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Haenssgen MJ, Elliott EM, Phommachanh S, Souksavanh O, Okabayashi H, Kubota S. Community engagement for stakeholder and community trust in healthcare: Short-term evaluation findings from a nationwide initiative in Lao PDR. Soc Sci Med 2024; 354:117079. [PMID: 38954978 DOI: 10.1016/j.socscimed.2024.117079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/15/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Trust remains a critical concept in healthcare provision, but little is known about the ability of health policy and interventions to stimulate more trusting relationships between communities and the health system. The CONNECT (Community Network Engagement for Essential Healthcare and COVID-19 Responses Through Trust) Initiative in Lao PDR provided an opportunity to assess the community-level impact of a trust-building community engagement approach. METHODS A mixed-method process evaluation was implemented from 10/2022-12/2023 among 14 diverse case study communities in four provinces across Lao PDR. Data collection involved two rounds of census surveys (3161 observations incl. panel data from 618 individuals) including an 8-item trust scale, 50 semi-structured interviews with villagers, and 50 contextualizing key informant interviews. The two data collection rounds were implemented before and three months after village-based CONNECT activities and helped discern impacts among activity participants, indirectly exposed villagers, and unexposed villagers in a difference-in-difference analysis. RESULTS Stakeholders attested strong support for the CONNECT Initiative although community-level retention of trust-related themes from the activities was limited. Quantitative data nevertheless showed that, at endline, the 8-item trust index (from [-8 to +8]) increased by 0.95 points from 4.44 to 5.39 and all trust indicators were universally higher. Difference-in-difference analysis showed that villagers exposed to the CONNECT activities had a 1.02-index-point higher trust index compared to unexposed villagers. Trust impacts improved gradually over time and were relatively more pronounced among men and ethnic minority groups. CONCLUSIONS The CONNECT Initiative had considerable direct and systemic effects on community members' trust in their local health centers in the short term, which arose from strong stakeholder mobilization and gradual institutional learning. Relational community engagement approaches have the potential to create important synergies in health policy and broader cross-sectorial strategies, but also require contextual grounding to identify locally relevant dimensions of trust.
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Affiliation(s)
- Marco J Haenssgen
- Department of Social Science and Development, Chiang Mai University, 239 Huay Kaew Rd. T. Suthep Muang, Chiang Mai, 50200, Thailand.
| | - Elizabeth M Elliott
- World Health Organization Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines
| | - Sysavanh Phommachanh
- Institute of Research and Education Development, University of Health Sciences, Payawat Village, Sisattanak District, Vientiane Capital, Laos
| | - Ounkham Souksavanh
- World Health Organization Representative, Country Office for Lao People's Democratic Republic, 125 Saphanthong Road, Unit 5 Ban Saphangthongtai, Sisattanak District, Vientiane Capital, Laos
| | - Hironori Okabayashi
- World Health Organization Representative, Country Office for Lao People's Democratic Republic, 125 Saphanthong Road, Unit 5 Ban Saphangthongtai, Sisattanak District, Vientiane Capital, Laos
| | - Shogo Kubota
- World Health Organization Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines
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Haenssgen MJ, Elliott EM, Phommachanh S, Phomkong S, Kounnavong S, Kubota S. Trust in healthcare: methodological and conceptual insights from mixed-method research in Lao People's Democratic Republic. BMJ Glob Health 2024; 9:e014640. [PMID: 38754897 PMCID: PMC11097858 DOI: 10.1136/bmjgh-2023-014640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/14/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Global health foregrounds trust as a key requirement for the achievement of international health initiatives, but it remains an elusive concept that is often mobilised without consideration of its dimensions, drivers and downstream behavioural consequences. This paper aims to contribute to the conceptual development and measurement of 'patient trust in primary healthcare' from the lower middle-income country perspective of rural Lao PDR. METHODS A two-phase mixed-method research design was implemented between January 2021 and April 2023. Phase 1 involved exploratory qualitative research to understand the local expressions and dimensions of patient trust in primary healthcare, with 25 semistructured interviews and 17 focus group discussions (120 participants) in eight villages in Bokeo Province. Phase 2 involved explanatory research to assess patterns of trust systematically at scale in 14 villages across four provinces, wherein 26 cognitive interviews, 17 expert interviews and non-participant community observations informed a community census survey with 1838 participants. We analysed qualitative data through content-oriented thematic analysis and developed an 8-item trust scale on that basis. Quantitative data analysis used descriptive statistical and regression analysis. RESULTS We found that trust in primary healthcare is readily understood and intrinsically valuable in rural Lao PDR. Key dimensions included communication, respectful care, relationship, fairness, integrity, reputation, assurance of treatment and competence. The survey highlighted that reputation, competence, integrity and respectful care had the lowest trust scores. Health centre operations predicted the local expressions of trust. The behavioural consequences of trust were limited to a positive statistical association with antenatal care uptake among pregnant women but outweighed by alternative measures that also captured the availability of healthcare facilities. CONCLUSIONS Overall, the development of our quantitative trust scale offers a process model for future researchers. We conclude that interpersonal, institutional and service-related trust require more explicit recognition in health system development and integration into health policy.
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Affiliation(s)
- Marco J Haenssgen
- Department of Social Science and Development, Chiang Mai University, Chiang Mai, Thailand
| | - Elizabeth M Elliott
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | | | - Sylivanh Phomkong
- World Health Organization Representative Office, Vientiane, Lao People's Democratic Republic
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Shogo Kubota
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
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Ronse M, Nguyen TT, Nguyen XX, Ingelbeen B, Schneiders ML, Tran DT, Muela Ribera J, Gryseels C, Peeters Grietens K. Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002982. [PMID: 38593159 PMCID: PMC11003614 DOI: 10.1371/journal.pgph.0002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 02/09/2024] [Indexed: 04/11/2024]
Abstract
Despite the global threat of antimicrobial resistance (AMR), evidence on the use and quality of medicines at community level is limited, particularly in impoverished, rural areas where prevalence of (bacterial) infections is high. To better understand the processes that drive vulnerability to AMR' effects, this study aimed to assess social factors underpinning access to-and use of-medical products and healthcare, among people from the Raglai ethnic minority in Ninh Thuan Province, Vietnam. We conducted ethnographic research in eight villages in 2018-2019, using interviewing and participant observation methods for data collection. Different types of informants (including community members and healthcare providers) were selected using purposive sampling strategies and analysis was retroductive. Our findings show that, despite the existence of a government-funded health insurance scheme, Raglai people's flexible therapeutic itineraries did not systematically start with formal healthcare. Different types of care (private/informal, public, shamanic) were combined in parallel or in alternation, determined by distance to the provider, cost, workload, perceived diagnostic capacity, perceived severity and aetiology of the illness, and trust in the provider. Available medicines were often tablets dispensed in plastic bags containing labelled tablets, unlabelled tablets (in bulk) or tablets ground to powder. Treatment was often considered effective when it relieved symptoms, which led to abandonment of the treatment course. When symptoms did not speedily abate, the illness aetiology would be reinterpreted, and "stronger" medicines would be sought. The precarious socio-economic status of some Raglai drove them in cycles of severe poverty when additional unforeseen factors such as illness, animal disease or loss of crops arose, hampering access to (in)formal healthcare providers and/or appropriate diagnosis and treatment. We conclude that Raglai communities are structurally unable to buffer themselves against the threat and consequences of AMR. Despite this vulnerability, they are among the least targeted by efforts to optimize antibiotic use, which are concentrated in secondary and tertiary healthcare facilities targeted at urban populations.
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Affiliation(s)
- Maya Ronse
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thuan Thi Nguyen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Malaria Epidemiology, National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam
| | - Xa Xuan Nguyen
- Department of Malaria Epidemiology, National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam
| | - Brecht Ingelbeen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Duong Thanh Tran
- Department of Malaria Epidemiology, National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam
| | - Joan Muela Ribera
- Department of Anthropology, Philosophy and Social Work, Rovira i Virgili, Tarragona, Spain
| | - Charlotte Gryseels
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Beiter D, Koy S, Flessa S. Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis. BMC Health Serv Res 2023; 23:912. [PMID: 37641129 PMCID: PMC10463960 DOI: 10.1186/s12913-023-09570-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/17/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cambodia is undergoing a series of reforms with the objective of reaching universal health coverage. Information on the causes of inefficiencies in health facilities could pave the way for a better utilization of limited resources available to ensure the best possible health care for the population. OBJECTIVES The purpose of this study is to evaluate the technical efficiency of health centers and the determinants for inefficiencies. METHODS This cross-sectional study used secondary data from a costing study on 43 health centers in six Cambodian provinces (2016-2017). Firstly, the Data Envelopment Analysis method with output-orientation was applied to calculate efficiency scores by selecting multiple input and output variables. Secondly, a tobit regression was performed to analyze potential explanatory variables that could influence the inefficiency of health centers. RESULTS Study findings showed that 18 (43%) health centers were operating inefficiently with reference to the variable returns to scale efficiency frontier and had a mean pure technical efficiency score of 0.87. Overall, 22 (51%) revealed deficits in producing outputs at an optimal scale size. Distance to the next referral hospital, size and quality performance of the health centers were significantly correlated with health center inefficiencies. CONCLUSION Differences in efficiency exist among health centers in Cambodia. Inefficient health centers can improve their technical efficiency by increasing the utilization and quality of health services, even if it involves higher costs. Technical efficiency should be continuously monitored to observe changes in health center performance over time.
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Affiliation(s)
- Dominik Beiter
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia.
| | - Sokunthea Koy
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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Hampshire K, Mariwah S, Amoako-Sakyi D, Hamill H. “ It is very difficult in this business if you want to have a good conscience”: pharmaceutical governance and on-the-ground ethical labour in Ghana. Glob Bioeth 2022; 33:103-121. [PMID: 35912379 PMCID: PMC9331207 DOI: 10.1080/11287462.2022.2103899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The governance of pharmaceutical medicines entails complex ethical decisions that should, in theory, be the responsibility of democratically accountable government agencies. However, in many Low- and Middle-Income Countries (LMICs), regulatory and health systems constraints mean that many people still lack access to safe, appropriate and affordable medication, posing significant ethical challenges for those working on the “front line”. Drawing on 18 months of fieldwork in Ghana, we present three detailed case studies of individuals in this position: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector. Through these case studies, we consider the significant burden of “ethical labour” borne by those operating “on the ground”, who navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks.
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Yera H, Bory S, Khieu V, Caron Y. Human trichinellosis in Southeast Asia, 2001-2021. Food Waterborne Parasitol 2022; 28:e00171. [PMID: 35875401 PMCID: PMC9305352 DOI: 10.1016/j.fawpar.2022.e00171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
To present the situation of human trichinellosis in Southeast Asia in the last 20th years we analyzed outbreak data and seroprevalence studies from 2001 to 2021 for this region. We queried PubMed (https://pubmed.ncbi.nlm.nih.gov) using keywords “Trichinella”, “human” and “Southeast Asia”. In addition, we described Trichinella species circulating in this region. In Southeast Asia, in communities eating pork, several cultural factors play important roles in the transmission of Trichinella to humans. The seroprevalences of Trichinella infection in humans are known for Laos and Vietnam to be 0–10.5% in some villages. Also, in Cambodia, Laos, Malaysia, Thailand and Vietnam relatively few human outbreaks (13) and cases (1604) have been recorded during the last 21st years. Their associated mortality rates were low (0.75%). Trichinella spiralis and T. papuae were transmitted after consumption of raw or undercooked pork from domesticated and wild pigs. T. papuae transmission was related to consumption of wild boar. In this region, trichinellosis was frequently subclinical and clinical or severe cases were sporadic and occurred more in male patients. Nevertheless, it is likely that trichinellosis is widely under-diagnosed and is an endemic disease. In Southeast Asia, trichinellosis occurred mostly in rural populations eating pork or boar meat. Since 2001, the majority of cases have been reported in northern Laos and Thailand. Trichinella spiralis and T. papuae have been isolated as causative species. There is no veterinary surveillance for Trichinella, except in Singapore.
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Affiliation(s)
- Hélène Yera
- Laboratoire de Parasitologie Mycologie, National Reference Laboratory for Human Trichinellosis, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Centre Université de Paris, Institut Cochin (U1016 Inserm/UMR8104 CNRS/UMR-S8104), Paris, France
| | - Sotharith Bory
- Infectious Diseases Unit, Medicine Department, Calmette Hospital, Phnom Penh, Cambodia
| | - Virak Khieu
- National Center for Parasitology Entomology and Malaria Control, Ministry of Health, Phnom Penh, Cambodia
| | - Yannick Caron
- Head of Animal Health Unit, Qualyse Laboratory, Tulle, France
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Khan M, Rahman-Shepherd A, Bory S, Chhorn S, Durrance-Bagale A, Hasan R, Heng S, Phou S, Prien C, Probandari A, Saphonn V, Suy S, Wiseman V, Wulandari LPL, Hanefeld J. How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan. BMJ Glob Health 2022; 7:bmjgh-2022-008596. [PMID: 35589155 PMCID: PMC9121421 DOI: 10.1136/bmjgh-2022-008596] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/20/2022] [Indexed: 11/09/2022] Open
Abstract
Background There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process. Methods Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan. Findings We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported. Interpretation Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.
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Affiliation(s)
- Mishal Khan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK .,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | - Afifah Rahman-Shepherd
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Anna Durrance-Bagale
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Rumina Hasan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | | | | | - Chanra Prien
- University of Health Sciences, Phnom Penh, Cambodia
| | | | | | | | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Johanna Hanefeld
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Center for International Health Protection, Robert Koch Institut, Berlin, Germany
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Kolesar RJ, Bogetoft P, Chea V, Erreygers G, Pheakdey S. Advancing universal health coverage in the COVID-19 era: an assessment of public health services technical efficiency and applied cost allocation in Cambodia. HEALTH ECONOMICS REVIEW 2022; 12:10. [PMID: 35092482 PMCID: PMC8800415 DOI: 10.1186/s13561-021-00354-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Achieving universal health coverage (UHC) is a global priority and a keystone element of the 2030 Sustainable Development Goals. However, COVID-19 is causing serious impacts on tax revenue and many countries are facing constraints to new investment in health. To advance UHC progress, countries can also focus on improving health system technical efficiency to maximize the service outputs given the current health financing levels. METHODS This study assesses Cambodia's public health services technical efficiency, unit costs, and utilization rates to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories. RESULTS Overall, for the public health system to be fully efficient output would need to increase by 34 and 73% for hospitals and health centers, respectively. We find public sector service quality, private sector providers, and non-discretionary financing to be statistically significant factors affecting technical efficiency. We estimate there is potential supply-side 'service space' to expand population coverage to an additional 4.69 million social health insurance beneficiaries with existing financing if the public health system were fully efficient. CONCLUSIONS Public health service efficiency in Cambodia can be improved by increasing utilization of cost-effective services. This can be achieved by enrolling more beneficiaries into the social health insurance schemes with current supply-side financing levels. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system.
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Affiliation(s)
- Robert John Kolesar
- Abt Associates, Room 125 (Level 1), Building B, Phnom Penh Center, Corner Sihanouk (274) & Sothearos (3) Blvd, Sangkat Bassac, Khan Chamkrarmon, Phnom Penh, Cambodia.
- University of Antwerp, Faculty of Business and Economics, Antwerpen, Belgium.
- General Secretariat for the National Social Protection Council, Cambodian Ministry of Economy and Finance, Phnom Penh, Cambodia.
- Centre d'Etudes et Recherche sur le Développement International (CERDI), Université Clermont Auvergne, Clermont-Ferrand, France.
| | | | - Vanara Chea
- General Secretariat for the National Social Protection Council, Cambodian Ministry of Economy and Finance, Phnom Penh, Cambodia
| | - Guido Erreygers
- University of Antwerp, Faculty of Business and Economics, Antwerpen, Belgium
| | - Sambo Pheakdey
- General Secretariat for the National Social Protection Council, Cambodian Ministry of Economy and Finance, Phnom Penh, Cambodia
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9
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Liverani M, Ir P, Wiseman V, Perel P. User experiences and perceptions of health wearables: an exploratory study in Cambodia. Glob Health Res Policy 2021; 6:33. [PMID: 34556184 PMCID: PMC8459510 DOI: 10.1186/s41256-021-00221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/14/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND In many low- and middle-income countries (LMICs), health system capacities to address the burden of non-communicable diseases (NCDs) are often inadequate. In these countries, wearable health technologies such as smartbands and smartwatches could be used as part of public health programmes to improve the monitoring, prevention, and control of NCDs. Considering this potential, the purpose of this study was to explore user experiences and perceptions of a health wearable in Cambodia. METHODS Data collection involved a survey, conducted between November 2019 and January 2020, among different categories of participants (including hypertensive participants, non-hypertensive participants, postgraduate students, and civil servants). All participants were given a sample of a watch-type wearable and advised to use it day and night. One month after product delivery, we conducted a survey to explore their views and experiences. Results were analysed by using descriptive statistics and Chi square or Fisher's exact test to compare responses from urban and rural participants. RESULTS A total of 156 adult participants completed the study. Technology acceptance was positive overall. 89.1% of the participants said they would continue using the watch and 76.9% of them would recommend it to either friends or relatives, while 94% said the device stimulated them to think more frequently about their health. However, challenges to technology adoption were also identified, including concerns with the accuracy and quality of the device and unfamiliarity with the concept of health self-monitoring, especially among the elderly. Short battery life and cost were also identified as potential barriers to continued use. CONCLUSIONS Health wearables are a promising new technology that could be used in Cambodia and in other LMICs to strengthen health sector responses to the challenges of NCDs. However, this technology should be carefully adapted to the local context and the needs of less resourced population groups. In addition, further studies should examine if adequate health sector support and infrastructure are in place to implement and sustain the technology.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. .,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan. .,Faculty of Public Health, Mahidol University, Bangkok, Thailand.
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
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10
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Liverani M, Ir P, Jacobs B, Asante A, Jan S, Leang S, Man N, Hayen A, Wiseman V. Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications. Health Policy Plan 2021; 35:1011-1020. [PMID: 33049780 DOI: 10.1093/heapol/czaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/13/2022] Open
Abstract
In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South-South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border 'medical tourism' to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289 Khan Toul Kork P.O. Box 1238 Phnom Penh, Cambodia
| | - Augustine Asante
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Stephen Jan
- The George Institute for Global Health, 1 King St, Newtown NSW 2042, Australia.,University of New South Wales, Sydney NSW 2052, Australia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Nicola Man
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Andrew Hayen
- University of Technology Sydney (UTS), 15 Broadway, Ultimo NSW 2007, Australia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,The Kirby Institute, UNSW, Sydney NSW 2052, Australia
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11
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Nalule Y, Buxton H, Ir P, Leang S, Macintyre A, Pors P, Samol C, Dreibelbis R. Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study. BMC Pregnancy Childbirth 2021; 21:429. [PMID: 34139995 PMCID: PMC8212449 DOI: 10.1186/s12884-021-03901-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022] Open
Abstract
Background Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants. Methods This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours. Results Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception. Conclusion The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03901-7.
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Affiliation(s)
- Yolisa Nalule
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Helen Buxton
- Division of Psychiatry, University College London, London, W1T 7BN, UK
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | | | | | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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12
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Singh SR, Mao B, Evdokimov K, Tan P, Leab P, Ong R, Vonthanak S, Tam CC, Hsu LY, Turner P. Prevalence of MDR organism (MDRO) carriage in children and their household members in Siem Reap Province, Cambodia. JAC Antimicrob Resist 2020; 2:dlaa097. [PMID: 34223049 PMCID: PMC8210010 DOI: 10.1093/jacamr/dlaa097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/06/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The rising incidence of infections caused by MDR organisms (MDROs) poses a significant public health threat. However, little has been reported regarding community MDRO carriage in low- and middle-income countries. METHODS We conducted a cross-sectional study in Siem Reap, Cambodia comparing hospital-associated households, in which an index child (age: 2-14 years) had been hospitalized for at least 48 h in the preceding 2-4 weeks, with matched community households on the same street, in which no other child had a recent history of hospitalization. Participants were interviewed using a survey questionnaire and tested for carriage of MRSA, ESBL-producing Enterobacterales (ESBL-E) and carbapenemase-producing Enterobacterales (CPE) by culture followed by antibiotic susceptibility testing. We used logistic regression analysis to analyse associations between collected variables and MDRO carriage. RESULTS Forty-two pairs of households including 376 participants with 376 nasal swabs and 290 stool specimens were included in final analysis. MRSA was isolated from 26 specimens (6.9%). ESBL-producing Escherichia coli was detected in 269 specimens (92.8%) whereas ESBL-producing Klebsiella pneumoniae was isolated from 128 specimens (44.1%), of which 123 (42.4%) were co-colonized with ESBL-producing E. coli. Six (2.1%) specimens tested positive for CPE (4 E. coli and 2 K. pneumoniae). The prevalence ratios for MRSA, ESBL-producing E. coli and ESBL-producing K. pneumoniae carriage did not differ significantly in hospital-associated households and hospitalized children compared with their counterparts. CONCLUSIONS The high prevalence of ESBL-E across both household types suggests that MDRO reservoirs are common in the community. Ongoing genomic analyses will help to understand the epidemiology and course of MDRO spread.
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Affiliation(s)
- Shweta R Singh
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Bunsoth Mao
- University of Health Sciences, Phnom Penh, Cambodia
| | - Konstantin Evdokimov
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Pisey Tan
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Phana Leab
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Rick Ong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Clarence C Tam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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13
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Caron Y, Bory S, Pluot M, Nheb M, Chan S, Prum SH, Lim SBH, Sim M, Sengdoeurn Y, Sovann L, Khieu V, Vallée I, Yera H. Human Outbreak of Trichinellosis Caused by Trichinella papuae Nematodes, Central Kampong Thom Province, Cambodia. Emerg Infect Dis 2020; 26:1759-1766. [PMID: 32687022 PMCID: PMC7392432 DOI: 10.3201/eid2608.191497] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
In September 2017, a severe trichinellosis outbreak occurred in Cambodia after persons consumed raw wild pig meat; 33 persons were infected and 8 died. We collected and analyzed the medical records for 25 patients. Clinical signs and symptoms included myalgia, facial or peripheral edema, asthenia, and fever. We observed increased levels of creatine phosphokinase and aspartate aminotransferase-, as well as eosinophilia. Histopathologic examination of muscle biopsy specimens showed nonencapsulated Trichinella larvae. A Trichinella excretory/secretory antigen ELISA identified Trichinella IgM and IgG. Biopsy samples were digested and larvae were isolated and counted. PCR for the 5S rDNA intergenic spacer region and a multiplex PCR, followed by sequencing identified the parasite as Trichinella papuae. This species was identified in Papua New Guinea during 1999 and in several outbreaks in humans in Thailand. Thus, we identified T. papuae nematodes in humans in Cambodia.
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Hodges S, Garnett E. The ghost in the data: Evidence gaps and the problem of fake drugs in global health research. Glob Public Health 2020; 15:1103-1118. [PMID: 32228359 PMCID: PMC7446034 DOI: 10.1080/17441692.2020.1744678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 02/09/2020] [Indexed: 10/31/2022]
Abstract
For the past several decades, global health research and policy have raised the alarm about the growing threat of counterfeit and low-quality drugs (henceforth 'fakes'). These high-profile and regularly-repeated claims about 'fake drugs' pepper scholarly publications, grey literature, and popular writing. We reviewed much of this work and found that it shares two characteristics that sit awkwardly alongside one another. First, it asserts that fake drugs constitute an urgent threat to lives. Second, it reports trouble with 'gaps' in the evidence on which their claims are based; that data is weaker and less conclusive than anticipated. Given the ubiquity of and urgency with these claims are made, we found this juxtaposition perplexing. To understand this juxtaposition better, we undertook a close reading of the strategies authors employed to negotiate and overcome data and evidence 'gaps' and asked questions about the cultures of scholarly publishing in global health research. We argue that a scholarly commitment to studying fakes despite--rather than because of-the evidence functions to support the continuation of similar research. It also works against asking different questions-for instance regarding the lack of easy access to pharmacological data that might make it possible to know fakes differently.
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Affiliation(s)
- Sarah Hodges
- Department of History, University of Warwick, Coventry, UK
| | - Emma Garnett
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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15
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Saulnier DD, Hean H, Thol D, Ir P, Hanson C, Von Schreeb J, Mölsted Alvesson H. Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia. BMJ Glob Health 2020; 5:e002272. [PMID: 32332036 PMCID: PMC7204936 DOI: 10.1136/bmjgh-2019-002272] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/27/2020] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Resilient health systems have the capacity to continue providing health services to meet the community's diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system's joined capacities for resilience. Yet little is known about how community participation influences health systems resilience. The purpose of this study was to understand how community management of pregnancy and childbirth care during floods is contributing to the system's capacity to absorb, adapt or transform as viewed through a framework on health systems resilience. METHODS Eight focus group discussions and 17 semi-structured interviews were conducted with community members and leaders who experienced pregnancy or childbirth during recent flooding in rural Cambodia. The data were analysed by thematic analysis and discussed in relation to the resilience framework. RESULTS The theme 'Responsible for the status quo' reflected the community's responsibility to find ways to manage pregnancy and childbirth care, when neither the expectations of the health system nor the available benefits changed during floods. The theme was informed by notions on: i) developmental changes, the unpredictable nature of floods and limited support for managing care, ii) how information promoted by the public health system led to a limited decision-making space for pregnancy and childbirth care, iii) a desire for security during floods that outweighed mistrust in the public health system and iv) the limits to the coping strategies that the community prepared in case of flooding. CONCLUSIONS The community mainly employed absorptive strategies to manage their care during floods, relieving the burden on the health system, yet restricted support and decision-making may risk their capacity. Further involvement in decision-making for care could help improve the health system's resilience by creating room for the community to adapt and transform when experiencing floods.
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Affiliation(s)
- Dell D Saulnier
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Hom Hean
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Dawin Thol
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Department of Preventive Medicine, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, Phnom Penh, Cambodia
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan Von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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16
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Khan MS, Bory S, Rego S, Suy S, Durrance-Bagale A, Sultana Z, Chhorn S, Phou S, Prien C, Heng S, Hanefeld J, Hasan R, Saphonn V. Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries? HUMAN RESOURCES FOR HEALTH 2020; 18:10. [PMID: 32046723 PMCID: PMC7014603 DOI: 10.1186/s12960-020-0452-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/30/2020] [Indexed: 05/06/2023]
Abstract
BACKGROUND Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
- Aga Khan University, Karachi, Pakistan.
| | - Sothavireak Bory
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | - Sonia Rego
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Sovanthida Suy
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Anna Durrance-Bagale
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | | | | | - Socheata Phou
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Chanra Prien
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | | | - Johanna Hanefeld
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Rumina Hasan
- Aga Khan University, Karachi, Pakistan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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17
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Affiliation(s)
- Patricia Kingori
- The Ethox Centre, and Wellcome Centre of Ethics and Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - René Gerrets
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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