1. Awareness and knowledge gaps regarding paediatric snakebite risks.

Most midwives described snakebite risks in general terms and did not distinguish between adult and child exposures. “We know snakebites happen here, but we are not told why children are more affected. We just look after them the same way.” (PHM, 34) Only a few PHMs had received formal training addressing the differences in signs, symptoms, and clinical progression of envenoming between children and adults. Most relied on anecdotal knowledge gained through community conversations or personal experience. There was limited familiarity with medically important snake species in their region, and virtually none had access to structured or updated guidance on identifying venomous versus non-venomous bites. “Many parents lack knowledge about identifying snakes, and many believe that a snakebite is only serious if there is bleeding. However, I have seen a case in my area where someone was bitten by a snake at night. He and his family didn’t act quickly, and by the time they brought him to the hospital, he was already dead.” (PHM, 65)

Surveillance and reporting systems for paediatric snakebite incidents were also inadequate. PHMs indicated they often became aware of cases only informally—through word of mouth or after the child was already hospitalized—rather than through any structured referral or notification mechanism. “We hear from the parents that a child got bitten, but there is no system for us to track or report it.” (PHM, 15) The knowledge gaps extended beyond clinical recognition to the prevention of exposure. For instance, although midwives knew that snakes tend to enter homes during certain seasons, few could articulate specific strategies that would protect children in particular—such as using raised beds, ensuring secure flooring, or encouraging protective footwear for outdoor play. Many participants attributed these deficits to the absence of paediatric-focused content in general health education materials and a lack of targeted training sessions for frontline workers. As a result, snakebite prevention and first aid were rarely emphasized in child health promotion work, despite the obvious risk.

2. Community-level beliefs and harmful practices.

Traditional beliefs surrounding snakes and snakebites remain deeply entrenched in rural Sri Lankan communities, strongly influencing household behaviours and healthcare-seeking responses—particularly in paediatric cases. Public Health Midwives consistently highlighted the tension between biomedical knowledge and longstanding local customs, which often led to harmful delays in accessing appropriate medical care for snakebite victims. A significant number of community members, especially elders, continued to favour indigenous healing methods over prompt hospital treatment. These included visiting a traditional healer who might chant incantations, place a “snake stone” on the bite site, administer herbal remedies, or perform spiritual rituals. “They believe the stone can pull out the venom. Even if we say go to the hospital, they waste time doing these things first.” (PHM, 39) One particularly concerning belief reported by PHMs was that assaulting the person who carries the patient to the healer could somehow reduce the effect of venom—a notion rooted in spiritual symbolism rather than biology. “Some believe that assaulting the message carrier to the traditional healer will reduce the toxin inside the body of the patient.” (PHM, 13) Numerous myths were linked to the spiritual significance of snakes, especially cobras and kraits. For instance, it was commonly believed that harming certain species could bring bad luck or provoke revenge from other snakes. “They think if you kill a cat snake, seven more will come. So, they are afraid even to chase it away.” (PHM, 16) “Some believe the cobra is sacred and will protect treasure. If you kill it, it brings misfortune.” (PHM, 5)

Another unusual belief was that rat snake bites immunise individuals against other venomous snakes, leading some community members to downplay or ignore bites from supposedly “harmless” species. “Some villagers believe if a rat snake bites you, no other venomous snake will bite you again. So, they don’t take it seriously.” (PHM, 61) Such beliefs often resulted in significant treatment delays, as families experimented with home remedies or sought spiritual interventions before considering medical care. In paediatric cases, these delays proved particularly dangerous. PHMs described instances where herbal poultices, such as papaya leaves, were applied and tightly bandaged over the bite—worsening local tissue damage or allowing systemic envenoming to progress. “In one case, they put papaya leaves and wrapped it tightly, and only came to hospital after the child started shaking.” (PHM, 44)

While younger parents were reportedly more open to biomedical guidance, older relatives often retained decision-making authority, especially in multigenerational households. PHMs expressed that directly contradicting elders or dismissing their practices often provoked resistance and disengagement. “If we say ‘this is wrong,’ they stop listening. We have to find a way to respect their beliefs while slowly changing them.” (PHM, 19) The midwives also noted that certain environmental and religious practices were perceived as protective. These included burning chilies, spreading kerosene oil around houses, or growing specific plants believed to repel snakes—such as marigolds, long coriander, and Devil’s trees.

“Some grow Marigold flowers, long coriander and Devil’s trees. They believe it keeps snakes away.” (PHM, 27) “During the rainy season, they clean around the house and apply kerosene oil in front of doors and windows to chase away snakes.” (PHM, 53) While some of these practices may contribute indirectly to environmental hygiene and deterrence, many are based on superstitions that do not prevent or mitigate envenomation. Nevertheless, they are often deeply valued and passed down through generations.

PHMs described how traditional beliefs, family hierarchies, and community norms strongly influenced healthcare-seeking behaviours following paediatric snakebites. They felt that efforts to improve outcomes must be rooted in cultural understanding and shaped by the local context. According to the PHMs, dismissing these beliefs outright could alienate families and reduce the effectiveness of interventions. Instead, they stressed the importance of introducing counter-narratives that are respectful of tradition while promoting evidence-based care, ideally through collaboration with trusted community leaders.

3. First aid knowledge and training limitations.

Although nearly all PHMs had heard of basic first aid principles for snakebites—such as washing the bite site and calming the patient—there was considerable variation in actual knowledge, confidence, and application. Many expressed uncertainties about the correct sequence of actions or whether certain practices, such as applying pressure bandages, were recommended for children.

“I know we should wash it, but some say you must tie above the bite. Others say never tie. So, we are confused.” (PHM, 47) Only a few participants mentioned immobilising the limb or advising patients to stay still—key components of WHO-recommended first aid. None of the PHMs mentioned having received hands-on training with paediatric mannequins or real-life simulations. Several had attended lectures or Zoom sessions, which they found insufficient for skill-building. “They gave us a series of lectures, but we need to practice. I have never applied a bandage on a child after a bite.” (PHM, 58) A recurrent concern was the fear of doing harm. This led many PHMs to default to advising immediate transport to the hospital without attempting any first aid themselves. “I tell them go to hospital quickly. I don’t want to make it worse by doing something wrong.” (PHM, 7) Some reported using outdated or potentially harmful practices due to a lack of clarity. For example, a few still advised tight bandages based on community norms. “We were told years ago to tie tightly. Now some say that’s wrong, but we’re not sure.” (PHM, 42) The lack of formal and consistent training was cited as a key barrier, and most PHMs expressed a strong desire for updated, child-focused, and practical training sessions to build their competence and confidence.

4. Role perception and practical challenges in community engagement.

Public health midwives consistently viewed themselves as integral, trusted actors in their communities—well-positioned to influence household behaviours and promote child safety, including in relation to snakebite prevention and first aid. However, their ability to fulfill this role was constrained by a range of practical, systemic, and contextual challenges that undermined their engagement at the community level. Foremost among these was workload pressure and competing priorities. PHMs are already tasked with an extensive portfolio of responsibilities, including maternal and child health surveillance, immunisation programs, nutrition counselling, and chronic disease monitoring. Adding snakebite prevention without dedicated time, resources, or formal policy backing was seen as unrealistic and burdensome by some. “We already have so much to do—pregnant mothers, children, home visits, clinics. Where can we fit snakebite education?” (PHM, 20)

Geographic and environmental constraints further compounded their difficulties, especially in remote or underserved areas. Poor road infrastructure, scattered settlements, and seasonal barriers—such as flooding or roaming elephants—often limited midwives’ ability to conduct home visits in high-risk zones. “Some houses are far inside the fields. In the rainy season, we can’t go. Even we get scared because of snakes and elephants.” (PHM, 48) Infrastructure limitations within the health system itself also hampered their effectiveness. Several PHMs highlighted the lack of appropriate medical facilities in their local hospitals. In many cases, bitten children must be transferred long distances to receive definitive care due to the absence of trained staff or antivenom. “We advise parents to bring their child to the hospital immediately. However, our local hospital does not have facilities for snakebite treatment. They transfer children to the main hospital 40 km away.” (PHM, 1)

Midwives also noted communication barriers, particularly in linguistically diverse areas. In Tamil-speaking regions, Sinhala-speaking PHMs struggled to engage meaningfully with caregivers due to language mismatches. “My area is rural and many parents are only Tamil-speaking. Language barriers are there for good communication.” (PHM, 13) Despite their willingness to educate and guide parents, PHMs reported that the absence of visual or material aids significantly weakened their health promotion efforts. Verbal education alone was often not retained, especially by elderly or less literate community members. “If we had posters, flip charts, or kits to show them, it would be easier. Now we only talk, and they forget.” (PHM, 36)

Midwives also encountered structural and policy-level barriers, such as the lack of consistent internet access in rural zones, limited funding for community education initiatives, and what they perceived as insufficient policy attention to snakebites as a public health issue. “There is a lack of interest about snakebite among policymakers. Even we don’t have proper internet connections in our areas to attend training or download materials.” (PHM, 11)

Additionally, cultural norms and household-level risk factors posed barriers to effective engagement. PHMs described visiting homes where children slept in unsafe conditions, such as unplastered rooms covered with plastic sheeting, which inadvertently attracted or concealed snakes. “We guide parents to take steps to prevent snakebites in their children. Sometimes their houses are not plastered so they use white polythene to cover baby room. They have found snakes in these areas.” (PHM, 38)

Nonetheless, midwives expressed a strong sense of commitment and a readiness to contribute more actively—provided they are given appropriate training, educational tools, and structured integration of snakebite topics into their existing service delivery platforms. “If you give us a plan and materials, we can do it step by step during our routine field visits.” (PHM, 22) This willingness reflects the untapped potential of Sri Lanka’s PHM network to serve as a foundational pillar in community-based snakebite prevention and first aid programs. However, for this potential to be realised, it is essential that their operational constraints, knowledge gaps, and contextual barriers are adequately addressed within health system strengthening initiatives.

5. Recommendations for system improvement.

The final theme focused on PHMs’ perspectives on how to enhance both the prevention and emergency response to paediatric snakebites in their communities. Drawing from their frontline experiences and insights into local dynamics, PHMs offered a wide range of pragmatic and actionable recommendations targeting families, schools, healthcare institutions, and broader policy structures. A consistent and emphatic recommendation was the urgent need to scale up awareness-building efforts at the community level. PHMs advocated for sustained and age-appropriate education targeting children, parents, and teachers. They particularly emphasized the value of integrating snakebite prevention into school-based health education initiatives, both as a means of knowledge transfer and behaviour change. “If we teach schoolchildren, they will remind their parents and siblings what to do. They learn fast and tell others.” (PHM, 27)

They also saw untapped potential in using existing community platforms, including religious gatherings, farmer societies, and women’s groups to disseminate key prevention and first aid messages. “People gather in mosques and temples. That is the time to talk to them, not wait for them to come to us.” (PHM, 62) “During mother and baby clinics or school health days, even if we speak for five minutes about snakebites, it can make a difference.” (PHM, 10)

Beyond prevention, midwives identified systemic gaps in emergency response infrastructure. They expressed strong support for the 1990 ambulance service but highlighted critical limitations in its reach and responsiveness—particularly in remote villages with poor roads, roaming elephants, and a single ambulance covering multiple regions. “At night, people fear going out because of elephants. The 1990 service is good, but we need more vehicles and faster response.” (PHM, 8) “Some families live very far, and the ambulance can’t always get there quickly. More local options would help.” (PHM, 32)

Several PHMs proposed the establishment of specialized treatment units within peripheral hospitals equipped with trained staff and consistent antivenom availability. This would help avoid delays caused by long-distance referrals to tertiary facilities. “Now we have to send everyone to the main hospital. If the small hospital had antivenom, it would save time.” (PHM, 22)

Midwives also suggested the creation of better coordination systems during emergencies, including digital tools and real-time communication channels. “We propose developing an app to facilitate easier collaboration among midwives and other healthcare professionals.” (PHM, 21) “If we have an emergency hotline number, we can directly connect with the hospital, inform them about the patient’s condition, and they can guide us on the appropriate actions to take in that situation.” (PHM, 50)

At the policy level, PHMs emphasized the need to embed snakebite prevention and management into routine public health functions. This included increasing the workforce, improving accountability, and formalizing responsibilities for monitoring environmental risk factors like snake breeding sites. “Increase the number of PHMs and PHIs (Public Health Inspectors) in high-population areas so they can monitor and identify snake breeding sites. If breeding sources are found outside houses, responsible individuals can be fined.” (PHM, 31) There was also concern about attitudinal barriers among overburdened healthcare staff. PHMs called for a shift in institutional culture to prioritize neglected rural health issues like snakebites. “Policies are adequate but the mindsets of healthcare professionals need to be changed. Most of them take these issues lightly because they have plenty of other work. If we increase the number of staff we can do a better service.” (PHM, 23) Training and re-training featured prominently in the recommendations. PHMs emphasized that a one-off awareness session was insufficient to ensure preparedness. Instead, they advocated for continuous professional development, ideally involving hands-on practice, simulations, role-playing, and locally contextualized printed or video materials.