Savina Chham

The burden of type-2 diabetes (T2D) and hypertension (HTN) in Cambodia is a major concern. The government and donors have introduced several interventions, yet human resource shortages hamper their implementation. Community health workers (CHWs) can be a valuable additional resource for health in T2D and HTN management. The current study aimed to assess (1) CHWs’ knowledge, attitude, and practices (KAP) in T2D and HTN management and (2) the potential health system barriers for incorporating CHWs in T2D and HTN management. This mixed-method study comprised a survey among 153 active CHWs to assess their KAP towards T2D and HTN, and semi-structured interviews with key informants were conducted to understand the challenges of the health system and propose solutions in incorporating CHWs in T2D and HTN management. Approximately 90% of CHWs correctly answered general knowledge questions on NCDs, risk factors, and prevention; however, only around 20–40% correctly answered questions on family history or tobacco use as risk factors. Most respondents appeared to have positive attitudes and have been practicing some activities related to T2D and HTN. Both financial and non-financial resource constraints were cited as challenges of the health system; therefore, re-structuring the definition of CHWs’ roles and responsibilities, and assessing the need and workload have been proposed as ways forward to effectively incorporate CHWs in T2D and HTN care. CHWs in Cambodia have shown their potential in T2D and HTN management; however, a well-designed strategy, including technical training, clearly defined roles and responsibilities, and strong support structure, is important to maximize their potential in the health system.

The prevalence of hypertension (HTN) of adults aged ≥ 40 years in Cambodia was high (35.2%) in 2020 and only one-third achieved well-cont

Background: The prevalence of raised blood pressure (RBP) in Cambodia has nearly doubled over the past decade. This study aimed to examine the associated factors and quantify the magnitude of educational and economic inequalities in relation to the prevalence of RBP among Cambodian adults. Methods: Data were obtained from the 2023 STEPwise approach to noncommunicable disease risk factor surveillance. The study included 3,186 adults aged 18–69 years. Multilevel logistic regression models were used to identify potential associated factors for RBP. The magnitude of educational and economic inequalities was assessed using the regression-based slope index of inequality (SII) and relative index of inequality (RII). Results: Overall, the prevalence of RBP was 16.2% (95% confidence interval [CI]: 14.5%–18.1%). The main associated factors for RBP were age 40–49 years (odds ratio [OR]: 4.97, 95% CI: 2.51–9.85), 50–59 years (OR:10.67, 95%CI: 5.52–20.62), and 60–69 years (OR:12.92, 95%CI: 6.55–25.48), overweight (OR:1.66, 95%CI:1.19–2.33), obesity (OR: 3.52, 95% CI: 2.38–5.21), and comorbid diabetes (OR: 2.53, 95% CI:1.81–3.54). Female sex (OR: 0.39, 95% CI: 0.25–0.63), current usage of smoking tobacco products (OR: 0.47, 95% CI: 0.27–0.83), adequate consumption of fruits and vegetables (OR: 0.63, 95%CI: 0.46–0.85), and underweight (OR:0.33, 95%CI:0.18–0.61) were associated with reduced risk of RBP. Substantial educational inequality was observed in relation to the prevalence of RBP, with RBP disproportionately affecting individuals without formal schooling at the national (SII: -18.9, 95% CI: -24.80 to -12.90, p < 0.001), rural-urban, and regional levels. Nationally, individuals with higher education levels were 67% less likely to have RBP than those without formal schooling (RII: 0.33, 95% CI: 0.17–0.66). Significant absolute economic inequalities in RBP prevalence, to the disadvantage of poor households, were also observed among urban residents (SII: -10.8, 95% CI: -20.10 to -1.50, p < 0.05) as well as those living in the plateau and mountain regions (SII: -13.8, 95% CI: -26.10 to -1.40, p < 0.05). Conclusion: RBP remains a major public health challenge in Cambodia, with substantial educational and context-specific economic inequalities. Addressing these social determinants through equity-oriented, context-sensitive interventions is essential to reduce the burden of RBP and prevent cardiovascular diseases in the Cambodian population.

Diabetes poses a significant public health challenge globally, affecting 529 million people and responsible for 79.2 million disability-adjusted life years in 2021 [1]. The prevalence of diabetes has more than tripled from 151 million in 2000, and is projected to reach 1.31 billion by 2050 [1]. This rise is especially prominent in middle-income countries undergoing […]

Introduction: The ‘Scale-Up diaBetes and hYpertension care’ (SCUBY) project provides evidence on scaling-up integrated care (IC) in Cambodia, Slovenia, and Belgium. This paper examines macro-level barriers and facilitators to scaling up IC in these settings. Methods: We used a multi-case study design, with each country being a case. Document review, focus groups, and stakeholder interviews were conducted. The WHO health system building blocks guided the thematic analysis. We then visualised and examined the interlinkages between barriers in each country. Results: Common challenges to scaling up IC across the three health systems relate to: governance and leadership; health workforce; inadequate health financing system; and fragmented health information systems. In Cambodia, access to non-communicable disease (NCD) services and medicine are important issues. IC scale-up is facilitated by its strong governance and public health service model in Slovenia but health workforce shortages risk progress. In Belgium, the fragmented governance system and predominant fee-for-service provider payment are important barriers. A common response to health workforce and workload challenges was task shifting: to primary care nurses in Belgium, peer supporters in Slovenia, and community health workers in Cambodia. Conclusions: Examining differences and similarities between barriers in each health system stimulated reciprocal learning. Interactions between health system barriers in specific contexts require further attention to move complex health systems forward.

Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia. This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation). ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems. Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.

Introduction: Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. Description: The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. Discussion: his codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across high- and low-income countries. Conclusion: The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes.

To assess the community health workers’ (CHWs) knowledge, attitude, and practices (KAP) in type-2 diabetes (T2D) and hypertension (HTN) management. We thus also sought to assess the potential health system barriers for incorporating CHWs in T2D and HTN management. Mixed-method study comprised (1) a survey among 153 active CHWs to assess their KAP of T2D and HTN, and (2) semi-structured interviews with key informants to understand challenges of the health system and proposed solutions in incorporating CHWs in T2D and HTN management. The majority of CHWs correctly answered general knowledge questions on NCDs, risk factors, and prevention; however, only one-quarter correctly answered questions on smoking, family history, or tobacco use as risk factors. Most respondents appeared to have positive attitudes and have been practicing some activities related to T2D and HTN. Both financial and non-financial resource constraints were cited as challenges of the health system; therefore, re-structuring the role definition of CHWs and task of responsibilities, and assessment the need and workload have been proposed as ways forwards to effectively incorporate CHWs in T2D and HTN care. CHWs in Cambodia have shown their potential in T2D and HTN management; however, a well-designed strategy including technical training, clearly defined roles and responsibilities, and strong supporting structure are important to maximize their potential in the health system.

Introduction: Hypertension (HTN) is a major public health problem and a leading cause of cardiovascular diseases and deaths globally. A continuum of HTN care is necessary for people living with HTN since this chronic disease requires comprehensive life-long healthcare management. Several studies have examined the factors influencing the adherence to HTN care. Socio-demographic and economic characteristics are commonly studied as influencing factors of each step of the cascade of HTN care, yet little is known about the effect of social support on the cascade of HTN care. Therefore, our study aims to assess the role of social support on the cascade of HTN care in Cambodia. Method: We performed a population-based survey (5070 individuals aged over 40 and over) to generate a cascade of care for HTN and assess the levels of social support in Cambodia. The cascade shows the patients’ flow in the health system and where they are lost (dropped) along all steps of the cascade from (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last 12 months, (v) treatment in the last 3 months, (vi) to being under control. Social support was assessed using the 8-item Medical Outcomes Study Social Support Survey. Multivariate logistic regression was used to determine the effect of social support (from a family member) on each step of the cascade. Results: Among people living with HTN, 22.4%, 27.0%, 21.6% and 28.9% reported receiving low, medium, high and very high levels of social support respectively. Higher levels of social support were found in female adults, married adults, adults aged over 60, as well as those living in a household of 4 to 5 members and those receiving some or having completed primary education. Participants who received medium and very high levels of social support had two times the odds of receiving treatment for HTN as participants with low levels of support both in the last 12 months and the last 3 months. While, participants who had high level of social support had five times the odds of receiving treatment for HTN (both in the last 12 and 3 months) as participants with low levels of social support. Conclusion: Social support from a family member is strongly associated with treatment compliance in the HTN cascade of care in Cambodia. Our findings suggest an exploration of using social support as a tool to promote adherence to treatment programs for HTN care. Implication for applicability/transferability Families are a potential source of social support for hypertensive patients to overcome social barriers and execute disease management tasks especially for treatment compliance. Promoting social support through a social intervention could be a viable path to improve care for hypertensive patients since chronic illness care poses challenges for isolated patients, but could be made easier with the assistance from family.

Background: Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia.Methods: Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis.Results: Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making.Conclusion: The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.