Revisiting the History: A Century of Public Health Nursing in Sri Lanka: A Scoping Review

Revisiting the History: A Century of Public Health Nursing in Sri Lanka: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Revisiting the History: A Century of Public Health Nursing in Sri Lanka: A Scoping Review Lakmali Senadheera, Nilmini Priyanthi, Janith Warnasekara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6339752/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Globally, public health nursing is an integral part of the community healthcare system, and it focuses mainly on disease prevention and health promotion. This study aims to systematically examine the evolution, roles, and discontinuities in public health nursing in Sri Lanka, highlighting historical milestones, training changes, and broader contributions to improving the community health of Sri Lanka. Methods/data sources: A scoping review was conducted via electronic databases (PubMed, Web of Science, EMBASE, MEDLINE, and Lens.org), supplemented by gray literature and manual searches in national archives, government reports, historical records, and local journals. Sources in English and Sinhala were included, and the data were synthesized thematically across identified historical periods. Results Based on our findings, we classified the history of public health nursing in Sri Lanka into four distinct eras: the Colonial Era, the Post-Colonial Era, the No-PHN Era, and the Re-establishment Era. This review traced how public health nurses were progressively involved in maternal and child health, control of communicable disease, and school health in the early decades, supported by progressively improved recruitment and training programs. It also revealed a prolonged interruption in public health nurse services in the 1980s, but with limited documentation and records for this discontinuation. In recent years, they have been reintroduced to reflect newly emerging health needs of the country, with a widened role that consists of palliative care, geriatric care, and prevention of noncommunicable diseases. Throughout the review, a lack of consistent documentation and visibility in published work and official records in the public health system of the country could be observed. Conclusions The evolution of public health nursing in Sri Lanka reflects the changes that have occurred in the health goals of the country over the past century. Since the beginning, public health nurses have shown their value and essential service through providing maternal and child health care and more contemporary services, including NCD prevention, palliative, and elderly care. Although this position was discontinued in the 1980s, resulting in clear gaps in service, its re-establishment could have redefined the role and responsibilities of public health nurses in Sri Lanka. Public health nurse History Nursing Sri Lanka Ceylon Figures Figure 1 Figure 2 Figure 3 Summary Statement What is already known? In Sri Lanka, public health nursing was first practised in 1926 and was crucial to improving the community health of the country in the early to mid-20th centuries. However, the post of PHN was discontinued in the 1980s for reasons that remain poorly understood and unrecorded despite the cadre being reintroduced recently. What does this paper add ? The history of public health nursing in Sri Lanka is being systematically reconstructed for the first time with this scoping review. It draws upon an extensive range of grey literature, archived resources, government reports, and historical document sources from national libraries and institutional repositories in both Sinhala and English. In addition to providing novel perspectives on the reasons for and consequences of the discontinuity and the current reestablishment of public health nurses’ (PHNs’) responsibilities, this paper divides the evolution of public health nursing into four distinct historical phases. Implications for practice/policy? This review fills a significant knowledge gap by documenting a century of PHN evolution. It offers a foundation of evidence for restructuring the scope, training, and deployment of PHNs in Sri Lanka. Furthermore, this study provides appropriate guidance to national stakeholders who are trying to improve the integration of PHNs into public health services, especially in fields such as palliative care, geriatric care, the control of noncommunicable diseases and community-level outreach. What does this paper contribute to the wider global clinical community? This study contributes to the field of public health nursing by offering a revised and comprehensive history. It will also serve as a valuable resource for future research and policy-making, helping to inform and improve public health initiatives in Sri Lanka. Background Public health nursing services are a vital component of healthcare systems in different countries. However, the utilization of public health nursing services has varied significantly across the globe, shaped by differing healthcare priorities and systems. With the Alma-Ata Declaration of 1978, the field of public health attracted increased attention because primary health care (PHC) was identified as the crucial component of achieving universal health coverage (UHC) [ 1 ], which covers the entire range of essential healthcare services, including health promotion, disease prevention, and palliative care [ 2 ]. Public health nursing is an integral part of the community healthcare system globally, as it involves more than just providing nursing services in communities [ 3 ]; it is a distinct and specialized approach to care for communities on the basis of public health principles [ 4 ]. The primary role of public health nurses (PHNs) is focused on disease prevention and health promotion, the reduction of disabilities, and follow-up care in a variety of settings [ 5 ] while providing comprehensive care to individuals, families, and groups of people, which contributes to the overall health of the population [ 6 ]. In the early 17th century, St Vincent Depaul established the modern principles of visiting nursing and social welfare [ 4 ]. In 1859, William Rathbone from Liverpool, England, was crucial in creating district nursing services [ 4 ]. Over the years, community health nurses have courageously implemented numerous new ways to foster the overall health of their communities [ 4 ]. The term "public health nursing" was coined in the 20th century by Lillian Wald in the United States to emphasize the worth of the nurses who served the community because their work rested on understanding all the problems that consistently accompany the ills of people experiencing poverty. Since the vast range of practices in public health nursing is distinctive, the term ‘public health nurse’ is used for different positions, but those who play similar roles include public health nurses, community nurses, district nurses, remote area nurses, and health visitors[ 3 ]. However, this document uses the term ‘public health nurses’ (PHNs) for all the above positions. Sri Lanka has successfully established universal health coverage with an example of a public health system in the region. Over the years, the primary focuses of the public health system have been maternal and child health and infectious disease prevention, with existing field-based staff such as public health midwives and public health inspectors. Although Sri Lanka is in an advanced position to achieve Universal Health Coverage (UHC) [ 7 , 8 ], ensuring the provision of equitable and universal healthcare has been challenging [ 7 ]. Additionally, the island is facing new health challenges, such as increasing elderly population and increasing NCD prevalence, which will be the primary cause of mortality [ 9 – 11 ]. Therefore, Sri Lanka seeks solutions to current health challenges [ 7 ]. Globally, in response to the new public health movement, PHNs play a pivotal role in disease prevention and health promotion [ 3 ] while indirectly supporting the reduction of healthcare costs by decreasing hospital admissions and treatment charges. Additionally, the community benefits from maintaining a better health status by receiving public health nursing services [ 10 ]. Public health nursing in Sri Lanka had its roots in 1926, soon after the establishment of the first health unit in Kalutara [ 12 ] and the International Health Division (IHD) [ 13 ]. In the early 1980s, PHN was converted into public health nursing sister (PHNS) or public health nursing tutor (PHNT) [ 3 ]. However, in 2018, PHN was reestablished in Sri Lanka and focused mainly on NCD prevention, palliative care, and elderly care [ 10 , 14 ]. Over the past few decades, PHNs in Sri Lanka have faced numerous challenges, including limited resources, staff shortages, political changes, and evolving health threats. In summary, public health nursing services in Sri Lanka continued until the 1980s and were subsequently discontinued and reintroduced in 2018. As many health experts believe, PHN is an essential service in Sri Lanka that must be improved to address emerging public health issues, including increased NCD prevalence, in Sri Lanka. Currently, only 217 PHNs are working in Sri Lanka, but if we could effectively use them to obtain optimal PHN services, it would be easy to improve community health at a lower cost. This highlights the need to critically examine the factors underlying their implementation, cessation, and eventual reinstatement with the healthcare trends of the respective periods. This information is crucial for utilizing historical insights to develop and enhance the current status of public health nursing in Sri Lanka. Hence, this study aims to fill these gaps by providing a comprehensive historical analysis. Thus, the objectives of this review were to review the history of public health nursing in Sri Lanka, highlighting the critical milestones of its evolution, contributions, and challenges faced by PHNs throughout the years. Furthermore, this study provides a detailed historical account of public health nursing in Sri Lanka by identifying the key figures and milestones in the development of public health nursing and exploring the impact of public health nursing on community health outcomes. Methods Scoping reviews are frequently used to investigate and compile the body of knowledge for a given subject [ 15 ]. Therefore, this methodology was selected because our aim was to explain what is known about the history of public health nursing in Sri Lanka (SL). Design Guidelines This scoping review (without a meta-analysis) followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Fig. 1 ). A comprehensive literature search was performed to identify research studies and grey literature related to the history of public health nursing in Sri Lanka. Review questions The review questions used in this review were as follows: What are the reasons for introducing PHNs to Sri Lanka (SL)? How do the PHNs grow and evolve in SL? What were their roles as PHNs in SL? Why did the government stop the services of PHNs in SL? Why was the post of PHNs converted into PHNS/PHNTs? Why were PHNs reintroduced into the Sri Lankan health care system? Inclusion and exclusion criteria In this scoping review, peer-reviewed scholarly sources (journal articles, academic theses, and conference proceedings) and grey literature published by the Sri Lankan government and related agencies (administrative reports, circulars, and guidelines) were included. Eligible documents were published in English and Sinhalese languages and contained primary or secondary data on PHNs in Sri Lanka and infectious diseases among pregnant women in Sri Lanka from 1926 to March 2024. We excluded articles that were not peer-reviewed and reported estimated data on PHNs in Sri Lanka. Even though the full-text articles were not available, all abstracts were available as conference proceedings were included since the data on this topic area were limited (Table 1 ). Search methods The Population, Intervention, Comparison, and Outcome (PICO) framework was used (without the optional ‘comparison’ and ‘intervention’ elements since these were not relevant to our research question) to guide the search [ 16 ]. Population (P): Public health nurses (PHNs) in Sri Lanka. Outcome (O): Any related information about PHNs in Sri Lanka. Table 1 Study selection criteria Inclusion Criteria Exclusion Criteria Country of interest Sri Lanka Rest of the world Language English and Sinhalese Any language except English and Sinhalese Publication Date Any year None Publication Type Peer-reviewed research Articles, Historical government reports, books, archived medical journals, and locally written sources Abstracts only, non-peer-reviewed articles Primary Outcomes Any information related to Public Health Nursing in Sri Lanka Not related to Public Health Nursing in Sri Lanka Databases and information resources This review conducted an internet-based search via the PubMed, Cochrane Review, Lens.org, Web of Science, EMBASE, and MEDLINE® databases for relevant articles. Additionally, Google Scholar was used to collect all the internet-based literature that was not indexed in the above databases, since most local journals were not indexed in the selected databases for the current study. The scoping review concerns Sri Lanka, so searching the local literature is crucial. Therefore, some bibliographic references, such as the Bibliography of Medical Publications related to Sri Lanka 1811–1976 [ 17 ] and its supplement Bibliography on Health in Sri Lanka 1977–1980 by Peiris and Uragoda [ 18 ] and the Bibliography of Publications on Food and Nutrition, 1847—1988 by Wickramanayake [ 19 ], were used to search for local literature. Additionally, archived issues of the Sri Lanka Journal of Medical Sciences and the Kandy Medical Journal, Proceedings of the Kandy Society of Medicine, other medical and health-related research work and published books were searched in five libraries (the National Library of Sri Lanka, the Library of the National Museum, the Sri Lanka Medical Association Library and the Peradeniya Medical Faculty Library, and the library of the Open University of Sri Lanka). The reference lists of the selected articles were searched for eligible papers to include missing articles from the main search throughout the process. Furthermore, given the lower availability of published scholarly works, the authors tended to search in grey literature, including local written historical documents such as Ceylon Blue Books, Ceylon Administrative Reports, and Ceylon Sessional Papers (1862–1926), because these records are official historical documents that provide yearly performance, progress, goals attained, and finances of Sri Lanka throughout that era. Furthermore, the Department of the National Archives of Sri Lanka preserved old national newspapers and handwritten documents, letters and notes by authorized officials (in the 1900s) (related to public health nursing). In addition, several other sources, such as government circulars, relevant websites, and related printed documents, complemented the facts accordingly. Search strategies The keywords and entry terms included in the initial search were "public health nursing", "community health nursing", "public health nurse", and "community health nurse" in combination with “Sri Lanka” or “Ceylon”. The search string that was used for PubMed was ("public health nursing"[Title/Abstract]. OR "community health nursing"[Title/Abstract]. OR "public health nurses"[Title/Abstract]. OR ("public health initiatives" AND "nursing perspective"[Title/Abstract].) OR ("health promotion" AND "nursing interventions"[Title/Abstract].) OR ("disease prevention" AND "public health nursing" [Title/Abstract].) OR ("maternal and child health" AND "nursing care" [Title/Abstract].) AND "history"[Title/Abstract]. OR "historical development"[Title/Abstract]. OR "evolution"[Title/Abstract]. AND (“Ceylon” OR “Sri Lanka”)). The search string for Web of Science was TOPIC: (Leptospirosis) OR TOPIC: ("public health nursing") OR TOPIC: ("public health nurse") OR TOPIC: (“community health nurse”) OR TOPIC: ("community health nursing") Refined by: TOPIC: (“Sri Lanka” OR “Ceylon”). The search string for Google Scholar was (("public health nursing" OR "community health nursing" OR "public health nurse" OR “community health nurse”) AND ("history" OR "historical development") AND (“Ceylon” OR “Sri Lanka”)). For Lens.org, the search string was (("public health nursing" OR "community health nursing" OR "public health nurses") AND ("history" OR "historical development") AND ("Ceylon" OR "Sri Lanka")). Study selection After removing duplicates from various databases, the title and abstract were screened to exclude irrelevant publications. These included articles that were not immediately pertinent to public health nursing in Sri Lanka. Detailed reviews of the full texts were conducted for all the articles selected during screening to evaluate the eligibility criteria further. The final evidence synthesis included all the research articles related to public health nursing. Furthermore, all the Ceylon Administrative Reports that reported details about public health nursing were included. In addition, Ceylon blue books related to the first PHNs were included. Furthermore, other relevant reports and government circulars were included. After the databases were searched, all possible records were compiled and entered into Zotero©, and the duplicates were removed via the Zotero function. The titles and abstracts were subsequently screened by two reviewers (LS and NP) on the basis of the inclusion criteria, and studies that were not related to public health nursing in Sri Lanka were removed. Only the remaining full-text studies were reviewed by three researchers (LS, NP and JW). Any disagreements that occurred among the reviewers were resolved through discussion. Data extraction Two reviewers (LS and NP) independently extracted the data. Quality appraisal Two reviewers (LS and NP) independently assessed each question by assigning a rating of ‘yes’ for a low risk of bias, ‘no’ for a high risk of bias, ‘Not Reported’ when no supporting information was available, and ‘NA’ if the criteria were not applicable. Any discrepancies in the quality ratings between reviewers were resolved through discussions and consensus with a third reviewer (JW). Studies rated as poor were removed to ensure the validity and reliability of the review’s conclusions, as their results may be unreliable. Data synthesis A narrative analysis was conducted to integrate the results appropriately to rewrite the history of PHNs in Sri Lanka. Data items This review used data items, including the study year, authors, abstract, and keywords, to assess the study and describe sequelae. Results/Findings Study selection After the databases were searched, all possible records (n = 2895) were compiled and added to Zotero©. Duplicates (n = 1589) were identified and eliminated via the Zotero tools, and 1306 records remained. After screening the titles and abstracts, 1198 papers were excluded. After screening the full texts of the remaining 108 papers, 92 were excluded on the basis of the inclusion criteria. The remaining 16 publications [ 3 , 10 , 27 – 30 , 12 , 13 , 21 – 26 ] were reviewed (the PRISMA flowchart illustrating the selection process is shown in Fig. 1 ). No additional papers could be identified through the reference lists of the included studies. However, more fruitful and supplementary information about the PHNs of Sri Lanka can be found in local documentary sources, including Ceylon Administrative Reports and Ceylon Blue Books. History of Public Health Nursing in Sri Lanka After carefully reviewing all the available historical evidence, we can rewrite the history of public health nursing in Sri Lanka. On the basis of the critical milestones, we can divide the history of PHNs into 4 phases: 1. PHNs in the colonial era (1926–1948) 2. PHNs in the post-colonial era (1948–1980) 3. No-PHNs era (1980–2018) 4. Re-establishment of the PHN era (2018 onwards) 01. History of PHNs in the Colonial Era (19261948) Establishment of the first Health Unit, Kalutara, in Sri Lanka It is impossible to talk about PHNs in Sri Lanka without addressing the first health unit because the origin of PHNs in Sri Lanka subsequently occurred after the establishment of the Kalutara Health Unit. In the middle of the 19th century, the British established plantation businesses in central Sri Lanka, and labourers were transported from southern India since the Kandyans (local people residing in the central Sri Lanka) refused to work on the estates [ 31 ]. Hookworm infection rapidly spread among Indian labourers, and 31 cases were first detected in Sri Lanka in 1888 [ 31 ]. Since there are approximately one billion hookworm patients worldwide, the International Health Board (Sanitary Commission and Rockefeller Foundation) decided to start a hookworm management programme in a few particular British territories, including Sri Lanka [ 31 ]. As a result, on 01st July 1926, the first health unit in Asia was established at Kalutara-Totamune, a suburb 43 km south of Colombo, in a land area of 25 square miles with a population of 33,000 [ 12 , 32 , 33 ], and this was a real step taken to improve rural health work along modern lines [ 12 ]. The Kalutara Health Unit consists of 01 medical officer as the director, 03 PHNs, 03 midwives, and 06 sanitary inspectors [ 32 ], but it undertook multiple activities while launching several health programs, including controlling hookworm infestations; taking antimalaria measures; engaging in maternal, prenatal, and newborn welfare activities; engaging in preschool and school hygiene; and engaging in public health awareness campaigns [ 32 ]. As per the Annual Report-1926 of the Rockefeller Foundation, the overall health unit programme was carried out satisfactorily throughout the year, even though maternity care and newborn hygiene were major issues in the district [ 32 ]. The First PHNs in Sri Lanka Upon establishing the Kalutara Health Unit (HU), the need for PHNs was well identified, and a series of studies were conducted by the Rockefeller Foundation to determine the demand for PHNs in Sri Lanka. The first research was conducted by Dr. Jacocks (1926), the "Advisory Health Officer" of the Department of Medical and Sanitary Services, who revealed no PHNs in Sri Lanka; thereafter, W.S. Carter suggested initiating a training programme for PHNs after doing his study [ 12 ]. In response to these reports, in 1926, the government established the post of “public health nurse" at Kalutara HU. On 19th July 1926, Ms J.M. Mutuwadi, who had worked as a Ceylonese Matron and a Housekeeper of Ceylonese Nurses attached to the Kandana Sanatorium [ 34 ]was appointed the first PHN in Sri Lanka after providing brief training in identifying hookworms, malaria infections, and maternity and infant welfare activities [ 12 ]. She received a similar salary (LKR 1260/=) to the other housekeepers of Ceylon nurses with the same grade (her 1st appointment date was 17th March 1911) [ 35 ]. S. Chinniah, Ceylon Matron, was then appointed as a PHN on 31st August, and her salary was LKR 840 [ 35 ]. Although the PHN was established in Sri Lanka in 1926, the title "Public Health Nurse" first appeared in the “Alphabetical List of the Names of Officers” in the Ceylon Blue Book in 1928. Therefore, although the PHN was written informally in 1926, the title "public health nurse" might have been first used formally in 1928. Additionally, their salary, along with their job grade, remained unchanged, irrespective of the new post. This may be due to the designation of the PHN being new to Sri Lanka and very suddenly appointing currently working nurses to that position. Nevertheless, no specific status for the post was established. Furthermore, the origin of PHNs has occurred mainly on the basis of the country's needs, approximately 3 weeks after the establishment of Kalutara HU. Furthermore, according to our search, no information related to PHNs could be found in any Ceylon Blue Book, Ceylon Sessional Papers, Ceylon Administrative Reports, or documentary sources published from 1860–1925. These reports are historical documents annually published by the Ceylon Government, including all the important information related to the administration, health, revenue, politics, law, economic situation, etc., of Sri Lanka as a summary and reported to Great Britain by the governor. Therefore, on the basis of this historical evidence, we can eventually confirm that the origin of public health nursing in Sri Lanka occurred in 1926, just after the establishment of the first health unit of Sri Lanka. Later, two more hospital matrons were appointed after the same training was given [ 12 ]. However, by 16th March 1927, J.M. Mutuwadi had resigned from the PHN post and rejoined Nurses Home, Ragama, as a Ceylon Matron/Matron in charge [ 33 ]. Similarly, between 1926 and 1928, at least 08 hospital matrons were employed as PHNs for the Kalutara health unit. Nevertheless, the retention of PHNs was very difficult because they either quit or moved back to work at hospitals [ 12 ]. Characteristics, Education, and Training of Early PHNs in Sri Lanka It was suggested that there should be 5 PHNs for a population of 40,000 [ 21 ]. A PHN should have a strong character, be sympathetic but forceful, have tact and initiative, and possess common sense [ 24 ] while having additional training in MCH, treatment for malaria, and hookworm infestation [ 24 ]. They must reside in the HU area, visit communities regularly to discuss health problems, and visit schools to understand prevailing health problems [ 24 ]. Although PHNs were in a key position in the HU programme [ 24 ], there were 05 HUs without PHNs by 1928, and the government was planning to establish 02 additional HUs in 1930 [ 12 ]. PHNs should provide unique training in delivering MCH (maternal and child health) care and treating malaria and hookworms [ 21 ], and the Rockefeller Foundation assisted in training PHNs in Sri Lanka [ 13 ]. Accordingly, when health units expanded gradually, Dr. Jacocks advised the government to appoint a full-time medical officer to train PHNs in Sri Lanka [ 12 ]. Accordingly, on 1st June 1928, Dr. Mrs. L.N.V. Chinnappa (MBBS, Madras), specializing in maternity and child welfare, was placed in this position [ 36 , 37 ]. The training of PHNs was initiated at the Kalutara health unit, which consists of 6 months in midwifery and 6 months in public health [ 26 ]. In 1928, 7 more hospital nurses were chosen for training [ 12 ], and the total number of PHNs in Sri Lanka was 11 [ 38 ]. However, the training did not progress as expected since it failed to retain new recruits of PHNs [ 12 ]. Dr. Jacocks mentioned that if “the Health Unit fails to succeed and develop in Ceylon, it will be for lack of PHNs” [ 12 ]. Furthermore, in 1928, Miss. Mary Beard, the director of nursing at the Rockefeller Foundation, visited Sri Lanka and showed that the success of the health unit programme depends on how thoroughly it is incorporated into villagers’ lives. In that case, the PHNs must play an essential role in the health unit project. Therefore, she emphasized that it is essential to have qualified PHNs in the Kalutara health unit since it was planning to use this institute as a model when expanding health unit facilities throughout the country. Furthermore, she stressed improving PHNs in Sri Lanka through training them to obtain more competent services [ 12 ]. By 1929, Sri Lanka had only five PHNs [ 39 ]s, and there was a significant shortage of PHNs, mainly because only unmarried women were recruited for the post [ 12 ]. This was the greatest challenge and barrier to the successful functioning of the health unit programme. The Department of Medical and Sanitary Services subsequently launched a specific programme for recruiting and training PHNs in the latter part of 1929 [ 31 ]. Hence, in the 1930s, the Rockefeller Foundation focused primarily on training professional health workers, especially PHNs [ 40 ]. The major critique at the time was that PHNs had not been trained in public health nursing principles, but this was impossible to accomplish in a brief period [ 12 ]. Dr. R. Briercliffe, the newly appointed director of medical and sanitary services in 1930, found that PHNs were essential in dealing with all areas of community public health issues. Furthermore, he emphasized the importance of PHNs in spreading public health awareness programmes and dealing with communicable diseases such as tuberculosis while improving children's welfare through collaboration with schools, education authorities, and school medical work. Furthermore, as a response to this shortage, he recruited married women as PHNs who had obtained hospital nursing training but had resigned from the service due to marriage and provided one year of training in midwifery and public health nursing [ 12 ]. In 1931, 10 more PHNs were recruited, and five PHNs were allocated to the Kalutara Health Unit [ 41 ]. In 1935, only qualified nurses employed in government hospitals were selected for PHN training, and the course duration was 6 months. Those who were not qualified in maternity nursing were provided a course at the Soysa Lying-in-Home, Colombo. However, the number of eligible candidates to be trained as PHNs is insufficient in the country [ 42 ]. PHNs held their first annual conference in 1935, which was a major milestone in history [ 42 ]. In 1936, 4 PHNs came from the Public Health Department of Mysore, India, and received training at Kalutara HU [ 43 ]. The PHNs convened their annual meeting on 22nd August 1936 in Negombo, inaugurated by Lady Tyrell. Additionally, they released their yearly publication, “The Public Health Nurse,” which included proceedings from the preceding conference [ 43 ]. In 1938, the above conference took place in Kandy (Central Sri Lanka), Ceylon, which is an indicator of the shift in PHN services outside the western province. In 1947, the Rockefeller Foundation conducted an influential public health campaign and undertook several studies to ascertain the level of nursing education on the island. The findings highlighted that the island must have a sufficient number of well-trained PHNs for the health unit programme to be successful in Sri Lanka. As a result, Janet D. Corwin, the foundation's nursing coordinator for South Asia, visited the island in June 1947 and prepared a detailed report recommending placing nursing in the hands of “educated Ceylonese women". Furthermore, her impression of the level of education among women was highly positive [ 40 ]. Furthermore, in 1947, public health nursing was considered a postgraduate qualification that was opened to both nurses and midwives upon completing a three-year nursing diploma, followed by a six-month training at Kalutara [ 40 ]. According to Cowin’s report, by 1947, there were 40 PHNs in Sri Lanka [ 44 ] for a population of six million, although approximately 700 PHNs were needed for the effective function of the health unit programme ( Table 2 ) . The authors of the current study strived to summarize the history of this era, as depicted in Fig. 2 . 02. History of PHNs in the post-colonial era (1948–1980) Sri Lanka received independence in 1948. In the post-colonial era, the health unit system was improved as part of the national healthcare program. Identifying the most prevalent and dangerous infectious diseases in each health unit region and controlling them with the aid of local populations through immunization, treatment, improved sanitation, and health education is a fundamental approach of the health unit system. These operations were coordinated mainly by PHNs together with midwives and sanitary inspectors who were locally appointed [ 24 ]. The child welfare projects organized by the PHNs of the health units in cooperation with the schools in the area were among the most significant activities of the health units. The PHNs conducted clinics on hygienic issues at schools around the province. They also visit mothers at home frequently to offer advice on childcare. Each health unit's nursing staff is often overburdened by the number of people needing these services, indicating that the child welfare job is the most demanding of all the health unit tasks [ 31 ]. Mrs. M.A. Jainu Deen was trained as the first Sri Lankan public health nurse at the University of Toronto. The Rockefeller Foundation hoped that she would be a good asset in developing PH nursing in Sri Lanka. However, she could not be put in the director position of the School of Nursing since the colonial bureaucracy of the Department of Medical and Sanitary Services was unwilling to accommodate North American-trained PHNs in senior positions. Therefore, Mrs. M.A. Jainu Deen was appointed as a PHN attached to the Kalutara health unit to train PHNs [ 40 ]. Accordingly, she became the first Sri Lankan public health nursing tutor in Sri Lanka in 1949 [ 3 ]. In 1950, it was feasible to recruit and train 19 additional PHNs instead of slow recruitment, thereby significantly accelerating the total number of PHNs in Ceylon to 64 [ 45 ]. This year, a four-week refresher course was initiated for PHNs, and 5 PHNs attended the program [ 45 ]. In 1952, lectures and demonstrations on field tuberculosis (TB) control were delivered to PHNs throughout their training. On July 21, 1952, systematic serological testing for pregnant women commenced at the six prenatal clinics of the Colombo municipality. The World Health Organization (WHO) PHN assisted during the first few weeks, training the matrons and assistant matrons of each clinic to facilitate blood collection [ 46 ]. In 1952, a two-week training program on venereal disease (VD) was provided to all PHNs (PHNs) employed at the Central VD clinic, enabling them to help with case identification, contact tracing, and contact investigations at their respective local stations [ 46 ]. Additionally, lectures on the epidemiological facets of VD were also conducted for PHNs at both the Kalutara Health Unit and the Central VD Clinic in Colombo in 1952 [ 46 ]. In 1953, two fellowships in public health nursing (a one-year program) were provided in the UK [ 47 ], and by August 1955, two PHNs had returned to the country following the completion of the course [ 48 ]. In 1955, the WHO supplied a Public Health Nursing Instructor and expanded the training program for PHNs by including two additional courses: Communicable Diseases and Hygiene. Furthermore, a preventive nursing course was conducted in Ceylon in 1955 [ 48 ]. In 1956, the Public Health Division released an "Evaluation of the Work of Public Health Auxiliary Personnel" focused on PHNs, public health inspectors (PHIs), and public health midwives (PHMs). This paper has demonstrated the changes that have occurred in the duties of these personnel from 1936–1956 [ 49 ]. In July 1957, Mrs. M.A. Jainu Deeen, the Principal PHN, attended the 8th triennial conference of the Associated Country Women of the World/UNESCO seminar held in Kandy, Ceylon [ 50 ]. In 1958, two PHNs departed the country after obtaining one-year C-Plan fellowships to Canada to pursue a Public Health Nursing Sister Tutor course [ 51 ]. In 1960, 18 graduate nurses completed their post-basic training in public health work [ 52 ]. Furthermore, in the same year, 17 senior PHNs were chosen for advancement to supervise PHNs and were appointed to the Galle and Matara Divisions following a three-month training period [ 52 ]. By 1961, the importance of ‘Health Education’ was emphasized, and it was incorporated as a crucial component of all the public health training conducted by the Health Unit in Kalutara [ 53 ]. Additionally, this year, a specific MCH course was started for 10 Supervising PHNs [ 53 ]. Furthermore, three-day refresher training for PHNs was launched in various health divisions, including Colombo, Kalutara, and Kandy, in 1962. Additionally, post-basic courses were conducted for PHNs, and 21 student PHNs completed the 9-month program in Public Health Nursing during that year [ 54 ]. Furthermore, the Sweden Ceylon Family Planning Project conducted training programs for PHNs, focusing on family planning initiatives established in the country in 1962 [ 54 ]. More information on education and training programmes conducted for PHNs is tabulated in the Additional Table 2 . Furthermore, several changes occurred in different training programmes parallel to improving public health nursing in Sri Lanka and those details are given in the Additional Table 3 . Table 2 Evolution of PHNs in Sri Lanka and their workload related to MCH (from 1926–1960) Year No. of PHNs worked in the year No. of Home visits done by PHNs No. of visits to expectant mothers No. of visits to infants No. of visits to pre-school children Document source 1926 03 N/M 721 1302 [55] 1927 02 N/M N/M N/M N/M [56] 1928 11 N/M N/M N/M N/M [38] 1929 05 N/M N/M N/M N/M [37] 1930 19 N/M N/M N/M N/M [57] 1931 12 N/M N/M N/M N/M [58] 1932 16 N/M N/M N/M N/M [59] 1933 19 N/M N/M N/M N/M [60] 1934 20 N/M N/M N/M N/M [61] 1935 33 N/M N/M N/M N/M [42] 1936 32 43 168 N/M N/M N/M [43] 1937 30 61 609 N/M N/M N/M [62] 1938 47 N/M 76 108 157 988 75 177 [63] 1939 44 N/M N/M N/M N/M [64] 1942 N/M 451 887 N/M N/M N/M [65] 1944 N/M 80 110 N/M N/M N/M [66] 1945 N/M 57 466 N/M N/M N/M [67] 1946 N/M 64 541 N/M N/M N/M [68] 1947 40 56 970 37 764 29784 20 932 [44] 1948 41 65 547 36 122 28 906 20 762 [69] 1949 45 71 255 42 112 23 580 34 810 [70] 1950 64 53 126 46 888 38 088 28 759 [45] 1951 68 N/M 34 902* 24 401* 21 485* [71] 1952 96 N/M 71 475 37 497 27 731 [46] 1953 111 57 427 52 041 37 680 30 533 [47] 1954 N/M N/M N/M N/M N/M [72] 1955 108 N/M N/M N/M N/M [48] 1956 129 84 485 58 937 75 296 81 138 [49] 1957 128 82 762 48 435 71 984 76 660 [50] 1958 122 81 199 45 625 78 882 92 359 [51] 1959 118 82 732 49 319 74 620 83 913 [73] 1960 133 83 504 46 506 79 194 109 942 [52] *First visit only N/M- Not Mentioned Data Source: Ceylon Administrative Reports from 1926–1978 , Ceylon Blue Books, The Department of National Archives, Sri Lanka. Table 3 Services and Responsibilities of early PHNs in Sri Lanka PHN Role/Service Year Document Source Control of Hookworm diseases 1926 • hookworm disease was widespread • hookworm treatment campaign for school children was carried out • Public health awareness sessions were organized under disease prevention • 3,259 patients were treated [ 21 ], [ 55 ] 1930 88 448 children were treated [ 21 ] 1943 04 PHNs were awarded certificates of competency in hookworm treatments. [ 75 ] Maternal and Child Welfare (MCW) work 1926 • After opening the Kalutara HU, pregnant mothers (n = 176), infants (n = 151), and preschool children (n = 98) were provided care at 85 clinics. • Home visits done by PHNs [ 21 ] 1927 Supervised PHMs in child births. [ 56 ] 1936 PHNs conducted health education sessions for mothers at both their home visits and the clinics by ‘Little Mothers’ through talks and demonstrations [ 43 ] Care for infants and preschoolers Several Health exhibitions were organized by locally appointed PHNs, midwives and sanitary inspectors in Kalutara town to encourage breastfeeding as a part of regular “Health and Baby Weeks”, which provided health information related to postnatal care for young mothers. [ 24 ] In 1929 ‘Empire Challenge Shield’ was awarded to Kalutara HU by the National Baby Week Council of England for organizing the best Baby Week held in the British Empire except the British Isles. [ 24 ] 1958 and 1959 PHNs focused more on infants and preschoolers during their home visits. [ 51 , 73 ] 1959 Furthermore, newborns and preschoolers were regularly provided free milk and cod liver oil, while Antepar treatment was implemented for helminthic infections. [ 73 ] 1961 Furthermore, since 1961, whenever PHNs are available, they should be primarily accountable for the health work of infants after the 10th day, preschoolers, and school-aged children. [ 53 ] Care for pre-schoolers 1959 Consequently, it was impracticable for PHNs to conduct regular visits to every preschool kid in their region. As a result, it was determined that the scope of PHNs should be significantly reduced to allow more targeted house visits, similar to practices in other countries. Due to this shift, the total number of home visits conducted by PHNs has decreased compared to the previous year. [ 73 ] School hygiene 1927 Intensive school hygiene was started in 02 schools. Problems related to vision, hearing, teeth and tonsils were detected among pupils, and those were referred for corrections. However, owing to a lack of parental cooperation, the school inspection was suspended until further arrangements were made [ 56 ] 1933 PHNs’ contributed to school health activities in a limited way. [ 60 ] 1938 38 PHNs were engaged in those activities [ 63 ] 1948 PHNs assisted in school health work in rural areas [ 69 ] 1949 attended in the correction of Pediculosis [ 70 ] 1953 assisted in correcting 13 273 detected pediculosis cases. [ 47 ] 1956 and 1957 PHNs are continuously engaged in school health work. [ 49 , 50 ] Furthermore, it was suggested that the PHN should take responsibility for school health services in areas where PHNs were available. [ 52 ] Vaccination 1955, 1956 and 1958 The total number of primary vaccinations performed in 1955, 1956 and 1958 were 239 187, 248 021, and 215 872, respectively. In addition to these, re-vaccination was also done accordingly. [ 48 , 49 , 51 ] 1958 PHNs especially vaccinated children at child welfare clinics, while vaccinators were utilized in estates and remote rural areas. [ 51 ] Estate health work 1932 PHNs conducted 26 visits over six estates and delivered nine health talks. [ 59 ] 1933-36 The PHNs of the Kalutara and Yatinuwara Health units conducted 29 visits to estates. It was continued in 1935 and 1936. [ 42 , 43 , 61 ] 1938 they conducted 47 health talks for the state population, with approximately 12 265 attendees in [ 63 ] VD control work 1948 the main features of Public Health work accounted as adoption to the health unit type of work throughout the country except carrying out special campaigns including control of Malaria, TB, Venereal Disease (VD), Filariasis, and Leprosy [ 69 ] 1950, A senior PHN was appointed to the Venereal Disease Clinic of the Lady Havelock Hospital, Colombo. Her sole duty was to confine herself to active case-finding, contract-tracing and follow-up work [ 45 ] TB control work 1949 The Special Grade PHN contributed to the TB survey as a staff member of the survey. [ 70 ] 1952 In 1952, PHNs (who worked at Kalutara HU) also contributed to mass radiography-related activities carried out by the mobile unit to screen pulmonary tuberculosis. [ 46 ] 1966 By May, a pilot project related to TB work was started in the North Western Province of SL. The project staff consisted of one PHN who had received specialist training via a WHO fellowship at the National TB Institute, Bangalore, India. [ 28 ] Administrative work 1956 A principal PHN also consisted of the central administration of Health Services that was functioning under the Deputy Director of Health (Public Health Services) [ 49 ] Work At Lady Ridgeway Children's Hospital (LRH) 1963 • The PHNN (HE) (Health Education) arranged health education sessions at the OPD and the malnutrition clinic. (Ex:- on nutrition and common infectious disorders can be found among children); • organized a well-baby clinic just for the babies of LRH personnel • involved in immunizations with polio and other vaccinations for children who came to obtain outdoor treatments. Later, another PHN was assigned to run the programme [ 74 ] PHNs, PHMs, and public health inspectors (PHIs) are the pillars of public health services, and staff are in charge of providing primary healthcare. By 1972, there were 161 PHNs; 113 of them had received public health training, while the others were PHNs only because they worked in public health. [ 13 ]. At that time, 3.2% of nurses were PHNs, whereas 93.6% of nurses worked in hospitals, accounting for 4,668 nurses [ 13 ]. PHNs were in charge of family care, which included home visits for families, child care (including immunizations and infant care), supervision of PHMs, school health work, health education, conducting clinics, immunizations, working with nonprofit organizations, conducting investigations into the deaths of mothers and children, and general administrative tasks ranging from reporting and recording to equipment maintenance. According to Simeonov, only 21.1% of PHNs' working time was spent on "technical duties," or work that was diagnostic, therapeutic, or health-promoting in nature. This information was obtained by analysing how PHNs spent their time among this imposing list of responsibilities. Most of their time was spent on noncontact work, including 28.1% for administration, 23.3% for travel, 9.2% for maintenance, and 16.5% for waiting for people, informal discussions, and other activities [ 13 ]. The Kalutara health unit was expanded, and in 1966, it was renamed the Institute of Hygiene [ 24 ]. In 1979, it was renamed the National Institute of Health Sciences, becoming the premier public health training facility in the country [ 24 ], and then PHN training was extended to one year, with a diploma in public health nursing being awarded after completion of the course [ 26 ] (Fig. 3 ). Throughout this period, the number of PHNs in Sri Lanka slowly increased with time, as shown in Table 2 . Furthermore, it depicts the services they provided to the communities even though the number of PHNs was lower. The role, responsibilities, and community healthcare services provided by PHNs have extended across a wide range of areas without being limited to MCH care. Roles and responsibilities of early PHNs in Sri Lanka (1926–1980) Administrative papers provide enough evidence to prove that PHNs play a significant role in public health services to improve the community health of Sri Lanka ( Table 3 ) . The PHNs were required to conduct regular visits to the communities, schools, and local dispensaries to obtain a firm understanding of the health challenges that are currently plaguing the area, and that they must reside in the health unit area [ 24 ]. The midwives were placed under the immediate supervision of the PHNs, and each midwife was expected to serve approximately 4,000 people within a three-mile radius. Furthermore, sanitary inspectors were required to help "midwives and nurses whenever possible" [ 21 ]. To improve the health status of 3 types of populations—pregnant mothers, infants, and preschool children— maternity clinics and “well baby” clinics were organized by PHNs, covering both urban and rural areas [ 55 ]. Home visits by PHNs were highlighted as a feature of these works in 1926 [ 55 ]. Voluntary organizations, such as social service leagues, have collaborated closely with maternal and child welfare (MCW) work [ 33 ]. As a result of this collaborative work and the combined effort of all the PHNs, Midwives, and members of the Social Service League, considerable progress in MCW work could be observed during 1927 [ 56 ]. Hence, MCW work was continuously popular, and the number of clinics conducted had to increase simultaneously with steadily increasing clinic attendance. However, the new work demand could not be adequately met due to the shortage of PHNs in 1936 [ 43 ]. Furthermore, 10844 normal deliveries were made by midwives under the supervision of PHNs at maternity homes, and these homes were very helpful for the community, resulting in the successful prevention of maternal and infant deaths [ 44 ]. Furthermore, by 1952, these homes were not restricted to the mothers who came to the areas for which they were originally intended [ 46 ]. Given the importance of providing MCH care as institutional care and domiciliary care, ignorant midwives have been considerably replaced by trained health care personnel [ 26 ]. In 1950, home visits by PHNs and midwives with great efficiency were highly appreciated since home visits resulted in a decrease in the incredibly satisfying mortality rates of mothers and children, which has been steady over the years [ 45 ]. By 1959, even though the MMR (maternal mortality ratio) and IMR (infant mortality rate) had been considerably reduced, anaemia-like conditions were prevalent among pregnant mothers because of nutritional deficiencies and poor standards of health owing to frequent pregnancies[ 73 ]. Unlike today, PHNs took the responsibility of caring for infants 10 days after delivery and caring for preschool children while playing a more managerial role [ 26 ]. Several health exhibitions were organized by locally appointed PHNs, midwives, and sanitary inspectors in Kalutara town to encourage breastfeeding as a part of regular “health and baby weeks”, which provide health information related to postnatal care for young mothers [ 24 ]. The infant mortality rate was reduced from 235 in 1924 to 216 per 1000 live births by 1927 [ 21 ]. In 1929, the Empire Challenge Shield was awarded to Kalutara HU by the National Baby Week Council of England for organizing the best Baby Week held in the British Empire, with the exception of the British Isles [ 24 ]. By 1959, preschoolers were consistently malnourished, inadequately cared for, and frequently afflicted by worm infestations. This year, owing to the scarcity of PHNs, the care provided to preschool children was continually insufficient, particularly in areas with large populations [ 73 ]. Consequently, it was impractical for PHNs to conduct regular visits to every preschool child in their region. As a result, the scope of PHNs should be significantly reduced to allow more targeted house visits, similar to practices in other countries. Owing to this shift, the total number of home visits conducted by PHNs has decreased compared with that in the previous year [ 73 ]. “The PHNs organized child welfare” works in collaboration with local schools, and they visit schools and conduct clinics related to sanitary matters. Furthermore, PHNs make routine home visits to advise mothers on childcare [ 24 ]. Thousands of people die from epidemics of smallpox and typhoid in many parts of Ceylon [ 21 ]. Although vaccination was performed mainly by PHIs, PHNs also engaged in vaccinations in response to outbreaks of smallpox in 1955, 1956 and 1958 [ 48 , 49 , 51 ]. In 1949, under tuberculosis control activities, PHNs worked attached to the BCG campaign and rehabilitation team (one at the clinic and 1 for follow-up work) [ 70 ]. In 1963, the LRH (Lady Ridgeway Hospital for Children) commenced an intensive health education activity, and a PHN [designated PHNN (HE) (Health Education)] was recruited to work on a full-time basis as a specific action. She should be responsible for delivering health education programmes for OPD patients, visitors, admitted patients, and the staff of LRH [ 74 ]. Health Education A total of 43 lectures were delivered under health education, primarily emphasizing the activities of the health unit, maternal and child welfare, communicable diseases, including malaria and hookworm disease, and social services, with an estimated attendance of 9,500 individuals. In addition, 13 conferences were held by PHNs in collaboration with sanitary inspectors and other health unit personnel [ 55 ]. Later, health education was conducted by various healthcare personnel, including PHNs and PHMs, at the clinics, during home visits, in schools, and in communities of villages held throughout the island using different teaching strategies, including school talks, village talks, and clinic talks. The number of sessions conducted is shown in Table 4 . Table 4 Health education provided by PHNs, together with other public health workers Year No. of PHNs worked in Sri Lanka health talks staff conferences lectures illustrated with Lantern slides lectures without Lantern slides Cinema shows 1937 30 At states-236 N/M 64 N/M N/M 1938 47 At states- 47 (attendance-12 265) N/M N/M N/M N/M 1946 N/M 82468 2115 (with staff) 382 (with others) 88 1734 56 1947 40 N/M N/M 130 2520 40 1951 68 School talks − 21 299), Village talks-(59 466), Clinic talks-(13 891) N/M 157 3661 333 1956 129 School talks (25 840), Village talks (121 189) Clinic talks (27 698) N/M N/M N/M N/M N/M- Not Mentioned More information about the services provided by early PHNs is given in the Additional Table 1 . 03. No PHNs Era (1980–2018) Discontinuation of PHNs from Sri Lanka In the early 1980s, PHN was discontinued in Sri Lanka (SL), but the specific reason is still uncertain because it was difficult to trace any particular evidence to clarify this phenomenon. However, the probable reasons are as shown in Table 5 below. However, our perspective concerning the reasons for the above critical decision to stop PHNs in SL made by the government may be due to less attention given to MCH care since, by then, SL had already achieved a remarkable improvement in the MCH in the Asian region further, since the low prevalence of noncommunicable diseases (NCDs) and the nonsignificant elderly population may have led to a lack of demand for NCD prevention and Palliative Care in the 1980s. On the basis of these findings, the necessity of a PHN may be lower for SL communities; thus, the government might stop the PHNs in SL. Our argument is supported by the re-establishment of PHNs in Sri Lanka in 2018, which focused mainly on NCD prevention, elderly care and palliative care. Furthermore, at that point, as a response to a trade union demand, the post of the PHN was converted into the Public Health Nursing Sister (PHNS) or Public Health Nursing Tutor (PHNT) owing to the limited number of positions available at that time [ 3 ]. Table 5 Probable reasons for the discontinuation of PHNs in Sri Lanka Source of evidence Probable Reason Jayasekara (2001) [ 3 ] The Sri Lankan government believed that primary healthcare activities in the communities could be managed by PHMs working together with the Medical Officer of Health (MOH) Jayasekara (2001) [ 3 ] Training of a PHM is less expensive than training of a PHN more than three years Authors’ perspectives of the current study MCH in Sri Lanka was at a significantly improved level in the region. Authors’ perspectives of the current study No demand for NCD prevention and care for associated health consequences (Ex:- Palliative Care, Geriatric care) due to less prevalence of NCDs in the 1980s in Sri Lanka. As a result of this change, nurses were no longer responsible for the community, and the services of PHNSs/PHNTs were limited to community clinics [ 3 ], which led to the following consequences, as mentioned in Table 6 . Table 6 Consequences of discontinuation of PHN services in Sri Lanka Source of evidence Consequences of discontinuation of PHN service Jayasekara (2001) [ 3 ] The discontinuation of other important parts of community care, such as elderly care, disability care, nutritional care, and occupational healthcare. Jayasekara (2001) [ 3 ] Senanayake et al. (2017) [ 22 ] The role of PHMs is limited to maternity and child healthcare, family planning, and health education only. Senanayake et al. (2017) [ 22 ] Health programmes ignore other family members, including males, adolescents, and elderly individuals, who are more vulnerable to NCDs; therefore, they could remain undetected. Period of No-PHNs in Sri Lanka During this period, public health midwives (PHMs) worked as frontline health workers by providing community-based maternal and child healthcare. Nevertheless, they did not engage in health promotion or preventive activities related to NCDs [ 76 ]. During the previous decades, when practising primary healthcare without the component of nursing at a basic level, the authorities recognized the necessity for the service of PHNs. Furthermore, the report of the Presidential Task Force (PTF) for the development of a National Health Policy has recommended the need to introduce “community nurses” [ 3 ]. Although no basic-level nurses have yet been included in the PHC team, very little progress has been made in community health nursing in Sri Lanka because of the acute shortage of nurses and slow responses of the authorities of Sri Lanka [ 29 , 30 ]. Jayasekara (2001) also highlighted the importance of community health nursing services in rural communities located far from health facilities [ 3 ]. Furthermore, some researchers have emphasized the importance of having strong community health nursing services to improve the health of not only women and children but also disabled and elderly people, as well as the mental health of people [ 22 , 25 , 30 , 77 ]. According to the findings of Randeni et al. (2014), community-dwelling people in Sri Lanka believe that having PHNs will be more beneficial to society because it improves access to health services, saves money spent unnecessarily on minor ailments (37%), and reduces the number of hospital admissions (29%) since PHNs will conduct home visits (43%), provide health advice and thereby improve health (38%). Furthermore, early detection of health problems (23%) increased the ability to resume care after being discharged from hospitals (94%) and increased the ability to obtain chronic care for bedridden patients (93%) [ 25 ]. In 2016, the WHO mentioned that ‘the post of PHN will re-emerge in Sri Lanka shortly as a new type of community worker comes from Sri Lanka’[ 76 ]. Furthermore, it has shown the importance of PHNs, as they are based in hospitals, provide home-based care for NCD patients in the direction of medical specialists, train family members in the care of patients, and follow up on treatment failure. Furthermore, the success of this new model will depend on mutual trust between the specialist and the PHN, who will have the opportunity to determine how patients manage their conditions as part of their daily lives [ 76 ]. 04. Re-establishment of PHNs in Sri Lanka (2018- to date) In 2011, the Ministry of Health (MoH) in Sri Lanka established Healthy Lifestyle Centres to address the lack of a coordinated screening programme for NCDs. In the same year, the MoH acknowledged that the current curative healthcare system needed to change from episodic patient management to a continuing-care approach that is more suitable for controlling NCDs. The "shared care cluster system" has been implemented to handle the added burden of NCDs. Services are organized around a hospital that offers specialized care, with primary care curative facilities located at the divisional and primary levels [ 11 ]. Later, in 2018, the post of the PHN was re-established in Sri Lanka under a new job titled ‘Public Health Nursing Officer’ (PHNO) [ 10 , 78 ]. Accordingly, 100 PHNs were designated for 100 Healthy Lifestyle Centers (HLCs), which were spread in 25 districts in Sri Lanka [ 10 ] in January 2018 [ 14 ]. The recruitment criteria for the post of PHN were having a Diploma in Nursing, and minimum of 2 years of experience in a state hospital or as a field officer, and being willing for fieldwork [ 79 ]. The primary focus of the training of PHNs includes preventing NCDs, providing palliative care, providing geriatric care, conducting research and surveys, and offering specialized services such as disaster management [ 78 ]. Although MCH services, including midwifery, are basic components of family health nursing and public healthcare in the global context [ 79 ], these are not required as entry qualifications for PHNs in Sri Lanka. This may be because new PHNs are not focusing on MCH care since it is already being performed by PHMs. However, midwifery training is required to become a Public Health Nursing Sister (PHNS. Currently, approximately 220 PHNs are working in Sri Lanka. They are widely dispersed in rural and distant areas of the country, reaching disadvantaged communities and social extremities [ 14 ]. In addition to providing comprehensive nursing care in the community, their mission is to collaborate with individuals, families, and communities to prevent and control NCDs. The nurses collaboratively work with multidisciplinary teams and serve mainly as researchers and care providers for the most vulnerable residents of the community, such as the elderly and those in need of palliative care. In addition, they respond to government programmes that were designed to increase people's involvement in health-related activities associated with their own health [ 10 ]. A review of the effectiveness of PHNs in Sri Lanka has shown that employing PHNs in the community setting of Sri Lanka has several advantages. Patients are not obliged to visit the hospital for some minor procedures, such as catheter care, or to maintain comprehensive documentation of the family health of the country [ 10 ]. Discussion This scoping review is the first scholarly attempt to document and critically analyse the history of public health nursing in Sri Lanka in a single document by collating evidence from diverse and dispersed sources through both online searches and extensive manual grey literature searches due to the limited availability of published scholarly works. Although public health nurses (PHNs) have played a significant role in improving MCH and primary health care in the country for approximately a century, their contribution remains largely absent in the academic literature and policy discussions. This neglect has resulted in a crucial knowledge gap that has hindered strategic attempts to best utilize the role of PHNs in Sri Lanka's dynamic health system, in addition to limiting professional and public understanding. PHNs in Sri Lanka had their roots in the founding of the Kalutara Health Unit in 1926, which was a collaborative project funded by the Rockefeller Foundation [ 32 , 55 ]. The appointment of Ms. J.M. Mutuwadi as the first PHN signified an upgrade to community-based and preventive healthcare. However, there was considerable turnover of PHNs in the early years since many hospital-trained nurses discovered that it was difficult to make the transition to fieldwork [ 12 , 33 ]. The obstacles were poor support, lack of transportation, and field isolation. Interestingly, similar difficulties did not deter other field-based health workers, such as PHIs and PHMs. This suggests that PHNs could compare hospital and community settings, and they may perceive that fieldwork was more challenging and less rewarding. However, the early stages of the PHN established a crucial framework for the preventive healthcare system in Sri Lanka. PHNs were increasingly embedded in the public health system throughout the postcolonial period (1948–1980), contributing to maternity and child health (MCH)[ 21 , 37 , 49 – 58 , 38 , 59 – 63 , 63 – 67 , 42 , 68 – 75 , 80 , 43 – 48 ], preschool and school health [ 47 , 49 , 50 , 52 , 56 , 60 , 63 , 69 , 70 ], communicable disease prevention [ 21 , 28 , 75 , 45 , 46 , 48 , 49 , 51 , 55 , 69 , 70 ], and home visits. The role of PHNs gradually expanded during this time, and simultaneously, PHMs became more specialized in MCH. Therefore, PHMs take on more responsibility for the care of mothers and infants, whereas PHNs shift towards preschool and school health and then to more comprehensive family health services [ 51 , 53 , 73 ]. Practical needs and staffing shortages influenced this change, but they also marked the start of the PHN role's marginalization. Nevertheless, a remarkable decrease in maternal and newborn mortality could be identified during this period, which was made possible by the combined efforts of PHNs, PHMs and other field health staff. When PHNs were removed from frontline community services in the 1980s, it was a turning point in history. Instead, the PHN position was restructured into PHNSs and PHNTs, which are supervising or teaching positions. Although official records on precise explanations could not be found, several factors probably contributed to this shift, including the belief that PHMs could handle MCH without PHNs, financial considerations that favoured PHM training and deployment, and union-driven demands to improve the status of the PHN position [ 3 ]. However, the authors of the current study believe that the demand for PHNs had decreased in the country by that time, mainly because the national health indicators had improved considerably (i.e., a significant reduction in MMR and IMR) by this point, whereas the burden of noncommunicable diseases (NCDs) had not yet become a major public health concern in Sri Lanka. Moreover, this assumption could be proven because the reintroduction of PHNs to the country in 2018 was mainly based on the steadily increasing NCD incidence in Sri Lanka. Nevertheless, this transition generated a gap in the provision of community health services, especially for groups (rather than mothers and infants), such as teenagers, elderly individuals, and people with chronic health issues, especially the male group [ 76 ]. Hence, the absence of specialized community nursing services has led to an imbalance in the comprehensive care model. In 2018, the reintroduction of PHNs occurred under a new designation, 'Public Health Nursing Officers' (PHNOs), reflecting a strategic response to these emerging gaps, especially the growing burden of NCDs, increasing ageing populations, and the need for palliative and home-based care [ 10 , 78 ]. One hundred PHNOs were allocated to 100 healthy lifestyle centers (HLCs) dispersed throughout the country after they underwent specialized training in palliative care, NCD prevention, geriatric care, disaster management and community research [ 10 , 14 , 78 ]. This upsurge could demonstrate how to acknowledge the need for qualified nurses for direct nursing care in community settings. However, the re-established PHN service is not involved in the provision of MCH care, and this exclusion raises important concerns. Globally, PHNs work with people of all ages, supporting not only MCH but also the health of adolescents and elderly individuals. Although the Sri Lankan context has excellent MCH achievements [ 81 , 82 ], it stands the risk of neglecting school-age children and adolescents, who are more likely to suffer from NCDs, newly emerging lifestyle-related conditions, and mental health disorders [ 22 , 25 , 30 , 77 ]. Although school and preschool health is a major part of the PHN's work, it is not explicitly included in its mandate, unlike in the past. This split of duties may hinder the PHN's ability to promote health across neglected age groups, while it compromises the continuity of treatment. Furthermore, even after being reintroduced, PHNs in Sri Lanka still struggle with poor support, poor facilities, and a lack of awareness of their service. Thus, policymakers must be committed to facilitating PHNs, increasing public and health professional awareness of PHN services, and offering chances for leadership and professional development to strengthen PHN services. Globally, PHNs are becoming increasingly active in community health policy and intersectoral collaboration. However, Sri Lanka has yet to utilize this potential. Most importantly, the present study illustrates how the history of PHNs in Sri Lanka reflects dynamics across several low- and middle-income countries (LMICs), where community-based healthcare cadres expand and contract in response to perceived needs and governmental agendas. The abrupt removal and later reintroduction of PHNs reflect the consequences of reactive rather than strategic workforce planning. Therefore, public health nursing must adopt a more proactive and integrated approach to address contemporary health issues effectively in Sri Lanka. The historical evolution of public health nursing (PHN) in Sri Lanka is representative of the broader challenges that many LMICs encounter in maintaining a steady, cohesive workforce of public health nurses. Despite having solid early roots, PHN services were discontinued in Sri Lanka for almost 40 years, demonstrating how shifts in institutional focus and political priorities can cause vital public health functions to be undermined. The WHO 2017 report on nursing and midwifery highlights the need for strategic investment in community-based nursing positions to attain Universal Health Coverage (UHC), and this example reflects global issues. The impacts of training, role clarity, and system-level support are several lessons learned from Sri Lanka's century-long experience that can help other LMICs attempt to reactivate or strengthen public health nursing with workforce planning. By analysing both historical gaps and contemporary policy revisions, this study offers transferable insights for countries seeking to develop resilient, community-embedded nursing services in resource-constrained environments. Conclusions The evolution of public health nursing in Sri Lanka reflects a century of adaptation to the country’s changing health goals. From their pioneering involvement with maternal and preventive health to their more recent contributions to NCDs and geriatric care, PHNs have consistently demonstrated their importance and relevance to society. Service gaps resulting from their expulsion from the community in the 1980s became more noticeable as the prevalence of NCDs increased. The reintroduction of PHNs led to redefining PHNs' roles, broadening their range of services while continually integrating them into Sri Lanka's primary healthcare system. Recommendations On the basis of the study findings, awareness-raising campaigns focused on both health professionals and the public are recommended to emphasize the value of PHN services. Further job descriptions for PHNs should be re-established, incorporating responsibilities, including school and adolescent health, to optimize PHN services in Sri Lanka. Limitations of the study The lack of published literature and archival evidence on PHNs in Sri Lanka limits the scope of this review. Furthermore, verification of certain important references found in bibliographies was not possible. Despite these drawbacks, the current study provides a fundamental synthesis that may inspire further investigations and the revision of public health nursing policies. Abbreviations HLCs Healthy lifestyle centres HU Health Unit IHD International Health Division IMR Infant mortality rate LMICs Low-and middle-income countries LRH Lady Ridgeway Hospital for Children MoH The Ministry of Health MOH Medical Officer of Health MCW Maternal and Child Welfare MCH Maternal and Child Health MMR Maternal Mortality Ratio NCDs Non-Communicable Diseases PHC Primary health care PHI Public health inspector PHM Public health midwife PHNs Public health nurses PHNO Public health nursing officer PHNS Public health nursing sisters PHNT Public health nursing tutor Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: Not applicable Competing interests: All the authors declare that they have no competing interests. Funding: Not applicable Availability of data and materials: All the data extracted from published articles are included in the manuscript. Authors’ contributions: LS was involved in the research design, literature search, data extraction, data interpretation, and final report writing. WN was involved in the research design, literature search, data extraction, and final report writing with LS and JW. JW conceived the study, guided the research process, reviewed the extracted data, and reviewed and edited the final manuscript. All the authors read and approved the final manuscript. Acknowledgements: Not applicable Authors' information (optional): 1 The Department of Community Medicine, Faculty of Medical and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Anuradhapura, Sri Lanka. 2 The Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Nawala, Nugegoda, Sri Lanka. . References WHO. WHO called to return to the Declaration of Alma-Ata [Internet]. 1978 [cited 2023 Oct 9]. Available from: https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata WHO. Universal health coverage [Updated 2023-06-29] [Internet]. 2023 [cited 2023 Sep 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc ). Jayasekara JGARS. Community nurses: An urgent need. Nurs Heal Sci. 2001;3:101–4. Kamalam S. Essentials in Community Health Nursing Practice. 3rd ed. Jaypee Brothers; 2017. WHO. Enhancing the role of community health nursing for universal health coverage. World Health Organization. [Internet]. 2017 [cited 2023 Sep 18]. Available from: https://www.who.int/publications/i/item/enhancing-the-role-for-community-health-nursing-or-universal-health-coverage Heydari H, Rahnavard ZGF. Exploring the Position of Community-Based Nursing in Iran: A Qualitative Study. IJCBNM. 2017;5:386–96. Ministry of Health Sri Lanka. Annual Health Bulletin. 2020. 2023. CENTRAL BANK OF SRI LANKA. ANNUAL REPORT (Volume I)- 2022. 2023. Crilly J, Chaboyer W, Wallis M. Continuity of care for acutely unwell older adults from nursing homes. 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WIKRAMANAYAKE TW, BIBLIOGRAPHY OF PUBLICATIONS ON FOOD. AND NUTRITION 1847–1988. CEYLON J Med Sci. 1989;31. Vesilind PJ. SRI LANKA Community-based workforce development for maternal and child health. Natl Geogr Mag. 1997;191:110–1. Hewa S. Sri Lanka’s approach to Primary Health Care: a success story in South Asia. Gall Med J. 2011;16:24. Senanayake S, Senanayake B, Ranasinghe T, Hewageegana NSR. How to strengthen primary health care services in Sri Lanka to meet the future challenges. J Coll Community Physicians Sri Lanka. 2017;23:43. Lanka SRI. Sri Lanka J of. 2012;3. Hewa S. Sri Lanka’s Health Unit Program: A Model of Selective. Prim Health Care Hygiea Int Interdiscip J Hist Public Heal. 2011;10:7–33. Randeni RHM, Wanniachchi SSK, Bisomenike SHM, Wijesekara GGWC, De Silva BSS. THE NEED OF A COMMUNITY HEALTH NURSE: A COMMUNITY PERSPECTIVE. Conf Annu Acad Sess 2014 Open Univ Sri Lanka. 2014;4:34–7. De Silva JKM. Family health programme in Sri Lanka: its origin and development. J Coll Community Physicians Sri Lanka. 1998;3:1. De Harendra DG. Perinatal care in Sri Lanka: Secrets of success in a low income country. Semin Neonatol. 1999;4:201–7. Jones M. Policy Innovation and Policy Pathways: Tuberculosis Control in Sri Lanka, 1948–1990. Med Hist. 2016;60:514–33. Jayasekara RS. Issues, challenges and vision for the future of the nursing profession in Sri Lanka: A review. Int Nurs Rev. 2009;56:21–7. Jayasekara RS, Schultz T. Health status, trends, and issues in Sri Lanka. Nurs Heal Sci. 2007;9:228–33. Hewa S. Civil Society Organizations and Global Health. Rev História Debates e Tendências. 2021;135–52. Rockefeller Foundation. The Rockefeller Foundation Annual Report 1926. 61 Broadway, New York.; 1926. Ceylon. Civil Establishments, The Ceylon Blue Book 1927. Colombo; 1927. Ceylon. Civil Establishments, The Ceylon Blue Book 1925. Colombo; 1925. Ceylon. Civil Establishments, The Ceylon Blue Book 1926. Colombo; 1926. Ceylon. Civil Establishments, The Ceylon Blue Book 1928. Colombo: Ceylon Government; 1928. Ceylon. Administration Report of The Director of Health Services 1929. Colombo: Ceylon Government; 1929. Ceylon. Administration Report of The Director of Health Services 1928. Colombo: Ceylon Government; 1928. Ceylon. Civil Establishments, The Ceylon Blue Book 1929. Colombo; 1929. Hewa S. Introducing Modern Nursing to Sri Lanka: Rockefeller Foundation and Colombo School of Nursing. Gall Med J. 2014;19:17. Ceylon. Civil Establishments, The Ceylon Blue Book 1931. Colombo: Ceylon Government; 1931. Ceylon. Administration Report of The Director of Health Services 1935. Colombo: Ceylon Government; 1935. Ceylon. Administration Report of The Director of Health Services 1936. Colombo: Ceylon Government; 1936. Ceylon. Administration Report of The Director of Health Services 1947. Colombo: Ceylon Government; 1947. Ceylon. Administration Report of The Director of Health Services 1950. Colombo: Ceylon Government; 1950. Ceylon. Administration Report of The Director of Health Services 1952. Colombo: Ceylon Government; 1952. Ceylon. Administration Report of The Director of Health Services 1953. Colombo: Ceylon Government; 1953. Ceylon. Administration Report of The Director of Health Services 1955. Colombo: Ceylon Government; 1955. Ceylon. Administration Report of The Director of Health Services 1956. Colombo: Ceylon Government; 1956. Ceylon. Administration Report of The Director of Health Services 1957. Colombo: Ceylon Government; 1957. Ceylon. Administration Report of The Director of Health Services 1958. Colombo: Ceylon Government; 1958. Ceylon. Administration Report of The Director of Health Services 1960. Colombo: Ceylon Government; 1960. Ceylon. Administration Report of The Director of Health Services 1961. Colombo: Ceylon Government; 1961. Ceylon. Administration Report of The Director of Health Services 1962. Colombo: Ceylon Government; 1962. Ceylon. Administration Report of The Director of Health Services 1926. Colombo: Ceylon Government; 1926. Ceylon. Administration Report of The Director of Health Services 1927. Colombo: Ceylon Government; 1927. Ceylon. Administration Report of The Director of Health Services 1930. Colombo: Ceylon Government; 1930. Ceylon. Administration Report of The Director of Health Services 1931. Colombo: Ceylon Government; 1931. Ceylon. Administration Report of The Director of Health Services 1932. Colombo: Ceylon Government; 1932. Ceylon. Administration Report of The Director of Medical and Sanitary Services for 1933. Colombo: Ceylon Government; 1933. Ceylon. Administration Report of The Director of Health Services 1934. Colombo: Ceylon Government; 1934. Ceylon. Administration Report of The Director of Health Services 1937. Colombo: Ceylon Government; 1937. Ceylon. Administration Report of The Director of Health Services 1938. Colombo: Ceylon Government; 1938. Ceylon. Administration Report of The Director of Health Services 1939. Colombo: Ceylon Government; 1939. Ceylon. Administration Report of The Director of Health Services 1942. Colombo: Ceylon Government; 1942. Ceylon. Administration Report of The Director of Health Services 1944. Colombo: Ceylon Government; 1944. Ceylon. Administration Report of The Director of Health Services 1945. Colombo: Ceylon Government; 1945. Ceylon. Administration Report of The Director of Health Services 1946. Colombo: Ceylon Government; 1946. Ceylon. Administration Report of The Director of Health Services 1948. Colombo: Ceylon Government; 1948. Ceylon. Administration Report of The Director of Health Services 1949. Colombo: Ceylon Government; 1949. Ceylon. Administration Report of The Director of Health Services 1951. Colombo: Ceylon Government; 1951. Ceylon. Administration Report of The Director of Health Services 1954. Colombo: Ceylon Government; 1954. Ceylon. Administration Report of The Director of Health Services 1959. Colombo: Ceylon Government; 1959. Ceylon. Administration Report of The Director of Health Services 1963. Colombo: Ceylon Government; 1963. Ceylon. Administration Report of The Director of Health Services 1943. Colombo: Ceylon Government; 1943. World Health Organization. Community-based Health Services: A Vital Part of Universal Health Coverage. SEARO Tech Consult Semin. 2016;1–16. Madhavi AVP, Nirmalie MI, Rajapaksa RCW, Chandralatha MMAR, Udaya Kumari WMS, Chandana L, BODY IMAGE PERCEPTION, AND DIETARY PATTERNS AMONG TEENAGE GIRLS. Trends Cogn Sci [Internet]. 2010;14:88–100. Available from: http://landing.adobe.com/en/sea/products/acrobat/69210-may-prospects.html?trackingid=KTKAA MoH. Duty list of a Public Health Nursing Officer [Internet]. Sri Lanka. 2017. Available from: https://ncd.health.gov.lk/images/pdf/circulars/duty_list_of_a_public_health_nursing_officer.pdf WHO. Expert Committee on Community Health Nursing & World Health Organization. Community health nursing: report of a WHO expert committee [‎meeting held in Geneva from 30 July to 5 August 1974]. 1974. Ceylon. Administration Report of The Director of Health Services 1940. Colombo: Ceylon Government; 1940. Agampodi TC, Amarasinghe GS, Wickramasinghe ND, Warnasekara JN, Perez-Escamilla RAS. Maternal and child health and nutrition (MCHN) policies and programs in Sri Lanka: a paradigm for public health in Asia. Sri Lanka J Med. 2021;30:70–87. Family Health Bureau. Annual Report of the Family Health Bureau. 2021. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1AdditionalTable1ServicesprovidedbyPHNsfrom19261963Inchronologicalorder.xlsx Services provided by PHNs from 1926-1963 (In chronological order) Additional file 1 should be named “Services provided by PHNs from 1926-1963 (In chronological order) AdditionalFile2AdditionalTable2EducationandtraininggiventoPHNs.xlsx Education and training given to PHNs Additional file 2 should be named “Education and training given to PHNs AdditionalFile3AdditionalTable3ChangesinothertrainingprogrammesinSriLanka.xlsx Changes in other training programmes in Sri Lanka Additional file 3 should be named “Changes in other training programmes in Sri Lanka Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 Jun, 2025 Reviews received at journal 29 May, 2025 Reviews received at journal 09 May, 2025 Reviewers agreed at journal 04 May, 2025 Reviewers agreed at journal 04 May, 2025 Reviewers invited by journal 02 May, 2025 Editor invited by journal 21 Apr, 2025 Editor assigned by journal 18 Apr, 2025 Submission checks completed at journal 18 Apr, 2025 First submitted to journal 30 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Senadheera","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYNCCCij94ADRWs5A6QSitTC2kaKFv//4w8eF82wSG9gPP2BIOENYB4PEjRxj45nb0hIbeNIMGBJuEOOoGzxs0rzbDic2MOQAHfaBCB3y548//807B6iF/w2RWgwOJJgx8zYAtUiAbCHGYYZAv0jzHEszbpN4BtROjPflzh9/+Jmnxka2nz/54YMPx4jQAgdsQHyAFA2jYBSMglEwCvAAAMRrN0sa27Y3AAAAAElFTkSuQmCC","orcid":"","institution":"Open University of Sri Lanka","correspondingAuthor":true,"prefix":"","firstName":"Lakmali","middleName":"","lastName":"Senadheera","suffix":""},{"id":451660121,"identity":"af7d6122-189f-40cd-af73-6c7c060410c2","order_by":1,"name":"Nilmini Priyanthi","email":"","orcid":"","institution":"Open University of Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"Nilmini","middleName":"","lastName":"Priyanthi","suffix":""},{"id":451660122,"identity":"0d0a4562-308e-47b5-9b89-3aa65d3e6422","order_by":2,"name":"Janith 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review\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/f5142589a61fd9d8ce9c0116.png"},{"id":82350319,"identity":"5a0754af-f07d-446e-a64c-fc282ad01d5f","added_by":"auto","created_at":"2025-05-09 10:51:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32962,"visible":true,"origin":"","legend":"\u003cp\u003eHistory of PHNs in Sri Lanka in the colonial era\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/ef4cfcccda8e11ca4a011ffc.png"},{"id":82350321,"identity":"6dbd2b98-ab42-465a-a0f2-6efe710335b3","added_by":"auto","created_at":"2025-05-09 10:51:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42312,"visible":true,"origin":"","legend":"\u003cp\u003eHistory of PHNs in Sri Lanka in the post-colonial Era\u003c/p\u003e","description":"","filename":"Onlinedrawingimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/9d1320d57f85b15c32575f40.png"},{"id":82355744,"identity":"265e6d32-aecd-4269-b326-6eec576f3b96","added_by":"auto","created_at":"2025-05-09 11:15:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2045947,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/7692ed99-c8e9-4b31-ba5f-91e4433231ff.pdf"},{"id":82350317,"identity":"c3379dda-5279-4bd5-a2fa-b2b8ccd9a575","added_by":"auto","created_at":"2025-05-09 10:51:32","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13537,"visible":true,"origin":"","legend":"\u003cp\u003eServices provided by PHNs from 1926-1963 (In chronological order)\u003c/p\u003e\n\u003cp\u003eAdditional file 1 should be named “Services provided by PHNs from 1926-1963 (In chronological order)\u003c/p\u003e","description":"","filename":"AdditionalFile1AdditionalTable1ServicesprovidedbyPHNsfrom19261963Inchronologicalorder.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/fa209a7e0a3f7625badee82a.xlsx"},{"id":82350316,"identity":"6de77bbc-bff3-4f56-be3b-82d430828aae","added_by":"auto","created_at":"2025-05-09 10:51:32","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13452,"visible":true,"origin":"","legend":"\u003cp\u003eEducation and training given to PHNs\u003c/p\u003e\n\u003cp\u003eAdditional file 2 should be named “Education and training given to PHNs\u003c/p\u003e","description":"","filename":"AdditionalFile2AdditionalTable2EducationandtraininggiventoPHNs.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/ba4c2776434d4e3c15b93b51.xlsx"},{"id":82350318,"identity":"5845b8fb-e673-44d1-8aef-b904525f414b","added_by":"auto","created_at":"2025-05-09 10:51:32","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":9966,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in other training programmes in Sri Lanka\u003c/p\u003e\n\u003cp\u003eAdditional file 3 should be named “Changes in other training programmes in Sri Lanka\u003c/p\u003e","description":"","filename":"AdditionalFile3AdditionalTable3ChangesinothertrainingprogrammesinSriLanka.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6339752/v1/d9d84aaf15d90f698cef04ce.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Revisiting the History: A Century of Public Health Nursing in Sri Lanka: A Scoping Review","fulltext":[{"header":"Summary Statement","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Sri Lanka, public health nursing was first practised in 1926 and was crucial to improving the community health of the country in the early to mid-20th centuries. However, the post of PHN was discontinued in the 1980s for reasons that remain poorly understood and unrecorded despite the cadre being reintroduced recently.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edoes\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethis paper\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eadd\u003c/strong\u003e\u003cstrong\u003e?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe history of public health nursing in Sri Lanka is being systematically reconstructed for the first time with this scoping review. It draws upon an extensive range of grey literature, archived resources, government reports, and historical document sources from national libraries and institutional repositories in both Sinhala and English. In addition to providing novel perspectives on the reasons for and consequences of the discontinuity and the current reestablishment of public health nurses\u0026rsquo; (PHNs\u0026rsquo;) responsibilities, this paper divides the evolution of public health nursing into four distinct historical phases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for practice/policy?\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review fills a significant knowledge gap by documenting a century of PHN evolution. It offers a foundation of evidence for restructuring the scope, training, and deployment of PHNs in Sri Lanka. Furthermore, this study provides appropriate guidance to national stakeholders who are trying to improve the integration of PHNs into public health services, especially in fields such as palliative care, geriatric care, the control of noncommunicable diseases and community-level outreach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat does this paper contribute to the wider global clinical community?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study contributes to the field of public health nursing by offering a revised and comprehensive history. It will also serve as a valuable resource for future research and policy-making, helping to inform and improve public health initiatives in Sri Lanka.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003ePublic health nursing services are a vital component of healthcare systems in different countries. However, the utilization of public health nursing services has varied significantly across the globe, shaped by differing healthcare priorities and systems. With the Alma-Ata Declaration of 1978, the field of public health attracted increased attention because primary health care (PHC) was identified as the crucial component of achieving universal health coverage (UHC) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which covers the entire range of essential healthcare services, including health promotion, disease prevention, and palliative care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Public health nursing is an integral part of the community healthcare system globally, as it involves more than just providing nursing services in communities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; it is a distinct and specialized approach to care for communities on the basis of public health principles [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The primary role of public health nurses (PHNs) is focused on disease prevention and health promotion, the reduction of disabilities, and follow-up care in a variety of settings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] while providing comprehensive care to individuals, families, and groups of people, which contributes to the overall health of the population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the early 17th century, St Vincent Depaul established the modern principles of visiting nursing and social welfare [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In 1859, William Rathbone from Liverpool, England, was crucial in creating district nursing services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Over the years, community health nurses have courageously implemented numerous new ways to foster the overall health of their communities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The term \"public health nursing\" was coined in the 20th century by Lillian Wald in the United States to emphasize the worth of the nurses who served the community because their work rested on understanding all the problems that consistently accompany the ills of people experiencing poverty. Since the vast range of practices in public health nursing is distinctive, the term \u0026lsquo;public health nurse\u0026rsquo; is used for different positions, but those who play similar roles include public health nurses, community nurses, district nurses, remote area nurses, and health visitors[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this document uses the term \u0026lsquo;public health nurses\u0026rsquo; (PHNs) for all the above positions.\u003c/p\u003e \u003cp\u003eSri Lanka has successfully established universal health coverage with an example of a public health system in the region. Over the years, the primary focuses of the public health system have been maternal and child health and infectious disease prevention, with existing field-based staff such as public health midwives and public health inspectors. Although Sri Lanka is in an advanced position to achieve Universal Health Coverage (UHC) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], ensuring the provision of equitable and universal healthcare has been challenging [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, the island is facing new health challenges, such as increasing elderly population and increasing NCD prevalence, which will be the primary cause of mortality [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, Sri Lanka seeks solutions to current health challenges [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Globally, in response to the new public health movement, PHNs play a pivotal role in disease prevention and health promotion [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] while indirectly supporting the reduction of healthcare costs by decreasing hospital admissions and treatment charges. Additionally, the community benefits from maintaining a better health status by receiving public health nursing services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePublic health nursing in Sri Lanka had its roots in 1926, soon after the establishment of the first health unit in Kalutara [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the International Health Division (IHD) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the early 1980s, PHN was converted into public health nursing sister (PHNS) or public health nursing tutor (PHNT) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, in 2018, PHN was reestablished in Sri Lanka and focused mainly on NCD prevention, palliative care, and elderly care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Over the past few decades, PHNs in Sri Lanka have faced numerous challenges, including limited resources, staff shortages, political changes, and evolving health threats.\u003c/p\u003e \u003cp\u003eIn summary, public health nursing services in Sri Lanka continued until the 1980s and were subsequently discontinued and reintroduced in 2018. As many health experts believe, PHN is an essential service in Sri Lanka that must be improved to address emerging public health issues, including increased NCD prevalence, in Sri Lanka. Currently, only 217 PHNs are working in Sri Lanka, but if we could effectively use them to obtain optimal PHN services, it would be easy to improve community health at a lower cost. This highlights the need to critically examine the factors underlying their implementation, cessation, and eventual reinstatement with the healthcare trends of the respective periods. This information is crucial for utilizing historical insights to develop and enhance the current status of public health nursing in Sri Lanka. Hence, this study aims to fill these gaps by providing a comprehensive historical analysis. Thus, the objectives of this review were to review the history of public health nursing in Sri Lanka, highlighting the critical milestones of its evolution, contributions, and challenges faced by PHNs throughout the years. Furthermore, this study provides a detailed historical account of public health nursing in Sri Lanka by identifying the key figures and milestones in the development of public health nursing and exploring the impact of public health nursing on community health outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eScoping reviews are frequently used to investigate and compile the body of knowledge for a given subject [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, this methodology was selected because our aim was to explain what is known about the history of public health nursing in Sri Lanka (SL).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eGuidelines\u003c/h2\u003e \u003cp\u003e This scoping review (without a meta-analysis) followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A comprehensive literature search was performed to identify research studies and grey literature related to the history of public health nursing in Sri Lanka.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eReview questions\u003c/h3\u003e\n\u003cp\u003eThe review questions used in this review were as follows: What are the reasons for introducing PHNs to Sri Lanka (SL)? How do the PHNs grow and evolve in SL? What were their roles as PHNs in SL? Why did the government stop the services of PHNs in SL? Why was the post of PHNs converted into PHNS/PHNTs? Why were PHNs reintroduced into the Sri Lankan health care system?\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003e In this scoping review, peer-reviewed scholarly sources (journal articles, academic theses, and conference proceedings) and grey literature published by the Sri Lankan government and related agencies (administrative reports, circulars, and guidelines) were included. Eligible documents were published in English and Sinhalese languages and contained primary or secondary data on PHNs in Sri Lanka and infectious diseases among pregnant women in Sri Lanka from 1926 to March 2024. We excluded articles that were not peer-reviewed and reported estimated data on PHNs in Sri Lanka. Even though the full-text articles were not available, all abstracts were available as conference proceedings were included since the data on this topic area were limited (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSearch methods\u003c/h3\u003e\n\u003cp\u003eThe Population, Intervention, Comparison, and Outcome (PICO) framework was used (without the optional ‘comparison’ and ‘intervention’ elements since these were not relevant to our research question) to guide the search [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003ePopulation (P): Public health nurses (PHNs) in Sri Lanka.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOutcome (O): Any related information about PHNs in Sri Lanka.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy selection criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclusion Criteria\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion Criteria\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of interest\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSri Lanka\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRest of the world\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnglish and Sinhalese\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny language except\u003c/p\u003e \u003cp\u003eEnglish and Sinhalese\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication Date\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAny year\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication Type\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer-reviewed research Articles, Historical government reports, books, archived medical journals, and locally written sources\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbstracts only, non-peer-reviewed articles\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAny information related to Public Health Nursing in Sri Lanka\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot related to Public Health Nursing in Sri Lanka\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDatabases and information resources\u003c/h2\u003e \u003cp\u003eThis review conducted an internet-based search via the PubMed, Cochrane Review, Lens.org, Web of Science, EMBASE, and MEDLINE® databases for relevant articles. Additionally, Google Scholar was used to collect all the internet-based literature that was not indexed in the above databases, since most local journals were not indexed in the selected databases for the current study. The scoping review concerns Sri Lanka, so searching the local literature is crucial. Therefore, some bibliographic references, such as the Bibliography of Medical Publications related to Sri Lanka 1811–1976 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and its supplement Bibliography on Health in Sri Lanka 1977–1980 by Peiris and Uragoda [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and the Bibliography of Publications on Food and Nutrition, 1847—1988 by Wickramanayake [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], were used to search for local literature. Additionally, archived issues of the Sri Lanka Journal of Medical Sciences and the Kandy Medical Journal, Proceedings of the Kandy Society of Medicine, other medical and health-related research work and published books were searched in five libraries (the National Library of Sri Lanka, the Library of the National Museum, the Sri Lanka Medical Association Library and the Peradeniya Medical Faculty Library, and the library of the Open University of Sri Lanka). The reference lists of the selected articles were searched for eligible papers to include missing articles from the main search throughout the process.\u003c/p\u003e \u003cp\u003eFurthermore, given the lower availability of published scholarly works, the authors tended to search in grey literature, including local written historical documents such as Ceylon Blue Books, Ceylon Administrative Reports, and Ceylon Sessional Papers (1862–1926), because these records are official historical documents that provide yearly performance, progress, goals attained, and finances of Sri Lanka throughout that era. Furthermore, the Department of the National Archives of Sri Lanka preserved old national newspapers and handwritten documents, letters and notes by authorized officials (in the 1900s) (related to public health nursing). In addition, several other sources, such as government circulars, relevant websites, and related printed documents, complemented the facts accordingly.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch strategies\u003c/h3\u003e\n\u003cp\u003eThe keywords and entry terms included in the initial search were \"public health nursing\", \"community health nursing\", \"public health nurse\", and \"community health nurse\" in combination with “Sri Lanka” or “Ceylon”. The search string that was used for PubMed was (\"public health nursing\"[Title/Abstract]. OR \"community health nursing\"[Title/Abstract]. OR \"public health nurses\"[Title/Abstract]. OR (\"public health initiatives\" AND \"nursing perspective\"[Title/Abstract].) OR (\"health promotion\" AND \"nursing interventions\"[Title/Abstract].) OR (\"disease prevention\" AND \"public health nursing\" [Title/Abstract].) OR (\"maternal and child health\" AND \"nursing care\" [Title/Abstract].) AND \"history\"[Title/Abstract]. OR \"historical development\"[Title/Abstract]. OR \"evolution\"[Title/Abstract]. AND (“Ceylon” OR “Sri Lanka”)). The search string for Web of Science was TOPIC: (Leptospirosis) OR TOPIC: (\"public health nursing\") OR TOPIC: (\"public health nurse\") OR TOPIC: (“community health nurse”) OR TOPIC: (\"community health nursing\") Refined by: TOPIC: (“Sri Lanka” OR “Ceylon”). The search string for Google Scholar was ((\"public health nursing\" OR \"community health nursing\" OR \"public health nurse\" OR “community health nurse”) AND (\"history\" OR \"historical development\") AND (“Ceylon” OR “Sri Lanka”)). For Lens.org, the search string was ((\"public health nursing\" OR \"community health nursing\" OR \"public health nurses\") AND (\"history\" OR \"historical development\") AND (\"Ceylon\" OR \"Sri Lanka\")).\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eAfter removing duplicates from various databases, the title and abstract were screened to exclude irrelevant publications. These included articles that were not immediately pertinent to public health nursing in Sri Lanka. Detailed reviews of the full texts were conducted for all the articles selected during screening to evaluate the eligibility criteria further. The final evidence synthesis included all the research articles related to public health nursing. Furthermore, all the Ceylon Administrative Reports that reported details about public health nursing were included. In addition, Ceylon blue books related to the first PHNs were included. Furthermore, other relevant reports and government circulars were included.\u003c/p\u003e \u003cp\u003eAfter the databases were searched, all possible records were compiled and entered into Zotero©, and the duplicates were removed via the Zotero function. The titles and abstracts were subsequently screened by two reviewers (LS and NP) on the basis of the inclusion criteria, and studies that were not related to public health nursing in Sri Lanka were removed. Only the remaining full-text studies were reviewed by three researchers (LS, NP and JW). Any disagreements that occurred among the reviewers were resolved through discussion.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData extraction\u003c/h2\u003e \u003cp\u003e Two reviewers (LS and NP) independently extracted the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eQuality appraisal\u003c/h2\u003e \u003cp\u003eTwo reviewers (LS and NP) independently assessed each question by assigning a rating of ‘yes’ for a low risk of bias, ‘no’ for a high risk of bias, ‘Not Reported’ when no supporting information was available, and ‘NA’ if the criteria were not applicable. Any discrepancies in the quality ratings between reviewers were resolved through discussions and consensus with a third reviewer (JW). Studies rated as poor were removed to ensure the validity and reliability of the review’s conclusions, as their results may be unreliable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData synthesis\u003c/h2\u003e \u003cp\u003eA narrative analysis was conducted to integrate the results appropriately to rewrite the history of PHNs in Sri Lanka.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData items\u003c/h2\u003e \u003cp\u003eThis review used data items, including the study year, authors, abstract, and keywords, to assess the study and describe sequelae.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results/Findings","content":"\u003ch2\u003eStudy selection\u003c/h2\u003e\n\u003cp\u003eAfter the databases were searched, all possible records (n\u0026thinsp;=\u0026thinsp;2895) were compiled and added to Zotero\u0026copy;. Duplicates (n\u0026thinsp;=\u0026thinsp;1589) were identified and eliminated via the Zotero tools, and 1306 records remained. After screening the titles and abstracts, 1198 papers were excluded. After screening the full texts of the remaining 108 papers, 92 were excluded on the basis of the inclusion criteria. The remaining 16 publications [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e] were reviewed (the PRISMA flowchart illustrating the selection process is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). No additional papers could be identified through the reference lists of the included studies. However, more fruitful and supplementary information about the PHNs of Sri Lanka can be found in local documentary sources, including Ceylon Administrative Reports and Ceylon Blue Books.\u003c/p\u003e\n\u003ch2\u003eHistory of Public Health Nursing in Sri Lanka\u003c/h2\u003e\n\u003cp\u003eAfter carefully reviewing all the available historical evidence, we can rewrite the history of public health nursing in Sri Lanka. On the basis of the critical milestones, we can divide the history of PHNs into 4 phases:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e1. PHNs in the colonial era (1926\u0026ndash;1948)\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e2. PHNs in the post-colonial era (1948\u0026ndash;1980)\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e3. No-PHNs era (1980\u0026ndash;2018)\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e4. Re-establishment of the PHN era (2018 onwards)\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch2\u003e01. History of PHNs in the Colonial Era (19261948)\u003c/h2\u003e\n\u003ch2\u003eEstablishment of the first Health Unit, Kalutara, in Sri Lanka\u003c/h2\u003e\n\u003cp\u003eIt is impossible to talk about PHNs in Sri Lanka without addressing the first health unit because the origin of PHNs in Sri Lanka subsequently occurred after the establishment of the Kalutara Health Unit. In the middle of the 19th century, the British established plantation businesses in central Sri Lanka, and labourers were transported from southern India since the Kandyans (local people residing in the central Sri Lanka) refused to work on the estates [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Hookworm infection rapidly spread among Indian labourers, and 31 cases were first detected in Sri Lanka in 1888 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Since there are approximately one billion hookworm patients worldwide, the International Health Board (Sanitary Commission and Rockefeller Foundation) decided to start a hookworm management programme in a few particular British territories, including Sri Lanka [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. As a result, on 01st July 1926, the first health unit in Asia was established at Kalutara-Totamune, a suburb 43 km south of Colombo, in a land area of 25 square miles with a population of 33,000 [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], and this was a real step taken to improve rural health work along modern lines [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Kalutara Health Unit consists of 01 medical officer as the director, 03 PHNs, 03 midwives, and 06 sanitary inspectors [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e], but it undertook multiple activities while launching several health programs, including controlling hookworm infestations; taking antimalaria measures; engaging in maternal, prenatal, and newborn welfare activities; engaging in preschool and school hygiene; and engaging in public health awareness campaigns [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. As per the Annual Report-1926 of the Rockefeller Foundation, the overall health unit programme was carried out satisfactorily throughout the year, even though maternity care and newborn hygiene were major issues in the district [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eThe First PHNs in Sri Lanka\u003c/h2\u003e\n\u003cp\u003eUpon establishing the Kalutara Health Unit (HU), the need for PHNs was well identified, and a series of studies were conducted by the Rockefeller Foundation to determine the demand for PHNs in Sri Lanka. The first research was conducted by Dr. Jacocks (1926), the \u0026quot;Advisory Health Officer\u0026quot; of the Department of Medical and Sanitary Services, who revealed no PHNs in Sri Lanka; thereafter, W.S. Carter suggested initiating a training programme for PHNs after doing his study [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. In response to these reports, in 1926, the government established the post of \u0026ldquo;public health nurse\u0026quot; at Kalutara HU. On 19th July 1926, Ms J.M. Mutuwadi, who had worked as a Ceylonese Matron and a Housekeeper of Ceylonese Nurses attached to the Kandana Sanatorium [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]was appointed the first PHN in Sri Lanka after providing brief training in identifying hookworms, malaria infections, and maternity and infant welfare activities [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. She received a similar salary (LKR 1260/=) to the other housekeepers of Ceylon nurses with the same grade (her 1st appointment date was 17th March 1911) [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. S. Chinniah, Ceylon Matron, was then appointed as a PHN on 31st August, and her salary was LKR 840 [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAlthough the PHN was established in Sri Lanka in 1926, the title \u0026quot;Public Health Nurse\u0026quot; first appeared in the \u0026ldquo;Alphabetical List of the Names of Officers\u0026rdquo; in the Ceylon Blue Book in 1928. Therefore, although the PHN was written informally in 1926, the title \u0026quot;public health nurse\u0026quot; might have been first used formally in 1928. Additionally, their salary, along with their job grade, remained unchanged, irrespective of the new post. This may be due to the designation of the PHN being new to Sri Lanka and very suddenly appointing currently working nurses to that position. Nevertheless, no specific status for the post was established. Furthermore, the origin of PHNs has occurred mainly on the basis of the country\u0026apos;s needs, approximately 3 weeks after the establishment of Kalutara HU.\u003c/p\u003e\n\u003cp\u003eFurthermore, according to our search, no information related to PHNs could be found in any Ceylon Blue Book, Ceylon Sessional Papers, Ceylon Administrative Reports, or documentary sources published from 1860\u0026ndash;1925. These reports are historical documents annually published by the Ceylon Government, including all the important information related to the administration, health, revenue, politics, law, economic situation, etc., of Sri Lanka as a summary and reported to Great Britain by the governor. Therefore, on the basis of this historical evidence, we can eventually confirm that the origin of public health nursing in Sri Lanka occurred in 1926, just after the establishment of the first health unit of Sri Lanka.\u003c/p\u003e\n\u003cp\u003eLater, two more hospital matrons were appointed after the same training was given [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, by 16th March 1927, J.M. Mutuwadi had resigned from the PHN post and rejoined Nurses Home, Ragama, as a Ceylon Matron/Matron in charge [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Similarly, between 1926 and 1928, at least 08 hospital matrons were employed as PHNs for the Kalutara health unit. Nevertheless, the retention of PHNs was very difficult because they either quit or moved back to work at hospitals [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eCharacteristics, Education, and Training of Early PHNs in Sri Lanka\u003c/h2\u003e\n\u003cp\u003eIt was suggested that there should be 5 PHNs for a population of 40,000 [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. A PHN should have a strong character, be sympathetic but forceful, have tact and initiative, and possess common sense [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] while having additional training in MCH, treatment for malaria, and hookworm infestation [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. They must reside in the HU area, visit communities regularly to discuss health problems, and visit schools to understand prevailing health problems [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although PHNs were in a key position in the HU programme [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], there were 05 HUs without PHNs by 1928, and the government was planning to establish 02 additional HUs in 1930 [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. PHNs should provide unique training in delivering MCH (maternal and child health) care and treating malaria and hookworms [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e], and the Rockefeller Foundation assisted in training PHNs in Sri Lanka [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Accordingly, when health units expanded gradually, Dr. Jacocks advised the government to appoint a full-time medical officer to train PHNs in Sri Lanka [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. Accordingly, on 1st June 1928, Dr. Mrs. L.N.V. Chinnappa (MBBS, Madras), specializing in maternity and child welfare, was placed in this position [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. The training of PHNs was initiated at the Kalutara health unit, which consists of 6 months in midwifery and 6 months in public health [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. In 1928, 7 more hospital nurses were chosen for training [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], and the total number of PHNs in Sri Lanka was 11 [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, the training did not progress as expected since it failed to retain new recruits of PHNs [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eDr. Jacocks mentioned that if \u0026ldquo;the Health Unit fails to succeed and develop in Ceylon, it will be for lack of PHNs\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, in 1928, Miss. Mary Beard, the director of nursing at the Rockefeller Foundation, visited Sri Lanka and showed that the success of the health unit programme depends on how thoroughly it is incorporated into villagers\u0026rsquo; lives. In that case, the PHNs must play an essential role in the health unit project. Therefore, she emphasized that it is essential to have qualified PHNs in the Kalutara health unit since it was planning to use this institute as a model when expanding health unit facilities throughout the country. Furthermore, she stressed improving PHNs in Sri Lanka through training them to obtain more competent services [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eBy 1929, Sri Lanka had only five PHNs [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]s, and there was a significant shortage of PHNs, mainly because only unmarried women were recruited for the post [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. This was the greatest challenge and barrier to the successful functioning of the health unit programme. The Department of Medical and Sanitary Services subsequently launched a specific programme for recruiting and training PHNs in the latter part of 1929 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Hence, in the 1930s, the Rockefeller Foundation focused primarily on training professional health workers, especially PHNs [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. The major critique at the time was that PHNs had not been trained in public health nursing principles, but this was impossible to accomplish in a brief period [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eDr. R. Briercliffe, the newly appointed director of medical and sanitary services in 1930, found that PHNs were essential in dealing with all areas of community public health issues. Furthermore, he emphasized the importance of PHNs in spreading public health awareness programmes and dealing with communicable diseases such as tuberculosis while improving children\u0026apos;s welfare through collaboration with schools, education authorities, and school medical work. Furthermore, as a response to this shortage, he recruited married women as PHNs who had obtained hospital nursing training but had resigned from the service due to marriage and provided one year of training in midwifery and public health nursing [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn 1931, 10 more PHNs were recruited, and five PHNs were allocated to the Kalutara Health Unit [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. In 1935, only qualified nurses employed in government hospitals were selected for PHN training, and the course duration was 6 months. Those who were not qualified in maternity nursing were provided a course at the Soysa Lying-in-Home, Colombo. However, the number of eligible candidates to be trained as PHNs is insufficient in the country [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. PHNs held their first annual conference in 1935, which was a major milestone in history [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e]. In 1936, 4 PHNs came from the Public Health Department of Mysore, India, and received training at Kalutara HU [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. The PHNs convened their annual meeting on 22nd August 1936 in Negombo, inaugurated by Lady Tyrell. Additionally, they released their yearly publication, \u0026ldquo;The Public Health Nurse,\u0026rdquo; which included proceedings from the preceding conference [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. In 1938, the above conference took place in Kandy (Central Sri Lanka), Ceylon, which is an indicator of the shift in PHN services outside the western province.\u003c/p\u003e\n\u003cp\u003eIn 1947, the Rockefeller Foundation conducted an influential public health campaign and undertook several studies to ascertain the level of nursing education on the island. The findings highlighted that the island must have a sufficient number of well-trained PHNs for the health unit programme to be successful in Sri Lanka. As a result, Janet D. Corwin, the foundation\u0026apos;s nursing coordinator for South Asia, visited the island in June 1947 and prepared a detailed report recommending placing nursing in the hands of \u0026ldquo;educated Ceylonese women\u0026quot;. Furthermore, her impression of the level of education among women was highly positive [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. Furthermore, in 1947, public health nursing was considered a postgraduate qualification that was opened to both nurses and midwives upon completing a three-year nursing diploma, followed by a six-month training at Kalutara [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. According to Cowin\u0026rsquo;s report, by 1947, there were 40 PHNs in Sri Lanka [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e] for a population of six million, although approximately 700 PHNs were needed for the effective function of the health unit programme \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThe authors of the current study strived to summarize the history of this era, as depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003ch2\u003e02. History of PHNs in the post-colonial era (1948\u0026ndash;1980)\u003c/h2\u003e\n\u003cp\u003eSri Lanka received independence in 1948. In the post-colonial era, the health unit system was improved as part of the national healthcare program. Identifying the most prevalent and dangerous infectious diseases in each health unit region and controlling them with the aid of local populations through immunization, treatment, improved sanitation, and health education is a fundamental approach of the health unit system. These operations were coordinated mainly by PHNs together with midwives and sanitary inspectors who were locally appointed [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The child welfare projects organized by the PHNs of the health units in cooperation with the schools in the area were among the most significant activities of the health units. The PHNs conducted clinics on hygienic issues at schools around the province. They also visit mothers at home frequently to offer advice on childcare. Each health unit\u0026apos;s nursing staff is often overburdened by the number of people needing these services, indicating that the child welfare job is the most demanding of all the health unit tasks [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eMrs. M.A. Jainu Deen was trained as the first Sri Lankan public health nurse at the University of Toronto. The Rockefeller Foundation hoped that she would be a good asset in developing PH nursing in Sri Lanka. However, she could not be put in the director position of the School of Nursing since the colonial bureaucracy of the Department of Medical and Sanitary Services was unwilling to accommodate North American-trained PHNs in senior positions. Therefore, Mrs. M.A. Jainu Deen was appointed as a PHN attached to the Kalutara health unit to train PHNs [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. Accordingly, she became the first Sri Lankan public health nursing tutor in Sri Lanka in 1949 [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn 1950, it was feasible to recruit and train 19 additional PHNs instead of slow recruitment, thereby significantly accelerating the total number of PHNs in Ceylon to 64 [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. This year, a four-week refresher course was initiated for PHNs, and 5 PHNs attended the program [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. In 1952, lectures and demonstrations on field tuberculosis (TB) control were delivered to PHNs throughout their training. On July 21, 1952, systematic serological testing for pregnant women commenced at the six prenatal clinics of the Colombo municipality. The World Health Organization (WHO) PHN assisted during the first few weeks, training the matrons and assistant matrons of each clinic to facilitate blood collection [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. In 1952, a two-week training program on venereal disease (VD) was provided to all PHNs (PHNs) employed at the Central VD clinic, enabling them to help with case identification, contact tracing, and contact investigations at their respective local stations [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. Additionally, lectures on the epidemiological facets of VD were also conducted for PHNs at both the Kalutara Health Unit and the Central VD Clinic in Colombo in 1952 [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn 1953, two fellowships in public health nursing (a one-year program) were provided in the UK [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e], and by August 1955, two PHNs had returned to the country following the completion of the course [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. In 1955, the WHO supplied a Public Health Nursing Instructor and expanded the training program for PHNs by including two additional courses: Communicable Diseases and Hygiene. Furthermore, a preventive nursing course was conducted in Ceylon in 1955 [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. In 1956, the Public Health Division released an \u0026quot;Evaluation of the Work of Public Health Auxiliary Personnel\u0026quot; focused on PHNs, public health inspectors (PHIs), and public health midwives (PHMs). This paper has demonstrated the changes that have occurred in the duties of these personnel from 1936\u0026ndash;1956 [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. In July 1957, Mrs. M.A. Jainu Deeen, the Principal PHN, attended the 8th triennial conference of the Associated Country Women of the World/UNESCO seminar held in Kandy, Ceylon [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]. In 1958, two PHNs departed the country after obtaining one-year C-Plan fellowships to Canada to pursue a Public Health Nursing Sister Tutor course [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. In 1960, 18 graduate nurses completed their post-basic training in public health work [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eFurthermore, in the same year, 17 senior PHNs were chosen for advancement to supervise PHNs and were appointed to the Galle and Matara Divisions following a three-month training period [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. By 1961, the importance of \u0026lsquo;Health Education\u0026rsquo; was emphasized, and it was incorporated as a crucial component of all the public health training conducted by the Health Unit in Kalutara [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, this year, a specific MCH course was started for 10 Supervising PHNs [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]. Furthermore, three-day refresher training for PHNs was launched in various health divisions, including Colombo, Kalutara, and Kandy, in 1962. Additionally, post-basic courses were conducted for PHNs, and 21 student PHNs completed the 9-month program in Public Health Nursing during that year [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e]. Furthermore, the Sweden Ceylon Family Planning Project conducted training programs for PHNs, focusing on family planning initiatives established in the country in 1962 [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eMore information on education and training programmes conducted for PHNs is tabulated in the \u003cem\u003eAdditional\u003c/em\u003e Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Furthermore, several changes occurred in different training programmes parallel to improving public health nursing in Sri Lanka and those details are given in the \u003cem\u003eAdditional\u003c/em\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eEvolution of PHNs in Sri Lanka and their workload related to MCH (from 1926\u0026ndash;1960)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of PHNs worked in the year\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of Home visits done by PHNs\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of visits to expectant mothers\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of visits to infants\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of visits to pre-school children\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDocument source\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1926\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e721\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[55]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1927\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[56]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1928\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[38]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1929\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[37]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[57]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[58]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[59]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1933\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[60]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1934\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[61]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[42]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[43]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[62]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e157 988\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[63]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1939\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[64]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e451 887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[65]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1944\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[66]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1945\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[67]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[68]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 970\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 764\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[44]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 906\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[69]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[70]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1950\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 888\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 759\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[45]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 902*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 401*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 485*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[71]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[46]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1953\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[47]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[72]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[48]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84 485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[49]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82 762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 435\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[50]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 625\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78 882\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92 359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[51]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82 732\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[73]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1960\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 506\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79 194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109 942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[52]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*First visit only N/M- Not Mentioned\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cem\u003eData Source: Ceylon Administrative Reports from 1926\u0026ndash;1978\u003c/em\u003e, \u003cem\u003eCeylon Blue Books, The Department of National Archives, Sri Lanka.\u003c/em\u003e\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eServices and Responsibilities of early PHNs in Sri Lanka\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePHN Role/Service\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDocument Source\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl of Hookworm diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1926\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; hookworm disease was widespread\u003c/p\u003e\n \u003cp\u003e\u0026bull; hookworm treatment campaign for school children was carried out\u003c/p\u003e\n \u003cp\u003e\u0026bull; Public health awareness sessions were organized under disease prevention\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3,259 patients were treated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1930\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 448 children were treated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e04 PHNs were awarded certificates of competency in hookworm treatments.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal and Child Welfare (MCW) work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1926\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; After opening the Kalutara HU, pregnant mothers (n\u0026thinsp;=\u0026thinsp;176), infants (n\u0026thinsp;=\u0026thinsp;151), and preschool children (n\u0026thinsp;=\u0026thinsp;98) were provided care at 85 clinics.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Home visits done by PHNs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1927\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSupervised PHMs in child births.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs conducted health education sessions for mothers at both their home visits and the clinics by \u0026lsquo;Little Mothers\u0026rsquo; through talks and demonstrations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare for infants and preschoolers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeveral Health exhibitions were organized by locally appointed PHNs, midwives and sanitary inspectors in Kalutara town to encourage breastfeeding as a part of regular \u0026ldquo;Health and Baby Weeks\u0026rdquo;, which provided health information related to postnatal care for young mothers.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn 1929\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lsquo;Empire Challenge Shield\u0026rsquo; was awarded to Kalutara HU by the National Baby Week Council of England for organizing the best Baby Week held in the British Empire except the British Isles.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1958 and 1959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs focused more on infants and preschoolers during their home visits.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFurthermore, newborns and preschoolers were regularly provided free milk and cod liver oil, while Antepar treatment was implemented for helminthic infections.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1961\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFurthermore, since 1961, whenever PHNs are available, they should be primarily accountable for the health work of infants after the 10th day, preschoolers, and school-aged children.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare for pre-schoolers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConsequently, it was impracticable for PHNs to conduct regular visits to every preschool kid in their region. As a result, it was determined that the scope of PHNs should be significantly reduced to allow more targeted house visits, similar to practices in other countries. Due to this shift, the total number of home visits conducted by PHNs has decreased compared to the previous year.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool hygiene\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1927\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntensive school hygiene was started in 02 schools. Problems related to vision, hearing, teeth and tonsils were detected among pupils, and those were referred for corrections. However, owing to a lack of parental cooperation, the school inspection was suspended until further arrangements were made\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1933\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs\u0026rsquo; contributed to school health activities in a limited way.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 PHNs were engaged in those activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs assisted in school health work in rural areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eattended in the correction of Pediculosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1953\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eassisted in correcting 13 273 detected pediculosis cases.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1956 and 1957\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs are continuously engaged in school health work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFurthermore, it was suggested that the PHN should take responsibility for school health services in areas where PHNs were available.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaccination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1955, 1956 and 1958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe total number of primary vaccinations performed in 1955, 1956 and 1958 were 239 187, 248 021, and 215 872, respectively. In addition to these, re-vaccination was also done accordingly.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs especially vaccinated children at child welfare clinics, while vaccinators were utilized in estates and remote rural areas.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstate health work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHNs conducted 26 visits over six estates and delivered nine health talks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1933-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe PHNs of the Kalutara and Yatinuwara Health units conducted 29 visits to estates. It was continued in 1935 and 1936.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ethey conducted 47 health talks for the state population, with approximately 12 265 attendees in\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVD control work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ethe main features of Public Health work accounted as adoption to the health unit type of work throughout the country except carrying out special campaigns including control of Malaria, TB, Venereal Disease (VD), Filariasis, and Leprosy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1950,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA senior PHN was appointed to the Venereal Disease Clinic of the Lady Havelock Hospital, Colombo. Her sole duty was to confine herself to active case-finding, contract-tracing and follow-up work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTB control work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe Special Grade PHN contributed to the TB survey as a staff member of the survey.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn 1952, PHNs (who worked at Kalutara HU) also contributed to mass radiography-related activities carried out by the mobile unit to screen pulmonary tuberculosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBy May, a pilot project related to TB work was started in the North Western Province of SL. The project staff consisted of one PHN who had received specialist training via a WHO fellowship at the National TB Institute, Bangalore, India.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministrative work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA principal PHN also consisted of the central administration of Health Services that was functioning under the Deputy Director of Health (Public Health Services)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork At Lady Ridgeway Children\u0026apos;s Hospital (LRH)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1963\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; The PHNN (HE) (Health Education) arranged health education sessions at the OPD and the malnutrition clinic. (Ex:- on nutrition and common infectious disorders can be found among children);\u003c/p\u003e\n \u003cp\u003e\u0026bull; organized a well-baby clinic just for the babies of LRH personnel\u003c/p\u003e\n \u003cp\u003e\u0026bull; involved in immunizations with polio and other vaccinations for children who came to obtain outdoor treatments. Later, another PHN was assigned to run the programme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\u003cbr\u003e\n\u003cp\u003ePHNs, PHMs, and public health inspectors (PHIs) are the pillars of public health services, and staff are in charge of providing primary healthcare. By 1972, there were 161 PHNs; 113 of them had received public health training, while the others were PHNs only because they worked in public health. [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. At that time, 3.2% of nurses were PHNs, whereas 93.6% of nurses worked in hospitals, accounting for 4,668 nurses [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. PHNs were in charge of family care, which included home visits for families, child care (including immunizations and infant care), supervision of PHMs, school health work, health education, conducting clinics, immunizations, working with nonprofit organizations, conducting investigations into the deaths of mothers and children, and general administrative tasks ranging from reporting and recording to equipment maintenance.\u003c/p\u003e\n\u003cp\u003eAccording to Simeonov, only 21.1% of PHNs\u0026apos; working time was spent on \u0026quot;technical duties,\u0026quot; or work that was diagnostic, therapeutic, or health-promoting in nature. This information was obtained by analysing how PHNs spent their time among this imposing list of responsibilities. Most of their time was spent on noncontact work, including 28.1% for administration, 23.3% for travel, 9.2% for maintenance, and 16.5% for waiting for people, informal discussions, and other activities [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe Kalutara health unit was expanded, and in 1966, it was renamed the Institute of Hygiene [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. In 1979, it was renamed the National Institute of Health Sciences, becoming the premier public health training facility in the country [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], and then PHN training was extended to one year, with a diploma in public health nursing being awarded after completion of the course [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThroughout this period, the number of PHNs in Sri Lanka slowly increased with time, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Furthermore, it depicts the services they provided to the communities even though the number of PHNs was lower.\u003c/p\u003e\n\u003cp\u003eThe role, responsibilities, and community healthcare services provided by PHNs have extended across a wide range of areas without being limited to MCH care.\u003c/p\u003e\n\u003ch2\u003eRoles and responsibilities of early PHNs in Sri Lanka (1926\u0026ndash;1980)\u003c/h2\u003e\n\u003cp\u003eAdministrative papers provide enough evidence to prove that PHNs play a significant role in public health services to improve the community health of Sri Lanka \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. The PHNs were required to conduct regular visits to the communities, schools, and local dispensaries to obtain a firm understanding of the health challenges that are currently plaguing the area, and that they must reside in the health unit area [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The midwives were placed under the immediate supervision of the PHNs, and each midwife was expected to serve approximately 4,000 people within a three-mile radius. Furthermore, sanitary inspectors were required to help \u0026quot;midwives and nurses whenever possible\u0026quot; [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eTo improve the health status of 3 types of populations\u0026mdash;pregnant mothers, infants, and preschool children\u0026mdash; maternity clinics and \u0026ldquo;well baby\u0026rdquo; clinics were organized by PHNs, covering both urban and rural areas [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. Home visits by PHNs were highlighted as a feature of these works in 1926 [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e]. Voluntary organizations, such as social service leagues, have collaborated closely with maternal and child welfare (MCW) work [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. As a result of this collaborative work and the combined effort of all the PHNs, Midwives, and members of the Social Service League, considerable progress in MCW work could be observed during 1927 [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e]. Hence, MCW work was continuously popular, and the number of clinics conducted had to increase simultaneously with steadily increasing clinic attendance. However, the new work demand could not be adequately met due to the shortage of PHNs in 1936 [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, 10844 normal deliveries were made by midwives under the supervision of PHNs at maternity homes, and these homes were very helpful for the community, resulting in the successful prevention of maternal and infant deaths [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]. Furthermore, by 1952, these homes were not restricted to the mothers who came to the areas for which they were originally intended [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. Given the importance of providing MCH care as institutional care and domiciliary care, ignorant midwives have been considerably replaced by trained health care personnel [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. In 1950, home visits by PHNs and midwives with great efficiency were highly appreciated since home visits resulted in a decrease in the incredibly satisfying mortality rates of mothers and children, which has been steady over the years [\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eBy 1959, even though the MMR (maternal mortality ratio) and IMR (infant mortality rate) had been considerably reduced, anaemia-like conditions were prevalent among pregnant mothers because of nutritional deficiencies and poor standards of health owing to frequent pregnancies[\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]. Unlike today, PHNs took the responsibility of caring for infants 10 days after delivery and caring for preschool children while playing a more managerial role [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Several health exhibitions were organized by locally appointed PHNs, midwives, and sanitary inspectors in Kalutara town to encourage breastfeeding as a part of regular \u0026ldquo;health and baby weeks\u0026rdquo;, which provide health information related to postnatal care for young mothers [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The infant mortality rate was reduced from 235 in 1924 to 216 per 1000 live births by 1927 [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. In 1929, the Empire Challenge Shield was awarded to Kalutara HU by the National Baby Week Council of England for organizing the best Baby Week held in the British Empire, with the exception of the British Isles [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. By 1959, preschoolers were consistently malnourished, inadequately cared for, and frequently afflicted by worm infestations. This year, owing to the scarcity of PHNs, the care provided to preschool children was continually insufficient, particularly in areas with large populations [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]. Consequently, it was impractical for PHNs to conduct regular visits to every preschool child in their region. As a result, the scope of PHNs should be significantly reduced to allow more targeted house visits, similar to practices in other countries. Owing to this shift, the total number of home visits conducted by PHNs has decreased compared with that in the previous year [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]. \u0026ldquo;The PHNs organized child welfare\u0026rdquo; works in collaboration with local schools, and they visit schools and conduct clinics related to sanitary matters. Furthermore, PHNs make routine home visits to advise mothers on childcare [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Thousands of people die from epidemics of smallpox and typhoid in many parts of Ceylon [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although vaccination was performed mainly by PHIs, PHNs also engaged in vaccinations in response to outbreaks of smallpox in 1955, 1956 and 1958 [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e]. In 1949, under tuberculosis control activities, PHNs worked attached to the BCG campaign and rehabilitation team (one at the clinic and 1 for follow-up work) [\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]. In 1963, the LRH (Lady Ridgeway Hospital for Children) commenced an intensive health education activity, and a PHN [designated PHNN (HE) (Health Education)] was recruited to work on a full-time basis as a specific action. She should be responsible for delivering health education programmes for OPD patients, visitors, admitted patients, and the staff of LRH [\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eHealth Education\u003c/h2\u003e\n\u003cp\u003eA total of 43 lectures were delivered under health education, primarily emphasizing the activities of the health unit, maternal and child welfare, communicable diseases, including malaria and hookworm disease, and social services, with an estimated attendance of 9,500 individuals. In addition, 13 conferences were held by PHNs in collaboration with sanitary inspectors and other health unit personnel [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eLater, health education was conducted by various healthcare personnel, including PHNs and PHMs, at the clinics, during home visits, in schools, and in communities of villages held throughout the island using different teaching strategies, including school talks, village talks, and clinic talks. The number of sessions conducted is shown in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eHealth education provided by PHNs, together with other public health workers\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo. of PHNs worked in Sri Lanka\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ehealth talks\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003estaff conferences\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003electures illustrated with Lantern slides\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003electures without Lantern slides\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCinema shows\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt states-236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt states- 47 (attendance-12 265)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82468\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2115 (with staff)\u003c/p\u003e\n \u003cp\u003e382 (with others)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool talks \u0026minus;\u0026thinsp;21 299),\u003c/p\u003e\n \u003cp\u003eVillage talks-(59 466), Clinic talks-(13 891)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e333\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool talks (25 840),\u003c/p\u003e\n \u003cp\u003eVillage talks (121 189)\u003c/p\u003e\n \u003cp\u003eClinic talks (27 698)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/M\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eN/M- Not Mentioned\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eMore information about the services provided by early PHNs is given in the \u003cem\u003eAdditional\u003c/em\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch2\u003e03. No PHNs Era (1980\u0026ndash;2018)\u003c/h2\u003e\n\u003ch2\u003eDiscontinuation of PHNs from Sri Lanka\u003c/h2\u003e\n\u003cp\u003eIn the early 1980s, PHN was discontinued in Sri Lanka (SL), but the specific reason is still uncertain because it was difficult to trace any particular evidence to clarify this phenomenon. However, the probable reasons are as shown in Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e below. However, our perspective concerning the reasons for the above critical decision to stop PHNs in SL made by the government may be due to less attention given to MCH care since, by then, SL had already achieved a remarkable improvement in the MCH in the Asian region further, since the low prevalence of noncommunicable diseases (NCDs) and the nonsignificant elderly population may have led to a lack of demand for NCD prevention and Palliative Care in the 1980s. On the basis of these findings, the necessity of a PHN may be lower for SL communities; thus, the government might stop the PHNs in SL. Our argument is supported by the re-establishment of PHNs in Sri Lanka in 2018, which focused mainly on NCD prevention, elderly care and palliative care.\u003c/p\u003e\n\u003cp\u003eFurthermore, at that point, as a response to a trade union demand, the post of the PHN was converted into the Public Health Nursing Sister (PHNS) or Public Health Nursing Tutor (PHNT) owing to the limited number of positions available at that time [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eProbable reasons for the discontinuation of PHNs in Sri Lanka\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSource of evidence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProbable Reason\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJayasekara (2001) [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe Sri Lankan government believed that primary healthcare activities in the communities could be managed by PHMs working together with the\u003c/p\u003e\n \u003cp\u003eMedical Officer of Health (MOH)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJayasekara (2001) [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraining of a PHM is less expensive than training of a PHN more than three years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAuthors\u0026rsquo; perspectives of the current study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMCH in Sri Lanka was at a significantly improved level in the region.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAuthors\u0026rsquo; perspectives of the current study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo demand for NCD prevention and care for associated health consequences (Ex:- Palliative Care, Geriatric care) due to less prevalence of NCDs in the 1980s in Sri Lanka.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAs a result of this change, nurses were no longer responsible for the community, and the services of PHNSs/PHNTs were limited to community clinics [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e], which led to the following consequences, as mentioned in Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eConsequences of discontinuation of PHN services in Sri Lanka\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSource of evidence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eConsequences of discontinuation of PHN service\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJayasekara (2001) [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe discontinuation of other important parts of community care, such as elderly care, disability care, nutritional care, and occupational healthcare.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJayasekara (2001) [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eSenanayake et al. (2017) [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe role of PHMs is limited to maternity and child healthcare, family planning, and health education only.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSenanayake et al. (2017) [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth programmes ignore other family members, including males, adolescents, and elderly individuals, who are more vulnerable to NCDs; therefore, they could remain undetected.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch2\u003ePeriod of No-PHNs in Sri Lanka\u003c/h2\u003e\n\u003cp\u003eDuring this period, public health midwives (PHMs) worked as frontline health workers by providing community-based maternal and child healthcare. Nevertheless, they did not engage in health promotion or preventive activities related to NCDs [\u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e]. During the previous decades, when practising primary healthcare without the component of nursing at a basic level, the authorities recognized the necessity for the service of PHNs. Furthermore, the report of the Presidential Task Force (PTF) for the development of a National Health Policy has recommended the need to introduce \u0026ldquo;community nurses\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although no basic-level nurses have yet been included in the PHC team, very little progress has been made in community health nursing in Sri Lanka because of the acute shortage of nurses and slow responses of the authorities of Sri Lanka [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Jayasekara (2001) also highlighted the importance of community health nursing services in rural communities located far from health facilities [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, some researchers have emphasized the importance of having strong community health nursing services to improve the health of not only women and children but also disabled and elderly people, as well as the mental health of people [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e77\u003c/span\u003e]. According to the findings of Randeni et al. (2014), community-dwelling people in Sri Lanka believe that having PHNs will be more beneficial to society because it improves access to health services, saves money spent unnecessarily on minor ailments (37%), and reduces the number of hospital admissions (29%) since PHNs will conduct home visits (43%), provide health advice and thereby improve health (38%). Furthermore, early detection of health problems (23%) increased the ability to resume care after being discharged from hospitals (94%) and increased the ability to obtain chronic care for bedridden patients (93%) [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. In 2016, the WHO mentioned that \u0026lsquo;the post of PHN will re-emerge in Sri Lanka shortly as a new type of community worker comes from Sri Lanka\u0026rsquo;[\u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e]. Furthermore, it has shown the importance of PHNs, as they are based in hospitals, provide home-based care for NCD patients in the direction of medical specialists, train family members in the care of patients, and follow up on treatment failure. Furthermore, the success of this new model will depend on mutual trust between the specialist and the PHN, who will have the opportunity to determine how patients manage their conditions as part of their daily lives [\u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003e04. Re-establishment of PHNs in Sri Lanka (2018- to date)\u003c/h2\u003e\n\u003cp\u003eIn 2011, the Ministry of Health (MoH) in Sri Lanka established Healthy Lifestyle Centres to address the lack of a coordinated screening programme for NCDs. In the same year, the MoH acknowledged that the current curative healthcare system needed to change from episodic patient management to a continuing-care approach that is more suitable for controlling NCDs. The \u0026quot;shared care cluster system\u0026quot; has been implemented to handle the added burden of NCDs. Services are organized around a hospital that offers specialized care, with primary care curative facilities located at the divisional and primary levels [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. Later, in 2018, the post of the PHN was re-established in Sri Lanka under a new job titled \u0026lsquo;Public Health Nursing Officer\u0026rsquo; (PHNO) [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e]. Accordingly, 100 PHNs were designated for 100 Healthy Lifestyle Centers (HLCs), which were spread in 25 districts in Sri Lanka [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e] in January 2018 [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. The recruitment criteria for the post of PHN were having a Diploma in Nursing, and minimum of 2 years of experience in a state hospital or as a field officer, and being willing for fieldwork [\u003cspan class=\"CitationRef\"\u003e79\u003c/span\u003e]. The primary focus of the training of PHNs includes preventing NCDs, providing palliative care, providing geriatric care, conducting research and surveys, and offering specialized services such as disaster management [\u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e]. Although MCH services, including midwifery, are basic components of family health nursing and public healthcare in the global context [\u003cspan class=\"CitationRef\"\u003e79\u003c/span\u003e], these are not required as entry qualifications for PHNs in Sri Lanka. This may be because new PHNs are not focusing on MCH care since it is already being performed by PHMs. However, midwifery training is required to become a Public Health Nursing Sister (PHNS.\u003c/p\u003e\n\u003cp\u003eCurrently, approximately 220 PHNs are working in Sri Lanka. They are widely dispersed in rural and distant areas of the country, reaching disadvantaged communities and social extremities [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition to providing comprehensive nursing care in the community, their mission is to collaborate with individuals, families, and communities to prevent and control NCDs. The nurses collaboratively work with multidisciplinary teams and serve mainly as researchers and care providers for the most vulnerable residents of the community, such as the elderly and those in need of palliative care. In addition, they respond to government programmes that were designed to increase people\u0026apos;s involvement in health-related activities associated with their own health [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. A review of the effectiveness of PHNs in Sri Lanka has shown that employing PHNs in the community setting of Sri Lanka has several advantages. Patients are not obliged to visit the hospital for some minor procedures, such as catheter care, or to maintain comprehensive documentation of the family health of the country [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review is the first scholarly attempt to document and critically analyse the history of public health nursing in Sri Lanka in a single document by collating evidence from diverse and dispersed sources through both online searches and extensive manual grey literature searches due to the limited availability of published scholarly works. Although public health nurses (PHNs) have played a significant role in improving MCH and primary health care in the country for approximately a century, their contribution remains largely absent in the academic literature and policy discussions. This neglect has resulted in a crucial knowledge gap that has hindered strategic attempts to best utilize the role of PHNs in Sri Lanka's dynamic health system, in addition to limiting professional and public understanding.\u003c/p\u003e \u003cp\u003ePHNs in Sri Lanka had their roots in the founding of the Kalutara Health Unit in 1926, which was a collaborative project funded by the Rockefeller Foundation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. The appointment of Ms. J.M. Mutuwadi as the first PHN signified an upgrade to community-based and preventive healthcare. However, there was considerable turnover of PHNs in the early years since many hospital-trained nurses discovered that it was difficult to make the transition to fieldwork [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The obstacles were poor support, lack of transportation, and field isolation. Interestingly, similar difficulties did not deter other field-based health workers, such as PHIs and PHMs. This suggests that PHNs could compare hospital and community settings, and they may perceive that fieldwork was more challenging and less rewarding. However, the early stages of the PHN established a crucial framework for the preventive healthcare system in Sri Lanka.\u003c/p\u003e \u003cp\u003ePHNs were increasingly embedded in the public health system throughout the postcolonial period (1948\u0026ndash;1980), contributing to maternity and child health (MCH)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50 CR51 CR52 CR53 CR54 CR55 CR56 CR57\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan additionalcitationids=\"CR60 CR61 CR62\" citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan additionalcitationids=\"CR64 CR65 CR66\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan additionalcitationids=\"CR69 CR70 CR71 CR72 CR73 CR74\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45 CR46 CR47\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], preschool and school health [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], communicable disease prevention [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], and home visits. The role of PHNs gradually expanded during this time, and simultaneously, PHMs became more specialized in MCH. Therefore, PHMs take on more responsibility for the care of mothers and infants, whereas PHNs shift towards preschool and school health and then to more comprehensive family health services [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Practical needs and staffing shortages influenced this change, but they also marked the start of the PHN role's marginalization. Nevertheless, a remarkable decrease in maternal and newborn mortality could be identified during this period, which was made possible by the combined efforts of PHNs, PHMs and other field health staff.\u003c/p\u003e \u003cp\u003eWhen PHNs were removed from frontline community services in the 1980s, it was a turning point in history. Instead, the PHN position was restructured into PHNSs and PHNTs, which are supervising or teaching positions. Although official records on precise explanations could not be found, several factors probably contributed to this shift, including the belief that PHMs could handle MCH without PHNs, financial considerations that favoured PHM training and deployment, and union-driven demands to improve the status of the PHN position [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the authors of the current study believe that the demand for PHNs had decreased in the country by that time, mainly because the national health indicators had improved considerably (i.e., a significant reduction in MMR and IMR) by this point, whereas the burden of noncommunicable diseases (NCDs) had not yet become a major public health concern in Sri Lanka. Moreover, this assumption could be proven because the reintroduction of PHNs to the country in 2018 was mainly based on the steadily increasing NCD incidence in Sri Lanka. Nevertheless, this transition generated a gap in the provision of community health services, especially for groups (rather than mothers and infants), such as teenagers, elderly individuals, and people with chronic health issues, especially the male group [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. Hence, the absence of specialized community nursing services has led to an imbalance in the comprehensive care model.\u003c/p\u003e \u003cp\u003eIn 2018, the reintroduction of PHNs occurred under a new designation, 'Public Health Nursing Officers' (PHNOs), reflecting a strategic response to these emerging gaps, especially the growing burden of NCDs, increasing ageing populations, and the need for palliative and home-based care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. One hundred PHNOs were allocated to 100 healthy lifestyle centers (HLCs) dispersed throughout the country after they underwent specialized training in palliative care, NCD prevention, geriatric care, disaster management and community research [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. This upsurge could demonstrate how to acknowledge the need for qualified nurses for direct nursing care in community settings. However, the re-established PHN service is not involved in the provision of MCH care, and this exclusion raises important concerns. Globally, PHNs work with people of all ages, supporting not only MCH but also the health of adolescents and elderly individuals. Although the Sri Lankan context has excellent MCH achievements [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e], it stands the risk of neglecting school-age children and adolescents, who are more likely to suffer from NCDs, newly emerging lifestyle-related conditions, and mental health disorders [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Although school and preschool health is a major part of the PHN's work, it is not explicitly included in its mandate, unlike in the past. This split of duties may hinder the PHN's ability to promote health across neglected age groups, while it compromises the continuity of treatment.\u003c/p\u003e \u003cp\u003eFurthermore, even after being reintroduced, PHNs in Sri Lanka still struggle with poor support, poor facilities, and a lack of awareness of their service. Thus, policymakers must be committed to facilitating PHNs, increasing public and health professional awareness of PHN services, and offering chances for leadership and professional development to strengthen PHN services. Globally, PHNs are becoming increasingly active in community health policy and intersectoral collaboration. However, Sri Lanka has yet to utilize this potential.\u003c/p\u003e \u003cp\u003eMost importantly, the present study illustrates how the history of PHNs in Sri Lanka reflects dynamics across several low- and middle-income countries (LMICs), where community-based healthcare cadres expand and contract in response to perceived needs and governmental agendas. The abrupt removal and later reintroduction of PHNs reflect the consequences of reactive rather than strategic workforce planning. Therefore, public health nursing must adopt a more proactive and integrated approach to address contemporary health issues effectively in Sri Lanka.\u003c/p\u003e \u003cp\u003eThe historical evolution of public health nursing (PHN) in Sri Lanka is representative of the broader challenges that many LMICs encounter in maintaining a steady, cohesive workforce of public health nurses. Despite having solid early roots, PHN services were discontinued in Sri Lanka for almost 40 years, demonstrating how shifts in institutional focus and political priorities can cause vital public health functions to be undermined. The WHO 2017 report on nursing and midwifery highlights the need for strategic investment in community-based nursing positions to attain Universal Health Coverage (UHC), and this example reflects global issues. The impacts of training, role clarity, and system-level support are several lessons learned from Sri Lanka's century-long experience that can help other LMICs attempt to reactivate or strengthen public health nursing with workforce planning. By analysing both historical gaps and contemporary policy revisions, this study offers transferable insights for countries seeking to develop resilient, community-embedded nursing services in resource-constrained environments.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe evolution of public health nursing in Sri Lanka reflects a century of adaptation to the country\u0026rsquo;s changing health goals. From their pioneering involvement with maternal and preventive health to their more recent contributions to NCDs and geriatric care, PHNs have consistently demonstrated their importance and relevance to society. Service gaps resulting from their expulsion from the community in the 1980s became more noticeable as the prevalence of NCDs increased. The reintroduction of PHNs led to redefining PHNs' roles, broadening their range of services while continually integrating them into Sri Lanka's primary healthcare system.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eOn the basis of the study findings, awareness-raising campaigns focused on both health professionals and the public are recommended to emphasize the value of PHN services. Further job descriptions for PHNs should be re-established, incorporating responsibilities, including school and adolescent health, to optimize PHN services in Sri Lanka.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eThe lack of published literature and archival evidence on PHNs in Sri Lanka limits the scope of this review. Furthermore, verification of certain important references found in bibliographies was not possible. Despite these drawbacks, the current study provides a fundamental synthesis that may inspire further investigations and the revision of public health nursing policies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHLCs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthy lifestyle centres\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Health Division\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInfant mortality rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow-and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLady Ridgeway Hospital for Children\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMoH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Ministry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Officer of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal and Child Welfare\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal and Child Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal Mortality Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Communicable Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary health care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health inspector\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health midwife\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHNs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health nurses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHNO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health nursing officer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHNS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health nursing sisters\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHNT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic health nursing tutor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eAll the authors declare\u0026nbsp;that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll the data extracted from published articles are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS was involved in the research design, literature search, data extraction, data interpretation, and final report writing. WN was involved in the research design, literature search, data extraction, and final report writing with LS and JW. JW conceived the study, guided the research process, reviewed the extracted data, and reviewed and edited the final manuscript. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eThe Department of Community Medicine, Faculty of Medical and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Anuradhapura, Sri Lanka.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eThe Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Nawala, Nugegoda, Sri Lanka.\u003csup\u003e.\u003c/sup\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. WHO called to return to the Declaration of Alma-Ata [Internet]. 1978 [cited 2023 Oct 9]. 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Annual Report of the Family Health Bureau. 2021.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Public health nurse, History, Nursing, Sri Lanka, Ceylon","lastPublishedDoi":"10.21203/rs.3.rs-6339752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6339752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGlobally, public health nursing is an integral part of the community healthcare system, and it focuses mainly on disease prevention and health promotion. This study aims to systematically examine the evolution, roles, and discontinuities in public health nursing in Sri Lanka, highlighting historical milestones, training changes, and broader contributions to improving the community health of Sri Lanka.\u003c/p\u003e\u003ch2\u003eMethods/data sources:\u003c/h2\u003e \u003cp\u003eA scoping review was conducted via electronic databases (PubMed, Web of Science, EMBASE, MEDLINE, and Lens.org), supplemented by gray literature and manual searches in national archives, government reports, historical records, and local journals. Sources in English and Sinhala were included, and the data were synthesized thematically across identified historical periods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBased on our findings, we classified the history of public health nursing in Sri Lanka into four distinct eras: the Colonial Era, the Post-Colonial Era, the No-PHN Era, and the Re-establishment Era. This review traced how public health nurses were progressively involved in maternal and child health, control of communicable disease, and school health in the early decades, supported by progressively improved recruitment and training programs. It also revealed a prolonged interruption in public health nurse services in the 1980s, but with limited documentation and records for this discontinuation. In recent years, they have been reintroduced to reflect newly emerging health needs of the country, with a widened role that consists of palliative care, geriatric care, and prevention of noncommunicable diseases. Throughout the review, a lack of consistent documentation and visibility in published work and official records in the public health system of the country could be observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe evolution of public health nursing in Sri Lanka reflects the changes that have occurred in the health goals of the country over the past century. Since the beginning, public health nurses have shown their value and essential service through providing maternal and child health care and more contemporary services, including NCD prevention, palliative, and elderly care. Although this position was discontinued in the 1980s, resulting in clear gaps in service, its re-establishment could have redefined the role and responsibilities of public health nurses in Sri Lanka.\u003c/p\u003e","manuscriptTitle":"Revisiting the History: A Century of Public Health Nursing in Sri Lanka: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 10:51:27","doi":"10.21203/rs.3.rs-6339752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-05T12:03:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T13:06:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-09T19:02:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221548840603345155082747136505426759867","date":"2025-05-04T13:18:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163421401932163633485329474158721984148","date":"2025-05-04T06:34:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-02T12:59:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-21T10:28:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-18T06:36:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-18T06:33:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-30T17:37:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2506ba57-9de0-45e6-ab30-4aa25913d30c","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-07T09:53:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 10:51:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6339752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6339752","identity":"rs-6339752","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}