Limited understanding, limited services, limited resources: patients' experiences with managing hypertension and diabetes in Cambodia

Hypertension and diabetes patients' perspective of challenges and their coping mechanisms in Mukono and Buikwe districts in Uganda - a qualitative study

Background: In sub-Saharan Africa, the burden of non-communicable diseases is steadily rising amidst a high prevalence of communicable diseases stretching the healthcare system. This study explored hypertension and diabetes patients' perspective of challenges and their coping mechanisms in Mukono and Buikwe districts in Uganda. Methods: This descriptive qualitative study involved four focus group discussions with 26 patients at four selected health facilities. All interviews were audio recorded, transcribed verbatim and data analysed following the thematic content analysis guided by the semantic approach with the aid of Atlas ti 6.0.15 software. Results: Five themes were identified regarding challenges and coping mechanisms of patients in managing their conditions. 1) Inadequate opportunities for diagnosis, with community screening supporting identification of patients. 2) Accessing care came amidst transport challenges, absence of health workers and the lack of essential supplies for monitoring conditions. Patients borrowed transport funds or trekked to health facilities and some formed groups to contribute resources to buy equipment and supplies. 3) Access to medications was affected by frequent drug stockouts at public health facilities which pushed patients to purchase own drugs or obtain these through friends and networks. However, other patients resorted to cheaper herbal remedies. 4) Monitoring and managing conditions was affected by insufficient knowledge and opportunities for self-monitoring. Information from health workers and experiences from peers bridged the knowledge gap while private facilities or community health workers supported self-monitoring. 5) Adopting changes in behaviour was challenging but patients fitted these within their usual routines and mobilised family members to also adopt lifestyle changes while ignoring those they deemed unrealistic. Conclusions: The coping mechanisms patients adopted to manage their chronic conditions reflects self-care initiatives at the individual and community levels which could be reinforced and supplemented to better support and empower patients as steps are taken to address existing challenges.

Disparities in access to ear and hearing care in Cambodia: a mixed methods study on patient experiences

OBJECTIVE

Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders.

METHOD

In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews.

RESULTS

Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment.

CONCLUSION

This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.

Influence of “Hospital-Community-Family” Integrated Management on Blood Pressure, Quality of Life, Anxiety and Depression in Hypertensive Patients

Objective

To explore the Influence of “hospital-community-family” integrated management on blood pressure, quality of life, anxiety and depression in hypertensive patients.

Methods

A total of 60 patients with hypertension were treated in our hospital from July 2019 to July 2021. The patients were randomly divided into control group (n =30) and study group (n =30). The former accepts routine management, while the latter accepts “hospital-community-family” integrated management. Nursing satisfaction, blood pressure, disease awareness rate, anxiety and depression scores, disease control ability and quality of life scores were compared.

Results

First of all, we compared the nursing satisfaction: the study group was very satisfied in 25 cases, satisfactory in 4 cases, general in 1 case, the satisfaction rate was 100.00%, while in the control group, 10 cases were very satisfied, 8 cases were satisfied, 7 cases were general, and 5 cases were dissatisfied, the satisfaction rate was 83.33%; The nursing satisfaction of the study group was higher than that of the control group (P <0.05). Secondly, we compared the level of blood pressure. There was no significant difference before management (P >0.05) but the blood pressure decreased after treatment. In the control group, the level of blood pressure in the study group was lower than that in the control group (P <0.05). In terms of disease awareness rate the scores of hypertension related knowledge hypertension harmfulness community management methods regular reexamination and blood pressure monitoring in the study group were significantly higher than those in the control group (P <0.05). There was no significant difference in anxiety and depression scores before treatment (P >0.05), but decreased after treatment. Compared with the control group, the anxiety and depression scores of the study group were lower (P <0.05). In terms of disease control ability, the total scores of diet management, medication management, behavior management and information management in the study group were higher compared to the control group (P <0.05). Finally, we compared the scores of qualities of life. Before management, there exhibited no significant difference (P >0.05). After management, the scores of quality of life decreased. Compared to the control group, the scores of physiological function, psychological function, social function and health self-cognition in the study group were lower than those in control group (P <0.05).

Conclusion

The application of integrated “hospital, community and family” management can vertically integrate medical resources and establish a truly effective hierarchical treatment model. Integrated “hospital-community-family” management can improve patient compliance with treatment, enhance patients' self-management ability and confidence, and improve the management efficiency of medical staff.

Assessing the Potential of Wearable Health Monitors for Health System Strengthening in Low- and Middle-Income Countries: A Prospective Study of Technology Adoption in Cambodia

Wearable health monitors are a rapidly evolving technology that may offer new opportunities for strengthening health system responses to cardiovascular and other non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). In light of this, we explored opportunities for, and potential challenges to, technology adoption in Cambodia, considering the complexity of contextual factors that may influence product uptake and sustainable health system integration. Data collection for this study involved in-depth interviews with national and international stakeholders and a literature review. The analytical approach was guided by concepts and categories derived from the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework—an evidence-based framework that was developed for studying health technology adoption and the challenges to scale-up, spread and sustainability of such technologies in health service organizations. Three potential applications of health wearables for the prevention and control of NCDs in Cambodia were identified: health promotion, follow-up and monitoring of patients and surveys of NCD risk factors. However, several challenges to technology adoption emerged across the research domains, associated with the intended adopters, the organization of the national health system, the wider infrastructure, the regulatory environment and the technology itself. Our findings indicate that, currently, wearables could be best used to conduct surveys of NCD risk factors in Cambodia and in other LMICs with similar health system profiles. In the future, a more integrated use of wearables to strengthen monitoring and management of patients could be envisaged, although this would require careful consideration of feasibility and organizational issues.

User experiences and perceptions of health wearables: an exploratory study in Cambodia

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.

Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications

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.

Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia

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.

Illnesses Encountered During Medical Volunteering in Takeo Province, Cambodia

Background and Objectives: Medical volunteering seeks to meet the clinical needs of underserved areas, but has been criticized for difficulties in addressing local health issues and resultant lack of sustainability. Our team has visited rural Cambodia annually since 2012. This study reports the illnesses encountered during the recent mission and share our experiences to improve the efficiency of medical volunteering. Materials and Methods: Infrastructure, such as public electricity or water, was unavailable, hence most medical care and records were hand-performed. We categorized (1) primary diagnoses (chief complaints) by duration of symptoms, and (2) primary and secondary diagnoses (illnesses that were not related to the chief complaint) by severity of illness since patients commonly reported multiple symptoms. Blood pressure and anthropometric values were also checked and analyzed. Results: We encountered 317 adult and 141 pediatric patients. Among adults, 61.3% had persistent chronic (>6 month) symptoms of their chief complaints. The commonest diagnoses of chronic symptoms were musculoarthritis (31.5%) and gastroesophageal reflux disease and/or gastritis (21.7%). Hypertension and/or cardiac problems were relatively common among males (13.6%). The most common diagnosis among the severest cases (specialized or intensive care recommended) was cardiac problems (14.8%), often with abnormalities in sonography or electrocardiogram. For children, the overwhelming majority of diagnoses were related to acute symptoms and low severity, and approximately half were cases of the common cold. Commonly prescribed drugs were antacids or mucosal protectors (31.3%), Non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers (27.6%), and antiparasites (17.7%) in adults, and NSAIDs (44.7%) and antiparasites (23.2%) in children. Among adults, 32.7% were diagnosed with hypertension, and body mass index (p = 0.003) and age (p < 0.001) were both correlated with hypertension and its grade. Conclusions: Our study offers practical help to volunteer health workers planning to visit Southeast Asia.

Patients' and healthcare providers' perspectives of diabetes management in Cambodia: a qualitative study

OBJECTIVE

This study aimed to explore the challenges encountered by patients and healthcare providers and opportunities for improvement in managing diabetes mellitus (DM) in a low- and middle-income country (LMIC) facing a rise in DM prevalence.

DESIGN

Qualitative cross-sectional study.

SETTING

Urban, semiurban, and rural areas in Cambodia.

PARTICIPANTS

Thirty health service providers and fifty-nine adult DM patients.

RESULTS

Most of the 59 DM patients reported having developed DM complications when they first sought treatment. The biggest challenges for the patients were geographical barriers, diet control, and shortage of medication supply. The healthcare staff expressed concerns about their limited knowledge and lack of confidence to treat diabetes, limited availability of diabetes care services, inadequate laboratory services, shortage of staff, poor patients' compliance, and insufficient medication supplies. Both healthcare staff and patients urged an expansion of diabetes services in Cambodia and prioritisation of diabetes care in a manner similar to communicable disease control programmes of the recent past.

CONCLUSIONS

Currently, the Cambodian healthcare system has very limited capacity to provide quality care for chronic diseases. As a consequence, many patients are either left untreated or have interrupted care due to several barriers including financial, geographical, and lack of knowledge and skills. A more comprehensive and multipronged approach is urgently needed to improve DM care, which would require a collaborative effort from government, external funding agencies, private sector, and communities.

Epidemiological survey of early childhood caries in Cambodia

Background

The Southeast Asian Forum for Early Childhood Caries identified the need for more epidemiological surveys involving preschool children. To date, the only data on Early Childhood Caries in Cambodia come from convenience samples and only using the basic dmft index without measurement of the early signs of disease.

Methods

A cross-sectional survey on an epidemiological sample of Cambodian preschool children was conducted in conjunction with the fourth follow-up of the Cambodian Health and Nutrition Monitoring Study. Children were examined in a field setting using both the South East Asian Index for Early Childhood Caries as well as the ‘pulpally involved, ulcerated, fistula, abscess’ (pufa) index. Caregivers also participated in a short questionnaire covering dietary habits, oral health knowledge and behaviors, as well as the Family Impact Scale (FIS) for Oral-Health-Related Quality-of-Life.

Results

The sample included 3985 participants between birth and 4-years of age, across three provinces. There was an even sex distribution (50.7% male). Overall 56.6% of participants had one or more carious lesions and 5.4% had one or more pulpally-involved teeth. There were some significant differences by age and location. Among those in the 3-year-old age group 84.9% had at least one decayed tooth, and 16.1% had one or more pulpally-involved teeth. There were differences in oral health knowledge and behaviors by province; those in Phnom Penh reported more favorable responses. Consumption of non-nutritious foods also differed between provinces with those in Phnom Penh consuming a higher mean number of sweet beverages per day. Those children with at least one pulpally involved tooth had a ten times greater chance of realizing an impact across the FIS.

Conclusions

Cambodian preschool children have a severe burden of dental caries and a high proportion of families are impacted by this problem. There were differences in oral health knowledge and behaviors according to province and this translated into differences in caries experience. The data from this study support the need for urgent action to address the issue of ECC in Cambodia.

Models of care for chronic conditions in low/middle-income countries: a 'best fit' framework synthesis

Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the ‘best fit’ framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as classified by the World Bank. The search yielded 404 articles, 338 were excluded after reviewing abstracts. Further, 42 articles were excluded based on criteria. Twenty-four studies were included for analysis. All themes of the CCM, identified a priori, were represented in primary studies. Four additional themes for the model were identified: a focus on the quality of communication between health professionals and patients, availability of essential medicines, diagnostics and trained personnel at decentralised levels of healthcare, and mechanisms for coordination between healthcare providers. We recommend including these in the CCM to make it relevant for application in an LMIC.

Equality in financial access to healthcare in Cambodia from 2004 to 2014

Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian Socio-Economic Survey, we assessed trends in reported illness, utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.