Barriers Associated With Access to Pediatric Healthcare Services in Cambodia

Introduction

The problem statement of the current study establishes the absence of qualitative research on the subject of child malnutrition and its possible ecological culprits. The current literature review seeks to elaborate on the problem statement of this study. Bedford and Sharkey (2014) point out that access to pediatric healthcare services is dependent on a number of factors. On its part, a study by Ghosh (2011) found that access to pediatric care is closely related to environmental factors. Towards this end, the review examines the ecological conceptual framework and how it relates to access to pediatric services.

The literature review also examines individual factors that can contribute to the accessibility of pediatric services. According to Rimal (2003), access to pediatric services is dependent on situations in a family. Individual factors like the number of children and one’s marital status are discussed. The context of the discussion is in Cambodia and countries with similar demographics. Other factors discussed in this literature review include personal and community factors. The review will provide more information on how to overcome the barriers to accessing pediatric care.

Review of the background statement

The Cambodia Demographic and Health Survey 2010 estimated that 40% of children under five are stunted. Such a condition is indicative of chronic malnutrition in the country (National Institute of Statistics, Directorate-General for Health & ICF Macro, 2011). Angkor Hospital for Children in Siem Reap, Cambodia, reported child malnutrition as one of its most frequent diagnoses among children in 2013 (Angkor Hospital for Children [AHC], 2014). The report demonstrates that patients with the most acute conditions mostly come from the poorest families within a given society. The implication is that access to healthcare is dependent on a number of factors.

The following is an outline of the factors affecting access to health care services:

  • Distance to hospitals from settlements
  • Economic status of households

The families who are financially disadvantaged are likely to postpone the visit to a hospital. Such families opt to make visits only when the child is in a critical condition. Waiting to seek treatment until a condition becomes severe would cause a family much more financial hardship. In Cambodia, the cost of medication is extremely high. For instance the approximate cost of inpatient at a local hospital is $149.29. The cost of a surgical procedure is estimated at around $333.47. When it comes to the cost of the Intensive Care Unit, AHC (2014) puts the figure at $798.70. The background of this study established that Cambodia is a low-income country, where in 2011, 19.8 percent of population lived below the poverty line (United Nations Development Program [UNDP], 2013). Poverty line in Cambodia is stands at 3,871 Riel per day. The figure is approximately 0.95 USD per day. When taken into mutual consideration, the hospital expenses contrasted against the poverty line estimate and the percentage of the Cambodian population living below the poverty line provides a further insight into high pediatric malnutrition diagnosis reported by the Angkor Hospital for Children.

Search Strategy

Pediatric care is an integral aspect of healthcare, particularly at the community level. As previously mentioned, there are a number of studies which have explored the subject. Consequently, the current review is an attempt at filling the existing literature gap on the subject. Towards this end, the literature review was carried out through a desktop analysis. A desktop study involves searching for the relevant sources from a variety of databases and engines. With respect to the contents of this review, the search strategy made use of a variety of academic and health related search engines.

Google Scholar, PubMED, HDAS and HCUP are the main databases that were used to obtain the relevant sources. However, Creswell (2009) advices on the need to expand one’s research by making use of common search engines like Yahoo. Consequently, Google and Yahoo were used as the appropriate search engines. Separately, Creswell (2009) cites the importance of making use of appropriate key words in the search strategy. The following is a list of the key words used to access materials for the study:

  1. pediatric care
  2. access to pediatric care
  3. barriers to accessing pediatric care
  4. healthcare conceptual framework
  5. factors that promote access to pediatric care
  6. care givers and pediatric care

Conceptual Framework

Overview

The proposed study will be informed by Ecological Conceptual Framework (ECF) based on the study conducted by Artuso, Cargo, Brown and Daniel (and cited in Bedford & Sharkey, 2014). ECF as it will be applied to a qualitative study design was chosen because it acknowledges the complex interaction between an individual’s decisions and his or her multi-layered environment. The healthcare system is riddled by a myriad of issues. However, most of the challenges facing the sector have been resolved in previous studies (Ormsby et al., 2012). Healthcare instances that involve massive interaction between patients and medical workers are required to take into account the community element. Access to pediatric care is an important part of childhood development. The implication is that there are social elements that can be described as, ‘determinants of health’. To this end, an ecological conceptual framework is ideal for the current review.

Objective of a conceptual framework

Conceptual frameworks are the requirements of practice developed from years of research. The ecological conceptual framework is action oriented (Page et al., 2011). According to Page et al. (2011), action oriented frameworks are important in supporting the problem under review. For instance, the current study touches on the communal aspect of healthcare.

The problem statement illustrates that malnutrition in children is one of the reasons for a pediatric care. Leroy, Ruel, Habicht, and Frongillo (2014) assessed child growth faltering (one of the main consequences of malnutrition) across 51 low- and middle-income countries. The study found that malnutrition persists due to the inability to access quality care.

The literature review takes into account the gaps in previous literature and advances upon each. For instance, a great number of surveys on this topic have been conducted since 2000. Unfortunately, there is little information surrounding the whole issue of how the environment fits into accessing pediatric care. To this end, more comprehensive, country-specific, culturally-sensitive reasons around the barriers to pediatric care need to be discussed (Baxter, Killoran, Kelly & Goyder, 2010).

An ecological conceptual framework is action based when it comes to supporting healthcare systems. A study carried out by Beer et al. (2012) found that an ecological conceptual framework helps in the identification of the determinants of health. In this regard, an ecological framework helps in understanding the specific barriers to accessing pediatric care.

Conceptual frameworks help to outline how different variables are interrelated. The study by Chimphamba et al. (2012) held similar perspective. Chimphamba et al. (2012) were evaluating access to healthcare for HIV+ couples. The study made use of the ecological conceptual framework. The framework allowed the researchers to relate the economic and social factors and how they contribute towards accessing medical care. Similarly, the ecological conceptual framework can be used in this study to evaluate how the barriers to accessing pediatric care are related.

Conceptual frameworks are essential in outlining how health inequalities result. Karen (2013) points out that the barriers to accessing pediatric care are brought about by the inequalities present in a society. However, there is a need for a comprehensive framework to outline the specifics around the whole inequality issue. The same explains why the ecological framework has been used in several studies. Haslett and Sefton (2013) applied the ecological framework in their study alongside the health belief model. The framework allowed the researchers to establish a link between accessing medical care, for mental patients, and economic abilities.

An ecological conceptual framework is essential when a study seeks to evaluate the most important factors affecting a given communal problem. The problem statement revealed that access to pediatric care in Cambodia is a huge problem. Insaf, Janine, and Ladan (2010) argue that inability to access medical care is a problem that requires communal responses. In light of this, the ecological framework evaluates the problem from the community perspective. In this regard issues like geographical location and societal perceptions are discussed.

The ecological conceptual framework encompasses a number of issues touching on the interactions between a people and their environment. According to Hallers-Haalboom et al. (2014), research into this particular framework is required to encompass the behavior setting of a particular group of people. In a separate study, Ormsby et al. (2012) found that the community is an integral aspect of the ecological framework. The two components of this framework bring about the need to evaluate the context.

Key elements of the ecological framework

As already mentioned, the ecological framework comprises of several key aspects. However, the current study is only interested in three. The following is an analysis of the three components of this framework.

Behavior setting

An ecological framework encompasses elements touching on the habitat of a people. Towards this end, there is a need to evaluate the behaviors of the population in a given geographical area (Raphael, Zhang, Liu & Giardino, 2010). Behavior setting takes into account the geographical location of a people and develops a pattern on how they interact. In the study by Raphael et al. (2010), the ecological framework was used in identifying the behaviors that occur on consecutive moments during the day to day activities of a given area. To this end, behavior setting is seen as an essential component in evaluating the patterns surrounding access to pediatric care.

Community

A study touching on the access to pediatric care is required to encompass an actual territory in a geographical set up. According to Sakisaka, Jimba, and Hanada (2010), a community is described as a territory in which people occupy and develop relational habits. Sakisaka et al. (2010) suggest that a community is required to have a definite structure. The structure allows for research into the elements that have a number of challenges.

The current study is based on the challenges faced in accessing pediatric care in the rural part of Cambodia. Sreeramareddy, Sathyanarayana, and Kumar (2012), sought to evaluate a similar problem in India. Sreeramareddy et al. (2012) made use of the ecological conceptual framework to understand the dynamics of rural communities in India. Consequently, the study was able to establish that most families in the area prefer home treatment than trekking long distance to access medical care.

The larger context of the ecological framework discusses the community to incorporate other elements like wild animals and plants. However, when it comes to healthcare systems, a community is understood from the point of view of humans and their related activities. A survey carried out by Thind and Cruz (2003) found that the determinants associated with health services are brought about by human involvement. To this end, a discussion on the community aspect of a study is required to take into account the cultural elements of a people.

Context

The element of context in an ecological framework allows a researcher to establish a proper understanding of the scenarios presented. According to Rimal (2003), healthcare related studies are required to contextualize a given problem. For instance, Sakisaka et al. (2010) carried out a study to establish the behaviors of mothers (as care givers) in cases where their children fall sick. The study was able to contextualize the problem to the wider parenting community. Consequently, Sakisaka et al. (2010) provided a rationale in which mothers can carry out their care giving roles without having to panic.

The review relies on the ecological conceptual framework to establish some of the community related issues that prevent access to pediatric care. For instance, the issues touching on individual factors (like age and education) require contextualization (Karkee, Lee & Pokhare, 2014; Krumkamp et al., 2013). In the absence of an ecological framework, issues like community and social aspects cannot be properly discussed with respect to the pediatric care. To this end, the existing gaps in literature are addressed courtesy of this model.

Individual Factors

Access to pediatric care is an integral part of community health. According to Kaljee et al. (2011), pediatric care ensures that the healthcare interests of children are well taken care of. For instance, in Vietnam parents often debate with the issue of pediatric care given their marital status, age and sex (Kaljee et al., 2011). The study found that healthcare systems require the individual involvement. Similarly, the current study examines the barriers to accessing pediatric care from an individual perspective.

Barriers to accessing pediatric care are best understood from the point of view of the care giver. Based on the ecological conceptual framework, care givers are humans. Consequently, individual factors play a huge role in evaluating how children can access quality pediatric care. Grundy, Annear, Chomat, Ahmed, and Biggs (2013) suggest that the educational level of a people is crucial to improving access to pediatric services. Grundy et al. (2013) found that individual factors associated with access to pediatric services include, age, marital status and family size.

Sex

As already mentioned healthcare is improved when the healthcare is improves when the care givers play their rightful role in the medical system. Das et al. (2013) used their study to illustrate the challenges of accessing pediatric care in Bangladesh. The study found that parents are the considered as the best primary care givers. According to Das et al. (2013), the maternal nature of mothers makes them ideal as the suitable care givers. Unfortunately, there are some rural areas where care giving duties are gender based.

In the problem statement, it was evident that access to pediatric care is mostly common in developing countries. In most cases, the problem is common in rural settings. Cambodia, for instance, is one of the most under developed countries in South Asia. The communities in the rural areas are largely patriarchal (Grundy et al., 2013). Consequently, issues of male chauvinism become prevalent. Towards this end, access to pediatric care, in places like Cambodia, is determined based on sexual dominance.

Communities where the care giver is a woman record a high rate of access to pediatric care. Unfortunately, male care givers are not as keen with pediatric care. In light of this, Das et al. (2013) suggest patriarchal societies act as a barrier to accessing pediatric care. Societies that curtail the involvement of the woman make it difficult for mothers to take their children to medical centers (Page et al., 2011). The resultant effect is that children in rural areas will continue to suffer from various ailments which could be prevented (Ozawa & Damian, 2011).

Age

Care giving is a skill that is perfected over time. As previously mentioned, care giving plays a central role in ensuring that children get to obtain pediatric care from proper healthcare facilities. According to Bedford and Sharkey (2014), care givers are required to be adults of a sound mind. Towards this end, cases of underage mothers present a challenge to ensuring the access to pediatric care is a success. The responsibility of motherhood is realized with age (Chhea, Lenore & Narelle, 2010). Consequently young caregivers tend to be less efficient when it comes to emphasizing on the need to accessing pediatric care.

In rural settings medical centers are few but the population, to be served, is high. The high ratio of patients to medical workers forces stakeholders to engage more medical professionals (Ghosh, 2011). Unfortunately, the practitioners hired are young and lack the necessary experience. The study by Grundy et al. (2013) found that inexperienced healthcare workers handle patients poorly. Consequently, such patients fail to return due to the poor quality of service. In the long run, age is seen as a barrier to accessing proper pediatric services.

Marital status

Rural settings still hold on to conservative traditions like marriage. The study by Opwora et al. (2011) found that unmarried women are stereotyped in most rural communities. In most cases, the children of such women are treated as outcasts. Opwora et al. (2011) point out that stereotyping against unmarried women discourages them from participating on the normal healthcare activities like attending pediatric care.

Marital status comes with a lot of responsibility. Opwora et al. (2011) found that married care givers often spend most of their time participating in communal affairs. Since most care givers are women, their daily chores prevent them from taking their children for pediatric services when the need arises. Marital status is seen as a barrier to accessing pediatric care when the demands are too much on the primary care giver. However Grundy et al. (2013) argue that changing times bring about a corresponding shift in the perspectives of a people on the importance of pediatric care.

Education

Healthcare systems are often associated with a number of knowledge based activities. For instance, communities are expected to have the necessary information touching on the importance of pediatric care. Meesen et al. (2011), argue that care givers carry out their activities based on their education levels. To this end, care givers with insufficient education end up performing poorly. Consequently, uneducated care givers act as barriers to pediatric care.

Rural settings are characterized by low levels of education. Meessen et al. (2011) point out that insufficient education causes a society to disregard the importance of pediatric care. The importance of education was seen in the study carried out by Khatun, Shahinur, Hafizur and Sabir (2013). According to Khatun et al. (2013), education was essential in informing the rural communities (in Bangladesh) about the dangers of diarrhea. The rural populations were taught on the need to take children to a pediatrician. In that study, insufficient education was seen as the main barrier to accessing pediatric care.

Pediatric services can only be provided by a pediatrician. Meessen et al. (2011) found that most rural communities adhere to the traditional forms of medicine. Khatun, Shahinur, Hafizur, and Sabir (2013) also found that rural inhabitants are knowledgeable on archaic matters. Consequently the care givers will lack the proper information touching on the importance of pediatric access. As a result, the patients tend to shun pediatric facilities.

Number of children

Rural areas are characterized by large families. Khatun et al. (2013) pointed out that lack of proper family planning is the reason why most rural-based families have plenty of children. In this regard, the families are often unable to meet the need for pediatric services. As already mentioned, most rural women are overworked. To this end, primary care givers with large families find it difficult to take all the children to hospital. The society provides a framework which ensures that the children get alternative treatment (Victoria et al., 2008). Large families act as barriers to the access of pediatric services and quality.

Personal Relationship Factors

Caregivers have a number of relationships in a society. The ecological conceptual framework, discussed in this review outlines the human interactions. As previously mentioned, an ecological framework encompasses elements touching on the areas where people have settled. Towards this end, there is a need to evaluate the behaviors of the population in a given geographical area (Scott, McMahon, Yumkella, Diaz & George, 2014). The element of behavior setting helps in the analysis of personal relationship factors. Raphael et al. (2010) found that the ecological framework was used in identifying the daily behaviors of a people. To this end, behavior setting is seen as an essential component in evaluating how personal relationships act as barriers in accessing pediatric care.

There are a number of relationships in a society. Elder et al. (2014) argue that the family is the primary relationship I a society. Elder et al. (2014) arrived at this conclusion based on their evaluation of child survival in developing nations. According to Elder et al. (2014), parents form tight bonds with their family in most rural settings. The conservative nature of most rural areas encourages the emphasis on strong family bonds. Other relationships include the ones shared among friends.

Family

The family is a basic unit in any given society. According to Chhea et al. (2010), rural settings like the kind found in Cambodia place high esteem on the family unit. Chhea et al. (2010) point out that the family the unit acts as a protective unit for children. In this regard, access to pediatric care is improved in cases where the bonds in a family are strong. For instance, when the family unit is strong there is a shared role in care giving. In the absence of the mother, there is always someone who will provide support when called upon.

The family is seen as an ideal unit through which can be used to encourage pediatric care. However, Chowdhury et al. (2011) established that the family can be one of the barriers towards accessing pediatric services. In this regard, the economical elements come into perspective. Chowdhury et al. (2011) point out that, economic challenges in a family strain the available resources. To this end, issues like pediatric care are seen as secondary needs. In such circumstances, diseases like diarrhea persist.

The family is also seen as an impediment to pediatric care in cases where there is internal conflict. Dingle, Powel-Jackson, and Goodman (2013) carried out a study to evaluate how to improve maternal health cases. The study found that domestic violence was one of the causes which prevented patients from accessing medical care. The fear that results from domestic violence prevents the care givers from going to hospital due to the questions that will emerge (Wallace et al., 2014). Dingle et al. (2013) found that most parents prefer to treat their children from home rather than face the authorities once the child reports of violence at the hospital.

Peer Relationships

Caregivers play a huge role in the development of children. However, influence from external sources tends to interrupt the care giving initiatives. For instance, there are cases when a care giver listens to bad advice from their friends. Advice of this nature can be the kind that is detrimental to the lives of children (Scott et al., 2014). Some friends can ask a caregiver among them to shun taking their child to hospitals.

The study carried out by Raphael et al. (2010) found that pediatric healthcare is important for growing children. In this regard, obtaining information that suggests pediatric services are not relevant is misleading. Access to pediatric care is usually interrupted by the continuous misleading information.

Community

As already mentioned, the current study is developed based on the ecological conceptual framework. The framework is essential in discussing how a community contributes towards preventing access to pediatric care (Emelumadu et al., 2014). According to Emelumadu et al. (2014), a community is understood from the constituent elements of an ecological framework.

As already mentioned, conceptual frameworks are essential in outlining how health inequalities result. The study by Karen (2013) established that the barriers to accessing pediatric care are brought about by the inequalities present in a society. In this regard, the inequalities in a given community act as barriers to accessing pediatric care. Grundy et al. (2013) applied the ecological framework in their study and found that healthcare services are provided based on an individual’s economic prowess. To this end, the economic status of a community is seen as the determinant towards accessing pediatric care.

The ecological framework, applied in this review, to identify the common problem in a given community. The problem statement revealed that access to pediatric care in Cambodia is a huge problem. Separately, Insaf et al. (2010) point out that the inability to access medical care is a problem that requires communal responses. In light of this, the ecological framework evaluates the problem from the community perspective. Communities that are stuck in the olden ways of medicine continue to suffer from the effects of their wayward practice.

Access to pediatric care is dependent on the physical components of a given community. Based on this argument, a number of studies have advanced their discussions on the role of communities with respect to pediatric care. Engle et al. (2011) argue that urban-rural disparities are constituent elements of a community that affect the access to pediatric care. In a separate study, Eng, Whitney, and Mulsow (2014) evaluated parental involvement when it came to pediatric care. The study by Eng et al. (2014) found that the distance from settlements to medical centers was also an impediment to accessing medical care. Other aspects of a community that are associated with access to pediatric services include infrastructure and security.

Insecurity

Rural areas are characterized by a scattered settlement pattern. According to Eng et al. (2014), security in such a settlement is difficult to coordinate. This major security shortcoming has emerged as one of the impediments to accessing pediatric care. A study carried out by Martinez et al. (2012) found that insecurity in rural places reduced the chances of parents taking their children to hospitals. Towards this end, child mortality rates tend to be higher in rural areas that have security challenges (Emelumadu et al., 2014).

Infrastructure

Community set ups are human habitations. Matsuoka, Hirotsugu, Lon, Tung, and Akiko (2010) found that the absence of proper infrastructure is a huge impediment in accessing pediatric care. In their study, Matsuoka et al. (2010) illustrate that most rural areas are characterized by a poor road network. Consequently access to medical facilities becomes a challenge. Morgan and Tan (2011) point out that all communities have a role to play towards the development of proper infrastructure. They are responsible for their own welfare.

Distance to medical facilities

Infrastructural developments include the various networks of transportation. There are some rural settings where the infrastructure is in order but pose a challenge when it comes to the distance. Matsuoka et al. (2010) found that the disadvantage of sparse settlement is the inability to develop centralized medical centers. To this end, settlements that are far from the medical facilities act as barriers towards accessing pediatric care. The long distances discourage movement. The scarcity of modes of transport adds to the challenges of distance (Wallace et al., 2014). Most rural settlers would opt for local treatment rather that trek long distances to obtain medical care.

Disparity in medical care

The quality of medical care in urban areas is quite different from the kind provided in the rural settlements. In this regard, Ormsby et al. (2012) carried out a study on eye-care in Cambodia. In their study, Ormsby et al. (2012) found that the patients from the rural areas experienced great difficulty with respect to eyes. Most of the complaints included negligence on the part of the patients from rural areas (Ormsby et al., 2012). The patients from urban areas had little complains touching on their sight. Ozawa and Damian (2011) conducted a study and found out that medical practitioners in rural areas do not provide quality pediatric services.

Urban areas have plenty of experienced medical staff. In the rural areas, individuals are forced to move to urban settlements in search of quality medical care. Ozawa and Damian (2011) point out that such a scenario acts as a barrier to accessing the poor pediatric services. Ormsby et al. (2012) point out that, rural and urban demographics all search for quality health care. To this end, the absence of quality pediatric care prevents persons from seeking the services.

Economy

Ecological frameworks explain the community based on the resources available. A study carried out by Ith, Angela, and Caroline (2013) found that maternal care in Cambodia is dependent on economical factors. For instance, communities with a poor economy cannot support infrastructural development. In such cases access to pediatric services is completely shattered. Finlayson and Soo (2013) argue that the economy is essential in providing for the right amount of medical personnel. The absence of the right kind of employees implies that quality pediatric care is absent. Household economies also have a role when it comes to the access of medical care. Issues like insurance and medical cover emerge (Eng et al., 2014).

The background information suggests that the cost of healthcare in Cambodia is pretty high. Scott et al. (2014) examine social relationships in a number of healthcare systems. Serbin, Michele, Hastings, Dale, and Schwartzman (2004) found that the high cost of living makes healthcare look like an option. Consequently most of the families do not see the need of having to go to hospitals when they fall sick (Ozawa & Damian, 2011).

Societal Perceptions

A society has a number of components. Hallers-Haalboom et al. (2014) are of the view that a society is made up of the religious, economical and cultural issues. Hallers-Haalboom (2014) point out that based on the societal components, people tend to develop perceptions which act as barriers to pediatric care (Platt, 2010; Webair & Abdulla, 2013).

Religious perceptions

Countries found in South Asia are religious to some extent. In rural (and some urban) areas religion holds sway over a number of the human activities. According to Webair and Abdulla (2013), childhood illnesses are given the same attention as some religious practices. The study by Webair and Abdulla (2013) focuses on how HIV+ patients in Yemen can access quality healthcare. The study found that religious rituals like prayers are performed on an individual rather than seeking medical attention.

The religious perceptions tend to tilt the opinions of the rural folk. For instance, the promise that a deity will cleanse a patient of evil spirits lures many to the religious groups (Victoria et al., 2008). In this regard, religion is seen as a major barrier towards accessing pediatric care. Fortunately, there is an awakening among many rural folk on the importance of conventional medicine (Victoria et al., 2008).

Child perceptions

Rural areas are usually characterized by a number of superstitions. In this regard, Telleen et al. (2012) examined access to oral healthcare in Latino children. The study found that the children brought in for dental care did so under the guise of a ‘tooth’ fairy, who would reward them for every tooth placed under a pillow. There are other perceptions which create the impression that children do not need to go to hospital all the time (Telleen et al., 2012).

The child related perceptions have the ability to sway the thinking of infants into believing in superstitious creatures. According to Steinhardt et al. (2009), some societies use children as a secondary need whose needs should not supersede those of other issues like food and shelter. For instance, there are societies where parents opt to spend on other issues since kids are not a priority (Van Damme, Luc, Ir, Wim & Bruno, 2004).

Summary

The current review is developed against the problem statement proposed for this study. A total of 50 sources were used in the discussions around various research initiatives around the subject. The problem statement establishes the absence of qualitative research on the subject of child malnutrition and its possible ecological culprits. The current literature review was meant to expound upon the problem statement of this study. Access to pediatric services is seen to be dependent on a number of reasons (Steinhardt et al., 2009).

The literature review takes into account the gaps in previous studies. To this end, the discussions have been an attempt at advancing the missing links. The review points out that, a great number of surveys on barriers to pediatric care form more than a decade. Unfortunately, there is little information surrounding the whole issue of how the environment fits into accessing pediatric care (Baxter et al., 2010). To this end, the review provided a more comprehensive, country-specific, culturally-sensitive reasons around the barriers to pediatric care need to be discussed (AHC, 2014).

The conceptual framework, adopted for this study, is the ecological model. Several studies have illustrated the importance of this model with respect to pediatric services. In this regard, the conceptual model was able to point the specific factor that affects access to pediatric care (Engle et al., 2011). The following is a list of the specific factors that contribute towards the barriers to pediatric services:

  • Individual factors – They include age, sex, marital status, education and the number of children.
  • Personal relationship factors – entails the relationships between family and friends albeit separately
  • Community factors – the disparity in treatment, infrastructure, distance from the medical facility and accessibility to the hospital.
  • Societal factors – they include religious, political and respective social standing behavior.

The entire review has laid the foundation for the rationale to be used when determining reasons why certain children cannot access pediatric care. Knowledge of the reasons why pediatric care is important in the sense that better measures can be put in place to avoid the perils that have resulted from malnutrition in Cambodia. The information obtained in this review does not fulfill the intention to fill existing gaps in literature. The review leaves room for more research on the subject of pediatric care. For instance, a comprehensive analysis of pediatric services should be discussed. An understanding of the features of pediatric services provides insights on how best to advocate for the treatment of malnutrition.

References

Angkor Hospital for Children. (2014). Angkor Hospital for Children 2013 annual report. Web.

Baxter, S., Killoran, M., Kelly, P., & Goyder, E. (2010). Synthesizing diverse evidence: The use of primary qualitative data analysis methods and logic models in public health reviews. Public Health, 124(2), 99-106.

Bedford, K. & Sharkey, B. (2014). Local barriers and solutions to improve care-seeking for childhood pneumonia, diarrhoea and malaria in Kenya, Nigeria and Niger: a qualitative study. PLoS ONE, 9(6) (2014): e100038.

Beer, N., Abdullah, S., Helena E., Andreas, J., Faiza, M., Guida, R.,…Karin, K. (2012). A qualitative study on caretakers’ perceived need of bed-nets after reduced malaria transmission in Zanzibar, Tanzania. BMC Public Health, 12(1), 606.

Chhea, C., Lenore, M., & Narelle, W. (2010). Health worker effectiveness and retention in rural Cambodia. Rural and Remote Health, 10(1391), 129-133.

Chimphamba, G., Belinda, H., Ellen, C., Johanne, S., Address, M., & Alfred, M. (2012). A social ecological approach to exploring barriers to accessing sexual and reproductive health services among couples living with HIV in Southern Malawi. ISRN Public Health, 4(2), 34-39.

Chowdhury, R., Sandra, C., Mohammed, A., Nurul, A., Mohammed, Y., & Streatfield. K. (2011). Care seeking for fatal illness episodes in neonates: A population-based study in rural Bangladesh. BMC Pediatrics, 11, 88.

Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches. London: Sage Publications.

Das, S., Nasrin, D., Ahmed, S., Wu, Y., Ferdous, F., Farzana, F.,…Faruque, A. (2013). Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh. The American Journal of Tropical Medicine and Hygiene, 89(1), 62-68.

Dingle, A., Powell-Jackson, T., & Goodman, C. (2013). A decade of improvements in equity of access to reproductive and maternal health services in Cambodia, 2000-2010. International Journal of Equity in Health, 12(51), 1-12.

Elder, P., Willo, P., Saifuddin, A., Gretchen, B., Merry, B., Waldemar A., & Venkatraman, C. (2014). Caregiver behavior change for child survival and development in low- and middle-income countries: An examination of the evidence. Journal of Health Communication, 19(1), 25-66.

Emelumadu, F., Ugochukwu, U., Ugwunna, U., Nkiru, N., Chigozie, O., & Obasi, K. (2014). Perception of quality of maternal healthcare services among women utilizing antenatal services in selected primary health facilities in Anambra State, Southeast Nigeria. Nigerian Medical Journal: Journal of the Nigerian Medical Association, 55(2), 148–155.

Eng, S., Whitney, S., & Mulsow, M. (2014). Cambodian parental involvement: The role of parental beliefs, social networks, and trust. The Elementary School Journal, 114(4), 573–594.

Engle, P., Lia, F., Harold, A., Jere, B., Chloe, O., Aisha, Y., & Meena, C. (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378(9799), 1339-1353.

Finlayson, K., & Soo, D. (2013). Why do women not use antenatal services in low- and middle-income countries?: A meta-synthesis of qualitative studies. PLoS Med, 10(1)234-245.

Ghosh, R. (2011). Child mortality in India: A complex situation. World Journal of Pediatrics, 8(1), 11-18.

Grundy, J., Annear, P., Chomat, A., Ahmed, S., & Biggs, B. (2013). Improving average health and persisting health inequities: Towards a justice and fairness platform for health policy making in Asia. Health Policy and Planning, 68(2), 299-310.

Hallers-Haalboom, E., Judi, M., Marleen, G., Endendijk, J., Sheila, B., Lotte, D., Marian, J., & Bakermans-Kranenburg, J. (2014). Mothers, fathers, sons and daughters: Parental sensitivity in families with two children. Journal of Family Psychology 28(2), 138-147.

Haslett, J., & Sefton. A. (2013). Small-area estimation of poverty and malnutrition in Cambodia. Web.

Insaf, T., Janine, M., & Ladan, A. (2010). Sociocultural factors influencing delay in seeking routine healthcare among Latinas: A community-based participatory research study. Ethnicity & Disease, 20(2), 148-154

Ith, P, Angela, D., & Caroline, H. (2013). Women’s perspective of maternity care in Cambodia. Women and Birth, 26(1), 71-75.

Kaljee, L., Anh, D., Minh, T., Huu-Tho, L., Batmunkh, N., & Kilgore, P. (2011). Rural and urban Vietnamese mothers utilization of healthcare resources for children under 6 years with pneumonia and associated symptoms. Journal of Behavioral Medicine, 34(4), 254–267.

Karen, F. (2013). Qualitative research in the health sciences: Methodologies, methods and processes. London: Routledge.

Karkee, R., Lee, A., & Pokharel, P. (2014). Women’s perception of quality of maternity services: A longitudinal survey in Nepal. BMC Pregnancy and Childbirth, 14(1), 45.

Khatun, A., Shahinur, R., Hafizur, R., & Sabir, H. (2013). A cross sectional study on prevalence of diarrhoeal disease and nutritional status among children under 5-years of age in Kushtia, Bangladesh. Science Journal of Public Health, 1(2), 56-61.

Krumkamp, R., Sarpong, N., Kreuels, B., Ehlkes, L., Loag, W., Schwarz, N.,…May, J. (2013). Health care utilization and symptom severity in Ghanaian children: A cross-sectional study. PLoS ONE, 8(11), 578-590.

Leroy, J., Ruel, M., Habicht, J., & Frongillo, E. (2014). Linear growth deficit continues to accumulate beyond the first 1000 days in low- and middle-income countries: Global evidence from 51 national surveys. The Journal of Nutrition, 114, 191981.

Martinez, M., Dung, T., Nem, Y., Leakhena, N., Bounnack, S., & Partridge, J. (2012). Barriers to neonatal care in developing countries: Parents’ and providers’ perceptions. Journal of Pediatrics and Child Health, 48, 852-858.

Matsuoka, S., Hirotsugu, A., Lon, P., Tung, R., & Akiko, O. (2010). Perceived barriers to utilization of maternal health services in rural Cambodia. Health Policy, 95(2/3), 255-263.

Meessen, B., Maryam, B., Kannarath, C., Kristof, D., Por, I., Chean, M., & Van Damme, W. (2011). Composition of pluralistic health systems: How much can we learn from household surveys? An exploration in Cambodia. Health Policy and Planning, 26(1), 30-44.

Morgan, F., & Tan, B. (2011). Rehabilitation for children with cerebral palsy in rural Cambodia: Parental perceptions of family-centered practices. Child: Care, Health & Development, 37(2), 161-167.

National Institute of Statistics, Directorate General for Health, & ICF Macro. (2011). 2010 Cambodia demographic and health survey: Key findings. Phnom Penh, Cambodia and Calverton, Marylonad, USA: National Institute of Statistics, Directorate General for Health, and ICF Macro.

Opwora, K., Antony, S., Ahmed, M., Laving, L., Lambert, O., Nyabola, K., & Olenja, J. (2011). Who is to blame?: Perspectives of caregivers on barriers to accessing healthcare for the under-fives in Butere District, Western Kenya. BMC Public Health, 11, 272.

Ormsby, G., Arnold, A., Busija, L., Manfred, M., Te, S., & Jill, E. (2012). The impact of knowledge and attitudes on access to eye-care services in Cambodia. Asia-Pacific Journal of Ophthalmology, 1(6), 331-335.

Ozawa, S., & Damian, G. (2011). Comparison of trust in public vs. private health care providers in rural Cambodia. Health Policy and Planning, 26(1), 20-29.

Page, A., Sarah, H., Francisco, J., Ali, D., Mahamane, L., & Grais, R. (2011). Health care seeking behavior for diarrhea in children under 5 in rural Niger: Results of a cross-sectional survey. BMC Public Health, 11, 389.

Platt, A. (2010). Healthcare for vulnerable groups in Cambodia (internal study report). Web.

Raphael, J., Zhang, H., Liu, J., & Giardino, A. (2010). Parenting stress in US families: Implications for pediatric healthcare utilization. Child: Care, Health and Development, 36(2), 216-224.

Rimal, R. (2003). Intergenerational transmission of health: The role of intrapersonal, interpersonal, and communicative factors. Health Education & Behavior, 30(1), 10-28.

Sakisaka, K., Jimba, M., & Hanada, K. (2010). Changing poor mothers’ care-seeking behaviors in response to childhood illness: Findings from a cross-sectional study in Granada, Nicaragua. BMC International Health and Human Rights, 10(1), 10.

Scott, K., McMahon, S., Yumkella, F., Diaz, T., & George, A. (2014). Navigating multiple options and social relationships in plural health systems: A qualitative study exploring healthcare seeking for sick children in Sierra Leone. Health Policy and Planning, 29(3), 292-301.

Serbin, A., Michele, H., Hastings, P., Dale, M., & Schwartzman, A. (2004). The influence of parenting on early childhood health and health care utilization. Journal of Pediatric Psychology, 10(50), 103-123.

Sreeramareddy, C., Sathyanarayana, T., & Kumar, H. (2012). Utilization of health care services for childhood morbidity and associated factors in India: A national cross-sectional household survey. PloS One, 7(12), 51904.

Steinhardt, L., Waters, H., Rao, K., Naeem, A., Hanse, P., & Peters, D. (2009). The effect of wealth status on care seeking and health expenditures in Afghanistan. Health Policy and Planning, 24(1), 1-17.

Telleen, S., Young, O., Kim, R., Chavez, N., Barrett, R., Hall, W., & Gajendra, S. (2012). Access to oral health services for urban low-income Latino children: Social ecological influences. Journal of Public Health Dentistry, 72(1), 8-18.

Thind, A., & Cruz, A. (2003). Determinants of children’s health services utilization in the Philippines. Journal of Tropical Pediatrics, 49(5), 269-273.

United Nations Development Program. (2013). Cambodia annual report 2012. Phnom Penh, Cambodia: United Nations Development Program.

Van Damme, W., Luc, V., Ir, P., Wim, H., & Bruno, M. (2004). Out-of-pocket health expenditure and debt in poor households: Evidence from Cambodia. Tropical Medicine & International Health, 9(2), 273-280.

Victora, C., Linda, A., Pedro, C., Reynaldo, M., Linda, R., Harshpal, S., & Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: Consequences for adult health and human capital. Lancet, 371(9609), 340-357.

Wallace, L., Summerlee, A., Dewey, C., Hak, C., Hall, A., & Charles, C. (2014). Women’s nutrient intakes and food-related knowledge in rural Kandal province, Cambodia. Asia Pacific Journal of Clinical Nutrition, 23(2), 263-271.

Webair, H., & Abdulla, S. (2013). Factors affecting health seeking behavior for common childhood illnesses in Yemen. Patient Preference and Adherence, 7, 1129-1138.