ISSN 1391-3174 Volume 25 - Issue 4 - December 2019the decision of reverting back to MMR 1st dose at 9 months, and this 2-dose schedule at 9 months and at 3 years has continued to date

ISSN 1391-3174

CoverStory – Measles: eliminated in Sri Lanka amidst the global re-emergence

Editorial – Antimicrobial resistance: a growing problem

DrFAWickramasingheOrationofCCPSL2018/19– Twenty-�ive years of Baby Friendly

Hospital Initiative in Sri Lanka: 1992-2017

OriginalResearch

· A qualitative study on barriers for the use of respiratory protective devices among rice

mill workers in Ampara District, Sri Lanka

· Adherence to infection control practices in relation to neonatal care in major

hospitals in a district of Sri Lanka

· Perceived self-ef�icacy and self-managing of chronic diseases among elderly

patients in a clinic setting: how capable are elders in promoting their own health?

Review– Colombo Declaration on Epidemiology in South East Asia

Volume 25 - Issue 4 - December 2019

Dr Poonam Khetrapal SinghRegional Director, WHO South-East Asia

“Sri Lanka's achievement comes at a time when globally measles cases are increasing. The country's success demonstrates its commitment, and the determination of its health workforce and parents to protect children against measles.”

Co-Editors

Carukshi Arambepola Department of Community Medicine, Faculty of Medicine

University of Colombo, Sri Lanka

Shamini Prathapan Department of Community Medicine, Faculty of Medical Sciences

University of Sri Jayewardenepura, Sri Lanka

Editorial Members

Chrishantha Abeysena Department of Public Health, Faculty of Medicine

University of Kelaniya, Sri Lanka

Ruwan Ferdinando National Institute of Health Sciences

Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka

Anuji Gamage Provincial Director of Health Services Office, North Central Province

Ministry of Health Nutrition and Indigenous Medicine, Sri Lanka

Sampatha Goonewardena Department of Community Medicine, Faculty of Medical Sciences


Vindya Kumarapeli Directorate of Non-Communicable Diseases


Nirupa Pallewatte National Programme for Tuberculosis Control and Chest Diseases


Manuja Perera Department of Public Health, Faculty of Medicine


Thilanga Ruwanpathirana Epidemiology Unit


Priyadarshani Samarasinghe Anti-Filariasis Campaign


Sudath Samaraweera National Cancer Control Programme


R Surenthirakumaran Department of Community Medicine, Faculty of Medicine

University of Jaffna, Sri Lanka

Shreenika Weliange Department of Community Medicine, Faculty of Medicine


Nuwan D Wickramasinghe Dept. of Community Medicine, Faculty of Medicine and Allied Sciences

Rajarata University of Sri Lanka, Sri Lanka

Supun Wijesinghe Health Promotion Bureau


International Advisory Board

Ranjith de Alwis International Medical University

Kuala Lumpur, Malaysia

Arvind Kasthuri St John’s Medical College

Bangalore, India

Journal of

THE COLLEGE OF COMMUNITY PHYSICIANS

OF SRI LANKA


Editorial Board

Co-Editors

Carukshi Arambepola Department of Community Medicine, Faculty of Medicine


Shamini Prathapan Department of Community Medicine, Faculty of Medical Sciences


Editorial Members

Chrishantha Abeysena Department of Public Health, Faculty of Medicine


Ruwan Ferdinando National Institute of Health Sciences


Anuji Gamage Provincial Director of Health Services Office, North Central Province

Ministry of Health Nutrition and Indigenous Medicine, Sri Lanka

Sampatha Goonewardena Department of Community Medicine, Faculty of Medical Sciences


Vindya Kumarapeli Directorate of Non-Communicable Diseases


Nirupa Pallewatte National Programme for Tuberculosis Control and Chest Diseases


Manuja Perera Department of Public Health, Faculty of Medicine


Thilanga Ruwanpathirana Epidemiology Unit


Priyadarshani Samarasinghe Anti-Filariasis Campaign


Sudath Samaraweera National Cancer Control Programme


R Surenthirakumaran Department of Community Medicine, Faculty of Medicine

University of Jaffna, Sri Lanka

Shreenika Weliange Department of Community Medicine, Faculty of Medicine


Nuwan D Wickramasinghe Dept. of Community Medicine, Faculty of Medicine and Allied Sciences

Rajarata University of Sri Lanka, Sri Lanka

Supun Wijesinghe Health Promotion Bureau


International Advisory Board

Ranjith de Alwis International Medical University

Kuala Lumpur, Malaysia

Arvind Kasthuri St John’s Medical College

Bangalore, India

Journal of

THE COLLEGE OF COMMUNITY PHYSICIANS

OF SRI LANKA


Editorial Board

Cover

Photograph: The World Health Organization announced that Sri Lanka has eliminated measles,

interrupting transmission of the indigenous virus that causes the killer childhood disease measles.

Graphic Design: Upula Vishwamithra Amarasinghe

Journal of THE COLLEGE OF COMMUNITY PHYSICIANS OF SRI LANKA

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Aims and scope

Journal of the College of Community Physicians of Sri Lanka (JCCPSL) is the official publication of the College

of Community Physicians of Sri Lanka. Its first issue was published in 1995.

JCCPSL is an open-access, peer-reviewed journal, which is published quarterly (four issues per year) from

2017. It publishes original research articles, reviews, brief reports, updates and short communications to

inform current research, policies and evidence based public health practices in all areas that are of common

interest to public health practitioners, clinicians and health policy makers. The Journal provides an

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137Journal of the College of Community Physicians of Sri Lanka

Gamage D. JCCPSL 2019, 25 (4) Open Access

Deepa Gamage

Epidemiology Unit, Ministry of Health, Sri Lanka

Correspondence: [email protected]

DOI: https://doi.org/10.4038/jccpsl.v25i4.8236

Cover Story

Measles: eliminated in Sri Lanka amidst the global re-emergence

Measles is a highly infectious disease with fatal and serious complications. After eradication of smallpox and

heading for eradicating polio, the next disease considered for eradication in the world would be measles, through

vaccination as a preventive strategy. The global experts are reviewing the feasibility of formulating eradication

strategies, while measles elimination strategies are on track throughout the world (1).

Sri Lanka has set targets for measles elimination to be achieved by 2020 (2) but received certification of

indigenous measles virus elimination one year ahead of its target. This achievement is a collective effort of all

preventive, laboratory and curative health care staff at all levels, as coordinated by the National Measles Elimination

Programme, Epidemiology Unit, Ministry of Health.

Received on 8 December 2019

Accepted on 10 December 2019

South East Asia (SEA) Region is immensely

involved in eliminating measles, in line with the

regional and global strategies for achieving and

maintaining a ‘measles free status’. At present,

none of the WHO-Regions remains as measles

eliminated. The Region of Americas, which was

declared measles eliminated in 2016 could not

remain so, with the resurgence of measles in some

countries for more than one year with continued

transmission. In 2018-2019, measles transmission

was experienced globally in outbreak proportions, with the main reason identified as non-vaccination due to

several contributing factors.

The Measles Containing Vaccine (MCV) at 9 months of age was introduced to Sri Lanka in 1984. The

country experienced an unexpected measles outbreak in 1999-2000 (3), which suggested the introduction of a

2nd dose (MCV-2) to all 3-year old children from 2001. As catch-up campaign, the adult age cohorts were

vaccinated with MCV-2 at 10-14 years in 2003 with high coverage (95%) and at 16-20 years in 2004 with

relatively low coverage (72%). As per the National Immunization Schedule, all age cohorts born after 1998

received MCV-2 to ensure high population immunity against measles transmission among younger population,

along with high vaccination coverage maintained for nearly two decades.

0000-0002-7131-7932

138 Journal of the College of Community Physicians of Sri Lanka


In 2011, a national policy decision taken to replace

MCV at 9 months and MCV at 3 years with Measles-

Mumps-Rubella (MMR) vaccine, advanced the 1st

MMR dose to 1 year of age for better zero-conversion.

On the verge of elimination in 2013, another

unexpected outbreak which continued till 2015 with

declining intensity, was experienced with high incidence

among infants with evidence of inadequate serum

immunity received as maternal antibodies. This led to

the decision of reverting back to MMR 1st dose at 9

months, and this 2-dose schedule at 9 months and at 3

years has continued to date.

After the outbreak situation in 2013-2015, with

gradual decline of the transmission, the last case

detected has been in April 2016 of indigenous measles

viral strain type B3. There onwards, few measles cases

have been identified from time to time as ‘imported

cases’ with different measles strains. The genotyping

revealed differences in the indigenously transmitted

measles virus types. These cases however were

contained successfully without transmission continued

for a year, conforming to the framework for

satisfactory elimination of measles in the country.

As effective case response, a more sensitive case

definition of “fever and maculopapular rash” used during

surveillance detects cases early. The strategy of

achieving high laboratory investigation is identified as

an essential component in heading for elimination and

sustaining post elimination status, ensuring the detection

of imported cases. Effective outbreak response includes

the initial response in detecting all possible contact cases

infected and outbreak response immunization in further

preventing cycles of transmission in affected locality.

Maintaining high population immunity is essential for

measles elimination. Serological evaluations have been

done in 2015 at different ages, which demonstrated

high population level immunity from 1-40 years. Field

level vaccine effectiveness carried out during outbreak

situation in 2014-2015 also showed very high vaccine

effectiveness among vaccinated age groups, ensuring

the quality of vaccine potency maintenance, adminis-

tration success and effectiveness of vaccination

schedule. All these applied epidemiological aspects,

including the routine vaccination coverage, standards

of reference laboratory at the Medical Research

Institute and surveillance standards including effective

outbreak responses have been evaluated by the SEA

Measles Regional Verification Committee (RVC).

Country experts in the National Measles Verification

Committee together with the National Centre for

Measles Elimination, Epidemiology Unit of the Ministry

of Health are responsible for advising, monitoring and

reporting the measles elimination situation to RVC

annually. The RVC is an independent expert committee

which had certified Sri Lanka as successfully elimi-

nated endogenous measles transmission in July 2019.

However, challenges are ahead for the country in

maintaining the measles elimination status. The early

reporting of all possible cases conforming to the case

definition is essential with laboratory confirmation.

Continuation of the 2-doses of MMR vaccination in

the National Immunization Schedule (4) with created

high demand to maintain high coverage at all levels

would successfully maintain measles immunity in the

population. Capacity of the public health care staff for

effectively responding to highly contagious measles

cases has to be a priority in curtailing outbreaks.

Adhering successfully to all these would help Sri Lanka

to sustain the achieved measles elimination status during

the currently existing global outbreak scenario.

References

1. Weekly Epidemiological Record. Measles Vaccine:WHO Position Paper. April 2017, No.17; 92: 205-228.

2. Ministry of Health. Measles, Rubella, CRSElimination Initiative – Sri Lanka. Circular 01-35/2017(05/06/2017). Available from: www.epid.gov.lk

3. Puvimanasinghe JP, Arambepola C, Abeysinghe NMR,Rajapaksa LC, Kulatilaka TA. Measles outbreak in SriLanka 1999-2000. Journal of Infectious Diseases 2003:187(Suppl 1): S241-S245.

4. Epidemiology Unit. Immunization Handbook.National Expanded Programme on Immunization.Colombo: Ministry of Health, 2012.



Regional Office for South-East Asia


Jayatilleke K. JCCPSL 2019, 25 (4) Open Access

Editorial

Kushlani Jayatilleke

Sri Jayewardenepura General Hospital, Nugegoda, Sri Lanka



Antimicrobial resistance: a growing problem

Antimicrobials are a group of compounds whenadministered orally, parenterally (intravenous orintramuscular) or locally, will kill or inhibit the growthof microorganisms, such as bacteria, viruses and fungi.Antibiotics are a group of medicines which will kill orinhibit the growth of bacteria. Antibiotics are useful intreating and preventing bacterial infections whichotherwise can lead to high mortality and morbidity.Transplant surgery, prosthetic joint implant surgeryand many other surgeries as well as chemotherapyand other complex procedures in medicine will not bepossible without effective antimicrobials.

Organism resistant to an antibiotic is one that isnot inhibited or killed by an antibacterial agent atconcentrations of the drug achievable in the body afternormal dosage. Bacteria can develop antibiotic resis-tance by developing several mechanisms. Producingan enzyme which can destroy the antibiotics such asExtended Spectrum Beta Lactamase (ESBL) enzymeswhich can destroy cephalosporins including 3rd gene-ration cephalosporins; changing the drug targetmolecule so that the antibiotics will not be able to bindto the organism; modifying the cell wall proteins sothat it will prevent antibiotic entry into the organism;and activation of efflux pumps to pump the antibioticout of the cell are some of these mechanisms.

Since the invention of penicillin in the 4th decadeof the 20th century, many classes of antibiotics wereinvented for about three decades. As soon as theseantibiotics were introduced for treatment, theresistance to these antibiotics started developing. Today,we see bacteria which are resistant to all availableantibiotics causing infections. Due to many reasons,

0000-0002-3931-6630

Received on:1 Nov 2019

Accepted on:16 Nov 2019

development of new antibiotics slowed down after1960s. It is predicted that more than 10 million deathsin 2050 will be due to antibiotic resistance globally,overtaking the number of deaths due to cancer. Mostof these deaths are predicted to occur in Asia.

Bacteria are part of the normal flora of humans aswell as other animals, and they are also found in theenvironment. They grow and divide by binary fissionand while doing so, they have a high tendency to havemutations in their genetic material. Such mutationsmay code for any of the mechanisms for antibioticresistance. Therefore, in a population of bacteria, therewould always be a few bacteria developing antibioticresistance due to mutation. If this population is leftwithout any intervention, the majority bacteria whodo not have mechanisms for antibiotic resistance willbe able to replace the antibiotic resistant bacteria withtime. If this population is exposed to the antibiotic towhich these bacteria became resistant to, then thebacteria that are sensitive to that antibiotic will die andthe resistant mutant will be selected and now withoutany competition, this will multiply leading to a populationof antibiotic resistant bacteria. This is how the use ofantibiotics lead to development of antibiotic resistantbacterial populations. Therefore, if we reduce the useof antibiotics, we can reduce the antibiotic resistancein the bacteria. This is apparent when we compare theuse of antibiotics and the rates of antibiotic resistancein different countries. Thus, the countries which havevery restrictive policies on antibiotic prescription suchas the United Kingdom has low levels of antibioticconsumption and low rates of antibiotic resistancecompared to Sri Lanka. Performing the appropriateinvestigations on time to diagnose bacterial infections,


Jayatilleke K. JCCPSL 2019, 25 (4) Open Access

and thus avoid use of antibiotics for treating viralinfections can help to reduce the misuse of antibiotics.

Another important factor about development ofantibiotic resistance is that as the mutants who havemechanisms of resistance may have higher minimuminhibitory concentrations, it is important to achieve highconcentrations of antibiotics to eliminate them. Use oflow doses of antibiotics can select out resistant bacteriaand lead to infections with antibiotic resistant bacteria.Therefore, using appropriate doses is extremely impor-tant to prevent the development of antibiotic resistance.The National Guidelines on Empirical and ProphylacticUse of Antimicrobials developed by the Sri LankaCollege of Microbiologists along with other clinicalcolleges was published by the Ministry of Health in2016, to guide rational use of antimicrobials.

Another important factor to consider is thatantibiotic resistant bacteria and their genetic materialcan spread from one person to another directly orthrough other animals and the environment. Since mostof the antibiotic resistant bacteria are prevalent inhospital environment, and healthcare associatedinfections are mostly caused by antibiotic resistantbacteria, infection prevention and control practices arehighly recommended to control the problem of antibioticresistance. Also, by preventing infections in the com-munity by infection control measures such as handhygiene and vaccination, we can reduce the need forantibiotics thus reducing antibiotic resistance.

World Health Organization has published a ‘GlobalAction Plan on Antimicrobial Resistance’. This hasrecommended five objectives as follows:

1. Improve awareness and understanding of anti-microbial resistance through effective communi-cation, education and training

2. Strengthen the knowledge and evidence-basethrough surveillance and research

3. Reduce the incidence of infection through effec-tive sanitation, hygiene and infection preventionmeasures

4. Optimize the use of antimicrobial medicines inhuman and animal health

5. Develop the economic case for sustainableinvestment that takes account of the needs ofall countries, and increase investment in newmedicines, diagnostic tools, vaccines and otherinterventions

Based on the Global Action plan, the ‘National

Strategic Plan for Combating Antimicrobial Resistancein Sri Lanka 2017-2022’ was published by the Ministryof Health with multi-sectoral involvement. Currently,awareness programmes are conducted all over thecountry to different categories including the generalpublic. World Antibiotic Awareness Week falls this yearfrom 18 - 24 November. Many activities are conductedin Sri Lanka to mark this week. Surveillance ofantibiotic resistance and utilization is commenced, andthe national antibiotic resistance data of 2018 havebeen submitted to Global Antimicrobial ResistanceSurveillance System (GLASS) by the focal point forcombating antimicrobial resistance (Deputy DirectorGeneral of Laboratory Services, Ministry of Health).Development of National Guidelines on InfectionPrevention and Control is under way while the InfectionControl Manual published by the Sri Lanka College ofMicrobiologists is being updated. ‘Red light anti-microbials’ which are the antimicrobials which canonly be prescribed with approval of a consultant clinicalmicrobiologist, were identified and published as acircular by the Director General of Health Services in2016. Activities are also ongoing in other sectors asone-health concept is very important to combat anti-microbial resistance.

Rational use of antimicrobials and the preventionand control of infections are the cornerstones of theprogramme for combating antimicrobial resistance. Byimplementing the National Strategic Plan and bycontinuing the efforts to implement all componentsrecommended in the Global Action Plan on Antimicro-bial Resistance, we should be able to control thisproblem.

References

1. WHO Newsroom. New report calls for urgent actionto avert antimicrobial resistance crisis.Available from: https://www.who.int/news-room/detail/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis.

2. WHO. Global Action Plan on Antimicrobial Resistance.Geneva: World Health Organization, 2015.Available from: https://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf?sequence=1

3. Ministry of Health. Empirical and prophylactic use ofantimicrobials. National Guidelines 2016. The Sri LankaCollege of Microbiologists in collaboration with otherprofessional colleges in healthcare and the Ministryof Health, Nutrition and Indigenous Medicine.Available from: http://slmicrobiology.lk/download/National-Antibiotic-Guidelines-2016-Web.pdf


Rowel DS. JCCPSL 2019, 25 (4) Open Access

Dr FA Wickramasinghe Oration - 2018/19The College of Community Physicians of Sri Lanka

Dhammica S Rowel

United Nations Children’s Fund (UNICEF), Sri Lanka Country Office, Sri Lanka



Received on:6 Dec 2019

Accepted on:9 Dec 2019

Twenty-five years of Baby Friendly Hospital Initiative in Sri Lanka:1992-2017

Past achievements, present challenges and the way forward

The concept of Baby Friendly HospitalInitiative

From the beginning of 20th century, food industrieswere marketing suitable substitutes for breastmilk.Maternity care was becoming an event supervised bymedical professionals, and as they were seeking‘scientific options’ for their clientele, harmful practicesrelated to breast milk substitutes spread rapidly acrossthe globe (1). Requirement for breastmilk substitutesgrew faster with the industrial revolution of 1930-40s,as more women entered the workforce. Medicalizationof birth formed obstacles to initiate and establishbreastfeeding. The community soon lost memories andskills to support breastfeeding, and the social modelof artificial feeding was established as the norm, inmany industrialized countries (2). These practices inturn spread across the globe into less developedcountries.

In 1939, the renowned Paediatrician and Epi-demiologist Dr Cicely Williams made a speech to theSingapore Rotary Club titled ‘Milk and Murder’. Sheprofessed that “Misguided propaganda on infant feedingshould be punished as the most criminal form ofsedition, and infant deaths resulting should be regardedas murder”. (3). After fourty years in 1979, a jointmeeting hosted by the WHO and UNICEF on infant

0000-0002-7903-7230

and young child feeding called for the development of‘International Code for Marketing of BreastmilkSubstitutes’, signifying the turning point in unethicalmilk formula advertising and marketing.

The International Code of Marketing of BreastMilk Substitutes alone was not successful in retrievingthe breastfeeding culture in the world, and therefore aglobal action plan was prepared in 1990 to address thedeclining rates of breastfeeding. This meeting pavedway to adopt the Innocenti Declaration on Protection,Promotion and Support of Breastfeeding, later endorsedby the 45th World Health Assembly (WHA) and theExecutive Board of UNICEF (4). The Innocenti Decla-ration established four operational targets, of whichthe second was to ensure that every facility providingmaternity services fully practises ‘Ten Steps to Suc-cessful Breastfeeding’. This inspired the establishmentof Baby Friendly Hospital Initiative (BFHI) and madeway to put into effect the WHO/UNICEF documenton ‘Protecting, Promoting and Supporting Breast-feeding: the Special Role of Maternity Services’ (5).

Inaugurated by the WHO and UNICEF in 1991,the BFHI forms the foundation to incentivize maternityfacilities to adopt the Ten Steps to Successful Breast-feeding and recognize those that do so by introducinga BFHI (Box 1) designation methodology.



Subsequently, many high-level policy documentshave reiterated the importance of implementing theTen Steps of BFHI. In 1992, the WHA called upon itsmember states to encourage and support all public andprivate health facilities providing maternity services tobecome ‘baby-friendly’. The Global Strategy on Infantand Young Child Feeding (6) reiterated this statement.Also, the 2nd International Conference on Nutrition in2014 recommended that countries implement policies,programmes and actions to ensure that health servicespromote, protect and support breastfeeding, includingthe BFHI.

Implementation of BFHI in Sri Lanka

Sri Lanka always had high ever-breastfeeding rates(98% in the Demographic and Health Survey (DHS)1993 and 2000; 99% in DHS 2006 and 2016) (7-10),which confirms the strong breastfeeding culture in thecountry. According to DHS data, early initiation ofbreastfeeding within one hour was 85.2% in 2006 and90% in 2016. Exclusive breastfeeding for completefour months, which was the national policy up to 2006was 19%, 52% and 83%, respectively in 1993, 2000and 2006. Since 2007, the national policy was exclusivebreastfeeding up to 6 months of age, and the DHS2016 showed that exclusive breastfeeding at 6 monthswas 82% with a median duration of 5.2 months. Theseimpressive breastfeeding indicators enabled Sri Lankato be number one in two successive World Breast

Ten Steps to Successful Breastfeeding1. Have a written breastfeeding policy that is routinely communicated to all health-care staff

2. Train all health-care staff in skills necessary to implement this policy

3. Inform all pregnant women about the benefits and management of breastfeeding

4. Help mothers initiate breastfeeding within one half-hour of birth

5. Show mothers how to breastfeed and maintain lactation, even if they should be separatedfrom their infants

6. Give new-born infants no food or drinks other than breast milk, unless medically indicated

7. Practice rooming-in that is allow mothers and infants to remain together 24 hours a day

8. Encourage breastfeeding on demand

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants

10. Foster the establishment of breastfeeding support groups and refer mothers to them on dischargefrom the hospital or clinic

Feeding Trends Initiative (WBTi) Assessments (11-12) conducted once in four years.

The BFHI was introduced to Sri Lanka in June1992 (13) to incentivize hospitals with maternityfacilities throughout the country to adhere to the TenSteps to Successful Breastfeeding and comply withthe International Code of Marketing of Breast-milkSubstitutes. De Soysa Hospital for Women was thefirst hospital to be declared a BFH in Sri Lanka (14),followed by 84 other specialist hospitals (base hospitaland above) in the country (13). The strong politicalcommitment reinforced successful implementation andscaling up of BFHI in Sri Lanka. Twenty-five yearssince its introduction and given the achievements ofthe breastfeeding programme, it is useful to reviewthe coverage and implementation of the BFHI in SriLanka.

• Coverage of BFHI

The over-arching goal of BFHI is to ensure thatall babies born in hospital and their mothers are fullysupported to initiate and establish breastfeeding, so thatthey exclusively breastfeed in the first six months andcontinue to breastfeed with adequate complementaryfeeding up to two years or beyond.

In Sri Lanka, 99.9% of deliveries occur in a healthfacility, out of which about 95% occur in government

Box 1



hospitals (15). The Annual Health Bulletin 2003 (16)notes that only 18% of births in government hospitalsoccurred in institutions below base hospital level (i.e.non-specialist hospitals), with further declines to 16%in 2005, 12% in 2007, 5.4% in 2011 and 3.6% in 2015(17-20), implying that 95% of the births in Sri Lankaoccur in specialist hospitals where Ten Steps of BFHIare likely to be closely followed. In comparison, globalestimates show that the overall coverage of births infacilities with BFHI is around 10%, with a highercoverage of 36% in the European Region, but lessthan 5% in Africa and Southeast Asia (21).

• Assessment and designation process of BFHI

The BFHI focuses on designation of facilities thatadhere to the Ten Steps through an assessment and adesignation process. Clear guidance on the assessmentprocess and tools required were provided in WHO/UNICEF Guidelines of 1989. Over the years, thecountries that opted BFHI designation have usedWHO/UNICEF Global BFHI Criteria for assessment(21), which recommends re-assessments every 3-5years, where the facility needs to demonstrate con-tinued adherence to Ten Steps of BFHI and theBreastfeeding Code (5).

In Sri Lanka, according to the National Surveyon Breastfeeding Situation (13), 84 hospitals com-prising teaching hospitals, provincial general hospitals,district general hospitals and base hospitals are ‘babyfriendly’ hospitals, however information from keyinformants reveal that formal BFHI assessment anddeclaration as per guidelines had never been conductedin Sri Lanka. In comparison, the Global Survey onImplementation of BFHI (21) revealed that 110 out of155 countries (71%) had an operational BFHI pro-gramme as of 2016-2017, however most of them hadnever gone through the designation process. Therewere only 22 countries who had designated themajority of hospitals as BFHs and another 21countrieswho had designated less than 20% of the hospitals.

Though not adopting the standard BFHI assess-ment and designation process, the practice of Ten Stepsof BFHI has been assessed in Sri Lanka at differentinstances. Some of the steps are assessed in routinehospital supervisions of the maternal and neonatal unitsusing standard tools (22). Adherence to the Sri LankaCode for Promotion, Protection and Support ofBreastfeeding and Marketing of Designated Products

(14) and the relevant circulars of the Ministry of Healthis monitored by the routine health system monitoringmechanisms. Lately, assessment of all the ten steps ofBFHI, mother baby friendly practices and baby friendlyneonatal care unit practices were included in theNational Quality Assurance Standards for antenatalunits, labour rooms, postnatal units and neonatal units(23-26), and are expected to be monitored with qualityassessment.

• BFHI programme integration

In the process of making Ten Steps of BFHI thestandard practice in all maternity units of health facilitiesin Sri Lanka, it was well-integrated into national policies,standards and guidelines for maternal and new-borncare. The National Nutrition Policy (27) states that allinfants should be exclusively breastfed up to completesix months and breastfeeding should be continued withadequate complementary feeding up to two years orbeyond. The breastfeeding policy as addressed in theMaternal and Child Health (MCH) Policy of 2012 is toprotect, promote and support breastfeeding practiceswith special emphasis in delivery settings (28).

The BFHI Guidelines (5) recommend that eachhospital with a maternity facility has a breastfeedingpolicy that is informed to all healthcare staff anddisplayed in the most common language used in thearea. In Sri Lanka, this is not practised strictly as perthe guideline, however the indicators such as earlyinitiation of breastfeeding within one hour reaching 90%and exclusive breastfeeding at 6 months reaching 82%(10) show that hospitals are conforming to the NationalPolicy on Breastfeeding. The practice of policy iswarranted by the standards set for breastfeeding inthe Standards for New-born Care; for Quality Improve-ment of New-born Health Services in Sri Lanka (29),for example, all mothers should receive skilled practicalhelp with early and exclusive breastfeeding, and fullinformation on the benefits of breastfeeding should bemade available to mothers and family. Guidelines toensure the implementation of these standards areexplicitly given in the National Guidelines for New-born Care (30).

With regards to capacity building of health staff,a training package, ‘18-hour Course’ was introducedin 1993 following the launch of BFHI. This was revisedin 2009 as the ‘20-hour BFHI Package’ and includesguidance from the Global Strategy on Infant and Young



Child Feeding (6) and a module on ‘mother-friendlycare’ (31). It has five sections:

Section 1 – Background and implementation

Section 2 – A short course for hospital directors

Section 3 – A 20-hour course for maternity staff

Section 4 – Provides tools that can be used bymanagers and staff for internalassessment

Section 5 – Provides guidelines and tools forexternal assessors for assessmentand reassessment on a regular basis

Furthermore, the first in-service training pro-gramme on breastfeeding, the WHO/UNICEF 40-hourBreastfeeding Counselling Course was introduced tothe country in 1995. Since then, training has beenconducted in hospitals by the Family Health Bureau incollaboration with the regional directors of healthservices, to train the staff in hospital maternal andneonatal units and in field. Such capacity building inbreastfeeding gives skills and competencies to the healthstaff to carry out Steps 2-9 of the BFHI. In 2006,another in-service training programme, the WHOEssential New-born Care Course (ENCC) which hasa comprehensive module on breastfeeding wasnationally introduced to train staff in the hospitals(Personal communication with key informants, 2018).

Despite the 40-hour Breastfeeding CounsellingCourse over 20 years, training profile of the doctorsand nurses in maternal and neonatal units does notappear to be satisfactory. More than 50% (53.8% ofdoctors and 63% of nurses) were trained only in UvaProvince. More than 50% of the midwives in maternalunits were trained except in Central, Eastern, NorthCentral and Sabaragamuwa Provinces (32).

With regards to integration at field level, thoughBFHI is an institution-based concept, two of the steps(Steps 3 and 10) have been addressed at the communitylevel in Sri Lanka. Step 3 (informing all pregnantwomen about the benefits and management ofbreastfeeding) takes place at designated breastfeedingsessions in the field MCH clinics (33) and Step 10(establishing breastfeeding support groups andreferring mothers to them on discharge from thehospital or clinic) in a modified manner to the areapublic health midwife.

Implementation of the International Codeon Marketing of Breast Milk Substitutes

In 1981 at the 34th WHA, the International Codeof Marketing of Breast Milk Substitutes was adopted.This received the attention of many governments toaddress the urgent need to promote breastfeeding. InSri Lanka, even prior to the WHO/UNICEF jointmeeting, action to promote breastfeeding by publishingdirections under Consumer Protection Act No 01 of1979 was initiated. In the Gazette Extraordinary No24, visual advertisements of infant milk foods in anymanner whatsoever or advertisements in radio werebanned. In September 1981, the Sri Lanka Code forPromotion of Breastfeeding and Marketing of BreastMilk Substitutes and Related Products was submittedto the Cabinet. The relevant provisions to marketingand advertising of infant foods was gazetted underConsumer Protection Act in 1983. This code wasrevised and updated in 2002 to overcome continuedviolations. Currently, the code is undergoing anotherrevision to address present challenges.

Challenges for BFHI implementation inSri Lanka

• Challenges in BFHI designation

About 50% of the countries included in the WHO2017 Survey indicated significant problems with theprocess of assessing and designating facilities as babyfriendly. There were concerns regarding the criteriaused for designation, bureaucracy associated withobtaining BFHI status, length of the BFHI question-naire, dedicated persons to conduct the assessment,cost and capacity building of the assessors.

The stipulated designation process in the guidancerequires services of assessors over a period of approxi-mately two weeks. Except in the Americas and Europe,in other areas such as in Africa, Eastern Mediterranean,Southeast Asia and Western Pacific Regions, they haveused government or UN funding to conduct BFHIassessments (21). Funding for national assessors andproviding facilities for assessment are considered majorhindrances for BFHI accreditation.

• Challenges in programme integration

Sri Lanka has been quite successful in its attemptsin integrating the concepts addressed in Ten Steps of



BFHI into the routine MCH Programme. Furtherimprovement is possible when breastfeeding data areanalysed in detail. The name BFHI has been forgottenby many and limited to a plaque in most of thehospitals. It was evident that in institutions where BFHITen Steps are practised, it was driven mainly bypersonal interest of an administrator or consultant (34).

Effective coverage of an evidence-based inter-vention requires achieving high coverage and standardquality. DHS 2016 shows that the percentage ofchildren breastfed within one hour has increased from80% to 90% during 2006-16 period (10). Thepercentage of children breastfed within one day hasremained stable at 98% compared to 97% in 2006-07period.

Early initiation of breastfeeding is a topic addressedin the WHO ENCC that has a module dedicated for‘Care around the time of birth’. In an evaluation of thequality of early initiation of breastfeeding in twoteaching hospitals in Colombo District, it was foundthat 100% of the new-borns were dried and wrappedsoon after birth but only 1.8% were put betweenmother’s breast soon afterwards (35). In a more recentfield-based study in Kandy District, the majority ofbabies (94.6%, n=335) were initiated on breastfeedingwithin one hour of birth while most of the babies(77.7%; n=275) were taken away from the motherbefore completion of the first feed (36). This impliesthat though early initiation of breastfeeding rate is high,its quality needs improvement.

According to DHS 2016 (10), the prevalence ofexclusive breastfeeding in infants aged 0-6 months was82%. Further analysis indicates that rates of exclusivebreastfeeding decline with increasing age (93.4% in0-1 months; 87.4% in 2-3 months; and 63.8% in 4-5months). All these rates have improved compared toDHS 2006 rates (9) but can be further improved if theunderlying concerns are addressed. In the studyconducted in Kandy District (36), early discontinuationof exclusive breastfeeding was significantly associatedwith mother being occupied in government or privatesector (p<0.001) and with first-born baby (p=0.007).Also, the prevalence of exclusive breastfeeding (EBF)up to 6 months was 50.8% (n=180). However, EBFup to 5 months or more was 81.3%, implying that themajority who failed in EBF up to 6 months had at leastcontinued up to 5 months. Main reason for early

cessation was ‘breast milk not being enough for baby’(52.9%; n=92). About 25% of them were influencedby a healthcare worker to start feeds other thanbreastmilk during the first six months (36).

Another noteworthy finding was that more than90% of the healthcare workers in Colombo SouthTeaching Hospital had correct knowledge on breast-feeding policy, educating mothers on hunger cues andon-demand feeding, and allowing mother and babytogether after delivery (37). Nearly 90% of them werealso confident in demonstrating positioning andattachment. However, more than 50% consideredexclusive breastfeeding as a very difficult task.

Training of healthcare workers in 40-hours breastfeeding counselling and 20-hours of BFHI is knownto be associated with provision of better breastfeedingsupport. However, the proportion of healthcareworkers who had received such training was not satis-factory. According to the Emergency Obstetric andNew-born Care Survey (32), only 38% of the medicalofficers, 30% of nursing officers and 26% of midwiveshad been trained in breastfeeding counselling. Senarathet al. (2007) showed that in-service training as anintervention is effective for changing practices (38).Immediate skin to skin contact was 37.5% (pre-intervention) and 83.3% (post-intervention) whilemother and baby kept together in labour room was25% (pre-intervention) and 91.7% (post-intervention).

Bottle necks to ensure quality and coverage of in-service training in Sri Lanka include the absence of adatabase on in-service training at institutional anddistrict levels, absence of a regular training scheduleat district level, lack of training faculty, a designatedperson to coordinate training in district and hospital,and lack of dedicated financial allocation for continuedin-service training (34).

Way forward

There is substantial evidence to show that intro-duction of BFHI has contributed to improvements inbreastfeeding. The WHO and UNICEF conducted are-evaluation of the BFHI programme, during whichcase studies, key informant interviews (21) andliterature review were conducted to understand thestatus and impact of BFHI. The WHO convened aguideline development group to revise the WHO



Guideline on Protecting, Promoting and SupportingBreastfeeding in facilities providing maternity and new-born services. The updated BFHI Guidance is the firstrevision of the Ten Steps since 1989 (39). In the newguideline, the ten steps are sub-divided into twosections;

• Institutional procedures necessary to ensure thatcare is delivered consistently and ethically(critical management procedures)

• Standards for individual care of mothers andinfants (key clinical practices)

Full application of the International Code ofMarketing of Breast-milk Substitutes and relevant WHAResolutions as well as the on-going internal monitoringof adherence to the clinical practices have beenincorporated into Step 1.

As already practised in Sri Lanka, the revisedguidance recommends integration of BFHI more intothe healthcare system. For full implementation of theinterventions and to ensure sustainability, continuumof breastfeeding interventions across lifecycle andhealth systems is essential. These interventions needto be delivered in the MCH Package.

It is noteworthy that most of the recommendationsin new BFHI Guidance (39) are already implementedin Sri Lanka. It therefore becomes a matter of stren-gthening the existing practices and introducing newones where relevant.

• Integrating BFHI across the life cycle andhealth system

Integrating BFHI and MCH/FP services meansoffering a broad set of services during the sameappointment at the same service delivery site. In SriLanka, breastfeeding is already incorporated intorelevant points in the lifecycle; antenatal education inthe clinic setting and at domiciliary visit; at the healthfacility from birth until discharge from postnatal wardor neonatal unit; at postnatal domiciliary visits,postnatal clinic visits, visits to child welfare clinicsand clinic visits for family planning.

• Capacity building for BFHI

Breastfeeding training should be integrated intoall MCH/FP trainings either pre-service or in-service

to achieve high coverage in capacity building. It isrecommended to have designated cadre for coordina-ting in-service training, setup an identified trainingFaculty, institute regular skills drills to ensure skillsretained at an optimum and compulsory refreshertraining and re-certification. Annual training calendarand a system of rewarding need to be incorporated toall categories of staff (34).

• BFHI in the institutional qualityimprovement process

Implementation of Section 2 of the new BFHIGuidance (key clinical practices) require integrationwith other initiatives for health care improvement, healthsystems strengthening and quality assurance. In orderto ensure the standard of ‘every woman and new-bornreceives evidence based routine care and managementof complications during labour, childbirth and earlypostnatal period’ quality improvement methodologiessuch as WHO/UNICEF point of care quality improve-ment methodologies should be utilized.

• BFHI in routine monitoring and evaluation

BFHI should be incorporated into the existingmonitoring and evaluation mechanism, such as routinesupervision and monitoring of the hospitals and fieldsetting. In Sri Lanka, this is already incorporated.Another opportunity is to discuss issues related to BFHIat the perinatal mortality review meetings. BFHI shouldalso be made an essential component of the qualityassessment and quality assurance programmes.

In Sri Lanka, there is a well-organized field MCHreview conducted quarterly at regional level andannually at the national level. Breastfeeding indicatorsin the field are reviewed at the field review meetings.Similar review process including BFHI indicators, isappropriate for the hospital setting. Regular monitoringand evaluation in the health system ensure sustainabilityand improvement of the quality of indicators.

• Fulfilling BFHI as per 2018 BFHIGuidelines

Countries are called upon to fulfil nine key res-ponsibilities through a national BFHI programme,including establishing or strengthening a nationalcoordination body, integrating the ten steps into nationalpolicies and standards, ensuring the capacity or all



health-care professionals, using external assessmentto regularly evaluate adherence to the ten steps,incentivizing change, providing necessary technicalassistance, monitoring implementation, continuouslycommunicating and advocating, and identifying andallocating sufficient resources. Also, country needs toaddress breastfeeding promotion, protection andsupport in communities, workplaces as well asadequate maternity protection and code legislation.

References

1. Palmer G. The politics of breastfeeding. London:Pandora Press, 1993.

2. Van Esterik P. Beyond the breast-bottle controversy.New Brunswick: Rutgers University Press, 1989.

3. Chetley A. The baby killer scandal. London: War onWant, 1979.

4. WHO & UNICEF. Innocenti Declaration on theProtection, Promotion and Support of Breastfeeding.Adopted at the WHO/UNICEF Policymakers' Meeting,Florence, Italy, 1990.

5. Rieger-Schemel L. Protecting, promoting andsupporting breastfeeding: the special role of maternityservices. Journal of Human Lactation 1989; 5(4):186-187.

6. WHO & UNICEF. Global Strategy on Infant and YoungChild Feeding. Geneva: World Health Organization,2003.

7. DCS & MOH. Sri Lanka Demographic Health Survey1993. Colombo: Department of Census & Statisticsand Ministry of Health, 1993.




11. Breastfeeding Promotion Network of India/International Baby Food Association Network (BPNI/IBFAN)-Asia. Are our babies falling through thegaps? Delhi: World Breastfeeding Trends initiative(WBTi), 2012.Available from: https://bpni.org/report/51-country-report.pdf.

12. International Baby Food Association Network(IBFAN)-Asia. Sri Lanka Assessment Report – The

state of Infant and Young Child Feeding (IYCF). Delhi:World Breastfeeding Trends Initiative (WBTi), 2016.Available from: http://worldbreastfeedingtrends.org/wbti-top-5-nations/.

13. Family Health Bureau. Breastfeeding: situation in SriLanka. Colombo: Ministry of Health, 2003.

14. Nutrition Coordination Division. Sri Lanka Code forPromotion, Protection and Support of Breastfeedingand Marketing of Designated Products (AmendedCode - 2002). Colombo: Ministry of Health, 2004.

15. Family Health Bureau. Annual Report on Family Health.Colombo: Ministry of Health, 2016.

16. Medical Statistics Unit. Sri Lanka Annual HealthBulletin. Colombo: Ministry of Health, 2013.




20. Medical Statistical Unit. Sri Lanka Annual HealthBulletin. Colombo: Ministry of Health, 2015.

21. WHO. National implementation of the baby-friendly hospital initiative. Geneva: World HealthOrganization, 2017.

22. Family Health Bureau. Labour Room ManagementGuidelines. Colombo: Ministry of Health, 2006.

23. Family Health Bureau. National Quality AssuranceStandard: Antenatal Units. Colombo: Ministry ofHealth, 2017.

24. Family Health Bureau. National Quality AssuranceStandards: Labour Rooms. Colombo: Ministry ofHealth, 2017.

25. Family Health Bureau. National Quality AssuranceStandards: Postnatal Units. Colombo: Ministry ofHealth, 2017.

26. Family Health Bureau. National Quality AssuranceStandards: Neonatal Units. Colombo: Ministry ofHealth, 2017.

27. Ministry of Health. National Nutrition Policy of SriLanka. Colombo: Ministry of Health, 2010.

28. Ministry of Health. Maternal and Child Health Policy.Colombo: Ministry of Health, 2012.

29. Family Health Bureau. Standards for New-born Care;For Quality Improvement of Newborn Health Servicesin Sri Lanka. Colombo: Ministry of Health, 2012.



30. Ministry of Health. National Guidelines for NewbornCare. Colombo: Ministry of Health, 2014.

31. WHO. Baby-Friendly Hospital Initiative; revised,updated and expanded for integrated care. Geneva:World Health Organization, 2009.

32. Family Health Bureau. National Emergency Obstetricand Neonatal Care Needs Assessment; CountryReport. Colombo: Ministry of Health, 2014.

33. Family Health Bureau. Maternal Care Package: aguide to field healthcare workers. Colombo: Ministryof Health, 2014.

34. Family Health Bureau. Newborn care in Sri Lanka: abottle neck analysis. Colombo: Ministry of Health,2015.

35. Abeysekera I. Practice of essential newborn care intwo teaching hospitals in Colombo District. MScDissertation (Community Medicine). Colombo: PostGraduate Institute of Medicine, 2010

36. Ratnayake HE & Rowel D. Prevalence of exclusive

breastfeeding and barriers for its continuation up tosix months in Kandy District, Sri Lanka. International

Journal of Breastfeeding 2018; 13: 36.

37. Maddumahewa V. Knowledge, attitudes, practice andthe factors associated with mother baby friendly

initiative among healthcare workers and postpartum

mothers at Colombo South Teaching Hospital. MScDissertation (Community Medicine). Colombo:Postgraduate Institute of Medicine, 2017.

38. Senerath U, Fernando DN, Rodrigo I. Effect of trainingfor care providers on practice of Essential NewbornCare in Hospitals in Sri Lanka. Journal of Obstetric,

Gynecologic and Neonatal Nursing 2007; 36(6):531-541.

39. UNICEF/WHO. Implementation Guidance:

Protecting, Promoting and Supporting Breastfeeding

in Facilities Providing Maternity and NewbornServices – the revised Baby-friendly Hospital

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Chandrathilaka KRM et al. JCCPSL 2019, 25 (4) Open Access

Original Research

KRM Chandrathilaka1*, Dulani Samaranayake2, Kantha Nirmali Lankatilake2, Rohini de AlwisSeneviratne3, Anuruddha Kumara Karunarathna4

1Department of Allied Health Sciences, Faculty of Medicine, University of Colombo, Sri Lanka; 2Departmentof Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka; 3Faculty of Medicine,General Sir John Kotelawala Defence University, Sri Lanka; 4Faculty of Agriculture, University of Peradeniya,Sri Lanka

*Correspondence: [email protected]


A qualitative study on barriers for the use of respiratory protectivedevices among rice mill workers in Ampara District, Sri Lanka

Abstract

Introduction: Rice milling often carried out in the informal work sector generates paddy dust which is a hazard tothe respiratory health of mill workers. Sri Lankan rice mill workers have shown reluctance in using respiratory

protective apparatus during rice milling.

Objectives: To describe the barriers for the use of respiratory protective devices during rice milling

Methods: A qualitative study was conducted in the divisions of Ampara and Uhana in Ampara District in Sri Lanka

during February 2016. Twenty-two in-depth interviews were conducted among rice mill workers, health professionals

and government officers related to rice milling industry. Data were analysed using content analysis method.

Results: The rice mill workers’ non-use of respiratory protective methods was mainly due to their negligence in

personal respiratory health care and lack of support from the employer, health care institutes and other relatedinstitutes. Low level of comprehension of workers and less manpower in health care and other institutions were

other contributing factors.

Conclusions: Low priority given for respiratory health care by the workers, poor work environment and less

support from the mill owner and relevant government authorities have resulted in non-use of respiratory protective

devices among rice mill workers. Improving unhealthy work behaviour such as non-use of respiratory protectivedevices of the informal work sector is recommended using industry-based health education programs.

Key words: informal workers, occupational health and safety, respiratory health, rice milling, work behaviour

Received on 26 February 2019

Accepted on 29 July 2019

0000-0001-9349-1491



Introduction

Rice milling, which converts paddy grain toconsumable rice is a dusty process (1) subjecting theworkers to various respiratory health problems due toexposure to dust (2-3). Dust is a major occupationalrespiratory health hazard causing inflammatoryreactions in the respiratory tract (4).

According to World Health Organization (WHO),workers’ health can be affected by individual, enterpriseand social factors (5). Studies have also shown thatorganisational structure, work pattern and peer influ-ence directly affect the workers’ protective behavioursin the workplace. Perceived severity of diseases, abilityto pay for health facilities and ignorance on safe workprocedures by the employees, pressure from theemployer for higher work demands and unfriendlywork environment (6-9) were among the key findingswhich have affected protective health behaviours.

Results from our baseline study (unpublished)showed that the rice mill workers were not usingrespiratory protective methods during rice millingactivities. Thus, this study was aimed at describingthe barriers affecting the use of respiratory protectivedevices among rice mill workers.

Methods

A qualitative study was conducted in February2016 in Ampara and Uhana Divisional SecretariatDivisions of Ampara District, Sri Lanka.

In-depth interviews were used as the study instru-ment. A total of 22 interviews was conducted amongconveniently selected rice mill workers, grass root levelgovernment administrative officers (Grama Niladhari/GN) and public health staff including the medicalofficers of health (MOH) and public health inspectors(PHI), district factory inspecting engineer and anagricultural officer of Post-harvest Technology Institutein Ampara. A preliminary survey conducted prior tothis study revealed that most of the rice mill workerswere males, therefore the mill workers selected forthe study were males between the ages of 18-65 years.Having a minimum of three-year work duration wasan inclusion criterion in their selection as they neededto have sufficient exposure in the work setting to beable to describe their perceptions on the use of res-piratory protective devices. The maximum represen-tativeness of workers was ensured by purposivelyrecruiting only one worker from a rice mill, thus 12workers from 12 rice mills out of 153 mills located inthe study area.

Table 1. Summary of the in-depth interviews carried out with each occupational group

Rice mill workers 12

Grama Niladhari officers (village officers) 03

Public health inspectors of Ampara and 03Uhana MOH areas

Medical officers of health of Ampara and 02Uhana MOH areas

District factory inspecting engineer, Ampara 01

Agricultural officer of Post-Harvest 01Technology Institute, Ampara

Occupational group No. of interviews Focused areas of questions

• Knowledge on respiratory health problems dueto rice milling

• Reasons for less attention on protective methodsagainst possible respiratory health effects dueto rice milling

• Views on wearing protective garment/respiratoryprotective devices

• Regulations and monitoring by relevantinstitutions towards the health care of the millworkers

• Views on the non-use of respiratory protectivedevices among rice mill workers



Table 1 shows the number of in-depth interviewsconducted and the main themes focused upon for eachoccupational group. This number was deemedsufficient when additional interviews yielded little orno new information on the questions. Data werecollected by the principal investigator having undergonetraining in qualitative methods prior to data collection.The interviews were conducted in the local language,Sinhala, after obtaining informed written consent fromall the participants. The dialogues were audio recordedwith prior permission from the participants and con-stantly checked to ensure uninterrupted recording.Notes were taken on key points raised during theinterviews while keeping records on non-verbalcommunications, such as gestures, body movementsand modulation of voice. Data were reviewed aftereach interview to assess how the questions were beinganswered before the next interview. All the audiorecordings were transcribed, translated into Englishand back translated into Sinhala by a language expert.The translated documents were compared with theoriginal Sinhala recordings to ensure that the samemeaning has been retained. The data were analysedusing content analysis method and key points wereidentified and coded to identify the factors affectingthe studied behaviour among rice mill workers.

Results

The themes which were concluded as barriersfor the use of respiratory protective methods by therice mill workers are presented below.

Attitudes and practices of rice mill workerstowards their personal health

All the participants were aware that rice dustcauses respiratory health problems and thought it canbe easily managed. Wheezing was recognized as acommon health problem by most of the workers whilethree workers emphasized asthma as a commondisease. One 53-year-old worker stated:

‘The large amount of dust will be a problem to usand years of exposure to it may be harmful too.’

Further to their limited knowledge on healtheffects, most of the workers considered wheezing orcold as easily managed health conditions, whichproved that they had given less priority to theirrespiratory health problems. A 48-year-old worker said:

‘Often I get a watery discharge from my nosebut don’t go to the hospital because I manage iteasily by drinking ‘kasaya’ (local traditionalmedicine) available at any shop. If it gets worseonly, I go to a doctor.’

Reluctance and difficulty in attending health carefacilities by the workers were also noted. Major reasonswere fear of losing both the daily wage and the jobdue to being absent from work and irregular workpatterns. One worker aged 40 years said:

‘If we think about our health and take a rest, noone is there to think how my family is going toeat tomorrow.’

Another aged 46 years stated:

‘We can’ t think of getting medicine for ourdiseases. If we don’ t go to work for a few daysdue to some reason, we would be replaced byanother worker by the owner.’

A 45-year-old worker mentioned:

‘Visit to the government hospital cannot be doneregularly during our working time because we can’tadjust our working time due to irregular workingdays in the mill.’

A cloth covering the mouth and nose and dis-posable masks were among the protective methodsused against the dust by the workers. One 55-year-old worker mentioned:

‘Most of us rarely wear at least a piece of clothcovering the nose and mouth during our work toprevent the dust. Some people use disposablemasks which are available at low cost.’

However, they have rarely used those methodsdue to the difficulties such as feel of breathlessnessand development of sweat specially around mouth andnose. A 42-year-old worker said:

‘You can’t imagine how difficult it is to wear apiece of cloth covering your face and work insidethe mill… After five, ten minutes, I start to sweatunder the piece of cloth and feel tired.’

Interestingly, most of the workers expressed theirinterest in wearing respiratory protective devices whenthey were informed about those. However, two of themtermed it as a ‘foolish idea’. A 45 and 53-year-oldworkers respectively mentioned:



‘I have to see whether it fits me. I have no ideahow it would be’

‘It may be irritating but like to wear it and test it.’

Thus, the mill workers have given low priority totheir respiratory health problems due to economicaldisadvantages caused by being absent from work anddifficulties in finding a suitable time to attend healthcare facilities. However, their proposed intention to usestandard respiratory protective methods was positive.

Employer support

The mill owner has not considered the workers’health issues despite paying an insufficient healthallowance occasionally. Thus, the workers haverefrained from communicating their health problemsto the owner. A worker aged 39 years stated:

‘The owner of the rice mill where I work doesn’tcare about our health so that we rarely tell themabout our health problems. He is only concernedin counting the number of rice bags we produceat the end of the day. Sometimes he gives moneyfor medicine, however, this money is not enoughbecause we normally attend private clinics.’

Further, negligence of installing dust and heatcontrolling methods by the owner was also raised bythe workers. A 42-year-old worker said:

‘There is no way of getting the heat out from themill. There are pumps to send the husk and dustoutside, however, those can’t control all the dustaccumulating inside the mill. The mill ownerdoesn’t take these things seriously.’

Thus, lack of attention to health issues of millworkers and lack of improvements in milling environ-ment by the mill owners have compelled the workersto continue working in an unhealthy work environment.

Work environment

According to the workers, major reason for notadhering to respiratory protective methods during workwas the usual hot environment inside the mills. Aworker aged 56 years stated:

‘It is not that easy to wear even a sarong (a clothwrapped around the waist to cover the lower partof the body) inside a building under this hot sun…I

used a mask recently and was exhausted afterfew minutes with difficulty in breathing.’

Both the mill owners and the workers werereluctant in maintaining a clean environment inside themills, despite the advice given by the public health staff,which has made the workers to continue with theirunhealthy practices. One MOH said:

‘We tell the mill owners on what they should doto maintain cleanliness in formal and informalways. However, it seems that they don’t followour advice.’Another PHI mentioned:

‘Mill workers don’t care about our guidancealthough we advise them regarding maintainingcleanliness inside the mills and its importance onworkers’ health.’

In the absence of necessary work environmentalmodifications for dust and heat control, difficulty inusing respiratory protective methods under theprevailing hot climate was a major barrier forrespiratory protection of the workers.

Attitudes and practices of the governmentofficers towards rice mill workers

The workers’ low level of comprehension wasraised as the major reason for their non-adherence toadvice on healthy work practices by all the interviewedgovernment officers. One PHI mentioned:

‘They find it difficult to understand what we sayon their health because their level of education islow. Therefore, regular monitoring and remindersare essential to reinforce our educationalmessages.’

However, it was not clear whether the public healthstaff has addressed the rice mill workers’ issuesaccording to their level of understanding, as a 48-year-old worker said:

‘I know dust creates problems, but there isnobody to educate me on what happens when thedust is inhaled and what I should do to work longin my job.’

Institutional support

Lack of health educational programmesconducted by the public health staff has led the rice



mill workers to be unaware of health issues specificto them. The major reason raised by the staff wastheir busy schedule although occupational health andsafety is a major component of their duty. One MOHsaid:

‘It’ s in our duty list to conduct health education,however our work schedule is really heavy, andwe don’t have much staff to conduct themregularly.’

The workers received medical advice occasionallyon their work practices. One worker was told to avoiddust exposure during his work by the medical officeronly when he went for treatment for asthma, thereforeavailability of continuing guidance may force theworkers towards protective work behaviour.

The health issues of workers were reported tothe higher authorities by GN officers although theworkers’ behaviour was unchanged despite theirinterventions. One GN officer said:

‘We often tell about workers’ health and otherissues to the higher administrative staff, but theirsuggestions have not made any change in theworking pattern or in the milling environment. Thereason mostly is these suggestions are notpractical.’

The post-harvest technology officer suggestedthat the workers would have benefited if sufficientresources and staff were available.

‘I can really contribute to educating the workersand mill owners on their health issues becauseI’m much familiar with these conditions. However,there are only few of us to carry on our duties.’

Further, the district factory inspecting engineerhas not performed regular workplace monitoring inrecent times due to the mostly spoken reason being,lack of support staff.

‘I’ve not been to those mills recently and don’tknow the actual situation because no one is hereto assist me to monitor the rice mills.’

Thus, despite occasional guidance on healthprotection, the absence of occupational health careservices to address health problems specific to ricemill workers was highlighted.

Discussion

In the current study, we were able to describe thereasons which have discouraged the rice mill workersfrom practising respiratory protective devices (Box 1).Wheezing and asthma being the only known healtheffects of dust exposure according to the workers,these are assumed to be cured easily. This lack ofknowledge on other long-term health effects such asfibrotic lung diseases, chronic bronchitis and pneu-moconiosis (1-3) seemed to be a reason which hasprevented them from practising protective methods.Demographic characteristics such as age, income andeducational level have been reported as determinantsof preventive behaviours of workplace injuries andaccidents (10). These, as emphasized by the publicstaff in this study may also have affected the workersfor their low comprehension about risks of dustexposure.

The mean respiratory and total dust levels insidethe rice mills in this study area were higher than therespective threshold levels (11) as the mills were notregularly cleaned and they lacked dust extractionmethods. Thus, the workers may have got used tothis unsafe dusty work environment without followingprotective methods against dust exposure. Physicallycomfortable work environment (12), which has beenconsidered as a factor related to workers’ protectivebehaviour may have further enhanced the mill workers’behaviour even though they have experienced physicaldiscomforts such as breathing difficulties.

Research studies have shown that perceivedoccupational risk level, being affected by workingexperience (8) and participation in occupational safetyprograms (9, 13), has had a major impact on healthbehaviour. In the current study, workers had neverhad opportunities to participate in health educationprograms, partly due to lack of attention fromunderstaffed healthcare institutions and low importancegiven by government officers. This has lessened theirattention towards personal health problems andunderstanding about the risks of dust exposure.Further, poor health seeking behaviour has led theworkers to self-medication (14-15). This may be dueto the cavalier attitude of the workers (7) towards theirhealth issues as well as the preventive measures whichdemand the need for regular monitoring.



Less priority given to the workers’ health by theemployer (7), pressure imposed on the workers dueto irregular work schedules and unpredictable workdemands on the workers during a working day(16-17), which have been proven in literature, werealso seen among the rice mill workers under study.Further, literature has shown that employee’s fear oflosing the daily wage has been related to their reluctanceto seek health care (9, 12), which was raised by themill workers in this study too, as they were concernedof safeguarding their jobs. Thus, it can be predictedthat rice mill workers missed opportunities to receivemedical advice for their respiratory health problemsdue to the above factors which would have led to non-use of respiratory protective devices.

Openness of the employers and relevant authoritiestowards the health of rice mill workers is essential tounderstand the true nature of the workers’ attitudes

and beliefs (18), which was not seen among theworkers. They had rarely been able to communicatewith the officials relevant to rice milling industry. Lackof trust in the employer/ supervisor has been identifiedas a cause for information filtering by the employeeswhen they convey their information upwards (19).Thus, the rice mill workers’ fear of communicatingtheir health matters to the mill owners may be due tolack of trust and understanding with the owners, whichmay have indirectly prevented them from reachinghealth care facilities.

Lack of commitment (20) and leadership support(21) from the employer have been major influencesfor safe behaviour, which were also indirectlyhighlighted by the participants. This lack of supportfrom the mill owners and lack of communication withthe relevant authorities regarding health issues havecreated an environment, which gives little or no priority

Attitudes and practices of RMWs towards their personal health

• Limited knowledge on possible health effects of dust exposure

• Low priority given to respiratory health problems

• Reluctance and difficulties in attending health institutions

Work environment factors

• Perceived difficulty in working in hot climate by RMWs

• Insufficient control measures for dust and heat inside the mills

• Adhering to dirty work environment inside the mills due to lack of regular cleaning

Employer factors

• Lack of attention towards health needs of the workers by the mill owner

• Lack of communication between the workers and the mill owner

• Attitudes and practices of the government officers towards rice mill workers

• Negative perception of comprehension level of the RMWs regarding health problems

Institutional factors

• Lack of health screening, monitoring and education programs

• Lack of resource people and support staff to conduct health programmes

• Lack of communication between RMW and officials from relevant institutions

• Lack of practical approaches towards improving workers’ health by policy makers

Box 1. Reasons for non-use of respiratory protective methods among rice mill workers



for health in the rice mills and indirectly leads the millworkers towards unhealthy work practices.

Wearing respiratory protective devices against dusthas been effective in reducing respiratory symptomsrelated to farmers’ lung (22) and occupational asthma(23-24). The mill workers had a positive attitudetowards wearing respiratory protective devices, whichencourages developing health educational programmesto improve their current behaviour.

According to the Factories Ordinance of Sri Lanka(25), all practicable measures should be taken to protectthe persons employed against inhalation of the dustand to prevent its accumulation in any workroom whileproviding and maintaining exhaust appliances. Further,International Labour Organization (ILO) (26) recom-mends that national policies should aim to identify andminimize the causes of occupational diseases, dange-rous occurrences and incidents in the work environ-ment. However, the government officers in this studyseemed to have not taken remedial action for theworkers’ unhealthy behaviour despite the existence ofinternational guidelines (26) and country regulations (25).

Being anxious about the interview and reluctancein expressing their views due to fear of the employerwere the major barriers observed during the interviewswith participants. Inclusion of professionals fromvarious institutions related to rice milling has enabledthe authors to analyse the study findings in a broadercontext. Ideas of the rice mill owners would have madethe study findings more versatile however, their refusalto participate was a major limitation.

Conclusions & Recommendations

The rice mill workers’ non-use of respiratoryprotective devices was mainly due to the low prioritygiven to personal respiratory health care as well aslack of support from the employer, health care institutesand other related institutes. Low level of comprehensionof workers and less manpower in health and otherinstitutions have intensified the problem. A general needto adhere to the health and safety policies according tothe work setting was observed. Industry-basedoccupational health and safety programs are neededto address the specific health behaviour based on theoccupation. Further investigations on the factorsaffecting unhealthy behaviour of informal work sectorare highly recommended to enhance the workers’quality of life.

Public Health Implications

• Continuous exposure to dust is one of the

major risk factors for acquiring respiratory

health problems. Thus, the unhealthy beha-

viour of non-use of respiratory protective

devices among workers who are continuously

exposed to dust, such as rice mill workers

should be addressed seriously.

• Finding reasons for their unhealthy res-

piratory practices facilitates the planning of

preventive measures by occupational health

professionals.

• Research, education and training of the

employers and workers on dust control and

use of personal protective methods by insti-

tutions related to occupational health and

safety are essential in maintaining equity of

health care.

Author Declarations

Competing interests: The authors declare that theyhave no competing interests.

Ethics approval and consent to participate: The studywas approved by the Institutional Ethics Committeeof the Faculty of Medicine, University of Colombo,Sri Lanka (EC 15-079). Written permission wasobtained from the District Secretary and RegionalDirector of Health Services of Ampara prior to thecommencement of the study. Informed written consentwas obtained from the participants.

Funding: Higher Education for Twenty First Century(HETC) project of the World Bank [Ref number:HETC/CMB/QIGW3/MED/TOR-08].

Acknowledgements: The funding body is gratefullyacknowledged by the authors.

Author contributions: All the authors contributed indesigning and analysing the results of the study. Thefirst author collected the data and drafted themanuscript. All authors proofread and modified thearticle.



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Jayasinghe C & Abeysena C. JCCPSL 2019, 25 (4) Open Access

Original Research

Chintha Jayasinghe1* & Chrishantha Abeysena2

1Epidemiology Unit, Ministry of Health, Sri Lanka: 2Department of Public Health, Faculty of Medicine, Universityof Kelaniya, Sri Lanka



Adherence to infection control practices in relation to neonatal care inmajor hospitals in a district of Sri Lanka

Abstract

Introduction: Adherence to infection control practices are crucial for neonatal care.

Objectives: To describe the adherence to clean birth and postnatal care practices by healthcare workers in

selected procedures in major hospitals in a district of Sri Lanka

Methods: This was a qualitative observational study. The study sample comprised healthcare workers (doctors,

nurses and midwives) attached to the labour room (LR), postnatal ward (PNW), neonatal intensive care unit(NICU) and operating theatre (OT). A total of 70 healthcare workers from the LR, 90 from the PNW, 50 from the

NICU and 60 from the OT were assessed in relation to each procedure they carried out. Four checklists were used

to record the observations on infection control standards. The performance of each healthcare worker for each

specific procedure was observed only once.

Results: Hand washing practices among the healthcare workers in LR, NICU, PNW and OT varied, with betterpractices seen in NICU and PNW. Recapping of the needles was done by 18.6%, 18.0% and 31.2% in LR, NICU and

PNW, respectively. Disposal of sharps to the bin was done by almost all healthcare workers in the LR, NICU and

PNW, respectively. All the healthcare workers used 70% alcohol to disinfect the skin, of whom the majority used

povidone iodine when drawing blood samples for blood culture in the NICU. Changing or washing gloves beforecutting the umbilical cord was observed in the majority of healthcare workers in LR and the minority in OT.

Conclusions: Adherence to infection control standards by healthcare workers in observed procedures was notup to the standard.

Key words: birth, infection, hand washing, postnatal, neonates, sepsis

Received on 19 June 2019

Accepted on 5 Oct 2019

0000-0002-0476-1785



Introduction

Infection control is a series of procedures andguidelines that are followed to prevent healthcareassociated infections. There are infections that areacquired by patients during their stay in hospital andinfections that are acquired by healthcare workers whileworking in the hospital. These are known as hospital-acquired infections (HAI). Patients who requiretreatment for HAI must stay longer in hospitals, aretreated with expensive antibiotics and have a highmortality. HAI may be transmitted by healthcareworkers to patients, from patient to patient and frompatient to healthcare workers (1-2). For every 100hospitalized patients, seven in the developed and 10 indeveloping countries will acquire at least one HAI (2).In low- and middle-income countries, the frequencyof ICU-acquired infections is at least 2-3-fold higherthan in high-income countries (2). New-borns are athigher risk of acquiring HAI in developing countries,with infection rates of 3-20 times higher than in high-income countries (2). It is estimated that at any giventime, more than 1.4 million people worldwide aresuffering from HAI (3). Infection control thereforehas been identified as a model for the emerging patientsafety movement.

There are various guidelines to achieve maximumcontrol of HAI (4-6). These guidelines should alwaysbe followed by all healthcare workers when attendingon patients, regardless of their diagnosis or presumedinfectious status. These guidelines mainly addresssubjects such as hand hygiene, use of personal pro-tective equipment, management of sharps, manage-ment of blood spills, and handling of blood, body fluidsand specimens (6). A systematic review concluded thatclean birth and postnatal care practices were effectivein reducing neonatal mortality from sepsis (7).

HAI also impose a great burden on hospitalresources. Adherence to the guidelines is therefore ofparamount importance to prevent infections in thehospital setting. In a setting where resources are poor,infection can exceed 20% but the World HealthOrganisation (WHO) declares that available data arescanty, and more research is urgently needed to assessthe burden of disease in developing countries (3).Therefore, it is important to find out the currentsituation on infection control practices amonghealthcare workers for the improvement of neonatalcare. The objective of this study was to describe the

adherence to infection control practices in relation toneonatal care by healthcare workers in selectedprocedures in the labour rooms (LR), neonatal intensivecare units (NICU), postnatal wards (PNW) andoperating theatres (OT) in secondary and tertiary carehospitals in a district of Sri Lanka.

Methods

This was a qualitative observational study carriedout in all four major hospitals in the district of Gampaha,namely Colombo North Teaching Hospital, DistrictGeneral Hospital Gampaha, District General HospitalNegombo and Base Hospital Wathupitiwala from July2010 to February 2011. In the four hospitals, therewere seven LR, five NICU, nine PNW and six OTconducting caesarean section. The study samplecomprised healthcare workers in the relevant units,namely doctors, nursing sisters, nursing officers andmidwives.

Ten healthcare workers were selected from eachunit of the four hospitals to assess the adherence toinfection control related to procedures, thus a total of70 healthcare workers from LR, 90 from PNW, 50from NICU and 60 from OT were recruited. Theperformance of each healthcare worker on eachidentified procedure was observed only once. Seventypes of procedures were observed in the LR; sevenin the NICU; two in the PNW; and five in the OT.

Four checklists were developed to record theobservations on infection control standards in the fourtypes of units. The checklists were prepared using thefollowing documents; WHO Essential New-born CareCourse, Integrated Management of Pregnancy andChildbirth (8), the LR Management Guidelines of theMinistry of Health (9) and Infection Control Manualby the College of Microbiologists (6). Essentially, thechecklist assessed the use of personal protectiveequipment (PPE) by healthcare workers, adherenceto infection control standards when performing normalvaginal delivery and caesarean section, hand hygieneand management of sharps, provision of new-born careincluding cord care and breastfeeding management andpractices, management of blood spills, examination ofnew born babies, blood drawing/IV cannulations forneonates, and management of specimens such as blood



and urine samples and procedures when performingBCG vaccinations. The checklists were reviewed bya group of experts including specialists in paediatrics,microbiology, public health and gynaecology. The face& content validity and the appropriateness of thechecklists were assessed by the experts. The checklists were further pre-tested in a hospital in ColomboDistrict for feasibility and appropriateness.

It was decided to observe selected proceduresfrom each unit on randomly selected dates. All unitswere visited during shifts according to a rosterprepared in advance. During each shift, only one ortwo procedures were observed from the same unit.Staff in the institution was unaware of the dates theobservations were carried out. Ten such observationswere made for each selected procedure from eachunit. Procedures were selected to represent all relevantcategories of staff. The checklist was filled shortlyafter the procedure was over.

Data analysis

Data analysis was done using the StatisticalPackage for Social Sciences (SPSS) version 16. Eachitem of the checklists included only two responses(Yes or No) and descriptive analysis was carried out.

Results

Adherence to infection control standards in thelabour room

As shown in Table 1, all healthcare workers (n=70;100.0%) wore sterile gloves before attending ondeliveries in the LR. Change of shoes before enteringthe LR was practised by 62.9%. Before attending ondeliveries, aprons were worn by 80% while only 57.1%washed their hands using either bar soap or liquid soap.Removal of bangles, rings and watches was practisedby 52.5% (n=21) while 100% washed over the surfaceof the hands. Majority (n=39; 97.5%) washed the backof the hands, 77% (n=31) washed inter-digital spaces,75% (n=30) washed back of the fingers, 62.5% (n=25)washed their thumbs separately and 70.0% (n=28)washed the tip of fingers. The majority (n=37; 95.7%)of healthcare workers used single use sterile towels towipe their hands after washing.

The used sharps were disposed into sharp binsby 90% of healthcare workers, whereas recapping

before disposing was done by only 18.6% of healthcareworkers. The majority (92.9%) of them dried the babyimmediately but only 41.4 % of babies were kept overthe abdomen for skin to skin contact. All healthcareworkers used sterile instruments to cut umbilicalcords, whereas 7.1% umbilical cords were cut withoutproper clamping of the cords. Umbilical cord stumpobservation for oozing was done for 75.7% ofdeliveries.

Leaving the baby over the mother’s chest wasdone during 36.8% of the deliveries and covering thebaby well in 92.9% deliveries. Although removing ofvernix is not practised now, it was observed in fourneonates (5.7%). Even though the best practice ofbreastfeeding is to initiate it during 30 minutes to one-hour period, it was observed only in 65.7% of neonates.More than 80% of mothers were helped to positionthe neonates for breastfeeding by the healthcare staff.TCL on blood spilled floor was applied only 11.4% ofthe times. Separate mops to wipe out the contaminatedplaces were used 71.4% of the times.

Adherence to infection control standards inNICUs

As shown in Table 2, the majority (96.0%) ofhealthcare workers changed their shoes when enteringthe NICU. No one wore sterile caps while in the NICU.Only 60% of healthcare workers washed hands beforeentering the NICU. While all healthcare workers washedtheir hands with soap after touching the sick neonates,only 80% of them did so before touching the neonates.A Majority (81.6%, n=34) of healthcare workerswashed the back of the fingers, whereas only 76.8%(n=32) workers washed the thumbs separately andthe tip of fingers. All of them washed over the surfacesof their hands, 94.7% (n=39) washed back of the hand,and 87.5% (n=36) inter digital spaces. There were78.1% (n=32) of healthcare workers who wiped theirhands using a single use sterile towel, whereas 21.9%(n=9) wiped their hands using disposable towels.

All the healthcare workers performed cannulationafter disinfection of the skin with 70% alcohol. Handswere washed by 86.0% before the insertion of cannula,whereas 50.0% wore sterile gloves. All the healthcareworkers used 70% alcohol for skin disinfection andsterile needles before drawing blood for blood culture.



Practices Yes NoNo. % No. %

Practices of personal protective equipment and hand washingChanged the shoes 44 62.9 26 37.1Wore masks 9 12.9 61 87.1Wore apron 56 80.0 14 20.9Wore gown 9 12.9 61 87.1Hand washed before wearing gloves 40 57.1 30 42.9Wore sterile gloves 70 100.0 0 100.0

Practice of handling sharps while assisting for deliveriesRecap before disposal of syringes 13 18.6 57 81.4Disposing the syringes without separating the needle 66 94.3 4 5.7Sharps disposed into sharp bin 63 90.0 7 10.0Change of sharps from person to person 2 2.9 68 97.1

Practices while delivering the babyDelivered the neonate over the mother’s abdomen 29 41.4 41 58.6Dried the baby immediately 65 92.9 5 7.1Wiped eyes and mouth 60 85.7 10 14.3Applied antimicrobial to eyes 0 0.0 70 100.0Discarded wet cloths immediately 61 87.1 9 12.9

Practices while providing umbilical cord careChanged or washed the gloves before cord was cut 54 77.1 16 22.9Clamped and cut the cord 65 92.9 5 7.1Used sterile instruments 70 100.0 0 0.0Observed for oozing 53 75.7 17 24.3Application of any substances over the stumps 0 0.0 70 100.0

Practice just after birth of neonateLeft the baby on mother’s chest for skin to skin contact after delivery 27 36.8 42 61.4Covered the baby well 65 92.9 5 7.1Covered the head of the baby 44 62.9 26 37.1Did not remove the vernix 66 94.3 4 5.7

Practices on breastfeedingInitiation of breast feeding within ½ hour to 1 hour 46 65.7 24 34.3Help in positioning of the neonates 57 81.4 13 18.6Help in attachment of the baby 54 77.1 16 22.9Any other substances given other than breast milk 0 0.0 70 100.0

Practices taken to prevent cross infectionApply TCL and keep it for 30 minutes over the blood spilled floor 8 11.4 62 88.6Use separate mop to wipe out the contaminated places 50 71.4 20 28.6Change the mackintosh for the delivery of a new mother 69 98.6 1 1.4Keep the contaminated materials in the separate bins 69 98.6 1 1.4

Table 1. Adherence to infection control practices by birth attendantsin the labour room (n=70)



Table 2. Adherence to infection control practices by staff in theneonatal intensive care units (NICU) (n=50)


Practice when entering the NICU

Change the shoes 48 96.0 2 4.0

Wear sterile masks 2 4.0 48 96.0

Wear sterile gown 17 34.0 33 66.0

Wear sterile caps 0 0.0 50 100.0

Wash hands before entering the NICU 30 60.0 20 40.0

Practice when handling the neonates

Washed hands before handling the neonates 41 80.0 10 20.0

Already nails cut short 46 92.0 4 8.0

Washed hands after touching the neonates 50 100.0 0 0.0

Practices when performing venipuncture on the neonates

Wash hands before inserting the cannulas 43 86.0 7 14.0

Wear a pair of sterile gloves before commencing the puncture 25 50.0 25 50.0

Use of 70% alcohol to clean the skin 50 100.0 0 0.0

Documentation of date on the BHT/dressing 26 52.0 24 48.0

Practices when drawing blood samples for blood culturesUse of 70% alcohol to clean the skin 50 100.0 0 0.0

Allow to dry 36 72.0 14 28.0

Use of Betadine for cleaning 34 68.0 16 32.0

Wash hands before drawing blood samples 48 96.0 2 4.0

Use of sterile gloves 49 98.0 1 2.0

Use of sterile syringes and needles 50 100.0 0 0.0

Practice when handling the sharps and disposal of sharps

Recap before disposing syringes 9 18.0 41 82.0

Disposed syringes without separating the needle 50 100.0 0 0.0

Sharps disposed to sharp bins 50 100.0 0 0.0

Change of sharps from person to person 0 0.0 50 100.0

Sharp bins not filled more than 3/4 41 82.0 9 18.0

Practices during hand washing

Advice mother to hand wash before handling the baby 27 54.0 23 46.0

Supervision of hand washing of mothers 5 10.0 45 90.0

Advice mothers to hand wash after handling the babies 12 24.0 38 76.0

Supply of clean sterile cup for breast milk extraction 50 100.0 0 0.0

Practices when handling the blood and specimens with body fluids

Place specimens in a leak proof container 50 100.0 0 0.0

Do not contaminate the outside of the container 41 82.0 9 18.0

Store specimen away from food and drinks 50 100.0 0 0.0

Transport specimens securely to prevent spillage 21 42.0 29 58.0



There were 96.0% of healthcare workers who washedtheir hands prior to wearing gloves. All the health careworkers disposed the sharps into sharp bins and all ofthem did not separate the needle from syringes. Noone (0%) changed the sharps from person to person,whereas 18.0% did the recapping of needles. Twenty-seven mothers (54.0%) were advised by nurses towash their hands before handling their sick neonatesin the NICU. Only 10.0% of mothers were supervisedby the healthcare workers for hand washing. All placedthe specimens in the leak proof container whereas18.0% of specimens were contaminated outside thecontainer. Only 42% of specimens were transportedsecurely to prevent spillage.

Adherence to infection control standards in thepostnatal wards

As shown in Table 3, there were 82.5% ofhealthcare workers who washed their hands beforeattending the neonates in the postnatal wards. Amongthose who washed hands before attending to the

neonates in the postnatal wards, 23.8% (n=17)removed bangles, 60.8% (n=40) used soap, 39.2%(n=26) used hand rubs, 49% (n=35) closed the tap byusing their elbow or through someone else and 57.5%(n=38) wiped their hands after washing. Out of the 66observations of hand washing and hand rubs, 71.4%(n=47) washed over the surface of the hand, 92.7%(n=61) washed the back of the hands, 72.9% (n=48)washed back of the fingers, 71.4% (n=47) washedinter digital spaces, 63.8% (n=42) washed thumbsseparately, and 60.8%, (n=40) washed the tips of thefingers.

Adherence to infection control practices relatedto neonatal care in operating theatre

As shown in Table 4, the majority (83.3%) ofhealthcare workers used nail brushes for the first timefor the scrub. All healthcare workers used antisepticsolutions for hand washing. Of them, 76.7% removedor did not wear jewellery such as rings.

Table 3. Adherence to infection control practices by healthcare workersin the postnatal wards (n=80)


Practice when entering the postnatal wards

Hand wash before attending to the neonates 66 82.5 14 17.7

Practices when performing BCG vaccinations

Hand washing before vaccination 62 77.4 18 22.6

Use of disposable needles 80 100.0 0 0.0

Discarding of needles without recapping 25 68.8 55 31.2

Dispose without separating needles 80 100.0 0 0.0

Dispose into sharp bins 77 96.2 3 3.8

Change sharps from person to person 0 0.0 0 0.0

Washed hand after vaccination 80 100.0 0 0.0



Table 4. Adherence to infection control practices by healthcareworkers in the operation theatres (n=60)


Practice before attending the caesarean section

Used nail brushes for the firsthand scrub 50 83.3 10 16.7

Applied antiseptic solutions 60 100.0 0 0.0

Removed or did not wear jewelry 46 76.7 14 23.3

Handheld high while washing 56 93.3 4 6.7

Completely changed into the theatre clothes 52 86.7 8 13.3

Caps properly covered the hair 55 91.7 5 8.3

Masks completely covered the nose and mouth 44 73.3 16 26.7

Wore double gloves 41 68.3 19 31.7

Masks changed after each operation 10 16.7 50 83.3

Practices when entering the Operation Theatre

Completely changed into the theatre clothes 0 0.0 60 100.0

Changed the shoes when entering the theatre 60 100.0 0 0.0

Caps properly covered the hair 45 75.0 15 25.0

Masks completely covered the nose and mouth 41 80.3 19 31.7

Washed hands before wearing the gloves 20 33.3 40 66.7

Wore sterile gloves 60 100.0 0 0.0

Practices by theatre nursing officers when assisting

the caesarean sections

Wiped eyes of the neonates immediately 46 76.7 14 23.3

Wiped mouth of the neonates immediately 50 83.3 10 16.7

Dried the baby immediately 49 81.7 11 18.3

Practices when performing the neonatal care in the operation theatre

Changed or washed the gloves before cutting the umbilical cord 19 31.7 41 68.3

Clamped and cut the cord 59 98.3 1 1.7

Observed for oozing 43 71.7 17 28.3

Used sterile instrument 60 100.0 0 0.0

Application of substances over the stump 0 0.0 60 100.0

Discarded wet clothes immediately 52 86.7 8 13.3

Application of antimicrobials to the eyes 0 0.0 60 100.0

Neonates who received the following care practices

Place the baby on the mothers’ abdomen or in

her arms for skin to skin contact 6 10.6 54 90.0

Started breastfeeding in the theatre itself 60 100.0 0 0.0

Brought caps and socks by mothers 38 63.3 22 36.7

Dressed neonates with caps and socks washed before 26 43.3 34 56.7



Fifty-two (86.7%) healthcare workers had com-pletely changed into theatre clothes when carrying outcaesarean section, while 55 (91.7%) and 73.3% ofworkers properly wore caps and masks, respectively.All the birth attendants were public health midwivesfrom the relevant wards. None of them changed theiruniform when entering the surgical theatre but allchanged shoes. Only 33.3% of birth attendants washedtheir hands before wearing sterile gloves for handlingthe neonates.

A majority (76.7%) of nursing officers wiped theeyes of neonates immediately and the mouth of 83.3%of neonates. Baby was dried immediately by 81.7%.Only 31.7% birth attendants changed or washed theirhands before cutting the umbilical cord. An observationfor oozing was done by 71.7% of birth attendants.Discarding of wet clothes was done immediately by86.7% of birth attendants. All the neonates were startedon breastfeeding in the theatre itself, whereas only10.6% of the neonates were kept in contact with themothers’ skin inside the theatre. Thirty-eight mothers(63.3%) had brought caps and socks for their neonatesbut only 43.3% of them had washed them beforedressing the neonates.

Discussion

In the present study, hand washing practicesobserved among healthcare workers varied across thestudy units. It was higher in NICU and PNW. It is awell-known fact that HAI spread due to cross infectionfrom poor hand hygiene of healthcare workers, andtherefore a simple hand washing procedure is of greatconsequence in preventing them. The low rates of handwashing reported by midwives might be due to lackof facilities for hand washing in the theatres other thanscrubbing area. One Sri Lankan study (10) found thathand washing practices before assisting in the deliverywas done by 65% of the birth attendants. Another study(11) revealed that it was 85.3%. In previous studies,the quality of hand washing had not been evaluatedbut in the present study, it is found to be poor. Theproportion of workers who adhere to the steps of handwashing correctly varied in different settings. Whenconsidering the step of washing thumbs separately,the practices in PNW was low. Almost all had usedeither soap or disinfectant for this purpose, whereasfew of them from LR and PNW did not wipe theirhands after washing. According to another Sri Lankan

study (12), only 10% of the healthcare workers hadoverall good practice of hand washing in the ICU setup of a teaching hospital. Doebbling et al. (13) foundthat the hand washing rate by ICU medical staff was12.4% before contact with the patient and 10.65%after contact. Marito and colleague (14) in Italy alsorevealed that even after intervention, compliance tohand washing in the NICU among doctors was 50.5%and 40.7% among nurses. Another study from Brazil(15) reported that hand hygiene adherence in terms oftechnique and frequency according to the WHOrecommendations was deficient in NICU.

When entering an LR, majority of them woreaprons and minority wore masks. In the NICU, lessthan 50% of them wore sterile gowns and few woremasks. In Georgia, the gown and glove compliance inthe surgical ICU among doctors was 40%, whereasamong nurses it was 68%. In the medical ICU, it was84% among nurses and 70% among doctors (16).

When considering the management of sharps anddisposal of sharps, recapping of needles was done byminority of workers in all the units. Disposal of sharpsto the sharp bin was done by almost all in the LR,NICU and PNW. One Sri Lankan study (10) also foundthat only 21% of healthcare workers practisedrecapping of needles.

Drawing of blood for cultures is important whenmanaging sepsis babies. When considering the stepsin drawing blood, all of the healthcare workers used70% alcohol to disinfect the skin, majority of themallowed to dry and used povidone iodine in the NICU.

Skin to skin contact of mother and baby and earlyinitiation of breastfeeding are two important practicesto prevent infections in new-borns. In the presentstudy, it was revealed that the majority of neonateswere started on breastfeeding within the first hour ofdelivery, vast majority of healthcare workers helpedto position the baby. A study from Sri Lanka (11) foundthat 98.9% commenced breastfeeding within the LRwhile 64.6% of healthcare workers helped the mothersto breastfeed.

Direct observations using checklists were com-mon practice in similar kind of studies (10-11,17). Thepresence of an observer while carrying on theprocedures may have influenced the practice of thehealthcare provider towards favourable direction. To



minimize this issue, at the beginning of the study, onlythe nursing officer in-charge was explained regardingthe observation of the procedures, but the healthcareproviders were unaware of the particular day theobservations were carried out. One of the limitationsof this study was the inability to obtain in-depthinformation underling their behaviour. Focus groupdiscussions would be more appropriate for this, inaddition to observing the behaviour.


The adherence to infection control standards byhealthcare workers in observed procedures were notup to the expected standards. During the basic trainingperiod, it is necessary to stress on infection controlstandards for all categories of health staff. At the sametime, it is compulsory to introduce regular in-serviceprogrammes and conduct routine reviews andevaluations for all types of staff categories regardinginfection control.


The adherence to different process of infection

control standards by healthcare workers varied.

It is compulsory to introduce regular in-service

programmes and conduct routine reviews and

evaluations for all types of staff categories

regarding infection control.

Author Declarations

Competing interests: The authors declare that theyhave no conflicts of interests in this study.

Ethics approval and consent to participate: The EthicsReview Committee of the Faculty of Medicine,University of Kelaniya granted ethical clearance.Administrative clearance for the data collection wasobtained from the Regional Director of Health Servicesof Gampaha District and directors of the relevanthospitals prior to data collection. Prior approval wasobtained from the consultants in charge of thegynaecology and paediatric wards and the NICU.

Acknowledgements: We are grateful to thePostgraduate Institute of Medicine, University ofColombo, the data collectors and the participants forthe study.

Author contributions: CJ participated in the design ofthe study, coordinated data collection, performed thestatistical analysis and helped to draft the manuscript.CA participated in the design of the study, performedthe statistical analysis, interpreted the data, drafted themanuscript and approved the final manuscript.

References

1. Sri Lanka College of Microbiologists. HospitalInfection Control Manual. Colombo: Sri LankaCollege of Microbiologists, 2005.

2. WHO. Health Care Associated Infections FACTSHEET.Available from: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf.

3. WHO. Improved hand hygiene to prevent health care-associated infections. Patient Safety Solutions 2009;9(10).Available from: https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution9.pdf.

4. WHO. Guideline on Hand Hygiene in Health Care(Advanced Draft). Global Patient Safety Challenge2005–2006: Clean Care is Safer Care. Geneva:World Health Organization, 2006. Available from:https://www.who.int/patientsafety/information_centre/Last_April_ versionHH_Guidelines%5B3%5D.pdf.

5. WHO. Handbook of Integrated Management ofChildhood Illnesses. Geneva: World HealthOrganization, 2005.Available from: https://apps.who.int/iris/handle/10665/42939.

6. Sri Lanka College of Microbiologists. NationalGuidelines for Infection Control. Colombo: Sri LankaCollege of Microbiologists, 2008.

7. Blencowe H, Cousens S, Mullany LC, Lee ACC,Kerber K, Wall S, Darmstadt GL, Lawn JE. Clean birthand postnatal care practices to reduce neonataldeaths from sepsis and tetanus: a systematic reviewand Delphi estimation of mortality effect. BMC PublicHealth 2011; 11(Suppl 3): S11.

8. WHO. Integrated management of pregnancy andchildbirth. pregnancy, childbirth, postpartum andnewborn care: a guide for essential practice.Geneva: World Health Organization, 2003.Available from: https://www.afro.who.int/sites/default/files/2017-06/mps%20pcpnc.pdf

9. Family Health Bureau. Guideline for Labour RoomManagement. Colombo: Ministry of Health, 2007.



10. Senarath LTUD. Essential newborn care in a districtof Sri Lanka and the effectiveness of intervention toimprove services. MD Thesis (Community Medicine).Colombo: Post Graduate Institute of Medicine,2004.

11. Goonewardena CSE. Selected aspect of quality ofintrapartum and postpartum care at primary carelevel institution in the Kalutara district and inter-vention to improve care. MD Thesis (CommunityMedicine). Colombo: Post Graduate Institute ofMedicine, 2001.

12. Kudavidanage BP, Gunasekara TDCP, HapuarrachiS. Knowledge, attitudes and practices of handhygiene among ICU staff in Anuradhapura TeachingHospital. Anuradapura Medical Journal 2001; 1:29-40.

13. Doebbling BN, Stanley GI, Sheetz CT. Comparativeefficacy of alternative hand washing agents inreducing nosocomial infections in intensive careunits. New England Journal of Medicine 1992; 327:88-93.

14. Marito PA, Ban KM, Bartolone A, Fowler EK, SaintS, Mannelli F. Assessing the sustainability of handhygiene adherence prior to the patient contact in theemergency department: a one year post interventionevaluation. American Journal of Infection Control2011; 39: 14-18.

15. Silva DS, Dourado AMG, Cerqueira CRE, Romero FH,Amaral NA, Pearce PF, et al. Hand hygiene adherenceaccording to World Health Organization Recom-mendations in a Neonatal Intensive Care Unit. RevistaBrasileira de Saúde Materno Infantil 2017; 17(3):551-559.

16. Gilbert K, Safford C, Crosby K, Flemiyoe GR. Doeshand hygiene compliance among health care workerschange when patients are in contact precaution roomin ICU. American Journal of Infection Control. 2010;38: 535-539.

17. Vidal SA, Ronfani L, Silverine SM, Mello MJ, SantoesER, Buzzetti R, Cattaneo A. Comparison of twotraining strategeies on essential newborn care inBrazil, Bulletin of the World Health Organization2001; 79(11): 1024-1031.


Yasaratna NR & Wijesinghe MSD. JCCPSL 2019, 25 (4) Open Access

Original Research

Niludi Ranwanee Yasaratna1* & MSD Wijesinghe2

1 Postgraduate Institute of Medicine, University of Colombo, Sri Lanka; 2Health promotion Bureau, Ministryof Heath, Sri Lanka



Perceived self-efficacy and self-managing of chronic diseases amongelderly patients in a clinic setting: how capable are elders in promotingtheir own health?

Abstract

Introduction: Non-communicable diseases and elderly population are on the rise worldwide. It has created amassive burden on health systems, economies and society. Sri Lanka is no exception. The situation indicates theneed for risk factor prevention and control through effective behaviour change programmes. Self-efficacy ispostulated as fundamental to achieve behaviour change of individuals to fill the present gap of risk factor control.

Objectives: To assess the perceived self-efficacy in managing chronic diseases to provide an insight into howconfident the elderly are in self-managing their diseases

Methods: A hospital-based descriptive cross-sectional study was conducted among elderly patients attendingthe medical clinic at BH Mulleriyawa. By systematic sampling method, 461 eligible patients diagnosed with one ormore five major chronic disease categories were selected. An interviewer-administered chronic disease self-efficacy questionnaire validated for Western countries was used to collect data. Mean perceived self-efficacyscore was calculated by adding scores of 10 domains. Adjusted odds ratios (AOR) with 95% confidence interval(CI) were calculated to find associations with the control of risk factors.

Results: The response rate was 92% (n=424). The study population had a mean perceived self-efficacy score of3.64 (SD=0.54) out of 5. The existence of multiple co-morbidities among the elderly was significantly associatedwith perceived self-efficacy (p=0.02). Respondents with a single disease showed ‘good’ perceived self-efficacycompared to those with two or more co-morbidities. With respect to disease control status, a statistically significantassociation was found between ‘good’ perceived self-efficacy and blood pressure control (<140/90 mmHg)(AOR=0.47; 95% CI=0.24, 0.89). However, statistically significant associations were not found between bloodsugar control (<110 mg/dl) or total cholesterol level (<240 mg/dl) with ‘good’ perceived self-efficacy.

Conclusions: The elderly patients’overall perceived self-efficacy level was found to be well above the average.Targeted interventions to improve self-efficacy may have a beneficial effect on disease control factors such asblood pressure. Further research studies are needed to longitudinally assess the temporality of perceived self-efficacy and its determinants.

Keywords: perceived self-efficacy, chronic diseases, elderly

Received on 16 Aug 2019

Accepted on 16 Nov 2019

0000-0002-7075-4081



Introduction

Sri Lanka has come a long way from its focus oncontrolling communicable diseases. Currently, chronicnon-communicable diseases are overtaking thecommunicable diseases as the dominant health problemand leading causes of mortality, morbidity and disabilityin the country. National survey on self-reported healthestimated that 17.8% of the total population has somechronic illness with a prevalence of 45.3% reportedfrom the age group 60 and above (1). Chronic illnessis the most common cause of premature mortality inSri Lanka and is estimated to cause 80% of the totalburden of disease, mental problems, injury and almost32.5% of current health expenditure (2). The illnessburden and costs are expected to increase further asthe prevalence of chronic illness increases with age.However, it has been estimated that 70-80% of peopleliving with chronic illness could reduce the illnessburden and costs by appropriate self-management (3).This reduction in illness burden is through theassociated decrease in hospital admissions, reverseddisease progression and halting the development ofcomplications (4).

Increased attention has been focused on chronicdisease self-management recently in order to attainpatient independence and improve quality of life overthe years. Disease management has changed fromtreatment modality to an approach of holistic health,in which patient plays a significant role in controllingtheir disease with the guidance of health care providers(5). Most of the chronic diseases like diabetes, heartdiseases and chronic respiratory disease though uniquein their pathophysiology, share common issues orcharacteristics in the management. These charac-teristics include lifestyle adjustment and risk factorcontrol (exercise, diet control, substance use), con-trolling symptoms and disability, complex drug regimenoptimization, coping with psychological and socialdemands, and effective coordination with the healthcare providers in follow-up and monitoring of physicalindicators (6). Many studies have shown that peoplewith better self-efficacy (7) are managing chronicillness optimally (8-9). This paper aims to assess theperceived self-efficacy and its associations in self-managing chronic diseases among elderly patients in aclinic setting to provide insights into effective behaviourchange programmes.

Methods

A hospital-based cross-sectional study wasconducted from August to September 2017 at the BaseHospital (BH) Mulleriyawa. This study setting wasselected since its medical clinic provides chronic diseasemanagement in a holistic manner, which addresses thecurative as well as preventive aspects. The study wascarried out among elderly patients (60 years and above)with chronic diseases (defined as patients with adiagnosis card of diabetes, ischaemic heart disease,hypertension, hypercholesterolemia, chronic asthmaor chronic obstructive pulmonary disease) registeredat the medical clinic BH Mulleriyawa. The eligibilitycriteria of a study unit were diagnosis of one or moreof five major chronic diseases for >1 year. The samplesize of 461 was calculated using a standard formulafor a descriptive study (10). The registered list ofpatients attending the medical clinic on each clinic datewas used as the sampling frame and systematicsampling method was used. First patient was selectedrandomly using a dice and subsequently every thirdpatient was selected. Perceived self-efficacy wasassessed by 35-item Perceived Self Efficacy Scale,which was an adapted version of ‘Stanford ChronicDisease Self-Management Scale’ (11). Face and contentvalidity of the scale was assessed. The questions werecategorized according to 10 domains (risk factor con-trol, activities of daily living, social support, recreation,health literacy, health service utility, symptom control,psychological status, complication management anddrug compliance). The scale was a Likert scale withfive categories. The final score was divided into twocategories as ‘poor’ (<3.64) and ‘good’ self-efficacy(>3.64) based on the mean of 3.64.

The disability status was assessed based onquestions for impairment of vision, hearing andmobility. In patients with diabetes and hypertension,their disease control status was assessed by averagingthe last three month values of fasting blood sugar (cutoff was taken as <110 mg/dl) and blood pressure (cutoff was taken as <140/ 90 mmHg) among those whohad the records. Similarly, in hypercholesterolemia,patient’s average of total cholesterol value within lastsix months (cut off was taken as <240 mg/dl) wastaken. Statistical significance was taken as p value<0.05 for inferential statistics and logistic regressionanalysis was performed to find the associations.



Results

The response rate was 92% (n=424). The meanage of respondents (n=424) was 69.6 years (SD=6.1),which ranged from 60 to 89 years. A major of themwere females (n=321; 75.7%); of Sinhalese ethnicity(n=408; 96.2%); married and having a living spouse(n=240; 56.6%). Nearly one-third of the respondentshave passed GCE Ordinary Level (n=125; 29.5%), with85.6% (n=363) presently unemployed. The distributionof socio-demographic and economic characteristicsof the respondents is illustrated in Table 1.

With regards to disability status (Table 2), themajority (n=402; 94.8%) of the study participants wereable to walk without support, had normal hearing(n=399; 94.1%) and could read independently with orwithout wearing spectacles (n=407; 96%). The visualimpairment was predominant in the respondentscompared to mobility and hearing. Only 17.5% (n=74)were diagnosed with a single disease entity. Majority(n=350; 82.5%) had multiple morbidities. Thecommonest combination was three co-morbidities. Thepercentage with three or more comorbidities was52.8% (n=157).

The overall mean value of perceived self-efficacywas 3.64 (SD=0.54). The median was 3.6 and rangedfrom 2 to 4.83. Table 3 shows the domains of perceivedself-efficacy and percentage below the cut-off (meanvalue of each domain). According to the scale, a vastmajority of respondents reported their self-efficacy as‘poor’ in risk factor control (74.8%), complicationmanagement (71.3%), symptom control (63.7%),psychological status (60.2%) and drug compliance(59.1%). Almost all respondents reported their self-efficacy was better in activities of daily living (1.4%)and health service use (0.7%) (Table 3).

Table 1. Distribution of socio-demographic/economic characteristics

Characteristics No. %Age60 - 69 226 53.370 - 79 170 40.180 - 89 28 6.6

GenderMale 103 24.3Female 321 75.7

EthnicitySinhala 408 96.2Tamil 6 1.4Muslim 5 1.2Other 5 1.2

ReligionBuddhist 372 87.7Christian 39 9.2Hindu 4 0.9Islam 9 2.1

Marital statusMarried (spouse living) 240 56.6Married (spouse not living) 161 38Divorced 12 2.8Unmarried 11 2.6

EducationNo education 22 5.2Grade 1 - 7 78 18.4Grade 8 140 33Grade 9 - 10 20 4.7Passed GCE O/ Level 125 29.5Passed GCE A/ Level 31 7.3Postgraduate 8 1.9

OccupationPresently employed 61 14.4Presently not employed 363 85.6

Source of income of respondents1

From children 193 46.3A pensioner 80 19.2From employment 62 14.9From allowances 30 7.2From properties 7 1.7Other 2 45 10.7

Gross monthly income of respondents (Rs.)≤ 5,000 207 48.85,001-10,000 56 13.210,001-15,000 47 11.115,001-20,000 59 13.9> 20,000 55 13.0

Living with whom 3

With children 298 70.6With spouse only 74 17.5With relatives 21 5.1Alone 28 6.6Other 4 1 0.2

(Continued)

1Data missing (n=7); 2Source of income of relatives or any other

persons; 3Data missing (n=2); 4Living in an elderly home



In this study, presence of co-morbidities amongthe elderly was associated significantly with perceivedself-efficacy (p=0.02). Respondents with a singledisease showed ‘good’ perceived self-efficacy com-pared to those with two or more co-morbidities. How-ever, no significant association was found in perceivedself-efficacy with recent hospitalizations due to chronicillness (p=0.2). A significant association was evidentbetween perceived self-efficacy and blood pressurecontrol. The participants with ‘good’ self-efficacy hadlower odds of having high blood pressure. The oddsfor having high total cholesterol and high fastingblood sugar were slightly higher among the ‘good’self-efficacy group; however, the results were notsignificant (Table 4).

Discussion

The present study found that the overall meanperceived self-efficacy score among elderly patientsattending the medical clinic at BH Mulleriyawa wassatisfactory. However, the self-efficacy of risk factorcontrol, complication management, symptom control,psychological status and drug compliance were foundto be low. Blood pressure level was associated withperceived self-efficacy, while blood sugar and totalcholesterol were exceptions that showed no asso-ciation with perceived self-efficacy.

Table 2. Frequency distribution of disabilitystatus and chronic diseases (N=424)

Disability No. %

MobilityWalk Independently 402 94.8Walk with support 19 4.4Cannot walk 3 0.7

HearingCan hear normally 399 94.1Impaired 25 5.9

VisionRead well 153 36.0Read with spectacles 254 60.0Difficult with spectacles 14 3.3Can recognize a person 1 0.2Cannot recognize a person 2 0.5

Chronic disease/sHypertension only 16 3.8Diabetes only 30 7.1Ischaemic heart disease only 8 1.9Hypercholesterolemia only 8 1.9Chronic lung diseases only 12 2.8Two co-morbidities 126 29.7Three co-morbidities 157 37.0More than three co-morbidities 67 15.8

Table 3. Domains of perceived self-efficacy and percentage below cut-off values

Risk factor control 4.63 2.2 2.25 74.8

Activities of daily living 5 4.42 4.66 1.4

Social support 5 3.52 3.5 15.6

Recreation 5 3.75 4 35.7

Health literacy 5 3.55 4 22.8

Health service utility 5 4.14 4.4 0.7

Symptom control 5 3.79 4 63.7

Psychological status 5 4 4.2 60.2

Complication management 5 3.7 4 71.3

Drug compliance 5 3.33 3.33 59.1

Domain of perceived self-efficacy Scores % below the mean

Maximum Mean Median



Table 4. Level of perceived self-efficacy and risk factor control

Good 0.47 (0.25 - 0.89) 1.45 (0.75 - 2.82) 1.17 (0.67 - 2.03)

Poor (Reference) 1.00 1.00 1.00

AOR (95% CI)

Blood pressure Total cholesterol Fasting blood Sugar>140 /90 mmHg >240 mg dl >110 mg/dl

Fasting blood sugarperceived self-efficacy1

1 All models were adjusted for age, gender, occupation, education and co-morbidity

There is a growing body of evidence in the worldwhich states that health-related self-efficacy issignificantly lower among individuals with greaterillness burden compared to their counterparts (12).In the disease profile of this study, many patients werediagnosed with multiple disease entities. The presenceof co-morbidity in the study sample was 82.5%. Asystematic review done on the prevalence of co-mor-bidities in South Asia reports that it ranges widelywithin 4.5%-83% (13). Afshar et al. (2015) (14) alsoreports that co-morbidity is common in low- andmiddle-income countries and is significantly associatedwith age. This is consistent with the results of ourstudy. Furthermore, this study also found that with ahigher number of co-morbidities, the perceived self-efficacy is rated low.

There is limited literature to support the asso-ciation of self-efficacy and the risk factor control.Nevertheless, with the limited evidence, our findingsare consistent with a study done in the USA, whichreported that over half (59%) who had good self-efficacy were better in managing their hypertension(15). A similar cross-sectional study done oncaretakers of Alzheimer patients, high levels of self-efficacy for problem-focused coping were associatedwith lower mean arterial blood pressure, systolic bloodpressure and pulse pressure (16). Some studies havefound evidence on the association of self-efficacy withthe management of cholesterol level of patients,contrary to what we found in our study. Gaughan(2003) (17) has assessed the self-efficacy as a usefultool for managing eating behaviour change inter-ventions for hypercholesterolemia, which reports amean self-efficacy of 4.97 for ‘heart-healthy eating’associated with low cholesterol level. However,Gaughan’s study had only focused on healthy eating,

whereas our study had considered multiple risk factorsincluding diet control. The present study did not findany significant association between the perceived self-efficacy and blood sugar control. As an outcomemeasure of disease control, the fasting blood sugarreport may not be a reliable method since it depends onmany factors. Furthermore, an actual good glycaemiccontrol can be achieved through a good behaviouralapproach as well as a change in diet and drugs even ina short-term basis. A more suitable measure would beusing HbA1c test, which was not practical due to thetime and resource limitations of the present study. Thishas been demonstrated in a study done in Myanmar onthe prevalence of glycaemic control and its associatedfactors among diabetic patients, which reports asignificant association of high self-efficacy level withgood glycaemic control by assessing the glycaemiccontrol using HbA1c (18).

This study was conducted in BH Mulleriyawa,which covers the target population. However, they maynot represent the clinic patient populations of other areasof the country. Therefore, the results cannot begeneralized to the elderly patient population as a whole.Furthermore, the study design was a cross-sectionaldesign which has the limitation of assessing causativeassociations between self-efficacy and risk factors. Acohort study design would be best to assess theoutcomes of disease control with the continuation ofchronic disease self-management programme, whichcould assess the temporality between perceived self-efficacy and risk factor control. Although maximumefforts were taken to minimize the information bias,the level of perceived self-efficacy was assessed usingan interviewer-administered questionnaire, which mayhave influenced the results.




During the planning and implementation of chronicdisease management among elderly patients, particularemphasis should be given to their socio-economiccharacteristics and social determinants. Assessmentof self-efficacy before the initiation of healthy behaviourpractices would assist in identifying patients’ level ofconfidence in chronic disease self-management. It willdirect the healthy behaviour change programmes tobe more focused at individual level, which will lead toachieving better risk factor reduction. In clinics, elderlypatients need to be given guidance to improve skills onchronic disease self-management covering all tendomains of the scale holistically. It should be doneregularly through a multi-disciplinary team as the elderlyare more vulnerable to cognitive impairment. Furtherresearch studies should be conducted longitudinally toassess the temporality of perceived self-efficacy andits determinants.


• Self-management of chronic diseases inelderly depends on their level of perceivedself-efficacy.

• Level of self-efficacy among elderly isassociated with socio economic charac-teristics and co-morbidities.

• Improving self-managing skills in elderly canimprove their level of self-efficacy.

• Healthy behaviour change programmesfocusing on perceived self-efficacy will im-prove self-management of chronic diseases

in elderly.

Authors Declarations

Competing interests: Authors declare that they haveno conflicts of interests.

Ethics approval and consent to participate: Ethicsapproval was granted by the Ethics Review Committeeof the Faculty of Medicine, University of Colombo(reference number EC-17-096).

Funding: Self-funded.

Author contributions: NRY conducted the researchas principal investigator. MSDW contributed as thetechnical supervisor of the research project.

References

1. Department of Census & Statistics. National Surveyon Self-reported Health. Colombo: Ministry ofNational Policies and Economic Affairs, 2014.

2. Health Economics Cell. Sri Lanka National HealthAccounts. Colombo, Ministry of Health, Nutrition &Indigenous Medicine, 2016.

3. Lorig KR, Sobel DS, Stewart AL, Brown BW, BanduraA, Ritter P, et al. Evidence suggesting that a chronicdisease self-management program can improve healthstatus while reducing hospitalization: a randomizedtrial. Medical Care 1999; 37(1): 5-14.

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7. Bandura A. Self-Efficacy. Encyclopedia of HumanBehavior 1994; 4(1994): 71-81.

8. Daniali SS, Darani FM, Eslami AA, Mazaheri M.Relationship between self-efficacy and physicalactivity, medication adherence in chronic diseasepatients. Advanced Biomedical Research 2017; 6: 63.

9. Vellone E, Fida R, D’Agostino F, Mottola A, Juarez-Vela R, Alvaro R, et al. Self-care confidence may bethe key: a cross-sectional study on the associationbetween cognition and self-care behaviors in adultswith heart failure. International Journal of NursingStudies 2015; 52(11): 1705-1713.

10. Charan J & Biswas T. How to calculate sample size fordifferent study designs in medical research? IndianJournal of Psychological Medicine 2013; 35(2):121-126.

11. Lorig K, Stewart A, Ritter P, González V, Laurent D,Lynch J. Outcome measures for health education andother health care interventions. Thousand Oaks CA:Sage Publications, 1996.

12. Bradford R, Finney LJ, Jennifer WH, Sauver LS,Wilson P. Health self-efficacy among populations withmultiple chronic conditions: the value of patient-centered communications. Advances in Therapy 2016;33(8): 1440-1451.

13. Pati S, Swain S, Hussain MA, Van Den Akker M,Metsemakers J, Knottnerus JA, et al. Prevalence andoutcomes of multimorbidity in South Asia: asystematic review. BMJ Open 2015; 5(10): e007235.



14. Kowal P, Arokiasamy P, Afshar S, Pati S, SnodgrassJJ. Multimorbidity: health care that counts “past one”for 1·2 billion older adults. Lancet 2015; 385(9984):2252-2253.

15. Warren-Findlow J, Seymour RB, Huber LRB. Theassociation between self-efficacy and hypertensionself-care activities among African Americanadults. Journal of Community Health 2012; 37(1):12-24.

16. Harmell AL, Mausbach BT, Roepke SK, Moore RC,Von Känel R, Patterson TL, et al. The relationshipbetween self-efficacy and resting blood pressure in

spousal Alzheimer’s caregivers. British Journal ofHealth Psychology 2011; 16(2): 317-328.

17. Gaughan ME. Heart healthy eating self-efficacy: aneffective tool for managing eating behavior changeinterventions for hypercholesterolemia. Topics inClinical Nutrition 2003; 18(4): 229-244.

18. Nyunt SW, Howteerakul N, Suwannapong N,Rajatanun T. Self-efficacy, self-care behaviors andglycemic control among type-2 diabetes patientsattending two private clinics in Yangon, Myanmar.Southeast Asian J Trop Med Public Health. 2010;41(4): 943-951.


Colombo Declaration. JCCPSL 2019, 25 (4) Open Access

COLOMBO Declaration on Epidemiology in South East Asia has been released with the consensus

reached after the deliberations of the 1st South East Asia Regional Group Meeting of International

Epidemiological Association and 24th Annual Scientific Sessions of the College of Community Physicians of

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The Regional Public Health/ Epidemiology Associations who worked on this and deliberated to make it

final are: the College of Community Physicians of Sri Lanka, Epidemiology Association of Bangladesh,

Epidemiology Foundation of India, Indian Association of Preventive and Social Medicine, Indian Public

Health Association, Indian Society for Medical Statistics, Indonesian Public Health Association, Korean

Epidemiology Society and Nepal Public Health Association.

Updates

Colombo declaration on epidemiology in South East Asia



Colombo Declaration. JCCPSL 2019, 25 (4) Open Access


JCCPSL 2019, 25 (4)

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cited in the text. All tables must be typed double spaced, and each

given on a separate page.

Figures

All the figures should be provided as separate files, one figure in

each file, and not embedded in the main manuscript.

HNB Assurance, a Journey of 15 Years with Many Delighted Stakeholders

HNB Assurance PLC (HNBA) is a premier Insurance solutions provider in Sri Lanka. Ranked as the sixth largest Insurance solutions provider in Sri Lanka, HNBA offers a full spectrum of Life Insurance solutions to suit every Insurance need. With a vision of becoming Sri Lanka’s most admired and trusted Insurance partner, HNBA was incorporated in 2001, and remains as a subsidiary of Hatton National Bank PLC (HNB). HNBA has been listed on the Colombo Stock Exchange since 2003 and currently holds a market share of 5.6% with a market capitalization of Rs. 2.9 Billion. HNBA has expanded its services throughout the country with a service network of 56 Branches. Following the Regulatory and Legislative requirements, HNB General Insurance Limited (HNBGI) was created in 2015. HNBGI remains a fully owned subsidiary of HNBA and offers a range of Motor and Non-motor Insurance solutions. HNBGI is listed among the top ten General Insurance service providers in Sri Lanka.

HNBA offers a range of comprehensive Insurance solutions ranging from Life Plans,

Mortgage Protection Plans, Group Insurance Plans, Child Insurance Plans and Retirement Insurance Plans. HNBGI specializes in Motor and Non-motor Insurance Plans ranging from a diverse product portfolio of Motor Insurance and Non-motor Insurance solutions such as; Home Insurance, Health Insurance, Fire Insurance, Travel Insurance, Marine Insurance and Takaful Insurance Solutions.

HNBA is rated within the Top 100 Brands and the Top 100 companies in Sri Lanka by

LMD and has secured a rating of A (lka) by Fitch Ratings Lanka for “National Insurer Financial Strength Rating” and “National Long-term Rating” and has won multiple awards and accolades for Brand Excellence, Digital Marketing and HR Excellence as well as for its Integrated Annual Reports. For further information, contact HNB Assurance on 0114 384 384 or access: www.hnbassurance.com. And HNB General Insurance on 0114 883 883 or access: www.hnbgeneral.com.

http://www.hnbassurance.com/

http://www.hnbgeneral.com/

Documents

ISSN 1391-3174 Volume 25 - Issue 4 - December 2019the decision of reverting back to MMR 1st dose at 9 months, and this 2-dose schedule at 9 months and at 3 years has continued to date