Summary Background COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios. Methods In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective. Findings Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka. Interpretation The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study. Funding The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust.

IntroductionUncontrolled hypertension is the leading risk factor for mortality globally, including low-income and middle-income countries (LMICs). However, pathways for seeking hypertension care and patients’ experience with the utilisation of health services for hypertension in LMICs are not well understood.ObjectivesThis study aimed to explore patients’ perspectives on different dimensions of accessibility and availability of healthcare for the management of uncontrolled hypertension in Sri Lanka.SettingPrimary care in rural areas in Sri Lanka.Participants20 patients with hypertension were purposively sampled from an ongoing study of Control of Blood Pressure and Risk Attenuation in rural Bangladesh, Pakistan, Sri Lanka.MethodWe conducted in-depth interviews with patients. Interviews were audio-recorded and transcribed into local language (Sinhala) and translated to English. Thematic analysis was used and patient pathways on their experiences accessing care from government and private clinics are mapped out.ResultsOverall, most patients alluded to the fact that their hypertension was diagnosed accidentally in an unrelated visit to a healthcare provider and revealed lack of adherence and consuming alternatives as barriers to control hypertension. Referring to the theme ‘Accessibility and availability of hypertension care’, patients complained of distance to the hospitals, long waiting time and shortage of medicine supplies at government clinics as the main barriers to accessing health services. They often resorted to private physicians and paid out of pocket when they experienced acute symptoms attributable to hypertension. Considering the theme ‘Approachability and ability to perceive’, the majority of patients mentioned increasing public awareness, training healthcare professionals for effective communication as areas of improvement. Under the theme ‘Appropriateness and ability to engage’, few patients were aware of the names or purpose of their medications and reportedly missed doses frequently. Reminders from family members were considered a major facilitator to adherence to antihypertensive medications. Patients welcomed the idea of outreach services for hypertension and health education closer to home in the theme ‘Things the patients reported to improve the system’.ConclusionPatients identified several barriers to accessing hypertension care in Sri Lanka. Measures recommended improving hypertension management in Sri Lanka including public education on hypertension, better communication between healthcare professionals and patients, and efforts to improve access and understanding of antihypertensive medications.Trial registration number NCT02657746.

BackgroundThe Ottawa Charter defines Health Promotion as the 'process of enabling people to increase control over, and to improve, their health'. The National Health Promotion Policy recognizes health promotion as an efficient and cost effective approach to promote health in Sri Lanka. The Public Health Midwife (PHM) is the grass root level health worker responsible for promoting the health of communities in Sri Lanka. Their knowledge regarding health promotion has not been assessed. The main aim of this study was to describe their knowledge on health promotion and associated factors. Methods A cross sectional descriptive study was conducted among all PHMM (N=364) in the Kandy District who were eligible, using a self-administered questionnaire. Level of knowledge was based on scores obtained for responses to close ended questions and case scenarios. Results Knowledge on health promotion was 'poor' among 238 (65.4%). Incorrect labeling of other activities as activities using a health promotion approach was common 257(70.6%). Training programmes 285(73.9%) were the commonest source of knowledge while 95(26%) were never trained on health promotion approach during their career. The factors that were significantly associated with a level of 'good' knowledge on health promotion in multivariate analysis were; experience in the public health field less than 20 years (p=0.012), participating in training programmes on health promotion (p=0.03) and experience in implementing health promotion programmes (p=0.04). Conclusions The study concludes that PHMM in the Kandy District have a 'poor' level of knowledge on health promotion and recommends increasing training opportunities and improving opportunities for application to improve the situation.

Tobacco is a determinant of poverty and a barrier for development. Monaragala, a rural, agricultural district, reports the highest poverty-related indicators in southern Sri Lanka. A cross-sectional study was used to describe the household expenditure on tobacco and its association with food- and education-related expenditures at household level. This study used a 4-stage cluster sampling method to recruit a representative sample of 1160 households. Response rate was 98.6%. Median monthly household income was LKR 20 000 (interquartile range [IQR] = LKR 12 000-30 000). The median monthly expenditure on tobacco was LKR 1000 (IQR = LKR 400-2000) with the highest spending tertile reporting a median of LKR 2700 (IQR = LKR 2000-3600).The proportionate expenditure from the monthly income ranged from 0.0% to 50% with a median of 5.0% (IQR = 2.0-10.0) and a mean of 7.4% (7.6). The poorest reported the highest mean proportionate expenditure (9.8%, SD = 10) from the household income. Household expenditure on tobacco negatively associated with expenditure on education.

ObjectiveHealthy lifestyle centres (HLCs) in Sri Lanka provide screening and lifestyle modification services targeting major non-communicable diseases (NCDs). Even though the service is highly accessible and affordable, HLCs are underused by its target population (adults >35 years). We aimed to explore the factors that influence the decision-making process of utilisation of HLCs in Sri Lanka.SettingTwo districts (Gampaha and Kalutara) from the highest populous province (Western) located adjacent to the capital district of Sri Lanka.ParticipantsNine service providers, 37 HLC clients and 52 community participants were selected using judgemental, convenient and purposive sampling methods. Theoretical sampling method was used to decide the sample size for each category.MethodA qualitative study design based on constructivist grounded theory was used. Data collected using in-depth interviews and focus group discussions during January to July 2019 and were analysed using the constant comparison method.ResultsThe decision-making process of utilisation of HLCs was found to be a chain of outcomes with three main steps, such as: intention, readiness and utilisation. Awareness of HLCs, positive attitudes on health, intrinsic or extrinsic motivators, positive attitudes on NCDs and screening were internal factors with a positive influence on intention. Readiness was positively influenced by positive characteristics of the HLCs. It was negatively influenced by negative attitudes on staff and services of HLCs and negative past experiences related to services in state healthcare institutions and HLCs, service provider-related barriers and employment-related barriers. Family-related factors, social support and norms influenced both intention and readiness, either positively or negatively.ConclusionThe decision-making process of utilisation of HLCs links with factors originating from internal, family, service provider and societal levels. Thus, a multifactorial approach that addresses all these levels is needed to improve the utilisation of HLCs in Sri Lanka.