Hir PT Cambodia

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007
Secondary Prevention of Disabilities in the

Cambodian Provinces of
Siem Reap and Takeo:
Perceptions of and use of the health system to
address health conditions associated with
disability in children
Report prepared for Handicap International Belgium by:

Betsy VanLeit
Prum Rithy
Samol Channa
28th February, 2007
TABLE OF CONTENTS
ABBREVIATIONS LIST..........................................................................................................4
EXECUTIVE SUMMARY .......................................................................................................5
CAMBODIAN CONTEXT .....................................................................................................10
General Context ...................................................................................................................10
Health System in Cambodia.................................................................................................10
Private Health Care System .............................................................................................10
Public health care system in Cambodia ...........................................................................11
Disability in Cambodia ........................................................................................................12
Disability Patterns by Age, Gender, and Rural/Urban Residence ...................................12
Types of Disabilities ........................................................................................................13
Children with Disabilities ................................................................................................13
GAP IDENTIFIED ..................................................................................................................14
Focus on Children ................................................................................................................14
Focus on Specific Provinces ................................................................................................15
Needed Information .............................................................................................................15
STUDY METHODOLOGY ....................................................................................................16
Questionnaire Development.................................................................................................16
Informed Consent.................................................................................................................17
Study Participants: ...............................................................................................................17
Households Where there was a Child with a Disability ..................................................17
Study Participant Households without Children with Disabilities ..................................18
Study Procedures .................................................................................................................19
Data Analysis .......................................................................................................................19
STUDY RESULTS..................................................................................................................20
Demographics of Survey Respondents ................................................................................20
Impairments and Functional Difficulties .............................................................................22
Child Attendance at School .............................................................................................24
History of Disability ............................................................................................................24
Causes of Health Difficulty .............................................................................................24
Health services used since time that health problem was observed.................................27
Additional Information ........................................................................................................32
General Health Perceptions of the Health System...............................................................33
Traditional and Western Health Choices .........................................................................35
Perceived Barriers to Care ...............................................................................................35
Perceptions of People with Disabilities ...........................................................................36
STUDY LIMITATIONS .........................................................................................................36
DISCUSSION OF STUDY RESULTS ...................................................................................36
Demographic Considerations...............................................................................................37
Impairment and functional status of children: inadequate use of existing resources ..........37
Impairment and functional status of children: Gaps in service and resources.....................38
History of disabling conditions and barriers to care ............................................................39
Pregnancy, maternal care and environment: impact on childrens conditions ....................40
MAJOR ISSUES IDENTIFIED ..............................................................................................41
Maternal care and environment: adverse impact on childrens conditions: ........................41
History of disabling conditions: barriers to care..................................................................41
Functional status of children: gaps in availability and use of services and resources .........42
Demographic considerations and issues ..............................................................................42
RECOMMENDATIONS.........................................................................................................42
Direct Action........................................................................................................................42
Cultivation of Health Partnerships.......................................................................................43
2
Strengthening the Capacity and Coordination of the Public Health System .......................43
HIBs proposed role in secondary prevention efforts ..........................................................44
SUMMARY OF THE CONTINUUM OF LEVELS OF HEALTH CARE............................45
ANNEX 1.................................................................................................................................46
ANNEX 2.................................................................................................................................47
ANNEX 3.................................................................................................................................48
ANNEX 4.................................................................................................................................54
ANNEX 5.................................................................................................................................57
ANNEX 6.................................................................................................................................58
ABBREVIATIONS LIST
ABC
BTC
CABDICO
CDHS
CDPO
CHHRA
CMVIS
CPA
CSES
DAC
DFID
DPM
HIB
INGO
LNGO
MOH
MOP
MPA
NCDP
NGO
NIS
NMCHC
PHD
PRC
PWD
OD
RH
RTAVIS
TBA
UNESCAP
UNICEF
URC
USAID
VHSP
WB
WHO
Association for Blind Cambodians

Belgian Technical Cooperation
Capacity Building of People with Disability in the Community Organization
Cambodian Demographic and Health Survey
Cambodian Disabled Peoples Organization
Cambodian Health and Human Rights Alliance
Cambodian Mine Victim Information Service
Complementary Package of Activities
Cambodian Socio-Economic Survey
Disability Action Council
Department for International Development
Department of Preventive Medicine, Ministry of Health
Handicap International Belgium
International Non-Governmental Organization
Local Non-Governmental Organization
Ministry of Health
Ministry of Planning
Minimum Package of Activities
National Centre of Disabled Persons
Non-Governmental Organization
National Institute of Statistics
National Maternal & Child Health Centre
Provincial Health Department
Physical Rehabilitation Centre
People with Disabilities
Operational District
Referral Hospital
Road Traffic Accident and Victim Information Service
Traditional Birth Attendant
United Nations Economic Social Commission in Asia and the Pacific
United Nations Childrens Fund
University Research Company
United States Agency for International Development
Villagers Health Support Group
World Bank
World Health Organization
EXECUTIVE SUMMARY
Background on Disability in Cambodia:
The disability prevalence rate in Cambodia is estimated at 4.7% of the population 1, meaning
that more than half a million Cambodians have a disability. Almost half of the population
with a disability is under 20 years of age. This is concerning because disability early in life
can have a negative impact on school attendance, quality of life and productivity for many
years to come.
Factors in Cambodia that put children at particular risk for disability include lack of antenatal
care or skilled delivery assistance for pregnant women (which may lead to congenital
conditions), as well as serious childhood illnesses (e.g. acute respiratory illness, fever and
diarrhea) that are often untreated by trained health providers 2. Vaccination rates are still low
for poor children, and analyses of height and weight measurements indicate that many
children are stunted or underweight 3. Cambodia still has a high infant and early childhood
mortality rate compared to the rest of the region 4, suggesting that young children are quite
vulnerable to disease and injury.
Rationale for the HIB Disability Study:
Although it is clear that problems during early childhood may lead to disability, we wanted to
know what the critical historical health factors were in households with an identified child
with a disability. Thus, we undertook a survey of 500 households in the provinces of Siem
Reap and Takeo where there was a child with a disability. We asked questions to learn what
caused the disability, how the family had used the health system, and how they perceived the
services they had used. All families signed an informed consent form before we administered
the interviews. We also surveyed 500 neighboring households where there was not a child
with a disability to learn additional information about community perceptions of the health
system.
HIB Study Results:
The following description highlights study findings from the 500 households where there was
a child with a disability as well as the 500 additional general household interviews in Siem
Reap and Takeo. The data from the two provinces were aggregated after an initial analysis
indicated that results were similar for both locations.
Demographics of Respondent Households (500 households with a child with a disability)
Most (71%) of the survey respondents in the households where there was a child with a
disability were the mothers. The children ranged in age from infancy to 18 years old, and
47% of them were 7-14 years old. Somewhat more than half of the children were boys. Most
of the parents identified themselves as farmers, and many (47%) reported having no
education. Respondent households were poor; in fact 48% of them reported making less than
4000 riels per day (the equivalent of 1 US dollar). The typical household in the survey had 49 family members living at home.
1
Knowles, JC (2005). Health, Vulnerability and Poverty in Cambodia: Analysis of the 2005 Cambodia Socio-Economic Survey
National Institute of Public Health and National Institute of Statistics [Cambodia] and ORC Macro. (2006). Cambodia
Demographic and Health Survey 2005. Phnom Penh and Calverton, Maryland, USA.
3
Ibid.
4
World Bank (2006) HNP at a Glance: Cambodia (accessed on World Bank website on 1/07)
2
Childrens Impairments and Functional Difficulties (500 households)

A quarter of the children with disabilities had difficulty seeing (ranging from mild visual
impairment to blindness). Almost none of the children wore glasses. Similarly, a quarter of
the children had difficulty hearing (ranging from mild hearing difficulty to deafness).
Approximately 42% of the children had difficulty with mobility, but only half of that group
had some type of walking aid (wheelchair, prosthesis, etc.). Many respondents reported that
they did not know where to get needed equipment, or they were concerned about cost.
Parents also reported that a significant number of children had trouble speaking,
understanding when others were speaking, playing or talking to others, learning at school,
remembering or concentrating on tasks, and holding and using objects with their hands. A
surprisingly large proportion of children had difficulty with activities because of emotional
problems (53%) or pain (42%). Of the school-aged children, 55% had attended some school,
but most of them only attended one or two grades.
History of Disability (500 households)
Respondents could give more than one answer concerning the illness or injury that led to
their child becoming disabled. A large percentage of respondents (40%) reported that their
child had something wrong at birth (congenital condition). Sickness was identified as a
causal factor in the childs disability for 46% of households. More than half of those who
reported sickness as a major problem stated that the disease involved fever, often
accompanied by convulsions. The next most commonly reported cause was accidents. A
large percentage of respondents (43%) stated that the childs health condition that led to
disability started within the first month of life, and 70% indicated that the problem had started
within the first year.
Families used a variety of services when their child developed a health condition including
hospitals, health centres, private facilities and providers, pharmacies, traditional healers,
rehabilitation centers and village health volunteers. Generally reported satisfaction was
highest for hospitals, but there was a range of satisfaction with each type of service used. A
large proportion (67%) of respondents stated that they wished they had used additional health
services for their children, especially hospitals. The main barriers to service use included the
costs of transportation, health services, and medications; costs associated with missing work
or buying food; lack of knowledge about relevant services or how to access them; and
distance to facilities. In summarizing, parents suggested that the reasons their children
eventually developed permanent disabilities had to do with financial costs, poor or inadequate
treatment, bad karma, bad luck and a lack of knowledge of the health care system.
Over half (56%) of the mothers of the children with disabilities reported receiving no
antenatal care, and of those who did, 52% was provided by midwives and 25% was provided
by traditional birth attendants (TBAs). A similar proportion (56%) had no postnatal care.
most of the antenatal care that did occur was provided by TBAs. Many (62%) of the mothers
stated that their children had problems in infancy, and as described earlier, the problems often
were associated with high fever and convulsions. In addition, most of the respondents (62%)
reported obtained their water from unprotected sources, and only 10% had indoor plumbing
or an outhouse, suggesting that basic sanitation was an issue in many households.
General Perceptions of the Health System (data from all 1000 households)
About three quarters of the respondents felt that their community was most susceptible to
illness and injury because of poor sanitation, poverty and poor nutrition. They reported
getting their information about health predominantly from television, radio, village meetings,
posters (more so in Takeo than Siem Reap), and friends and neighbors. Many felt that access
to and quality of health services was adequate or good, but many also felt that costs were
6
high. More than half of respondents reported that they would choose to take a sick family
member to the hospital (62%) or health centre (58%). A large percentage (82%) would
choose to take an injured family member to the hospital and 50% would take an injured
family member to the health centre. However, the cost barrier (for transportation, care, food,
medicine and lost work time) was viewed as prohibitive by most respondents.
We also asked respondents which conditions were effectively treated by traditional healers
and which were effectively treated by western style providers. Respondents preferred
traditional healers for broken bones. For all other conditions, western providers were
preferred.
Issues Identified from Study Results
Many children who end up with permanent disabling conditions have congenital
problems (associated with lack of antenatal and postnatal care, or treatable health
problems) very early in life
Families do not seek needed treatment because they are concerned about costs, dont
know what services are available, or dont realize that conditions in early infancy can
lead to permanent disability (and may be treatable)
There are currently very limited services available to help infants and children with
developmental disabilities, and many do not end up attending school
Parents of children with disabilities have limited education, time and money to
address their childrens needs and may not be aware of existing resources
Recommended Approach
Secondary prevention is the critical bridge that connects primary health care and
rehabilitation. In secondary prevention, health problems are identified early, and services and
referrals are provided to assure rapid, effective interventions that minimize the possibility of
permanent disability. In order to respond to the issues identified in the previous section, we
propose the following activities:
Direct Action
There is a need for screening and early detection training activities:
Local health providers such as Village Health Support Group Volunteers, TBAs, and Health
Centre staff need to be able to:
Recognize serious illness and injury and refer children to hospitals for treatment
Recognize congenital or other childhood developmental problems and refer families
to community-based early intervention services (as they become available)
Recognize serious congenital or other childhood developmental problems and refer
families to targeted hospitals that have expertise in early childhood evaluation and
intervention as appropriate
There is a need for community-based early intervention services:
Families of children with disabilities need low-cost, local, simple interventions and solutions
to help their children function as effectively as possible. Early intervention activities need to
be participatory and empowering, so that families become actively involved in decisionmaking and problem-solving concerning the needs of their children. The goal is for the
families to evolve into effective self-help groups.
7
There is a need for education concerning how to use the health system:
Families need to know what types of services are actually relevant and available, and how to
access financial support for services or identify services that are free of charge.
Cultivation of Health Partnerships
There is a need for organizations involved in activities to improve maternal and child health
outcomes to communicate and collaborate well
It is impossible to overstate the importance of collaboration in the health sector to
synergistically strengthen and develop a web of coordinated services that meet prevention
needs. Effective partnerships in the health system will better support families in need of
services. These partnerships need to include international organizations, local NGOs, and
government facilities and providers. The end result of increased collaboration will be a more
seamlessly provided continuum of services.
There is a need to for communication and coordination between organizations addressing the
needs of children with disabilities in different sectors (e.g. rehabilitation and education)
The needs of children with disabilities do not neatly fit any particular sector boundaries and
are actually multi-dimensional. For example, organizations involved in advocating for
mainstreaming of children with disabilities in the schools need to work closely with
organizations involved in rehabilitation in order to assure positive educational outcomes for
children with disabilities.
Strengthening the Capacity and Coordination of the Public Health System
There is a need for the MOH to take the lead in assuring an effective continuum of health
services to prevent avoidable disability
The Department of Preventive Medicine in the MOH is the appropriate governmental body to
assume leadership in assuring secondary prevention action in the health sector. By taking
responsibility for secondary prevention, the MOH can then instruct the Public Health
Department (PHD) concerning health service provision.
There is a need to address issues of financial cost in the health system
Cost of services, transportation, food etc. are clearly critical to decision-making concerning
using health services. It will be tremendously helpful if the evolving health equity fund
system provides funding for the kinds of services needed in secondary prevention, covers
associated costs (e.g. transportation) and is clearly communicated to those in need of
financial support to use the health care system.
There is a need for different departments in the MOH to work closely together to address
secondary prevention needs
There are close links between maternal health, child health and disability prevention. The
National Maternal and Child Health Centre is responsible for addressing concerns about
maternal mortality, and focusing attention on antenatal, delivery and postnatal care issues. It
is clear that these maternal concerns also impact the health of and prevention of disability in
infants.
SUMMARY OF THE CONTINUUM OF LEVELS OF HEALTH CARE

PRIMARY PREVENTION
SECONDARY PREVENTION
Prenatal and postnatal care are

provided regularly to women
Women are encouraged to deliver

babies while accompanied by
skilled providers
Local providers receive training

from NGOs to improve the
quality of prenatal and postnatal
care
Local providers (health centres,
TBAs etc.) can refer women for
health services if the pregnancy
seems to be high risk in any way
Pregnant women need to have
adequate
nutrition and sanitation and
shelter while they are pregnant
Barriers to services (access and
cost) are addressed adequately in
the health system
The referral system is functional
so that families obtain and can
follow through with referrals
The Ministry of Health
recognizes the relationship of
primary, secondary and tertiary
prevention, and advocates for
health services on a continuum
Local providers are trained to

refer women for health services if
the delivery has problems or the
newborn has a congenital
condition or becomes ill or
injured
Doctors and nurses at identified
hospitals have specialized
training in recognizing and
treating congenital conditions or
health problems that manifest
early in life
Community-based providers have
training to provide early
intervention services to families
and to foster self-help groups
Community-based providers are
knowledgeable about other
resources that may benefit
families, and make referrals as
appropriate (e.g. to the PRC for
mobility devices)
TERTIARY PREVENTION
(REHABILITATION)
Providers trained in rehabilitation
provide appropriate services to young
children with disabilities (including
technical services for children with
clubfoot, cerebral palsy, etc.)
Outreach workers provide communitybased rehabilitation services to
children and families
Families are made aware of all of the
services that might benefit their child
with a disability, even in early infancy
Families are encouraged to send their
child with a disability to school
The school system recognizes that
children with disabilities should
receive an education, and works to
overcome barriers that may hinder
school participation (e.g. need for
special accommodations and
equipment)
Barriers to service (e.g. cost and
transportation) are addressed
adequately so that families can
actually use them
Families know the importance of

seeking immediate attention if the
newborn or infant becomes ill
Barriers to services (especially
access and cost) are addressed
adequately
recognizes secondary prevention
as an important component of an
effective healthcare system and
facilitates the development of
secondary prevention
CAMBODIAN CONTEXT
General Context
Cambodia currently ranks 129th out of 177 of countries in the United Nations Human
Development Index (HDI), and 73rd among 102 developing countries for the Human Poverty
Index (HPI-1) 5. Many aspects of Cambodian society were effectively destroyed by about
500,000 tons of American bombs between 1972 and 1974 and the Khmer Rouge regime that
followed during which more than 1.5 million out of 7 million people died. This was followed
by the Vietnamese liberation-occupation that ended officially with the Paris Peace Accords of
1991. Only during the past 10 years has the country has entered a period of stability, and
achieved economic growth of about 7.4% per annum. 6
For many rural Cambodians, living conditions have failed to improve, and in many cases
have worsened in the face of growing inequalities, e.g. in terms of asset ownership. The
health dimension is an important factor in this regard. Access to health care is reported as the
first reason for impoverishment in Cambodia 7. The public service has difficulties providing
adequate health care, and a lack of transparency in the handling of the state budget hampers
the development of government services. With a health sector that has many basic needs,
disability related issues are not seen as a priority, and rehabilitation services often rely on
external assistance to function 8.
There are about 13 million people in Cambodia, with an annual growth rate between 1998
and 2004 of 1.8% 9 (refer to annex 1). There has been a high birth rate in recent years, and
children make up almost half of the population. Over 84% of Cambodians live in rural areas,
and the average population density is 74 inhabitants per kilometer. Most rural Cambodians
make their living growing rice. At present, 35% of Cambodians live below the poverty
line 10.
Health System in Cambodia
The Cambodian healthcare system has a formal public component, and a private, informal
component 11. Cambodians actively use both systems, so it is necessary to give some
consideration to their individual structure and function while recognizing that there is limited
communication between them.
Private Health Care System
Rural Cambodians are most likely to use the private health care system 12. Unregulated
private clinics are common, and private practitioners (who often lack training in pharmacy or
healthcare) are rarely regulated by the Ministry of Health. Treatment commonly consists of
injections as well as oral medications that are often self-prescribed. Traditional medicine is
also practiced extensively in Cambodia, especially in the rural areas. Traditional healers
called Kru Khmer, are often consulted first or solely by villagers in need of healthcare.
5
United Nations Development Programme (2006). Human Development Report 2006. New York: Palgrave Macmillan.
World Bank Report (2006). Cambodia: Halving Poverty by 2015? Poverty Assessment 2006
ibid
8
Gregson KJ., Sandhy, S., Vien, K., & Soeng, S. (2006). Evaluation of the Physical Rehabilitation Sector in Cambodia
9
Cambodian Ministry of Planning, National Institute of Statistics (2004). The 2004 Cambodia Socio Economic Survey Report.
Phnom Penh.
10
World Bank (2005). World Development Report 2006 Overview : Equity and Development. New York: Oxford University
Press.
11
Van de Put (DATE ?). Empty hospitals, thriving business : Utilization of health services, and health seeking behaviour in two
Cambodian districts. Report on Medical Anthropological Research in Cambodia.
12
Cambodian Ministry of Planninng, National Institute of Statistics (2004). The 2004 Cambodian Socio-Economic Survey
Report. Phnom Penh.
6
7
10
Traditional healers will often provide services on a barter basis, and are flexible in the
amount of payment they expect. This is important to poor people who may have little income
to spend on health care.
Public health care system in Cambodia
In August 2002, the Ministry of Health (in agreement with objectives set out by of the
Association of South East Asian Nations or ASEAN) adopted a Strategic Plan of the Health
Sector for 20032007 13. The plan espoused pro-poor policies, and emphasized the following
areas: health services delivery; behavioural change of health providers; quality improvement;
human resources development; health financing; and institutional development. The health
services delivery priorities that are most pertinent to primary and secondary prevention
efforts include the following objectives:
1. To further improve coverage and access to health services especially for the poor and
other vulnerable groups through strategic location of health facilities.
2. To strengthen the delivery of quality basic health services through health centres
based on Minimum Package of Activities
3. To strengthen the delivery of quality care, especially for obstetric and pediatric care,
in all hospitals through measures such as the Complementary Package of Activities
A series of health sector reforms beginning in 1996 led to the current National Health
Coverage Plan (NHCP) that is provided in 73 Operational Districts (ODs) 14. The Provincial
Health Department (PHD) is the administrative structure that manages the ODs. (See
organization chart of Provincial health department in annex 2)
Each OD is responsible for a network of health centres providing a Minimum Package of
Activities (MPA) and referral hospitals (district and provincial level) that provide a
Complementary Package of Activities (CPA). There are 3 levels of CPA provision, with
provincial hospitals (CPA 3) providing the largest array of specialty and ancillary services.
In the CPA 2 hospitals (typically district level) and CPA 3, the following services are
recommended for the end of 2007: community based rehabilitation, health education, and
some physical rehabilitation. It is clear that such a system of health centres and hospitals
requires an effective referral system to function well, and there is currently an ongoing study
by the URC Health Sector Strengthening Project to examine how well the referral system is
operating 15.
At the community level, commune councils have the responsibility of overseeing the function
of the health centres, and primary health care is supposed to be administered with guidance
from a Villagers Support Group for Health whose members operate on a volunteer basis.
Health centre catchment areas cover 7-14,000 people, and each Health Centre typically has 612 employees (typically including 2 levels of nurses, and 2 levels of midwives).
Supported by international donors, health equity funds are cash benefits designed to improve
access for the poor to the public health system 16 17. There are currently a number of different
equity fund projects around the country. Some require pre-registration and some do not.
Different plans cover different costs which may include various components of care and/or
transportation. Health equity funds encourage the poor to use the public health system, and
13
Strategic Plan 2003-2007 of the Health Sector of the Ministry of Health, August 2002
HLSP Consulting Asia (2002). Final Report: Provision of Basic Health Services in the Provinces of Siem Reap and Odor
Meanchey, Cambodia, July 2002
15
Draft Guidelines for Referral Systems in Cambodia, August 2005
16
Meesen, B., Van Damme, W., Tashobya, CK., & Tibouti, A. (2006). Poverty and user fees for public health care in lowincome countries: lessons from Uganda and Cambodia. The Lancet, 368, pp 2253-2257.
17
Ministry of Health, World Health Organization and Belgian Technical Cooperation (2006). Report: Health Equity Fund Forum,
01-03 February 2006. Phnom Penh.
14
11
they also serve as a financial incentive for public health providers to treat, as the equity funds
boost the income of the hospitals and the budget for staff bonuses.
Disability in Cambodia
A recent national socio-economic survey identified the disability prevalence rate at 4.7% of
the population 18, which suggests that more than half a million Cambodians are disabled.
Disability Patterns by Age, Gender, and Rural/Urban Residence
The 2004 CSES data indicates that reported disability rates increase with age. However,
Cambodia has a young population, so actual numbers tell a different story. Although almost
41% of those 75 or over have a disability, they only account for 1.3% of the disabled
population in Cambodia, and conversely, although only 1.1% of 0-4 year olds have a
disability, they account for 9.9% of all disabilities 19
Table A. Mean percentages of the population with one or more reported disabilities by age, 2004
Population
distribution
Age group
Male
Female
Urban
Rural
Total
(%)
0-4 years
1.3
0.9
0.7
1.2
1.1
9.9
5-9 years
1.2
0.9
0.7
1.1
1.1
11.9
10-14 years
1.5
1.4
0.8
1.5
1.4
14.5
15-19 years
1.7
1.3
0.7
1.6
1.5
12.3
20-24 years
1.7
1.8
1.2
1.9
1.8
10.6
25-34 years
3.7
3.0
2.8
3.4
3.3
12.6
35-44 years
7.1
4.6
4.4
6.0
5.8
11.4
45-54 years
10.5
8.8
7.3
9.9
9.5
8.1
55-64 years
13.7
17.3
14.3
16.1
15.8
4.9
65-74 years
25.9
29.4
27.6
28.0
27.9
2.9
75 and more
41.0
40.6
30.2
42.7
40.8
1.3
Total
4.5
4.9
4.0
4.9
4.7
100.0
Source: 2004 CSES (15-month sample), Reported in Knowles (2005).
The main reported causes of disability include old age (27%) and disease (26%). Knowles
grouped health-related causes together and found that they accounted for 35% of all reported
disabilities 20. An analysis of causes of disability indicates that there is variation by age,
gender and rural or urban residence. For example, accidents/injuries are most common among
working age males, reported non-communicable diseases (e.g. diabetes and hypertension)
increase with age, and communicable diseases are more commonly reported by rural
residents and the poor. The poor report most common causes of disability as including:
mines/UXO, malnutrition, violent attacks, domestic violence, mental trauma and bad luck,
whereas the rich report major causes of disability as including: old age, traffic accidents and
disease 21.
Table B. Distribution of the reported causes of disabilities by sex and by urban-rural residence, 2004
Reported cause of disability
Male
Female
Urban
Rural
Total
Mine, UXO
6.4
0.8
2.3
3.6
3.4
Traffic accident
3.4
2.2
4.2
2.6
2.8
Work accident
5.6
2.1
3.3
3.8
3.7
Disease
23.8
27.5
25.5
25.8
25.8
Old age
22.2
30.6
30.5
26.2
26.7
18
Ibid.
20
Ibid, p 7.
21
Ibid, p 8.
19
12

Reported cause of disability
Male
Female
Urban
Congenital
9.4
8.0
7.9
Fever
5.8
5.9
2.7
Difficult obstetric delivery
0.0
2.6
0.7
Chemical accident
0.5
0.4
0.3
Rape
0.0
0.0
0.0
Violent attack
0.3
0.3
0.6
Domestic violence
0.1
0.7
0.4
Suicide attempt
0.2
0.0
0.0
Mental trauma
1.0
1.4
1.4
War injuries
6.1
1.0
4.2
Malnutrition
1.2
2.8
1.3
Burns
0.4
0.1
0.3
Torture
0.1
0.2
0.0
Bad luck
1.4
1.1
1.2
Other
7.9
7.2
8.8
Not known
4.2
5.0
4.4
Total
100.0
100.0
100.0
Source: 2004 CSES (15-month sample). Reported in Knowles, 2005.
Rural
8.8
6.3
1.5
0.5
0.0
0.2
0.4
0.1
1.2
3.2
2.2
0.2
0.2
1.3
7.3
4.7
100.0
Total
8.7
5.9
1.4
0.5
0.0
0.3
0.4
0.1
1.2
3.3
2.1
0.2
0.2
1.3
7.5
4.6
100.0
Types of Disabilities
The CSES data indicates that 22% of people with disabilities report more than one type of
disability. Vision-related problems are the most commonly reported type of disability, and
mobility-related disabilities are the next frequently identified problem. Females are more
likely to report vision-related and mental disabilities, and males are more likely to report
mobility-related disabilities.
Table C. Distribution of reported types of disability by sex and urban-rural residence, 2004
Type of disability
Male
Female
Urban
Rural
Vision
27.1
31.5
31.8
29.2
Hearing
14.7
15.5
15.1
15.1
Speaking
4.4
4.9
4.6
4.7
Mobility
26.1
21.3
18.8
24.1
Feeling (tactile)
11.3
10.2
12.6
10.4
Mental
6.3
10.7
8.1
8.8
Learning difficulties
1.4
0.9
1.2
1.2
Fits/epilepsy
1.5
1.3
1.1
1.4
Other
7.2
3.7
6.6
5.1
Total
100.0
100.0
100.0
100.0
Source: 2004 CSES (15-month sample) Reported in Knowles (2005).
Total
29.5
15.1
4.7
23.5
10.7
8.7
1.2
1.4
5.3
100.0
Children with Disabilities

As we have seen, children make up a large proportion of the disabled population in
Cambodia. This is concerning, because disability early in life can have a negative impact on
quality of life and productivity for many years to come.
Children with disabilities are much less likely to attend school because their disabilities
required special services (e.g. accommodations for vision and hearing impairments) that are
not typically available in Cambodian schools 22. Stigma and discrimination also appear to
play a role in keeping children out of school 23 24. This is obviously problematic in that
education is crucial to improving later employment and earning prospects.
22
Thomas, P (2005). Poverty Reduction and Development in Cambodia : Enabling Disabled People to Play a Role. Disability
Knowledge and Research Programme, funded by DFID.
24
Analyzing Development Issues Team (2006). The Challenge of Living with Disability in Rural Cambodia: A Study of Mobility
Impaired People in the Social Setting of Prey Veng District, Prey Veng Province. Funded by CCC and VI.
23
13
The CSES collected data about the causes of disability, but the information was not analyzed
by age group (refer to Table B). However, several of the leading identified causes of
disability include disease (reported as the cause by 26% of respondents), congenital
conditions (9%) and fever (6%), and it is plausible that these causes may account for
much of childhood disability.
Concerns about childhood disease and congenital conditions that could lead to disability are
corroborated by a recent Cambodian Demographic and Health Survey (CDHS) report 25. This
extensive nationwide study indicates that many pregnant women did not receive antenatal
care from health professionals and that the number of babies delivered by health
professionals or in health facilities was very low, particularly in rural areas. Obviously the
risks for birth complications and disability increase when women do not have access to health
professionals and facilities before and during delivery.
The CDHS report 26 suggests that serious childhood illnesses including acute respiratory
illness (cough with short rapid breathing or difficulty breathing), fever, and diarrhea are
common, but often go untreated in health facilities or by trained health providers. The
percentage of children who received some type of oral rehydration treatment for diarrhea
varied across the country. In Siem Reap it was 33.6% and in Takeo it was 53.3%. This data
indicates that many children are not being taken for treatment when they have childhood
illnesses that put them at risk for developing disabilities. In addition, vaccination rates for
children are still low, particularly for poor children and in provinces outside Phnom Penh.
Finally, analyses of height and weight measurements indicate that 37% of children are
stunted, 7% are wasted, and 36% are underweight 27. These conditions all suggest acute
and/or chronic illness or inadequate food supplies, and are implicated in the development of
disability. Similarly, the 2005 CSES 28 found that children under 5 continue to demonstrate
protein-energy malnutrition at very high rates probably because of incorrect infant-feeding
practices coupled with infections, high risk of diarrhea and (especially in rural provinces)
inadequate food supply.
GAP IDENTIFIED
Focus on Children
A Cambodian picture emerges suggesting that a number of factors put children at risk for
development of disability. In fact, Cambodia still has a high infant and early childhood
mortality rate compared to the rest of the region (1 in 12 children die before reaching their 5th
birthday) 29. Many international organizations are engaged in implementation of primary
prevention efforts (e.g. improving vaccination rates or access to nutritious food), but there is
a gap concerning secondary prevention. The governmental expenditure on public health is
only 2% of the gross domestic product 30. Early screening, detection and referral of children
at risk for disability could potentially have a great impact in minimizing the negative impact
25
National Institute of Public Health and National Institute of Statistics [Cambodia] and ORC Macro (2006). Cambodia
Demographic and Health Survey 2005. Phnom Penh, Cambodia and Calverton, Maryland, USA.
26
ibid
27
ibid
28
29
National Institute of Public Health, National Institute of Statistics [Cambodia], and ORC Macro (2006).
Demographic and Health Survey 2005. Phnom Penh, Cambodia and Calverton, Maryland, USA.
30
World Bank (2006) HNP at a Glance: Cambodia (accessed on World Bank website on 1/07).
Cambodia
14
of serious disease, congenital conditions or trauma, but these services are not currently
available to Cambodians. Based on this contextual information, we made the decision made
to focus our secondary prevention attention on infants and children.
Focus on Specific Provinces
The provinces of Siem Reap and Takeo were chosen because Handicap International is
already very active in those provinces, so extending services from tertiary prevention
(rehabilitation) to include secondary prevention would be a logical expansion of current
activities and could capitalize on existing resources and relationships.
Needed Information
However, in order to develop targeted, appropriate and effective secondary prevention
strategies, we needed some additional information. Although it is clear that problems during
pregnancy, delivery or early childhood can lead to disability, we did not actually have health
history information for identified children with disabilities that would prove the hypothetical
link and provide specific guidance for secondary prevention development. We needed to
know the following:
What was actually meant when people report that there was a child in their household
with a disability? The CSES provided a gross picture of disability prevalence and
types of disabilities reported, but this information did not really provide clear
information about the actual functional status and participation of children with
disabilities. (This information would help us to better understand the population we
wished to serve)
How did children proceed from a congenital condition, illness or injury to having a
permanent disability? How had the family reacted, how had they used the health
system, and how effective had those interventions actually been? In addition, what
was the impact of having a child with a disability on the family? (This information
would help us understand how the health system was actually being used when there
is a child in a household with a serious health condition as well as perceptions about
the strengths and weaknesses of the existing system)
What kind of antenatal and postnatal care had the mother had? What were the
circumstances in the household that may have had an impact on development of
childhood disability? (This information would give us a better picture of the interplay
of risk factors early in the life of identified children with disabilities)
In general, how do people in two rural provinces perceive health issues in their
community? How do they get health information? How do they view the health
system strengths and weaknesses? Where would they go for help? What are the
barriers to obtaining needed services? (This information would help us identify the
most effective strategies for assuring secondary prevention)
And finally, how do people in the rural provinces view people with disabilities? (This
information would help us to gain some insight into decision-making made in
households where there was a child with a disability)
15
These questions became the basis for a survey in Siem Reap and Takeo that would help us to
develop needed secondary prevention activities in a more targeted manner. Fieldwork to
collect data occurred from October through December 2006.
STUDY METHODOLOGY
Questionnaire Development
Existing disability instruments that were scrutinized for possible use for the study included:
World Health Organization Disability Assessment Schedule or WHODAS II 31, Ten Question
Questionnaire 32, Washington Group Question Set 33, and the WHO/UNESCAP Disability
Questionnaire Version A 34. None of these tools was sufficient to obtain the data that we
needed, although some questions from these instruments were used in our final survey tool.
Two questionnaires were developed for the study to answer the questions raised in the
previous section. The first, entitled: Disability in Cambodian Provinces of Siem Reap and
Takeo (refer to annex 3 for questionnaire) was developed by the HIB Project Manager over
a period of three months with input from multiple individuals and organizations. The
intended respondent was typically an adult who was the parent or significant caregiver of the
child with the disability. Interviewers encouraged the children with disabilities to also be
present during the interview if possible. If the child with the disability was old enough to
respond to some questions (10 years or older) and cognitively intact, then the surveyor had
the option of interviewing the child as the main respondent.
The questionnaire included a demographic section that asked about members of the
household (number and relationships, economic status, educational status etc.) The next
section asked for a description of the impairments and activity limitations of the child with a
disability. This section was critical for a good understanding of how the child was actually
functioning as opposed to just labeling a child as disabled. The next section asked about
the history of the disability- events that led from initial episode(s) of sickness, injury or
congenital condition to permanent disability, and how the family used the health system
during that period. The next section asked questions about the mothers pregnancy and
delivery of the child with the disability as well as questions pertaining to the childs infancy,
and the environment in which the child was living. These questions were included to better
determine the extent to which events during pregnancy and early childhood influenced the
development of disabling conditions.
The shorter questionnaire entitled Cambodian Health Perceptions Survey (refer to annex 4
for questionnaire) was used with respondents who had children with disabilities, and also
respondents who did not have children with disabilities. It included a demographic section,
followed by questions that probed respondents views about why people get sick or injured,
how they obtain health information, how they view the health system, what types of health
services and providers they would use (or not), and how they perceive people with
disabilities.
31
World Health Organization (2000). World Health Organization Disability Assessment Schedule (WHODAS II). February
2000
32
Stein, Z, Belmont L., & Durkin, M (1987).Mild mental retardation and severe mental retardation compared: experiences in
eight less developed countries. Upsala Journal of Medical Science 44 (Suppl) 89-96.
33
Madans J. (2006). The definition and measurement of disability: The work of the Washington Group (powerpoint
presentation, November 2006)
34
WHO/UNESCAP Project on Health and Disability Statistics: Disability Question Set Testing (workshop in Bangkok, June,
2006).
16
Questionnaire development, translation, pilot testing, and revisions occurred during August
September, 2006. We also did some field interviews with health service providers in Siem
Reap and Takeo including Health Centre staff members, PRC staff members, Hospital
administrators, traditional healers, TBAs, NGO representatives, and Village Health Support
Group volunteers to gain their perspectives as well. Finally, input was solicited from a range
of key informants including groups representing people with disabilities (e.g. CDPO, ABC,
NCDP, CABDICO), organizations involved in the health sector (e.g. World Bank, Save the
Children Australia and CARE), and organizations involved with disability-related work (e.g.
Cambodia Trust, Maryknoll, Krousar Thmey, CCMH etc.).
Informed Consent
We also developed an informed consent form for all respondents (refer to annex 5 for the
English translation of the form). The interviewer was instructed to read the informed consent
form aloud, and then respond to any questions that potential study participants had about the
study. Respondents then had the option to sign the informed consent form (using a
thumbprint if necessary) or not. Interviews were only conducted after informed consent had
been obtained in this manner.
Study Participants:
Households Where there was a Child with a Disability
We wished to administer the Disability in Cambodian Provinces of Siem Reap and Takeo
to a sample that reflected the population of rural households where there were children with
disabilities. Thus, we used a purposeful approach to sampling, targeting households where
there was known to be a child with a disability. We used the database from CABDICO to
select participants in Siem Reap because it covered multiple districts in the province and
provided a wide range of subjects in terms of age and type of disability. CABDICO has
existed (initially as a program of Handicap International Belgium) since 1999, and has
interviewed and worked with many people in the community who have a disability.
CABDICOs database categorized disabilities in the following way: vision problems (one or
both eyes blind, or low vision); mobility problems (clubfoot, polio, amputee, hemiplegia and
other more rare conditions); hearing/speech problems (deaf, deaf mute, cleft palate); mental
retardation, (this category also included Downs syndrome, epilepsy); and cerebral palsy.
To choose the sample, first we selected all children in the CABDICO database born between
1988 and 2006, and then sorted the database by childs birth year into three groups (0-6 years,
7-14 years, and 15-18 years). These age groups corresponded grossly to preschool age
children, school-aged children, and those who might be in the workforce or less commonly in
secondary school. Because we were particularly interested in learning about events leading
to disability (e.g. related to early childhood illness or a difficult delivery) we chose fewer
households with children in their later teen years. This choice was based on the rationale that
it would be difficult for families to remember events that occurred many years ago.
As the 2004 CSES 35 reported that the main types of disability in Cambodia included
problems in the areas of vision, hearing, mobility, feeling (tactile), and mental function, we
wanted to be sure to include children with those types of conditions. These categories lacked
clear definitions, and the CSES results were based on self-perceptions, but we knew that we
were interested in a wide variety of types of disabilities.
35
Ministry of Planning, National Institute of Statistics (2004). The 2004 Cambodia Socio-Economic Survey Report. Phnom
Penh, Cambodia.
17
Next, we sorted the names according to age and type of impairment/disability so that we had
15 subgroups (see table D). Then we randomly chose names from each age-disability type
subgroup until we had the totals identified below. Unfortunately, the CABDICO database had
fewer children proportionally who were 0-4 years old, so we were not always able to choose
as many very young children as we would have liked (and thus the resulting numbers in each
category differed somewhat from the ideal described in Table D).
To identify a sample in Takeo, we obtained household names from several different
organizations including the HIB Physical Rehabilitation Center in Takeo, Rehabilitation of
the Blind in Cambodia (RBC), Krousar Thmey (works with deaf children) and the Childrens
Centre for Mental Health (CCMH). These datasets did not give us the number of children
needed who had visual impairments, hearing impairments or mental impairments, so in some
cases we asked Village Leaders to help identify households where there was a child with the
type of impairment we were looking for.
Table D: Planned Stratified Sample of Children with Disabilities per Province
Type of impairment
0-6 years old
7-14 years
15-18 years
Visual impairment
20
20
10
Hearing impairment
20
20
10
Moving impairment
20
20
20
Mental impairment
20
20
-Multiple impairment
20
20
10
TOTALS per province
100
100
50
TOTALS
50
50
60
40
50
250
In the field, if the interviewer was unable to find a respondent (e.g. the family had moved or
the child had died), then s/he was instructed to ask the Village Chief or village members for
the name of another household where there was a child with a disability. We made this
choice to minimize extensive unscheduled travel time. It often took hours to get to a village
and find a household. To start over and go to another village would have been expensive and
it would have been impossible to finish the interviews in a timely manner. This meant that in
the end the numbers of children with specific types of impairments was not identical to the
sample frame in the above chart.
Study Participant Households without Children with Disabilities
In addition to the households described above we also administered the Cambodian Health
Perceptions Survey to neighboring rural families where there was not a child with a
disability. After completing the interview (both questionnaires) in a household where there
was a child with a disability, interviewers were instructed to leave the house, turn left, and
then go to the next house they encountered where someone was home and there was not a
child with a disability. There, they were instructed to request permission to administer the
Cambodian Health Perceptions Survey. This gave us a simple, somewhat crude way of
matching general households to households where there was a child with a disability.
We chose a total sample of 1000 households: 500 in Siem Reap (250 with a child with a
disability and 250 without); and 500 in Takeo (250 with a child with a disability and 250
without). This sample size allowed us to have a least 20 subjects in each of the stratified
subgroups that we were most interested in (see table D). Time and financial restraints also
played a role in sample size determination.
18
Study Procedures
Interviewer Training
Six interviewers were hired to complete all of the interviews. They received two and a half
days of training from the HIB Project Manager, Project Officer, Data Officer and Field
Supervisor. A training manual for field surveying was developed and used to assist the
training process and as a reference for interviewers throughout the survey period. All
materials were initially written in English and then translated into Khmer by the HIB
translator. Most of the interviewer training was conducted in Khmer, although the Project
Managers involvement required a certain amount of translation between Khmer and English.
The interviewers practiced administering the questionnaires, first to each other, and then to
volunteer PRC clients with supervision and feedback until all of the interviewers could
administer the survey correctly on their own. In the field, interviewers were again supervised
until we were assured of their consistency and competence.
Field Procedures
On a daily basis, each interviewer was expected to complete two interviews in households
where there was a child with a disability (the longer interview) as well as two shorter
interviews in neighboring households where there was not a child with a disability. This was
not always possible in the most remote operational districts of the provinces where there were
great distances between houses, and the roads were quite rudimentary. In addition, as we
surveyed during the rainy season, it was sometimes very difficult to travel on motorbikes in
areas that were flooded. Interviewers sometimes were able to get around in boats under those
circumstances. Finally, it was sometimes difficult to find participants at home during the
harvest season when they were out in the rice fields. At those times, the interviewers were
instructed to arrange a more suitable time when they could come back to complete the
interview.
In each household, the interviewer explained the purpose of the survey, and then read the
one-page informed consent form out loud. If the participant was willing to sign the consent
form, then the interviewer could go on to administer the questionnaire.
Field Supervision
A field supervisor was hired to supervise the interviewers on a daily basis in the field. She
was responsible for quality control, and checked the completed questionnaires at the end of
the day to make sure that they were completed thoroughly and clearly. The Field Supervisor
observed interviewers on a regular basis to assure that interviews were handled professionally
and according to protocol. She also handled issues related to finding households, contacting
local authorities, organizing transport, finding rural accommodation as needed, assuring team
security or any other practical difficulties that arose on a day to day basis.
Data Analysis
We used the database Access to enter field data. Later, the SPSS statistical package was
used for data analysis. Two data enterers were hired and trained to enter all of the data under
the supervision of the data officer. The data officer was responsible for checking and
cleaning the data, and he was assisted in this task by the Project Officer. The project
manager provided input concerning all unusual or unique coding and data entry questions and
oversaw all data analysis. Data was analyzed descriptively for this study report.
19
STUDY RESULTS
Initially the data from the two provinces were analyzed separately to determine whether there
were differences between them. We found only minor differences on a few questions, so the
decision was made to aggregate the data and analyze it as one dataset. Thus, the following
description about households where there is a child with a disability (refer to questionnaire in
annex 3) reports findings from 500 households in Siem Reap and Takeo provinces. We also
analyzed the data from the two subgroups (500 households where there was a child with a
disability and 500 households where there was not) and found that they were very similar.
Thus we aggregated the data from all 1000 households and will report some results for the
entire study sample (refer to questionnaire in annex 4). We will point out the few instances
where there were differences between the two provinces or groups.
Demographics of Survey Respondents
Family Financial Status (all 1000 households)
Almost half of the respondents (48%) were very poor, and reported making less than 4000
riels per day (the equivalent of 1 US dollar). Another 34% made the equivalent of 1-2 US
dollars per day, and only 18% made more than that.
Land Ownership of Family (all 1000 households)
Ninety-four percent (94%) of families in the study reported owning their own home and land.
Four percent (4%) reported no ownership, 2% owned just the home, and 1% owned just their
land. However, we did not ask whether families actually had titles or other documentation of
their land and home ownership.
Family Members at Home (all 1000 households)
The majority of survey families had 4-7 family members living at home with an average of
6.7. The number of family members living together ranged from 2-15.
Number of Households
Figure 1: Number of Family Members Living at Home
Number of Family Members
20
Relationship of Survey Respondent to Child with Disability (500 households)

The great majority of the survey respondents were mothers of the children with a disability.
Table 1: Relationship of Respondent to Target Child
Frequency
Percentage
Mother
356
71%
Father
67
13%
Grandmother
39
8%
Brother
3
1%
Sister
11
2%
Grandfather
10
2%
Other
14
3%
Total
500
100%
Age and Gender of Children (500 households)

As previously described, we originally intended to have a greater proportion of young
children in the survey, but the database was skewed toward older children which made
sampling young children problematic. Pragmatic field decisions (when we were unable to
find a subject) also affected the final age distribution.
Table 2: Age and gender of children
Age
Frequency
1 years
20
2 -3 years
26
4 6 years
92
7 to 14 years
231
15 to 18 years
131
Gender
Male
Female
TOTAL
273
227
500
Percentage
4%
5%
19%
46%
26%
55%
45%
100%
Parental occupation and education (500 households)

The vast majority of parents (71% of fathers and 74% of mothers) identified themselves as
farmers. In Takeo, the percentage of parents who farmed was about 10% less than the
percentage in Siem Reap. Because our survey was carried out during the harvest time of the
year, the interviewers sometimes conducted the interviews out in the field or arranged to meet
with respondents when they were not in the rice fields. Other respondents stated that they
were self employed, or labored for others, but their numbers were small. Ten percent of the
fathers (48) and 5% of the mothers (18) were reported to be dead.
The respondents in the two provinces differed somewhat in years of education. In Siem
Reap, the majority of parents of children with disabilities reported never having gone to
school. In Takeo, there was much more variation with a range of 0-12 years of education.
21

Table 3: Years of Parental Education
Years of
Fathers
Education
(Takeo)
0
84 (34%)
1
6 (2%)
2
7 (3%)
3
16 (6%)
4
21 (8%)
5
15 (6%)
6
18 (7%)
7
35 (14%)
8
17 (7%)
9
19 (8%)
10-12
12 (5%)
TOTAL
250
Mothers
(Takeo)
78 (31%)
8 (3%)
16 (6%)
31 (13%)
32 (13%)
26 (10%)
17 (7%)
22 (9%)
7 (3%)
9 (4%)
4 (1%)
250
Fathers
(Siem Reap)
150 (60%)
5 (2%)
20 (8%)
22 (9%)
16 (6%)
5 (2%)
8 (3%)
9 (4%)
9 (4%)
4 (2%)
2 (1%)
250
Mothers
(Siem Reap)
160 (64%)
16 (6%)
17 (7%)
20 (8%)
14 (6%)
9 (4%)
4 (2%)
3 (1%)
3 (1%)
4 (2%)
0 (0%)
250
TOTALS
472 (47%)
35 (3%)
60 (6%)
89 (9%)
83 (8%)
55 (5%)
47 (5%)
69 (7%)
36 (4%)
36 (4%)
18 (2%)
1000
Impairments and Functional Difficulties

Respondents were asked about problems experienced by their children pertaining to seeing;
hearing; communicating and interacting; learning, concentrating and remembering; holding
and using objects; moving; emotional conditions (e.g. anxiety or depression); pain; breathing
difficulties; and convulsions or blackouts. Some of these questions emphasized difficulty
associated with physical or mental impairments, and some pertained more specifically to
activity difficulties. All had been identified in previous literature as important to function in
daily life 36 37. The results are described below in Tables 4 10.
Table 4: Respondent report concerning child visual performance
Difficulty seeing
Number
Not difficult
375
Somewhat difficult
49
Difficult
76
Total
500
Percentage
75%
10%
15%
100%
The 125 respondents who reported that their child had some difficulty or difficulty
seeing were then asked about the use of eyeglasses. Eight (8) or 2% of the group did wear
glasses. The other 117 did not. Of this group who did not wear glasses, 29 respondents felt
that the condition was not serious enough to warrant their use. A few stated that the
condition was too serious to be amenable to glasses. Others identified barriers related to
accessing and affording glasses or other equipment.
Table 5: Respondent report concerning child auditory performance
Difficulty Hearing
Frequency
Not difficult
377
Somewhat difficult
41
Difficult
82
Total
500
Percentage
75%
8%
17%
100%
Responses to this question were similar to the ones related to seeing. Of the 123 children
who had some difficulty or difficulty hearing, 5 wore hearing aids. Nineteen respondents felt
that the condition was not serious enough for hearing aids, and the others did not know how
to access or pay for them, felt that the condition was too serious for adaptive aids, or stated
that the child was too young to wear them.
36
37
UN Dept of Economic and Social Affairs (2001). Guidelines and Principles for the Development of Disability Statistics.
WHO/UNESCAP Project on Health and Disability Statistics (2005). Disability Statistics Training Manual (draft).
22
Tables 6 and 7 describe difficulty in a variety of tasks associated with interpersonal

relationships, communication and cognition. About 30-50% of children had at least some
difficulty in one or more of these important areas.
Table 6: Respondent report of child communication/relationship performance
Does you child have difficulty with the
No Sometimes
Yes
following task?
Speaking ( child over 2 years)
295 (59%)
45 (9%)
142 (28%)
Understanding when others are speaking 317 (63%)
86 (17%)
77 (15%)
Playing with or talking to others
258 (52%) 104 (21%)
121 (24%)
N/A*
18 (4%)
20 (4%)
17 (3%)
Total
100%
500
500
500
N/A*
20 (4%)
19 (4%)
12 (2%)
Total
100%
500
500
500
*N/A applies to children that respondents felt were too young to demonstrate these skills.
Table 7: Respondent report of child cognitive (mental) performance on tasks

Does your child have difficulty with
the following task?
No Sometimes
Yes
Learning at school or home
230 (46%) 121 (24%)
129 (26%)
Remembering things
295 (59%) 109 (22%)
77 (15%)
Concentrating on tasks
263 (53%)
78 (16%)
147 (29%)
*N/A applies to children who respondents felt were too young to demonstrate these skills.
Table 8 provides information concerning basic sensory and sensory-motor tasks. More than a
quarter of the children were reported to have at least some difficulty in these areas.
Table 8: Respondent report of child sensory performance on tasks
the following task?
Gripping, holding or using tools or
other things
Feeling things with his/her hands or
feet
No
Sometimes
Yes
N/A*
Total
100%
352 (71%)
72 (14%)
70 (14%)
6 (1%)
500
348 (70%)
70 (14%)
72 (14%)
10 (2%)
500
Table 9 describes performance associated with movement and mobility. Approximately a

third of all children had some difficulty in this domain.
Table 9: Respondent report of child movement-related performance on tasks
the following task?
No
Sometimes
Yes
Moving around in the house
329 (70%)
66 (13%)
94 (19%)
Moving outside the house
301 (60%)
68 (14%)
118 (24%)
Walking on an even surface for 50
meters
319 (64%)
53 (11%)
115 (23%)
Climbing steps
310 (62%)
63 (13%)
114 (23%)
N/A*
11(2%)
13 (3%)
13 (3%)
13 (3%)
Total
100%
500
500
500
500
A total of 208 children had some type of difficulty moving around. Parents of 52% of those
children reported the use of some type of walking aid (wheelchair, prosthesis, orthotic device
or crutch). That meant that 100 (or 48%) of the children with mobility concerns did not use
any type of adaptive equipment or device. When asked why not, about half of them (49)
reported that they didnt feel that the condition was serious enough. The other half indicated
that they did not know where to find equipment or they were concerned that they couldnt
pay for it.
We also asked respondents about the impact of general factors such as emotional conditions,
pain, breathing problems and convulsions (fits) on function, and learned that a relatively
high percentage of children had difficulty with each of these areas of concern.
23

Table 10: Respondent report of other factors associated with task performance
tasks because of this factor?
No
Sometimes
Yes
Emotional condition*
219 (44%)
143 (28%) 124 (25%)
Pain
277 (58%)
130 (27%)
88 (15%)
Breathing difficulty
344 (79%)
97 (19%)
59 (12%)
Convulsions or blackouts
342 (69%)
** 158 (32%)
N/A
14 (3%)
5 (0%)
0
0
Total
500
500
500
500
*includes anxiety, sadness, worry, depression, and strange thoughts or ideas

** In this question we asked simply whether the child ever had convulsions or blackouts yes or no
Child Attendance at School

Ninety-eight (98) of the children were less than 6 years old, and so would not be expected to
attend school. This left 402 children who were school-aged. Of this group, 223 of them
(55%) actually attended school. The other 179 (45%) did not attend school at all.
Figure 2: Grade Attendance and Age of Child
35
Number of children
30
25
Age
20
6-8
9-11
15
12-14
15-18
10
5
0
G1
G2
G3
G4
G5
G6
G7
G8
G9
G 10
It is apparent from Graph 2 that many of the children who did attend school stopped after the
early grades, even the older children. We also asked (for those who did attend school) about
their regularity of attendance, and most (78%) reported regular attendance. Seventeen (17)
respondents reported that their children attended special education classes for the deaf or
blind provided by Krousar Thmey.
Reasons given for not attending school included: problems with transportation, teachers not
knowing how to teach children with disabilities, difficulties with accessibility, lack of special
equipment, expenses associated with school, sickness, pain, a need for the child to help with
work around the house, and discrimination.
History of Disability
Causes of Health Difficulty
Respondents gave a variety of reasons when asked what they thought caused their childs
health condition that led to a disability. Table 11 gives specific frequencies and percentages.
24

Table 11: Reported Cause of Disability
Stated Cause
Frequency* Percentage of 500
Sickness or disease
228
46%
Congenital
199
40%
Accident at play/work
76
15%
Bad karma (past life)
49
10%
Bad luck
40
8%
Injections
23
5%
Malnutrition
17
3%
Difficult birth
11
2%
No vaccinations
5
1%
Violence
4
1%
Chemical or drug
4
1%
Traffic accident
3
1%
Other**
30
6%
*Respondents could give more than one reason, so total is greater than 500
** Other reasons identified included maternal health problems, genetic reasons,
a fall suffered when the child was leaving the house, a mine accident, a burn,
or a belief that the problem was caused by a dead ancestor.
The majority of respondents reported that their childs health problem began at birth or within
the first year of life.
Table 12: Length of time until beginning of childs health problem
Length of time until beginning of problem Frequency Percentage of 500
Less than one month
One to six months
> 6 months to 12 months
> 12 months to 24 months
> 24 months
TOTAL
216
79
55
37
113
500
43%
16%
11%
7%
23%
100%
For the 228 respondents who reported that their child had become disabled because of illness
or disease, we then asked for a name of a disease or some type of description of it. More than
half of them described fever (hot disease) or often fever accompanied by convulsions.
Others described a variety of conditions including unconsciousness, ear infections, vomiting
and diarrhea, measles, meningitis, dengue fever, difficulty breathing, asthma, pneumonia,
tuberculosis, various kinds of infections and skin conditions including blisters and boils.
When asked who provided a diagnosis, 42% reported that they named the disease themselves
and 34% referred to family members or friends. Doctors made the diagnosis 12% of the time,
and other providers including traditional healers, and nurses rarely identified the condition.
We were also interested to explore correlations between the cause of the childs health
condition and the types of functional impairments reported. Table 13 gives specifics
concerning those associations. No obvious patterns emerge different causes of health
conditions appear to be diffusely distributed in terms of the kinds of impairments and activity
limitations that are resultant.
25
Fits, blackouts or loss

consciousness
Breathing problems
pain that makes daily

activities difficult
Concentrating
Emotional problem
Climbing
steps
Walking on an even
surface for 50 meters
Moving outside
the house
Moving around
in the house
Feeling things with

his/her hands or feet
Remembering
things
Gripping, holding or
using tools or other things
26
Learning at school,
home or work place
Playing or
talking to others
Understanding when
others are speaking
Speaking
Hearing
Table 13:
History of Health Condition and
Difficulty with Activities
Seeing
TOTAL
Difficult birth
97
Sickness or disease
41
61
90
87
100
127
105
73
73
87
99
88
96
130
149
104
87
107
1704
Accident traffic
13
Accident play/ work
27
41
11
16
18
30
23
15
17
24
25
24
29
35
50
47
22
19
473
Accident mine/ UXO
Chemical substance or drugs
27
Rape/violent attack/domestic violence
25
Malnutrition
11
10
10
10
11
130
Burn (acid or fire)
Bad luck
15
20
18
22
16
16
12
11
12
14
13
12
15
25
16
16
12
272
Bad karma (from past life)
10
24
31
25
32
24
23
11
15
10
12
11
11
26
32
17
22
13
349
Injections
13
10
12
15
15
16
13
19
12
10
170
Didnt have vaccinations
48
1280
Congenital
61
53
88
67
102
100
63
50
50
47
62
55
55
107
151
74
57
38
Other
10
16
17
13
17
11
13
13
13
13
14
13
14
13
12
218
Total
157
212
270
241
317
355
265
203
206
226
265
239
256
369
471
306
231
222
4811
Health services used since time that health problem was observed
Respondents were asked to identify all of the services their child used after the onset of
the congenital condition, injury or sickness and how helpful they found the services.
These are listed in Table 14. Respondents could list all services that they used, so the
numbers are higher than the number of respondents. Overall, respondents reported that
services they used were helpful 27% of the time, somewhat helpful 36% of the time and
not helpful 37% of the time.
Table 14: Facilities/services used by respondents and rating of helpfulness
Facility or Service used
Frequency of use
not helpful somewhat helpful
(% of 500)
Traditional healer
156 (31%)
79
52
Rehabilitation Centre
111 (22%)
25
34
Kantha Bopha Hospital^
101 (20%)
23
37
Health Centre
90 (18%)
39
39
Provincial Hospital
81 (16%)
38
18
Pharmacy
73 (15%)
19
41
Angkor Childrens Hospital^
54 (11%)
12
13
No treatment
48 (10%)
41
2
Self treatment
48 (10%)
21
22
Referral (district) Hospital
47 (9%)
22
16
Private Hospital+
46 (9%)
15
21
Private Clinic
45 (9%)
16
21
Village Health Volunteer
39 (8%)
14
18
National Hospital
15 (3%)
5
4
Other *
116 (23%)
42
52
helpful
26
53
38
13
25
14
27
0
4
8
10
10
4
6
52
*Other responses included Ochambak Hospital (listed 28 times for eye care), Caritas Organization (listed 17 times for eye care), Chey
Chunmas Hospital (listed 16 times for mental health care), other unidentified hospitals associated with various organizations, Takmao
Hospital, The Keankhlang PRC, the Battambang Hospital, Krousar Thmey for deaf services, a Thai hospital, a Japanese hospital, a
Heart hospital, a Vietnamese hospital, and other hospitals in various provinces in Cambodia.
+Some respondents reported using a private hospital, but did not specify which one they used
^These are both private, internationally funded pediatric hospitals in Siem Reap
Respondents were also asked to identify which service/facility they used first, and how
satisfied they were their choice (Table 15). There were a variety of views concerning
satisfaction with each type of health facility or provider. Proportionally, those with the
highest levels of satisfaction went to the private pediatric hospitals in Siem Reap or to
specific rehabilitation centres.
27
Table 15: Respondent satisfaction with initial treatment for child

First service used
Frequency
Not at all
Somewhat
of first use
satisfied
satisfied
% of 500
Traditional Healer
80 (16%)
30
33
Health Centre
44 (9%)
12
23
Kantha Bopha Hospital
40 (8%)
11
18
Rehabilitation Centre
38 (8%)
4
9
Private Hospital+
35 (7%)
12
20
Provincial Hospital
31 (6%)
13
10
Angkor Childrens Hospital
28 (6%)
2
10
Private Clinic
26 (5%)
10
8
Pharmacy
25 (5%)
6
14
Referral Hospital
20 (4%)
5
13
Village Health Volunteer
19 (4%)
8
7
National Hospital
7 (1%)
3
1
Other*
65 (13%)
19
25
No treatment or self treatment
42 (8%)
40
2
TOTAL
500
135
191
Very
satisfied
15
9
12
25
3
8
14
8
5
2
2
3
18
0
124
* Other includes CABDICO, Krousar Thmey, Heart Hospital, Thailand provider, other organizations and hospitals.
+ refers to unspecified private hospital
1
1
2
1
1
1
11
1
3
1
1
2
2
1
4
2
1
14
5
1
4
2
5
7
1
6
34
5
2
3
6
1
7
5
2
6
41
4
2
2
2
4
1
1
1
0
1
6
1
23
10
3
10
4
24
1
8
31
13
9
20
12
22
167
28
Other
Congenital
No vaccinations
2
2
1
1
1
2
1
1
1
Injections
Burn
Malnutrition
Drug abuse
substance or rugs
Violence
Mine Accident
Play/Work Accident
Traffic Accident
1
11
1
9
6
5
5
3
1
16
1
2
3
12
75
Bad karma
2
1
1
12
4
22
10
20
22
15
2
51
7
17
15
26
223
Bad luck
Provincial hospital
National hospital
Private hospital
Referral hospital
Health centre
Private clinic
Pharmacy
Rehabilitation center
Traditional healer
Angkor children hospital
Kunthabopha hospital
Village health volunteer
Other
Total
Sickness or
disease
Table 16:
Reported Cause of
Disability and
First Service Used
Difficult birth
Table 16 gives associations between the first service chosen and the reported cause of the
childs disability. There are no clearly defined use patterns for different types of
conditions. Instead, facility and provider use appear diffusely distributed for each type of
health problem identified.
3
1
4
1
1
1
1
4
3
5
2
2
28
We were also interested in logistical and financial issues related to respondents first
treatment choices. Not surprisingly, respondents reported using motorbikes most often to
go to health facilities, and the next most common transportation methods included
walking and taxis. In Siem Reap, walking and bicycling for care were more common
than in Tako. On the other hand, taxi use was almost exclusively reported in Takeo.
Table 17: Transportation to Health Facilities
Type of Transport
Motorbike
Walked
Taxi or tuk tuk
Bicycle
Bus
Boat
Ambulance
None: Treated by provider at home
No treatment or self treatment
Other*
Frequency**
147
83
80
60
14
5
4
45
57
5
Percentage of 500
29%
17%
16%
12%
3%
1%
1%
9%
11%
1%
*other responses included oxcarts, horse carts, and cars that belonged to NGOs.
** total does not equal 500 because some respondents stayed at home for treatment and some used more than one type of transport
In many cases there were no transportation costs because respondents walked, rode
bicycles, got free rides from friends or organizations, or received treatment at home. In
the end 236 respondents reported transportation expenses. Slightly more than half of
those who did pay for transportation reported costs between 500 and 10,000 riels. Most
of the others paid up to 50,000 riels and 7 respondents paid more than that.
We were interested in knowing how long the child spent at the first health facility used,
as this would also typically affect parental time as well. Figure 3 indicates that there was
a wide variety of time spent:
number of respondents
Figure 3: Time spent at first treatment facility

200
180
160
140
120
100
80
60
40
20
0
186
163
66
28
0h
22
<=1h
2h to 5h
35
6h to 12h 13h to 24h
>24h
Number of hours
29
Reported costs of the first treatment ranged from nothing to greater than 500,000 riels.
More than a third of respondents (36%) spent between 10,000 and 50,000 riels. When
there was a financial charge, families reported paying for the treatment themselves 70%
of the time.
Figure 4: Cost of initial treatment for child

200
180
160
140
120
100
80
60
40
20
0
180
112
79
59
54
16
500R to
10000R
10000R to
50000R
50000R to
100000R
100000R to
500000R
>500000R
No cost*
Number of Riels
*No payment was reported if the person self-treated, went to a private pediatric hospital, saw a traditional healer, went to the
Physical Rehabilitation Centre or had a free check up at the Health Centre.
In addition to direct treatment costs, there also opportunity costs associated with lost
work time. Many parents reported losing an hour to a month, and a few lost as many as 3
months work time. Table 20 describes that particular cost dimension of the childs
condition to the parents.
250
200
200
150
100
118
96
50
25
50
11
>90 day
>30 day
to 90
day
>10 day
to 30
day
>1day
to
10day
1h to
24h
(1day)
0
No time
lost
Figure 5: Lost parental work time in response to child injury or illness
Amount of time
When asked if there were services that families had not initially used, that they wished
they have used, the answer was a resounding yes on the part of 337 (67%) of the
respondents. As seen in Table 18, provincial hospitals topped the list, followed next by
national hospitals and rehabilitation centres.
30

Table 18: Services which families wished they had used for their child
Type of facility or service
Frequency of response*
Percentage of 337
Provincial hospital
81
24%
National hospital
44
13%
Rehabilitation Center
33
10%
Private Hospital+
24
7%
Kantha Bopha Hospital
21
6%
Traditional Healer
18
5%
Angkor Childrens Hospital
17
5%
Referral Hospital
11
3%
Private Clinic
10
3%
Health Centre
3
1%
Other**
110
33%
*Total =376 and reflects the fact that not all respondents wanted additional services, but some identified more than 1 that they wanted
+Some respondents chose private hospital without specifying which one they were referring to
** Other responses included going to: specialty eye care hospitals or service providers, going for specialty mental health services,
obtaining doctors or services from other countries, going to other hospitals in Cambodia. or seeing monks who also are healers
Respondents reported a variety of reasons why they did not initially use the service(s)
that they wished that had obtained. As can be seen in Table 19, more than two thirds of
the responses concerned cost.
Table 19: Reasons for not obtaining needed health services for child
Reason given
Frequency of response*
Cost of service or medication
135
Cost of transportation
224
Could not afford to buy food
90
Distance to service
80
Didnt know how to access service
121
Didnt trust health providers
6
Other**
46
Percentage of 337
40%
66.5%
27%
24%
36%
2%
14%
* Total reasons given = 702 and reflects the fact that respondents were allowed to give multiple responses
** Other reasons included not knowing what was available, thinking that the situation wasnt serious,
assuming that there was no treatment (e.g. for congenital conditions), or being too busy to take the child for care.
Finally, families were asked to summarize why they thought that their child ended up
developing a disability. Many of the answers had to do with finances or concern about
the health system, but some also revolved around issues of bad luck and karma (related to
past lives or ancestors).
Table 20: Perceptions about why child developed a serious disability
Reason given
Lack of knowledge about health system
185
37%
Cost of treatment
176
35%
Poor or inadequate treatment
170
34%
Lack of money for medicine
163
33%
Bad karma
106
21%
Bad luck
74
15%
Lack of money for transportation
25
5%
Child just born that way
22
4%
Bad advice from others
7
1%
Other**
60
12%
*Numbers equal more than 500 because respondents could give more than one answer.
** Other answers included malnutrition, lack of time to get care for child, or too far to services or didnt seek treatment
31
Additional Information
In order to better understand the history of the development of the childs disabling
condition, we also asked questions concerning antenatal care for the mother, issues
concerning pregnancy and delivery, postnatal care, early childhood issues, and the
general environmental conditions of the home (water and sanitation). We were
concerned that in some households, the childs problem may have begun even before
birth without the family necessarily understanding that was the case.
The majority of women reported that they had no antenatal care. The range was 0-8
visits with a mean of 1.4 visits for both antenatal and postnatal care.
Table 21: Number of antenatal visits and postnatal visits
Number of visits
Antenatal visits
Frequency and %
0
277 (56%)
1
26 (5%)
2
49 (10%)
3
76 (15%)
4
32 (6%)
5
25 (5%)
6
7 (1%)
7
4 (1%)
8
4 (1%)
Dont know
0 (0%)
TOTAL
500
Postnatal visits
Frequency and %
278 (56%)
73 (15%)
52 (10%)
75 (15%)
3 (1%)
7 (1%)
3 (0%)
5 (1%)
0 (0%)
4 (1%)
500
More women in Takeo reported antenatal care and postnatal care than women in Siem
Reap, and there were some differences concerning who actually provided antenatal,
delivery and postnatal care as seen in Table 22.
Table 22: Antenatal, Delivery and Postnatal Care in Siem Reap and Takeo
Antenatal Care
Delivery
Type of
Siem
Siem
Provider
Reap Takeo Total
Reap Takeo Total
0
4
0
3
Doctor
4
3
18
26
2
16
Nurse
44
18
38
79
36
59
Midwife
117
95
46
9
211
170
TBA
55
381
0
3
1
2
other
3
3
Total
102
121
223
250
250
500
Postnatal Care
Siem
Reap
2
5
20
70
5
102
Takeo
1
17
37
55
6
116
Total
3
22
57
125
11
218
Twenty two percent (22%) of all women reported that they thought their pregnancy was
difficult. Almost all (90%) had their baby at home, and the vast majority of them were
attended by a TBA during delivery. Only 4% of all women went to a hospital, another
4% used a health centre and 2% reported using private facilities for delivery.
32
Only 7% of the women thought reported that they thought their baby was premature, but
76 (or 15%) estimated that their baby was only 1-2 kilograms when born. Almost all of
the women stated that they breastfed their child (however we did not ask detailed
questions about this topic). Only about 10% of the respondents were sure about which
vaccinations their child had received, and the number of vaccinations reported ranged
from 0-9, with 219 respondents reporting that they didnt know how many had been
given.
Many of the women (307 or 62%) reported that their child had problems in infancy,
including high fever (the most commonly cited problem by 135 women) convulsions,
falls, dengue fever, and other assorted conditions including unspecified eye problems,
pneumonia, asthma, difficulty breathing, diarrhea and vomiting, measles, unspecified
weakness or abnormalities in the limbs, loss of consciousness, ear infection and various
skin conditions such as boils and blisters.
Finally, in response to basic environmental health questions, 62% of the respondents
reported that their water came from an unprotected well or from a spring or river, and the
vast majority (90%) did not have indoor plumbing or an outhouse. Almost all (96%)
stated that they did sleep in beds protected from mosquitoes, although we did not probe to
determine what exactly was meant by this response.
General Health Perceptions of the Health System (1000 households)
In order to learn about Cambodian views of the health system, we started by asking
respondents perceptions of the main reason(s) why people in their community became
sick or injured. Most people gave more than one response.
Table 23: Respondent perceptions of why community members get sick or injured
Reason given
Frequency*
Percentage of 1000
Poor sanitation
773
77%
Poor nutrition
714
71%
Poverty
646
65%
Distance to health care
184
18%
Chemicals in food
116
12%
Cost of health care
98
10%
Lack of immunizations
83
8%
Changes in weather
66
7%
Poor quality health care
57
6%
Landmines and UXO
44
4%
Bad luck
42
4%
Mosquito bites
37
4%
Congenital problems
30
3%
Unsafe roads
31
3%
Lack of pharmacies
24
2%
Karma
15
2%
Other**
61
6%
*Total is greater than 1000 because respondents could give more than one answer
**Other responses included: unsafe homes; dangerous work or play places; lack of clean water;
lack of knowledge about health; and bird flu
33
When asked where they get their information about health issues, the most common
responses were television or radio, followed by village meetings. There was one
noticeable difference between responses in the two provinces: in Takeo, posters were
rated as a much more important form of information than they were in Siem Reap (195 of
the 287 affirmative responses about the importance of posters came from Takeo).
Table 24: Respondent sources of health information
Information source
Television
754
75%
Radio
611
61%
Village meetings
397
40%
Posters
287
29%
Village Chief
230
23%
NGOs or other organizations**
224
22%
Friends and neighbors
203
20%
Health system providers+
71
7%
Billboards
65
7%
School
17
2%
Newspaper or magazine
11
1%
*Total is greater than 1000 because respondents could give more than one answer
** Included RHAC, RACHA, RACHANA, PACT, SEDA, CEDAC, Koma, Red Cross and World Vision
+Included VHSG, referral hospital staff, health centre staff
Respondents were then asked to rate the quality of and access to a range of health
facilities and providers. The responses are tabulated in Table 25. Many of the
respondents knew nothing about the possibility of using health equity funds to pay for
services or other related costs. Most respondents seemed fairly satisfied with both the
quality and accessibility of health facilities and some providers.
Table 25: Respondent perceptions of health service quality and access
Characteristic rated
Bad
OK
Good
(% of 1000) (% of 1000) (% of 1000)
Access to hospital
150 (15%)
333 (33%)
503 (50%)
Quality of hospital
40 (4%)
406 (41%)
540 (54%)
Access to health center
90 (9%)
487 (49%)
415 (42%)
Quality of health center
87 (9%)
659 (66%)
248 (25%)
Access to doctors
70 (7%)
214 (21%)
673 (67%)
Quality of doctors
39 (4%)
233 (23%)
685 (69%)
Access to private providers
89 (9%)
366 (37%)
519 (52%)
Quality of private providers
90 (9%)
606 (61%)
279 (28%)
Access to traditional healers
60 (6%)
432 (43%)
472 (47%)
Quality of traditional healers
250 (26%)
658 (66%)
57 (6%)
Cost of health care
362 (36%)
525 (53%)
109 (11%)
expensive
moderately inexpensive
expensive
Access to health equity funds
31 (3%)
105 (11%)
329 (33%)
Access to pharmacies
135 (14%)
679 (68%)
175 (18%)
Quality of pharmacies
48 (5%)
477 (48%)
464 (47%)
Dont Know
(% of 1000)
14 (2%)
14 (2%)
8 (1%)
6 (1%)
43 (4%)
43 (4%)
26 (3%)
25 (3%)
36 (4%)
35 (4%)
4 (<1%)
Total
535 (54%)
11 (1%)
11 (1%)
1000
1000
1000
1000
1000
1000
1000
1000
1000
1000
1000
1000
1000
1000
When asked to identify where they would go if a family member was sick or injured, the
majority indicated that they would go to the hospital, especially in the case of injury.
Many also stated that they would consider going to a health centre for any kind of health
34
condition. Of course the responses only indicate what people thought they would do
hypothetically. It is clear from the previous dataset (in which respondents were asked
what they actually had done) that the there were in fact barriers (either real or perceived)
to obtaining hospital care.
Table 36: Care preferences for seriously sick or injured family members
Facility/service chosen
Frequency if sick
Frequency if injured
( % of 1000)
(% of 1000)
Hospital
615 (62%)
815 (82%)
Health Center
584 (58%)
495 (50%)
Private Provider
309 (31%)
256 (26%)
Traditional healer
75 (8%)
138 (14%)
Talk to family or friend
74 (7%)
76 (8%)
Self treat
147 (15%)
7 (1%)
Other**
42 (4%)
11 (1%)
*Answers total more than 1000 because respondents could give more than one response.
**In other some respondents specifically specified one of the two pediatric hospitals in Siem Reap
Traditional and Western Health Choices

Respondents were asked to identify which types of health conditions were best treated by
traditional healers, and which should be treated by western medicine. They were allowed
to answer both if they felt that both types of providers were able to treat the condition
effectively. Interestingly, broken bones were the only type of condition that respondents
thought were better treated by traditional healers than western style providers: 77% of
respondents thought that traditional healers did a good job of treating broken bones, and
51% believed that western medicine did a good job. For all other conditions, many more
respondents chose western healthcare over traditional forms of healing. The only other
conditions where quite a few respondents thought that traditional healers were
particularly helpful involved cerebral palsy (33%), measles (36%) and chickenpox (36%).
Perceived Barriers to Care
When asked why they might not seek help for health conditions, 94% of respondents
reported that they perceived significant barriers as listed in the following table:
Table 27: Barriers to Seeking Health Care Services
Identified Barrier
Frequency of Response*
Cost of transportation
750
Cost of health care
479
Cost of medicine
476
Lack of money to buy food
401
Lack of transportation
278
Dont know where to go
19
Other**
29
Percentage of 1000
75%
48%
48%
40%
28%
2%
3%
*The total is greater than 1000 as respondents could choose more than one.
**Other barriers included not being able to miss work, and not liking or trusting the hospital or health centre
Not surprisingly, 88% of respondents reported that missing work to school to manage a
family members health problem would have very harmful financial repercussions.
When asked whose role it was to take care of those who were sick or injured (respondents
could give more than one answer), 80% identified family members. Twenty one percent
35
(21%) thought it was the hospitals role, and a few respondents suggested a role for
neighbors, village leaders, NGOs or the government.
Perceptions of People with Disabilities
Finally, we asked a number of questions designed to assess respondents perceptions of
people with disabilities. All 1000 respondents felt that people with disabilities deserved
treatment to improve their quality of life. Similarly, 98% thought that children with
disabilities should be allowed to go to school, and 97% felt that adults should be able and
allowed to work. Somewhat fewer respondents, (88%) believed that people with
disabilities should be allowed to get married, and 91% thought that it was appropriate for
them to have children. Those who felt that people with disabilities should not get married
or have children often pointed to practical concerns that it would be hard for them to
work, make a living, and feed a family. Some suggested that it would be difficult for a
person with a disability to attract a spouse, and that discrimination or poor treatment by
others might make daily activities and tasks problematic or put the person at risk for
harm. No one mentioned karma as a rationale for differential treatment.
STUDY LIMITATIONS
This study was only administered in 1000 households in two provinces in rural
Cambodia. Half of those households had a child with a disability and half did not. Thus
caution must be used in generalizing the results to the country at large. However, most of
the results were quite similar for the two provinces (in different parts Cambodia),
suggesting that responses to questions were not entirely dependent on specific location in
the country.
We used certain targeted databases to find households where there were children with
disabilities. Thus, the sample may be biased in certain ways (e.g. almost all of the
households had some type of contact with an NGO), and not reflective of the entire
population of households where there is a child with a disability in Cambodia.
DISCUSSION OF STUDY RESULTS

This household study helps to confirm and clarify a number of factors that will be
important in conceptualizing secondary prevention needs and potential activities. As far
as we know, it is the first survey in Cambodia to provide a description of how an
identified group of children with disabilities first became sick or injured (or started with a
congenital condition), how the families used the health system to address their childrens
needs, what the perceived barriers were, how they would imagine using the health system
in the future, and how the children are functioning at present. The study assists us to
identify important issues that must be addressed to prevent avoidable disability or
complications of disability in the future.
36
Demographic Considerations
When introducing the survey, interviewers asked to speak to an adult who had significant
contact and caregiver responsibilities with the child with a disability. In 71% of the
cases, mothers responded. This reminds us that at least certain aspects of any prevention
project must target the mothers of children with disabilities, as they are actively involved
in their childs care.
In addition, many of the respondents in the households with a child with a disability had a
very limited educational background; in fact 47% of the respondents had no education at
all. The majority of the Cambodian population has had some primary school 38. This
information suggests that there may be a relationship between low education and having
a child with a disability in the household. In addition most of the parents in the study
were rice farmers, making a subsistence living growing food for their own consumption.
This reminds us that any new initiatives designed to educate families about services or
activities to prevent or minimize childhood disability would need to take into
consideration the target populations limited educational background, as well as the
constraints of employment that (especially during certain times of the year) requires a
tremendous amount of time and labor.
Finally, study respondents were poor, with 48% reporting making less than 4000 riels a
day (the equivalent of 1 US dollar). Nationwide data suggests that 34% of the
Cambodian population live on less than $1 USD per day 39, indicating that our study
sample was over-representative of the very poor. It was clear from many respondent
answers to survey questions that financial limitations were a key factor in health-related
decision-making, which will need to be taken into careful consideration in prevention
programming. This has been described repeatedly by others working in the health sector
in Cambodia 40 41.
Impairment and functional status of children: inadequate use of existing resources
There is a tendency in the literature to describe people with disabilities as though they
are a homogeneous group with identical needs, and of course this is not true. We
intentionally targeted a heterogeneous sample that was representative of the different
types of disabilities found in Cambodia as described in the 2004 Cambodia SocioEconomic Survey 42.
38
National Institute of Pulbic Health, National Institute of Statistics [Cambodia] and ORC Macro (2006). Cambodia
Demographic and Health Survey 2005. Phnom Penh, Cambodia andCalverton, Maryland, USA: National Institute of
Public Health, National Institute of Statistics and ORC Maryland.
39
The World Bank (2005). World Development Report 2006: Equity and Development. World Bank and Oxford
University Press, NY: NY, p 279.
40
Meesen, B., Van Damme, W., Kirunga Tashobya, C., & Tibouti, A. (2006). Poverty and user fees for public health care
in low-income countries: lessons from Uganda and Cambodia. The Lancet, 368, 2253-2257.
41
Van Damme, W., Van leemput, I., Ir, P., Hardeman, W., & Meesen B. (2004). Out of pocket health expenditure and debt
in poor households: evidence from Cambodia. Tropical Medicine and International Health, 9, 1303-17.
42
Knowles, JC (2005). Health, vulnerability and poverty in Cambodia: Analysis of the 2004 Cambodia Socio-Economic
Survey. Washington DC: The World Bank.
37
Indeed, as is clear from tables 4-10, we found a very high number of children with
reported difficulties in all aspects of function including seeing, hearing, communicating,
developing and sustaining relationships, cognitive aspects performance, sensory
dimensions of task performance, and movement-related performance of activity. In
addition, a large proportion of children reportedly also had difficulty with emotional
problems, pain, breathing difficulty, and convulsions or loss of consciousness. Some
children had distinct problems in one of these areas such as vision or hearing, and others
had difficulties in multiple areas.
Some of these types of impairments and associated activity limitations are being
addressed by NGOs and other international organizations. For example, Krousar Thmey
has services for deaf children, and our study reflects the fact that at least some of the
families know that and are using the available services. Similarly, it is clear from the
survey results that many families already know about the PRCs in Takeo and Siem Reap,
and have used their services. In other cases, families obviously learned about services
eventually, and reported that they wished they had used available services earlier or at all
(e.g specialty services for specific types of impairments such as visual problems).
However, it is equally clear that some families still do not know about available services
(for example, the finding that some children with a mobility disorder do not have an
assistive device to aid movement). In other cases, families appear to know about
potential services, but they worry about the cost and do not know that some services and
facilities (e.g. the private pediatric hospitals in Siem Reap) are provided free of charge.
Finally, delay seems to be an issue: for example many families who do use the PRC
waited for many years before going there, and they would potentially have benefitted
more it they went sooner 43
All of these examples point to the importance of assertive outreach educational efforts. If
there are services available, then we need to make sure that people know about them, are
clear about how to access them, and understand which services are free of charge. It is a
shame for important services to go begging because people lack awareness or knowledge
about them.
Impairment and functional status of children: Gaps in service and resources
On the other hand, there are currently very limited early interventions available for
children with complex problems and multiple impairments such as cerebral palsy or other
developmental conditions. As already mentioned, the PRCs do treat children with
cerebral palsy, but usually years after the condition has been identified. They are not
prepared to treat infants with neuro-developmental conditions. There are some
community-based outreach services available through CABDICO in Siem Reap province,
but CABDICOs ability to provide needed treatment is quite restricted due to the small
size of the organization and limitations in staff knowledge and training. In addition, there
are extremely limited treatment options available for children with pain, convulsions,
43
Data collected for External Evaluation of the Rehabilitation Sector in Cambodia, fall 2006 but not actually used in final
report.
38
cognitive, or mental health issues, and yet it is clear from the study results that the needs
are great.
Many respondents did not seek any type of services because their child had a congenital
condition, and they assumed that there was nothing to be done about it. The awareness
that the impact of congenital conditions can potentially be minimized by early
intervention is lacking in both the general population and also among health care
providers. When we asked several TBAs in the field how often they delivered babies
with developmental concerns, their response was never, indicating that they are not
trained to recognize signs of congenital disorders or perhaps they do not wish to do so for
fear of being blamed.
Finally, our study indicates that only 55% of school-aged children with disabilities are
attending school at all (and often for only one or two years). In comparison, an 81%
primary school completion rate is reported for Cambodia in the 2006 World Development
Report 44. A wide range of reasons were given for non-attendance related to: child health
issues, lack of access, inability of the school to accommodate childrens needs, and
concerns about how the child was treated; and all are worrisome as primary school is
crucial to opportunities later in life 45. The only special education that was identified by
parents was a school for blind and deaf children (Krousar Thmey), indicative of the fact
that there are almost no special education services available for children with complex or
serious disabilities.
History of disabling conditions and barriers to care
Respondents in this study reported that 86% of the time their childs disability was
caused by illness or a congenital condition. In addition, 70% of respondents reported that
their childs problem started within the first year of life. Fever was identified most
frequently when respondents were asked to describe their childs disease, described as the
hot disease, and often accompanied by convulsions or other symptoms. There is
evidence 46 that untreated illness in early childhood can lead to complications and
permanent disabling conditions later on. This information clearly suggests that if we
intend to prevent avoidable disability or complications of disability, then it is going to be
necessary to intervene early in infancy and childhood.
In response to the onset of their childs illness or congenital condition, some families did
nothing, some went to see a traditional healer, and some went to a public hospital, health
center, pharmacy or private provider or private facility. These results are similar to those
found by the 2005 Cambodian Demographic Health Survey which also describes a range
of services used when people are sick or injured 47. There were no identifiable patterns of
use (e.g. exclusively going to a traditional healer versus a hospital for certain kinds of
conditions), suggesting perhaps that people are not sure of the best treatment facility for
44
World Bank (2005). World Development Report 2006 : Equity and Development.
Ibid.
UNICEF (2002). Facts for life. United Nations Childrens Fund: New York.
47
National Institute of Public Health, National Institute of Statistics [Cambodia] and ORC Macro (2006). Cambodia
Demographic and Health Survey 2005. Phnom Penh, Cambodia and Calverton, Maryland, p 34.
45
46
39
different types of conditions, or they may decide where to go based on what services and
facilities they have heard of, or they may decide on services because of logistical
considerations such as distance and cost.
Although participants had a wide range of opinion about how helpful the services were,
generally they seemed to view hospital services more favorably than other treatment
choices. It is interesting to note that although the most commonly chosen first provider
was the traditional healer (31%), only 17% of those who actually used a traditional healer
rated the care as helpful. This suggests that people may be using traditional healers
because of ease of access and low cost, but not because that would necessarily be their
first choice for care.
Respondents reported that often they wished they had gone to a hospital or used the
health system for care, but they did not do so because of financial costs associated with
care (the cost of care itself, the cost of transportation, opportunity costs from lost work
time, and issues related to obtaining food). In other cases they either didnt initially
know about available services, or didnt know how to get there (access and transportation
issues). These results are similar to findings from other health system reports and studies
in the country 48 49. Interestingly, many had specific names of hospitals that they wished
they had used that covered a wide variety of Cambodian provinces and even other
countries as well. It is unclear how or when families learned about these other potential
resources for their child.
Finally, some families believed that the childs disability really had to do more with bad
luck or bad karma than anything else, and that nothing could be done to help the
situation. Unfortunately, some respondents reported doing nothing at first or attempting
self-treatment, and they were eventually unhappy and dissatisfied with the poor outcomes
associated with these choices.
Frequently mentioned issues concerning health-related costs and lack of knowledge
suggest that demand-side barriers particularly kept people from seeking or obtaining
needed health services for their child early in life, when the problem had just begun to
manifest. These findings indicate the importance of developing strategies to lessen
impediments to rapid health-seeking behavior. Respondents typically reported that they
thought access to most types of providers and facilities was OK or good (Table 29),
suggesting that they were less concerned about the availability of services, but more
concerned about cost barriers.
Pregnancy, maternal care and environment: impact on childrens conditions
The majority (56%) of mothers in this study did not have any antenatal care. This
proportion is higher than the 30% figure reported for rural women in the 2005 Cambodia
48
ibid
Knowles JC (2005). Health, Vulnerability and Poverty in Cambodia: Analysis of the 2004 Cambodia Socio-Economic
Survey. Washington DC: World Bank.
49
40
Demographic Health Survey (CDHS) 50. The vast majority of women in our study
delivered their babies at home accompanied by TBAs, (higher than home birth rates
reported in the CDHS), and 56% of our respondents reported no postnatal care at all
compared to 31% for rural residence in the CDHS. In addition, a large percentage (62%)
of women reported that the child had health problems in infancy. These results suggest
an association between inadequate antenatal care, lack of skilled provider birth
assistance, limited postnatal contact with health professionals, and resultant health
problems on the part of infants.
More generally, we can observe that the mothers in this study had limited education, very
limited resources, and unusually low levels of pregnancy-related health care. These
associations do not necessarily indicate causal relationships between factors, but certainly
highlight the potentially pernicious cycle in which limited education, impoverishment,
and poor health outcomes (in this case disabilities in children) reinforce each other in a
negative manner.
Finally, results indicate that most respondents in our rural study still do not have access to
clean water and adequate sanitation. It is easy to forget the importance of basic
environmental conditions when considering strategies to prevent or minimize disability.
Addressing the issue of clean water and adequate sanitation alone could potentially lead
to vast improvements in health outcomes for pregnant women, infants, and young
children 51.
MAJOR ISSUES IDENTIFIED

We now shift to exploring what these results mean in terms of major issues, and
recommendations to address identified concerns. The issues are listed in chronological
order to highlight how the focus of attention must start with pregnant women, attend to
very young infants at risk for disability, and finally address the needs of children with
disabilities as well as their families.
Maternal care and environment: adverse impact on childrens conditions:
Many children who end up with permanent disabling conditions have congenital
problems (associated with lack of maternal antenatal and postnatal care, treatable
health problems, and basic environmental conditions) very early in life
History of disabling conditions: barriers to care
Families do not seek needed treatment for their child early in life because they are
concerned about costs, dont know what services are available, or dont realize
50
National Institute of Public Health, National Institute of Statistics [Cambodia] and ORC Macro (2006). Cambodia
Demographic and Health Survey 2005. Phnom Penh, Cambodia and Calverton Maryland, p 139.
51
United Nations Development Programme (2006). Human Development Report 2006. New York: Palgrave Macmillan.
41
that conditions in early infancy can lead to permanent disability (and may be
treatable)
Functional status of children: gaps in availability and use of services and resources:
There are currently very limited services available to help infants and children
with established developmental disabilities, some existing services are
underutilized, and many children do not end up attending school or participating
fully in typical childhood activities
Demographic considerations and issues:
Parents of children with disabilities have limited education, time, and money to
address their childrens needs and they may not be aware of existing resources
RECOMMENDATIONS
Secondary prevention is the critical bridge that connects primary health care and
rehabilitation for people with identified disabilities. In secondary prevention, health
problems are identified early, and services and referrals are provided to assure rapid,
effective interventions that minimize the possibility of permanent disability.
Philosophically, we favor an approach to prevention that is participatory and builds
capacity at both the community and health system level. Whether working with families,
community level health providers, provincial hospital administrators, or officials in the
Ministry of Health, we need to always view our work through an empowerment
perspective which has been shown to lead to more sustainable and effective outcomes 52.
An approach to improving secondary prevention efforts will require a blend of direct
actions, cultivation of health (and other) partnerships, and efforts to strengthen and build
capacity within the health system. Each of these will be described in turn.
Direct Action
There is a need for screening and early detection training activities:
Local health providers such as Village Health Support Group Volunteers, TBAs, and
Health Centre staff need to be able to:
Recognize serious illness and injury and refer children to hospitals for treatment
Recognize congenital or other childhood developmental problems and refer
families to community-based early intervention services (as they become
available)
52
Wallerstein, N. (2006). What is the evidence of effectiveness of empowerment to improve health? WHO Regional
Office for Europes Health Evidence Network (HEN), February 2006.
42
Recognize serious congenital or other childhood developmental problems and

refer families to targeted hospitals that have expertise in early childhood
evaluation and intervention as appropriate
There is a need for community-based early intervention services:

Families of children with disabilities need low-cost, local, simple interventions and
solutions to helping their children function as effectively as possible. Early intervention
activities need to be participatory and empowering, so that families become actively
involved in decision-making and problem-solving concerning the needs of their children.
The goal is for the families to evolve into effective self-help groups.
There is a need for education concerning how to use the health system:
Families need to know what types of services are actually relevant and available, and
how to access financial support for services.
Cultivation of Health Partnerships
There is a need for organizations involved in activities to improve maternal and child
health outcomes to communicate and collaborate well
It is impossible to overstate the importance of collaboration in the health sector to
synergistically strengthen and develop a web of coordinated services that meet prevention
needs. Effective partnerships in the health system will better support families in need of
services. These partnerships need to include international organizations, local NGOs, and
government facilities and providers. The end result of increased collaboration will be a
seamlessly provided continuum of services and less duplication of services.
There is a need to for communication and coordination between organizations
addressing the needs of children with disabilities in different sectors (e.g. rehabilitation
and education)
The needs of children with disabilities do not neatly fit any particular sector boundaries
and are actually multi-dimensional. For example, organizations involved in advocating
for mainstreaming of children with disabilities in the schools need to work closely with
organizations involved in rehabilitation in order to assure positive educational outcomes
for children with disabilities.
Strengthening the Capacity and Coordination of the Public Health System
There is a need for the MOH to take the lead in assuring an effective continuum of
health services to prevent avoidable disability
The Department of Preventive Medicine in the MOH is the appropriate governmental
body to assume leadership in assuring secondary prevention action in the health sector.
By taking responsibility for secondary prevention, the MOH can then instruct the Public
Health Department (PHD) concerning health service provision. In addition, it will be
tremendously helpful if the evolving equity fund system provides funding for the kinds of
services needed in secondary prevention.
43
There is a need to address issues of financial cost in the health system

Cost of services, transportation, food etc. are clearly critical to decision-making
concerning using health services. It will be tremendously helpful if the evolving health
equity fund system provides funding for the kinds of services needed in secondary
prevention, covers associated costs (e.g. transportation) and is clearly communicated to
those in need of financial support to use the health care system.
There is a need for different departments in the MOH to work closely together to
address secondary prevention needs
The National Maternal and Child Health Centre is another component of the MOH that
should also be involved because of the close links between maternal health, child health
and disability prevention. The current Health Sector Strengthening Project (HSSP) is
addressing concerns about maternal mortality, and focusing attention on antenatal,
delivery and postnatal care issues. It is clear that these maternal concerns also impact the
health of infants; thus there is a potential link between the HSSP and the secondary
prevention activities described in this section of the report.
HIBs proposed role in secondary prevention efforts
HIB is already an active participant in the rehabilitation sector and has been for many
years. We have become increasingly involved in prevention through our work in the
areas of road traffic safety and mine risk education. We would like to help improve the
health care system by increasing our involvement in secondary prevention in the area of
early screening, detection and early intervention services. We propose to become
involved in the following activities:
HIB plans to develop Secondary Prevention Outreach Teams in Siem Reap and Takeo
that provide training and services associated with screening and early detection of
children at risk for disability. The teams will also become involved in early intervention
activities in the community. In many cases, there are simple techniques (e.g. related to
feeding a child or positioning him/her correctly) that can lead to improved function and
quality of life. And finally, the teams will become involved in raising family awareness
of existing services and financial supports (e.g. pre-registration for health equity funds),
and assisting families to overcome barriers to care so that they actually obtain needed
health services.
HIB is cognizant of the fact that many organizations are already engaged in providing
effective prevention services through the health system and at the community level. We
wish to develop closer linkages with these organizations in order to assure coordinated,
non-duplicative service provision.
Finally, HIB would like to work closely with the Department of Preventive Medicine in
order to assure that secondary prevention efforts become part of the health system over
time.
44
SUMMARY OF THE CONTINUUM OF LEVELS OF HEALTH CARE

PRIMARY PREVENTION
Prenatal and postnatal care are
provided regularly to women
Local providers receive training
from NGOs to improve the
quality of prenatal and postnatal
care
Local providers (health centres,
TBAs etc.) can refer women for
health services if the pregnancy
seems to be high risk in any
way
Pregnant women need to have
adequate
nutrition and sanitation and
shelter while they are pregnant
Barriers to services (access and
cost) are addressed adequately
in the health system
The referral system is
functional so that families
obtain and can follow through
with referrals
recognizes the relationship of
primary, secondary and tertiary
prevention, and advocates for
health services on a continuum
SECONDARY
PREVENTION
Women are encouraged to
deliver babies while
accompanied by skilled
providers
Local providers are trained to
refer women for health services
if the delivery has problems or
the newborn has a congenital
condition or becomes ill or
injured
Doctors and nurses at identified
hospitals have specialized
training in recognizing and
treating congenital conditions or
health problems that manifest
early in life
Community-based providers
have training to provide early
intervention services to families
and to foster self-help groups
Community-based providers are
knowledgeable about other
resources that may benefit
families, and make referrals as
appropriate (e.g. to the PRC for
mobility devices)
TERTIARY PREVENTION
(REHABILITATION)
Rehabilitation professionals provide
appropriate physical rehabilitation
services to young children with
disabilities (including technical
services for children with clubfoot,
cerebral palsy, etc.)
Outreach workers provide
community-based rehabilitation
services to children and families
Families are made aware of all of the
services that might benefit their child
with a disability, even in early
infancy
Families are encouraged to send their
child with a disability to school
The school system recognizes that
children with disabilities should
receive an education, and works to
overcome barriers that may hinder
school participation (e.g. need for
special accommodations and
equipment)
Barriers to service (e.g. cost and
transportation) are addressed
adequately
Families know the importance

of seeking immediate attention
if the newborn or infant
becomes ill
Barriers to services (especially
access and cost) are addressed
adequately
recognizes secondary
prevention as an important
component of an effective
healthcare system and facilitates
the development of secondary
prevention
45
ANNEX 1: Age Pyramid in Cambodia: (Intercensal Data Population Survey 2004, Cambodian National Institute of Statistics)
46
ANNEX 2:Organizational Chart of the Provincial Level Health

PHD
Provincial Health Department
Mother Child Health Supervisor

has monthly or quarterly meetings
with midwives
PROVINCIAL HOSPITAL
OD
( Operational District)
Midwives
RH
(Referral Hospital)
HC
( Health Centres)
HC
1
HC
2
HC
3
HC
4
VHSG (Village Health

Support Group) Monthly Meeting
All those groups

are linked to each
HC.
HCCMC (Health Centre Co

Management Committee)
COMMUNE COUNCIL
IS THE LOCAL AUTHORITY
AND CONTROLS DIFFERENT
DEPARTMENTS AT THE
COMMUNE LEVEL, HEALTH
CENTRE INCLUDED.
* TBAs (Traditional Birth Attendants)

Monthly meeting at the HC level
47
ANNEX 3
48
49
50
51
52
53
ANNEX 4
54
55
56
ANNEX 5
INFORMED CONSENT FORM
Disability in Cambodian Provinces of Siem Reap and Takeo Survey
Handicap International Belgium is conducting a research study in Siem Reap and Takeo.
The purpose of the study is to learn more about children with disabilities in Cambodia.
We also want to know how people view the health care system and how they view people
with disabilities.
The information that we obtain through this survey will help us to identify strategies to
minimize or possibly to prevent the development of disability in people who experience
serious injury or illness. You are being asked to participate in this study because you
have a child with a disability.
Your participation will involve completing a survey that may take around 60 minutes to
complete. Your involvement in this study is voluntary and you may choose not to
participate. You can refuse to answer any of the questions at any time. All information
that you provide will be kept confidential, and the final report that we write will not
provide any names or information that would allow others to identify you. Results will
be presented in summary form only.
If you have any questions or concerns about this research project, please feel free to call
Betsy VanLeit at 012-929-710.
By signing this form at the bottom of the page, you are agreeing to participate in the
study.
Sincerely,
Betsy VanLeit
Secondary Prevention Project Manager
I understand the purpose of the study and I agree to participate:

Name: ________________________
Date: _____________
57
ANNEX 6
58

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Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in the

Report prepared for Handicap International Belgium by:

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Association for Blind Cambodians

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Childrens Impairments and Functional Difficulties (500 households)

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

SUMMARY OF THE CONTINUUM OF LEVELS OF HEALTH CARE

Prenatal and postnatal care are

Women are encouraged to deliver

Local providers receive training

Local providers are trained to

Families know the importance of

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Children with Disabilities

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Figure 1: Number of Family Members Living at Home

Number of Family Members

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Relationship of Survey Respondent to Child with Disability (500 households)

Age and Gender of Children (500 households)

Parental occupation and education (500 households)

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Impairments and Functional Difficulties

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Tables 6 and 7 describe difficulty in a variety of tasks associated with interpersonal

Table 7: Respondent report of child cognitive (mental) performance on tasks

Table 9 describes performance associated with movement and mobility. Approximately a

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

*includes anxiety, sadness, worry, depression, and strange thoughts or ideas

Child Attendance at School

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Fits, blackouts or loss

pain that makes daily

Feeling things with

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Accident play/ work

Accident mine/ UXO

Chemical substance or drugs

Rape/violent attack/domestic violence

Burn (acid or fire)

Bad karma (from past life)

Didnt have vaccinations

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Table 15: Respondent satisfaction with initial treatment for child

Secondary Prevention of Disabilities in Cambodia Final Study Report 2007

Figure 3: Time spent at first treatment facility