Introduction

Cambodia has shown advanced progress in achieving the Millennium Development Goals (MDGs) for maternal and child health (MCH) and infectious diseases [1]. Yet, the burden of non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) is a major concern for the country. A 2016 STEPS survey estimated the prevalence of T2D and HTN among adults aged 40–69 years in Cambodia as 3.3% and 23.5%, respectively [2].

The Royal Government of Cambodia’s strong political commitment towards achieving Universal Health Coverage (UHC) provides the Ministry of Health (MoH) with an opportunity to improve health service delivery [3]. To ensure service availability for T2D and HTN, the MoH and donor organisations have introduced a multitude of primary healthcare (PHC) interventions, including (1) establishment of Non-Communicable Disease (NCD) clinics at referral hospitals (RHs), (2) introduction of the World Health Organization Package of Essential Non-Communicable Disease Interventions (WHO PEN) programme in health centres (HCs), and (3) expansion and integration of MoPoTsyo’s community-based Peer Educator Network [4].

Ensuring universal access to T2D and HTN healthcare services through scale-up of health intervention packages is one of the stepping stones towards UHC for NCDs in Cambodia; however, it has been severely constrained by health system challenges such as weak governance, limited financial resources, and especially, a lack of human resources [5,6]. Human resources are needed for T2D and HTN service delivery at the PHC and community levels since managing these NCDs require a comprehensive and cross-cutting approach—including life-long healthcare support, early case detection, psychosocial promotion, self-management, and medical support [7].

To adequately address the growing need for T2D and HTN services in the context of the PHC system struggling due to limited human resources for health, community health workers (CHWs) have increasingly been recognised as a promising frontline healthcare workforce to support the PHC system additionally [8,9]. The Alma Ata Declaration of 1978 established CHWs as an essential element of the comprehensive PHC approach—“suitably trained socially and technically to work as a health team and respond to the community’s expressed health needs” [10]. Increasingly, CHWs are being seen as a prerequisite for the health system to achieve the goal of UHC [11] through various tasks performed in different health programmes. Previous studies from other low- and middle-income countries (LMICs) have demonstrated that CHW-based programmes are effective in HTN and diabetes control, reducing coronary heart disease risk [12,13], helping improve blood pressure [14], and are beneficial in diabetes management [15]. A study in Pakistan showed that family-based home education delivered by CHWs achieved effective lowering of blood pressure levels in the population [16]. With insufficient numbers of trained health professionals at the PHC level, CHWs could thus also be a valuable extension of the professional healthcare team in NCD health services in Cambodia and a crucial step in scaling up management of NCDs.

In Cambodia, CHW programmes are a part of the broader national “Community Participation Policy for Health” [17]. In this policy, CHWs are referred to as “Village Health Support Group” (VHSG) members and are volunteers at HCs [18]. Apart from VHSGs, CHWs are known by many different names due to their engagement in specific health interventions implemented at the PHC level by various Vertical Health Programmes (such as HIV/AIDS, infectious diseases (Tuberculosis or Malaria) and MCH [19–21]) in which they have extra roles. However, so far, engagement of CHWs in T2D and HTN healthcare services has been limited in the country.

Since Cambodia’s strategic action plan to address the NCD epidemic in a sustainable manner is to have both facility-based and community-based interventions [22], assessing the competences of CHWs to contribute to NCD management is crucial to evaluate their potential in national efforts to scale-up interventions that address the growing burden of T2D and HTN. Although some other countries such as Uganda [23] and South Africa [24,25] have studied CHWs’ knowledge on NCDs, this information was lacking in Cambodia. In response to this knowledge gap, our study sought to provide an overview of CHWs’ knowledge, attitude, and practices (KAP) in T2D and HTN management. In addition, it was also necessary to assess whether the health system is ready and willing to incorporate CHWs as a central tool in its care for T2D and HTN. We thus also sought to assess the potential health system barriers for incorporating CHWs in T2D and HTN management.

Methods

Results

Socio-demographic variables and characteristics of CHWs

Table 1 presents the socio-demographic variables and characteristics of the CHWs. Among all participants, the mean age was 49 years (standard deviation; SD = 14), 51.0% were females, 79.1% were currently married, 43.8% had at least completed primary education, 39.2% were farmers, and 48.4% had an annual income of 4–17 million riels (USD 1000–4250).

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Table 1. Socio-demographic variables and characteristics of study participants (N = 153).

https://doi.org/10.1371/journal.pone.0351958.t001

The CHWs had spent on average 8.6 years (SD = 6.5) as a CHW. In our study, 44.5% of respondents performed only one role, 30.5% performed two roles, and 24.8% performed three roles linked to community health-related work.

The current roles included (1) being a formal VHSG who is involved in community out-reach activity of the HCs, (2) observing whether tuberculosis patients take their medicines as Community Direct Observation Therapy Watchers, and other roles such as (3) diagnosing and treating malaria as Village Malaria Workers (VMWs) or Mobile Malaria Workers (MMWs), (4) peer educator for T2D and HTN, (5) Red Cross volunteers, (6) working for non-government organisations’ social protection programmes, and (7) distributing contraceptive pills as Community-Based Distributors.

Knowledge, attitude, and practice

As presented in Table 2, most respondents answered about six out of seven NCD-related knowledge items correctly (M = 6.3, SD = 0.8). The majority of CHWs (90.2%) agreed that NCDs cannot directly spread between people, 96.7% agreed that NCDs can be prevented with a healthy diet, 91.5% agreed that diabetes is an NCD, 94.8% did not agree that regular exercise will put you at risk of diabetes, 93.5% agreed that HTN is an NCD, and 94.8% agreed that reducing salt intake may reduce the risk of high blood pressure. The highest prevalence of misunderstanding was seen in item 7 (related to smoking) of NCD-related knowledge, where 74.5% incorrectly believed the statement was true.

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Table 2. Response to knowledge, attitude and practice items.

https://doi.org/10.1371/journal.pone.0351958.t002

On average, about three out of five T2D risk-factor knowledge items were answered correctly (M = 3.4, SD = 0.9). The majority of CHWs agreed that lack of exercise (86.9%) is risk factor of T2D, while fruit and vegetable intake (88.9%) and walking exercise (96.1%) are not risk factors of T2D. A minority of participating CHWs correctly agreed that a family history of T2D (23.5%), and tobacco use (48.4%) are risk factors of T2D.

On an average, the participating CHWs scored 4.6 out of 5 on the T2D prevention knowledge items (M = 4.6, SD = 0.7). The CHWs acknowledged that ways of preventing T2D include regular exercise (96.7%), not having too much oily food (89.5%), vegetables consumption (92.2%), not drinking sweet beverages (92.8%), and doing physical activities (94.1%).

Similarly, around four out of five HTN risk-factor knowledge items were answered correctly (M = 4.5, SD = 0.6). The CHWs acknowledged that risk factors of HTN include eating salty foods (96.7%), lack of exercise (95.4%), tobacco use (70.6%), while walking exercise (96.7%), and fruit and vegetable intake (93.5%) are not a risk factor of HTN.

Lastly, approximately four of five HTN prevention knowledge items were answered correctly (M = 4.6, SD = 0.8). The CHWs acknowledged that ways of preventing HTN include exercising (96.7%), vegetables consumption (94.1%) and doing physical activities (96.1%). They agreed that having too much of oily food (86.3%) and eating salty food (94.1%) are not ways of preventing HTN.

Most respondents had a positive attitude on the importance of receiving on-time treatment for T2D patients (98.7%), the importance of lifelong treatment for T2D (84.9%), the importance for people over 40 years of age to receive HTN screening regularly (99.3%), and the importance of taking medicine regularly for HTN patients (99.3%). Since they had encountered some patients living with T2D and HTN in their villages, CHWs tended to be very positive on the statement on disease management including screening and treatment. Moreover, some CHWs had been informed about the T2D and HTN service availability at the HC, which allowed them to be able to inform and encourage villagers to have their blood pressure and blood glucose screened.

Regarding practices, 83.0% CHWs had ever advised people over 40 years of age to have blood glucose screening and 85.6% had ever advised those over 40 years of age to undergo blood pressure screening.

Discussion

Our study provides evidence on the potential contribution of CHWs to scale-up T2D and HTN care in Cambodia by assessing their KAP as well as the health system barriers and potential solutions for successful implementation. Our main findings highlight the knowledge of CHWs in Cambodia, and identify key facilitators to CHW scale-up, namely strengthened support (both financial and non-financial) to CHWs and revised financing structures.

Overall, the general knowledge among CHWs on T2D and HTN was good, albeit still limited on certain risk factors. The latter finding is consistent with studies in other low-income settings such as in Eastern Uganda [29]. This might be explained by the fact that current training opportunities mainly consist of occasional information sharing, workshops from the HCs, and media advertisements on curative aspects with little attention to risk factors. A large proportion of CHWs were aware of the most common NCDs and the majority knew about prevention of T2D and HTN, reflecting their fundamental knowledge and the potential role of CHWs to engage in this programme. The demonstrated positive attitudes and good practices with regard to T2D and HTN potentially resulted from the high prevalence of T2D and HTN in their communities, as also indicated in the study in Uganda [29].

Despite assessing the CHWs’ KAP, it is also essential to understand the health system barriers that could hinder their performance in the future engagement in T2D and HTN health intervention. Our study found that the major barriers for further implementation of CHW interventions related to training, support, and financing. Capacity building was cited as an important step. To deepen and broaden their capacity in prevention and disease management, not only for T2D and HTN, but also related to connections with other diseases, CHW trainings should cover more disease areas, and include risk factors and preventive measures. A study in LMICs has also confirmed that the design of a targeted training curriculum was one of the key factors that could affect the effectiveness of a CHW training programme [30].

However, their performance is further affected by health system factors, more specifically resource constraints (financial and non-financial barriers). Substantial financial investment from the government is needed through an innovative funding mechanism to improve structural support. Previous studies have demonstrated that boosted tax revenues for NCDs could be a potential fund-raising mechanism; for instance, a study from Tonga has shown that the NCD tax policy can be successfully employed as a strategy to support health goals for NCD services [31]. The Thai Health Promotion Foundation has also been able to generate an annual revenue of USD 120 million from a 2% surcharge of excise tax on tobacco and alcohol [32], which was used to support evidence generation, a public campaign, and social mobilization to address NCD risk factors. Evidently, village health volunteers in Thailand are a key part of the PHC receiving 1000 Thai Baht (USD 32) per month [33]. In Cambodia, the government has issued sub-decree number 193 on 4 December 2019 on assigning health management and health service delivery to the capital and province administration [34]. This allows room for financial allocation of the provincial administrator budget to operate health related-activities [35]. The local governance must be more accountable to its population’s health through improved access to NCD care at public health facilities. This can be achieved by bringing services closer to the villagers and re-allocating local funds to NCD services including CHW engagement in all health services of the HC. A study that analysed the cost-effectiveness of CHWs in Mozambique showed that including a minimum wage for CHWs could lead to a large gain in efficiency in the implementation of health interventions [36].

Non-financial resources, such as continuous training, material support, or supervision from healthcare professionals were also cited as essential elements for CHWs’ engagement in T2D and HTN care. Previous studies have pointed out that the essential elements for an effective work environment for CHWs include supplies and equipment, supportive supervision, and respect from the community [23,37]. Inadequate supply could impact the community’s trust on the role of CHWs as has also been demonstrated in previous studies concerning CHW programmes [38,39].

The majority of the CHWs in our study had more than two roles including MCH or infectious diseases; therefore, over-burdening CHWs is a clear concern, which has also been indicated in other developing countries [40]. A previous study conducted in Cambodia has also outlined that CHWs had a number of roles and responsibilities as part of their volunteer work [41]. Therefore, the design of future community-based interventions should be planned rigorously to ensure adequate support to maximise CHWs’ performance and to avoid over-burdening. This is in line with a review on the influence of the work environment on CHWs’ productivity and effectiveness, which stated that a manageable workload carried out in an organised manner, with a reasonable geographic distance to cover, the needed supplies and equipment, a supportive supervisor, and respect and acceptance from the community and the health system are prerequisites for an effective community-based strategy [37].

CHWs can play a role as crucial extensions of the health workforce, especially in the scale-up of T2D and HTN care because they can provide services to the community such as raising awareness and improving screening, and can contribute to increasing coverage, addressing the horizontal dimension of scale-up—as defined in the previous multi-country research study [42]. Their special role in providing self-management support to patients can also contribute to expand the existing package of interventions through vertical scale-up.

Further research is needed on identifying the appropriate scale-up mechanisms for a comprehensive and effective community-based health intervention as a part of T2D and HTN management.

Limitations and strengths of the study

Our study has some limitations especially related to its purposive selection of the six ODs, which restricts the generalisability of study findings to other areas of the country, and the limited sample size, which undermines the power of an in-depth analysis of quantitative data. Yet, the strength of our study was the high response rate from the CHWs and that it involved the synergies between both quantitative and qualitative data that enabled the triangulation of findings. The findings were not only obtained from CHWs but also from respondents from the Vertical Health Programmes who have long-term experience in engaging CHWs in their respective programmes. Interviews were documented using interview record notes rather than audio recordings due to participant-related constraints. This approach may have limited the verbatim capture of responses and possibly affected the depth of qualitative data; however, measures such as contemporaneous note-taking and review by the research assistant team specialised in qualitative research were used to reduce potential information loss.

Conclusion

The evidence generated from our study will be beneficial as a stepping stone for future policy design on community participation as a part of T2D and HTN management in the Cambodian healthcare system.

The potential of CHWs in T2D and HTN management with their fundamental background could be maximised through well-designed community-based strategies that focus on their work characteristic, and support needed in the health system. The first strategy is to develop a technical support mechanism through a well-designed training curriculum that covers diverse topics to fill in their knowledge gaps, especially on risk factors. Second, their roles and responsibilities should be sharpened to their characteristics and be clearly defined to avoid over-burdening. A strong support structure is essential to ensure that the two strategies mentioned above can be fully and effectively implemented, thereby maximizing the potential of CHWs’ performance.

Supporting information

Acknowledgments

All authors with to thank all the key informants for spending their valuable time contributing to this study.