Journal of Rural Medicine
Field report

Health disparity toward noncommunicable diseases
among residents in rural Cambodia: a descriptive study
Yurie Kobashi1, 2, Hong Chhay1, Thyryfong Savat3, Manabu Okawada4,Masaharu Tsubokura2, and Yushifumi Hayashi3
1

Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Cambodia
Department of Public Health, Fukushima Medical University School of Medicine, Japan3
Department of Neurosurgery, Sunrise Japan Hospital Phnom Penh, Cambodia
4
Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Cambodia
2

Abstract
Objective: Regional disparities in health services is a crucial problem in Cambodia. Particularly, a number of NCD risk factors are
more common among the rural poor. Fortunately, 80% of NCDs are preventable and cost-effective interventions exist. Therefore,
health care needs assessments regarding NCDs in poor rural areas are vital. The object of this pilot study was to identify health careneeds regarding NCDs among residents in poor rural areas in Cambodia.
Materials and Methods: A medical health check-up and questionnaire survey were conducted with 208 rural residents who participated in a free health check-up and doctor consultation in Kaoh Peam Reang.
Results: One hundred sixteen (55.8%) females were included in the total sample size of 208 participants; the majority (52.9%) werebetween 35 and 65 years of age. Twenty-five participants (12%) were current smokers, and 44 (21%) were current alcohol drinkers.
Eighty (38.5%) participants had hypertension and 44 participants (21.2%) had a body mass index over 25. Alcohol drinking andsmoking habits were more common among men. The five most frequent medical complaints were headache (18.3%), lower backpain (14.4%), foot and hand pain (13.9%), joint pain (10.1%), and difficulty breathing (10.1%).
Conclusions: The medical need for doctor consultations regarding chronic disease and chronic pain might be higher in poor rural
areas in Cambodia.
Key words: regional disparity, global health, noncommunicable disease(J Rural Med 2020; 15(4): 212–216)

Introduction
Reducing regional disparities is a significant public healthissue to ensure that essential medical care is provided to allpeople1). In particular, proper evaluation of medical needs isessential in reducing regional disparities1). Noncommunicable diseases (NCDs) are the most common cause of deathworldwide2–4), and more than 90% of premature deaths fromReceived: May 21, 2020
Accepted: June 25, 2020
Correspondence: Yurie Kobashi, Department of Public Health, Fukushima Medical University School of Medicine, Fukushima City,Fukushima 960-1295, Japan
E-mail: yurie-s@umin.ac.jp
This is an open-access article distributed under the terms of theCreative Commons Attribution Non-Commercial No Derivatives(by-nc-nd) License <http://creativecommons.org/licenses/by-nc-nd/4.0/>.

©2020 The Japanese Association of Rural Medicine

NCDs occur in low- and middle-income countries (LMIC)2).
Cambodia is classified as an LMIC by the World Bank,and regional disparities in health services is a crucial problem in Cambodia5, 6). Eighty-four percent of the nation’s
wealthy population live in Phnom Penh, the capital city5).
Indicators of health needs, such as the mortality rate ofchildren under five years of age, are approximately threetimes higher in rural areas than in urban areas5). Further, theCambodian healthcare system is already flooded with more
NCD patients than it is able to treat7). A number of NCD risk
factors are more common among the poor rural populationcompared to urban locations, including tobacco use, solid
fuel use, insufficient fruit and vegetable consumption, andharmful use of alcohol8). Fortunately, 80% of NCDs are preventable and a range of highly cost-effective interventions
exist8). Therefore, needs assessments with respect to NCDs
in poor rural areas are vital.
This study aimed to identify health care needs regarding NCDs among residents in poor rural areas in Cambo-

doi: 10.2185/jrm.2020-028 | 212

Journal of Rural Medicine
dia, with a view to developing strategies to reduce regional
health disparities.

MethodThis study used a cross-sectional descriptive survey design.

Location of the study
Kaoh Peam Reang is an island located in the MekongRiver in the Prey Veng province of Cambodia. It covers
an area of 7.14 km 2 and has a population of approximately
1,155. The area is located 86 kilometers southeast of Phnom
Penh, and the climate, according to the Köppen climateclassification, is tropical monsoon. The residents live usingboats, which increases their difficulties in accessing essential medical care. Almost all the residents are engaged inagriculture and fishery. Since most people are living under
the poverty line, the island is often a target for social service or volunteer work. There is one health center on theisland; however, it is mostly non-functional. There are noother health facilities.
Free health check-up
This free health check-up is managed by Sunrise Japan
Hospital (SJH), a private hospital in Phnom Penh that has
14 medical departments, 50 beds for inpatients, an intensive care unit, and endovascular treatment facilities. Mostpatients who visit the hospital are from the area surrounding Phnom Penh. SJH, which opened in 2016, aims to provide Japanese-standard quality medical care in Cambodia.
The hospital has 213 employees, including Cambodian andJapanese staff as well as staff from other countries. SJH has
treated 100,000 patients since it opened.
Participant recruitment
SJH arranged to conduct free health check-ups to improve rural residents’ health and to promote the hospital,as part of its social responsibility activity. To decide on thelocation and to recruit participants, we solicited the help ofa collaborator who is engaged in social responsibility activities in Kaoh Peam Reang. The collaborator requested an influential local person in Kaoh Peam Reang to recruit participants. This local person announced the details (date, time,place, contents) of the free health check-ups for residents.
The check-up included education about diabetes, measurement of weight, height, and body temperature, and consultation with a doctor for those individuals who had a healthproblem. The check-ups were conducted at a meetinghousein the center of the island. The medical consultations wereconducted by approximately 10 doctors from SJH. The doctors were Cambodian and Japanese and included both genders. Two hundred eight residents participated in this study.

Survey tool
The questionnaire developed for the participants in thefree medical health check-up was based on a general questionnaire that is used at SJH for a general feasibility healthsurvey in rural areas. Medical doctors were consulted about
the contents of the questionnaire. The instrument included
questions about age, gender, past medical history, medical
drug use, alcohol and tobacco habits, and respondents’ chief
medical complaint. Physicians made diagnoses based on a
medical interview and physical examination, and prescribed
medication as needed.
ProcedureThis study was undertaken in December 2019. The questionnaire included an explanation written in Khmer language that the data would be used for research and improvement of residents’ health. First, a nurse from SJH collected
the questionnaire and conducted a brief interview with eachpatient to assess personal data. Participants then underwent
a consultation with a doctor, which included a physical examination. If the doctor made a diagnosis, he or she provided advice to participants.
Data analysis
The characteristics of participants who attended a doctor consultation were analyzed descriptively. Hypertension
was defined as systolic blood pressure above 140 or diastolic blood pressure above 90. Stratified analyses of age andgender were conducted. In addition, patients’ major complaints and diagnoses made by the doctors were analyzed
descriptively. Analysis was performed using STATA/IC(Lightstone, Texas USA, version15) and Excel. This study
was approved by the National Ethics Committee for HealthResearch (approval number 078NECHR).

Results
Table 1 presents the characteristics of the participants inthis study. A total of 208 individuals, including 116 females(55.8%), participated in this research. Sixty-one participants(29.3%) had a past medical history, and 35 participants(16.8%) were taking prescribed or over-the-counter medication daily. A total of 25 participants (12.0%) smoked tobacco, and 44 participants (21.2%) consumed alcohol daily.
Eighty participants (38.5%) had hypertension.
Table 2 shows the rate of alcohol and smoking habits,hypertension, and BMI (body mass index) in each age andgender group. Two-thirds of people (66.7%) in the 35–49
age group were current alcohol drinkers and 24.2% percent
of people in this age group had a smoking habit. Alcoholand tobacco consumption were higher among males thanfemales (P<0.001; Fisher’s exact test). The rate of hypertension was also higher among males than females (P<0.001;2020; 15(4): 212–216 | doi: 10.2185/jrm.2020-028 | 213

Journal of Rural Medicine
Table 1 Characteristics of participants living in KaohPeam Reang area, Prey Veng province, Cambodia in 2019 (n=208)n (%)
GenderMaleFemale
Unknown

85 (40.9)116 (55.8)
7 (3.4)

Age
<19
20–34
35–49
50–64
65–80
80<Unknown

15 (7.2)
24 (11.5)
45 (21.6)
65 (31.3)
49 (23.6)
4 (1.9)6 (2.9)

Smoke tobacco
No
Yes
Unknown

108 (51.9)
25 (12.0)
75 (36.1)

Consume alcoholNo
Yes
Unknown

89 (42.8)
44 (21.2)
75 (36.1)

Past medical history
NoYes
Unknown72 (34.6)
61 (29.3)
75 (36.1)

Daily medication use
NoYes
Unknown

98 (47.1)
35 (16.8)
75 (36.1)

Body temperature (degrees Celsius)
Under 37
37.0–37.5
Over 37.5
Unknown

154 (74.0)
48 (23.1)
4 (1.9)2 (1.0)Hypertension
NoYes
Unknown

126 (60.6)
80 (38.5)
2 (1.0)Body Mass Index
Under 18.4
18.5–24.9
25–29.9
Over 30
Unknown

33 (15.9)
122 (58.7)
37 (17.8)
7 (3.4)9 (4.3)Hypertension: systolic blood pressure above 140 or diastolic blood pressure above 90.

Fisher’s exact test). The rate of high BMI was similar in bothgenders (P=0.609; Fisher’s exact test). Eighty hypertensive
patients were identified; however, only 8 patients were identified as taking medication for hypertension.

Table 3 shows the five most frequent medical complaints
identified by the participants and the five most frequentdiagnoses made by the doctors, with the exception of hypertension. The most common complaint mentioned by respondents was headache (18.3%), followed by lower backpain (14.4%). The most frequent diagnosis provided by thedoctors was arthritis (16.8%), followed by gastroenteritis(13.5%).

Discussion
Health care needs assessments regarding NCDs in poor
rural areas in Cambodia are vital. This study found thatthe major medical complaint was chronic pain and medical
needs for consultation for chronic pain are high in such poor
rural areas. Poor people living in rural areas have unmet
needs for medical care for chronic diseases8). It is necessary
to develop a system in which health care for treating chronic
diseases is accessible to all.
The proportion of people who have lifestyle-related disease risk factors such as smoking tobacco and alcohol consumption might have regional differences. In comparison toa previous (2008) nation-wide survey on smoking in Cambodia, smoking rates among participants in our study werelow (37.9% among men and 2.8% among women in this survey, 48.0% among men and 3.6% among women in the 2008survey)9). However, the proportion of people who consume
alcohol was high in our study compared to a previous (2013)
survey on alcohol consumption in Cambodia (51.7% amongmen and 18.1% among women in this survey, 35.4% among
men and 7.5% among women in the 2013 survey)10). Whenconsidering these results, it is necessary to consider not
only prevalence rates in the whole country but also rates ineach region in order to provide effective health education forresidents. In Cambodia, alcohol consumption and tobaccosmoking rates were overwhelmingly high among men9, 10).
In addition, household air pollution is one of the biggest risk
factors in Cambodia4). In fact, most residents in the ruralarea of Prey Veng province use wood as fuel5). These risk
factors might be the cause of difficulty in breathing, which
was listed among the major complaints by residents in thissurvey. It is vital to reduce these risk factors by educating
patients to improve their lifestyle habits.
One limitation of this study was that we did not obtain information regarding the type of tobacco habit: cigarette smoking, pipe smoking, or chewing tobacco. Chewing tobacco is
widely used among Cambodian women9); however, we did not
ask about chewing tobacco in this study. Another limitation isthat the sampling in this study was not random, and a selection bias exists because almost all participants had a medical
complaint that required consultation with a doctor. Besides,
the sample size was small, and the numbers of missing cases
was high for smoking, alcohol consumption, medication use,

2020; 15(4): 212–216 | doi: 10.2185/jrm.2020-028 | 214

Journal of Rural Medicine
Table 2 Participant characteristics for each age and gender among participants living in Kaoh Peam Reang area, Prey Veng province, Cambodia in 2019 (n=208)
Body Mass Index n (%)

Alcoholn (%)

Smokern (%)

Hypertensionn (%)

Under 18.4

18.4–24.9

25–29.9

Over 30

Age
Under 19
20–34
35–49
50–64
65–80
Over 80

0 (0)3 (21.4)
22 (66.7)
12 (27.9)
7 (21.2)
0 (0)

0 (0)
1 (7.1)8 (24.2)
7 (16.3)
6 (18.2)
2 (50)

1 (7.1)7 (29.2)
16 (35.6)
30 (46.9)25 (51.0)
1 (25.0)

6 (50.0)
2 (8.3)4 (8.9)5 (8.1)
13 (27.7)
1 (25.0)

6 (50.0)
14 (58.3)
27 (60)38 (61.3)
31 (66.0)
3 (75.0)0 (0.0)6 (25.0)
12 (26.7)
16 (25.8)
3 (6.4)0 (0.0)0 (0.0)2 (8.3)2 (4.4)3 (4.8)0 (0.0)0 (0.0)GenderMaleFemale

30 (51.7)
13 (18.1)

22 (37.9)
2 (2.8)50 (59.5)
29 (25.2)

14 (17.1)
17 (15.2)

53 (64.6)
66 (58.9)

12 (14.6)
25 (22.3)

3 (3.7)4 (3.6)(%) = The number of participant who answered (or measured) yes / total number of participants in each age and gender group.
Hypertension: systolic blood pressure above 140 or diastolic blood pressure above 90.

Table 3 Five major medical complaints and five major diagnoses among participants living in Kaoh Peam Reang
area, Prey Veng province, Cambodia in 2019 (n=208)n (%)
Medical complaints of participants
HeadacheLower back pain
Foot/hand pain
Joint pain
Breathing difficulties

38 (18.3)
30 (14.4)
29 (13.9)
21 (10.1)
21 (10.1)

Medical diagnoses (except hypertension)
Arthritis
Gastroenteritis
BackacheTension type headache
Urinary tract infection

35 (16.8)
28 (13.5)
23 (11.1)
14 (6.7)
11 (5.3)

and past medical history variables. Furthermore, we did notsurvey household air pollution although it is a major risk factor in Cambodia4). Despite these limitations, this study wasvaluable as a pilot project to identify the health care needs
relating to NCDs among poor rural island residents.

Conclusion
The medical needs for doctor consultations regarding
chronic disease and chronic pain might be higher in poor rural areas. It is vital to work towards developing a system inwhich health care for treating chronic diseases is accessible

to all, and to tailor-make health education for each district’sresidents. Further research and additional countermeasuresthat can improve the health problems of rural residents areneeded.
Funding sources: This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Disclosures: All the authors report no proprietary orcommercial interest in any product mentioned or concept
discussed in this article.
Author contributions: All the authors made a substantial contribution to this research. YK, MT, and HC contributed to writing the paper. All members contributed to thestudy design, data collection, and coordination with localstakeholders.

Acknowledgment
The authors are thankful to the residents and staff inKaoh Peam Reang who cooperate in the free health checkups. In addition, the authors thank all the people who cooperated in the free health check-ups and this study. Theauthors thank Sunrise Japan Hospital staff who engage insocial responsibility activities. The authors would like to say
thank you to Professor Andy Crump who gave us constructive advice for improving our English and our writing.

2020; 15(4): 212–216 | doi: 10.2185/jrm.2020-028 | 215

Journal of Rural Medicine
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