Volunteer community health workers (CHWs) are an important link between the public health system and the community. The ‘Community Participation Policy for Health’ in Cambodia identifies CHWs as key to local health promotion and as a critical link between district health centres and the community. However, research on the challenges CHWs face and identifying what is required to optimise their performance is limited in the Cambodian context. This research explores the views of CHWs in rural Cambodia, on the challenges they face when implementing health initiatives. Qualitative methodology was used to capture the experiences of CHWs in Kratie and Mondulkiri provinces. Two participatory focus groups with CHWs in Mondulkiri and ten semi-structured interviews in Kratie were conducted. Results from both studies were used to identify common themes. Participants were CHWs, male and female, from rural Khmer and Muslim communities and linked with seven different district health centres. Findings identify that CHWs regularly deliver health promotion to communities. However, systemic, personal and community engagement challenges hinder their ability to function effectively. These include minimal leadership and support from local government, irregular training which focuses on verticalised health programmes, inadequate resources, a lack of professional identity and challenges to achieving behaviour change of community members. In addition, the CHW programme is delivered in a fragmented way that is largely influenced by external aid objectives. When consulted, however, CHWs demonstrate their ability to develop realistic practical solutions to challenges and barriers. The fragmented delivery of the CHW programme in Cambodia means that government ownership is minimal. This, coupled with the lack of defined core training programme or adequate resources, prevents CHWs from reaching their potential. CHWs have positive and realistic ideas on how to improve their role and, subsequently, the health of community members. CHWs presented with the opportunity to share learning and develop ideas in a supportive environment would benefit health initiatives.

Introduction Onchocerciasis is targeted for elimination mainly with annual community-directed treatment with ivermectin (CDTI). High infection levels have been reported in South-West Cameroon, despite ≥15 years of CDTI. The aim of this study was to assess factors associated with continued onchocerciasis transmission and skin disease. Methods A large-scale cross-sectional study was conducted in 2017 in 20 communities in a loiasis-risk area in South-West Cameroon. A mixed-methods approach was used. Associations between infection levels, skin disease and adherence to CDTI were assessed using mixed regression modelling. Different community members’ perception and acceptability of the CDTI strategy was explored using semi-structured interviews. Results Onchocerciasis prevalence was 44.4% among 9456 participants. 17.5% of adults were systematic non-adherers and 5.9% participated in ≥75% of CDTI rounds. Skin disease affected 1/10 participants, including children. Increasing self-reported adherence to CDTI was associated with lower infection levels in participants aged ≥15 years but not in children. Adherence to CDTI was positively influenced by perceived health benefits, and negatively influenced by fear of adverse events linked with economic loss. Concern of lethal adverse events was a common reason for systematic non-adherence. Conclusion CDTI alone is unlikely to achieve elimination in those high transmission areas where low participation is commonly associated with the fear of adverse events, despite the current quasi absence of high-risk levels of loiasis. Such persisting historical memories and fear of ivermectin might impact adherence to CDTI also in areas with historical presence but current absence of loiasis. Because such issues are unlikely to be tackled by CDTI adaptive measures, alternative strategies are needed for onchocerciasis elimination where negative perception of ivermectin is an entrenched barrier to community participation in programmes.

This paper draws on the experiences of a doctoral student undertaking a cross-cultural, cross-language participatory action research (PAR) project in rural Cambodia. Cambodia is a largely Buddhist country with a complex history of religion, invasion, colonisation, war and oppression. Despite a democratic constitution, political control and fear of challenging authority are ever present; and all had an impact on the participation and development of this project. I recruited eight volunteer community health workers (CHWs) and two research assistants (RAs) with an aim to explore methods and challenges faced when trying to improve health with and for community members. Over eight participatory workshops and a two-day training session CHWs identified, implemented and reflected on solutions to community health problems. Simultaneously, the RAs and I reflected on the processes and challenges we faced. Creating opportunity for reflexivity allowed for discussion to emerge around culture, position and power and how these were impacting on the research process and outcomes. Established social hierarchical power structures in Cambodia presented challenges to undertaking a PAR project with emancipatory and social change aims. Such structures also impacted on the ability and readiness of participants to be critical and analytical. The importance of the RAs as cultural navigators and the necessity of embracing their situated knowledge as both an insider and outsider is a key finding.

Global health gains can be achieved through strengthening health systems to identify and address implementation challenges in low- and middle-income countries. Participatory research, that promotes joint problem and solution finding between communities and different health systems actors, supports policy implementation analysis at all levels. Within the neglected tropical disease programmes in Liberia and Nigeria, we applied participatory action research (PAR) to address programmatic and health system bottlenecks with health systems strengthening embedded. This paper shares learning from 20 interviews with co-researchers, from national and sub-national levels and academic researchers who worked collaboratively to understand challenges, co-create solutions and advocate for policy change. Through analysis and reflections of existing PAR principles, we inductively identified five additional guiding principles for quality, ethical standards and ongoing learning within PAR projects that aim to strengthen health systems. (1) Recognize communities as units of identity and define stakeholder participation to ensure equitable engagement of all actors; (2) enable flexible action planning that builds on existing structures whilst providing opportunities for embedding change; (3) address health systems and research power differentials that can impede co-production of knowledge and solution development; (4) embed relational practices that lead to new political forms of participation and inquiry within health systems and (5) develop structures for ongoing learning at multiple levels of the health system. PAR can strengthen health systems by connecting and co-creating potentially sustainable solutions to implementation challenges. Additional research to explore how these five additional principles can support the attainment of quality and ethical standards within implementation research using a PAR framework for health systems strengthening is needed.

The UN's Sustainable Development Goals (SDGs) and pledge to leave no one behind have raised the importance of ensuring equitable health outcomes and healthcare delivery. Multisectoral approaches to tackling neglected tropical diseases (NTDs), including prevention, diagnosis, treatment, and healthcare, have had a limited focus on gender. Yet, gender roles and relations shape vulnerability to NTDs, access to prevention and treatment, and experience of living with NTDs [1]. Understanding the similarities and differences of disease vulnerability and experience between genders can support NTD actors to deliver equitable prevention, diagnosis, and treatment services. The NTD community, including researchers and practitioners, needs to better understand these dynamics and take action to advance gender equality, meet the NTD roadmap 2020 goals, and contribute towards the SDGs and universal health coverage (UHC). The UHC movement is advocating for clear action to address the gender determinants of health. This viewpoint synthesizes evidence from a discussion paper [2] developed by the UN Development Programme (UNDP) and TDR (Special Programme for Research and Training in Tropical Diseases sponsored by UNICEF, UNDP, World Bank, and WHO) in partnership with the Liverpool School of Tropical Medicine to support governments and nongovernment organizations to understand how to recognize and address gender inequities within NTD programs and improve delivery through gender analysis. Gender refers to the socially constructed roles, behaviors, activities, attributes, and opportunities that any society considers appropriate for men and women, boys and girls, and people with nonbinary identities [3, 4]. Gender, sex, and their intersections with other social determinants of health shape peoples' vulnerability to and experience of multiple NTDs and their ability to access care and treatment [3, 5]. This can be complex and will vary between diseases, contexts, and other social and demographic factors such as age. Fig 1 highlights differences in disability-adjusted life years (DALYS) from different NTDs by age and sex from the Global Burden of Disease (GBD) Study [6]. By examining how gender shapes who is infected with NTDs, who accesses preventive medicines, who is diagnosed and treated, who is exposed or vulnerable to NTDs, and how and whose behavior is risk prone or risk averse, inequities can be better understood, challenged, and addressed.

Background: Onchocerciasis is a priority neglected tropical disease targeted for elimination by 2025. The standard strategy to combat onchocerciasis is annual Community-Directed Treatment with ivermectin (CDTi). Yet, high prevalence rates and transmission persist following > 12 rounds in South-West Cameroon. Challenges include programme coverage, adherence to, and acceptability of ivermectin in an area ofLoa loaco-endemicity. Loiasis patients harbouring heavy infections are at risk of potentially fatal serious adverse events following CDTi. Alternative strategies are therefore needed to achieve onchocerciasis elimination where CDTi effectiveness is suboptimal.Methods/design: We designed an implementation study to evaluate integrating World Health Organisation-endorsed alternative strategies for the elimination of onchocerciasis, namely test-and-treat with the macrofilaricide, doxycycline (TTd), and ground larviciding for suppression of blackfly vectors with the organophosphate temephos. A community-based controlled before-after intervention study will be conducted among > 2000 participants in 20 intervention (Meme River Basin) and 10 control (Indian River Basin) communities. The primary outcome measure isO. volvulusprevalence at follow-up 18-months post-treatment. The study involves four inter-disciplinary components: parasitology, entomology, applied social sciences and health economics. Onchocerciasis skin infection will be diagnosed by skin biopsy andLoa loainfection will be diagnosed by parasitological examination of finger-prick blood samples. A simultaneous clinical skin disease assessment will be made. Eligible skin-snip-positive individuals will be offered directly-observed treatment for 5 weeks with 100 mg/day doxycycline. Transmission assessments of onchocerciasis in the communities will be collected post-human landing catch of the local biting blackfly vector prior to ground larviciding with temephos every week (0.3 l/m³) until biting rate falls below 5/person/day. Qualitative research, including in-depth interviews and focus-group discussions will be used to assess acceptability and feasibility of the implemented alternative strategies among intervention recipients and providers. Health economics will assess the cost-effectiveness of the implemented interventions.Conclusions: Using a multidisciplinary approach, we aim to assess the effectiveness of TTd, alone or in combination with ground larviciding, following a single intervention round and scrutinise the acceptability and feasibility of implementing at scale in similar hotspots of onchocerciasis infection, to accelerate onchocerciasis elimination.