Kosala Saroj Amarasiri Jayasinghe

Social, cultural and economical determinants of diabetes mellitus in Kalutara district, Sri Lanka: a cross sectional descriptive study

IntroductionSri Lanka is a country that is expected to face a high burden of diabetes mellitus (DM). There is a paucity of data on social and demographic determinants of DM, especially in the plantation sector.AimsTo describe social and economic correlates and inequalities of DM in Kalutara District.MethodsA cross sectional descriptive study was carried out among adults over the age of 35 years. A sample of 1300 individuals was selected using stratified random cluster sampling method from 65 Grama Niladari Divisions (GND), which were representative of urban, rural and plantation sectors. Twenty households were randomly selected from each division and one adult was randomly selected from each household. Data were collected using a pre-tested questionnaire. Fasting plasma blood sugar of ≥126mg/dl was used to define DM. Significance of prevalence of diseases and risk factors across different socio-economic strata were determined by chi square test for trend.ResultsOf 1234 adults who were screened (628 males), 202 (14.7%) had DM. Higher DM proportions (16.1%) were seen in the highest income quintile and in those educated up to Advanced Levels (AL) and above (17.3%). Prevalence in the urban, rural and plantation sectors were 23.6%, 15.5% and 8.5% respectively. Prevalence among Sinhalese, Tamils and Muslims were 14.4%, 29.0% and 20.0% respectively. There was a gradient in prevalence according to the unsatisfactory basic needs index of the GND with the highest proportion (20.7%) observed in the richest GND. The highest social status quintile demonstrated the highest proportion (17.4%) with diabetes mellitus.ConclusionThere is a higher prevalence of diabetes mellitus in the more affluent and educated segments of society. There is also a higher prevalence among urban compared to rural and estates. Sri Lanka is in an early stage of the epidemic where the wealthy people are at a higher risk of DM.

A cross sectional survey on social, cultural and economic determinants of obesity in a low middle income setting

IntroductionObesity is an increasing problem in South Asian countries and Sri Lanka is no exception. The socioeconomic determinants of obesity in Sri Lanka, and in neighbouring countries are inadequately described. Aim was to describe social, cultural and economic determinants of obesity in a representative sample from Kalutara District in Sri Lanka.MethodsThis was a cross sectional descriptive study conducted among adults aged 35–64 years. A representative sample was selected using stratified random cluster sampling method from urban, rural and plantation sectors of Kalutara District. Data were collected using a pre-tested questionnaire. A body mass index of 23.01 kg/m2-27.50 kg/m2 was considered as overweight and ≥27.51 kg/m2 as obese. Waist circumference (WC) of ≥ 90 cm and ≥80 cm was regarded as high for men and women respectively. Significance of prevalence of obesity categories across different socio-economic strata was determined by chi square test for trend.ResultsOf 1234 adults who were screened, age and sex adjusted prevalence of overweight, obesity and abdominal obesity (high WC) were 33.2% (male 27.3%/female 38.7%), 14.3% (male 9.2%/female 19.2%) and 33.6% (male 17.7%/female 49.0%) respectively. The Muslims had the highest prevalence of all three obesity categories. Sector, education, social status quintiles and area level deprivation categories show a non linear social gradient while income shows a linear social gradient in all obesity categories, mean BMI and mean WC. The differences observed for mean BMI and mean WC between the lowest and highest socioeconomic groups were statistically significant.ConclusionThere is a social gradient in all three obesity categories with higher prevalence observed in the more educated, urban, high income and high social status segments of society. The higher socioeconomic groups are still at a higher risk of all types of obesity despite other public health indicators such as maternal and infant mortality displaying an established social gradient.

Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala. Participants All adult (age >17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients. Trial registration number NCT02523456; Results.

A retrospective study of physiological observation-reporting practices and the recognition, response, and outcomes following cardiopulmonary arrest in a low-to-middle-income country

Background and Aims: In Sri Lanka, as in most low-to-middle-income countries (LMICs), early warning systems (EWSs) are not in use. Understanding observation-reporting practices and response to deterioration is a necessary step in evaluating the feasibility of EWS implementation in a LMIC setting. This study describes the practices of observation reporting and the recognition and response to presumed cardiopulmonary arrest in a LMIC. Patients and Methods: This retrospective study was carried out at District General Hospital Monaragala, Sri Lanka. One hundred and fifty adult patients who had cardiac arrests and were reported to a nurse responder were included in the study. Results: Availability of six parameters (excluding mentation) was significantly higher at admission (P < 0.05) than at 24 and 48 h prior to cardiac arrest. Patients had a 49.3% immediate return of spontaneous circulation (ROSC) and 35.3% survival to hospital discharge. Nearly 48.6% of patients who had ROSC did not receive postarrest intensive care. Intubation was performed in 46 (62.2%) patients who went on to have ROSC compared with 28 (36.8%) with no ROSC (P < 0.05). Defibrillation, performed in eight (10.8%) patients who had ROSC and eight (10.5%) in whom did not, was statistically insignificant (P = 0.995). Conclusions: Observations commonly used to detect deterioration are poorly reported, and reporting practices would need to be improved prior to EWS implementation. These findings reinforce the need for training in acute care and resuscitation skills for health-care teams in LMIC settings as part of a program of improving recognition and response to acute deterioration.

A survey on socioeconomic determinants of diabetes mellitus management in a lower middle income setting

BackgroundInformation on socioeconomic determinants in the management of diabetes mellitus is scarce in lower middle income countries. The aim of this study is to describe the socioeconomic determinants of management and complications of diabetes mellitus in a lower middle income setting.MethodsCross sectional descriptive study on a stratified random sample of 1300 individuals was conducted by an interviewer administered questionnaire, clinical examinations and blood investigations. A single fasting venous blood sugar of ≥126 mg/dl was considered diagnostic of new diabetics and poor control of diabetes mellitus as HbA1C > 6.5 %.ResultsThere were 202 (14.7 %) with diabetes mellitus. Poor control was seen in 130 (90.7 %) while 71 (49.6 %) were not on regular treatment. Highest proportions of poor control and not on regular medication were observed in estate sector, poorest social status category and poorest geographical area. The annual HbA1C, microalbuminuria, retinal and neuropathy examination were performed in less than 6.0 %. Social gradient not observed in the management lapses. Most (76.6 %) had accessed private sector while those in estate (58.1 %) accessed the state system.The microvascular complications of retinopathy, neuropathy and microalbuminuria observed in 11.1 %, 79.3 % and 54.5 % respectively. Among the macrovascular diseases, angina, ischaemic heart disease and peripheral arterial disease seen in 15.5 %, 15.7 % and 5.5 % respectively. These complications do not show a social gradient.ConclusionsDiabetes mellitus patients, irrespective of their socioeconomic status, are poorly managed and have high rates of complications. Most depend on the private healthcare system with overall poor access to care in the estate sector.