Socioeconomic inequality and determinants of postnatal home visits made by public health midwives: An analysis of the Sri Lanka Demographic and Health Survey.

IntroductionThe impact of socioeconomic inequalities on health outcomes and service delivery is increasingly researched globally. This study assessed the overall and sector-wise socioeconomic inequality in postnatal home visits made by Public Health Midwives (PHMs) in Sri Lanka and decomposed the observed socioeconomic inequality into potential determinants.MethodsData from the Sri Lanka Demographic and Health Survey (SLDHS) 2006-07 were used. Data were collected from ever-married women who gave birth to their last child in 2001 or later (up to 2007). Whether the PHM visited the home to provide postnatal care within one month of the delivery was the health outcome of interest. Sri Lanka is divided into three sectors (areas) as urban, rural, and estate (plantation) based on the geographical location and the availability of infrastructure facilities. Concentration indices were calculated and concentration curves were plotted to quantify the overall and sector-wise socioeconomic inequality. Decomposition analysis using probit regression was performed to estimate the contribution of potential determinants to the observed socioeconomic inequality.ResultsOverall, 83.0% of women were visited by a PHM within one month of the delivery. The highest number of home visits was reported in the rural sector (84.5%) and lowest was reported from the estate sector (72.4%). A pro-poor, pro-rich, and no inequality were observed across urban, rural, and estate sectors respectively. Wealth had a small contribution to the estimated inequality. Province of residence and the education level of women were the main determinants of the observed socioeconomic inequality.ConclusionAddressing the socioeconomic inequality of postnatal home visits made by PHMs should not be seen as a health system issue alone. The associated social determinants of health should be addressed through a multi-sectoral approach encompassing the principles of primary health care

Socioeconomic inequality and determinants of postnatal home visits made by public health midwives:An analysis of the Sri Lanka Demographic and Health Survey

Introduction: The impact of socioeconomic inequalities on health outcomes and service delivery is increasingly researched globally. This study assessed the overall and sector-wise socioeconomic inequality in postnatal home visits made by Public Health Midwives (PHMs) in Sri Lanka and decomposed the observed socioeconomic inequality into potential determinants.Methods: Data from the Sri Lanka Demographic and Health Survey (SLDHS) 2006–07 were used. Data were collected from ever-married women who gave birth to their last child in 2001 or later (up to 2007). Whether the PHM visited the home to provide postnatal care within one month of the delivery was the health outcome of interest. Sri Lanka is divided into three sectors (areas) as urban, rural, and estate (plantation) based on the geographical location and the availability of infrastructure facilities. Concentration indices were calculated and concentration curves were plotted to quantify the overall and sector-wise socioeconomic inequality. Decomposition analysis using probit regression was performed to estimate the contribution of potential determinants to the observed socioeconomic inequality.Results: Overall, 83.0% of women were visited by a PHM within one month of the delivery. The highest number of home visits was reported in the rural sector (84.5%) and lowest was reported from the estate sector (72.4%). A pro-poor, pro-rich, and no inequality were observed across urban, rural, and estate sectors respectively. Wealth had a small contribution to the estimated inequality. Province of residence and the education level of women were the main determinants of the observed socioeconomic inequality.Conclusion: Addressing the socioeconomic inequality of postnatal home visits made by PHMs should not be seen as a health system issue alone. The associated social determinants of health should be addressed through a multi-sectoral approach encompassing the principles of primary health care

Impact of vitamin A supplementation on health status and absenteeism of school children in Sri Lanka

The objective of this study was to determine the impact of Vitamin A supplementation on health status and absenteeism of school children. A randomized double blind placebo controlled trial over a period of 13 months was conducted in a rural area of Sri Lanka involving 613 school children attending Grades 1-5 (aged 5 to 13 years). Children were assigned to either 200,000 IU of Vitamin A (n=297) or placebo (n=316) once every 4 months. Socio-demographic data were obtained at baseline, and anthropometry and haemoglobin concentrations were assessed at baseline and post intervention. Serum vitamin A concentrations were assayed by HPLC in a subgroup of children (n=193) before administration of each dose. School absenteeism was recorded. The two groups of children were similar at baseline in all variables. The subgroup of children was comparable to the main study population. The prevalence of vitamin A deficiency (<20 μg/dL) in the subgroup of children was 8.2%. Changes in anthropometric indices and haemoglobin concentrations were similar in the two groups. The major causes for absenteeism were non-health causes and supplemented children lost a fewer number of school days due to illness than placebo children (p=0.053). Vitamin A concentrations improved with each dose and the improvement was greater with better compliance. Vitamin A supplementation with 200,000 IU every 4 months over 13 months improved vitamin A status and school attendance but not anthropometric status of these children

Treatment seeking behaviour and treatment practices of lymphatic filariasis patients with lymphoedema in the Colombo district, Sri Lanka

This cross-sectional, descriptive study describes the treatment-seeking behavior of 413 lymphoedema patients attending 2 filariasis clinics in the Colombo district, Sri Lanka. A pretested, interviewer-administered questionnaire obtained information regarding sources and types of treatment taken, time taken for diagnosis, and details regarding diethylcarbamazine citrate (DEC) treatment. There was a mean delay of 2.37 years (SD 1.37) in diagnosing filariasis after the first appearance of limb swelling. General practitioners were the most frequent first-contact health care providers and the most visited source overall, followed by government hospitals and Ayurvedic practitioners. Approximately 95% of patients were on DEC treatment ranging from 10 days to 43 years (mean 2.5 years SD ± 1.1). Sixty-one percent of patients reported always having taken the recommended DEC course. Nonsteroidal anti-inflammatory drugs, diuretics, and antibiotics were liberally prescribed. Approximately 97% had sought treatment from a medical practitioner for an acute adenolymphangitis attack. Despite the area being endemic for filariasis, there was a delay in treatment and inappropriate use of DEC in patients with chronic filarial lymphoedema

Physical activity tracking among Sri Lankan adults: findings from a 7-year follow-up of the Ragama Health Study

Limited data are available on physical activity tracking among adults in low- and middle-income countries. Using a longitudinal design, we assessed trends and correlates of physical activity among Sri Lankan adults. Individuals selected through age-stratified random sampling, were screened initially in 2007 (n = 2986) and reevaluated in 2014 (n = 2148). On both occasions, structured interviews and clinical measurements were completed. Approximately 40% of the participants engaged in recommended levels of physical activity both at baseline and follow-up. One-fifth reported increased physical activity at follow-up, a similar proportion reported being persistently inactive or a reduction in physical activity. In the adjusted analysis, being persistently active was associated with male sex, a lower educational level and income, being free of any chronic disease conditions, better self-rated health, and sitting time <8 hours. Our findings support public health interventions to help maintain recommended physical activity levels over time, particularly for subgroups at high-risk of physical inactivity

Epigenome-wide association of DNA methylation markers in peripheral blood from Indian Asians and Europeans with incident type 2 diabetes: a nested case-control study

BACKGROUND: Indian Asians, who make up a quarter of the world’s population, are at high risk of developing type 2 diabetes. We investigated whether DNA methylation is associated with future type 2 diabetes incidence in Indian Asians and whether differences in methylation patterns between Indian Asians and Europeans are associated with, and could be used to predict, differences in the magnitude of risk of developing type 2 diabetes. METHODS: We did a nested case-control study of DNA methylation in Indian Asians and Europeans with incident type 2 diabetes who were identified from the 8-year follow-up of 25 372 participants in the London Life Sciences Prospective Population (LOLIPOP) study. Patients were recruited between May 1, 2002, and Sept 12, 2008. We did epigenome-wide association analysis using samples from Indian Asians with incident type 2 diabetes and age-matched and sex-matched Indian Asian controls, followed by replication testing of top-ranking signals in Europeans. For both discovery and replication, DNA methylation was measured in the baseline blood sample, which was collected before the onset of type 2 diabetes. Epigenome-wide significance was set at p<1 × 10(−7). We compared methylation levels between Indian Asian and European controls without type 2 diabetes at baseline to estimate the potential contribution of DNA methylation to increased risk of future type 2 diabetes incidence among Indian Asians. FINDINGS: 1608 (11·9%) of 13 535 Indian Asians and 306 (4·3%) of 7066 Europeans developed type 2 diabetes over a mean of 8·5 years (SD 1·8) of follow-up. The age-adjusted and sex-adjusted incidence of type 2 diabetes was 3·1 times (95% CI 2·8–3·6; p<0·0001) higher among Indian Asians than among Europeans, and remained 2·5 times (2·1–2·9; p<0·0001) higher after adjustment for adiposity, physical activity, family history of type 2 diabetes, and baseline glycaemic measures. The mean absolute difference in methylation level between type 2 diabetes cases and controls ranged from 0·5% (SD 0·1) to 1·1% (0·2). Methylation markers at five loci were associated with future type 2 diabetes incidence; the relative risk per 1% increase in methylation was 1·09 (95% CI 1·07–1·11; p=1·3 × 10(−17)) for ABCG1, 0·94 (0·92–0·95; p=4·2 × 10(−11)) for PHOSPHO1, 0·94 (0·92–0·96; p=1·4 × 10(−9)) for SOCS3, 1·07 (1·04–1·09; p=2·1 × 10(−10)) for SREBF1, and 0·92 (0·90–0·94; p=1·2 × 10(−17)) for TXNIP. A methylation score combining results for the five loci was associated with future type 2 diabetes incidence (relative risk quartile 4 vs quartile 1 3·51, 95% CI 2·79–4·42; p=1·3 × 10(−26)), and was independent of established risk factors. Methylation score was higher among Indian Asians than Europeans (p=1 × 10(−34)). INTERPRETATION: DNA methylation might provide new insights into the pathways underlying type 2 diabetes and offer new opportunities for risk stratification and prevention of type 2 diabetes among Indian Asians. FUNDING: The European Union, the UK National Institute for Health Research, the Wellcome Trust, the UK Medical Research Council, Action on Hearing Loss, the UK Biotechnology and Biological Sciences Research Council, the Oak Foundation, the Economic and Social Research Council, Helmholtz Zentrum Munchen, the German Research Center for Environmental Health, the German Federal Ministry of Education and Research, the German Center for Diabetes Research, the Munich Center for Health Sciences, the Ministry of Science and Research of the State of North Rhine-Westphalia, and the German Federal Ministry of Health

Epigenome-wide association of DNA methylation markers in peripheral blood from Indian Asians and Europeans with incident type 2 diabetes:A nested case-control study

BACKGROUND: Indian Asians, who make up a quarter of the world’s population, are at high risk of developing type 2 diabetes. We investigated whether DNA methylation is associated with future type 2 diabetes incidence in Indian Asians and whether differences in methylation patterns between Indian Asians and Europeans are associated with, and could be used to predict, differences in the magnitude of risk of developing type 2 diabetes. METHODS: We did a nested case-control study of DNA methylation in Indian Asians and Europeans with incident type 2 diabetes who were identified from the 8-year follow-up of 25 372 participants in the London Life Sciences Prospective Population (LOLIPOP) study. Patients were recruited between May 1, 2002, and Sept 12, 2008. We did epigenome-wide association analysis using samples from Indian Asians with incident type 2 diabetes and age-matched and sex-matched Indian Asian controls, followed by replication testing of top-ranking signals in Europeans. For both discovery and replication, DNA methylation was measured in the baseline blood sample, which was collected before the onset of type 2 diabetes. Epigenome-wide significance was set at p<1 × 10(−7). We compared methylation levels between Indian Asian and European controls without type 2 diabetes at baseline to estimate the potential contribution of DNA methylation to increased risk of future type 2 diabetes incidence among Indian Asians. FINDINGS: 1608 (11·9%) of 13 535 Indian Asians and 306 (4·3%) of 7066 Europeans developed type 2 diabetes over a mean of 8·5 years (SD 1·8) of follow-up. The age-adjusted and sex-adjusted incidence of type 2 diabetes was 3·1 times (95% CI 2·8–3·6; p<0·0001) higher among Indian Asians than among Europeans, and remained 2·5 times (2·1–2·9; p<0·0001) higher after adjustment for adiposity, physical activity, family history of type 2 diabetes, and baseline glycaemic measures. The mean absolute difference in methylation level between type 2 diabetes cases and controls ranged from 0·5% (SD 0·1) to 1·1% (0·2). Methylation markers at five loci were associated with future type 2 diabetes incidence; the relative risk per 1% increase in methylation was 1·09 (95% CI 1·07–1·11; p=1·3 × 10(−17)) for ABCG1, 0·94 (0·92–0·95; p=4·2 × 10(−11)) for PHOSPHO1, 0·94 (0·92–0·96; p=1·4 × 10(−9)) for SOCS3, 1·07 (1·04–1·09; p=2·1 × 10(−10)) for SREBF1, and 0·92 (0·90–0·94; p=1·2 × 10(−17)) for TXNIP. A methylation score combining results for the five loci was associated with future type 2 diabetes incidence (relative risk quartile 4 vs quartile 1 3·51, 95% CI 2·79–4·42; p=1·3 × 10(−26)), and was independent of established risk factors. Methylation score was higher among Indian Asians than Europeans (p=1 × 10(−34)). INTERPRETATION: DNA methylation might provide new insights into the pathways underlying type 2 diabetes and offer new opportunities for risk stratification and prevention of type 2 diabetes among Indian Asians. FUNDING: The European Union, the UK National Institute for Health Research, the Wellcome Trust, the UK Medical Research Council, Action on Hearing Loss, the UK Biotechnology and Biological Sciences Research Council, the Oak Foundation, the Economic and Social Research Council, Helmholtz Zentrum Munchen, the German Research Center for Environmental Health, the German Federal Ministry of Education and Research, the German Center for Diabetes Research, the Munich Center for Health Sciences, the Ministry of Science and Research of the State of North Rhine-Westphalia, and the German Federal Ministry of Health