Protocol for systematic review and meta-analysis: magnitude, reasons, associated factors, and implications of the out-of-pocket expenditure during pregnancy.

OBJECTIVES: Health-related out-of-pocket expenditure (OOPE) impedes utilization for maternal health care. We aim to systematically review the magnitude, reasons, associated factors, and implications of OOPE during pregnancy. STUDY DESIGN: The study design is a protocol for systematic review and meta-analysis. METHODS: A comprehensive literature search will be conducted with the electronic databases of PubMed, Web of Science, Scopus, Cochrane, Trip, Social care online, IDEAS, EconPapers, ERIC, and EconStor. A manual search will be carried out for the reference lists of eligible studies and reviews. The search strategy will include combining two key blocks of terms, namely: 'pregnancy' and 'OOPE,' using database-specific subject headings and text words. Two independent reviewers will screen and assess data quality and extract data for synthesis. Any disagreements during any stage will be determined by consensus with the involvement of a third reviewer. The 'Mixed methods appraisal tool' will be adapted for the quality appraisal of the eligible studies. A narrative synthesis will be provided for the reasons, associated factors, and implications of OOPE, and a meta-analysis will be conducted for the magnitude of OOPE. Furthermore, a subgroup analysis will be done with countries with different income levels and health care policies. TRIAL REGISTRATION: PROSPERO 2020 CRD42020168566.

Knowledge, Attitudes, and Practices of Responsive Feeding in Rural Sri Lanka (A Qualitative Study)

Introduction: Responsive Feeding has been proven to be an effective feeding method for children who are at early stages of development. The concept is not popular at the primary health care level and it is reported as a missing link in the current nutrition program in Sri Lanka. Objective: To explore responsive feeding practices among caregivers who have an infant aged between 6 to 12 months and residing in rural Anuradhapura. Methods: A qualitative approach was adopted. The study was carried out in Padaviya Medical Officer of Health area. Study participants were 18 mothers and all ten Public Health Midwives. Diary studies, interviews and focus group discussion were conducted to collect data. The framework approach was used to analyze the data. Results: Pleasant and healthy feeding environment is non-existent. Identification of hunger and satiety cues was poor and hunger sensitive schedule to feed the child was absent. Feeding situations commenced in an emotionally supportive manner, but were not optimally utilized to promote psycho-social stimulation. During the feeding caregivers neglect emotional support and ultimately moves to forceful feeding. Conclusions: The knowledge, attitude and practices are poor on responsive feeding among caregivers and health workers. This may contribute to poor growth and development in children. Action is needed to implement RF practices in the community.

Nutritional status among primary school children in rural Sri Lanka; a public health challenge for a country with high child health standards.

BACKGROUND: Nutritional status of pre adolescent children is not widely studied in Sri Lanka. The purpose of this study was to determine the nutritional status among pre-adolescent school children in a rural province of Sri Lanka. METHODS: A school based cross sectional study was carried out in North Central Province in 100 rural schools, selected using multi stage cluster sampling with probability proportionate to size. Children in grade one to five were enrolled with a maximum cluster size of fifty. Anthropometric measurements were done by trained data collectors and venesection was done at site by trained nurses. WHO AnthoPlus was used to calculate the BMI, height for age and weight for age Z scores. Survey design adjusted prevalence estimates with linearized standard errors were generated using svy function of STATA. Mean haemoglobin concentration (Hb) was calculated using methaeamoglobin method. Screening for iron deficiency and thalassemia trait was done using peripheral blood films. RESULTS: Height and weight measurements were done for 4469 of children and the Hb data was available for 4398 children. Based on the survey design adjusted estimates, prevalence of severe thinness, thinness, overweight and obesity in this population was 8.60% (SE 0.94), 2.91%(SE 0.74), 2.95%(0.26) and 2.43%(SE 0.92) respectively. Similarly, survey design adjusted prevalence of underweight and stunting were, 25.93% (95% CI 24.07-27.89%) and 43.92%(95% CI 40.55-47.56%). Adjusted mean estimates for hemoglobin was 12.20 (95% CI 12.16-12.24) g/dL. Prevalence of anemia was 17.3% (n = 749). Prevalence of mild and moderate anemia was 9.4 and 7.6% respectively. CONCLUSION: This study confirms that malnutrition is still a major problem in North Central Province, Sri Lanka.

Outbreak of leptospirosis after white-water rafting: sign of a shift from rural to recreational leptospirosis in Sri Lanka?

This paper reports the first recreation-related leptospirosis outbreak in Sri Lanka in 20 office workers who were involved in white-water rafting during a staff outing. Two weeks after the rafting event on 7 September 2012, six participants developed fever, of which four had classical clinical features of leptospirosis. Four weeks after the exposure, an outbreak investigation was conducted for 19 of the 20 participants. Of the six fever patients, four were confirmed as having acute leptospirosis using either single sample MAT titre ≥ 1/400 (n = 2) or positive IgM ELISA (n = 2). An afebrile patient with headache and myalgia also had a MAT titre ≥ 1/400. Seventeen of the 19 participants investigated showed anti-leptospiral antibodies. None of the participants had a history of leptospirosis or recent outdoor exposures other than the rafting event. This outbreak provides evidence of the changing epidemiology of leptospirosis and suggests a wider range of risk exposures including those related to recreational activities of more affluent urban populations in addition to the well recognized occupational hazards of rural farming.

Factor structure and normative data of the Sinhalese version of self reported Strength and Difficulties Questionnaire (SDQ) for adolescents.

OBJECTIVES: To describe the normative data, factor structure and the internal consistency of the Sinhalese, self reported version of SDQ for adolescents. METHODS: The present study was carried out in eight provinces in Sri Lanka. A sample of school going adolescents aged 12-16 years were selected from Sinhalese medium schools using a multi stage cluster sampling technique with probability proportionate to size. The component structure of the SDQ was examined using principal component analysis. Normative banding and the cut off values were determined, based on the distribution of raw data in this non-clinical sample. RESULTS: The study sample consisted of 535 (45.3%) boys and 645 (54.5%) girls. Mean total difficulty score for girls (10.66±5.440) was significantly (p=0.014) higher than that for boys (9.93±4.671). Mean scores for emotional (2.97±2.009), conduct (2.11±1.755) and peer (2.24±1.760) subscales were also significantly higher among girls than that of boys (2.7±1.915, 1.78±1.406 and 2.04±1.383 respectively). In the factor analysis, only factor that was loaded with all five items in the original subscale was "emotional" and the loading values were more than .445 for all five items. None of the other extracted factors contained more than 3 items from one subscale. Internal consistency (Cronbach's alpha) for total difficulties was satisfactory in the total sample as well as in boys and girls separately (>.71). However, in all five subscales, Chrobach's alpha was less than six, showing a low homogeneity. CONCLUSIONS: Factor structure and internal consistency of the current Sinhalese version of the self reported SDQ is not satisfactory. Revalidation of this version of SDQ is recommended to capture the intended objectives of the SDQ.

Anaemia in pregnancy in the district of Anuradhapura, Sri Lanka--need for updating prevalence data and screening strategies.

OBJECTIVES: To determine the prevalence of anaemia during pregnancy in Anuradhapura district and evaluate present screening methods for anaemia. METHODS: Modified WHO 30 cluster sampling method with increased precision was used to estimate the prevalence of anaemia in the Anuradhapura district, Sri Lanka. Serum haemoglobin was measured using methemoglobin method. Clinical examination was carried out to evaluate the conjunctival method in anaemia screening. Values recorded from haemoglobin colour scale method used in the field antenatal clinics were collected. RESULTS: A total of 990 pregnant women participated in the study. In the first, second and third trimesters, prevalence of anaemia was 7.6%, 19.7% and 19.3% respectively. Gestational age adjusted anaemia prevalence among pregnant women in this study population was 14.1% (95% CI 12.0-16.4%). Mean and median haemoglobin concentration of the study sample was 11.8g/dL (SD 1.02g/dl and IQR 11.2-12.5g/dl). Among anaemic pregnant women, average values for Mean Corpuscular Volume (MCV), Mean Corpuscular Haemoglobin (MCH), and Mean Corpuscular Haemoglobin Concentration (MCHC) were, 82.9 fl (SD 11.5), 27.6 (SD-3.6) pg/cell and 32.9g/dl (SD 1.8) respectively. Sensitivity and specificity of haemoglobin colour scale method was 50% (95% CI 29.0-71.0%) and 76.3% (95% CI 66.9-83.7%) respectively. Sensitivity and specificity of conjunctival method in detecting anaemia during pregnancy was 18.8% (95% CI 11.9-28.4) and 69.3% (95% CI 58.2- 78.6%). CONCLUSIONS: Prevalence of anaemia in the district of Anuradhapura was less than 50% of the estimated prevalence for Sri Lanka. Both haemoglobin colour scale and conjunctival method were having low validity in detecting anaemia in pregnancy.