclusive breastfeeding in this population with an odds ratio of 4.50 (95% CI 1.331-15.215).

CONCLUSION

Employment identified as a risk factor for early cessation of EBF needs well planned further research to overcome this practical issue. Also might need revision of workplace policies, establishment of lactation areas in office premises to overcome some of these issues.

Circular economy strategies for waste management in Sri Lanka: A focus on demolitions and repurpose and material recovery and production stages

In Sri Lanka, the management of Construction & Demolition (C&D) waste poses a major problem, leading to environmental degradation and depletion of resources. This study aims to tackle these issues by examining the implementation of Circular Economy (CE) strategies within the construction industry of Sri Lanka. The focus is on reducing waste generation and maximizing resource utilization during the demolitions and repurpose, as well as material recovery and production stages of the building project life cycle. These stages are crucial in terms of waste generation and resource consumption. A qualitative approach was employed in this research, utilizing the Delphi technique to gather insights through a series of three rounds of expert interviews. In the first round, 17 experts were involved, followed by 15 in the second round, and 12 in the final round. The data collected from these interviews were analysed using manual content analysis methods. Based on the research findings, a total of 14 C&D Waste Management (WM) issues were identified specifically in the Demolitions and Repurpose Stage in Sri Lanka. For each issue, suitable strategies were proposed to overcome them effectively. Furthermore, the study examined the impact of CE strategies on minimizing these issues within the context of the project management iron triangle. Similarly, the Material Recovery and Production Stage of the building presented eight C&D WM issues, each accompanied by corresponding strategies to address them. The research also explored the influence of CE strategies in mitigating these issues, considering the project management iron triangle. During the demolitions and repurpose stage, CE strategies focus on reducing waste generation and optimizing resource utilization. This involves carefully deconstructing buildings to salvage and recover materials that can be reused or repurposed.

Human Oro-Nasopharyngeal Myiasis by Chrysomya Bezziana (Old-World Screwworm): The First Reported Case in Sri Lanka

Myiasis is the invasion of mammalian tissues by dipterous larvae. Cutaneous myiasis is the commonest type, and less commonly, internal tissues and organs are affected. Here, we report the first case of oro-nasopharyngeal myiasis caused by the third-instar larvae of Chrysomya bezziana (Old-World screwworm) in Sri Lanka. A retired 71-year-old female tea-plucker presented to the hospital with a 4-day history of nasal bleeding and neck discomfort. Except for well-controlled hypertension, she had no significant medical history. On examination, there was an ulcerated area in the posterior oro-nasopharynx filled with maggots. Hematological analysis showed a high C-reactive protein level (24 mg/dL) and white blood cell count (17.5 × 109/L) with 80% neutrophils. Computed tomography showed severe inflammation of the pharynx with no features of a neoplasm or parapharyngeal abscess. An examination was performed under anesthesia followed by manual removal of larvae, surgical debridement with biopsy, and treatment with antiparasitic medicines and antibiotics. Histopathology excluded neoplasm and only showed inflammatory changes. All extracted larvae were morphologically similar and identified as third-instar larvae of C. bezziana using a trinocular zoom stereomicroscope. The patient recovered and was discharged from the hospital on the 15th day and was well at 2 months follow-up.

Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka

BACKGROUND

Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict.

AIMS

To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war.

METHOD

In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods.

RESULTS

Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population.

CONCLUSIONS

Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.