Diabetes Prevention through Village Health Support Guides in
Cambodia: AQualitative Investigation of Opportunities and
ChallengesJulie Wagner1*, Lim Keuky2, Lorraine Fraser-King3,
Theanvy Kuoch4 and Mary Scully41University of Connecticut Health
Centre, Farmington, CT-06030, USA2Doctorate of Pharmacology, D.E.A.
Endocrinology, Cambodian Diabetes Association, Siem Reap,
Cambodia3Cambodian Diabetes Association, Siem Reap, Cambodia4Khmer
Health Advocates, 1125 New Britain Ave Ste 202, West Hartford,
CT-06110, USA*Corresponding author: Julie Wagner, Associate
Professor, University of Connecticut Health Centre, MC3910 263
Farmington Ave, Farmington, CT-06030, USA, Tel:+860-679-4508;
E-mail: [email protected] date: Mar 18, 2015; Acc date: Mar 30,
2015; Pub date: Apr 3, 2015Copyright: 2015 Wagner J, et al. This is
an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricteduse,
distribution and reproduction in any medium, provided the original
author and source are
credited.AbstractObjectives:LifestylemodificationcanpreventtypeIIdiabetes.RatesofdiabetesarehighinCambodia.TheCambodian
genocide and its aftermath resulted in destruction of the
healthcare system and a critical shortage in theCambodian
healthcare workforce. Cambodia has a well-established system of
community health workers, or
villagehealthsupportguides(Guides).ThisstudyexploredopportunitiesforandchallengestotrainingGuidestodeliverdiabetes
prevention interventions.Design: In depth interviews were conducted
with 12 Guides in Khmer. Guides also completed a 22-item
validatedKhmer language quiz regarding their knowledge of
diabetes.Results: Participants were 75% female, on average 52 years
old, with 8 years of education and 9 years
Guidesexperience.Guideswereawarethatdiabetesisaproblemfortheircommunitiesandwereeagertoaddressit.However,theyhadverylowdiabetesknowledge(quizmean=57%correct).Threethemesemerged:dedicationtobeing
a Guide, current responsibilities and need for additional and high
quality training, and striving to do a good
jobinthefaceofbarriersandinsufficientresources.Participantseasilyidentifiedfactorsthatwouldsupporttheirowntraining
in diabetes, and factors that would promote their teaching diabetes
prevention in their
villages.Conclusions:DiabetespreventionisoverdueinCambodia.Guidesarepoisedtobetrainedtodelivertheseprograms.Suchtrainingshouldberesponsivetotheirperceivedneeds.Politicalwillmustbecultivatedtosupportappropriate
resources.Keywords:Diabetes;Prevention;Communityhealthworkers;Cambodia;
QualitativeIntroductionArecentreportfoundthatSoutheastAsiawashometomorethan72millionadultswithdiabetesin2013,anumberthatisexpectedtoexceed123millionin2035[1].Over90%ofthemhavetypeIIdiabetes.Cambodiaisacaseinpoint.Kingetal.[2]studied2246randomlyselectedadultsaged25yearsandolderintwoCambodiancommunities.Prevalenceofdiabeteswas5%intheruralcommunityand
11% in the semi-urban community. Fully one quarter of all adultsin
the semi-urban community had some degree of glucose
intolerance.Type II diabetes is multifactorially determined, and in
Cambodia
maybelinkedtolifestylechangesassociatedwithurbanizationandindustrialization,highratesofmentalillness,historicalexposuretostarvation
and current
malnutrition.ThereisanurgentneedfordiabetespreventionprogramsinCambodia.TrialshaveshownthattypeIIdiabetescanbedelayedorpreventedwithstructuredlifestylemodification.DietandexerciseinterventionshavebeenshowntobeeffectiveinChina[3]andIndia[4].ThesefindingsillustratethebenefitsoflifestyleondiabetesriskamongyoungerindividualswithlowerbodymassindexthanCaucasian
populations typically studied in the US [5] and Europe
(e.g.,[6]).Unfortunately,barrierstoimplementingdiabetespreventionprograms
in Cambodia are formidable. In addition to lack of
financialresourcesandcompetingpublichealthpriorities,thereisacriticalshortageofhealthcareworkers.TheMillenniumDevelopmentGoalsrecommendsathresholdof2.3healthworkersper1,000people.ThedensityofglobalhealthworkersinCambodiaislessthanhalfthat,withanationalaverageofonlyonehealthworker(doctor,nurseormidwife)per1,000people[7].Asinmanyothercountries,thereisaparticularly
acute shortage of health workers in rural and remote areasof
Cambodia.Theshortageofhealthcareworkersisdirectlytiedtothecountrystragicpoliticalhistory.Afternearly100yearsofcolonialrule,therewasaperiodofpoliticalinstabilityandwesterninterferenceinthe1970s,duringwhichagenocideoccurredthatkilledapproximately1/3ofthecountryspopulation.Theaimofthegenocidewastodeconstruct
Cambodia back to an agrarian and primitive Year
Zero,whereinanyWestern,modern,ornon-Khmerinnovationswouldbeeliminated.
During the time of great destruction as the CambodiansJournal of
Community Medicine& Health EducationWagner, et al., J Community
Med Health Educ2015,
5:2http://dx.doi.org/10.4172/2161-0711.1000347Research Article Open
AccessJ Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2 1000347call it, individuals who had, or were
believed to have had,
educationalattainmentwereespeciallytargetedandCambodianslostapproximately90%mostoftheireducatedclassduringthisgenocideanditsaftermath[8].Consequently,thehealthcareworkforcewasvirtuallyeliminated.Cambodianhospitals,whichwereprovidingmedical
care at least as good as in other parts of Southeast Asia at
thetime,weredestroyed.Aftertheconflictended,civilunrestcontinuedintothe1980sandanembargoonnormalaiduntil1993posedadditionalchallengestothere-establishmentofnormalhealthcareinCambodia[9].AlthoughthesituationinCambodiaisnowrelativelystable,
the legacy of a decade of conflict is still evident in the
healthcaresystem.Thenumberandqualityofmedicalfacilitiesiscriticallylow.Thenumberofphysicians,nurses,andalliedhealthprofessionalsistotally
inadequate to address current population needs. Thus,
diabetesprevention,ifitisgoingtohappeninCambodia,willneedtobedelivered
by persons other than health professionals.Village health support
guidesCommunityhealthworkersaremembersofacommunitywhoarechosenbycommunitymembersororganizationstoprovidebasichealthandmedicalcaretotheircommunity.TheWorldHealthOrganization(WHO)statesthatthetitlecommunityhealthworkerembracesavarietyofcommunityhealthaideswhoareselected,trainedandworkinginthecommunitiesfromwhichtheycome[10].Whereasrolesandactivitiesofcommunityhealthworkersareenormouslydiversethroughouttheirhistory,withinandacrosscountriesandprograms,theWHOidentifiestheirkeyfeatureasresponding
to local societal and cultural norms and customs to
ensurecommunityacceptanceandownership.Othernamesforthistypeofhealthcareproviderincludevillagehealthworker,communityhealthaide,communityhealthpromoter,andlayhealthadvisor[11].InCambodia,theyarereferredtoasVillageHealthSupportGuides,orGuides.ThesystemofGuideswasdevelopedinCambodiatoaddressthe
critical shortage of professional healthcare workers in
Cambodia.GuidesarethegrassrootsfoundationofthehierarchicalhealthcaresysteminCambodia.Guidesservethevillage(orinmoreurban
areas, the commune) in which they live. Each Guide is based
attheirlocalHealthCentre,whichservesnumerousvillagesandisrunbyaChief,i.e.,anurseormidwife,oroccasionallyaphysician.EachHealth
Centre Chief reports to the Operational District Director,
whoreportstotheProvincialHealthDirector,whointurnreportstotheMinistry
of Health at the top of the pyramid. Thus, Guides occupy
thebottomofthispyramidandprovidethemostdirectandimmediatelinktothepopulationofanymemberofthehealthcaresystem.RolesandresponsibilitiesofGuidesinCambodiaweredefinedbytheMinistryofHealthintheCommunityParticipationforHealthPolicy[12]andare:providingfeedbackfromthecommunitytotheHealthCentre,andkeepingtheGuideandthecommunityinformedaboutHealthCentreactivities;coordinatingtrainingactivitiesfortheGuidetosupportHealthCentreactivitiesinthecommunity;providinginformationaboutHealthCentreservicesandfeestothecommunity;reportingconsumersatisfactionanddissatisfactiontotheHealthCentreChief;facilitatingoutreachactivities;and,promotingclientrights
and good
governance.Guidesreceivenosalary.However,theirOperationalDistrictDirectorhasthediscretiontodirectfundstooffertheirGuidesincentivesincludingfreeordiscountedmedicationfortheGuideand/ortheGuidesfamily,freeordiscountedmedicalcareatreferralhospitalswhenneeded,and/orasmallperdiemforattendingthemonthlymeetings.Althoughtheirlevelofeducationisthoughttobegenerally
quite low, they are usually among the higher educated
peopleintheirvillageandeachGuidemusthavesomebasiclevelofliteracyandnumeracybecausetheyarerequiredtocompletemonthlyreporting
forms.OfthevariousmembersofthehealthcaresysteminCambodia,GuidesmaybebestpositionedtoreachruralCambodianstodeliverdiabetesprevention.Globally,communityhealthworkersareakeysourceofbasichealthcaretohundredsofmillionsofpeople[13-16]and
in some settings may be the only source of health care [17,18].
Theabilityofcommunityhealthworkerstoengagecitizensinhealthprogramsisthoughttobedue,inpart,totheirunusuallycloseunderstandingofthecommunitytheyserveandbecausetheyaretrustedandrespectedmembersoftheircommunity.However,theirreadinessandwillingnesstoengageinchronicdiseaseprogramsgenerally,anddiabetespreventionspecifically,isnotknown.Indeed,recentstudiesofcommunityhealthworkersacrosstheglobehaverevealedsignificantdeficienciesintheirclinicalcompetency[19,20].Thisstudywasaqualitativeinvestigationtobetterunderstandtheopportunitiesandchallengesforimplementingdiabetespreventionprograms
through Guides in
Cambodia.MethodsSubjectsStudyareaandparticipants:ThisprojectwasconductedinSiemReap
province. According to the most recent census [21], with
896,309residents,itranksas6thoutof24provincesinpopulationsize.Theprovinceissubdividedinto12districts,100communesand907villages.InmoderntimestheprovinceofSiemReapisbestknownasthe
site of the Angkor Wat temple
ruins.ThisstudyemployedasampleofconvenienceofGuideswholivedinSiemReapprovinceandwhowereavailableandwillingtoparticipate
during the timeframe of the data collection (spring 2014).Materials
and MethodsData
collectionAlloftheinterviewswereconductedbyabilingual,nativeKhmer-speakingresearchassistantwhowastrainedbythefirstauthor(JW).Interviews
were conducted in Khmer and were translated into Englishby the same
research assistant who was sensitive to the cultural
contextofparticipantsandtheresearchgoalsofeachinterviewquestion.Handwrittennotesweretakenregardingverbalandnonverbalcommunication.
Whenever possible, interviews were conducted in
thefield;whennoise,distance,orspaceavailabilitymadethisimpossiblethentheinterviewswereconductedinaprivatemeetingroomattheCambodian
Diabetes
Association.MeasuresIn-depth,semi-structuredinterviewswereconductedusingawritten
question guide with follow up probes. Questions addressed
theparticipants demographics; history as a Guide; motivation for
being aGuide; selection and training; current activities;
perceptions
regardingchallengestosuccessfulGuidework;and,levelofinterestinaddressing
diabetes in their villages.Citation:
JulieWagnerJ,KeukyL,Fraser-KingL,KuochT,ScullyM(2015)DiabetesPreventionthroughVillageHealthSupportGuidesinCambodia:AQualitativeInvestigationofOpportunitiesandChallenges.JCommunityMedHealthEduc5:347.doi:10.4172/2161-0711.1000347Page
2 of 7J Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2
1000347Apreviouslyvalidated[22]testofbasicdiabetesknowledgewasadministeredtoeachparticipant.ThetestwaswritteninKhmerforlowliteracyrespondentsusingatrue/false/Idontknowresponseoption.
Nine items tap into knowledge regarding diabetes risk
factors,7regardingdiabetespreventionstrategies,and6regardingdiabetesmanagement.Thetestwasreadaloudtoeachparticipantinordertoaccount
for varying literacy
levels.ProceduresEthicalapprovalwasobtainedfromthereviewcommitteeattheCambodian
Diabetes Association. Staff from the Cambodian
DiabetesAssociationworkedwithHealthCentreChiefsintheprovincetoidentifypotentialparticipantsandinvitedthemtoparticipatebyphone.
Participants were socialized to the study, and written
informedconsentwasobtainedfromallparticipants.Eachinterviewlastedapproximately75minutes.Participantswereprovidedwithlightrefreshmentsandwerecompensated$10fortheirtimeandanytransportation
costs.Data analysisQuantitative descriptive data analysis was
conducted for the
quizdatausingSPSSv21(Chicago,IL),andqualitativedataanalysiswasconductedfortheinterviewdata[23].Qualitativedatawereanalyzedthroughathematicanalysisapproach[24].Translatedtranscriptionsof
interview excerpts and field notes were reviewed. As a first step
thepartsofthetextthatrelatedtoeachquestionwereidentifiedandmarkeddistinctly.Asasecondstep,codesweredevelopedandcategorizedintoafewernumberofthemes.Third,severalcodeswerefurtherrefinedwiththeaimofmakingthemclosertowhattheparticipantsactuallysaid.Finally,quoteswereidentifiedthatwererepresentativeofmajorthemes.Duringthewholeprocessofdatacollectionandanalysis,memoswererecordedtocaptureideasandreflections.ResultsFourteenGuideswereinvitedtoparticipate;12agreedandprovidedinformedconsent.Theonlyreasonprovidedbyrecruitsfordeclining
to participate was scheduling conflicts. Participants were
onaveragemean=51.6(SD=9.6,range38-66)yearsoldand75%(n=9)female.Meanyearsofeducationwas7.9(SD=1.7,range6-12).Nonehadreceivedadiagnosisofdiabetes.Participantsscoredameanof57%
(SD=10%) total correct on the diabetes quiz. Subscale scores
were56%(SD=11%)correctondiabetesriskfactors,76%(SD=13%)ondiabetesprevention,and40%(SD=15%)correctondiabetesmanagement.Threethemesemergedfromtheanalysis:dedicationtobeingaGuide,currentresponsibilitiesandneedforadditionalandhighqualitytraining,andstrivingtodoagoodjobinthefaceofbarriersand
insufficient resources.Theme #1: Dedication to being a
guideHistoryofguidework:ParticipantsreportedthattheyhadbeenworkingasaGuideformean=8.5(SD=6.0,range2-20)years.Participants
described a variety of ways that they had become
Guides.Mosthadbeenaskeddirectlybyvillagechiefsorpolicechiefs.Somewerenominatedbychiefsalongwithothersandthenthevillagecommitteevotedonthenominees.Afewwereappointeddirectlybyvillagecommitteesand2wereelectedbycommonvoteofvillagers.Twostatedthattherewasnoselectionprocessperse,i.e.,thattheyweretheonlypeopleintheirrespectivevillageswhowerewillingtoserve
as
Guides.Mostparticipantsdescribedthattheworkwasnotimmediatelyrewarding,andthatwithinthefirstfewmonthstheyhadconsideredquitting.Nopay,requiredattendanceatnumerousmeetings,paperwork,andlackofinitialinfluenceovervillagerhealthbehaviorswereallinitiallydiscouraging.Yet,alltheparticipantshadperseveredandforavarietyofreasons,mainlygainingaccesstofreeordiscountedmedicalservicesandmedicationsfortheirfamilies.Withoutexception,eachdescribedthatovertimetheworkbecameintrinsicallyrewardingandthatnowtheycouldnotbediscouragedfrom
continuing. However, participants acknowledged that many
newGuidesdoinfactquitwithinthefirstfewmonthsandthatthereishigh
turnover in the
position.Motivationtobeaguide:Participantswereasked,giventhedrawbacks,whattheirmotivationwasforbeingaGuide.Allreportedanaltruisticdesiretohelptheirvillagesimprovetheirhealth.Severalimpliedthattheyfeltsomeobligationtodoso.Theyacknowledgedthat
they had easier lives than others in their village, by virtue of
highereducation and not being a farmer. Some stated that other
people in thevillage simply did not have the education or time to
be a Guide.
Manyalsoreportedself-improvementasabenefit,i.e.,learningnewinformationandnewskills.Afewmentionedthattheyortheirfamiliesreceivedfreeordiscountedmedicationand/ormedicalcarefor
their
work.Whenquerieddirectly,severalparticipantsconfirmedthatabeliefin
kamma influenced their decision to start or continue their work as
aGuide.KammaisaPaliwordthatmeansaction.ItreferstotheBuddhistnaturallawofcauseandeffectwherebywholesomeintentions(motivations,thoughts,orvolitions)producewholesomeeffectsfortheactorandunwholesomeintentionsproduceunwholesomeeffectsfortheactor.InpopularBuddhismasitispracticedinCambodia,thereisabeliefinasimplesystemofrewardsforgoodactionsandpunishmentsforbadactionsthatmaycometofruitioninthisorfuturelives.Oneparticipantsaid,Ihavemyowngood
health because I help
others.Whenquerieddirectly,severalparticipantsalsoconfirmedthathavinglivedthroughthegenocideprovidesmotivationforGuidework.TherewassentimentthatCambodianshadsufferedsomuch,andsomanysocialinstitutionshadbeendestroyed,thathelpingvillagers
improve their health had healing qualities and provided
hopeforthefuture.Oneparticipantwhohadbeen30yearsoldduringthewarstated,WehadnohealthCentre,nopagoda,alltheknowledgeablepeopledied.WemustrecoverfromPolPot.Anotherdescribedhowtherewerenodoctorsormedicineduringtheconflict.Oneparticipantbecamedistressedandcriedinresponsetothissegment
of the interview, explaining that both her parents and
severalsiblingshadbeenkilled.SheexpressedthatGuideworkhelpsmakeright
what was wrong during the time of genocide.Theme #2:
Responsibilities and need for additional highquality
trainingGuideresponsibilities:Participantslistedon-goingactivitiesincludingattendingmonthlyHealthCentremeetings,attendingtrainingsprovidedbynon-governmentalorganizations(NGOs),deliveringhealtheducationatmonthlyvillagecommitteemeetings,Citation:
JulieWagnerJ,KeukyL,Fraser-KingL,KuochT,ScullyM(2015)DiabetesPreventionthroughVillageHealthSupportGuidesinCambodia:AQualitativeInvestigationofOpportunitiesandChallenges.JCommunityMedHealthEduc5:347.doi:10.4172/2161-0711.1000347Page
3 of 7J Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2
1000347deliveringhealtheducationtosmallgroupsofvillagers,andvisitingfamilies
with known health problems. Participants reported that,
oncetheyweretrainedinaparticulartopic,theywouldinvitegroupsofapproximately50villagerstoattendaneducationalsessionandapproximately
20 would attend. It is during these small group teachingsessions
that the bulk of health information is conveyed to the
generalpublic.Participants were also asked how many hours per month
they
spendonGuideteachingactivitiesintheirvillage.Everyparticipanthaddifficultyquantifyingtheiractivitiesstatingthattheyvarybymonthandbyseasonaccordingtotheagriculturalcalendar.SeveralGuideswere
individuals who were salaried employees of the village
committee(the local governing body). Because of their position in
the
committee,andtheirassociatedintimateknowledgeofvillageaffairs,theywereaskedtoserveasGuides.TheseindividualsfounditverydifficulttoteaseaparttheirpaidcommitteeworkfromtheirvoluntaryGuidework,
claiming that there was a high degree of overlap. When pushedto
provide a number, responses ranged from 4 to 12 days per
month.Participantswereaskedhowconfidenttheywereinmodifyingvillagershealthbehaviors.HalfoftheparticipantsexpressedthesentimentthateverythingisbetternowthanwhentheyhadstartedasGuides.Therewascommonsentimentthatdoingsotookalongtime,butwaseventuallysuccessful.Referringtoahand-washingpromotion,oneparticipantsaid,Everythingisbetternow.Manypeoplewouldliketofollowme,buttheyareforgetful.So,Itellthemagainandagain.Irepeat,remind.Tworeportedthatinformationprovided
in schools and on television was more compelling to
villagersthaninformationfromGuides,andsuggestedthathealthmessagesfromvarioussourcesshouldbecoordinated.Oneexpressedlackofconfidence
and said, Sometimes they know more than
me.Participantswereaskedifandhowtheirworkwasevaluated.Allstatedthattheirpaperworkwasspot-checked.OnestatedthattheHealthCentreChiefinquiredwithvillagers.Whenasked,nonereported
that they received substantive feedback about their work.
Onestatedthathisevaluationsfocusedonlyonthenegativeandwerediscouraging.AnotherrecommendedthattheNGOtrainerscouldattendthesessionswhenGuidestrainedvillagers,inordertoprovidemeaningful
feedback about their teaching skills and style.Need for additional
high quality
trainingParticipantsuniformlyreportedreceivinginitialhalf-dayor1-daytrainingregardingtheirGuiderolesandresponsibilitiesfromHealthCentreChiefs.Subsequenttrainingsonspecifichealthissueswereprovided
by various NGOs. The health issues they had been trained
inwerenearlyunanimous:prenatalcareandtheimportanceofdeliveryattheHealthCentreratherthanathome;prevention/containmentofH1N1;managementofchildhooddiarrhoeathroughcleanwater;andcontainmentoftuberculosisandmalaria.OneparticipantreportedtraininginHIV.TworeportedhavingattendedadiabetesawarenessactivityattheCambodianDiabetesAssociation,butthiswasseparatefrom
their monthly Guide
training.NearlyallGuidesreportedthattheyrequiredmoretrainingtosuccessfullymeettheirresponsibilities.Acommonsentimentwasexpressedthat,althoughtheyhadreceivedmanytrainings,trainingsessionsvariedwidelyinquality,suchsessionswereoftenrepetitious,andtheyoftenlackedgoodtrainingmaterialssuchaspostersandbrochures.Theimportanceoftrainingmaterials(asopposedtojustlectures)wasstressedbymostparticipants.Theyexplainedthattraining
materials were helpful so that they could review the
materialsafterthetraining,thusremindingthemwhathadbeentaughtandreinforcing
the content.When asked what topics they would like to be trained
in, one statedcancer, one stated emergency response to
injury/accident. Participantsvolunteered diabetes, one stating that
he wanted the diabetes
training,very,verymuchandtheotherstating,Itsthemostdangerous.Iwanttoknowhowtopreventit.Onceyouhaveit,howtoprotectyourselffromit.Whenquerieddirectlyabouttheirdesiretobetrainedindiabetesprevention,allparticipantsrespondedaffirmatively.Theme
#3: Striving to do a good job in the face of barriersand
insufficient
resourcesBarriers:Participantsreportedseveralbarrierstoconductingtheirwork.AcommonbarrierwascomplaintsfromfamilymembersthattimespentonGuideactivitiestookthemawayfromactivitiesthatcouldprovidefinanciallyforthefamily.ThiswasmoretruefortheGuideswhowerefarmers,butnotexclusively.Onestated,IfIamworking
in the field and I am called, my wife and daughter complain.Another
reported that her husband discouraged her from doing Guidework, and
another that his wife and family frequently asked him to dowork
that earned money for the family. An older Guide stated that
hischildrentellhimhelooksoldandtiredduetotheworkandthatheshouldrelaxmore.Oneparticipantwastheprimarycaretakerforherageing
mother who frequently encouraged her to stop being a
Guide.Insufficientresources:ParticipantsrespondedeasilywithmanyinsufficientresourcesfortheirworkasGuides.Theyreportedinsufficient
resources at the institutional level, i.e., lack of
medicationsattheHealthCentre,lackofnursingstaff,andlackofmedicalequipment.TheyalsoreportedlackofresourcesattheGuidelevel.Participantsfromlargevillagesstatedthattheyneededbicyclestoreachdistantfamilies,andcellphoneminutestostayincontactwithvillagers
and Health Centre
Chiefs.SeveralGuidesdesiredsomesortofidentificationabadge,identificationcard,t-shirtorhatthatwouldidentifythemasaGuide.
Several reported that when they attended large meetings,
othersdidnotknowtheirroleandsotheytendedtobeexcludedfromimportantconversations.Oneparticipantalsoreportedthatwhenhewent
to the hospital for medical care, which should have been free
forhimasaGuideinhisarea,hehadnowayofprovingthathewasaGuide,sohadtopayforhiscare.Severalparticipantsreportedthattheydesiredbetterteachingmaterials,suchasmanualizedcurriculaandteachingprops.Onlyoneparticipantstatedthatshehadeverything
she needed for her
work.Whenaskedaboutincentives,therewerevaryingopinionsregarding
whether Guides should be financially compensated for theirwork, but
there was unanimous agreement that Guide expenses shouldbe
covered.DiscussionThemainfindingfromthisstudyisthatGuidesareawarethatdiabetesisaproblemfortheirvillages,andtheyareeagertotacklediabetesprevention.However,theirlevelofdiabetesknowledgeisquitelimited,socomprehensivetrainingwouldbenecessarybeforesuchprogramscanbeundertaken.ThisfindingisconsistentwithliteratureshowingdeficienciesincommunityhealthworkerclinicalCitation:
JulieWagnerJ,KeukyL,Fraser-KingL,KuochT,ScullyM(2015)DiabetesPreventionthroughVillageHealthSupportGuidesinCambodia:AQualitativeInvestigationofOpportunitiesandChallenges.JCommunityMedHealthEduc5:347.doi:10.4172/2161-0711.1000347Page
4 of 7J Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2 1000347competency [19,20]. Such trainings
must be responsive to Guide
inputregardingresources,barriers,andcontextualdisincentivesfortheirwork.Guideswouldbenefitfromdiabetespreventionprogramswithsystematictrainingandamanualizedcurriculumthatincludes,forexample,flipcharts,postersandhandouts,andpropssuchasfoodmodels.Ideally,Guidediabetespreventionactivitieswouldbedonealongwithpublicawarenesscampaigns,suchasinschoolsandontelevision,
that reinforce the Guides diabetes prevention
messages.Guidesshouldalsoideallybegiventhematerialresourcesthatwouldallowthemtobemaximallyeffectiveatdiabetesprevention.Cellphoneminutesandabicyclecouldbeprovidedtopromotedisseminationofpreventionactivities.Guideworkshouldalsobemademorerewarding,perhapsinanindividualizedmannerdepending
upon the needs and desires of the Guide and the
resourcesoftheOperationalDistrictDirector.RecognitionasaGuidecouldbeeasily
provided with, for example, an identification card and
certificateofattendancefordiabetestraining.Compensationandpublicrecognition
could help to quell family discouragement of
Guides.EvaluationofandfeedbacktoGuidesshouldbemoresystematicand
more substantive. For example, NGO trainers could attend
Guideeducationsessioninthevillageandprovideimmediateandindividualizedfeedback.Theneedforcontext-specific,high-qualitysupervision
of community health workers in low-income countries
hasbeendescribedandevidencesuggeststhatimprovingsupervisionqualityhasagreaterimpactthanincreasingfrequencyofsupervisionalone
[25].Finally,theGuideworkforceshouldbeexpanded.TheGuidesinterviewedforthisstudywerededicatedtotheirvolunteerworkdespitecompetingdemandsandsometimesdiscouragementfromfamilymembers.However,diabetespreventioneffortswillrequirealargecohortoftrainedGuides.AccordingtotheMinistryofHealth[12],oneGuideismeanttocover10-50householdsdependingoncommunity
needs. Yet, respondents indicated that in many villages ofseveral
hundred households, there was only a single Guide. Further,
anunknownbutpotentiallyhighnumberofGuidesdropoutwithinthefirstfewmonthsofbeingrecruited.Attentiontotheirconcernsregardingtime,money,roleburden,andlackofsatisfactioncouldpotentiallyhelpretainsomeofthem,thusincreasingthenetnumberof
active Guides.The future of preventing diabetes in
CambodiaIthasbeenobservedthatthesharpincreaseintheprevalenceofT2DMinsoutheastAsia[1]ismostlyassociatedwiththelifestyletransitionstowardsurbanizationandindustrialization.InCambodia,urbanizationhasincreasedbetweenthelast2nationalcensuses(1998to
2008) with the percentage of urban population increasing from
17.4in 1998 to 19.5 in 2008
[21].Cambodiansalsocarryadditionalriskfactorsthatareuniquetothembecauseoftheircountryshistory.First,Cambodianshavehighratesofmentalillnessfromhavingsurvivedgenodice.EvendecadesaftertheVietnameseinvasionthattoppledtheregime,evidencesuggeststhatratesofpost-traumaticstressdisorder(62%)anddepression(51%)remainextremelyhighamongCambodiansaroundtheworld[26]andinCambodia[27].Bothdisordersprospectivelyincreaseriskforincidenttype2diabeteswithrelativerisksof1.6and2.1,respectively[28,29].Second,theyearsoffamineduringwartimemayhaveincreasedsusceptibilitytotype2diabetes.StudiesfromtheDutch
Hunger Winter [30] and the Jewish holocaust [31] suggest
thatintra-uterineexposuretostarvationconditionsmayincreaseriskofadultobesityandtype2diabetes.Exposuretoseverenutritionalconditions
may change gene expression and alter disease susceptibilitythrough
epigenetic modifications [32]. Thus, as Cambodians who
wereconceivedduringtheconflictageintomiddleandlateradulthood,rates
of diabetes may be expected to increase beyond base rates of
thediseaseinotherpartsofAsia.Inshort,Cambodiamustimplementdiabetes
prevention programs or potentially experience an epidemic oftype 2
diabetes.Contextual
challengesWhereasGuidesarepromisingagentsfordiabetesprevention,Cambodiafaceschallengesinprovidinghealthcare,particularlypreventivehealthcare,thatexertastrongopposinginfluence.First,therearedemographicchallenges.Cambodiaspopulationis13.4million
[21]. The annual growth rate of the population during the
lastdecadeinCambodiais1.54percent,whichishigherthanthegrowthrateofSoutheastAsiamoregenerally(1.3percent).Second,asintherestofthedevelopingworld,fundingforhealthcareisminimal.Although
government spending on health has been steadily increasing,it is
nearly matched spending by private donors and NGOs for
whomthereislittleaccountability[33].Moreover,byfarthelargestportionofhealthexpenditure,60-73%,comesfromout-of-pocketspending,i.e.,paidforbypatientsandfamiliesthemselves[33,34].Ahealthcaresysteminwhichpatientsprovidethemajorityofthespendingwillcontinuetostruggletoprovidepreventivecare.Third,eventheMinistryofHealthrecognizesthewidespreaddiscontentamongstgovernment
employees in Cambodia resulting from low salaries;
highlevelsofdualemployment;thesmallnumbersofformallytrainedalliedhealthprofessionalsandinappropriatelyqualifiedmanagerialpersonnelinthegovernmentservice[35].Thissystem,inwhichhealthcare
providers often receive undesirably low salaries, is prone
tocorruptioninwhichhealthcareprovidersextortmoneydirectlyfrompatients,ontopofanyfeespaidtothehealthcarefacility.Indeed,corruptionateverylevelerodestheabilitytodeliverqualitycare.Lastly,
at all levels of the healthcare system in Cambodia, the focus
onprevalent communicable diseases renders non-communicable
diseasesalowpriority.Malaria,tuberculosis,andHIVareprevalent,deadly,costly,andpreventabledisorders.Thus,non-communicableandchronicdiseaseswithdelayedconsequences,suchastype2diabetes,donotreceivecommensuratefunding[36].Insummary,althoughGuidespresentanopportunitytodeliverdiabetespreventionprograms,theywouldbedoingsointhecontextofanunderfundedandcorruptsystemthatdoesnotprioritizechronicdisease.Thus,thebattleagainstdiabetesinCambodiaisdaunting.Yetleadershipmustshow
the political will to address the rising tide of diabetes or its
longterm consequences will be devastating for the
country.LimitationsThis study was limited to a single geographical
province.
Recruitswhowerenotableorwillingtoparticipatemayhavehadsystematically
different views and knowledge than those who chose
toparticipate.ParticipantshadallbeenGuidesforseveralyears;thosewho
started and quit early on were not interviewed. Thus, this
samplewas probably more motivated and dedicated than Guides early
in
theirrole.ParticipantsknewthatthestudywasconductedbytheCambodianDiabetesAssociation,whichmayhavecreateddemandcharacteristics.
However, these limitations are generally outweighed byCitation:
JulieWagnerJ,KeukyL,Fraser-KingL,KuochT,ScullyM(2015)DiabetesPreventionthroughVillageHealthSupportGuidesinCambodia:AQualitativeInvestigationofOpportunitiesandChallenges.JCommunityMedHealthEduc5:347.doi:10.4172/2161-0711.1000347Page
5 of 7J Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2 1000347the studys strengths. This is the
first study, and to our knowledge
thefirstendeavor,toexploreGuidesaspotentialpersonnelfordiabetespreventioninCambodia.TheindepthinterviewsweresupplementedbyavalidatedKhmerlanguagequantitativemeasureofdiabetesknowledge.Finally,resultsprovideconcretesuggestionstoinformdiabetes
prevention training programs for Guides.ConclusionDiabetes will
create a massive burden on Cambodian society
unlessaggressiveactionisurgentlytaken.Cambodiafacesaseverelyunderfundedhealthcaresystemandacriticalshortageofhealthcareworkers,particularlyinruralareas.Guidesareapromisingmechanismthroughwhichdiabetespreventionmightbedelivered.Threethemesemergedfromthisstudy:dedicationtobeingaGuide,theneedforadditionalandhighqualitytraining,andworkinginthefaceofbarriersandinsufficientresources.Diabetespreventionprograms
should exploit the opportunities and attend to the
challengesreportedbyGuidesinordertomaximizetheirsuccessfulimplementation.AcknowledgmentsWe
would like to acknowledge Ms. Ien Srey Horn for her
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JulieWagnerJ,KeukyL,Fraser-KingL,KuochT,ScullyM(2015)DiabetesPreventionthroughVillageHealthSupportGuidesinCambodia:AQualitativeInvestigationofOpportunitiesandChallenges.JCommunityMedHealthEduc5:347.doi:10.4172/2161-0711.1000347Page
7 of 7J Community Med Health EducISSN:2161-0711 JCMHE, an Open
AccessVolume 5 Issue 2 1000347
