Sexual and reproductive health services access and provision in Cambodia during the COVID-19 pandemic: a mixed-method study of urban–rural differences

Quantitative survey findingsDescriptive analysis

Table 1 shows sociodemographic characteristics of 423 participants, including 139 young women, 79 young men, and 205 older women aged 25–49. Most participants (81%) were Khmer, 1% were Vietnamese, and 18% were Phnong—all living rurally. Most had completed primary (30%), secondary (29%), high school (22%), or university (10%), while 9% had no formal education (6% urban versus 13% rural). Educational attainment varied by location, e.g. more university degrees among urban participants (15% urban versus 5% rural), as well as gender and age, with 43% of young men having finished high school, 32% of young women having finished secondary education, and 43% of older women having finished primary education. Over 60% were married, although over 91% of young men were single.

Table 2 shows urban–rural differences in contraceptive methods used. Main differences included the proportion of participants who used no contraception (i.e. urban 58%, rural 54%), used injectables (i.e. urban 2%, rural 8%), condoms (i.e. urban 4%, rural 1%), pills (i.e. urban 12%, rural 20%), and natural methods (i.e. for rhythm, 11% urban versus 7% rural; for withdrawal 18% urban versus 12% rural). In considering access during COVID-19 pandemic compared with previously, responses were mixed with higher percentages of rural participants describing both increased ease (18% versus 12%, respectively) and increased difficulty accessing contraception (i.e. 57% versus 40%, respectively).

Multivariable analysis

Table 3 shows that rural households had over twice the adjusted odds (AOR 2.49; 95% CI 1.32–4.91) of reporting that changing contraceptive methods during the pandemic was possible compared to urban participants. However, rural participants also had approximately three times higher adjusted odds of both reporting contraceptive access as more difficult (AOR 2.92; 95% CI 1.39–6.13) and easier (OR3.29; 95%CI 1.21–8.92) in 2020 than in 2019 as compared with urban participants.

Table 3 Associations between rural setting and perceptions and reported behaviours during the COVID-19 pandemic compared to pre-pandemic (n = 423)

Rural participants had no significant differences in adjusted odds of reporting increased physical aggression toward household members (AOR 1.89; 95% CI 0.84–4.58), family tension (AOR 1.20; 95%CI 0.75–1.92), depressive symptoms (AOR 1.39; 95% CI 0.88–2.19), or tension towards children (AOR 0.98; 95% CI 0.46–2.06) as compared to urban participants.

Qualitative interview findingsParticipant characteristics

Table 4 summarises characteristics of our 21 key informants, 9 in urban Phnom Penh and 12 in rural provinces (i.e. 7 in Kampong Cham and 5 in Mondulkiri). In total, 15 were health-workers (e.g. at provincial health department, operational districts, referral hospitals, health centres) and 6 were community health support group members. More than 80% of participants were women (i.e. 89% in urban and 75% in rural areas). Median age was 47 (range 25–64) years and career duration was 10 (range 3–25) years. No urban–rural differences were noted in gender, age, or years of service.

Table 4 Qualitative interviewee characteristics (n = 21)Thematic findings

We included one deductive theme (i.e. SRH services access and use) and two inductive themes (i.e. staffing and salary reductions; health and risk communication) that best described our data. While qualitative interviews were primarily intended to clarify and triangulate survey results, we noted that most interviewees focused primarily on their own experiences as SRH service providers during the initial months of COVID-19 and have reported these findings accordingly.

SRH services access and use

Views on the impact of the pandemic on access and use of SRH services varied. Participants indicated that rural areas were more affected by mitigation measures than urban areas, as existing transport shortages to connect households to nearby health centres were exacerbated by the public transport ban. However, some interviewees indicated that services for women and adolescents remained relatively unaffected. A rural interviewee from Kampong Cham province indicated that health providers continued to offer maternal and child-related vaccination services and antenatal and postnatal services in village health centres.

"We have all services, prescription services, health check-ups, and maternal and child-related vaccination available. We offer vaccination in the villages and every day at the centre. We offer other services such as delivery, postpartum check-up, birth control methods such as condoms, injections, pills, intrauterine devices, natural contraception like calendar contraception, and condoms." (KII-HC Krouch, Kampong Cham)

Particularly in rural areas, fear of interacting with patients was exacerbated by poor adherence to safe-distancing recommendations among service-users and the concomitant fear of infection. Interviewees described how large numbers of patients and caretakers continued to gather in groups within health facilities.

"It's really a challenge! Firstly, we are so scared of that public health emergency and afraid we would get that disease from clients because most of them who come here, we don't know if they have that disease or not. Some of them cooperated with us by wearing masks and keep social distancing. Some of them don't wear mask and they are in groups, big groups … when there is someone sick, there are at least three to four persons to take care of a patient. It's hard because of different traditions." (KII-RH, Mondulkiri)

"[We are] worried about COVID, afraid it would transmit. Afraid it would transmit in the community. It must be difficult, and we also do not have enough materials. We are the healthcare providers, so we protect ourselves, but the community people come without wearing masks. We tell them to wear masks, but some still do not wear masks. They act normal and are not afraid of the virus" (KII-HC Krouch, Kampong Cham)

Urban interviewees additionally highlighted how fear of infection hindered service-users from accessing available healthcare services.

"During this COVID, the numbers of clients have been decreasing, they are afraid to come. The rates of those who are the existing service-users also decrease." (KH-PHD, Phnom Penh)

Some urban providers reported fewer service-users seeking SRH services from March to May 2020, mainly due to fear of infection and lack of sufficient money. As many service-users lost their employment during the lockdowns, especially those working for the private sector at karaoke clubs and garment factories, they were unable to afford out-of-pocket payments for healthcare services.

"Most of the women who come here complained about their financial crisis. High unemployment. Many women who work at Karaoke used to come here before, but now they seem not to have any income… we are worried that it would be less and less if the public health emergency keeps going." (KII-HC Mean Chey, Phnom Penh)

Transportation and physical access to services remained a long-term challenge for SRH in rural areas, even prior to the COVID-19 pandemic. Participants reported that awareness and training sessions were temporarily halted in some villages where unpaved roads prevented transportation of essential supplies and equipment.

“We cannot do awareness-raising because we are seeking for where the children are to offer vaccination and women who need to get pregnancy check for prenatal and postnatal. Doing that we cannot offer all services because it's a long way, we cannot carry all materials to all communities as they need, the road is an unpaved road, it's difficult to travel." (KII-HC Keo Seyma, Mondulkiri)

Staffing and salary reductions

Health-worker experiences during the initial phase of the pandemic varied. Some rural providers reported being overwhelmed by the number of service-users and insufficient medical staff, while others reported a decrease in their workload. Reduced staffing and services made it difficult for service-users to access required SRH services, and if services were available, service-users could expect delays or interruptions due to staffing shortages.

"Lack of staff…because of the epidemic, we sent two staff to the border. So when there are many patients, we face difficulties, we are so busy… We provide service to everyone, but it is a bit slow." (KII-HC Dak Dam, Mondulkiri)

All providers described feeling overwhelmed by the lack of social and professional support. They reported being quarantined away from their families, which negatively affected their psychological wellbeing, consequently predisposing some to depression and anxiety. On a professional level, the COVID-19 pandemic decreased opportunities for training and supervision, leading to a decrease in professional support and training that was particularly noted by rural participants.

'We are always affected by COVID. It's also been decreasing related training because we are not allowed to gather as big group, and the supervision activities also reduced, and the patients have been decreasing too." (KII-PHD, Kampong Cham)

Some rural health-workers also mentioned loss of income due to the cessation of secondary activities such as evaluations and training workshops. Supplementary income from activities organised by development partners provided a significant portion of health-workers’ monthly wages, so this was a significant loss at a time when salary disbursements were also affected by COVID-19 related staffing shortages.

"[I have] no [supplementary] income. It's because the evaluation was stopped, so no income. There is no evaluation program, so the income has been decreased… During the public health emergency, I couldn't attend any workshops, meetings, so no income… [I have lost] about 20% of salary" (KII-OD Prey Chhor, Kampong Cham)

Most providers reported that working hours had doubled between December 2019 and July 2020, with many indicating their compensation had also increased in accordance with the hours worked. Some attributed the longer working hours to the increased number of service-users. However, others reported seeing fewer patients and therefore being paid less.

"I got paid less during the March to April (2020) period." (KII-HC Prek Pou, Kampong Cham)

While this pattern was not consistent, it appeared that the pandemic contributed to increased service use in some rural facilities and reductions in other, primarily urban, facilities.

Health and risk communication

During the first year of the pandemic, health-workers in rural areas reported the quality of their communication with service-users worsened due to the precautionary measures they took when interacting with service-users, such as wearing facemasks and personal protective equipment. All providers described being more careful around service-users.

"We are more careful. When clients come, all staff wear masks and wash hands with alcohol, keep hygiene all the time. We wear gloves. Everything we need to be more careful than before…." (KII-HC Dak Dam, Mondulkiri).

Some rural interviewees reported a lack of collaboration between frontline health-workers and governmental actors, due to preferences for in-person communication and budget constraints.

"When we need to communicate with village or commune chiefs, we invite them. Sometimes, the village [chief] doesn't update the commune [sub-district] or police, so they contact us. It's difficult because there is no budget to travel to village or commune." (KII-HC Keo Seyma, Mondulkiri)

Besides their usual clinical duties, providers described the added burden of training and enforcing service-users to wear facemasks and maintain safe-distancing when they attended health facilities.

"We have always prepared alcohol for hand sanitizer. We tell them to wear masks, and we keep them far from each other one meter, sitting far from each other, and educate them to wear a mask" (KII-HC Krouch, Kampong Cham).

Both urban and rural interviewees highlighted that public risk communications about COVID-19 did not effectively engage with minoritized communities. While the reasons why were not clarified, several interviewees described perceived discrimination from the government and the public toward minority communities, which risked isolating and depriving these communities of healthcare services during the pandemic. However, some also demonstrated their own lack of awareness in describing these marginalised communities.

"A lot of Khmer Muslims […] so they said they are not afraid of COVID, they are afraid of not worshipping..." (KII-OD Mekong, Phnom Penh)

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