This study was approved by the National Ethics Committee for Health Research, Ministry of Health, Cambodia (Ref 226 NECHR). The national assessment was conducted in three stages between September and December 2017 by the National Center for Tuberculosis and Leprosy Control (CENAT) under technical support of KHANA Center for Population Health Research and Stop TB Partnership.
First, we employed the consensus development method [15, 16] through a two-day consultative workshop held with 70 participants and a validation workshop with participants representing all levels of the national health system in Cambodia and communities included in the multi-stakeholder technical working groups (Table 1). The workshops sought to gather information required for the assessment, opinions on gender- and key population-specific barriers to quality TB services, and the definition and prioritization of key populations and to validate the preliminary findings with the participants, respectively. Opinions gathered from the participants were synthesized, and conclusions were derived through a reflexive process. The participants also ranked the key populations to be prioritized for the national TB response. The participants were grouped into teams of five. Each group was tasked to score a list of 20 key populations up with a minimum of one point to a maximum of 10 using a scoring framework illustrated in Appendix 1. The scores from all groups were tabulated and the combined scores were used to rank the top five key populations to be prioritized.
Table 1
Members of the multi-stakeholder technical working group
Organizations/Groups |
National Center for Tuberculosis and Leprosy Control (CENAT) |
National Center for HIV/AIDS, Dermatology, and STD (NCHADS) |
Ministry of Women Affairs (MoWA) |
General Directorate of Prisons (GDP) |
Non-governmental organizations: - KHANA - Cambodia Anti-Tuberculosis Association (CATA) - Reproductive and Child Health Alliance (RACHA) - Reproductive Health Association of Cambodia (RHAC) - Cambodia Health Committee (CHC) - Catholic Relief Services (CRS) - Operation ASHA (Op-ASHA) |
United Nations and donor agencies - World Health Organization (WHO) - United States Agency for International Development (USAID) |
Community and key population representatives |
Second, we conducted a comprehensive desk review of documents from all levels of the national health system – national programs, provincial health departments, operational districts, health centers, and aid agencies – to obtain information on gender- and key population-related policies and intervention programs in the national TB response (Table 2).
Table 2
Key sources of information included in the desk review for the assessment
Documents | Year | Author/Publisher | References |
National Strategic Development Plan 2014–2018 | 2014 | Ministry of Planning | 20 |
Health Strategic Plan 2008–2015 | 2008 | Ministry of Health | 21 |
Health Strategic Plan 2016–2020 | 2016 | Department of Planning and Health Information | 22 |
National Strategic Plan for Comprehensive and Multi-Sectoral Response to HIV and AIDS III 2011–2015 | 2010 | National Center for HIV/AIDS, Dermatology and STD | 23 |
National Strategic Plan for HIV/AIDS and Prevention and Control in the Health Sector 2016–2020 | 2016 | National AIDS Authority | 24 |
Cambodia Inter-censal Population Survey 2013 | 2013 | National Institute of Statistics | 25 |
Population Projection of Cambodia 2013–2023 | 2013 | National Institute of Statistics | 26 |
National Strategic Plan for Control of Tuberculosis 2014–2020 | 2014 | National Center for Tuberculosis and Leprosy Control | 5 |
Strategic Plan for HIV/AIDS and STI Prevention Control in the Health Sector in Cambodia 2015–2020 | 2014 | National Center for HIV/AIDS, Dermatology and STD | 27 |
Cambodia Demographic and Health Survey 2014 | 2015 | National Institute of Statistics | 28 |
Action Framework for Tuberculosis Key Population | 2017 | Stop TB Partnership and UNAIDS | 10 |
Gender Assessment Tool for National HIV and TB Response | 2017 | Stop TB Partnership and UNAIDS | 11 |
Progress Report of National Center for HIV/AIDS, Dermatology and STD and National Center for Tuberculosis and Leprosy Control 2016 | 2016 | National Center for Tuberculosis and Leprosy Control | 29 |
Abbreviations: HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; STD, sexually transmitted disease; STI, sexually transmitted infections. |
Third, we conducted 19 in-depth interviews (IDIs) with policymakers and implementers in relevant national programs, provincial health departments, operational districts, and health centers as well as representatives of non-governmental organizations (NGOs), aid agencies, TB affected communities, and key populations. Thirty focus group discussions (FGDs) were conducted with nine groups of participants in the capital city of Phnom Penh and six other provinces (Banteay Meanchey, Kampong Chhnang, Prey Veng, Siem Reap, and Takeo). The participant groups included people living with HIV, people with diabetes, elderly aged 55 and above, TB contacts, and people who use and inject drugs (PWUD/PWID). A total of 206 individuals participated in the FGDs. A stratified purposive sampling method was employed to recruit the study participants. Potential participants for the IDIs and FGDs were invited either in-person or via the telephone calls, and emails. All participants provided verbal informed consent before the data collection started.
The data collection was performed by a group of four gender-balanced field data collectors with experience in qualitative research and under close supervision of the principal investigators. A two-day training was conducted to orientate data collectors on the project. Information on the study and its objectives were provided verbally to potential participants. Interviews were arranged with those who agreed to partake at a time and location of their convenience. Each IDI and FGD took between 30 to 45 minutes to complete, and they were audio-recorded and subsequently transcribed verbatim. Participants were reimbursed for their time and effort (equal to USD 5) at the end of the participation.
The IDIs and FGDs were conducted using a semi-structured guide in Khmer. The guide comprised of broad themes to understand the policies protecting gender equality and the rights of other TB key populations, barriers in access to TB services, and current gaps in TB control and prevention efforts. The guide was pilot-tested at the TB clinic of the National Center for Tuberculosis Control and Leprosy Control and the Phnom Penh Municipal Hospital. Individuals who participated in the pilot study were excluded from the main study.
Content analyses were performed on qualitative data using NVIVO 10 (QSR International) by retrieving and categorizing textual references based on the main interview questions. Emerged themes were added to the codebook. Conclusions and recommendations were drawn from pre-existing and emerged themes. Qualitative data were triangulated with findings from the desk review for a comprehensive situational gender and key population assessment of the national TB response in Cambodia.