{"paper_id":"3420b2a9-602b-401a-b74f-515080453f18","body_text":"Expanding the role of village malaria workers in Cambodia: \nimplementation and evaluation of four health education packages\nMipharny Betrian1ƚ, Dafne Umans1ƚ, Moul Vanna2, Sam Ol2, Bipin Adhikari3, 4*, Chan Davoeung5, James J \nCallery3, 4, Yok Sovann6, Thomas J Peto3, 4, Richard J Maude3, 4, 6, 7, Rob W van der Pluijm3, 4, Voeunrung \nBunreth5, Martin P. Grobusch1, Michèle van Vugt1, Yoel Lubell3, 4, Lorenz von Seidlein3, 4, Arjen M \nDondorp3, 4, Siv Sovannaroth9, Dysoley Lek9, 10, Rupam Tripura3, 4\n1Centre of Tropical Medicine and Travel Medicine, Amsterdam University Medical Centres, location \nAMC, University of Amsterdam, the Netherlands\n2Action for Health and Development, Battambang, Cambodia\n3Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of \nOxford, Oxford, UK\n4Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, \nBangkok, Thailand\n5Battambang Provincial Health Department, Battambang, Cambodia\n6The Open University, Milton Keynes, UK\n7The University of Hong Kong, Hong Kong Special Administrative Region, China\n8Pailin Provincial Health Department, Pailin, Cambodia\n9National Centre for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia\n10School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia\nȽ Joint first authors\n* Correspondence: Bipin Adhikari (Bipin@tropmedres.ac) \n4th March 2023\nFor submission to PLoS ONE\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\nAbstract\nBackground\nEarly access to correct diagnosis and appropriate treatment is essential for malaria elimination, and in \nCambodia this relies on village malaria workers (VMWs). Decreasing malaria transmission leave VMWs \nwith diminished roles. Activities related to the control of other health conditions could keep these \ncommunity health workers relevant.\nMethods \nDuring 2022, 120 VMWs attended training at local health centres on four health education packages: 1. \nhygiene and sanitation; 2. disease surveillance; 3. management of mild illness; 4. vaccination and \nantenatal care. All training and evaluation sessions were documented through meeting minutes, and 19 \nfocus group discussions (FGDs) were conducted among VMWs and health centre personnel. Audio-\nrecords of FGDs were transcribed and translated in English and underwent thematic analysis.\nResults \nVMWs reported strong interest in the training and welcomed the expansion of their roles thus assuring \ntheir continued relevance. VMWs prioritized disease surveillance and management of mild illness \namong the available training packages because these topics were seen as most relevant. While training \nwas considered comprehensible and important, the low literacy among VMWs was an impediment \nsuggesting training materials need to be delivered visually. Since VMWs have limited resources, \nincentives could ensure that VMWs are motivated to undertake additional roles and responsibilities. \nConclusions \nThe transformation of VMWs into community health workers with roles beyond malaria is a promising \napproach for sustaining health care provision in remote areas. Training needs to consider the low \nscientific literacy, time constraints and limited resources of VMWs.\nKeywords: community health workers; health education; malaria; qualitative research; Southeast Asia\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n3\nIntroduction \nThe Greater Mekong Subregion (GMS) in Southeast Asia had historically a high burden of febrile \nillnesses, including malaria [1]. However, since the millennium there has been a substantial decrease in \nmalaria transmission in the region. To prevent the further evolution and spread of antimalarial drug \nresistance in the GMS, concerted efforts are underway to eliminate all human malaria by 2030 [2, 3]. \nEarly, accurate diagnosis and effective treatment is the current main strategy for malaria elimination. In \nthe GMS, as in most of Southeast Asia, the success of this strategy depends on networks of community \nhealth workers (CHWs) [4]. \nDue to a shortage of healthcare professionals in rural areas, local volunteers provide basic health \nservices in many low or lower middle-income countries (LMICs). These CHWs networks can improve \naccess to testing and treatment despite a lack of sophisticated medical training [5]. In some places CHWs \nprovide a broad range of health services [6]. In Cambodia CHWs work in vertical programmes, such as \nfor malaria control. As malaria transmission diminishes in Southeast Asia, the importance of other \nfebrile illnesses caused by non-malarial pathogens increases. Since village malaria workers (VMWs) \ncurrently do not manage non-malarial causes of fever, fewer patients attend them, thus limiting their \nusefulness and relevance. Identifying new duties, diagnostics, and activities to evolve VMW networks \ninto CHW networks will extend their spectrum of usefulness. Expansion of the roles of CHWs beyond \nmalaria has been applied successfully elsewhere and resulted in an increased number of patients tested \nfor malaria, and in strengthened rural healthcare services [6].\nIn Cambodia, VMWs are tasked with health promotion, diagnosis and treatment of malaria [7, 8]. \nCurrently, VMWs are unable to manage patients once malaria has been ruled out [4]. There are multiple \nhealthcare providers in Cambodian villages including government health care centres, non-\ngovernmental organizations (NGOs) that provide health information, and village health support groups \n(VHSG) who educate community members and brief healthcare personnel on prevalent health \nconditions in the villages. If VMW are to expand their roles, they must be integrated into these existing \nstructures. To meet Cambodian malaria elimination targets, it is essential that febrile patients continue \nto attend VMWs until local elimination is achieved and the risk of re-importation subsides. We report \nhere a research project which provided short health education courses on non-malaria activities to \nCambodian VMWs, and a qualitative assessment of the acceptability and feasibility of this approach for \nsustaining and strengthening the VMW programme.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n4\nMethods\nStudy context\nThis study is part of operational research supported by the Global Fund to Fight AIDS, Tuberculosis and \nMalaria entitled Sustaining village health worker programmes with expanded roles in the GMS. In \nCambodia, this included a project to explore the feasibility of expanded roles of VMWs, of which this \nstudy was a part. It was a collaboration between Mahidol Oxford Tropical Medicine Research Unit \n(MORU) and Action for Health Development Cambodia (AHEAD) and was supervised by the Cambodian \nNational Center for Entomology, Parasitology and Malaria Control (CNM). AHEAD led the field \nimplementation of the study and this study reports activities from June to December 2022. During the \nstudy, VMWs were offered training on various diseases in four districts of Battambang province. The \ntraining and its evaluation were conducted primarily using qualitative methods. \nParticipants\nVMWs and health centre personnel were chosen from four districts (Samlout, Koas Krala, Pailin and \nRukh Kiri) in Battambang province. Nine health centres were included where most of the training and \nevaluation were conducted. The VMWs were selected for the current training regardless of their age, \nexperience, or socio-demographic background. Personnel employed at the nine health centres were \ninvited to provide feedback regarding the health education training. Written informed consents from all \npotential participants were obtained before the interview/discussion sessions. \nTraining packages\nFour broad topics for the health education packages were established in advance by AHEAD in \nconsultation with CNM and partners. Based on the discussions with health centre personnel and VMWs, \nthe topics were refined to reflect the prevalences of diseases within these rural areas (excluding \nmalaria). Four innovative health education packages were developed, covering the following topics: 1. \nhygiene and sanitation; 2. disease surveillance (subtopics: COVID-19, dengue); 3. management of mild \nillness (subtopics: typhoid fever, respiratory infection, first aid and dehydration); 4. vaccination and \nantenatal care (ANC). The training sessions for each topic were conducted at local health centres and \neach session had a duration of 90-120 minutes. Training was given in small groups led by a trainer from \nAHEAD with occasional support from health centre chiefs, and the content was based on a lesson guide. \nCommunication was mostly verbal with some use of posters, flipcharts, and materials from previous \nhealth education activities. These training materials contained key messages in text and pictures. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n5\nTraining was structured into one of the topics (and subtopics) and were delivered primarily orally with \nexamples of the conditions, consequences and potential ways to manage them. Training sessions were \nalso interactive and included the opportunity for questions and participation by attendees, for example \nrole play during first aid training.\nData collection and analysis\nA total of 14 FGDs were conducted at the nine health centres during the implementation phase of the \nstudy (June to August 2022) and these FGDs took place immediately after health education workshops. \nThis was done to capture the initial impression from the VMWs of the health education. During the \nevaluation phase (from October 2022), five FGDs with VMWs, organised one to two months after they \nhad received training on the topic. Additionally, one FGD was conducted with community members. \nEach FGD had a duration of 30 to 60 minutes. The FGDs were conducted in Khmer and facilitated by two \nmembers of the AHEAD supervisory team, with six to eleven participants per session. All audio \nrecordings were translated and transcribed into English and were cross-checked by the local \ninterviewers and investigators. No information was collected that could identify individual participants \nduring or after data collection.  \nAll audio transcripts were transcribed and translated to English, and then collated into qualitative data \nanalysis software: NVivo version 12 by QSR international, Australia, and into Microsoft Excel. The \nanalyses were conducted using a deductive method that used an existing codebook derived from the \ninterview guide to inform the data coding. Further codes that emerged from reading the transcripts line-\nby-line were added into the existing codebook. At all stages, data analysis was conducted under the \nsupervision of a social scientist (BA). Any disagreements on coding process, codes and corresponding \ndescriptions were resolved by discussions and, at times, by seeking input from interviewers. Major \nthemes and sub-themes from the coded data and corresponding data are the basis of the results \npresented below. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n6\nResults\nDemographic characteristics of participants\nThe study population was 102 (91.1%) VMWs and 10 (8.9%) health centre personnel. The majority of \nparticipants (105; 93.8%) were more than 30 years old. 57.1% (n=57) of the participants were females. \nThe highest education level of the participants was primary level (25.9%), secondary level (34.8%) and \nhigh school (30.4%) for the VMWs. The remaining 8.9% of participants had a higher-level education \ncorresponding to their specialization such as laboratory technician, midwife, or nurse. During the \nevaluation phase, four FGDs were held with 41 (98%) VMWs and 1 (2%) health centre personnel. The \nmajority of the participants were female (n=24; 57%) and more than 30 years old (n=38, 90%).  [Table 1]\nExpanding the roles of VMWs\nThe majority of the VMWs and health centre personnel were satisfied with the proposed expansion of \nthe roles of the VMWs, which seemed to serve their motivation to continue improving their level of skills \nand contribute to their community. Although adding responsibilities to their existing role would increase \ntheir workload and could be burdensome, the VMWs felt that their sense of communal responsibilities \noutweighed the workload. \nI: When we add more tasks or roles to the village malaria workers, do they have more workload?\nR: Frankly, there are quite a lot of tasks for us. It is a big workload. It is a burden, but we need to \ndo it for the health of the community \n- FGD with sixteen VMWs and one health centre worker, Koas Kralor\nAdding roles and responsibilities to VMWs and their services to the community were further justified \nbecause community members reported VMWs as the preferred source of health care. VMWs were \nconsulted first and patients had an opportunity to discuss and decide whether to visit health centre or a \nreferral hospital. Their preference to consult VMWs were also rooted in their proximity, good \nrelationship and familiarity. \nI: Why did they decide to go to the VMW  as the first service provider?\nR: Because he lives so close to us, so we feel warm. On the other hand, he frequently visits every house in the \nvillage when he does not go to work.\n- FGD with eight community members, Prey Tralach\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n7\nTraining packages\nAccording to the VMWs and health centre staff the health information from the training sessions were \nclear and covered the most important points, namely cause, symptoms, treatment, and prevention for \nthe diseases. \n              I: Do you think what we have learned is useful or not and if it is, how is it useful?\nR: It is good because we help explain to them and also help let them understand the \nmanifestations, the symptoms, the care and the prevention \n- FGD with six VMWs and one health centre worker, Chark Roka\nNonetheless, there were suggestions to improve the training. Participants suggested to include longer, \nand more comprehensive training in future. The VMWs also requested receiving more feedback from \nfacilitators throughout the training sessions.\nI: Do you think the content is acceptable, with each topic shown with a few pictures and the time?\nR: We would like the opportunity for a two-day training course and to practice providing       \neducation for each other, this way we are prepared when we conduct it in the community \n             - FGD with twelve VMWs and two health centre workers, Boeung Run\nThe majority requested more resources, such as pamphlets and leaflets to provide education to the \ncommunity members. More visual materials were requested, such as images or posters because some \nVMWs have only limited literacy. \nI: Regarding the methodology you received from the trainer to use to disseminate to people in \nthe community, how do you improve on it?\nR: We need to have enough teaching materials to show the community. If we do not have \nmaterials, they will not understand what we teach them\n- FGD with twenty-six VMWs and two health centre workers, Koas Kralor\nDuring the evaluation, VMWs reiterated the importance of visual aids in training. VMWs suggested the \nneed for physical materials such as pictures, posters or leaflets presentations that could be referred to if \nand when required. Training on visualizing the health topics, including formal coursebooks, were also \nrecommended. VMWs recommended broadcast media such as radio or television, and megaphones for \nwider information sharing. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n8\nRecommended topics for training\nThe most common preferences for future education topics amongst the participants were frequently \nencountered non-communicable diseases, such as diabetes, hypertension, arthritis and gout.\nI: I want you to clarify in terms of teaching people in the community, which diseases do you want \nto focus on? The diseases which you think may occur in the future or currently, but no one \nnotices it?\nR: High blood pressure and diabetes, we do not know how to prevent them and would like to \nreceive knowledge to instruct the population on how to prevent these \n- FGD with twelve VMWs and two health centre workers, Boeung Run\nVMWs showed interest in additional tasks such as measuring blood pressure and glucose levels. Health \ncentre personnel thought that measuring blood pressure was a straightforward task that VMWs could \ncomplete, suggesting VMWs could potentially serve as a link between the health centres and community \nby monitoring these diseases.\nI: What other activities or topics would you like to learn, or know, besides what we have learned \nor described just now?\nR: I would like to request a blood pressure monitor and heartbeat monitor, since there are plenty \nof elderly people in the villages with high blood pressure, who frequently ask me if I can measure \ntheir blood pressure\n- FGD with twelve VMWs and two health centre workers, Boeung Run\nDuring the evaluation phase as well, VMWs echoed some of the recommendations they shared at the \noutset. In response to how they would like to see their roles in the future and what topics they \npreferred, a mix of both communicable (e.g. tuberculosis, cholera, and the common cold) and non-\ncommunicable (e.g. diabetes and hypertension) diseases was recommended. Some VMWs shared \nincreased workload could be a concern when expanding their roles. It was reiterated that financial \nsupport is critical to compensate for the time invested. Another challenge was a possible overlap of new \nroles allocated to VMWs with the pre-existing roles of other health volunteers.\nTraining implementation in the community\nVMWs disseminated health education to their communities in several ways. Larger gatherings of people \nwere found to be ineffective because VMWs found communicating in big groups difficult. The majority \nof respondents preferred training in small groups consisting of three to four participants. VMWs \nconducted health education when the village chief would gather villagers for a meeting or after \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n9\nceremonies and funerals at the pagoda, and some preferred to educate community members \nindividually, for example.\nI: The mode of education? You conduct education differently, right?\nR: It is easier with a small group of people, for example one or two people, when we see people, \nwe just start talking and provide information. In most cases, when we conduct education, it is \nafter people visit us for a test, just two to three people face to face. If education is conducted in a \nlarge group, they do not value us.\n- FGD with six VMWs and one health centre worker, Chark Roka\nI: What about during the holiday seasons such as New Year’s Day or Buddha Day? Can you \nconduct dissemination then?R: Every Sunday elderly people gather to do exercise and they also \nhave a meeting every month. I always take the opportunity to teach them during these \ngatherings. I also do it at funerals or on Buddha Day\n- FGD with twenty-six VMWs and two health centre workers, Koas Kralor\nChallenges\nThe VMWs reported their incentives to be too low to carry out their roles and responsibilities, \nspecifically when they had to travel to engage community members, which prevented them from \ncarrying out other tasks. Incentives also enhanced motivation of community members to participate. For \ninstance, community members were less interested in engaging in health education sessions if there \nwas no incentive, such as snacks, soap, gifts or other materials related to the theme of the education \nsession.\nI: What about during the holiday seasons such as New Year’s Day or Buddha Day? Can you \nconduct dissemination then?\nR: It is quite impossible to gather community members and teach them unless there is something \nto give them as an incentive. \n- FGD with twenty-six  VMWs and two health centre workers, Koas Kralor\nI: Well, is there anything else?\nR: If there is a budget, then it would be a little better but if it is too scarce then it does not even \ncover the gasoline fee back and forth\n- FGD with eight VMWs and two health centre workers, Kampong Lpov\nIt was difficult to retain the participants' attention and presence when providing health education. Some \nparticipants did not take the health education sessions seriously. It was challenging to assemble \nparticipants because of their competing priorities, particularly farmers during the peak of farming \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n10\nseason. Most of the participants in meetings organized by VMWs were female, and absence of men was \nattributed to farm work.\nI: When you conducted awareness raising, did you ever have issues with participants, for \nexample did they follow your advice, or consider it important?\nR: Some of them did not follow our advice, mostly because they thought we did not have enough \nknowledge to educate them\n- FGD with seventeen VMWs and one health centre worker, Tasanh\nI: When do you think it is an effective time to conduct dissemination regarding health education?\nR: During this season people often go to the mountains to harvest crops, so we rarely see them \nbecause they have already gone to the plantation. Since it is harvesting season, they have all \ngone to the plantation and it is hard to gather them for a meeting. \n- FGD with twenty-six VMWs and two health centre workers, Koas Kralor\nReflections by VMWs on training packages\nVMWs felt that the training packages had potential to prevent disease in the community, and were \npleased because these topics were chosen by them and the community members. Training packages \nwere felt to enhance community members’ ability to deal with certain symptoms and diseases without \nneeding to visit health workers. VMWs reported that additional support from other respected members \nof the community or health centre staff would be useful to circulate the information they learned during \nthe education sessions to the wider community. Village leaders, monks, health centre staff and teachers \nwere most often named as potential aides to strengthen their message and training to community \nmembers. Nonetheless, VMWs expressed that health education should be conducted with their \ninvolvement, as they would otherwise be seen as ‘unnecessary’ and potentially lose status and trust \nfrom community members.  \nThe VMWs kept records of their dissemination activities within their communities and these were \nreviewed by research staff. Self-reported data from the VMWs’ logbooks showed a total of 6,192 \ncommunity members (59% female) had received training on health topics from the VMWs. There were \ndifferences in the numbers of community members who were reached during subsequent dissemination \nof the health topics by VMWs. Disease surveillance was the most commonly discussed topic whereas \nvaccination & ANC was the topic on which the least amount of community members (n=481) were \neducated [table 2]. A total of 6,001 community members were educated on one of the four topics \nincluded in the training. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n11\nDiscussion\nThis study reports practicalities associated with the implementation and evaluation of training on health \ntopics among VMWs and community members in rural western Cambodia. The training packages were \nfound to be relevant because of their potential to expand VMWs’ roles. Simple, visual, and physical \ntraining materials are needed for the training to communicate with an audience with limited literacy. \nVMWs networks have been an important resource to implement training packages and were found to \nyield positive outcomes in Myanmar, Vietnam and Bangladesh [9-11]. \nThe majority of the VMWs and health centre personnel were positive about the expansion of the roles \nof the VMWs. Several VMWs acknowledged that adding responsibilities to their existing role would \nincrease their workload because of the competing responsibilities they had, however, they also saw the \nhealth-related responsibilities more as a service to the community. Adding new roles and responsibilities \nwas thought to promote their relevance and hence their sense of recognition by the community [12, \n13]. Indeed, in recent mass drug administration and malaria chemoprophylaxis activities in Southeast \nAsia, CHWs have played an important role [14, 15]. In Cambodia, like in many LMICs, CHWs are the first \npoint of contact for the majority of health problems [12, 16]. There is growing international evidence of \nthe potential benefits of seeking health care from CHWs in terms of cost, coverage, quality of services, \nand reductions in disease morbidity and mortality [17-21]. CHWs and VMWs have an inherent interest \nto be of value, thus want to expand their roles and responsibilities [12, 13, 16]. \nDespite the basic nature of the content, it was difficult for the participants to understand and retain all \nthe key points contained in the health information they received. Many VMWs recommended providing \nthem with physical training materials such as flow charts, pamphlets, or leaflets, so that they could \nretain and reflect on the content. Elsewhere in rural Southeast Asia low literacy and language barriers \nhave been highlighted as challenges to health communication [22, 23]. Visualization has been proven to \nincrease attention, recall, comprehension and adherence of audiences with low literacy levels [24]. This \nlimitation in literacy highlights the need to enhance the clarity and visualization of the information \npresented [22, 23]. Even among those who are fully literate, many participants only have primary or \nsecondary school education, and some concepts of basic biology and disease transmission are not easy \nto communicate to them [25]. \nVMWs reported some of the challenges of the training packages that included brief training, lack of \nrefresher training; and recommended longer and frequent training sessions which have been \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n12\ndemonstrated to be beneficial by the previous studies [4, 26-28]. One-off training may be inadequate \nand could be counterproductive. A need for repeated training was also highlighted by a recent study \namong VMWs in Kravanh district, Cambodia [12]. Refresher messages (training) have also been an \nimportant strategy to strengthen understanding and retention among the audience [29]. \nVMWs also reported challenges in carrying out training in their community, specifically the lack of \nincentives to compensate for their time was a major concern. In this study, the incentives were \ninadequate to complete all the training activities. VMWs used their own resources such as vehicles and \ngasoline. Inadequate compensation can be a major problem and has been reported in other countries \ne.g. Bhutan and Uganda [28, 30, 31]. Both financial and non-financial incentives have been shown to \npromote productivity by CHWs [30-32].\nTo reinforce VMWs’ credibility when offering health education to community members, local health \ncentre staff or local authority figures could be mobilized to garner respect from community members. \n‘Authority engagement’ has been shown to be an important element of achieving community \nparticipation [22, 33]. Apart from engaging with the authorities and community leaders, engaging and \nliaising with health workers is vital as they bear ‘institutional’ and ‘inter-personal’ trust among the \ncommunity members because they depend on them for health-related matters [34-36]. \nVMWs and community members recommended other health topics that they would like to be trained \non in future. Such recommendations were motivated by their own desire to be relevant for wider \ndiseases in the community and community members’ motivation to expand their knowledge base. These \nrecommendations suggest that VMWs are open to new health topics and demonstrate their readiness \nto undertake new responsibilities. Nonetheless, studies caution about balancing the responsibilities \ngiven to VMWs, particularly to not compromise the quality of services by overburdening them [37, 38]. \nStriking a balance between disease coverage and quality of service therefore requires further \noperational studies. \nStrengths and limitations\nTo make up for delays during COVID-19 restrictions, the initial implementation of training happened \nquickly, therefore local health centre staff were not trained in advance to lead the education sessions \nand local NGO staff had to deliver the training. Due to time constraints, visual health education \nmaterials were not available for all topics, which could have enhanced the sessions. Language barriers \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n13\nbetween international members of the research team, local staff, and study participants, limited the \ncommunication during FGDs.\nBased on stakeholder feedback, future education topics to be considered for further expansion of \nVMWs roles could focus on non-communicable diseases, as these are prevalent in most populations and \ncould be useful in preventing long lasting complications. Multiple projects elsewhere have successfully \nequipped volunteers with the necessary tools and education to conduct monitoring of non-\ncommunicable diseases [11, 39-41]. Promising tasks might include measuring blood pressure, measuring \nblood glucose levels and assisting community members with taking or administering medication.\nConclusion\nThis study explored the implementation and feedback of health training packages among village malaria \nworkers in Cambodia. Training on health topics can successfully be provided to this population with the \nutilization of visual aids, and flowcharts with simplified information and tasks. Training on health topics \nwas well-received by the participants and their dissemination to their communities represents a \npromising and feasible new role for them. The study findings imply that training sessions should be \ninteractive and offered repeatedly, and fair incentives should be provided for VMWs to take on new \nresponsibilities. \nDeclarations\nEthical approval\nEthics approval was obtained from the National Ethics Committee for Health Research Cambodia \n(NECHR 0125), the Oxford Tropical Research Ethics Committee (OxTREC ref 517-21), and the study is \nregistered on clinicaltrials.gov (NCT05045547). \nCompeting interests\nWe declare no competing interests.\nStudy Sponsor\nUniversity of Oxford, UK.\nFunding\nThis work was supported by Wellcome Trust [219644] and The Global Fund to Fight AIDS, Tuberculosis \nand Malaria [QSE-M-UNOPS-MORU-20864-007-42]. This research was funded in whole, or in part, by the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n14\nWellcome Trust [220211]. For the purpose of Open Access, the author has applied a CC BY public \ncopyright license to any Author Accepted Manuscript version arising from this submission. The funders \nhad no role in study design, data collection and analysis, decision to publish, or preparation of the \nmanuscript.\nData sharing statement\nData collected for the study, including deidentified individual participant data and a data dictionary \ndefining each field in the set, will be made available to others. These data will be available with \npublication via the MORU data sharing committee, Chairperson, Professor Phaikyeong Cheah, \nphaikyeong@tropmedres.ac. Access will be provided for analysis by bona fide researchers with or \nwithout investigator support, after approval of a proposal, and upon a signed data access agreement.\nAcknowledgements\nWe thank the study participants, and the staff who conducted the study at health centres in Pailin and \nBattambang provinces, with special thanks to Lim Vanthy and Bou Sakun who facilitated the focus group \ndiscussions, and to Sazid Zaman, Jacklyn Adella and Marc Visser. \nAuthor contributions\nMB, DU, TJP, BA, RT and JC conceived the study. MB, DU, MV, SO, BA, RT, JC and TJP led the \nimplementation and data collection. MB, DU, and BA conducted the data analysis followed by discussion \nwith JC, RT and TJP. MB, DU, BA, and TJP wrote the first draft of the manuscript. All authors read, \nrevised, and approved the final version of the manuscript.\nReferences\n1. Chhim S, Piola P, Housen T, Herbreteau V, Tol B: Malaria in Cambodia: A Retrospective Analysis \nof a Changing Epidemiology 2006-2019. Int J Environ Res Public Health 2021, 18.\n2. Organization WH: Strategy for malaria elimination in the Greater Mekong Subregion: 2015-\n2030. Manila: WHO Regional Office for the Western Pacific; 2015.\n3. Organization WH: World malaria report 2022. World Health Organization; 2022.\n4. Canavati SE, Lawpoolsri S, Quintero CE, Nguon C, Ly P, Pukrittayakamee S, Sintasath D, \nSinghasivanon P, Peeters Grietens K, Whittaker MA: Village malaria worker performance key to \nthe elimination of artemisinin-resistant malaria: a Western Cambodia health system \nassessment. Malar J 2016, 15:282.\n5. Benskin LL: A concept development of the village health worker.  Nurs Forum 2012, 47:173-182.\n6. McLean ARD, Wai HP, Thu AM, Khant ZS, Indrasuta C, Ashley EA, Kyaw TT, Day NPJ, Dondorp A, \nWhite NJ, Smithuis FM: Malaria elimination in remote communities requires integration of \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n15\nmalaria control activities into general health care: an observational study and interrupted \ntime series analysis in Myanmar. BMC Med 2018, 16:183.\n7. Ashley EA, Dhorda M, Fairhurst RM, Amaratunga C, Lim P, Suon S, Sreng S, Anderson JM, Mao S, \nSam B, et al: Spread of artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med \n2014, 371:411-423.\n8. National Center for Parasitology EaMCC, Cambodia: Cambodia Malaria Elimination Action \nFramework 2021 - 2025. Available online at \nhttps://www.cnm.gov.kh/userfiles/Cambodia%20Malaria%20Elimination_English%20FINAL.p\ndf (Accessed on 21st March, 2022). 2020.\n9. Win Han O, Hoban E, Gold L, Kyu Kyu T, Thazin L, Aung T, Fowkes FJI: Optimizing Myanmar's \ncommunity-delivered malaria volunteer model: a qualitative study of stakeholders' \nperspectives. Malar J 2021, 20:79.\n10. Long H, Ma Z, Hanh TTD, Minh HV, Rawal LB, Urmi DS, Jafar TH, Tang S, Abdullah AS: Engaging \nvillage health workers in non-communicable disease (NCD) prevention and control in Vietnam: \nA qualitative study. Glob Public Health 2020, 15:611-625.\n11. Rawal L, Jubayer S, Choudhury SR, Islam SMS, Abdullah AS: Community health workers for non-\ncommunicable diseases prevention and control in Bangladesh: a qualitative study. Glob Health \nRes Policy 2020, 6:1.\n12. Adhikari B, Tripura R, Dysoley L, Callery JJ, Peto TJ, Heng C, Vanda T, Simvieng O, Cassidy-\nSeyoum S, Ley B, et al: Glucose 6 Phosphate Dehydrogenase (G6PD) quantitation using \nbiosensors at the point of first contact: a mixed method study in Cambodia. Malar J 2022, \n21:282.\n13. Kok MC, Broerse JEW, Theobald S, Ormel H, Dieleman M, Taegtmeyer M: Performance of \ncommunity health workers: situating their intermediary position within complex adaptive \nhealth systems. Hum Resour Health 2017, 15:59.\n14. Tripura R, von Seidlein L, Sovannaroth S, Peto TJ, Callery JJ, Sokha M, Ean M, Heng C, Conradis-\nJansen F, Madmanee W, et al: Antimalarial chemoprophylaxis for forest goers in southeast \nAsia: an open-label, individually randomised controlled trial. Lancet Infect Dis 2022.\n15. von Seidlein L, Peto TJ, Landier J, Nguyen TN, Tripura R, Phommasone K, Pongvongsa T, Lwin KM, \nKeereecharoen L, Kajeechiwa L, et al: The impact of targeted malaria elimination with mass \ndrug administrations on falciparum malaria in Southeast Asia: A cluster randomised trial. PLoS \nMed 2019, 16:e1002745.\n16. Adhikari B, Tripura R, Peto TJ, Callery JJ, von Seidlein L, Dysoley L, Dondorp AM: Village malaria \nworkers for the community-based management of vivax malaria. The Lancet Regional Health-\nSoutheast Asia 2023, 9:100128.\n17. Yeboah-Antwi K, Pilingana P, Macleod WB, Semrau K, Siazeele K, Kalesha P, Hamainza B, \nSeidenberg P, Mazimba A, Sabin L, et al: Community case management of fever due to malaria \nand pneumonia in children under five in Zambia: a cluster randomized controlled trial. PLoS \nMed 2010, 7:e1000340.\n18. Kalyango JN, Rutebemberwa E, Karamagi C, Mworozi E, Ssali S, Alfven T, Peterson S: High \nadherence to antimalarials and antibiotics under integrated community case management of \nillness in children less than five years in eastern Uganda. PLoS One 2013, 8:e60481.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n16\n19. Christopher JB, Le May A, Lewin S, Ross DA: Thirty years after Alma-Ata: a systematic review of \nthe impact of community health workers delivering curative interventions against malaria, \npneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa. Hum Resour \nHealth 2011, 9:27.\n20. McCord GC, Liu A, Singh P: Deployment of community health workers across rural sub-Saharan \nAfrica: financial considerations and operational assumptions. Bull World Health Organ 2013, \n91:244-253b.\n21. Vaughan K, Kok MC, Witter S, Dieleman M: Costs and cost-effectiveness of community health \nworkers: evidence from a literature review. Hum Resour Health 2015, 13:71.\n22. Adhikari B, Pell C, Phommasone K, Soundala X, Kommarasy P, Pongvongsa T, Henriques G, Day \nNPJ, Mayxay M, Cheah PY: Elements of effective community engagement: lessons from a \ntargeted malaria elimination study in Lao PDR (Laos). Glob Health Action 2017, 10:1366136.\n23. Kajeechiwa L, Thwin MM, Nosten S, Tun SW, Parker D, von Seidlein L, Tangseefa D, Nosten F, \nCheah PY: Community engagement for the rapid elimination of malaria: the case of Kayin \nState, Myanmar. Wellcome Open Res 2017, 2:59.\n24. Houts PS, Doak CC, Doak LG, Loscalzo MJ: The role of pictures in improving health \ncommunication: a review of research on attention, comprehension, recall, and adherence. \nPatient Educ Couns 2006, 61:173-190.\n25. Priest S: Critical science literacy: What citizens and journalists need to know to make sense of \nscience. Bulletin of Science, Technology & Society 2013, 33:138-145.\n26. Zheng C, Anthonypillai J, Musominali S, Chaw GF, Paccione G: Community Perceptions of Village \nHealth Workers in Kisoro, Uganda. Ann Glob Health 2021, 87:82.\n27. O'Brien MJ, Squires AP, Bixby RA, Larson SC: Role development of community health workers: \nan examination of selection and training processes in the intervention literature. Am J Prev \nMed 2009, 37:S262-269.\n28. Musinguzi LK, Turinawe EB, Rwemisisi JT, de Vries DH, Mafigiri DK, Muhangi D, de Groot M, \nKatamba A, Pool R: Linking communities to formal health care providers through village health \nteams in rural Uganda: lessons from linking social capital. Hum Resour Health 2017, 15:4.\n29. Kahneman D: Thinking, fast and slow. Macmillan; 2011.\n30. Tshering D, Tejativaddhana P, Siripornpibul T, Cruickshank M, Briggs D: Identifying and \nconfirming demotivating factors for village health workers in rural communities of Bhutan. Int \nJ Health Plann Manage 2018, 33:1189-1201.\n31. Tshering D, Tejativaddhana P, Siripornpibul T, Cruickshank M, Briggs D: Motivational Factors \nInfluencing Retention of Village Health Workers in Rural Communities of Bhutan. Asia Pac J \nPublic Health 2019, 31:433-442.\n32. Zheng CY, Musominali S, Chaw GF, Paccione G: A Performance-Based Incentives System for \nVillage Health Workers in Kisoro, Uganda. Ann Glob Health 2019, 85.\n33. Peto TJ, Tripura R, Davoeung C, Nguon C, Nou S, Heng C, Kunthea P, Adhikari B, Lim R, James N, \net al: Reflections on a community engagement strategy for mass antimalarial drug \nadministration in Cambodia. Am J Trop Med Hyg 2018, 98:100-104.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n17\n34. Adhikari B, Yeong Cheah P, von Seidlein L: Trust is the common denominator for COVID-19 \nvaccine acceptance: A literature review. Vaccine X 2022, 12:100213.\n35. Gilson L: Trust and the development of health care as a social institution. Soc Sci Med 2003, \n56:1453-1468.\n36. Molyneux CS, Peshu N, Marsh K: Trust and informed consent: insights from community \nmembers on the Kenyan coast. Soc Sci Med 2005, 61:1463-1473.\n37. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, Adeyi O, Barker P, \nDaelmans B, Doubova SV, et al: High-quality health systems in the Sustainable Development \nGoals era: time for a revolution. Lancet Glob Health 2018, 6:e1196-e1252.\n38. Jain S: India's army of unrecognised, unpaid female health workers. BMJ 2021, 375:n2509.\n39. Widyasari V, Rahman FF, Lin KH, Wang JY: The Effectiveness of Health Services Delivered by \nCommunity Health Workers on Outcomes Related to Non-Communicable Diseases among \nElderly People in Rural Areas: A Systematic Review. Iran J Public Health 2021, 50:1088-1096.\n40. Le HT, Le TA, Mac TD, Nguyen DN, Vu HN, Truong ATM, Quang Do AT, Bui HTT, Do HTT, Nguyen \nATH, et al: Non-communicable diseases prevention in remote areas of Vietnam: Limited roles \nof health education and community workers. PLoS One 2022, 17:e0273047.\n41. Raithatha SJ, Kumar D, Amin AA: Training Village Health Workers in Detection and Monitoring \nof Noncommunicable Diseases: A Low Cost Option for Rural Areas Facing the Emerging Health \nEpidemic. Fam Community Health 2017, 40:253-257.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted March 12, 2023. ; https://doi.org/10.1101/2023.03.10.23287110doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}