Does having a Master of Public Health (MPH) improve physician assistants’ ability to address the social determinants of health in their clinical practice?

Background: There is mounting evidence that clinicians need to address the social determinants of heath (SDOH) in their practice. Physician Assistants (PAs) who complete a joint degree with a Master of Public Health (MPH) may be able to address the SDOH in their practice better than those who do not have the degree. The primary aim of this study was to determine whether or not having a Master in Public Health (MPH) improves PAs’ ability to address the SDOH in their clinical practice. Methods: A cross-sectional study was conducted with 25 practicing PAs who were jointly trained with the MPH degree and 32 practicing PAs who were not jointly trained. An online survey was administered to a gather SDOH knowledge, attitude and behavior data using an adapted 13-item SDOH scale. Results: This study found that jointly trained PA/MPH clinicians reported significantly more perceived knowledge about SDOH (37.6 vs 31.1; P = .028), were more likely to identify SDOHs as important to their patients’ health (38.6 vs 32.9; P = .035), were more likely to intend to address SDOH with their patients’ (29.7 vs 23.5; P = .031) and reported feeling more comfortable talking about SDOH with their patients (3.75 vs 3.2; P = .05) despite no significant differences in reported barriers to addressing SDOH. Conclusion: These findings suggest that joint clinical training with the MPH can positively impact PAs ability to address the SDOH in their clinical work and lays the groundwork for future research

Burnout at the Frontline: The Effect of a Reproductive Health Voucher Program on Health Workers in Uganda

Background: Low job satisfaction among healthcare workers in developing countries can increase risk of burnout and have a negative effect on the quality of services. Novel financing strategies such as voucher programs, which aim to increase the utilization of services by the poor by offering physical vouchers for subsidized care, may unintentionally exacerbate burnout for health care workers by creating higher workloads. Methods: A semi-structured survey that included both closed and open-ended questions as well as a locally-adapted job satisfaction scale was used to collect information on provider perceptions of changes in job satisfaction, workload, staffing and salaries since the start of a health voucher program at facilities in fifteen districts in western Uganda. Results: Voucher providers reported feeling more rewarded and more motivated than comparison providers. While frontline workers at both sites were less satisfied than their managers overall (p Conclusions: Providers at voucher facilities may experience a more enabling work environment but job satisfaction differences between manager and frontline workers may intensify when staffing, workload and incentives are not addressed. Strategies to support staff when implementing new demand creation programs should be prioritized. Incentive strategies for staff and management guidance for facilities managers will be important components of successful voucher programs

HIV Risk and Psychological Distress among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Background: In Cambodia, there has been an increase in entertainment work as a result of the breakdown of the traditional brothel-based sex industry, presenting new challenges to addressing the health issues and needs of people working in the entertainment industry. This study aims to identify factors associated with psychological distress among female entertainment workers (FEWs) in Cambodia. Methods: A two-stage cluster sampling method was used to randomly select 657 FEWs from entertainment establishments in Phnom Penh and Siem Reap in April and May 2014 for interviews using a structured questionnaire. Psychological distress was measured using the General Health Questionnaire (GHQ-12), and multivariate logistic regression analysis was conducted. Results: Almost half of FEWs (43.2 %) had a higher level of psychological distress (GHQ-12 \u3e 3), while 19.5 % reported having suicidal thoughts, and 7.3 % reported having attempted to commit suicide in the past 3 months. Controlling for confounding factors, women with a higher level of psychological distress were significantly more likely to rate their overall health (AOR = 1.88, 95 % CI 1.20 to 2.94) and quality of life (AOR = 2.39, 95 % CI 1.47 to 3.87) as poor. They were also significantly more likely to have suicidal ideation (AOR = 2.41, 95 % CI 1.45 to 3.76), rate their HIV risk as higher than the general population (AOR = 0.48, 95 % CI 0.31 to 0.74), have been forced to drink at work (AOR = 1.77, 95 % CI 1.19 to 2.62), have had clients requesting not to use a condom (AOR = 3.48, 95 % CI 1.14 to 10.62), be not able to find condoms when they needed it (AOR = 0.64, 95 % CI 0.45 to 0.93), have had a family member who said hurtful things to them during childhood (AOR = 1.84, 95 % CI 1.24 to 2.75), and have had a parent or guardian who had been physically abused (AOR = 1.93, 95 % CI 1.34 to 2.82). Conclusions: FEWs in Cambodia experience high levels of psychological distress, which likely stems from both past negative experiences and current working conditions. For women that are experiencing psychological distress, intervention programs aimed at improving mental health should specifically address substance use, condom availability and negotiation skills, and suicide risk

AIDS-Related Stigma and Mental Disorders among People Living with HIV: A Cross-Sectional Study in Cambodia

Background: AIDS-related stigma and mental disorders are the most common conditions in people living with HIV (PLHIV). We therefore conducted this study to examine the association of AIDS-related stigma and discrimination with mental disorders among PLHIV in Cambodia. Methods: A two-stage cluster sampling method was used to select 1,003 adult PLHIV from six provinces. The People Living with HIV Stigma Index was used to measure stigma and discrimination, and a short version of general health questionnaire (GHQ-12) was used to measure mental disorders. Multivariate logistic regression analysis was conducted. Results: The reported experiences of discrimination in communities in the past 12 months ranged from 0.8% for reports of being denied health services to 42.3% for being aware of being gossiped about. Internal stigma was also common ranging from 2.8% for avoiding going to a local clinic and/or hospital to 59.6% for deciding not to have (more) children. The proportions of PLHIV who reported fear of stigma and discrimination ranged from 13.9% for fear of being physically assaulted to 34.5% for fear of being gossiped about. The mean score of GHQ-12 was 3.2 (SD = 2.4). After controlling for several potential confounders, higher levels of mental disorders (GHQ-12\u3e4) remained significantly associated with higher levels of experiences of stigma and discrimination in family and communities (AOR = 1.9, 95% CI = 1.4–2.6), higher levels of internal stigma (AOR = 1.7, 95% CI = 1.2–2.3), and higher levels of fear of stigma and discrimination in family and communities (AOR = 1.5, 95% CI = 1.1– 2.2). Conclusions: AIDS-related stigma and discrimination among PLHIV in Cambodia are common and may have potential impacts on their mental health conditions. These findings indicate a need for community-based interventions to reduce stigma and discrimination in the general public and to help PLHIV to cope with this situation

Are Text Messages a Feasible and Acceptable Way to Reach Female Entertainment Workers in Cambodia with Health Messages? A Cross-Sectional Phone Survey

Background: Despite great achievements in reducing the prevalence of HIV, eliminating new HIV infections remains a challenge in Cambodia. Entertainment venues such as restaurants, karaoke bars, beer gardens, cafes, pubs, and massage parlors are now considered important venues for HIV prevention efforts and other health outreach interventions. Objective: The purpose of this study was to explore phone use and texting practices of female entertainment workers (FEWs) in order to determine if text messaging is a feasible and acceptable way to link FEWs to health services. Methods: This cross-sectional phone survey was conducted in May 2015 with 97 FEWs aged 18–35 years and currently working at an entertainment venue in Phnom Penh. Results: Of the 96 respondents, 51% reported sending text messages daily; of them, 47% used Khmer script and 45% used Romanized Khmer. Younger FEWs were more likely to report daily texting (P Conclusions: The findings from this study support the development of mHealth interventions targeting high-risk groups in urban areas of Cambodia. Our data suggest that mHealth interventions using texting may be a feasible way of reaching FEWs in Phnom Penh

Prevalence of and Factors Associated with Utilization of Herbal Medicines Among Outpatients in Primary Health Centers in Cambodia

BACKGROUND: Traditional, complementary and alternative medicine (TCAM) is seen as a way to provide healthcare in both developed and developing countries across the world. In Cambodia, there is a long tradition of using TCAM. However, scant studies have been conducted on the extent of Cambodian TCAM use and how it interacts with allopathic health care to date. In this study, we examined the prevalence of and factors associated with utilization of herbal medicines among patients with chronic diseases in primary health care settings in Cambodia. METHODS: A cross-sectional survey was conducted in 2015 with outpatients receiving treatment and care for chronic diseases in two urban and two rural primary health centers purposively selected from Phnom Penh, Kampong Cham and Siem Reap. Every eligible patient was randomly selected at the health centers using a systematic sampling procedure. I-CAM-Q was used to measure TCAM use. A multivariate logistic regression model was constructed to identify factors associated with herbal medicine use. RESULTS: In total, 1602 patients were included in this study, of whom 77.7% were female, and 51.2% were recruited from urban primary health centers with a mean age of 46.5 years (SD = 15.2). Of total, 27.0% reported at least one consultation with a TCAM provider in the past 12 months. The most common modality of TCAM used was herbal medicine (89%). Herbs were obtained at drug or folk stores (36.9%), from herbalists directly (28.5%) or from their own gardens (18.6%). Of herb users, 55.2% reported that herbs were somewhat helpful. After adjustment, herb users were significantly more likely to be female (AOR = 1.42, 95% CI = 1.12-2.67), have completed less schooling (AOR = 0.66, 95% CI = 0.45-0.96), were unemployed or homemakers (AOR = 0.23, 95% CI = 0.13-0.52) and have a gastrointestinal illness (AOR = 0.49, 95% CI = 0.39-0.62). CONCLUSIONS: Herbal medicines are broadly used among chronic disease patients in Cambodia. Understanding TCAM use in the general population will support health care practitioners and policy makers to make informed decisions about the use of TCAM. Integration of TCAM into the primary health system should be further explored

The Impact of a Community-Based HIV and Sexual Reproductive Health Program on Sexual and Healthcare-Seeking Behaviors of Female Entertainment Workers in Cambodia

Background: In Cambodia, despite great successes in the fight against HIV, challenges remain to eliminating new HIV infections and addressing sexual reproductive health (SRH) issues in key populations including female entertainment workers (FEWs). To address these issues, the Sustainable Action against HIV and AIDS in Communities (SAHACOM) project has been implemented since late 2009 using a community-based approach to integrate HIV and SRH services. This study evaluates the impact of the SAHACOM on sexual and healthcare-seeking behaviors among FEWs in Cambodia. Methods: A midterm and endpoint comparison design was utilized. Midterm data were collected in early 2012, and endpoint data were collected in early 2014. A two-stage cluster sampling method was used to randomly select 450 women at midterm and 556 women at endpoint for face-to-face interviews. Results: Compared to women at midterm, women at endpoint were significantly less likely to report having sexual intercourse in exchange for money or gifts in the past three months (OR = 2.1, 95 % CI = 1.6-2.7). The average number of commercial sexual partners in the past three months also decreased significantly from 5.5 (SD = 13.3) at midterm to 3.6 (SD = 13.9) at endpoint (p = 0.03). However, women at endpoint were significantly less likely to report always using condom when having sexual intercourse with clients in exchange for money or gifts (OR = 2.6, 95 % CI = 1.5-4.5). Regarding sexually transmitted infections (STIs), women at endpoint were significantly less likely to report having an STI symptom in the past three months (OR = 1.8, 95 % CI = 1.4-2.3) and more likely to seek treatment for the most recent STI symptom (OR = 1.6, 95 % CI = 1.1-1.9). Furthermore, women at endpoint were significantly more likely to be currently using a contraceptive method (OR = 1.4, 95 % CI = 1.1-1.8) and less likely to report having an induced abortion (OR = 1.4, 95 % CI = 1.1-1.7) during the time working as a FEW. Conclusions: The overall findings of the study indicate that the SAHACOM is effective in reducing sexual risk behaviors and improving the access to SRH care services among FEWs in Cambodia. However, several unfavorable findings merit attention

Factors Associated with Induced Abortion among Female Entertainment Workers: A Cross-Sectional Study in Cambodia

Objective: To explore risk factors associated with induced abortion among sexually active female entertainment workers (FEWs) in Cambodia. Design: Cross-sectional study. Setting: Phnom Penh and Siem Reap, Cambodia. Participants: This study included 556 FEWs aged 18–47 years randomly selected from entertainment establishments in the two cities in 2014 using a two-stage cluster sampling method. Data were collected through face-to-face interviews using a structured questionnaire. Primary outcome measure: History of induced abortion during the time working as a FEW. Results: Of the total sample, 45.6% reported currently using a contraceptive method with condom (42.4%) being the most common method, followed by pills (25.6%). One-fourth (25%) of the respondents reported having been pregnant at least once, and 21.4% reported having at least one induced abortion during the time working as a FEW. After controlling for other covariates in a multivariate logistic regression model, FEWs with a history of induced abortion remained significantly more likely to be currently working in a karaoke bar (AOR=1.75, 95% CI 1.10 to 2.78), to have worked longer as a FEW (AOR=1.42, 95% CI 1.06 to 1.43), to have had a greater number of sexual partners in the past 12 months (AOR=1.86, 95% CI 1.02 to 1.54), to be currently using a contraceptive method (AOR=1.52, 95% CI 1.01 to 2.29), to be able to find condoms when they needed them (AOR=2.03, 95% CI 1.09 to 3.82), and to report inconsistent condom use with non-commercial partners in the past 3 months (AOR=1.62, 95% CI 1.06 to 3.44). Conclusions: This study highlights the high rates of unwanted pregnancies that ended in induced abortions among FEWs in Cambodia. Access of FEWs to quality sexual and reproductive healthcare services is deemed a high priority. Integrated interventions to improve sexual and reproductive health among these vulnerable women should be tailored to reach the most-at-risk groups

Factors Associated with Inconsistent Condom Use among Men Who Have Sex with Men in Cambodia

Background: Compared to the general population, men who have sex with men (MSM) are at greater risk for HIV and less understood due to their more hidden and stigmatized nature. Moreover, the discrepancy in findings in the literature merits further investigations in MSM populations from different cultures and settings. We therefore conducted this study to explore factors associated with inconsistent condom use among high-risk MSM in Cambodia. Methods: This cross-sectional study was conducted in 2014 among 367 MSM randomly selected from Battembang and Siem Reap using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect information on characteristics of respondents, HIV testing history, self-perception of HIV risk, substance use, sexual behaviors, mental disorders, and HIV knowledge. Multivariable logistic regression analysis was performed to identify factors independently associated with inconsistent condom use. Results: On average, 62.3% of respondents reported that they always used condoms over the past three months. The rates varied with types of sexual partners; the proportion of respondents who reported always using condoms was 55.1%, 64.2%, 75.9%, 73.0%, 78.1%, and 70.3%, for sexual partners who were girlfriends, boyfriends, female sex workers, male sex workers, female clients, or male clients, respectively. After adjustment, inconsistent condom use was significantly associated with age of 25 (AOR = 1.77, 95% CI = 1.09-2.86), self-rated quality of life as good or very good (AOR = 4.37, 95% CI = 1.79-5.67), self-perception of higher HIV risk compared to the general population (AOR = 2.37, 95% CI = 1.35-4.17), illicit drug use in the past three months (AOR = 5.76, 95% CI = 1.65-10.09), and reported consistent lubricant use when selling anal sex to men in the past three months (AOR = 2.85, 95% CI = 1.07-8.12) Conclusions: We found risky sexual behaviors to be considerably high among MSM in this study, especially among those who used illicit drugs or were older than 25. HIV education and social marketing should be expanded and specifically designed for MSM to better educate on the increased risk of HIV with unprotected anal sex and illicit drug use as risk factors, and the importance of the use of both condoms and lubricant during anal intercourse

Factors Associated with Recent HIV Testing among High-Risk Men Who Have Sex with Men: A Cross-Sectional Study in Cambodia

Background: Despite remarkable success in the fight against HIV, HIV prevalence in many countries remains high among key populations including men who have sex with men (MSM), and HIV testing rates is relatively low among this hard-to-reach population. This cross-sectional study explores factors associated with recent HIV testing among MSM in Cambodia. Methods: This study was conducted in 2014 and included 384 MSM randomly selected from two provinces of Battembang and Siem Reap, using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect data on socio-demographic characteristics, HIV testing history, sexual behaviors, HIV testing attitudes, and HIV knowledge. Multivariate logistic regression analysis was performed to identify factors independently associated with recent HIV testing. Results: Mean age of the participants was 23.4 (SD = 5.2). Of total, 83.6 % had been tested for HIV at least once in their lifetime, and 65.1 % had been tested for HIV in the past six months. After controlling for other covariates, MSM who had been tested for HIV in the past six months were significantly more likely to regard themselves as female (AOR = 2.29, 95 % CI = 1.06-5.37), have received some form of HIV education in the past six months (AOR = 3.97, 95 % CI = 1.91-8.26), perceive that they were at higher HIV risk compared to the general population (AOR = 2.48, 95 % CI = 1.14-4.86), have been diagnosed with an STI in the past six months (AOR = 3.19, 95 % CI = 1.02-9.24), report using a condom at last sexual intercourse with a man or woman (AOR = 2.24, 95 % CI = 1.06-3.13), and report using a condom at last sexual intercourse with a boyfriend (AOR = 2.17, 95 % CI = 1.04-5.31). Conclusions: This study highlights the common practices of risky sexual behaviors and relatively low rate of recent HIV testing among MSM in Cambodia. HIV education and social marketing should be expanded and tailored for MSM, specifically addressing the risk of unprotected anal intercourse and the importance of regular HIV testing for early enrolment in the care and treatment cascade