Public Health Outreach in Impoverished Areas of Cambodia: Addressing the Issues Related to Prescription Practices

During a two-week public health internship organized by Projects Abroad in impoverished areas in Cambodia, the authors participated in health check-ups and outreach activities. We identified issues such as polypharmacy and medication misuse. These problems stem from symptom-based prescriptions without considering individual patient conditions due to limited diagnostic equipments and medications. Our solution involved suggesting a documentation akin to Japan's prescription record books, and Drug Information Leaflets (DILs). Prescription record books would enable patients to record the medications they purchased at the pharmacy, so that physicians would know what medications patients are taking during their health checkups, and thus  prevent polypharmacy. In addition, the DILs included medication details and illustrations, considering the low literacy rates in the areas. We emphasized the need for sustained non-communicable diseases (NCDs) treatment and the potential of external perspectives to introduce innovative healthcare approaches and improvements within local communities.


The Experience
The first and second authors of this manuscript participated in a two-week public health internship organized by Projects Abroad in Phnom Penh, the capital of Cambodia, from February to March 2023.During this period, we visited various locations such as elementary schools, community spaces, and facilities for people with disabilities in impoverished areas on the outskirts of Phnom Penh, conducting activities such as basic health check-ups and outreach lessons on health.In Japan, we engaged in fieldwork as medical students, focusing on identifying community challenges and considering how medical students could offer solutions.Our focus area was characterized by single-parent households whose children frequently suffer from relative poverty and a diverse foreign resident population, especially from the Asian region. 1 We participated in this internship to learn lessons on how to sustain and enhance our outreach activities in Japan.In this paper, we address the issues related to prescription practices observed through health check-ups during our internship, such as polypharmacy and medication misuse.
We visited each location every 1-2 weeks for health check-ups with a local pediatrician and staff from Projects Abroad.We brought simple diagnostic equipment such as thermometers, sphygmomanometers, glucometers, pulse oximeters, paperbased medical records, and a medication box (Figure 1).The primary target of the health check-ups was older people residing in the surrounding areas.Since we visited during the day, most consisted of women, who kept to their houses.We conducted brief health interviews and vital sign checks for patients.We also prescribed medications from a limited range of drugs based on the patient's symptoms without making a specific diagnosis since the diagnostic equipment and medications were limited.For example, if a patient complained of stomach aches, we prescribed omeprazole as a response, irrespective of the specific location or nature of the abdominal pain.This may not happen in high-income countries, but this is not a rare practice in low and middle-income countries, especially in impoverished areas.
Through this internship, we noticed two prescription-related issues: polypharmacy and medication misuse.First, easy access to medicines may promote polypharmacy in Cambodia.As there are over 3000 pharmacies in cities in Cambodia, 2 citizens could get medications without prescriptions at lower costs compared to medical institutions, potentially leading to self-medication. 3hen self-medication is the main source of pharmacotherapy, it can easily lead to polypharmacy, especially considering that our targets were older women, who generally have multiple symptoms.The clinical implications of polypharmacy cannot be overlooked; for instance, studies have reported that elderly patients prescribed more than five medications experienced a 4.5-fold increase in the incidence of falls, 4  compliance by 24% compared with fixed-dose combination. 5In our check-ups, the most commonly prescribed medication for suspected hypertension was calcium channel blockers, which have numerous adverse effects such as constipation.To treat these adverse events, patients took medicines themselves from pharmacies, resulting in prescribing cascades.However, through these repetitions, we could neither identify if patients took medications through pharmacies nor what kind it was, since in some cases, patients themselves did not even know.Therefore, we proposed introducing documentation similar to Japan's prescription record books, which have been widely adopted to address polypharmacy.The prescription record book enables different facilities to share patients' medication records and serves to prevent excessive or duplicate prescribing.It would be helpful if patients could record the medications, they purchased at the pharmacy so that physicians would know what medications patients take during their health check-ups.
The second issue was medication misuse.The local physician verbally explained to patients about the effects, dosage, timings (such as morning, afternoon, evening, or before or after meals), and quantities of each prescribed medication.It is difficult to remember the details of medications just by listening to the explanation, especially when multiple medications are prescribed.Some people overdose on their medications, while others have low adherence due to a lack of understanding of the role of their medications.A previous study focusing on impoverished areas of Cambodia has indicated that individuals with lower family income tend to exhibit lower adherence rates. 6Since our target area was characterized by relative poverty, addressing the medication information was significant.Therefore, we designed Drug Information Leaflets (DILs) indicating detailed information about each medication, which has been reported to improve medication adherence (Figure 2).Legend: The DILs included a photograph of the medication, names, effects, dosage, and timings (morning, afternoon, evening; before or after meals) written in the Khmer language.
Considering the low literacy rates, we tried to use more charts and photographs than text.In Cambodia, the literacy rates for individuals aged 15 and above were reported to be 73.6%(males: 84.7%, females: 64.1%) in 2007, 8 and 84% in 2021. 9The area we visited for health check-ups consisted mainly of older women, and considering the particularly impoverished nature of our target region, the literacy rates would be much lower than the national average.The DILs were collaboratively discussed with the local staff, physicians, and other volunteers, focusing on their necessity.
Issues of polypharmacy and medication misuse can inadvertently jeopardize health.In Cambodia, non-communicable diseases (NCDs) are becoming a prevalent health issue.However, the untreated rates of NCDs in Phnom Penh are high, with reported rates for hypertension being 46.1% in males and 39.9% in females, and for diabetes, 44.3% in males and 37.2% in females. 10ur project plays an important role in caring for NCDs by continuously visiting specific areas.It is necessary to address polypharmacy and medication misuse to maximize the effectiveness of these health check-ups.Our medication record book and DILs could help solve some of these problems.
Recent outreach activities in Japan have been challenged by the need to respect local cultures and customs in targeted areas without overstepping boundaries as outsiders.However, our experience highlighted the potential to incorporate new approaches and methods from external perspectives.For example, introducing medication record books and DILs could improve local healthcare.Based on this experience, we aim to actively explore approaches that consider the resources and needs of the local community, examining the issues from an overarching perspective rather than feeling constrained as outsiders.Embracing the role of people from different areas or regions, we aspire to explore implementable approaches that could gradually disseminate and become integrated into the region's healthcare landscape, even in the years and decades to come.

Figure 1 .
Figure 1.Health Check-Up Station Operated by Medical Interns in Phnom Penh, Cambodia.
and free-drug combination regimen increased the risk of medication non-Iba C, et al.Public Health Outreach in Impoverished Areas of Cambodia: Addressing the Issues Related to Prescription Practices Int J Med Stud • 2024 | Jan-Mar | Vol 12 | Issue 1 DOI 10.5195/ijms.2024.2326| ijms.info101

Figure 2 .
Figure 2. Sample Drug Information Leaflets Utilized in Cambodian Public Health Outreach.