Assessing Climate Change Adaptation and Health in Coastal Cambodia: The Human-Environment Interaction

This thesis examines the relationship between humans and their environment in the context of climate change in coastal Cambodia. Specifically, this thesis focuses on household energy consumption behavior, climate change adaptation and subjective human health impacts. A cross-sectional survey of 1823 individuals in four coastal provinces in Cambodia was conducted. A series of quantitative analyses, including complementary log-log regression, ordered logistic regression and logistic regression analysis, were employed to analyze the data. The results showed that both past experience of extreme climatic events and awareness of climate change had a positive relationship with household energy reduction behavior. Females and rural residents were less likely to report reduction in household energy. Perceived self-efficacy, education and duration of residence had positive relationships with both anticipatory and reactive adaptation to climate change although to varying degrees. Perceived socio-ecological impact of climate change and barriers to protect against the impact of climate change had negative associations with self-rated health. Furthermore, older individuals, females and higher income households had negative associations with self-reported health. However, individuals who had attained higher formal education and those who were employed reported better health status. This study makes contributions to theory, methodology and more importantly policy issues around climate change in coastal Cambodia. Using theoretical constructs from the Social Cognitive Theory, the findings show that direct personal agency (first-hand experiences) of climatic hazard events plays a key role in behavior response to climate change through a reduction in household energy consumption. Perceived self-efficacy also plays an important role in both anticipatory and reactive adaptation to climate change. The overall interaction between personal and social-environment in this context influences self-rated health. The utilization of a plurality of statistical techniques in this study contributes to a deeper understanding of the interaction of coastal populations and their environment in Cambodia under a changing climate. Finally, the findings of this study may serve as a potential road map for policy makers on household energy reduction, climate change adaptation and coastal community health in Cambodia

Acceptability of Active Case Finding with a Seed-and-Recruit Model to Improve Tuberculosis Case Detection and Linkage to Treatment in Cambodia: A Qualitative Study

Background With support of the national tuberculosis (TB) program, KHANA (a local non-governmental organization in Cambodia) has implemented an innovative approach using a seed-and-recruit model to actively find TB cases in the community. The model engaged community members including TB survivors as seed and newly diagnosed people with TB as recruiters to recruit presumptive TB cases in their social network in a snowball approach for screening and linkage to treatment. This study aimed to explore the acceptability of the active case finding with the seed-and-recruit model in detecting new TB cases and determine the characteristics of successful seeds. Methods This qualitative study was conducted in four provinces (Banteay Meanchey, Kampong Chhnang, Siem Reap, and Takeo) in Cambodia in 2017. Fifty-six in-depth interviews and ten focus group discussions (with a total of 64 participants) were conducted with selected beneficiaries and key stakeholders at different levels to gain insights into the acceptability, strengths, and challenges in implementing the model and the characteristics of successful seeds. Transcripts were coded and content analyses were performed. Results The seed-and-recruit active case finding model was generally well-received by the study participants. They saw the benefits of engaging TB survivors and utilizing their social network to find new TB cases in the community. The social embeddedness of the model within the local community was one of the major strengths. The success of the model also hinges on the integration with existing health facilities. Having an extensive social network, being motivated, and having good knowledge about TB were important characteristics of successful seeds. Study participants reported challenges in motivating the presumptive TB cases for screening, logistic capacities, and high workload during the implementation. However, there was a general consensus that the model ought to be expanded. Conclusions These findings indicate that the seed-and-recruit model is well-accepted by the beneficiaries and key stakeholders. Further studies are needed to more comprehensively evaluate the impacts and cost-effectiveness of the model for future expansion in Cambodia as well as in other resource-limited settings

Gender-Based Violence in the Asia-Pacific Region during COVID-19: A Hidden Pandemic behind Closed Doors.

Since the early stages of the COVID-19 pandemic, there have been reports of increased violence against women globally. We aimed to explore factors associated with reported increases in gender-based violence (GBV) during the pandemic in the Asia-Pacific region. We conducted 47 semi-structured interviews with experts working in sexual and reproductive health in 12 countries in the region. We analysed data thematically, using the socio-ecological framework of violence. Risks associated with increased GBV included economic strain, alcohol use and school closures, together with reduced access to health and social services. We highlight the need to address heightened risk factors, the importance of proactively identifying instances of GBV and protecting women and girls through establishing open and innovative communication channels, along with addressing underlying issues of gender inequality and social norms. Violence is exacerbated during public health crises, such as the COVID-19 pandemic. Identifying and supporting women at risk, as well as preventing domestic violence during lockdowns and movement restrictions is an emerging challenge. Our findings can help inform the adoption of improved surveillance and research, as well as innovative interventions to prevent violence and detect and protect victims

Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol.

BACKGROUND: Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients' and health facilities' burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model's effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. METHODS: We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD-a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers' work burden, the model's cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. DISCUSSION: This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04766710 . Registered 23 February 2021, Version 1

Sexual and reproductive health services access and provision in Cambodia during the COVID-19 pandemic: a mixed-method study of urban-rural differences.

BACKGROUND: The COVID-19 pandemic pushed governments worldwide to implement unprecedented mitigation measures, including safe-distancing, lockdowns, disruption of non-essential services, border closures and travel restrictions, with both potential to affect rural and urban service-users differently and unintended consequences including reductions in sexual and reproductive health (SRH) services. We aimed to explore rural-urban differences in progress and challenges in SRH services provision in Cambodia, particularly during initial months of the COVID-19 pandemic. METHODS: We used a mixed-methods study design, including a household survey of 423 adolescents and women aged 18-49 and semi-structured interviews with 21 healthcare providers. We analysed survey data using multivariable logistic regression to identify associations between rural-urban setting and contraceptive perceptions or access. We analysed interview data thematically. RESULTS: Rural-urban residence was significantly associated with reported perceptions about and access to contraceptives. Rural participants had higher odds of stating it was possible to change contraceptive methods early in the COVID-19 pandemic, compared with urban participants. Qualitative data showed that although SRH services continued, health-workers faced differential challenges in rural and urban areas, e.g. service-users not attending due to job losses in urban areas and not complying with safe-distancing and mask-wearing requests in rural areas. CONCLUSIONS: COVID-19 and inadequate mitigation responses differentially affected rural and urban SRH service providers and service-users, exacerbating existing socioeconomic stressors while adding new fears of infection, transport constraints, and reduced livelihoods. Added financial support could help mitigate challenges in both rural and urban areas

Developing an infection prevention and control intervention to reduce hospital-acquired infections in Cambodia and Lao People’s Democratic Republic: the HAI-PC study protocol

BackgroundHospital-acquired infections (HAIs) are significant public health issues, especially in low-and middle-income countries (LMICs). Hand hygiene and low-level disinfection of equipment practices among healthcare workers are some of the essential measures to reduce HAIs. Various infection prevention and control (IPC) interventions to reduce HAI incidence have been developed. However, effective interventions have not been well developed in the LMICs context. Therefore, this protocol aims to develop, pilot, and assess the feasibility and acceptability of an IPC intervention in Cambodia and the Lao People’s Democratic Republic.MethodsThis study will consist of four phases guided by the Medical Research Council (MRC) Framework. Three hospitals will be purposely selected – each from the district, provincial, and national levels – in each country. The gap analysis will be conducted in Phase 1 to explore IPC practices among healthcare workers at each hospital through desk reviews, direct observation of hand hygiene and low-level disinfection of equipment practices, in-depth interviews with healthcare workers, and key informant interviews with stakeholders. In Phase 2, an IPC intervention will be developed based on the results of Phase 1 and interventions selected from a systematic literature review of IPC interventions in LMICs. In Phase 3, the developed intervention will be piloted in the hospitals chosen in Phase 1. In Phase 4, the feasibility and acceptability of the developed intervention will be assessed among healthcare workers and representatives at the selected hospitals. National consultative workshops in both countries will be conducted to validate the developed intervention with the national technical working groups.DiscussionThe MRC Framework will be employed to develop and evaluate an intervention to reduce HAIs in two LMICs. This theoretical framework will be used to explore the factors influencing hand hygiene compliance among healthcare workers. The gap analysis results will allow us to develop a comprehensive IPC intervention to reduce HAI incidence in Cambodia and Lao People’s Democratic Republic. Findings from this protocol will feed into promising IPC interventions to reduce HAI incidence in other resource-limited settings.Clinical trial registrationClinicalTrial.Gov, identifier NCT05547373

Monitoring and Evaluation of National Vaccination Implementation: A Scoping Review of How Frameworks and Indicators Are Used in the Public Health Literature.

An effective Monitoring and Evaluation (M&E) framework helps vaccination programme managers determine progress and effectiveness for agreed indicators against clear benchmarks and targets. We aimed to identify the literature on M&E frameworks and indicators used in national vaccination programmes and synthesise approaches and lessons to inform development of future frameworks. We conducted a scoping review using Arksey and O'Malley's six-stage framework to identify and synthesise sources on monitoring or evaluation of national vaccination implementation that described a framework or indicators. The findings were summarised thematically. We included 43 eligible sources of 4291 screened. Most (95%) were in English and discussed high-income (51%) or middle-income (30%) settings, with 13 in Europe (30%), 10 in Asia-Pacific (23%), nine in Africa (21%), and eight in the Americas (19%), respectively, while three crossed regions. Only five (12%) specified the use of an M&E framework. Most (32/43; 74%) explicitly or implicitly included vaccine coverage indicators, followed by 12 including operational (28%), five including clinical (12%), and two including cost indicators (5%). The use of M&E frameworks was seldom explicit or clearly defined in our sources, with indicators rarely fully defined or benchmarked against targets. Sources focused on ways to improve vaccination programmes without explicitly considering ways to improve assessment. Literature on M&E framework and indicator use in national vaccination programmes is limited and focused on routine childhood vaccination. Therefore, documentation of more experiences and lessons is needed to better inform vaccination M&E beyond childhood

Perceived Self-Efficacy and Adaptation to Climate Change in Coastal Cambodia

In response to climate change at different spatial scales, adaptation has become one of the focal points of current research and policy developments. In the context of coastal Cambodia, there is little research on local level adaptation to climate change. Using ordinal logistic and logistic regression analyses, this study examines the relationship between perceived self-efficacy and anticipatory and reactive adaptation to climate change among 1823 households in coastal communities in Cambodia. Findings indicate that individuals who reported higher categories of self-efficacy were more likely to report both anticipatory (OR = 1.74, p < 0.001) and reactive adaptation (OR = 3.61, p < 0.001) measures. Similary, tndividuals who had higher education had higher odds of reporting anticipatory adaptation (OR = 1.71, p < 0.001) and reactive adaptation (OR = 1.63, p < 0.05) when compared with those without formal education. Participants who have been living in their current residence for six years or more were more likely to report anticipatory adaptation (OR = 1.09, p < 0.05) and reactive adapation (OR = 1.22, p < 0.001) compared with those who had lived there for a shorter duration of time. Region of residence was positively associated with both anticipatory and reactive adaptation. In this context, it is important to note that individuals in the most agriculture-dependent and climate sensitive province reported the least anticipatory and reactive adaptation measures. Policy makers should target empowerment of the most vulnerable population to facilitate better adaptation behavior, and mainstreaming of knowledge on climate change adaptation through both formal and informal education at the community level

The unusual suspects? Perception of underlying causes of anthropogenic climate change in coastal communities in Cambodia and Tanzania

Public perception of the underlying causes of anthropogenic climate change is a complex and subjective issue that is critical to effective risk communication. This issue is important to scientists and policymakers because of the role of individual perceptions in influencing their protective behaviour towards risk (e.g., the adoption of climate risk reduction and mitigation strategies). This cross-sectional study elucidated people's perceptions of the underlying causes of human-induced climate change in coastal communities in Cambodia and Tanzania. The multinomial logistic regression model was based on a geographically and demographically stratified national sample of 3,706 individuals conducted between March and September 2013. The distribution of the fundamental causes of anthropogenic climate change in the pooled sample was deforestation (29%), overpopulation – births and immigration (18%), greenhouse gas emissions (12%), illegal resource extraction (14%), and God's will and transgressing cultural norms (26%). Few people in both countries believed that, the usual suspect, greenhouse gas emission was the fundamental cause of anthropogenic climate change. The number of poor rural residents who indicated that deforestation was the major underlying cause of climate change was approximately three times more than members of the same sub-group who noted that greenhouse gas emissions were the underlying cause of climate change. People who had tertiary education were less likely to consider God's will and transgressing cultural norms as the underlying cause of anthropogenic climate change rather than attributing it to greenhouse gas emissions. Therefore, it is imperative to mainstream climate change into educational curricula in both countries

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review

Abstract Background Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years. Methods A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures. Results From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive. Conclusions This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential