Detection and phylogenetic analysis of contemporary H14N2 Avian influenza A virus in domestic ducks in Southeast Asia (Cambodia)

Avian influenza virus (AIV) in Asia is a complex system with numerous subtypes and a highly porous wild birds-poultry interface. Certain AIV subtypes, such as H14, are underrepresented in current surveillance efforts, leaving gaps in our understanding of their ecology and evolution. The detection of rare subtype H14 in domestic ducks in Southeast Asia comprises a geographic region and domestic bird population previously unassociated with this subtype. These H14 viruses have a complex evolutionary history involving gene reassortment events. They share sequence similarity to AIVs endemic in Cambodian ducks, and Eurasian low pathogenicity and high pathogenicity H5Nx AIVs. The detection of these H14 viruses in Southeast Asian domestic poultry further advances our knowledge of the ecology and evolution of this subtype and reinforces the need for continued, longitudinal, active surveillance in domestic and wild birds. Additionally, in vivo and in vitro risk assessment should encompass rare AIV subtypes, as they have the potential to establish in poultry systems.

Developing ophthalmology in Cambodia

Over 180,000 Cambodian people are blind and a further 10,000 suffer avoidable blindness each year. Ninety percent of this blindness is avoidable, 79% is curable and 11% is preventable. Three-quarters of this blindness is due to cataracts and the remainder is due to uncorrected vision, glaucoma, corneal scarring and pterygium. The Khmer Sight Foundation (KSF) is a charity reincarnated by Professor Sunil Shah and Sean Ngu. Its mission is to deliver a sustainable eye care model for the country. KSF takes a three pronged approach to this. It is working to develop sustainable eye-care within the country through building physical infrastructure. The second approach is to impact the current cataract backlog of over 300,000 patients with the aid of international support. Thirdly, KSF is paving the way for the next generation through the development of an optometry education programme and training of Cambodian ophthalmologists. Here we present the workings of KSF, clinical cases we have encountered and elaborate upon the future goals of this charity.

Precarious livelihoods at the intersection of fishing and sand mining in Cambodia

Fishing and sand mining in Cambodia may not appear to have much in common. However, digging deeper reveals important parallels. Both fishing and sand mining support livelihoods and are connected to a limited natural resource. Meanwhile, they are both typified by precarious livelihoods, on the one hand, and overexploitation, on the other. In bringing these two topics together, the paper combines empirical qualitative research from two separate studies conducted by the co-authors in Cambodia, one in coastal fishing villages and another in the sand mining industry along the Mekong River. We argue that the interplay between fishing and sand mining has paradoxical impacts on livelihoods, supporting one group while undermining another. Using a precarity analysis lens, we show how an unconventional, and largely invisible frontier of natural resource exploitation-sand mining-is intertwined with fisheries, and expands our understanding of the relationship between precarious labour, environmental change, and livelihoods.

Metagenomic insight into the pathogenic-related characteristics and resistome profiles within microbiome residing on the Angkor sandstone monuments in Cambodia

To reveal the characteristics of indigenous microbiome including the pathogenic-related ones on Angkor monuments in Cambodia and the distribution pattern of resistome at different locations, several sites, namely Angkor Wat, Bayon of Angkor Thom, and Prasat Preah Vihear with different exposure levels to tourists were selected to conduct the metagenomic analysis in this study. The general characteristics of the microbiome on these monuments were revealed, and the association between the environmental geo-ecological feature and the indigenous microbiome was delineated. The most common microbial groups included 6 phyla, namely Acidobacteria, Actinobacteria, Gemmatimonadetes, Nitrospirae, Proteobacteria and Verrucomicrobia on the monuments, but Firmicutes and Chlamydiae were the most dominant phyla found in bats droppings. The taxonomic family of Chitinophagaceae could serve as a signature microbial group for Preah Vihear, the less visited site. More importantly, the pathogenic-related characteristics of the microbiome residing on Angkor monuments were uncovered. A set of specific antibiotic resistance genes (ARGs) with cross-niches dispersal capacity (between the environmental microbiome and the microbiome within warm blood fauna) was identified to be high by the source tracking analysis based on ARGs profile varies in this study. Among the 10 ARG-types detected in this study, 6 of them are confined to resistance mechanism of antibiotic efflux-pump. The findings of this study provide new a new direction on public health management and implication globally at archaeological sites for tourism.

The role of stakeholder structure in fostering community ownership: A case study of community-based projects

Community health projects have played a crucial role in improving health issues. Listening to communities' voices and achieving community ownership are essential for conducting effective health projects. However, there are limited studies on the frameworks for collecting, aggregating, and operationalizing community preferences and values. In this study, we selected two cases of community field surveys from Japan and Cambodia to discuss who may represent a community and propose a practical approach to achieving community ownership. Both cases involved various stakeholders. From the insights of these two cases, we suggested the following three key components in the community project: the community representative, the communicator, and the institute outside the community. Notably, the community representative's role as the community's direct voice should be properly recognized and institutionalised to establish community ownership. We proposed the following key terms of the qualifications of community representatives: they should be able to represent voices from the community, should have extensive experience to decide the project direction and manage the project, and should be independent of outside actors. Our theoretical model of the structure of different stakeholder groups in community-based projects will be helpful to accelerate community capacity strengthening; moreover, it can help build the appropriate community institution and process, including multi-stakeholder groups to promote community ownership in health programs.

Pesticide screening of surface water and soil along the Mekong River in Cambodia

Widespread use of pesticides globally has led to serious concerns about environmental contamination, particularly with regard to aquatic and soil ecosystems. This work involved investigating concentrations of 64 pesticides in surface-water and soil samples collected in four provinces along the Mekong River in Cambodia during the dry and rainy seasons (276 samples in total), and conducting semi-structured interviews with local farmers about pesticide use. Furthermore, an ecological risk assessment of the detected pesticides was performed. In total, 56 pesticides were detected in surface water and 43 in soil, with individual pesticides reaching maximum concentrations of 1300 ng/L in the surface-water samples (tebufenozide) and 1100 ng/g dry weight in the soil samples (bromophos-ethyl). The semi-structured interviews made it quite evident that the instructions that farmers are provided regarding the use of pesticides are rudimentary, and that overuse is common. The perceived effect of pesticides was seen as an end-point, and there was a limited process of optimally matching pesticides to pests and crops. Several pesticides were used regularly on the same crop, and the period between application and harvest varied. Risk analysis showed that bromophos-ethyl, dichlorvos, and iprobenfos presented a very high risk to aquatic organisms in both the dry and rainy seasons, with risk quotient values of 850 for both seasons, and of 67 in the dry season and 78 in the rainy season for bromophos-ethyl, and 49 in the dry season and 16 in the rainy season for dichlorvos. Overall, this work highlights the occurrence of pesticide residues in surface water and soil along the Mekong River in Cambodia, and emphasizes the urgent need for monitoring and improving pesticide practices and regulations in the region.

Engaging multisector stakeholders to identify priorities for global health innovation, change and research: an engagement methodology and application to prosthetics service delivery in Cambodia

PURPOSE

While innovation is known to catalyse solutions to global sustainable development challenges, lack of engagement from stakeholders during conceptualisation and development may influence the degree of success of implementation.

METHODS AND MATERIALS

This paper presents a complete and novel engagement methodology, developed from value led business modelling approaches, for working with multi-sector stakeholders. The methodology can be used to determine barriers and facilitators to clinical practice innovations or translational research, within a country-specific context. The approach has then been applied in the Cambodian prosthetics and orthotics sector to provide a practice-based exemplar application of the framework.

RESULTS

This approach seeks to ensure the suitability and sustainability of clinical practice and research programmes being implemented within a complex ecosystem. A theoretical basis, drawn from academic and business innovation sectors, has been consolidated and adapted for practical application to design, direct, and inform initiatives in low resource settings.

CONCLUSIONS

The methods presented provide a way to both develop and articulate the mission, vision, and goals of any proposed change, and to effectively communicate these with stakeholders in a way that engages the personal and professional values that exist in their ecosystem. It provides a structured process through which meaningful conversations can happen, and a basis for relationship management with key stakeholders; intrinsic to enable a sustained legacy from research and development.

Knowledge, compliance, and challenges in anti-malarial products usage: a systematic review of at-risk communities for zoonotic malaria

BACKGROUND

Zoonotic malaria is a growing public health threat in the WHO Southeast Asia (SEA) and Western Pacific (WP) regions. Despite vector-control measures, the distribution of Macaque fascicularis and M. nemestrina, and Anopheles mosquitoes carrying non-human simian malaria parasites poses challenges to malaria elimination. The systematic review assesses the literature on knowledge and malaria-preventive practices in zoonotic malaria-affected areas across the WHO SEA and WP, aiming to identify challenges for malaria control.

METHODS

Peer-reviewed articles published in English, Malay and Indonesian between January 2010 and December 2022 were searched in OVID Medline, Scopus, Web of Science, and Google Scholar. Studies of any design-excluding reviews, conference proceedings, and reports from all WHO SEA and WP countries vulnerable to zoonotic malaria-were included. Backwards-reference screening and thematic analysis were conducted.

RESULTS

Among 4,174 initially searched articles, 22 peer-reviewed articles met the inclusion criteria. An additional seven articles were identified through backwards-reference screening, resulting in a total of 29 articles for this review. Half of these studies were conducted in Cambodia, Myanmar, Malaysia, and Thailand, mainly in forests and remote communities. The review highlighted inconsistencies in the operationalization of knowledge, and five major themes were identified related to knowledge: causation and transmission, symptoms, treatment, severity and complications, and malaria prevention. While participants generally had some understanding of malaria causation/transmission, minority and indigenous ethnic groups demonstrated limited knowledge and held misconceptions, such as attributing malaria to drinking dirty water. Preventive practices included traditional and non-traditional or modern methods-with a preference for traditional approaches to avoid mosquito bites. Challenges to malaria control included feasibility, cost, and access to healthcare services.

CONCLUSION

This review provides insights into knowledge, local understandings, and preventive practices related to malaria in the WHO SEA and WP regions. The findings highlight the need for future research to explore the knowledge of at-risk communities regarding zoonotic malaria, their perceive threat of the disease and factors exposing them to zoonotic malaria. New strategies must be developed for zoonotic malaria programs tailored to local contexts, emphasizing the significance of community participation, health education, and socio-behavioural change initiatives. It is important to consider the interconnectedness of human health, environmental and non-human primates conservation. Socio-cultural nuances should also be carefully considered in the design and implementation of these programs to ensure their effect tailored to local contexts.

Discovery of Encyclometra bungara (Digenea: Encyclometridae) in a new host (Enhydris enhydris) from Thailand and Cambodia through morphological and molecular identification

The genus Encyclometra is one of the two genera in family Encyclometridae, known for parasitising the oesophagus, stomach and intestine of snakes. Among Encyclometra, the species present are: Encyclometra colubrimurorum, Encyclometra japonica, Encyclometra asymmetrica and Encyclometra bungara. Species discrimination within Encyclometra has predominantly relied on morphological differences, such as the length of the caeca and the position of the testes. Morphological overlaps exist among these species making species discrimination challenging. Additionally, the use of molecular information has been limited for Encyclometra. To determine the Encyclometra species infecting Enhydris enhydris from Thailand and Cambodia, morphological and molecular identification was conducted. Morphological characters and measurements were obtained from 30 Encyclometra adults, and they were compared with previous studies of other Encyclometra species. Novel sequences of E. bungara were generated using the nuclear 18S and 28S ribosomal RNA genes, and the mitochondrial cytochrome c oxidase subunit 1 gene. Our results revealed that the specimens could be morphologically identified as E. bungara, with support from molecular information obtained from the phylogenies of the 3 genetic markers employed. Molecular analysis showed that the Encyclometra specimens were distinct from E. colubrimurorum and E. japonica. Through morphological and molecular identification of the Encyclometra specimens found in E. enhydris from Thailand and Cambodia, we describe and provide a record of E. bungara in a new host and new locality. Additionally, novel molecular sequences were generated, revealing the phylogenetic position of E. bungara within the superfamily Gorgoderoidea.

Feasibility, accuracy and acceptability of self-sampled human papillomavirus testing using careHPV in Cambodia: a cross-sectional study

OBJECTIVE

Self-sampled human papillomavirus (HPV) testing is a potential option for cervical cancer screening, but research is scarce in Cambodia. We evaluated the feasibility, accuracy, and acceptability of self-sampled HPV testing using careHPV.

METHODS

A cross-sectional study including women aged 20-49 years attending 2 national hospitals in the capital city was conducted. Women underwent both self-sampling and clinician-sampling of specimens, and were then asked to complete an acceptability questionnaire. The paired samples were analyzed for high-risk HPV by careHPV and genotyped by polymerase chain reaction (PCR).

RESULTS

A total of 375 women were eligible for inclusion. Based on PCR, 78.9% were negative for HPV in both self and clinician-samples, 9.9% had a complete HPV type match, and 6.1% had all HPV types in clinician-samples also detected in self-samples. In 5.1%, one or more HPV types identified in the clinician-samples were missed in self-samples. When using careHPV, the overall agreement between the 2 sampling methods was 95.7% (95% confidence interval [CI]=95.8-95.6) with good concordance (κ=0.66, 95% CI=0.56-0.76). Nearly 90% of the women preferred clinician-sampling over self-sampling, citing greater comfort, ease, and speed.

CONCLUSION

Self-sampled HPV testing using careHPV could be an option for cervical cancer screening in Cambodia; however, it requires periodic quality control of handling procedures. In addition, women's health education regarding the accuracy of self-sampled HPV testing and the importance of follow-up in cases of positive results is needed.

Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants

OBJECTIVE

In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services.

METHOD

This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia.

RESULTS

Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times.

CONCLUSION

Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.

Evaluating the variation characteristics of ecological resilience along expressways in developing countries: the case of the Phnom Penh-Sihanoukville Expressway in Cambodia

Expressway construction has caused a significant threat to the ecological environment in developing countries, and therefore the variation characteristics of ecological resilience along the expressway in developing countries are of major importance. This empirical study focuses on a typical area within a 2-km range of the Phnom Penh-Sihanoukville Expressway in Cambodia and uses remote sensing and geographic information systems (GIS) technology to analyze the variation characteristics of ecological resilience along the expressway. The results of the study reveal that due to the construction of expressways, the land use types transferred into or out of the land use types increase and furthermore the land use types show a trend of decreasing natural attributes and increasing human attributes. It is found that expressway construction has an observed effect on the transfer rate of the center of gravity of land use type, and the direction of the center of gravity shifts in the direction of expressway construction. The impact of construction on the ecological resilience of the western region with higher vegetation coverage was higher than that of the eastern region with higher urbanization. The research develops a theoretical evaluation model based on land use type of the variation characteristics of ecological resilience along the expressway, which can be used to enable the sustainability of expressway construction and maintain the regional ecological environment.

Host-response transcriptional biomarkers accurately discriminate bacterial and viral infections of global relevance

Diagnostic limitations challenge management of clinically indistinguishable acute infectious illness globally. Gene expression classification models show great promise distinguishing causes of fever. We generated transcriptional data for a 294-participant (USA, Sri Lanka) discovery cohort with adjudicated viral or bacterial infections of diverse etiology or non-infectious disease mimics. We then derived and cross-validated gene expression classifiers including: 1) a single model to distinguish bacterial vs. viral (Global Fever-Bacterial/Viral [GF-B/V]) and 2) a two-model system to discriminate bacterial and viral in the context of noninfection (Global Fever-Bacterial/Viral/Non-infectious [GF-B/V/N]). We then translated to a multiplex RT-PCR assay and independent validation involved 101 participants (USA, Sri Lanka, Australia, Cambodia, Tanzania). The GF-B/V model discriminated bacterial from viral infection in the discovery cohort an area under the receiver operator curve (AUROC) of 0.93. Validation in an independent cohort demonstrated the GF-B/V model had an AUROC of 0.84 (95% CI 0.76-0.90) with overall accuracy of 81.6% (95% CI 72.7-88.5). Performance did not vary with age, demographics, or site. Host transcriptional response diagnostics distinguish bacterial and viral illness across global sites with diverse endemic pathogens.

Phylogeny and spatial distribution of Japanese encephalitis virus vector species in Cambodia

In Southeast Asia, despite the use of Japanese encephalitis vaccines and vaccination coverage, Japanese encephalitis (JE) transmission is still a major public health issue. The main vectors of this virus are mosquitoes from the genus Culex, which diversity and density are important in Southeast Asia. The main vector species of Japanese encephalitis virus (JEV) in Cambodia belong to the Vishnui subgroup. However, their morphological identification solely based on the adult stage remains challenging, making their segregation and detection difficult. In order to identify and describe the distribution of the three main JEV vector species in Cambodia, namely Culex vishnui, Cx. pseudovishnui and Cx. tritaeniorhynchus, mosquito samplings were carried out throughout the country in different environments. Phylogenetic analysis of the cytochrome c oxidase subunit I (coI) gene using maximum-likelihood tree with ultrafast bootstrap and phylogeographic analysis were performed. The three main Culex species are phylogenetically separated, and represent two distinct clades, one with Cx. tritaeniorhynchus and the second with Cx. vishnui and Cx. pseudovishnui, the latter appearing as a subgroup of Cx. vishnui. The phylogeographic analysis shows a distribution of the Vishnui subgroup on the entire Cambodian territory with an overlapped distribution areas leading to a sympatric distribution of these species. The three JEV vector species are geographically well-defined with a strong presence of Cx. pseudovishnui in the forest. Combined with the presence of Cx. tritaeniorhynchus and Cx. vishnui in rural, peri-urban, and urban areas, the presence of JEV-competent vectors is widespread in Cambodia.

Density and population size estimates of the endangered northern yellow-cheeked crested gibbon Nomascus annamensis in selectively logged Veun Sai-Siem Pang National Park in Cambodia using acoustic spatial capture-recapture methods

Many gibbon species are threatened with extinction, including the endangered northern yellow-cheeked crested gibbon, Nomascus annamensis. Assessing gibbon populations and understanding how human disturbances and environmental factors impact these populations is vital for effective conservation planning. In 2010, auditory surveys revealed that Veun Sai-Siem Pang National Park (VSSP) in Cambodia contains one of the largest known N. annamensis populations in the world, with an estimated 456 (95% CI 421-490) gibbon groups. Illegal selective logging is common in the park, but the impact of continued logging on the gibbon population has not been investigated. To determine any change in the N. annamensis population since 2010, between January and April 2019 we conducted auditory surveys at 13 sites that were at least 4 km apart. We surveyed each site for three days, each day recording the gibbon calls heard over 3.25 hours from three listening posts located 500 m apart. At the same sites, we assessed the logging intensity using transects and ecological plots. Gibbon densities can be influenced by various environmental factors such as canopy height and forest type. Therefore, in addition to investigating the relationship between the density of N. annamensis groups and logging, we included five additional environmental variables in our acoustic spatial capture-recapture models. Our best fit model with the lowest AIC value included canopy height, forest type, distance to villages, and logging. We estimate that there are 389 (95% CI 284-542) N. annamensis groups currently in VSSP. Selective logging is widespread in the park, primarily targeting four tree species. The estimated felling time of these logged trees, together with previous reports, indicate that the species most targeted in VSSP varies over time. To conserve the N. annamensis population in VSSP, it is crucial that action is taken to reduce illegal logging.

Sustainable development goals and multisectoral collaborations for child health in Cambodia: a qualitative interview study with key child health stakeholders

OBJECTIVES

Multisectoral collaboration highlighted as key in delivering on the Sustainable Development Goals (SDGs), but still little is known on how to move from rhetoric to action. Cambodia has made remarkable progress on child health over the last decades with multisectoral collaborations being a key success factor. However, it is not known how country stakeholders perceive child health in the context of the SDGs or multisectoral collaborations for child health in Cambodia.

DESIGN, SETTINGS AND PARTICIPANTS

Through purposive sampling, we conducted semistructured interviews with 29 key child health stakeholders from a range of government and non-governmental organisations in Cambodia. Guided by framework analysis, themes, subthemes and categories were derived.

RESULTS

We found that the adoption of the SDGs led to increased possibility for action and higher ambitions for child health in Cambodia, while simultaneously establishing child health as a multisectoral issue among key child stakeholders. There seems to be a discrepancy between the desired step-by-step theory of conducting multisectoral collaboration and the real-world complexities including funding and power dynamics that heavily influence the process of collaboration. Identified success factors for multisectoral collaborations included having clear responsibilities, leadership from all and trust among stakeholders while the major obstacle found was lack of sustainable funding.

CONCLUSION

The findings from this in-depth multistakeholder study can inform policy-makers and practitioners in other countries on the theoretical and practical process as well as influencing aspects that shape multisectoral collaborations in general and for child health specifically. This is vital if multisectoral collaborations are to be successfully leveraged to accelerate the work towards achieving better child health in the era of the SDGs.

Assessment of Forest Ecosystem Variations in the Lancang-Mekong Region by Remote Sensing from 2010 to 2020

Five countries in the Lancang-Mekong region, including Myanmar, Laos, Thailand, Cambodia, and Vietnam, are facing the threat of deforestation, despite having a high level of forest coverage. Quantitatively assessing the forest ecosystem status and its variations based on remote sensing products for vegetation parameters is a crucial prerequisite for the ongoing phase of our future project. In this study, we analyzed forest health in the year 2020 using four vegetation indicators: forest coverage index (FCI), leaf area index (LAI), fraction of green vegetation cover (FVC), and gross primary productivity (GPP). Additionally, we introduced an ecosystem quality index (EQI) to assess the quality of forest health. To understand the long-term trends in the vegetation indicators and EQI, we also performed a linear regression analysis from 2010 to 2020. The results revealed that Laos ranked as the top-performing country for forest ecosystem status in the Lancang-Mekong region in 2020. However, the long-term trend analysis results showed that Cambodia experienced the most significant decline across all indicators, while Vietnam and Thailand demonstrated varying degrees of improvement. This study provides a quality assessment of forest health and its variations in the Lancang-Mekong region, which is crucial for implementing effective conservation strategies.

Estimating the Prevalence and Identifying the Correlates of Sexting Behaviors Among Cambodian Male Adolescents

Male youths are more likely to experience peer pressure that encourages them to engage in risky behaviors than female youths, and this pressure can lead to an increased risk of sexting among male youths. This study aimed to investigate the prevalence of and factors associated with sexting among Cambodian male youths. The correlational cross-sectional study design was utilized. This study surveyed 647 Cambodian male youths aged 15 to 24 years. The measurement included sending or receiving messages (sexts) that contain sexually explicit messages, images, or videos, and affecting factors to sexting. Around 32.5% of participants sent sexts, and 38.9% received them. Open relationships, pornographic website use, perception of friends' sexual activity, frequent thoughts about sex, higher sexual sensation-seeking tendencies, positive attitudes toward sex, and sexual experience were associated with increased likelihood of sending and receiving sexts. Based on the findings of this study, by offering suitable education, guidance, and intervention programs, we can effectively mitigate the adverse repercussions of sexting while fostering healthy sexual behaviors among youths.

i-MoMCARE: Innovative Mobile Technology for Maternal and Child Health Care in Cambodia-study protocol of a cluster randomized controlled trial

BACKGROUND

The Government of Cambodia established the village health support groups (VHSGs) in 2003 to facilitate primary healthcare activities, including maternal and child health (MCH) services. However, VHSGs face several challenges that hinder them from performing optimally, including a lack of regular structured training and remuneration and limited and inconsistent support and supervision from the health centers (HCs). This implementation research aims to develop, implement, and evaluate a digital health intervention to improve the performance of VHSGs through better support and supervision and increase the MCH service coverage in rural Cambodia.

METHODS

i-MoMCARE, a two-arm cluster randomized controlled trial, will be conducted between 2022 and 2025. Five operational districts (ODs) have been randomized to an intervention arm and the other five ODs to the control arm. The intervention will last for 24 months. Around 200 VHSGs in the intervention arm will be equipped with a mobile application as a job aid and 20 HC staff with a web interface to improve support and supervision of VHSGs. The potential beneficiaries will include pregnant women, mothers, and children under 2 years old. We will measure the outcomes at baseline and endline. The primary outcomes will consist of a composite MCH index constructed from maternal and newborn care indicators, child immunization, and treatment of under-two children. Secondary outcomes will include coverage of selected MCH services. We will conduct the intention-to-treat and per-protocol analyses. We will conduct qualitative interviews with selected beneficiaries and stakeholders to evaluate the intervention's acceptability, feasibility, and scalability. We will also conduct a cost-effective analysis using decision-analytic modeling incorporating a societal perspective that explores different time horizons, intervention effects, and when scaled up to the national level.

DISCUSSION

i-MoMCARE is expected to increase MCH service access and coverage in rural Cambodia. It will contribute to advancing digital health use in primary healthcare interventions, which remains in its infancy in the country. Furthermore, the study findings will be a valuable addition to a growing body of literature on the effectiveness and feasibility of mobile health to improve coverage of MCH services in rural low- and middle-income country settings.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05639595. Registered on 06 December 2022.

An integrated framework for examining groundwater vulnerability in the Mekong River Delta region

The Mekong River provides water, food security, and many other valuable benefits to the more than 60 million Southeast Asian residents living within its basin. However, the Mekong River Basin is increasingly stressed by changes in climate, land cover, and infrastructure. These changes can affect water quantity and quality and exacerbate related hazards such as land subsidence and saltwater intrusion, resulting in multiple compounding risks for neighboring communities. In this study, we demonstrate the connection between climate change, groundwater availability, and social vulnerability by linking the results of a numerical groundwater model to land cover and socioeconomic data at the Cambodia-Vietnam border in the Mekong River Delta region. We simulated changes in groundwater availability across 20 years and identified areas of potential water stress based on domestic and agriculture-related freshwater demands. We then assessed adaptive capacity to understand how communities may be able to respond to this stress to better understand the growing risk of groundwater scarcity driven by climate change and overextraction. This study offers a novel approach for assessing risk of groundwater scarcity by linking the effects of climate change to the socioeconomic context in which they occur. Increasing our understanding of how changes in groundwater availability may affect local populations can help water managers better plan for the future, leading to more resilient communities.

Access to food markets, household wealth and child nutrition in rural Cambodia: Findings from nationally representative data

Access to informal fresh food markets plays a vital role in household food security and dietary quality in transitioning rural economies. However, it is not well understood if market access also improves child nutrition and if the improvement applies to all socioeconomic groups. In this secondary research study, we combined a national listing of food markets (n = 503) with a national household survey to examine the associations of market access with diet and height across wealth groups in children aged 6 to 23 months in rural Cambodia. All children under two years of age with dietary data (n = 1537) or anthropometry data (n = 989) were selected from the household survey. Food markets were geocoded using Google Maps or villages' geographical coordinates publicly available in the Open Development Mekong data platform. Regression calibration was then used to estimate household distance to the nearest market. Descriptive results indicated a highly uneven distribution of food markets with median household distance to the nearest markets ranging between 4 km (IQR: 3-8 km) in the lowland areas and 9 km (IQR: 4-17 km) in the highland areas. Results from the multivariate linear regressions showed that distance to the nearest market was modestly associated with child dietary diversity score (β: -0.17; 95% CI: -0.29, -0.05) but it was not related to child height-for-age z-score, and that household wealth did not modify the associations between distance to markets and child dietary diversity score. These findings suggest that improving access to food markets alone might not lead to meaningful improvement in child diet. Detailed surveys on household food acquisition are needed to clarify the role of food markets relative to other food sources such as subsistence fisheries, subsistence gardening and mobile food traders.

Hardship financing, productivity loss, and the economic cost of illness and injury in Cambodia

BACKGROUND

Financial risk protection is a core dimension of universal health coverage. Hardship financing, defined as borrowing and selling land or assets to pay for healthcare, is a measure of last recourse. Increasing indebtedness and high interest rates, particularly among unregulated money lenders, can lead to a vicious cycle of poverty and exacerbate inequity.

METHODS

To inform efforts to improve Cambodia's social health protection system we analyze 2019-2020 Cambodia Socio-economic Survey data to assess hardship financing, illness and injury related productivity loss, and estimate related economic impacts. We apply two-stage Instrumental Variable multiple regression to address endogeneity relating to net income. In addition, we calculate a direct economic measure to facilitate the regular monitoring and reporting on the devastating burden of excessive out-of-pocket expenditure for policy makers.

RESULTS

More than 98,500 households or 2.7% of the total population resorted to hardship financing over the past year. Factors significantly increasing risk are higher out-of-pocket healthcare expenditures, illness or injury related productivity loss, and spending of savings. The economic burden from annual lost productivity from illness or injury amounts to US$ 459.9 million or 1.7% of GDP. The estimated household economic cost related to hardship financing is US$ 250.8 million or 0.9% of GDP.

CONCLUSIONS

Such losses can be mitigated with policy measures such as linking a catastrophic health coverage mechanism to the Health Equity Funds, capping interest rates on health-related loans, and using loan guarantees to incentivize microfinance institutions and banks to refinance health-related, high-interest loans from money lenders. These measures could strengthen social health protection by enhancing financial risk protection, mitigating vulnerability to the devastating economic effects of health shocks, and reducing inequities.

Behavioral Determinants of Physical Activity Among Secondary School Students Aged 14-15 Years in Cambodia

BACKGROUND

There is little known about physical activity (PA) behaviors and its determinants in Cambodian adolescents, particularly with regard to the home and school settings. Therefore, we aimed to investigate these behaviors and determinants on their PA.

METHODS

The samples collected were from 168 high school students, aged 14-15 years. They were requested to complete the self-report PA questionnaire. Time spent in PA during weekday and weekend by school location and gender, and determinants on PA were analyzed. Differences in the mean values of the PA levels (in minutes) during weekday and the weekend between genders, and between school locations were analyzed using independent sample t tests. The percentage of students' perceptions on the determinants were calculated. Chi-squared test was used to compare the differences in prevalence of students' activities during their free time with respect to school location and gender.

RESULTS

The majority of the parents (86.9%-98.2%) demonstrated strong support for their children for academic work. Rural students spent an average time of moderate-to-vigorous PA greater than their counterparts from the urban areas during their weekend days (329.1 vs 239.2 min, respectively). Moderate to vigorous PA was likely to be higher during the weekends compared with weekdays among the boys (387.9 vs 361.4 min, respectively). Girls were more likely to spend their time on moderate to vigorous PA during the weekdays compared with the weekends (205.4 vs 180.5 min, respectively).

CONCLUSION

Consideration should be given to gender, school location, free time, and the environmental setting for the contextualization of more effective PA interventions with Cambodian youths.

Prevalence of Strongyloides in Southeast Asia: a systematic review and meta-analysis with implications for public health and sustainable control strategies

BACKGROUND

Strongyloidiasis, caused by the nematodes Strongyloides stercoralis and Strongyloides fuelleborni, is estimated to affect over 600 million individuals worldwide. The disease is endemic in Southeast Asia, where a warm-humid climate and socio-economic conditions maintain the parasite's life cycle and transmission. However, the current diagnostic methods may not be sufficiently sensitive, suggesting that the true prevalence of strongyloidiasis could be seriously underestimated in this. This study aims to determine the prevalence of strongyloidiasis in Southeast Asia through a systematic review and meta-analysis and to discuss the implications of the estimated prevalence on diagnostic approaches and control strategies.

METHODS

Following PRISMA guidelines, we conducted a systematic literature search in PubMed and Google Scholar databases to identify studies reporting Strongyloides prevalence data in the 11 Southeast Asian countries up to December 2022. A random effects model was employed to estimate the pooled prevalence of S. stercoralis at both regional and country levels.

RESULTS

Out of 3722 articles identified, 224 met our inclusion criteria. For S. stercoralis specifically, we found 187 articles, of which 52.4% were from Thailand. All Southeast Asian countries, except Brunei, had at least one study on Strongyloides prevalence. The estimated pooled prevalence of S. stercoralis regionally was 12.7% (95% CI 10.70-14.80%), ranging from 0.4 to 24.9% at the country level. Cambodia had the highest pooled prevalence (24.9%, 95% CI 15.65-35.38%), followed by Lao PDR (16.5%, 95% CI 9.50-24.95%). Moreover, we obtained a pooled prevalence of 10% (95% CI 7.06-13.52%) in a group comprising immigrants, workers, and veterans from Southeast Asian countries. S. stercoralis infects various host types, including nonhuman primates, domestic dogs and cats, rodents, and transport carriers such as cockroaches and vegetables.

CONCLUSIONS

A high prevalence of strongyloidiasis in Southeast Asia was revealed, highlighting the importance of the region's ongoing research, surveillance, and control efforts. Factors contributing to the strongyloidiasis transmission include the role of animal hosts, the impact of global connectivity, and the significance of the co-endemicity of other Strongyloides species. Based on these findings, a multi-pronged One-Health approach is essential for sustainable intervention and control.

Strategies for deploying triple artemisinin-based combination therapy in the Greater Mekong Subregion

BACKGROUND

This is a qualitative study to identify implementation challenges for deploying triple artemisinin-based combination therapy (TACT) in the Greater Mekong Subregion (GMS) of Southeast Asia and to explore strategies to overcome these challenges.

METHODS

In-depth interviews were conducted in three countries that have repeatedly been confronted with ACT failures: Cambodia, Vietnam, and Lao PDR. Thirty-nine key stakeholders in the healthcare systems in these countries were interviewed. One participatory workshop was conducted in Cambodia, where scenarios for potential TACT deployment were discussed.

RESULTS

The results section is organized around four strategic themes that emerged from the data: policy support, data and evidence, logistics and operation, and downstream engagement. The study revealed that countries in the GMS currently rely on ACT to eliminate Plasmodium falciparum malaria by 2025. TACT is, however, considered to be a useful backup strategy in case of future treatment failures and to prevent the re-establishment of malaria. The study showed that a major challenge ahead is to engage decision makers and healthcare providers into deploying TACT, given the low case incidence of falciparum malaria in the GMS. Interview respondents were also skeptical whether healthcare providers would be willing to engage in new therapies for a disease they hardly encounter anymore. Hence, elaborate information dissemination strategies were considered appropriate and these strategies should especially target village malaria workers. Respondents proposed several regulatory and programmatic strategies to anticipate the formation of TACT markets in the GMS. These strategies include early dossier submission to streamline regulatory procedures, early stakeholder engagement strategies to shorten implementation timelines, and inclusion of TACT as second-line therapy to accelerate their introduction in case they are urgently needed.

CONCLUSIONS

This paper presents a qualitative study to identify implementation challenges for deploying TACT in the GMS and to explore strategies to overcome these challenges. The findings could benefit researchers and decision makers in strategizing towards potential future deployment of TACT in the GMS to combat artemisinin and partner drug resistance.

Uncovering the advertising and promotional strategies of tobacco companies in Cambodia: recall of below-the-line marketing among young male smokers

INTRODUCTION

Tobacco companies have used below-the-line marketing in novel ways to promote their brands to youth in low/middle-income countries in Southeast Asia. This study explores how young male smokers in Cambodia experience below-the-line marketing strategies.

METHODS

Convenience sampling was used to recruit 147 young male smokers (18-24 years) in Cambodia in early 2020. Local research assistants conducted mixed-methods interviews with participants in Khmer or English. Participants recalled exposure to below-the-line marketing strategies and provided in-depth descriptions about their experiences with individual sales promotions. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using thematic analysis.

RESULTS

54% of participants recalled exposure to at least one below-the-line marketing strategy, including point-of-sale promotions (32.7%), individual sales promotions (27.9%) and online advertising (14.3%). Participants described individual sales promotions in public settings, and recalled that promoters were mostly female, attractive and targeted young males. Tactics used to encourage young people to accept promotional offers included free cigarettes and sample packets, swapping current cigarettes for new brands and collecting consumer details after interviewing. The brands and product features of cigarettes being promoted were readily described by participants.

CONCLUSION

This study provides evidence that illegal below-the-line marketing is still occurring in Cambodia, and increased monitoring and enforcement of advertising restrictions is needed.

Applying the COM-B behaviour change model to a pilot study delivering volatile pyrethroid spatial repellents and insecticide-treated clothing to forest-exposed populations in Mondulkiri Province, Cambodia

BACKGROUND

Southeast Asia is making tremendous progress towards their 2030 malaria elimination goal but needs new interventions to stop forest malaria. This study trials two new vector control tools, a volatile pyrethroid spatial repellent (VPSR) and insecticide-treated clothing (ITC), amongst forest-exposed populations in Mondulkiri Province Cambodia to inform their potential use for eliminating forest malaria.

METHODS

21 forest-exposed individuals were given a questionnaire on their perceptions of malaria and preventive practices used, after which they trialed two products sequentially. Clothes was treated with ITC by the study team. Mixed methods were used to understand their experience, attitudes, and preferences regarding the products trialed. Quantitative data was summarized and qualitative insights were analysed using thematic analysis, applying the Capability, Opportunity, and Motivation Behaviour Change (COM-B) model and Behaviour Change Wheel Framework to identify intervention functions to support tailored product rollout amongst these populations.

RESULTS

Study participants reported a need for protection from mosquito bites in outdoor and forest-exposed settings and perceived both products trialed to be effective for this purpose. The VPSR product was preferred when travel was not required, whereas ITC was preferred for ease of use when going to the forest, especially in rainy conditions. COM-B analysis identified that key enablers for use of both products included their perceived efficacy and ease of use, which required no skill or preparation. For barriers to use, the odour of ITC was sometimes perceived as being toxic, as well as its inability to protect uncovered skin from mosquito bites, while the perceived usefulness of the VPSR product trialed was limited by its water sensitivity in rainy forest settings. Intervention components to encourage appropriate and sustained use of these products include education about how to use these products and what to expect, persuasion to use them from community leaders and targeted channels, and enablement to facilitate convenient and affordable access.

CONCLUSION

The rollout of VPSRs and ITC amongst forest-exposed populations can be useful for eliminating malaria in Southeast Asia. Study findings can be applied to increase product uptake among forest exposed populations in Cambodia, while manufacturers can aim to develop products that are rainproof, easy to use in forest settings, and have favourable odour profiles to target users.

Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis

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.

The Field Epidemiology Training Program's Contribution to Essential Public Health Functions in Seven National Public Health Institutes

Objective: This study explores how Field Epidemiology Training Programs (FETP) whose National Public Health Institutes (NPHI) are supported by U.S. Centers for Disease Control and Prevention (CDC) have contributed to strengthening essential public health functions. Methods: We conducted 96 semi-structured interviews with public health experts including NPHI staff, non-NPHI government staff, and staff from non-governmental and international organizations in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda, and Zambia. We managed data using MAXQDA and employed direct content analysis to derive themes. Results: Three overarching themes emerged in relation to FETPs' role within the NPHIs' public health functions. These themes included contribution to improving country surveillance systems, role in providing leadership in outbreak responses, and strengthening countries' and the NPHIs' surveillance workforce capacity. Participants also shared challenges around FETPs' implementation and suggestions for improvement. Conclusion: The results demonstrate the value of FETPs in strengthening public health systems through building workforce capacity and improving surveillance systems. By identifying the successes of FETPs in contributing to essential public health functions, our findings might inform current and future FETP implementation and its integration into NPHIs.

Traditional medicine consumption in postpartum for HBV-infected women enrolled in the ANRS 12345 TA PROHM study in Cambodia

In Cambodia, traditional medicine was commonly described as being used by pregnant women at two time points: one month before birth and during early postpartum. The present study aims to describe traditional medicine consumption during postpartum phase for women enrolled in the TA PROHM study and to investigate the possible association between traditional medicine consumption and acute liver toxicity. An ethnobotanical survey was conducted in 2 groups of HBV-infected pregnant women (with and without postpartum hepatocellular injury) enrolled in the study. Hepatocellular injury was defined by having Alanine Aminotransferase (ALT) > 2.5 times the Upper Limit of Normal (ULN = 40 U/L) at the 6th week postpartum visit. Interviews were done using a standardized questionnaire. Plant samples were collected and later identified by two traditional healers. Chi-square test was used to find the association between hepatocellular injury and traditional medicine consumption or a specific plant species. In total, 75 women were enrolled and 52 (69.3%) used at least one traditional remedy composed of 123 different plants and 12 alcoholic macerations of porcupine stomach. Orally consuming at least one remedy with alcohol was significantly associated with hepatocellular injury (33% vs 13%, p = 0.034). Among the 123 plants species identified, four were found to be associated with hepatocellular injury, namely Amphineurion marginatum (Roxb.) D.J.Middleton [Apocynaceae] (p = 0.022), Selaginella tamariscina (P.Beauv.) Spring [Selaginellaceae] (p = 0.048), Mitragyna speciosa Korth. [Rubiaceae] (p = 0.099) and Tetracera indica (Christm. & Panz.) Merr. [Dilleniaceae] (p = 0.079). Consumption of traditional medicine in postpartum is a common practice for women enrolled in the TA PROHM study. Alcohol-based remedies may exacerbate the risk of acute hepatocellular injury in HBV-infected women already exposed to immune restoration. The complex mixtures of herbs need to be further evaluated by in vitro and in vivo studies.

Protocol for a randomized controlled trial in Cambodian individuals with PTSD: Trauma-Informed Treatment Algorithms for Advancing Novel Outcomes (Project TITAN)

INTRODUCTION

Low- and middle-income countries shoulder a disproportionate burden of mental health disorders with limited resources to support the provision of care using culturally relevant, evidence-based interventions. This is particularly true in Cambodia where the population continues to confront traumatic consequences of the Khmer Rouge genocide that targeted educated people, including treatment providers. Trauma-Informed Treatment Algorithms for Advancing Novel Outcomes (Project TITAN) will examine proof of concept and preliminary efficacy of culturally tailored interventions for symptoms of post-traumatic stress (PTS) among Cambodian adults.

METHODS

A stepped care randomized controlled trial enrolling people seeking mental health treatment and priority populations with high rates of trauma exposure, including female entertainment and sex workers and sexual and gender minorities. In total, 160 participants with symptoms of PTS are randomized to Stabilization Techniques or Behavioral Activation plus Stabilization Techniques, implemented within a culturally relevant framework. Individuals who do not demonstrate a reduction in symptoms of PTS after six treatment sessions receive Eye Movement Desensitization and Reprocessing therapy. PTS, depression, anxiety, and substance use are assessed at baseline and two and four months post-randomization.

PLANNED ANALYSES

The percentage of individuals achieving reductions in symptoms of PTS after four months is the primary outcome. Secondary outcomes are depression, anxiety, and substance use over four months. Finally, machine learning analyses will be conducted to identify features at baseline and during treatment that predict outcomes.

DISCUSSION

Findings will guide future development and implementation of interventions to improve mental health conditions among individuals in Cambodia and other resource-limited settings.

The inclusion of diagnostics in national health insurance schemes in Cambodia, India, Indonesia, Nepal, Pakistan, Philippines and Viet Nam

The Lancet Commission on Diagnostics highlighted a huge gap in access to diagnostic testing even for basic tests, particularly at the primary care level, and emphasised the need for countries to include diagnostics as part of their universal health coverage benefits packages. Despite the poor state of diagnostic-related services in low-income and middle-income countries (LMICs), little is known about the extent to which diagnostics are included in the health benefit packages. We conducted an analysis of seven Asian LMICs-Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, Viet Nam-to understand this issue. We conducted a targeted review of relevant literature and applied a health financing framework to analyse the benefit packages available in each government-sponsored scheme. We found considerable heterogeneity in country approaches to diagnostics. Of the seven countries, only India has developed a national essential diagnostics list. No country presented a clear policy rationale on the inclusion of diagnostics in their scheme and the level of detail on the specific diagnostics which are covered under the schemes was also generally lacking. Government-sponsored insurance expansion in the eligible populations has reduced the out-of-pocket health payment burden in many of the countries but overall, there is a lack of access, availability and affordability for diagnostic-related services.

Building on Community Research Partnerships and Training Students in a Multi-Phase Community-Based Participatory Research Study With Young Women of Cambodian Heritage in Massachusetts

Refugees bring significant economic and cultural benefits to communities and yet face elevated risk of chronic disease and barriers to good health in the U.S. Community-based participatory research (CBPR) can benefit refugee communities and provide training/mentoring opportunities for students. The Cambodian Women's Health Study was a four-phase, multi-year CBPR university-community collaboration with the Massachusetts Cambodian community that focused on health, nutrition, pregnancy, and food security among primarily young women of Cambodian heritage ages 15-30 years old. Phase 1 was a focus group discussion (FGD, n = 4) and cross-sectional survey (n = 56) with pregnant women. Phase 2 was a cross-sectional survey (n = 107) with nonpregnant women. Phase 3 was a series of FGD (seven FGD, n = 38) with women. Phase 4 was a student-led translational nutrition intervention (three classes) with women (n = 11) and men (n = 10). The study design included compensation and support for the community partner and included structured mentoring of students (six graduates, eight undergraduates) in CBPR methods, adult learning, and cultural humility. Benefits to the community agency included enhanced research capacity, including supervising student research assistants, and robust compensation. Benefits to students included intensive mentoring and training. Successes included cost-effectiveness and strong recruitment and experiences with participants. Challenges included issues with student-led recruitment and organization that required additional mentoring and reflection. To work toward socially just and equitable research and interventions, CBPR collaborative efforts should include intentional meaningful compensation and community capacity-building as well as structured mentoring and training for student researchers and should build on existing work and relationships within communities.

"Overcrowded but lonely": exploring mental health and well-being among young prisoners in Cambodia

PURPOSE

Young prisoners are one of the most vulnerable groups in society for mental health problems and ill-being. Therefore, there is a crucial need to understand their physical, psychological and social situations. This study aims to explore young Cambodian prisoners' experiences and perceptions of mental health and well-being, their determinants and their coping strategies.

DESIGN/METHODOLOGY/APPROACH

Six focus group discussions were carried out in three prisons with a total of 48 young prisoners between the ages of 15 and 24 years (50% women, 50% men). Semi-structured questions guided the discussions, and thematic analysis was applied to analyse the data.

FINDINGS

Young prisoners reported multifaceted experiences of mental health and well-being. The majority described adverse mental health experiences, while some revealed better well-being, partly influenced by the socio-economic support from outside the prisons and previous involvement or not in drug abuse. The experience of physical overcrowding without emotional attachment among the fellow prisoners was perceived as the overarching determinant of loneliness and mental health problems, while socio-emotional support and rituals were described as the most important coping mechanisms.

ORIGINALITY/VALUE

This pioneering study from Cambodia gives young prisoners an opportunity to voice their experiences and perceptions of mental health and well-being in the prison setting. The findings in this study underline the importance of prison authorities tackling overcrowding to promote well-being and reduce mental health problems. Also, the coping mechanisms outlined by the participants should be considered when planning psychosocial interventions.

The Effect of Oral Iron Supplementation on Gut Microbial Composition: a Secondary Analysis of a Double-Blind, Randomized Controlled Trial among Cambodian Women of Reproductive Age

The World Health Organization recommends untargeted iron supplementation for women of reproductive age (WRA) in countries where anemia prevalence is greater than 40%, such as Cambodia. Iron supplements, however, often have poor bioavailability, so the majority remains unabsorbed in the colon. The gut houses many iron-dependent bacterial enteropathogens; thus, providing iron to individuals may be more harmful than helpful. We examined the effects of two oral iron supplements with differing bioavailability on the gut microbiomes in Cambodian WRA. This study is a secondary analysis of a double-blind, randomized controlled trial of oral iron supplementation in Cambodian WRA. For 12 weeks, participants received ferrous sulfate, ferrous bisglycinate, or placebo. Participants provided stool samples at baseline and 12 weeks. A subset of stool samples (n = 172), representing the three groups, were randomly selected for gut microbial analysis by 16S rRNA gene sequencing and targeted real-time PCR (qPCR). At baseline, 1% of women had iron-deficiency anemia. The most abundant gut phyla were Bacteroidota (45.7%) and Firmicutes (42.1%). Iron supplementation did not alter gut microbial diversity. Ferrous bisglycinate increased the relative abundance of Enterobacteriaceae, and there was a trend towards an increase in the relative abundance of Escherichia-Shigella. qPCR detected an increase in the enteropathogenic Escherichia coli (EPEC) virulence gene, bfpA, in the group that received ferrous sulfate. Thus, iron supplementation did not affect overall gut bacterial diversity in predominantly iron-replete Cambodian WRA, however, evidence does suggest an increase in relative abundance within the broad family Enterobacteriaceae associated with ferrous bisglycinate use. IMPORTANCE To the best of our knowledge, this is the first published study to characterize the effects of oral iron supplementation on the gut microbiomes of Cambodian WRA. Our study found that iron supplementation with ferrous bisglycinate increases the relative abundance of Enterobacteriaceae, which is a family of bacteria that includes many Gram-negative enteric pathogens like Salmonella, Shigella, and Escherichia coli. Using qPCR for additional analysis, we were able to detect genes associated with enteropathogenic E. coli, a type of diarrheagenic E. coli known to be present around the world, including water systems in Cambodia. The current WHO guidelines recommend blanket (untargeted) iron supplementation for Cambodian WRA despite a lack of studies in this population examining iron's effect on the gut microbiome. This study can facilitate future research that may inform evidence-based global practice and policy.

Learning while earning: Barriers and pedagogies toward Sustainable Development Goal 4, "quality education" for child street-sellers in Siem Reap, Cambodia

BACKGROUND

For children living in a village near Angkor Wat, Siem Reap, Cambodia, selling low cost goods to tourists supplements family incomes and progresses familial social and educational aspirations. However, the Cambodian Government has legislated to remove children selling on the streets in order to project a modern, orderly society. Simultaneously, the tourist campaigns of local non-governmental organisations (NGOs) discourage tourists from purchasing goods from children, based on the premise that work prevents school attendance.

OBJECTIVE

To explore the lived experiences of street-selling children focusing particularly on formal and non-formal education within a human development framework and compare and contrast this to the positions of the Cambodian Government and local NGOs.

PARTICIPANTS AND SETTING

The research participants comprised 22 Cambodian street-sellers aged 8-15 years in central Siem Reap, Cambodia.

METHOD

Rights-based, participatory research was conducted over two periods totalling five months, between 2013 and 2015.

RESULTS

The child street-sellers were initially able to work and attend school with their selling financing their schooling costs. During the research, 14 participants (64%) were forced from their selling activities and unable to pay schooling costs, subsequently left school. However, the successful child street-sellers devised strategies to continue selling, remain in school, learn English through tourist interactions and fulfil their familial and cultural obligations.

CONCLUSION

Contrary to Government policy and NGO campaigns, many child streets-sellers in Siem Reap work to finance their own schooling and progress their own human development and are adversely impacted and have their rights violated when removed from the street.

High consumption of unhealthy commercial foods and beverages tracks across the complementary feeding period in rural/peri-urban Cambodia

Consumption of unhealthy commercial foods and beverages (UCFB) is common among infants and young children living in low- and middle-income countries. Such foods can displace other nutritious foods, however, there is limited evidence on how this consumption tracks across time. This study assessed and tracked UCFB consumption of children living in rural/peri-urban Cambodia during the complementary feeding period, identified UCFB consumption patterns of these children, and explored the association between UCFB consumption and growth. A 6-month longitudinal cohort study was implemented among 567 caregivers of children aged 10-14 months at recruitment. UCFB consumption was estimated each month via a telephone-administered 7-day food frequency questionnaire, and UCFB consumption patterns were identified based on changes in this frequency of consumption over time. The majority of children either maintained (45.7%, n = 246) or developed (43.5%, n = 234) an unhealthy consumption pattern and only 10.8% (n = 58) of children maintained/transitioned into a healthy consumption pattern. High consumers of UCFB at 10-14 months had a 4.7 (CI: 4.7 [3.1-7.2]) times odds of being high consumers of UCFB at 15-19 months (p < 0.001). There was a trend of lower length-for-age z-scores (LAZ) among children maintaining or developing an unhealthy consumption pattern (~-0. SD LAZ) compared to children maintaining/transitioning into a healthy consumption pattern, however, this association was not statistically significant. Findings indicate that high UCFB consumption begins during infancy and tracks into early childhood. National policies and programmes centred on early interventions addressing the use of UCFB for infant and young child feeding are needed.

Using Relational Community Engagement within the Digital Health Intervention (DHI) to Improve Access and Retention among People Living with HIV (PLWH): Findings from a Mixed-Method Study in Cambodia

We examined the impact of COVID-19-associated restrictive measures on the HIV care system in Cambodia through a complexity lens and aimed to use the findings to integrate social and relational processes into the design and implementation of proposed solutions that could support program outcomes during these times. Through a mixed-method design, we generated data on the strength of connection and quality of relationships between stakeholders and how this, in turn, provided a more holistic understanding of the challenges experienced during a pandemic. We interviewed 43 HIV care providers and 13 patients from eight HIV clinics and 13 policy-level stakeholders from relevant institutions involved in HIV care from April to May 2021. We identified several challenges, as well as an opportunity to improve HIV care access that built upon a strong foundation of trust between the HIV care providers and receivers in Cambodia. Trusting relationships between providers and patients provided the basis for intervention development aiming to improve the care experience and patients' engagement in care. Iterative research processes could better inform the intervention, and communication resources provided through relational skills training are key to their application and sustainability.

Mosquito diversity (Diptera: Culicidae) and medical importance in four Cambodian forests

BACKGROUND

A total of 290 mosquito species are recorded in Cambodia among which 43 are known vectors of pathogens. As Cambodia is heavily affected by deforestation, a potential change in the dynamic of vector-borne diseases (VDBs) could occur through alteration of the diversity and density of sylvatic vector mosquitoes and induce an increase in their interactions with humans. Understanding mosquito diversity is therefore critical, providing valuable data for risk assessments concerning the (re)emergence of local VBDs. Consequently, this study mainly aimed to understand the spatial and temporal distribution of sylvatic mosquito populations of Cambodia by determining which factors impact on their relative abundance and presence.

METHODS

A study was conducted in 12 sites from four forests in Cambodia. All mosquitoes, collected during the dry and rainy seasons, were morphologically identified. The diversity and relative density of mosquito species in each site were calculated along with the influence of meteorological and geographical factors using a quasi-Poisson generalized linear model.

RESULTS

A total of 9392 mosquitoes were collected belonging to 13 genera and 85 species. The most represented genera were Culex, accounting for 46% of collected mosquitoes, and Aedes (42%). Besides being the most abundant species, Culex pseudovishnui and Aedes albopictus, which are known vectors of numerous arboviruses, were present in all sites during both dry and rainy seasons. The presence of mosquito species reported to be zoo-anthropophilic feeders was also observed in both forested and urban areas. Finally, this study demonstrated that altitude, temperature and precipitation impacted the abundance of mosquitoes but also influenced species community composition.

CONCLUSION

The results indicate an important diversity of mosquitoes in the four forests and an influence of meteorological and geographical factors on their community. Additionally, this work highlights in parallel the abundance of species considered to be of medical importance and therefore underlines the high risk of pathogen emergence/re-emergence in the region.

Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019

Over the past decades, many low- and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expenditure (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impoverishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial protection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted interventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.

Integrated assessment of climate change and reservoir operation on flow-regime and fisheries of the Sekong river basin in Lao PDR and Cambodia

This study assesses the cumulative impact of climate change and reservoir operation on flow regime and fisheries in the Sekong River Basin. Ensemble of five selected Regional Climate Models (RCMs) were used to project the future climate under RCP4.5 and RCP8.5 scenarios. The projected future climate was used to simulate the future hydrology using the SWAT model while HEC-ResSim was utilized for reservoir simulation. Finally fish-flow relationship was developed to estimate the fish catch and productivity in future. Upon investigation we found that, Sekong River Basin is likely grow warmer and drier in future under climate change. The basin is expected to face 1.3-3.6 °C rise in mean annual temperature and receive 0-6% less annual rainfall in future. The wet season in the basin is anticipated to be drier (0% to -6%) while the dry season rainfall shows no particular trend (-3%-10%). Such a change in climate is likely to alter the mean annual flow in future between -3 and 5% at Attapeu, -6 to 2% at Ban Veunkhane, Lao PDR, and -7 to 1% at Siempang, Cambodia (basin outlet). Under climate change, we expect decrement in minimum flow but increment in the maximum flow while opposite is anticipated under reservoir operation. Operation of Xekaman 1 and Sekong 4A are likely to increase the minimum flow at river outlet by 32-59% and 13-18% respectively whereas maximum flow is expected to decrease by 28-5%. In addition, climate change is likely to have crucial impact on fisheries with up to 19% and 12% reduction in fish catches and fish productivity respectively. However, reservoirs tend to have negligible impact on fisheries.

Air pollution mitigation assessment to inform Cambodia's first clean air plan

Cambodia's 16.5 million people are exposed to air pollution in excess of World Health Organisation guidelines. The Royal Government of Cambodia has regulated air pollutant emissions and concentrations since 2000, but rapid economic growth and energy consumption means air pollution continues to impact human health. In December 2021, the Ministry of Environment of Cambodia published Cambodia's first Clean Air Plan that outlines actions to reduce air pollutant emissions over the next decade. This work presents the quantitative air pollution mitigation assessment underpinning the identification and evaluation of measures included in Cambodia's Clean Air Plan. Historic emissions of particulate matter (PM_2.5, black carbon, organic carbon) and gaseous (nitrogen oxides, volatile organic compounds, sulphur dioxide, ammonia, and carbon monoxide) air pollutants are quantified between 2010 and 2015, and projected to 2030 for a baseline scenario. Mitigation scenarios reflecting implementation of 14 measures included in Cambodia's Clean Air Plan were modelled, to quantify the national reduction in emissions, from which the reduction in ambient PM_2.5 exposure and attributable health burdens were estimated. In 2015, the residential, transport, and waste sectors contribute the largest fraction of national total air pollutant emissions. Without emission reduction measures, air pollutant emissions could increase by between 50 and 150% in 2030 compared to 2015 levels, predominantly due to increases in transport emissions. The implementation of the 14 mitigation measures could substantially reduce emissions of all air pollutants, by between 60 and 80% in 2030 compared to the baseline. This reduction in emissions was estimated to avoid approximately 900 (95% C.I.: 530-1200) premature deaths per year in 2030 compared to the baseline scenario. In addition to improving air pollution and public health, Cambodia's Clean Air Plan could also to lead to additional benefits, including a 19% reduction in carbon dioxide emissions, simultaneously contributing to Cambodia's climate change goals.

Screening tools for predicting mortality of adults with suspected sepsis: an international sepsis cohort validation study

OBJECTIVES

We evaluated the performance of commonly used sepsis screening tools across prospective sepsis cohorts in the USA, Cambodia and Ghana.

DESIGN

Prospective cohort studies.

SETTING AND PARTICIPANTS

From 2014 to 2021, participants with two or more SIRS (Systemic Inflammatory Response Syndrome) criteria and suspected infection were enrolled in emergency departments and medical wards at hospitals in Cambodia and Ghana and hospitalised participants with suspected infection were enrolled in the USA. Cox proportional hazards regression was performed, and Harrell's C-statistic calculated to determine 28-day mortality prediction performance of the quick Sequential Organ Failure Assessment (qSOFA) score ≥2, SIRS score ≥3, National Early Warning Score (NEWS) ≥5, Modified Early Warning Score (MEWS) ≥5 or Universal Vital Assessment (UVA) score ≥2. Screening tools were compared with baseline risk (age and sex) with the Wald test.

RESULTS

The cohorts included 567 participants (42.9% women) including 187 participants from Kumasi, Ghana, 200 participants from Takeo, Cambodia and 180 participants from Durham, North Carolina in the USA. The pooled mortality was 16.4% at 28 days. The mortality prediction accuracy increased from baseline risk with the MEWS (C-statistic: 0.63, 95% CI 0.58 to 0.68; p=0.002), NEWS (C-statistic: 0.68; 95% CI 0.64 to 0.73; p<0.001), qSOFA (C-statistic: 0.70, 95% CI 0.64 to 0.75; p<0.001), UVA score (C-statistic: 0.73, 95% CI 0.69 to 0.78; p<0.001), but not with SIRS (0.60; 95% CI 0.54 to 0.65; p=0.13). Within individual cohorts, only the UVA score in Ghana performed better than baseline risk (C-statistic: 0.77; 95% CI 0.71 to 0.83; p<0.001).

CONCLUSIONS

Among the cohorts, MEWS, NEWS, qSOFA and UVA scores performed better than baseline risk, largely driven by accuracy improvements in Ghana, while SIRS scores did not improve prognostication accuracy. Prognostication scores should be validated within the target population prior to clinical use.

"Help Children Walking on the Right Path": Understanding Parents' and Grandparents' Perceptions on Violence Against Children in Cambodia and Prevention Strategies

This study examined parents' and grandparents' understanding of violence against children (VAC) strategies to prevent VAC in the home. Research questions: What do parents and grandparents understand about VAC? Which child discipline practices are violent? What are strategies to prevent VAC? Participants: 30 parents and grandparents from a small rural community. Six focus group discussions (FGDs) in which participants shared their perceptions and practices relating to child discipline, forms of VAC, and proposed intervention strategies. In two community forums, participants discussed intervention strategies produced in separate FGDs and agreed on three priority strategies. During the FGDs and community meetings, none of the participants ever mentioned any laws, regulations, or government strategies to address VAC in the home. Participants expressed confusion and mixed feelings and responses on forms of VAC. Some agreed on deception, manipulation, intimidation (som lot), threats (Kom ream, harsh words, scolding (je), and physical punishment (i.e., beating or beating with an object) as an unacceptable discipline that would adversely impact children's well-being. Others agreed on cautiously using such disciplines to a certain degree and context. Participants proposed three priority strategies to address VAC in the home, of which two-community awareness and education and community-based efforts-fit with the Cambodia 2017 to 2024 Action Plan Strategies to Prevent and Respond to VAC. The third strategy, addressing alcohol harm-related violence, though not regarded in the 2017 to 2024 Action Plan, was considered pivotal in preventing VAC. Parents and grandparents have a substantial role in child protection at home. Nevertheless, without a clear definition of VAC or articulation of protecting children from violence in the home, it would be challenging to involve parents/grandparents for effective intervention. Participants' three priority strategies have a substantial policy and program implications for Cambodia's primary prevention of VAC action strategy. Community-based mobilization, education, and capacity building need to start and sustain the community.

Healthcare usage and expenditure among people with type 2 diabetes and/or hypertension in Cambodia: results from a cross-sectional survey

OBJECTIVE

To assess usage of public and private healthcare, related healthcare expenditure, and associated factors for people with type 2 diabetes (T2D) and/or hypertension (HTN) and for people without those conditions in Cambodia.

METHODS

A cross-sectional household survey.

SETTINGS

Five operational districts (ODs) in Cambodia.

PARTICIPANTS

Data were from 2360 participants aged ≥40 years who had used healthcare services at least once in the 3 months preceding the survey.

PRIMARY AND SECONDARY OUTCOME

The main variables of interest were the number of healthcare visits and healthcare expenditure in the last 3 months.

RESULTS

The majority of healthcare visits took place in the private sector. Only 22.0% of healthcare visits took place in public healthcare facilities: 21.7% in people with HTN, 37.2% in people with T2D, 34.7% in people with T2D plus HTN and 18.9% in people without the two conditions (p value <0.01). For people with T2D and/or HTN, increased public healthcare use was significantly associated with Health Equity Fund (HEF) membership and living in ODs with community-based care. Furthermore, significant healthcare expenditure reduction was associated with HEF membership and using public healthcare facilities in these populations.

CONCLUSION

Overall public healthcare usage was relatively low; however, it was higher in people with chronic conditions. HEF membership and community-based care contributed to higher public healthcare usage among people with chronic conditions. Using public healthcare services, regardless of HEF status reduced healthcare expenditure, but the reduction in spending was more noticeable in people with HEF membership. To protect people with T2D and/or HTN from financial risk and move towards the direction of universal health coverage, the public healthcare system should further improve care quality and expand social health protection. Future research should link healthcare use and expenditure across different healthcare models to actual treatment outcomes to denote areas for further investment.

The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia

Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.

Adverse Childhood Experiences and Intimate Partner Violence Among Youth in Cambodia: A Latent Class Analysis

Adverse childhood experiences (ACEs) are a global public health problem, including in low- and middle-income country settings, and are associated with increased risk of intimate partner violence (IPV) during young adulthood. However, current measurement of ACEs may underestimate sequelae of different combinations, or classes, of ACEs and mask class-specific associations with adult exposure to IPV. We used data among ever-partnered young women and men aged 18-24 years from the Cambodia Violence Against Children Survey (N_w = 369; N_m = 298). Participants retrospectively reported on seven ACEs and lifetime physical and/or sexual IPV victimization and perpetration. Latent classes comprised of ACEs were used as predictors of physical and/or sexual IPV perpetration and victimization, controlling for household wealth. Identified latent classes for women were "Low ACEs" (60%), "Community Violence and Physical Abuse" (23%), and "Physical, Sexual and Emotional Abuse" (17%). Latent classes for men were "Low ACEs" (48%) and "Household and Community Violence" (52%). Among women, those in the Physical, Sexual and Emotional Abuse class were more likely to experience and perpetrate physical and/or sexual IPV in their romantic relationships compared to the reference group (Low ACEs). Women in the Community Violence and Physical Abuse class were more likely to perpetrate physical and/or sexual IPV, but not experience IPV, compared to women in the Low ACEs class. Among men, those in the Household and Community Violence class were more likely to perpetrate physical and/or sexual IPV against a partner, compared to men in the Low ACEs class. Overall, patterns of ACEs were differently associated with IPV outcomes among young women and men in Cambodia. National violence prevention efforts might consider how different combinations of childhood experiences shape risk of young adulthood IPV and tailor interventions accordingly to work with youth disproportionately affected by varied combinations of ACEs.

Cultural adaptation of the person-centered maternity care scale at governmental health facilities in Cambodia

BACKGROUND

In Cambodia, the importance of valuing women's childbirth experiences in improving quality of care has been understudied. This is largely because of absence of reliable Khmer tools for measuring women's intrapartum care experiences. Generally, cross-cultural development of those tools often involves translation from a source language into a target language. Yet, few earlier studies considered Cambodian cultural context. Thus, we developed the Cambodian version of the Person-Centered Maternity Care (PCMC) scale, by culturally adapting its original to Cambodian context for ensuring cultural equivalence and content validity.

METHODS

Three rounds of cognitive interviewing with 20 early postpartum women were conducted at two governmental health facilities in Cambodia. Cognitive interviewing was composed of structured questionnaire pretesting and qualitative probing. The issues identified in the process of transcribing and translating audio-recorded cognitive interviews were iteratively discussed among study team members, and further analyzed.

RESULTS

A total of 14 issues related to cultural adaptations were identified in the 31 translated questions for the Cambodian version of the PCMC scale. Our study identified three key findings: (i) discrepancies between the WHO recommendations on intrapartum care and Cambodian field realities; (ii) discrepancies in recognition on PCMC between national experts and local women; and (iii) challenges in correctly collecting and interpreting less-educated women's views on intrapartum care.

CONCLUSION

Not only women's verbal data but also their non-verbal data and cultural contexts should be comprehensively counted, when reflecting Cambodian women's intrapartum practice realities in the translated version. This is the first study that attempted to develop the tool for measuring Cambodian women's experiences during childbirth, by addressing cross-cultural issues.

Spatiotemporal impacts of climate change and human activities on water resources and ecological sensitivity in the Mekong subregion in Cambodia

Water resources in the Mekong subregion in Cambodia (MSC) have experienced dramatic changes in past decades, threatening regional ecosystem quality and sustainable development. Thus, it is important to explore the spatiotemporal impacts of climate change and human activities on water resources and ecological sensitivity. This study proposed an effective framework including spatiotemporal analysis of land use/cover change (LUCC) and ecological sensitivity assessment by combining remote sensing (RS) and geographic information system/science (GIS). An optimized feature space and a machine learning classification algorithm were constructed to extract four typical land cover types in the MSC from 1990 to 2020. An ecological sensitivity evaluation system, including four sub-sensitivities calculated by twelve indicators, was then constructed. The results suggest that severe shrinkage of water resources occurred before 2006, decreasing by 21.68%. The correlation between water resources and climate conditions displays a high to low level as human activity becomes involved. A significant spatiotemporal evolutionary pattern of ecological sensitivity was observed under the impact of external interference. Generally, the largest proportion of MSC belongs to the lightly sensitive level, which is mainly concentrated in the lower reaches, with an average of 33.93%. The highly sensitive area with a significant value in ecological protection has a slightly downward trend from 23.72 in 1990 to 22.55% in 2020.