Sri Lankan Setting Research Articles

Validation of the Sinhala version of the Autism Treatment Evaluation Checklist (ATEC)

Background: Autism Spectrum Disorder is a neuro developmental disorder which has a trend in its increasing prevalence globally. Measuring the outcome of intervention will have a great value for parents and clinicians. At present, there are no tools validated in the Sri Lankan setting to assess treatment outcomes in Autism Spectrum Disorder. Autism Treatment Evaluation Checklist (ATEC) is a self-administered questionnaire in Sinhala for parents/caregivers that is a feasible method of evaluating outcome in a busy clinic.Aims: This study was conducted to translate and culturally adapt the ATEC to the Sinhala language and to establish the validity and reliability of the translation to the local setting.Methods: Permission was sought from the developers of the ATEC questionnaire and ethical approval was obtained for the study. Study was conducted in two stages. In the first stage, ATEC was translated using the translation-back translation method. An expert panel produced a pre-final questionnaire which was pre-tested prior to formulating the final Sinhala version of ATEC. The second stage of the study was conducted to establish validity and reliability of Sinhala ATEC questionnaire in the Sri Lankan popu-lation. Content validity was assured in each step of the translation by the expert committee. Construct validity of the Sinhala ATEC questionnaire was assessed by comparing the sample of 119 parent/caregiver filled final version of the Sinhala ATEC score against the Consultant Child and Adolescent Psychiatrist assessment of the same children conducted independently and recorded according to DSM-5 (level 1, 2 or 3). Test-retest reliability was determined by the same parent/caregiver filling the Sinhala ATEC one week later, in a sample of 14 children. Intra-rater reliability was taken by com-paring 18 pairs of parents/caregivers Sinhala ATEC scores for the same child.Results: Sinhala ATEC showed high validity and reliability. Its concurrent validity has a strong positive Pearson correlation of 0.856 with the Consultant Psychiatrist assessment. Correlation was higher in total score and as well as in subscale II- Sociability score of the Sinhala ATEC. Internal consistency was revealed by Cronbach’s alpha 0.778. Cut off points to distinguish mild autism spectrum disorder from the rest taken as “48 or less” with sensitivity 82%, specificity 94% and area under the curve 0.968. Cut off to separate severe autism spectrum disorder from the rest were taken as “76 or more” with sensitivity 84%, specificity 90%and area under the curve 0.971. Reliability tests, intra class correlation was 0.98 and 0.96 for test-retest and intra rater reliability showed high reliability of Sinhala ATEC. For developing burnout in this study population.Conclusions: Translated version of Sinhala ATEC is suitable for the use in the Sri Lankan population as it shows high validity and reliability. However, further studies are recommended in other areas of the country to assess its usefulness across diverse subcultures and clinical settings.

Screening for familial hypercholesterolemia in Sri Lanka: A laboratory-based multicenter study

Background: Familial hypercholesterolemia (FH) is a genetic lipid disorder characterized by increased concentrations of low-density lipoprotein cholesterol (LDL-C) in the circulatory system, resulting in a markedly increased vulnerability in the development of atherosclerotic cardiovascular disease at an early age. The prevalence of FH in a Sri Lankan setting was identified in a tertiary hospital laboratory and a primary care family practice laboratory by performing opportunistic screening for index cases using laboratory criteria as a starting point. Methodology: This study assessed the prevalence of FH using the Dutch Lipid Clinic Network (DLCN) Criteria score. The evaluation was conducted over 6 months in both a tertiary hospital laboratory and a primary care laboratory. Once patients were identified by high LDL, the patients were recruited to the study and assessed clinically. Secondary causes were excluded, and clinical evaluations of the patients were done to see if they had clinical features of FH. Results: Of the total of 3039 serum lipid profiles that were reviewed, there were 42 (1.38%) lost to follow-up. There were 72 samples with high LDL (190 mg/dL) ≥4.9 mmol/L (190 mg/dL). Of the patients with LDL >4.9 mmol/L, 16 (0.52%) cases with identified secondary causes (untreated hypothyroidism [n = 13], nephrotic syndrome [n = 3], and no secondary investigations [n = 14]) were excluded. In total, the point prevalence of likely phenotypical FH based on DLCN (probable or confirmed) and an LDL-C >4.9 mmol/L was calculated as approximately 14/3039 (1:217). Conclusions: The point prevalence of FH in patients undergoing lipid profile testing in a tertiary hospital laboratory and a primary care laboratory was 1:217 which is comparable with the prevalence of FH in the general population in the world (based on 1 in 200–250). Based on the laboratory criteria, initiating screening for FH in resource-limited settings could be an effective screening strategy to identify patients with FH. Until national screening programs are established, the laboratory as an avenue to trigger screening for FH is useful in lower-middle-income countries like Sri Lanka.

A rare case of Systemic Lupus Erythematosus presenting as acute myopericarditis with bilateral pleural effusions.

Acute myopericarditis is a rare presentation in clinical practice with multiple aetiologies. Eventhough cardiac manifestations are known to be present in up to 50% of Systemic Lupus Erythematosus (SLE) patients, acute myopericarditis is an uncommon presentation, occurring in up to 1% of patients. Here we report a patient who presented with fever and pleuritic type chest pain and was managed as acute myopericarditis with bilateral exudative pleural effusions and later diagnosed to have SLE. The patients were initially treated with nonsteroidal anti-inflammatory drugs and later with steroids and hydroxychloroquine. Early diagnosis of myopericarditis and identification of the aetiology is essential to halt the progression of disease. Pericarditis due to Tuberculosis need to be excluded before starting steroids in the Sri Lankan setting.

An ABO-incompatible living donor liver transplant in an infant with acute liver failure in the Sri Lankan setting

Liver transplant (LT) is the standard therapy for medically refractory acute liver failure (ALF). Finding a deceaseddonor graft in an emergency is challenging and often overcome by living-donation. Blood group matching is practised for LT though ABO-incompatible liver transplant (ABOi-LT) is performed inselected circumstances. We report an infant who underwent successful ABOincompatible living donor LT for ALF of unknown aetiology. This being the country’s first ABOi-LT, the youngest LT recipient to date and the youngest receiving emergency LT for ALF; we describe the novel experience at a resource-limited setting in Sri Lanka (SL).

Out-of-Pocket Expenditure for Antenatal Care Amid Free Health Care Provision: Evidence From a Large Pregnancy Cohort in Rural Sri Lanka.

Global evidence suggests that high out-of-pocket (OOP) expenditure negatively affects health service utilization and creates an economic burden on households during pregnancy. This study aimed to estimate the magnitude and associated factors of OOP expenditure for antenatal care (ANC) in a rural Sri Lankan setting by following up with a large pregnancy cohort (The Rajarata Pregnancy Cohort [RaPCo]) in Anuradhapura District, Sri Lanka. Data were collected from July 2019 to May 2020. An interviewer-administered questionnaire was used to collect socioeconomic data and OOP expenditures in the first trimester. Self-administered questionnaires were used monthly to collect OOP expenditures in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics, nonparametric statistics, and a multiple linear regression model. The majority of participants used both government and private health facilities for ANC. The mean (standard deviation [SD]) OOP expenditure per ANC visit was US$4.18 (US$4.19), and the mean (SD) OOP expenditure for total ANC was US$57.74 (US$80.96). Pregnant women who used only free government health services also spent 28% and 14% of OOP expenditure on medicines and laboratory investigations. Household income (P<.001), household expenditure (P<.1), used health care mode (P<.05), maternal morbidities (P<.05), and the number of previous pregnancies (P<.1) were the statistically significant independent predictors of OOP expenditure. OOP expenditure per visit for ANC equals half of the daily household expenditure. Despite having freely available government health facilities, most pregnant women tend to use both government and private health facilities and incur higher OOP expenditure. Free government health care users also incur a direct medical OOP expenditure for medicines and laboratory investigations. Monthly household income, expenditure, used health care mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOP expenditure.

Public and patient involvement (PPI) in systematic reviews: challenges in Sri Lankan setting and recommendations for the potential way forward

Introduction: Public and patient involvement (PPI) in systematic reviews is an area of growing interest due to the importance of ensuring that research is relevant, appropriate and acceptable to the people it seeks to benefit.Objectives: To provide an overview of the rationale and methods for involving the public in systematic reviews, as well as identify common and specific challenges associated with it while carrying it out in low-resource setting in a country like Sri LankaMethods: The report begins with an introduction to PPI and its importance in health research, followed by a description of PPI involvement in each step of a systematic review. The report then explores the resources available to guide researchers on how to incorporate PPI into systematic reviews and identifies the barriers that exist to effective PPI.Conclusions &amp; Recommendations: The report concludes by highlighting the importance of PPI in systematic reviews and the need for more work to promote greater engagement and involvement of patients and the public in research in Sri Lankan context.

Assessing the construction site supervisory attributes in effectuating mathematical theories and applications to construction operations

PurposeSite supervision features largely influence the productivity status of construction operational processes. This study aims to use a case study containing mixed methods to test the site supervisory traits in applying mathematical theories to construction operations for directing supervisory capabilities under various operational characteristics.Design/methodology/approachA total of 62 construction site supervisors were trained as part of a new apprenticeship programme. Through literature reviews and expert consultations, grading criteria were designed with various degrees of descriptions and score ratings. The supervisory attributes were evaluated under seven competency element characteristics mapped with the relevant learning domains.FindingsThe results demonstrate a detailed sectional view of performance ratings of supervisors under different characteristics of competency factors with the validity, reliability, applicability and generalisability assurance of the research findings using relevant statistical tests and expert evaluations.Research limitations/implicationsThough the research applications were engaged directly with the construction industry in the Sri Lankan setting, other developing countries and emerging industries can also employ equivalent tactics to attain similar outcomes in their industry-based operations.Originality/valueThe research findings have led to producing a new guide that makes significant impacts on deciding the capability levels in construction supervisory attributes while executing problem-solving applications in construction planning and operational processes. Accordingly, the findings push to open a gate to intake advanced cognitive attributes towards addressing the industry's knowledge gap on how the problem-solving-based apprenticeship protocols need to be linked with the supervision features.

Parental knowledge and attitudes about child sexual abuse and their practices of sex education in a Sri Lankan setting.

Parental knowledge and attitudes about child sexual abuse and their practices of sex education in a Sri Lankan setting.

Live donor profile in paediatric liver transplantation: a three-year experience

Introduction: Liver transplantation for paediatric patients was started in Sri Lanka in 2020, focusing on living donors. This retrospective study examines the donors evaluated at the Colombo North Centre for Liver Disease for the first twelve paediatric liver transplants.Methods: Related donors and undirected donors were encouraged. Donor assessment was done in stages: initial screening, haematological investigations, imaging, and ethical approval. Twelve donors were selected for ethical approval and donor surgery.Results: A total of 36 donors underwent workup. 24 were rejected, and 12 were accepted. The reasons to reject were abnormal LFTs and fatty liver disease 16 (67%), the presence of comorbidities 5 (21%), and unfavourable anatomy 2 (8%). In one donor (4%), surgery was abandoned due to rising intraoperative lactate levels. Of the rejected group, 17 were males and 7 were females, and the median age was 33 (Range 43-20) years. 12 donors (7 related and 5 non-related) had a median age of 33 (range 25-41) and a median BMI of 19.25 (16.3-22.5) and a male-to-female ratio of 7:5. Left lateral sector donation was done in 6 while left lobe donation in 4 and right lobe donation in 2 were done respectively.Conclusion: Fatty liver disease was the predominant cause of donor disqualification. Living donor paediatric liver transplantation is feasible in the Sri Lankan setting. It would be a safer option due to the detailed donor workup given the high prevalence of fatty liver disease in the population.

Factors Contributing to Increased Building Fire Incidents in Sri Lanka

Aim: Despite the existence of established fire codes, the frequency of building fires in Sri Lanka has been on the rise in recent years. The primary objective of building codes is to ensure minimum acceptable fire safety standards in buildings, but deviations from the code can increase fire risk factors and exacerbate the severity of fires. This study aims to identify and rank such risk factors in three stages, beginning with design and concluding with maintenance. Introduction: Metodologia tego badania obejmuje podejście jakościowe, które uwzględnia przegląd literatury, ankietę opartą na kwestionariuszu oraz częściowo ustrukturyzowane wywiady ze specjalistami z branży pożarniczej. Kwestionariusz został opracowany w kontekście Sri Lanki. Wykwalifikowany i doświadczony zespół specjalistów ds. pożarnictwa został poproszony o uszeregowanie przygotowanego kwestionariusza, który został podsumowany w dwunastu kategoriach ryzyka. Chociaż metod oceny ryzyka pożarowego jest niewiele, w niniejszym badaniu zastosowano metodę wskaźnika względnej istotności. Wyniki uzyskane z pięciostopniowej skali Likerta, gdzie „1” to najmniejszy poziom ryzyka, a „5” to najwyższy poziom ryzyka, zostały przekonwertowane w celu identyfikacji priorytetów z RII. Project and methods: The methodology of this research consists of a qualitative approach, which includes a literature review, a questionnaire-based survey, and semi-structured interviews with fire industry professionals. The questionnaire was developed in a Sri Lankan context following an extensive literature review that included the author's experience. The qualified and experienced panel of fire specialists was asked to rank the prepared questionnaire, which was summarized into twelve risk categories. Though there are few fire risk ranking methods, the relative importance index method was applied in this research as it is simple and easy to use for ranking the risk factors. The results obtained from the five-point Likert scale, where “1” is the least risk level and “5” is the highest risk level, were converted to identify priorities with RII. Results: In the Sri Lankan context, it was discovered that issues with design and the approval of inaccurate building plans are the first and second major isk factors, respectively, out of the twelve categories identified. Thus, it was evident that deviations made at the design stage are the most significant risk factors, according to the Sri Lankan setting. Most of the mistakes that are made at the design stage cannot be rectified at a later stage under normal conditions, as it could incur huge costs to change the building structures. Conclusions: The study summarizes twelve factors that contribute to fire-related incidents in Sri Lankan buildings. Among these factors, the survey data shows that incorrect building design and the approval of inaccurate building plans for construction are the primary contributors to the high frequency and severity of fire-related incidents. Despite the availability of comprehensive fire safety regulations in Sri Lanka, the research reveals a significant gap in their implementation, from design to maintenance. These findings stress the importance of incorporating fire and safety management criteria into the building design stage, covering both construction and subsequent maintenance, to prevent fire incidents in Sri Lanka. Keywords: prescriptive fire codes, fire risk factors, fire risk assessment, fire risk ranking, building fire safety

Macroeconomic Determinants of Income Inequality in Sri Lanka

Even though several different income redistribution plans have been put in place by succeeding governments, income disparity has persisted in Sri Lanka over the past 50 years. Using secondary data from 1978 to 2021, this study aims to pinpoint the macroeconomic factors that contribute to income inequality in Sri Lanka. The basic estimating method is the autoregressive distributed lag model (ARDL), a rarely used analytical tool in Sri Lanka. The results show that the primary macroeconomic predictors of income inequality in Sri Lanka among the selected variables are government spending, trade openness, average prices, the share of agriculture in the GDP, and per capita GDP. Additionally, the findings demonstrate that trade openness and government spending cause income inequality, supporting Barro's theory. Additionally, the average price level and the percentage of agriculture in the GDP have helped to lessen income disparity in the nation. Per capita GDP also shows a marginal significance, supporting Kuznets’ view, which stresses that increasing a country’s GDP increases inequality. However, financial deepening and secondary school enrolment ratios do not show significant impacts emphasizing that financial and education factors do not contribute to inequality in the Sri Lankan setting. The study suggested that policy priority should be given to developing the agricultural sector and catching the spillover effect of international trade to reduce income inequality. That would ultimately lead to lowering trade-induced inequality. Furthermore, a crucial policy choice to lower the expense of daily life for the poor is to maintain a constant overall price level. Government transfer programs should primarily target the poor and maintain a proper monitoring mechanism to capture the outcome of those transfers also important. Currently, such a follow-up system is not in place; therefore, the government’s targets of reducing inequality couldn’t be realized to the fullest.

Comparison of elastic tissue stain with haematoxylin and eosin stain in the detection of venous invasion in colorectal carcinoma in the Sri Lankan setting

Comparison of elastic tissue stain with haematoxylin and eosin stain in the detection of venous invasion in colorectal carcinoma in the Sri Lankan setting

Accuracy of estimated height from ulnar length using MUST equation

Background &amp; Aim: Height is an important parameter in the assessment of nutritional status. Height is difficult to measure directly in critically ill patients; alternative methods are used to predict the height. One such method used in the Sri Lankan setting is the Malnutrition Universal Screening Tool (MUST) equations using ulnar length. But the accuracy of the estimated height from the ulnar length in local setting is not studied much. The present study is carried out as a pilot study in order to evaluate the equation for estimated height from ulnar length for the Sri Lankan population. Methods: A single-centre cross-sectional study was carried out by using hospital staff in a base hospital in the central province of Sri Lanka during a staff clinic session. Height was measured by a stadiometer (Seca-203) and ulnar length non-stretchable tape. MUST equation was used the calculate the estimated height and it was compared with actual height to check the accuracy. Results: The mean age of the males and females is 39.8 (SD ± 10.2) and 40.7 (SD ± 10.0) years, respectively. The actual height of males was 165.6 cm (SD ± 6.2) and 153.8 cm (SD ± 5.6) in females. The estimated height in males is 175.6 cm (SD ± 4.9) and in females 165.3 cm (SD ± 4.7). The mean difference of estimated height was positive 10.0 cm (SD ± 5.1) in males and in females, it is 11.5 cm (SD ± 4.4). Conclusions: The estimated height from ulnar length in this subgroup differs significantly from the actual height. Therefore, MUST equation should be used cautiously until a further countrywide assessment is done to develop a population-specific equation to predict height using ulnar length.

Validation of modified Children’s Health Survey for Asthma (CHSA) Questionnaire for the Sri Lankan setting

Asthma is one of the most common chronic diseases in the childhood in developing and developed countries. Health related quality of life has become essential part of health outcome measurement in chronic disorders. The present study was conducted to assess the validity and reliability of western developed scale for use in Sri Lankan children and their care givers. This study was a hospital based cross sectional study for validation of the western developed CHSA questionnaire. Study population was 100 children who was diagnosed as having asthma. Factor analysis of the data in the present study identified seven relevant factors. Two separate factors each were extracted for physical health (child) domain and emotional health (family) domain. Two separate factors each were extracted for physical health (child) domain and emotional health (family) domain. Cronbach alpha of above 0.7 for all domains indicate the internal consistency of the measure.

Validation of modified Children's Health Survey for Asthma (CHSA) Questionnaire for the Sri Lankan setting

Validation of modified Children's Health Survey for Asthma (CHSA) Questionnaire for the Sri Lankan setting

Acceptability, simplicity, and relevance of the new human papillomavirus/DNA test among 35-year-old ever-married women in a district of Sri Lanka: focus group discussions

BackgroundTwo major drawbacks of the present cervical cancer screening programme in Sri Lanka are, the suboptimal sensitivity of the pap smear and the low coverage. The sensitivity of the HPV/DNA screening test is high. The objective of the study was to explore the acceptability relevance and simplicity of the new HPV/DNA screening implementation among ever-married women in a district of Sri Lanka.MethodsFocus group discussions (FGD) (n = 3) in the public health divisions of the Kalutara district were used to collect data during December 2018. The study population comprised of ever-married women 35 years old, who, carried out an HPV/DNA test at a community Well Woman Clinics (WWCs) (n = 89). A list of WWCs was prepared according to an alphabetical order under urban, rural, and estate sector categories and allocated a number. One WWC was selected from each sector randomly for the three FGDs representing the estate, rural, and urban clinics. A convenient sampling technique was used to select participants for each FGD (n = 8). The information collected at each interview was summarized at the end of each interview. The analysis was done with manual content.ResultsMost of the participants were Sinhalese (n = 17, 70.9%), Buddhist (n = 18, n = 75%), and non-working (n = 18, n = 75%). The community awareness of HPV/DNA screening and field staff performance were highly appreciated by most of the participants. Most were aware of the high sensitivity of the HPV/DNA test, therefore the early detection rate of cervical cancer precursors is high. Most of the participants expressed the HPV/DNA test as a convenient and neutral test. Most were mentioned the necessity of repeated clinic visits for the pap test and colposcopy in HPV/DNA screened positive follow-up but there was marked acceptability (n = 23, 95.8%) for HPV/DNA test.ConclusionsAcceptability of the new HPV/DNA screening test was high. Most of the participants perceived the HPV/DNA test to be simple and also relevant. Therefore, the HPV/DNA screening test can be recommended to be incorporated into the National Cervical Cancer Screening Programme as its suitability was well explored in the Sri Lankan setting.

Leptospiral 3-hydroxyacyl-CoA dehydrogenase as an early urinary biomarker of leptospirosis in a Sri Lankan setting – Interim results

The Sri Lankan Journal of Infectious Diseases (SLJID) is an open access, peer-reviewed, biannual journal published by the Sri Lankan Society for Microbiology (SSM). The Journal considers articles from all professional disciplines involved in the field of infectious diseases. The Journal has been in publication since 2011, is included in the DOAJ since 2018 and is a member of COPE since 2021. The SLJID practices a double-blind peer review policy. From 2022, the SLJID publishes accepted manuscripts online immediately after copy-editing, enabling rapid dissemination of scientific knowledge. The published articles are subsequently compiled into two issues in April and October. The SLJID does not charge any article processing or publication fee.

Comparison of actual height and estimated height from ulna length in a selected population of Sri Lankan adults

Rationale: Height is an important parameter in assessment of nutritional status. Height is difficult to measure directly in critically ill patients requiring alternative methods for height estimation. One such method used in the Sri Lankan setting is the Malnutrition Universal Screening Tool (MUST) equation (1) for height estimation using ulna length. But data regarding the accuracy of estimating height from ulna length for the Sri Lankan population hasn’t been studied well. The objective of the following study was to evaluate the accuracy of estimated height from ulna length in adults attending the Medical Nutrition clinic in Base Hospital Gampola as a pilot study in order to evaluate the equation for the Sri Lankan population in the future.

Short and Long Term Determinants of Bank Credit Growth in Sri Lanka

The Purpose: The aim of this paper is to identify the determinants of credit growth of commercial banks in Sri Lanka during the period from 2008 to 2019. Design/ methodology/approaches: The analysis consists of macro-level data collected from monthly basis including bank-specific, macroeconomic, and monetary policy variables that affect credit growth. Co-integration test is conducted using Autoregressive Distributed Lag (ARDL) approach to determine the long-term determinants of credit growth. Findings: The results revealed that growth of money supply, non-performing loan ratio, lending rate, and inflation rate and efficiency ratio have a strong link with credit growth compared to other bank-specific variables, and therefore they can be considered as long term determinants of commercial banks’ credit growth in Sri Lanka. The findings further revealed that growth of GDP and credit growth tend to have a relationship which supports the ‘demand following’ hypothesis of finance-growth theory. All other bank specific variables indicated marginal impact on the credit growth in the short-run. Policy implications: The results suggested that the government should prioritize all growth promoting policies, because, low economic growth disturbs aggregate demand in the country. To achieve a desired growth, continuation of expansionary monetary and fiscal policies is necessary with a close coordination between them. Continuation of the monetary targeting framework of the CBSL is also necessary since money supply growth influences credit growth in the country. Originality: This research is expected to be a pioneering work in the field as studies focusing especially on credit growth are relatively limited in the Sri Lankan setting.

Perceptions on respectful maternity care in Sri Lanka: Study protocol for a mixed-methods study of patients and providers.

Over the past few decades, interest in providing and measuring Respectful Maternity Care (RMC) has increased markedly. Sri Lanka is reportedly shown to have better maternal health statistics and studies on quality improvement are lacking in this unique population. We aim to describe healthcare providers' perceptions and women's expectations, perceptions and their gaps in service provision regarding RMC in Sri Lanka. A descriptive cross-sectional study with a mixed-methods approach comprising of qualitative component followed by a quantitative component will be conducted in Castle Street Hospital for Women (CSHW) and De Soysa Hospital for Women (DSHW), Colombo, Sri Lanka. Healthcare providers (HCP- doctors, nurses and midwives) and vaginally delivered postnatal women (in postnatal wards and postnatal well-baby clinics) will be recruited through convenience sampling. In-depth interviews will be conducted with each of the four categories. Thematic analysis will be adopted to analyze qualitative data and the findings will further be used to improve the quantitative phase questionnaires. Self-administered questionnaire will be administered to a 378 vaginally delivered postnatal women [quota sampling across ten wards], exploring demographic details, and maternal opinion on various aspects of RMC. Locally validated Women's Perceptions of RMC tool (WP-RMC) will also be used to measure the level of RMC among these postnatal women along with the questionnaire 01. Qualitative findings will be used for cognitive validation of the WP-RMC into the Sri Lankan setting. This study will explore HCP's and women's expectations, perceptions and their gaps in service provision regarding RMC in two maternity hospitals in Sri Lanka. Assessment of the quality of care with regards to RMC have not been reported previously in this setting.