Behavioural Risk Factors for Non-Communicable Diseases Among Returnee Sri Lankan Migrant Workers from Middle East: A Cross-Sectional Study

doi:10.21203/rs.3.rs-3810263/v1

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Behavioural Risk Factors for Non-Communicable Diseases Among Returnee Sri Lankan Migrant Workers from Middle East: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-3810263/v1

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Background: Non-Communicable Diseases (NCDs) are rising among South Asian migrant populations. Despite Sri Lanka’s over 1.5 million temporary migrant workforce, there’s insufficient data on Behavioural Risk Factors (BRFs) for NCDs among returnee migrant workers. This study aims to describe the prevalence of BRFs for NCDs and associated factors among returnee Sri Lankan migrant workers from Middle-East.

Methods: This community-based, cross-sectional study was conducted among 680 returnee Middle East migrant workers in the Kurunegala District, Sri Lanka selected using multi-staged cluster sampling. Pretested Interviewer-Administered Questionnaire was utilized for the data collection. The analysis encompasses descriptive statistics and logistic regression using SPSS version 26.

Results: Response rate was 94.4% (n=642). Estimated prevalence of BRFs included daily smoking 12.3% (95%CI 9.8-15.1), current alcohol uses 20.1% (95%CI 17.0-23.4), inadequate fruits and vegetables consumption 89.3% (95%CI 86.6-91.6), and physical inactivity 31.4% (95%CI 27.8-35.2). Significant associations were identified, such as daily smoking with extended post-return period (AOR 0.58, 95%CI 0.39-0.86), having accumulated savings (AOR 2.98, 95%CI 1.33-6.69), being diagnosed with NCDs (AOR 2.85, 95%CI 1.36-6.69). Current alcohol use correlated with - being currently employed (AOR 7.79, 95%CI 2.72-22.33), being male (AOR 46.49, 95%CI 13.10-164.95), having accumulated savings (AOR 2.75, 95%CI 1.30-5.82), higher education level (AOR 0.38, 95%CI 0.19-0.74). Insufficient fruits and vegetables consumption was associated with; over LKR50,000 household income (AOR 0.24, 95%CI 0.12-0.46), and having accumulated savings (AOR 0.38, 95%CI 0.19-0.74). Physical inactivity was correlated with; being male (AOR 0.23, 95%CI 0.14-0.40), having chronic disease/ disability (AOR 1.91, 95%CI 1.20-3.04).

Conclusion: Socio-economic and migration-related characteristics of returnee migrant workers were associated with the BRF for NCDs. Migrant-friendly, tailored interventions addressing these factors are recommended for promoting healthy lifestyles among returnee migrant workers.

migrant worker

NCDs

behavioural risk factors

Non-Communicable Diseases (NCDs) pose a significant public health concern in Sri Lanka, contributing to high rates of morbidity, motility, and disability(1, 2). Globally, NCDs are attributed to over 17 million premature deaths annually, with over 80% of these deaths disproportionately occur in low and middle-income countries(3). Managing NCDs incurs substantial costs and poses a catastrophic burden on developing countries. Major behavioural risk factors for chronic NCDs include Smoking/tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol, all addressable through preventive interventions(2). Early intervention and reducing exposure to major behavioural risk factors are crucial to mitigate adverse outcomes of chronic NCDs(4). Primary prevention before the onset of these chronic diseases, stands as the most cost-effective approach(2).

Existing literature underscores the alarming rise of NCDs among South Asian migrant populations(4). Katulanda et al. (4), reveal a twofold higher prevalence of NCDs and behavioural risk factors among South Asian immigrants compared to native residents in host countries. This suggests the adaption of certain unhealthy behaviours from the host country contributes to increased NCD risk factors among South Asian immigrants(4).

While migration itself may not be a direct NCD risk factor, it serves as a social determinant of migrants’ health. Living and working conditions, coupled with factors in the migration cycle, make migrants vulnerable to these diseases(5, 6). Temporary migrant workers undergo two transitional phases: integration into host countries, and reintegration upon returning home countries (7). These transitions expose them to health risks, and stressors heightening the likelihood of adopting risk behaviours(6, 8, 9).

Over the past three decades, temporary contract-based employment in Gulf countries has surged(10). As per the 2019 Annual report of the Central Bank of Sri Lanka, over 1.5 million Sri Lankans, constituting approximately one-fifth of the national labour force, are currently employed abroad as temporary migrant workers(11). Most of these Sri Lankan labour migrants seek employment in the Middle East, with over 90% in labour-oriented manpower-level jobs and the remaining 10% in professionals, clerical workers (11).

Given the significant volume of outbound migration from Sri Lanka, the Migration Health policy emphasizes the importance of investigating the health status of migrant workers, including NCD risk factors(9). However, there is limited research on behavioural risk factors for NCDs among migrant population(12). This evidence gap in understanding the behavioural risk factors for Chronic NCDs among Sri Lankan migrants underscores a noticeable void in migration health research (12). Furthermore, the scarcity of NCD-related data among migrant populations poses a formidable challenge for implementing disease prevention and control programs for migrants in Sri Lanka (4, 12).This study aims to describe the prevalence of BRFs for NCDs and associated factors among returnee Middle-East migrant workers in the Kurunegala District Sri Lanka.

This community-based, cross-sectional study conducted between August 2021 to May 2022 to assess the prevalence of behavioural risk factors for Non-Communicable Diseases (NCDs) and their associated factors among returnee Middle East migrant workers residing in the Kurunegala District Sri Lanka. The study population were male and female returnee Middle East migrant workers aged between 35–49 years. Eligible participants were returnees who had employed under skilled, semi-skilled, housemaids, and unskilled manpower level positions in the Middle East and returned to home country a minimum of 12 months ago.

The sample size for this descriptive study (n = Z_1−α/2²p(1-p)/d²) was determined (13), with a Z score of 1.96 for a 2-sided alpha error of 5% and the absolute precision (d) as ± 0.05. Based on the 2015 STEPS survey in Sri Lanka, around 28% of the population consumes WHO-recommended servings of fruits/vegetables, implying that about 72% practice unhealthy dietary habits by consuming lower than the recommended servings of fruits/vegetables(1). Consequently, we estimated that 70% of returnee migrant workers do not consume recommended (≥ 5) servings of fruits/ vegetables.

N = \(\frac{1.96\times 1.96\times 0.70\times (1-0.70)}{0.05\times 0.05}\)= 322

The Intra-class Correlation Coefficient (ICC) for Fruits and Vegetables consumption/intake in Sri Lanka is = 0.309(14). Therefore, the Design effect (DE) would be DE = 1 + ICC (m-1)

DE = 1 + 0.309(4 − 1) = 1.9

Estimated non-response rate = 10%

n (number of participants) = 322×1.9× 100/90 = 679 (rounded up to = 680).

A multi-stage cluster sampling technique was used to recruit a representative sample of returnee Middle East migrant workers. Initially, ten Divisional Secretariat (DS) divisions were selected and thereafter specific Grama Niladhari (GN) divisions (Primary sampling units) were chosen within the selected DS divisions using the probability proportionate size (PPS) sampling method. The returnees within the Primary sampling units were selected through a household survey.

Data collection used a pretested Interviewer-Administered Questionnaire (IAQ). To ensure consistency, data collectors received comprehensive training, and frequent communication was maintained among the seven data collectors. Data analysis focused on describing the frequency, prevalence and 95% confidence intervals(95%CI) for the main behavioural risk factors for chronic NCDs, namely Tobacco/smoking use, alcohol consumption, physical inactivity, and dietary habits. Descriptive data were stratified by sex, examining both sexes, males, and females separately. Each behavioural risk factor (BRF) was dichotomized based on its theoretical and practical importance (e.g. Smoking status was categorized as daily smokers and non-daily smokers, alcohol consumption as current drinkers and non-drinkers, physical activity levels as physically active/ physically inactive, etc). The independent variables included socio-demographic, economic, and migration-related factors associated with each BRF was determined using logistic regression analysis. Model fit was assessed using Omnibus Tests of Model Coefficients and the Hosmer and Lemeshow test. Statistical significance was set at p < 0.05.

Informed written consent was obtained from all participants and confidentiality of the data was maintained. Ethical clearance was obtained from the Ethics review committee, Faculty of Medicine, University of Kelaniya (Ref.No: P/22/03/2021).

Among the calculated sample size of 680 returnee Middle East migrant workers, 642 participated, yielding a response rate of 94.4%. Females comprised 52.5% (n=337), surpassing males at 47.5% (n=305). Approximately, 40% (n=254) were within the 45-49 age group. The majority were Sinhalese (79.7%, n=511), and from rural sectors (91.7%, n=588). Most participants (88.4%, n=566) were married during data collection (Table01).

Regarding education, 40% (n=272) completed secondary education (grades 6-11), with no participants holding degrees. However, 7.0% (n=45) had obtained relevant vocational training or diplomas related to their Middle East job requirements (Table01). About 65% (n=415) were employed during data collection, with 31.9% (n=203) in the private sector, and 26.7% (n=170) self-employed. Only two respondents had secured government jobs upon returning to Sri Lanka. Additionally, 44% (n=278) reported monthly household incomes between Rs.25,000 and Rs.50,000 (Table01).

Table 1 Frequency Distribution of Demographic, Socio-economic Characteristics of the Study Sample
Characteristics	Study respondents
	Number	Percentage (%)
Sex (n=642)
Male	305	47.5
Female	337	52.5
*Age (n=642) (X̄ =* 42.7 years)**
35 to 39	175	27.3
40 to 44	213	33.2
45 to 49	254	39.5
Sector (n=642)
Urban	53	8.3
Rural	589	91.7
Estate	0	0.0
Ethnicity (n=641)
Sinhalese	511	79.7
Tamil	46	7.2
Muslim	84	13.1
Missing = 01
Religion (n=639)
Buddhist	463	72.5
Christian/ Roman Catholic	61	9.5
Islam	84	13.1
Hindu	31	4.9
Missing =03
Marital status (n=640)
Married	566	88.4
Single	43	6.7
Divorced/Separated	15	2.3
Widowed	16	2.5
Missing =02
Highest Education (n=642)
Grade 1 to 5	61	9.5
Grade 6 to 11	272	42.4
O/L to Grade 12	209	32.5
Passed A/L	55	8.6
Vocational training/ Degree or above	45	7.0
Current Employment status (n=642)
Yes	415	64.6
No	227	35.4
Types of employment status (n=637)
Public employee	2	0.3
Private employee	203	31.9
Employer	24	3.8
Own account worker	170	26.7
Contributing family worker	11	1.7
Economically inactive & Unemployed	227	35.6
Missing= 05
*Household income (n=637) (X̄ =53,754 LKR)*
< 10000	7	1.1
10000 – 25000	103	16.2
25001 – 50000	278	43.6
50001 – 75000	164	25.7
> 75001	85	13.3
Missing =05

Approximately 22% of participants (n=141) self-reported having one or more Chronic Non-Communicable Diseases (NCDs). The prevalent NCDs included Diabetes Mellitus (15.3%, n=98), ischemic heart disease (4.9%, n=31), Chronic Lung Diseases (3.6%, n=23), Cancer (1.4%, n=9), and strokes (0.2%, n=1).

The estimated prevalence of daily smokers in the sample was 12.3% (95%CI 9.8-15.1), and 8.0% (95%CI 6.0-10.4) for non-daily smokers (Table02). Among males, 25.9% (95%CI 21.1-31.3) were daily smokers, and 16.3% (95%CI 12.3-20.9) were non-daily smokers. Among females, the majority were never-smokers (94.3%, n=316). Smokeless tobacco use prevalence was 11.6% (95%CI 9.3-14.4) overall, 18.9% (95%CI 14.7-23.8) among males, and 5.1% (95%CI 3.0-8.0) among females.

Regarding alcohol use, 20.1% (95%CI 17.0-23.4) of the sample were current drinkers consumed alcohol during the past 30 days (Table02). Estimated prevalence of current alcohol use was 41.1% (95%CI 35.5-47.0) among males and 1.2% (95%CI 0.3-3.0) among females. Notably, over 95% of the females(n=322) were lifetime abstainers or former drinkers.

The study revealed a high prevalence of inadequate fruit and vegetable consumption (less than 5 servings per day) among returnees at 89.3% (95% CI 86.6-91.6). Males had 91.4% (95% CI 87.6-94.3), while females were slightly lower percentage at 87.4% (95% CI 83.3-90.8). Notably, 12.6% of females met recommended daily intake of fruit and vegetable, surpassing the 8.6% among males.

Approximately 70% of respondents met WHO-recommended minimum physical activity levels during work, transport, and recreational proceedings. Overall, physical inactivity prevalence was 31.4% (95%CI 27.8-35.2), comprising 16.4% (95%CI 12.4-21.1) for males and 45.0% (95%CI 39.5-50.5) for females (Table02).

Table 2 Distribution of Behavioural Risk Factors for NCDs by Sex

Description

Males

Females

Both sex

Percentage (%)

95% CI

Percentage (%)

95% CI

Percentage (%)

95% CI

Smoking Status

Never-smoker

132

43.9

[38.3, 49.5]

316

94.3

[91.9, 96.8]

448

70.4

[66.9, 74.0]

Former smoker

13.9

[10.0, 17.9]

5.1

[2.7, 7.4]

9.3

[7.0, 11.5]

Non-daily smoker

16.3

[12.3, 20.9]

0.6

[0.1, 2.1]

8.0

[6.0, 10.4]

Daily smoker

25.9

[21.1, 31.3]

0.0

12.3

[9.8, 15.1]

Missing =06

301

100.0

335

100.0

636

100.0

Use smokeless tobacco products*

Yes

18.9

[14.7, 23.8]

5.1

[3.0, 8.0]

11.6

[9.3, 14.4]

244

81.1

[76.2, 85.3]

318

94.9

[92.0, 97.0]

562

88.4

[85.6, 90.6]

Missing =06

301

100.0

335

100.0

636

100.0

Alcohol use

Abstainer / former drinkers

128

42.8

[37.1, 48.6]

322

96.4

[93.8, 98.1]

450

71.1

[67.4, 74.6]

Non-current drinker

16.1

[12.1, 20.7]

2.4

[1.0, 4.7]

8.8

[6.8, 11.3]

Current drinker

123

41.1

[35.5, 47.0]

1.2

[0.3, 3.0]

127

20.1

[17.0, 23.4]

Missing =09

299

100.0

334

100.0

633

100.0

Fruits and Vegetable Consumption

Consumed ≥5 servings of fruits and vegetables per day

8.6

[5.7, 12.4]

12.6

[9.2, 16.7]

10.7

[8.4, 13.4]

Consumed <5 servings of fruits and vegetables per day

276

91.4

[87.6, 94.3]

291

87.4

[83.3, 90.8]

567

89.3

[86.6, 91.6]

Missing=07

302

100.0

333

100.0

635

100.0

Levels of Physical Activity

Physically Active**

250

83.6

[78.9, 87.6]

181

55.0

[49.5, 60.5]

431

68.6

[64.8, 72.2]

Physically Inactive*

16.4

[12.4, 21.1]

148

45.0

[39.5, 50.5]

197

31.4

[27.8, 35.2]

Missing=14

299

100.0

329

100.0

628

100.0

The level of physical activity was assessed using IPAQ.

*IPAQ -Insufficiently active was re-categorized as Physically inactive,

**Both IPAQ groups Sufficiently active and highly active were combined into Physically active

Factors Associated with the Behavioural Risk Factors for Non-Communicable Diseases Among the Study Sample

Binary logistic regression analysed the relationship between each behavioural risk factor for Non-Communicable Diseases (NCDs) and selected socio-demographic, economic, migration, and health-related characteristics.

The first model (Table03) examined factors influencing the likelihood of daily tobacco smoking patterns among returnee migrant workers. This model demonstrated a good fit, with significant Omnibus tests (X²=133.18, df=14,p<0.000) and a non-significant Hosmer and Lemeshow test (X²=1.76,df=8,p=0.988). The model correctly classified overall 89.7% of cases, indicating very good accuracy. Factors significantly associated with daily tobacco smoking included increased period since return (AOR 0.58, 95%CI 0.39-0.86), having accumulated savings (AOR 2.98, 95%CI 1.33-6.69), being diagnosed with NCDs (AOR 2.85, 95%CI 1.36-6.69). Therefore, holding all the predictor variables constant, the odds of daily smoking increased by 2.98 times for returnees with accumulated savings compared to those lacking accumulated savings.

Table 03 Logistic Regression Predicting the Likelihood of Daily Smoking
	B	S.E.	Wald	df	Sig.	Exp(B)	95%CI for EXP(B)
	B	S.E.	Wald	df	Sig.	Exp(B)	LL	UL
Age	-.057	.042	1.850	1	.174	.944	.869	1.026
Duration Employed Abroad	-.011	.069	.024	1	.876	.989	.863	1.133
Period since Return	-.551	.206	7.128	1	.008	.577	.385	.864
Ethnicity (Sinhalese)	.580	.465	1.559	1	.212	1.786	.719	4.439
Household Income(>50,000LKR)	.317	.373	.723	1	.395	1.373	.661	2.849
Currently Employed (Yes)	.836	.513	2.653	1	.103	2.307	.844	6.306
Sex (Male)	19.997	2329.085	.000	1	.993	483568769.777	.000	.
Skill Category (Unskilled or Housemaids)	.229	.343	.447	1	.504	1.258	.642	2.462
Having Chronic Disease/ disability (Yes)	-.048	.389	.015	1	.902	.953	.444	2.044
Accumulated Savings (Yes)	1.091	.413	6.993	1	.008	2.978	1.326	6.686
Having NCDs (Yes)	1.047	.378	7.663	1	.006	2.850	1.358	5.981
Marital Status (Married)	-.081	.482	.028	1	.867	.922	.358	2.373
Education Level (Passed O/L or higher)	-.137	.360	.145	1	.703	.872	.430	1.766
Country of Foreign Employment (Saudi Arabia)	-.485	.475	1.041	1	.307	.616	.242	1.563
Constant	-18.954	2329.086	.000	1	.994	.000

The second model assessed factors associated with the current drinker status of alcohol. The model fit was robust, with significant Omnibus tests (X²=198.93,df=14,p<0.000) and nonsignificant Hosmer and Lemeshow test (X²=5.00,df=8,p=0.758). Overall, the model accurately classified 84.9% of cases, indicating high accuracy. Factors significantly associated with current alcohol consumption included lengthening period since return (AOR 0.67, 95%CI 0.48-0.94), being currently employed(AOR 7.79, 95%CI 2.72-22.33), being male(AOR 46.49, 95%CI 13.10-164.95), having accumulated savings (AOR 2.75, 95%CI 1.30-5.82), being diagnosed with NCDs (AOR 2.37, 95%CI 1.18-4.76), being married (AOR 6.33, 95%CI 2.20-18.17), passed O/L or higher education level (AOR 0.38, 95%CI 0.19-0.74) (Table 04). When all other predictors hold constant, the odds of being a current drinker of alcohol increased by 46.49 times for males compared to female returnee migrant workers. Additionally, when all other predictors hold constant the odds of being a current drinker increased by 7.79 times for currently employed respondents compared to unemployed returnee migrant workers.

Table 04 Logistic Regression Predicting the Likelihood of current drinker state of alcohol
	B		S.E.	Wald	df	Sig.	Exp(B)	95%CI for EXP(B)
	B		S.E.	Wald	df	Sig.	Exp(B)	LL	LL
Age		-.049	.038	1.676	1	.195	.953	.885	1.025
Duration Employed Abroad		-.095	.066	2.116	1	.146	.909	.799	1.034
Period since Return		-.398	.174	5.238	1	.022	.672	.478	.944
Ethnicity (Sinhalese)		-.148	.371	.160	1	.689	.862	.417	1.784
Household Income (>50,000LKR)		.251	.335	.562	1	.453	1.285	.667	2.478
Currently Employed (Yes)		2.052	.537	14.580	1	.000	7.786	2.715	22.326
Sex (Male)		3.839	.646	35.299	1	.000	46.486	13.101	164.951
Skill Category (Unskilled or Housemaids)		-.222	.314	.497	1	.481	.801	.433	1.484
Having Chronic Disease/ disability (Yes)		-.106	.346	.094	1	.759	.899	.457	1.771
Accumulated Savings (Yes)		1.010	.383	6.959	1	.008	2.746	1.296	5.817
Having NCDs (Yes)		.861	.356	5.848	1	.016	2.366	1.177	4.755
Marital Status (Married)		1.845	.538	11.765	1	.001	6.330	2.205	18.169
Education Level (Passed O/L or higher)		-.964	.342	7.954	1	.005	.381	.195	.745
Country of Foreign Employment (Saudi Arabia)		.462	.413	1.257	1	.262	1.588	.707	3.564
Constant		-4.266	1.794	5.656	1	.017	.014

The third model explored the factors associated with insufficient daily fruits and vegetables consumption. The model exhibited good fit, with significant Omnibus tests (X²=53.03,df=14, p<0.000) and a non-significant Hosmer and Lemeshow test (X²=14.56,df=8,p=0.068). Overall, the model correctly classified overall 87.9% of cases, indicating very good accuracy. Household income over LKR50,000 (AOR 0.24, 95%CI 0.12-0.46), and having accumulated savings (AOR 0.38, 95%CI 0.19-0.74), were significantly associated with inadequate fruits and vegetables consumption (Table 05). When all other predictors hold constant, the odds of the inadequate fruits and vegetables consumption decrease by 0.24 times for respondents with a monthly household income over LKR 50,000 compared to those with LKR 50,000 or less. Similarly, when all other predictors hold constant the odds of the inadequate consumption of fruits and vegetables reduces by 0.38 times for respondents having accumulated savings compared to those without.

Table 05 Logistic Regression Predicting the Likelihood of Inadequate Consumption of Fruits and Vegetables
	B	S.E.	Wald	df	Sig.	Exp(B)	95%CI for EXP(B)
	B	S.E.	Wald	df	Sig.	Exp(B)	LL	UL
Age	.015	.040	.133	1	.716	1.015	.938	1.097
Ethnicity (Sinhalese)	-.776	.473	2.686	1	.101	.460	.182	1.164
Sex (Male)	.436	.369	1.399	1	.237	1.547	.751	3.188
Marital Status (Married)	-.052	.516	.010	1	.920	.949	.345	2.611
Education Level (Passed O/L or higher)	.103	.309	.112	1	.738	1.109	.605	2.032
Household Income (>50,000LKR)	-1.449	.337	18.487	1	.000	.235	.121	.455
Currently Employed (Yes)	-.104	.381	.074	1	.785	.901	.427	1.902
Duration Employed Abroad	.106	.062	2.899	1	.089	1.112	.984	1.256
Skill Category (Unskilled or Housemaids)	-.165	.360	.209	1	.647	.848	.418	1.718
Country of Foreign Employment (Saudi Arabia)	-.312	.370	.712	1	.399	.732	.355	1.511
Period since Return	.008	.159	.003	1	.957	1.009	.739	1.377
Accumulated Savings (Yes)	-.972	.343	8.033	1	.005	.378	.193	.741
Having NCDs (Yes)	.783	.489	2.560	1	.110	2.187	.839	5.705
Having Chronic Disease/ disability (Yes)	.442	.388	1.300	1	.254	1.556	.728	3.325
Constant	2.282	1.890	1.458	1	.227	9.794

The fourth model investigated factors associated with the physical inactivity of returnee migrant workers. The model demonstrated good fit, with significant Omnibus tests (X²=80.11,df=14, p<0.000) and a non-significant Hosmer and Lemeshow test (X²=12.15, df=8, p=0.144). The model correctly classified 74.1% of cases, indicating high accuracy. Results revealed that being male (AOR 0.23, 95%CI 0.14-0.40), unskilled or housemaid category of foreign employment (AOR 2.17, 95%CI 1.29-3.65), having chronic disease/ disability (AOR 1.91, 95%CI 1.20-3.04), having accumulated savings (AOR 1.58, 95%CI 1.01-2.47), were significantly associated with physical inactivity (Table 06). Controlling all other predictors, the odds of physical inactivity were 0.23 times lower for males compared to female returnee migrant workers. Additionally, when all other predictors were constant, the odds of physical inactivity were 1.91 times higher for respondents with chronic disease or disability compared to respondents without such conditions.

Table 06 Logistic Regression Predicting the Likelihood of Physical Inactivity
	B		S.E.	Wald	df	Sig.	Exp(B)	95%CI for EXP(B)
	B		S.E.	Wald	df	Sig.	Exp(B)	LL	LL
Age		-.010	.031	.105	1	.746	.990	.932	1.052
Duration Employed Abroad		-.007	.039	.029	1	.865	.993	.921	1.072
Period since Return		-.159	.115	1.888	1	.169	.853	.681	1.070
Ethnicity (Sinhalese)		.388	.288	1.813	1	.178	1.474	.838	2.593
Household Income (>50,000LKR)		-.125	.234	.285	1	.594	.882	.557	1.397
Currently Employed (Yes)		.216	.252	.734	1	.392	1.240	.758	2.031
Sex (Male)		-1.450	.277	27.513	1	.000	.234	.136	.403
Skill Category (Unskilled or Housemaids)		.775	.265	8.575	1	.003	2.171	1.292	3.648
Having Chronic Disease/ disability (Yes)		.646	.237	7.396	1	.007	1.907	1.198	3.038
Accumulated Savings (Yes)		.460	.226	4.157	1	.041	1.584	1.018	2.465
Having NCDs (Yes)		.060	.274	.048	1	.827	1.062	.621	1.816
Marital Status (Married)		.500	.351	2.032	1	.154	1.648	.829	3.277
Education Level (Passed O/L or higher)		-.408	.224	3.317	1	.069	.665	.429	1.032
Country of Foreign Employment (Saudi Arabia)		-.086	.286	.091	1	.763	.917	.524	1.607
Constant		-.866	1.480	.343	1	.558	.420

Non-communicable diseases (NCDs) and their behavioural risk factors (BRFs) among returnee labour migrants remains underexplored, probably due to challenges in accessing the target migrant populations(2, 12). This study contributes valuable insights to both research and practice in the landscape of NCDs among returnee labour migrants of Sri Lanka. The study focuses on four main BRFs: tobacco use, alcohol consumption, physical inactivity, and unhealthy diet.

Tobacco use

Approximately 20% of participants in this study were current smokers, with a daily smoking rate of 12.3% (95%CI 9.8–15.1). Smoking was exclusively observed among males, with 43% being current smokers, and 25% smoking daily. Compared to the NCD risk factor survey in Sri Lanka 2021 (WHO-STEPS survey), which focused on the general population aged 18–69, present study revealed higher current and daily smoking prevalences among male migrant workers(15). Both present study and the NCD risk factor survey noted a significant gender disparity, with men exhibiting higher smoking rates than women (15). This trend, particularly among returnee male migrant workers, may result from unhealthy behaviours acquired during their time in the Middle East. A similar trend was identified in a retrospective cohort study by Khlat et al. (16), noting a significant surge in smoking rates among male migrants while residing in the host country, surpassed the pre-departure smoking rates. Moreover, the prevalence and intensity of smoking among migrants increase over their time in the host country(16), underscores the impact of migration on heightened smoking habits among migrants.

This study revealed that returnee migrant workers' daily smoking habits were significantly associated with the time since their return, having accumulated savings, and being diagnosed with NCDs. These findings broadly consistent with Tennakoon et al. (17) study cardiovascular risk factors including smoking habits among Sri Lankan migrant workers in Oslo, Europe. Further, present study findings are also aligned with the observations made by Khlat et al.(16), indicating a significant association between smoking and migration-related characteristics.

Alcohol consumption

In this study estimated prevalence of current alcohol use among both sexes (20.1%), males (41.1%) and females (1.2%) who consumed alcohol during the past 30 days. Present study male current drinking slightly exceeded the findings of the National alcohol use prevalence survey in Sri Lanka which showing 39.6% of males as current drinkers(18). However, the NCD risk factor survey in Sri Lanka in 2021 (WHO-STEPS survey) revealed that 43.3% of the males and 1.2% of the females self-reported that they had consumed alcohol. Thereby the findings of present study were broadly compatible with the results of WHO-STEPS survey 2021(15).

The “current drinker” state of alcohol use was significantly associated with being male, being married, having passed O/L or higher education, and being currently employed. This finding aligns with Hikmet et al. (19), study demonstrating a strong relationship between socio-demographic, characteristics the alcohol use patterns. The current study’s results broadly collaborate with previous research exploring the relationships between alcohol use and socio-demographic characteristics in the general population (18, 20).

Interestingly, this study uncovered significant associations between two BRFs (daily smoking and current alcohol consumption) and the presence of chronic NCDs. Contrary to expectations, respondents diagnosed with NCDs did not necessarily modify their lifestyle. This indicates the necessity for patient-cantered health promotional interventions among returnee migrants to empower them in adopting healthier behaviours.

Fruits and Vegetables Consumption

Only 8.6% of males and 12.6% of females were consuming recommended servings (≥ 5) of fruits and vegetables per day. The estimated prevalence of inadequate daily intake of fruits and vegetables for both sex, males and females were 89.3%, 91.4% and 87.4%. These findings were much higher than the results of NCD risk factor survey in Sri Lanka(15).

This study found a significant association between inadequate consumption of fruits and vegetables and monthly household income exceeding LKR50,000, as well as having accumulated savings. The observed association could be attributed to the higher purchasing power of returnees with better income and accumulated savings. Research on dietary patterns in the Sri Lankan general population indicates that socio-economic characteristics, including purchasing power directly influence the food consumption patterns(21).

Levels of Physical Activity

Most males (83.6%) and over half of females (55.0%) achieved recommended physical activity levels, resulting in physical inactivity rates of 31.4% for males and 45.0% for females. This highlights a notable gender disparity, which is aligning with the NCD risk factor survey, which revealed that physical inactivity is nearly twice as prevalent among females compared to males (15).

Key findings emerged were the significant association between physical inactivity with being female, being an unskilled-housemaid employee in Middle East, and having other chronic diseases/disabilities. These results consistent with a prior systematic review of mid-life migrants, which identified significant associations between physical activity and current health status, employment, household income, and life skills(22). Additionally, other studies on migrants similarly underscore the association of gender and personal health issues in physical inactivity(23, 24).

This study has limitations, primarily, in its exclusively focus on returnee migrant workers from Kurunegala District, limiting the generalizability to the broader returnee migrant worker population. Additionally, the focus on specific labour-oriented manpower levels because they represent significant majority of the international labour force from Sri Lanka. However, the exclusion of the minority professionals’ categories, middle-level, and clerical workers, may challenge the representativeness of the entire spectrum of outbound labour force.

This study’s findings address existing gaps in the literature on BRFs for NCDs among migrant workers. Insights gained are valuable for policymakers, health administrators, and healthcare providers in understanding health related behaviours of returnee migrant workers. Elevated BRFs among returnees, compared to the general population, emphasize the need of voluntary health assessment for returnee migrants to identify and manage NCDs. Further, health promotion interventions targeting prevention and promoting healthier lifestyles, are crucial for both diagnosed and apparently healthy returnees, in reducing the burden of NCDs and improving the overall well-being of this returnee labour migrant population.

In conclusion, this study shed light on the prevalence and associated factors of behavioural risk factors for NCDs among returnee migrant workers. Findings reveal elevated prevalence rates of daily smoking and insufficient fruits and vegetables consumption among returnee migrants compared to the general population, as per the NCD risk factor survey Sri Lanka 2021. The findings highlight many socio-demographic, economic, migration and health-related factors significantly associated with the behavioural risk factors for NCDs. The study fills important gaps in the existing literature, particularly concerning NCDs among temporary labour migrants. The study offers insights for targeted interventions and reorient healthcare systems to address the specific needs of returnee migrant workers. Further research and health-promotive interventions are warranted to formulate comprehensive strategies effectively addressing the BRFs among migrant workers.

BRF: Behavioural Risk Factors

DS: Divisional Secretariat

GN: Grama Niladari

LKR: Sri Lankan Rupee

NCDs: Non-Communicable Diseases

PPS: Probability Proportionate Size

STEPS: STEPwise approach to NCD risk factor surveillance

WHO: World Health Organization

Ethics approval and consent to participate: Ethical clearance for this study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya (Ref. No: P/22/03/2021). Informed written consent was obtained from all participants, and all methods involving human participants were conducted in adherence to ethical standards.

Consent for publication: This manuscript does not contain data from any individual person, hence consent for publication is “Not applicable”.

Availability of data and materials: The dataset used for analysis during this study is available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This manuscript is based on the Post graduate Thesis in Public Health of the corresponding author. This study was self-funded by the corresponding author.

Authors' contributions: Pasindu Dilshan Wijeratne (Corresponding author): PDW developed the research proposal, data collection, data analysis, interpretation, and writing the manuscript. Arunasalam Pathmeswaran: AP contributed to the development of the research design, supervised data collection, participated in data analysis and interpretation.

Acknowledgements: Researchers would like to acknowledge all the study participants for their valuable contributions.

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Behavioural Risk Factors for Non-Communicable Diseases Among Returnee Sri Lankan Migrant Workers from Middle East: A Cross-Sectional Study

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