Cambodian Children Research Articles

Empirical study on Cambodian children's drawing by the S-HTP method (Year 2)

Empirical study on Cambodian children's drawing by the S-HTP method (Year 2)

Decreased Type I Interferon Production by Plasmacytoid Dendritic Cells Contributes to Severe Dengue.

The clinical presentation of dengue virus (DENV) infection is variable. Severe complications mainly result from exacerbated immune responses. Type I interferons (IFN-I) are important in antiviral responses and form a crucial link between innate and adaptive immunity. Their contribution to host defense during DENV infection remains under-studied, as direct quantification of IFN-I is challenging. We combined ultra-sensitive single-molecule array (Simoa) digital ELISA with IFN-I gene expression to elucidate the role of IFN-I in a well-characterized cohort of hospitalized Cambodian children undergoing acute DENV infection. Higher concentrations of type I IFN proteins were observed in blood of DENV patients, compared to healthy donors, and correlated with viral load. Stratifying patients for disease severity, we found a decreased expression of IFN-I in patients with a more severe clinical outcome, such as dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). This was seen in parallel to a correlation between low IFNα protein concentrations and decreased platelet counts. Type I IFNs concentrations were correlated to frequencies of plasmacytoid DCs, not DENV-infected myloid DCs and correlated inversely with neutralizing anti-DENV antibody titers. Hence, type I IFN produced in the acute phase of infection is associated with less severe outcome of dengue disease.

Adaptive Functioning Behaviors for Trauma-Affected Children in the Cambodian Context

Across contexts, the roles and responsibilities for children are shaped by a range of sociocultural factors; thus, a contextually specific exploration of adaptive functioning norms is important in optimizing the acceptability, effectiveness, and sustainability of mental health intervention and community programming. The current study aimed to examine child adaptive functioning behaviors for children in Cambodia, a country faced with continuing recovery efforts from war and genocide, intergenerational trauma transmission, poverty, and minimal access to health and mental health services. Qualitative interviews were conducted with 30 children (ages 10–13, 16 girls) and 30 caregivers (ages 30–62, 24 females) in the Battambang province of Cambodia receiving mental health services related to caregiver intimate partner violence. Results reveal trauma-affected children in Cambodia engage in a range of familial, occupational, social, religious, and academic functioning domains. Children in this sample reported behaviors that reflect policy and community level priorities of development of children as a societal and economic resource, distress management strategies of self and others informed by mental health therapy and local healing strategies, and engagement in religio-cultural Khmer Buddhist practices and ceremonies. Findings highlight the importance of contextually specific conceptualizations of functional impairment in guiding assessment and community program design and identifying areas for monitoring intervention effectiveness.

Reducing malnutrition in Cambodia. A modeling exercise to prioritize multisectoral interventions.

Undernutrition is a major contributor to child morbidity and mortality and poses a large burden to the economy, in Cambodia. This study explored factors contributing to child stunting and wasting and their regional inequalities among 1,938 Cambodian children aged 6–23.9 months. Data were drawn from a longitudinal study (year 2017) conducted in six districts of two north‐eastern provinces and the capital and used as cross‐sectional. Socio‐demographic and household characteristics, children's feeding practices during the previous 24 hr, and children's length and weight measurements were collected. Gradient boosting models were used to calculate the contribution of determinants to child undernutrition whereas concentration index was used to assess the impact of those determinants on stunting and wasting inequalities among socioeconomic groups. It was found that low‐household wealth could predict 21% to 45% of child stunting and 23% to 36% of wasting across regions. After wealth, source and treatment of drinking water were found the second major predictor for stunting (15%) and wasting (21%). Combining child nutrition and household water, sanitation and hygiene indicators predicted around 30% of child undernutrition, either in the form of stunting or wasting. Mothers' education predicted >30% of stunting in the north‐eastern region. Results highlight that a complex interplay of factors contributes to child stunting and wasting. An integrated, intersectoral, equity‐focused approach that addresses children's dietary quality, household's water, sanitation and hygiene conditions, mother's education, and poverty is likely to yield the highest impact in achieving further gains in nutritional status among Cambodian children.

Improving children's nutritional status in Cambodia: Multidimensional poverty and early integrated interventions.

One in three Cambodian children under 5 years of age are stunted. This study adopted a multidimensional approach to understand the influence of a series of contextual factors on the nutritional status of Cambodian children. In this study, we use a multidimensional poverty framework to identify a combination of interventions likely to achieve reductions in child stunting, in Cambodia. We used the UNICEF Multiple Overlapping Deprivation Analysis tool and data from the Cambodia Demographic and Health Survey 2014 to assess children's multidimensional poverty across nutrition, health, early childhood development, water, sanitation, and housing dimensions. We found that 80% of children under age five were deprived in at least two poverty dimensions. Multivariate logistic regression analysis revealed that reducing the likelihood of being deprived in three or more poverty dimensions was associated with a significant reduction of the probability of being stunted, after controlling for potential confounders. The combined probability of nondeprivation in nutrition, sanitation, and health dimensions had the largest effect on reducing the probability of stunting. The results of this study highlight the multiple, intersecting needs of children and their associated explanatory factors. Targeted and integrated cross‐sectoral policies that reinforce comprehensive early childhood interventions are needed for improving nutritional status as part of a wider set of child poverty reduction measures in Cambodia.

Salmonella Typhi and Paratyphi A infections in Cambodian children, 2012–2016

ObjectivesEnteric fever remains an important diagnostic and treatment challenge in febrile children living in the tropics. In the context of a national Salmonella enterica serovar Paratyphi A outbreak, the objective of this retrospective study was to compare features of S. Typhi and S. Paratyphi A infections in Cambodian children. MethodsClinical and laboratory features were reviewed for 192 blood culture-confirmed children with S. Typhi and S. Paratyphi A infections presenting to a paediatric referral hospital in Siem Reap, 2012–2016. ResultsChildren with S. Typhi infections were younger, were more likely to have chills and/or diarrhoea, and were more frequently hospitalized than those with S. Paratyphi A infections. Over three quarters (88.3%) of S. Typhi isolates were multidrug-resistant, compared to none of the S. Paratyphi A. ConclusionsIn this small study of Cambodian children, S. Typhi infections were more severe than S. Paratyphi A infections. Antibiotic resistance limits treatment options for enteric fever in this population.

Patterns of Anemia in Married Women and Their Children in Cambodia: A Synthetic Cohort Analysis.

To explore the prevalence of anemia in three cohorts of women, namely, married yet to be mothers, married and are mothers, and currently pregnant, to ascertain the patterns in anemia in women. We analyzed a sample of 130,965 married women from four Demographic Health Surveys: 2000, 2005, 2009 and 2015. The primary focus for the analysis was married women aged 15 to 49 years. In the absence of a longitudinal data that followed the same women over the periods, a synthetic cohort of the women of that age-group was constructed to get women aged 15 to 64 years over the four surveys. Women who were aged 15 to 19 years in 2000 were the same as those 30 to 34 years in 2015, while those aged 45 to 49 years in 2000 were the same as 60 to 64 years in 2015. Logistic regression revealed that young mothers were significantly more infected (p < .001). Pregnancy affected anemia in the women (p < .001). Being younger and richer were associated with odds ratios of 0.599 (95% confidence interval, CI: [0.560, 0.640]) and 0.765 (95% CI: [0.726, 0.807]) for anemia, respectively. Being pregnant had odds ratio of 1.642 (95% CI: [1.439, 1.872]) for anemia. Public health strategies should target social deprivation at the household level while addressing maternal health issues. An analysis of data on unmarried women and their children is recommended.

Interactions of Dimethylarsinic Acid, Total Arsenic and Zinc Affecting Rice Crop Management and Human Health in Cambodia

Background.In parts of Cambodia and in many other parts of the world, irrigation of rice with groundwater results in arsenic (As) accumulation in soil and rice, leading to health concerns associated with rice consumption. At times, some As is present as relatively nontoxic, non-regulated, dimethylarsinic acid (DMA). Low levels of zinc (Zn) have been found in rice from Bangladesh, Cambodia, and China where As levels in rice are high. Furthermore, there have been claims that Zn deficiency is responsible for stunting the growth of children in Cambodia and elsewhere, however in rural Asia, rice is the major source of Zn. Current data are inadequate for both Zn and DMA in Cambodian rice.Objectives.The present study aimed to provide a preliminary evaluation of the relationship between the content of Zn and DMA in rice grain in Preak Russey, an area with elevated levels of As in groundwater and to improve the management of Zn deficiency in rice.Methods.Rice agriculture was evaluated along the Mekong River in Cambodia. Analyses for metals, total As, and As species in rice and water were conducted by inductively coupled plasma mass spectrometry. Analysis of total Zn and As in soils and total Zn in rice were analyzed using X-ray fluorescence (XRF) spectrometry.Results.Rice in Preak Russey had Zn concentrations less than a third the level recommended by the United Nations World Food Programme. There was a significant (p < 0.05) negative correlation between the Zn content of rice and DMA in rice with the lowest Zn and highest DMA levels occurring near irrigation wells, the source of As.Conclusions.The highest levels of DMA in rice were associated with Zn deficiency in rice.Competing Interests.The authors declare no competing financial interests

Frequent unregulated use of antibiotics in rural Cambodian infants.

BackgroundDespite a high prevalence of antibiotic resistance in Cambodia, few studies have assessed health-seeking behaviour and the use of antibiotics by caregivers of young children in Cambodia.MethodsWe conducted a cross-sectional survey of infants <12 months of age and their caregivers, assessing the frequency of reported illness, common symptoms and associated health-seeking behaviour through structured questionnaires administered by trained fieldworkers at a home visit. In a subset of these participants, ages 4–8 months with no acute malnutrition, we conducted a 3-month surveillance with fortnightly home visits.ResultsOf 149 infants (ages 1–11 months, 54.4% male) enrolled in the cross-sectional study, 76 (51.4%) reported symptoms of diarrhoea, fever or cough in the previous 14 d, with associated use of antibiotics reported in 22 (14.8%) infants. In 47 infants enrolled in the longitudinal surveillance, there were 141 reported episodes of illness in 44 (94%) infants with 21 infants (45%) reported to have received antibiotics in 32/141 (22.7%) episodes. Amoxicillin was the most commonly reported antibiotic in both surveys (68% [40/59 episodes reporting the use of antibiotics]).ConclusionsAntibiotic usage is high in this population and appears to be occurring largely outside of the formal healthcare system.

Key expressions of trauma-related distress in Cambodian children: A step toward culturally sensitive trauma assessment and intervention.

More than half of all children in Cambodia experience direct abuse and over 70% experience other traumatic events, which significantly increase their risks for a range of physical and mental health problems. Additionally, Cambodian children face longstanding sociopolitical, intergenerational, and cultural factors that compound the impact of other trauma. As a result, rates of posttraumatic stress symptoms among Cambodian youth are high. However, care providers often rely on Western-based nosology that does not account for culturally specific expressions of trauma. A greater understanding of culturally-salient expressions of distress can help inform diagnostic assessment accuracy and treatment effectiveness and monitoring. The current study utilized a qualitative design to interview 30 Cambodian caregivers of children with trauma experiences and 30 Cambodian children (ages 10-13 years) with trauma experiences to identify key local expressions of trauma. Findings reveal certain PTSD symptoms and culturally-specific frequent and severe trauma-related problems for Cambodian children and domains of functioning impacted by trauma. Certain symptoms seem particularly important to evaluate in this group, such as anger, physical complaints (e.g., headache and palpitations), and cognitive-focused complaints (in particular, "thinking too much"). All caregivers and children reported physical health as impacted by trauma-related problems, highlighting a particularly salient domain of functioning for this population. Expressions of distress explored in the current study are discussed in the context of assessment and intervention development to inform diagnostic and clinical efforts for those working with trauma-exposed Cambodian children.

Local clinician perspectives on cause, impact, and treatment of key expressions of distress in Cambodian children.

Child trauma and posttraumatic stress in Cambodia is highly prevalent, perpetuated within a postwar sociocultural context. The examination of locally meaningful expressions of distress is needed to provide culturally sensitive assessment and treatment of trauma-affected Cambodian children. The acceptable, feasible, and sustainable incorporation of expressions of distress into assessment and intervention development relies on key mental health professionals operating in Cambodia, who can provide invaluable perspectives on child trauma experiences in this particular sociocultural context. In this study, qualitative interviews were conducted with 15 Cambodian mental health professionals (MHPs) who work directly with trauma-affected Cambodian children. MHPs were presented with seven key posttraumatic problems derived from previous qualitative interviews with Cambodian children and caregivers, and discussed 1) the causes of these problems, 2) the impact of the problem on the child or those around them, 3) the current treatment for the problem in Cambodia, and 4) recommended treatment. MHPs provided unique insights and perspectives of trauma-affected children in the Cambodian context regarding key target problems, including palpitations, difficulties in school, headache, and thinking too much, and highlighted future directions for assessment and intervention. Recommendations are discussed in regard to programming design and organizational training development to promote culturally salient, feasible, and sustainable mental health service provision in Cambodia.

Early childhood caries status and its associated factors among young children in a rural area of Cambodia

BackgroundThe purpose of this cross-sectional study was to measure prevalence and severity of early childhood caries (ECC), and its associated factors among 1- and 2-year-old children in Kampong Cham province, Cambodia. Materials and methodsData, from a representative sample of 128 children (69 males, 59 females; mean age = 22.98 ± 7.68 months), were collected at seven villages in Khpob Ta Nguon district, Kampong Cham province from May to October in 2018. The dental caries status was recorded following WHO guidelines. The socio-economic status, dietary habits and oral hygiene habits of the children were assessed through an interview questionnaire administered to their primary caregivers. ResultsECC prevalence was 50.0%. The mean dft was 2.46 ± 3.08, and 100% of cavitated lesions were untreated. A logistic regression revealed that 1-year-old children who continued night breast-feeding after 12 months were more likely to have ECC (OR = 5.32, 95%CI = 1.33–21.30), whereas the 2-year-old children who continued night breast-feeding beyond 12 months (OR = 13.36, 95%CI = 2.14–82.31), bottle-feeding after 12 months (OR = 6.10, 95%CI = 1.56–23.87), and children who did not adopt tooth brushing by the 1st birthday (OR = 32.23, 95%CI = 4.51–230.54) were more likely to have ECC. ConclusionThe findings of this study indicate that ECC prevalence and severity among this group of rural Cambodian children were high. Oral health programs focusing ECC prevention from an early age should be conducted in this population.

A method of estimating age of undocumented children and young adults of different socioeconomic status in Cambodia

A growing number of Cambodian children without legal documentary evidence of date of birth are vulnerable to exploitation. This study aimed to evaluate the applicability of southern Chinese reference dataset for dental age estimation on Cambodian children and young adults of different socioeconomic status. Dental panoramic tomographs (DPT) of 371 Cambodian children and young adults belonging to lower and higher socioeconomic status (SES) groups were analyzed. All the left maxillary and mandibular permanent teeth including the third molars were scored based on Demirjian's classification of tooth development stages. Chronological age (CA) was calculated from the date of birth and date of exposure of radiograph. The mean age of attainment for each stage of development was obtained from the southern Chinese reference dataset. Dental age (DA) was calculated by averaging the mean age scores for all the teeth. Paired t-test and correlation analysis were conducted to measure associations between the chronological age and the dental age for males and females in the lower and higher socio-economic status groups. Underestimation of age was observed in both SES groups using the southern Chinese reference dataset. For the higher SES group, the difference between the chronological and dental age (CA-DA) was 0.26 years for females and 0.11 years for males. The difference was statistically significant only in females (p < 0.05). In the low SES group, the results showed a difference of 0.07 years in females and 0.01 years in males; the differences were not statistically significant in both sexes (p > 0.05). A strong correlation was observed between the CA and DA in both sex and SES groups ranging from 0.969 to 0.988 (p < 0.05). The southern Chinese dental reference dataset can be used to estimate the age of undocumented Cambodian male and female children and young adults of both higher and lower SES.

A measurement scale to assess responsive feeding among Cambodian young children.

The caregiver–child interaction during mealtime, which refers to responsive feeding (RF), influences child's dietary intake. In Cambodia, given the level of malnutrition, getting better knowledge of RF among young children is essential, but to do so, using an appropriate assessment tool is necessary. We aim to develop and to validate a measurement tool to assess RF in two different situations (before and after an intervention) among children 6–23 months old. This research is part of a larger trial assessing the impact of nutrition education combined or not with the provision of complementary foods on child nutritional status. The “Opportunistic Observation Form” from the Process for the Promotion of Child Feeding package was used to collect data on RF through direct observations of child's meal episodes. Data were used to define an initial scale composed of four constructs and 15 indicators. Confirmatory factor analyses (CFA) and Hancock and Mueller's H reliability indices were computed to assess the validity and reliability of the scale. The final tool was applied to baseline and endline data. At baseline, the sample included 243 pairs and, at endline, 248 pairs. The final scale included two latent constructs (RF and active feeding) that comprise three indicators for active feeding and five for RF. Criteria for fit indices of CFA were met for both constructs though better at baseline. Reliability coefficients were above 0.80 for each construct at baseline and endline. This research proposes a scale that could be used to assess active feeding and RF. Further validation is warranted in different contexts.

Whole-blood PUFA and associations with markers of nutritional and health status in acutely malnourished children in Cambodia.

To measure fatty acid composition, particularly whole-blood PUFA content, in acutely malnourished children and identify associations with markers of nutritional and health status. PUFA were assessed in dried blood spots obtained from a cross-sectional study. Nutritional and health status were assessed by anthropometry, haemoglobinopathies, inflammation and blood counts. Cambodia. The study was conducted with 174 children aged 0·5-18 years with acute malnutrition. Among total fatty acids (FA), the relative percentage of total PUFA was 20 % FA, with 14 % of the children having very low PUFA (mead acid (MA):arachidonic acid (AA) >0·02, n-6 docosapentaenoic acid:DHA >0·2 and total n-6:n-3 PUFA >10·5). Wasting was not associated with any PUFA. Stunting and low height were consistently positively associated with total PUFA and positively with n-6 PUFA. Height was positively associated with n-3 long-chain PUFA (LCPUFA). The presence of haemoglobinopathies or inflammation was positively associated with MA:AA, but not total PUFA. Elevated blood platelet counts were positively correlated with linoleic acid and appeared to be influenced by anaemia (P = 0·010) and inflammation (P = 0·002). Monocyte counts were high during inflammation (P = 0·052) and correlated positively with n-6 LCPUFA and n-3 LCPUFA. Children with acute malnutrition or stunting had low PUFA, while elevated platelets and monocytes were associated with high PUFA. In acutely malnourished children, inflammation could lead to elevated blood cell counts resulting in increased whole-blood PUFA which does not reflect dietary intake or nutritional status.

The Effect of Parental Migration on the Schooling of Children Left Behind in Rural Cambodia

Growing rural-to-urban and international migration flows have sparked concerns about investments in the education of left-behind children in Cambodia. We drew on a panel household-level survey conducted in rural villages in 2014 and 2017 to analyze the relationship between parental migration and schooling of children. The analysis revealed that children of migrant parents lag significantly behind in terms of years of completed schooling. We used the longitudinal dimension of the data to estimate a placebo test, which greatly reduced concerns related to the possible confounding effect of unobserved heterogeneity. The negative effect that we uncovered appeared to be driven largely by reduced parental input in children’s education rather than by an increase in child labor.

Cambodian Developmental Milestone Assessment Tool (cDMAT): Performance reference charts and reliability check of a tool to assess early childhood development in Cambodian children

BackgroundChildhood development milestones are essential skills that define how children participate in their environment socially, physically, and intellectually. A culturally-sensible and environmentally-appropriate tool is needed to assess their performance and detect disabilities at an early stage. MethodThis observational study aimed to create reference charts of performances among healthy rural and semi-rural Cambodian children aged 0–83 months for each milestone using the Denver II-based Cambodian Development Milestone Assessment Tool (cDMAT). Inter-observer reliability testing yielded Kappa scores. Results and conclusion1330 children included in the analyses represented an average population sample with similar gender balance, expected poverty distribution and the illiteracy rate among their mothers (81% with no or attended <7th-grade education). While gender, poverty and the mother's education level were not found to be confounding factors, the child's school enrolment status was (p < 0.005). The performance reference charts document the PASS ratios from which age onwards <25%, 25–75%, 75–90%, 90–99% and 99–100% of the children in each monthly cohort can perform a particular milestone. The mean inter-observer reliability ranged from substantial (Kappa 0.61 for delay) to excellent (Kappa 0.84 for immediate) in all domains. The performance reference charts of a culturally-sensible and environmentally-appropriate cDMAT can be used in Cambodia with special attention given to the child's school enrolment as it was found to be a confounding factor affecting child development. Creating a small-scale pilot program linking the cDMAT to early intervention would help raise awareness and create local expertise on early childhood development.

Perspectives from abroad: Reflections from my time working in a Cambodian children's hospital

In April, I spent a month working at the Angkor Hospital for Children in Siem Reap, Cambodia, with one of my pediatric colleagues, Dr. Jennifer Mann. Hasbro Children's Hospital has had a long partnership with Angkor and has sent many pediatric attendings and residents over the years. I spent the majority of my first weeks there working in the general inpatient unit, where I saw cases that I had never encountered during my time in medical school and residency, as well as many that I had. Due to lower rates of vaccination among Cambodian children, I saw patients with diseases I had only read about in textbooks. I also saw numerous children suffering from severe malnutrition, including an infant where the family was using rice water for feeding after the mother was unable to produce breast milk. I also learned about diseases endemic to the area that I had either never heard of or had only encountered in passing, such as melioidosis and Dengue fever.

The hydro‐logic of genocide: Remaking land, water, and bodies in democratic Kampuchea, 1975–1979

Recent scholarship in hydropolitics and the hydrosocial cycle has emphasised the ways that water and society are co‐constitutive, acknowledging the productive entanglement of hydraulic and social actors and processes. In this paper, we apply a hydrosocial framework to understand an infamous waterscape of mass violence. Between 1975 and 1979, the Khmer Rouge planned and partially implemented an extensive irrigation system to increase rice production in the Cambodian countryside. The programmes of rationing, forced labour, and execution imposed by the government during construction killed up to two million people. We find that these infrastructural projects helped the Khmer Rouge remake water into a technology of capital accumulation and social control. The production of these systems enrolled water as an active agent into new relations of power, providing the state with classification and control over not only water but also the physical bodies of Cambodian men, women, and children. Furthermore, we find the Khmer Rouge's infrastructural violence was predicated on the production of new subjectivities – ones that emerged from a narrow imagination of idealised rice plants and labouring bodies. This case illustrates how a pervasive materialist logic, combined with the imperative of capital accumulation, may evolve into justification for mass murder.

A Comparative Exploration of the Motivational Factors of Faith-Based and Secular NGOs and Their Actors in Cambodia

ABSTRACTSecular and faith-based NGOs are significant non-state service providers in the developing world, yet limited research has been conducted comparing their motivational factors. This paper considers the motivations driving the work of Christian faith-based organisations (FBOs) and secular NGOs working with women and children in Cambodia. The qualitative research design included 41 interviews, with respondents from thirteen FBOs and twelve secular NGOs. The paper makes two substantive arguments. First, faith-related motivations were expressions of the ways in which religious faith infused FBOs in the study. Second, the development context in which the organisations worked led to a clear distinction between FBOs and secular NGOs. The paper makes a theoretical contribution about the importance of considering the convergence of both the development context and the infusion of faith in FBOs when examining similarities and differences between these two types of organisations.