Effectiveness of Household Lockable Pesticide Storage to Reduce Pesticide Self-Poisoning in Rural Asia: a Community-Based Cluster Randomised Controlled Trial

Background Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning. Methods We did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496. Findings Between Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80–1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88–1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86–1·08) self-harm events involving all methods. Interpretation We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia

A community-based cluster randomised trial of safe storage to reduce pesticide self-poisoning in rural Sri Lanka: study protocol

BACKGROUND: The WHO recognises pesticide poisoning to be the single most important means of suicide globally. Pesticide self-poisoning is a major public health and clinical problem in rural Asia, where it has led to case fatality ratios 20-30 times higher than self-poisoning in the developed world. One approach to reducing access to pesticides is for households to store pesticides in lockable "safe-storage" containers. However, before this approach can be promoted, evidence is required on its effectiveness and safety. METHODS/DESIGN: A community-based cluster randomised controlled trial has been set up in 44,000 households in the North Central Province, Sri Lanka. A census is being performed, collecting baseline demographic data, socio-economic status, pesticide usage, self-harm and alcohol. Participating villages are then randomised and eligible households in the intervention arm given a lockable safe storage container for agrochemicals. The primary outcome will be incidence of pesticide self-poisoning over three years amongst individuals aged 14 years and over. 217,944 person years of follow-up are required in each arm to detect a 33% reduction in pesticide self-poisoning with 80% power at the 5% significance level. Secondary outcomes will include the incidence of all pesticide poisoning and total self-harm. DISCUSSION: This paper describes a large effectiveness study of a community intervention to reduce the burden of intentional poisoning in rural Sri Lanka. The study builds on a strong partnership between provincial health services, local and international researchers, and local communities. We discuss issues in relation to randomisation and contamination, engaging control villages, the intervention, and strategies to improve adherence

Foreign Direct Investment in Sri Lanka: Determinants and Impact

Sri Lanka is a relatively small sized island economy possessing significant resource and location advantages and demonstrating impressive human capital indicators, which only few countries are fortunate to have. At the same time, the country is recovering from nearly three decades of civil war, which ended in 2009. However, Sri Lanka has performed poorly in terms of attracting FDI. Research in FDI in the context of Sri Lanka is limited. Only a handful of studies (Wijeweera & Mounter, 2008; Athukorala & Jayasuriya, 2004; Athukorala, 2003; Athukorala, 1995) have looked at FDI in the context of Sri Lanka. To fill the research gap, this thesis attempts to formulate systematic and in-depth studies of FDI in Sri Lanka, investigating the determinants, impact and policy issues. First, efforts are made to provide an analytical piece that set out the environmental context of Sri Lanka before providing details focusing on FDI. This is followed by three empirical chapters on the determinants and impact of FDI in Sri Lanka. With regard to determinants of FDI, special attention is given to civil war, human capital and stock market price level. For the impact, the focus is on the impact of FDI on productivity. Civil war is a major source of political instability and is likely to discourage FDI. Based on the nearly three decades of civil war in Sri Lanka during the period of 1983-2009, the first empirical study demonstrates that presence of war can have a negative effect on incoming FDI. Though this is unsurprising, this study demonstrates different levels of impact of war on FDI in manufacturing and services. The negative effects are much higher in manufacturing than in services. Investigating the impact of war by market-orientation of manufacturing FDI, this study further finds that there is a higher negative impact on FDI in export intensive manufacturing than in market-seeking manufacturing. Human capital is often considered to be a determining factor for FDI. Recent studies also emphasise the importance of stock market in attracting FDI. Given Sri Lanka’s impressive human capital indicators and recent development of stock market, the second research study explores these two determinants by conducting a panel study based on annual FDI inflows to a sample of countries in Asia. It shows that the relationship between human capital and FDI flows was significantly negative for Sri Lanka while, in general, human capital has been a positive determinant of FDI flows to the rest of the countries in the sample. Further analysis shows that Sri Lanka is constrained to capitalise on its human capital due to linguistic limitations of human capital and qualitative weaknesses in the education system. Although the importance of human capital in attracting FDI is widely recognised in the theoretical consideration, empirical evidence is inconclusive, particularly for developing countries. In this context, findings of this study highlight the importance of recognising country specific limitations in human capital in understanding the relationship between human capital and FDI. This study also revealed a significant negative relationship between host country stock market valuations and FDI in the context of Sri Lanka and other countries with under-developed stock markets. These results indicate that cheap assets hypothesis (and expensive assets hypothesis)is likely to be applicable in the context of countries with under-developed stock markets, and therefore, in the context of Sri Lanka. Based on the firm level data for Sri Lanka, the third empirical study revealed that foreign firms are quite distinctive from local firms. Compared to domestic firms, foreign firms are larger, more productive and more profitable. Foreign firms also tend to hire high proportion of skilled workers, pay higher wages and undertake more in-house training programmes. They are more active in R&D and more innovative. They are more export oriented but rely more on inputs of foreign origin. A cross sectional econometric study estimating direct and indirect effects of FDI on firm level labour productivity indicated a positive own firm effects of FDI and negative spillover effects of foreign firms on local firms and other foreign firms in the same sector. In summary, Sri Lanka‘s economy is characterised by a lower level of industrialisation and is narrowly concentrated in a few sectors with little participation in technical intensive sectors. Foreign firms, through their distinctive characteristics identified in this thesis, are likely to bring in much needed expertise and skills that could help to overcome these structural deficiencies. However, Sri Lanka’s mediocre performance in attracting FDI, poor performance in attracting FDI into technology intensive sectors, and absence of positive spillovers from foreign firms to local firms may all have resulted in poor performance of local firms in terms of upgrading their firm specific capabilities. The goal of the national FDI policies are twofold. First a country should attract the right type of FDI. Second, the country should devise appropriate policies to extract benefits from it. It appears that Sri Lanka has performed poorly in both of these aspects, and this has in turn, deprived the country the much needed skills and technologies, and decelerated the development of the country. End of the civil war has given renewed hopes for Sri Lanka. Sri Lanka’s impressive human capital indicators appear as a key strength. However, due to issues with quality of education and linguistic limitations of human capital, the extent to which Sri Lanka can exploit its impressive human capital indicators to lure FDI is rather limited. Weak institutional environment, poorly managed exchange rate policy and poor infrastructure appear to be major issues in terms of boosting future FDI inflows to Sri Lanka

Experimental study of dynamic air permeability for woven fabrics

Dynamic permeability is relevant to textile applications subjected to fluid/gas flow under high pressure, such as automotive airbags, wearable airbags and parachute fabrics. Dynamic permeability can be determined when a porous medium is tested under transient pressure conditions. This paper utilizes a reliable approach to measure and characterize dynamic permeability for woven fabrics. The experimental principle is based on the ideal gas law and the non-linear Forchheimer equation. Compared with static permeability measured under a constant low pressure, the dynamic permeability is an intrinsic property determined by change of fabric geometry and structure due to a high-pressure load. The pressure-induced deformation is identified, including effects on fiber and yarn arrangement, yarn porosity and fabric thickness. The level of deformation is a function of the number of fabric layers and initial pressure drop. The experimental results show that the dynamic permeability is higher than the static permeability for loose fabric, while it is lower for tight fabrics. For tight fabric, more fabric layers and a lower initial pressure can reduce the difference between the static and the dynamic permeability. Analytical models are used to explain and predict both static and dynamic permeability

Symptom burden in chronic kidney disease; a population based cross sectional study

Abstract Background Physical and psychological symptoms are among main manifestations of Chronic Kidney Disease (CKD). This study aimed to assess the symptom burden and self-perceived severity of symptoms among CKD patients living in a district in Sri Lanka. Method A community based cross-sectional study included a sample of randomly selected 1174 CKD patients from all 19 Medical Officer of Health areas in the district of Anuradhapura. Trained para-medical staff visited the households and administered the locally validated questionnaire to assess the presence and severity of symptoms. The inquiry was on 25 symptoms in a 5 point Likert scale indicating the severity during the previous week. Symptom burden score was constructed by summing each symptom severity score which ranged from 0 to 125. Results A total of 1118 CKD patients participated with a response rate of 95.2%. The mean age was 58.3 (SD 10.8) years and 62.7% were males. A majority were in CKD stage 4 (58.3%). Bone/joint pain was the most experienced symptom (87.6%; 95%CI 85.6–89.5). Loss of libido was the most severe symptom. The median symptom burden score was 35.0 (IQR 20.0–50.0). Multiple linear regression revealed education up to Advanced Level (β −9.176), CKD stage V (β 3.373), being dialyzed (β 20.944), comorbidities (β 4.241) and being employed (β −9.176) to be significant predictors of symptom burden. Conclusions Patients in all stages of CKD experience high symptom burden warranting rigorous measures to relieve symptoms and to improve the well-being of CKD patients

Relevance of heat stress and dehydration to chronic kidney disease (CKDu) in Sri Lanka.

Chronic kidney disease in the absence of hypertension and diabetes is a growing problem among agricultural laborers in tropical and subtropical regions. It is unclear if heat stress and dehydration are risk factors for this form of chronic kidney disease (CKDu). To investigate this relationship, agricultural workers in four villages (n = 261) in North Central Province, Sri Lanka completed the US National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation of heat stress, translated into Sinhalese (July 2017). We constructed a heat stress/dehydration index based on the frequency of 16 symptoms (range 0-32; reliability, 0.84). Workers provided a urine sample for dipstick assessment of urine albumin-creatinine ratio (ACR) and refractometer analysis of urine concentration. Of 261 respondents, 41 participants reported diabetes or chronic kidney disease. They scored higher on the heat stress-dehydration index (10.78 vs. 8.03, p < .01) and were more likely to have ACR > 30 (85.4% vs. 69.4%, p < .05). Among 216 non-pregnant agricultural workers without diabetes or kidney disease (mean age, 46.6; 37% male), villagers in the high-CKDu prevalence area were more likely to show signs of dehydration (for example, greater urine concentration, 1.015 vs. 1.012, p < .05, among males); however, the heat stress-dehydration index overall was not associated with ACR or urine concentration. Because an elevated ACR (proteinuria) is not a reliable marker of early CKDu, additional studies are needed to assess the association between heat stress-dehydration symptoms and risk of CKDu

Additional file 1: of Symptom burden in chronic kidney disease; a population based cross sectional study

Chronic Kidney Disease Symptom Index – Sri Lanka. The symptom index used to assess the prevalence, severity and burden of symptoms among CKD patients in the current study. (PDF 313 kb

A community-based cluster randomised trial of safe storage to reduce pesticide self-poisoning in rural Sri Lanka: study protocol

Abstract Background The WHO recognises pesticide poisoning to be the single most important means of suicide globally. Pesticide self-poisoning is a major public health and clinical problem in rural Asia, where it has led to case fatality ratios 20-30 times higher than self-poisoning in the developed world. One approach to reducing access to pesticides is for households to store pesticides in lockable "safe-storage" containers. However, before this approach can be promoted, evidence is required on its effectiveness and safety. Methods/Design A community-based cluster randomised controlled trial has been set up in 44,000 households in the North Central Province, Sri Lanka. A census is being performed, collecting baseline demographic data, socio-economic status, pesticide usage, self-harm and alcohol. Participating villages are then randomised and eligible households in the intervention arm given a lockable safe storage container for agrochemicals. The primary outcome will be incidence of pesticide self-poisoning over three years amongst individuals aged 14 years and over. 217,944 person years of follow-up are required in each arm to detect a 33% reduction in pesticide self-poisoning with 80% power at the 5% significance level. Secondary outcomes will include the incidence of all pesticide poisoning and total self-harm. Discussion This paper describes a large effectiveness study of a community intervention to reduce the burden of intentional poisoning in rural Sri Lanka. The study builds on a strong partnership between provincial health services, local and international researchers, and local communities. We discuss issues in relation to randomisation and contamination, engaging control villages, the intervention, and strategies to improve adherence. Trial Registritation The trial is registered on ClinicalTrials.gov ref: NCT1146496 (http://clinicaltrialsfeeds.org/clinical-trials/show/NCT01146496).</p