CULTURAL FACTORS & SOCIAL DETERMINANTS OF HEALTH
Cultural factors and social determinants of health influence an individual's everyday life in Cambodia. According to the World Health Organization (2019), "The social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems."
COMMUNICATION
Language: Khmer, also known as Cambodian, is the official language of Cambodia. Khmer is spoken by approximately 90% of the population (Nag, 2017; Wetzel, 2014). English is the main foreign language used in Cambodia since 1993, however, it was previously French (Nag, 2017).
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Verbal Communication:
Verbal communication tends to be indirect, meaning their communication relies less on words and more on nonverbal communication. This has the purpose of maintaining harmony and preventing offense or confrontation (Scroope, 2017)
Non-Verbal Communication:
Minimal physical contact is acceptable among people of the same gender and couples. Pointing is considered to be rude. Indirect eye contact tends to be used most often in this culture (Scroope, 2017).
RELIGION
In 2017, it was surveyed that approximately 96.9% of the Cambodian population identify with Buddhism (Scroope, 2017). Theravada Buddism is the most prominent form practiced in Cambodia (Scroope, 2017; Wetzel, 2014). This form of Buddhism provides a "sense of stability within Cambodian society by offering a structure for people to base their every day routines around" (Scroope, 2017).
FAMILY STRUCTURE
The immediate family tends to be the core of the family, however, Cambodians also usually have a strong attachment to extended family and friends (Scroope, 2017). Each person in the family has certain expectations, roles, and responsibilities. Everyone is expected to show respect to their elders and maintain the reputation of their family. There are specific roles designed for family members as well (Scroope, 2017). For example, if the family needs financial assistance, help running the family business, or taking care of the household, the responsibility often falls to the youngest daughter to stop her studies in order to take on this role (Scroope, 2017; Tumlin, 2000). Finances also play a role in the family structure. For example, extended family may live together due to financial issues (Scroope, 2017).
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Generally, children trafficked in Cambodia for labor exploitation come from low-income families (Tumlin, 2000; U.S. Department of State, 2020). Additionally, families in poverty are more likely to be desperate enough to sell their daughters into bonded prostitution to pay off a debt. Prostitution has, unfortunately, become a way for daughters to fulfill their expectations of providing financial support to the family. Bonded entry into prostitution entails parents or associates who sell a child or young woman to a person for promised employment in return for cash (Derks, 1998; Little 2020). Children whose families have divorced or died are at risk for trafficking. Additionally, children with family members abusing drugs or involved in illegal activities and children who are neglected by their parents are more easily influenced by trafficking recruiters (Tumlin, 2000).
POVERTY
The poverty rate in Cambodia in 2014 was 13.5%, which is exponentially lower than in 2007 (The World Bank, 2021). However, it appears most families in Cambodia who escaped poverty did so by a small margin. Around 4.5 million people remain near-poor. Additionally, the COVID-19 pandemic has increased poverty; at least 150,000 households have been identified as newly poor between June 2020 and January 2021 (The World Bank, 2021).
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High numbers of poverty and food insecurity in Cambodia has made children more vulnerable to trafficking (Tumlin, 2000). Poverty is one of the main underlying causes of the trafficking problem (Little, 2020; Derks, 1998).
Watch this video to gain more understanding on what poverty in Cambodia looks like and how it affects children and their families every day.
EDUCATION
In Cambodia, many students are falling behind in school, particularly those who live in poor rural and urban areas (UNICEF, n.d.). While approximately 97% of children are enrolled in primary education, they are still failing to reach learning standards appropriate for their age (UNICEF, n.d.). Children fall behind in school for a number of reasons, including not being prepared for school, low-quality teaching and learning, and irregular attendance. Often, this leads to many children dropping out altogether prior to secondary school (UNICEF, n.d.).
Child prostitutes generally have lower educational levels(Gay, 2018; Tumlin, 2000). Many have dropped out of school due to financial difficulties in their families (Gay, 2018; Tumlin, 2000). Illiteracy and low education levels are linked to the increased vulnerability of children to sexual exploitation (Tumlin, 2000). In fact, 30% of prostitutes are under 18 and have little to no schooling (Gay, 2018). Additionally, traffickers have been found to target children who lack social skills or knowledge about the world (Tumlin, 2000).
HEALTH CARE
Traditionally, Cambodians have used self-care and self-medication to deal with illnesses (Wetzel, 2014). This is likely due to having access to most drugs over-the-counter at low cost, having few hospitals and physicians, and the high cost of Western medical care (Wetzel, 2014). Typically, an individual seeks assistance from a health practitioner if their own remedies do not help (Wetzel, 2014). Furthermore, primary health care workers in Cambodia are predominantly midwives, and they are tasked to provide maternal and child health services (Khim & Andermann, 2021).
SAFETY AND LAW ENFORCEMENT
The U.S. Department of State classifies Phnom Penh, the capital of Cambodia, as a critical-threat location for crime. The majority of crimes committed are typically property crimes committed for financial gain (Overseas Security Advisory Council [OSAC], 2020). However, assault and sexual violence do occur, and there were a number of shootings and stabbings reported in 2019. National and transnational organized crime involve human trafficking, along with drugs and wildlife (OSAC, 2020).
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Local police tend to be under-funded, under-staffed, poorly equipped, and poorly trained (OSAC, 2021). Therefore, the responsiveness and capabilities of police forces are reported as substandard when compared to police in the United States. Additionally, many crimes go unreported (OSAC, 2021). Furthermore, studies have shown that communities with weak law enforcement of existing trafficking and labor laws and communities lacking in general recreation activities for children are more vulnerable to trafficking (Tumlin, 2000).
The Cambodian government is showing sufficient efforts to eliminate trafficking, however, it seems they do not meet the minimum standards to do so (U.S. Department of State, 2021). Their efforts have included improving data collection and monitoring prosecutions and convictions of traffickers, as well as victim identification data; continuing to investigate, prosecute, and convict traffickers; and continue to implement a national action plan to combat trafficking. The Cambodian government has shown that they do not have the capacity or resources available to provide adequate protection services to trafficking victims. For example, there is not enough shelter capacity throughout the country dedicated to providing assistance to trafficking victims (U.S. Department of State, 2021).
FOOD SECURITY AND NUTRIENT SUFFICENCY
According to U.S. Agency for International Development (USAID), agriculture in Cambodia has the potential to be an engine for economic growth and food security, however, the country must improve the production and post-harvest infrastructure, streamline the business environment, and increase capacity for financial services to reach rural entrepreneurs. (USAID, 2021). Approximately 65% of Cambodians rely on agriculture, fisheries, and forestry for their livelihoods. Undernutrition is an important public health concern (United Nations World Food Programme [WFP]).
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It has been reported that one-fifth of Cambodians are food-deprived, meaning they eat less than the daily caloric requirements (USAID, 2021). Additionally, 32% of children under the age of 5 are stunted, while 24% are underweight (WFP, 2021). Many are not receiving enough food nor eating the proper nutrients to grow and develop. Dietary deficiencies in zinc, iodine, and B-vitamins are affecting children, as well as women of reproductive age (WFP, 2021).
OTHER CONSIDERATIONS
A study done by Khim and Andermann (2021) looked at the social determinants of children's health in Cambodia. They found that major issues were related to a lack of knowledge of child care, safe places for children, safe drinking water, adequate food, income, employment, and effects of second-hand smoke. Additional issues included alcohol and drug use, feeling of insecurity, isolation, and discrimination (Khim & Andermann, 2021).
Children are more vulnerable to trafficking when they live in communities affected by political instability and armed conflict, environmental disasters, and crisis of modern development schemes that result in mass displacements of people (Tumlin, 2000).
In Cambodia, virgin girls who are considered beautiful are the most expensive and valuable (Sutton, 2020; Derks, 1998; Tumlin, 2000). In fact, selling a girl who is a virgin brings in enormous amounts of money to the family (Derks, 1998; Little, 2020; Tumlin, 2020). There is a belief, commonly upheld by Asian men, that sex with virgins increases male vigor, will bring good health, and even cure diseases (Sutton, 2020). However, children who are sexually abused or have lost their virginity are typically shunned in this culture (Tumlin, 2000). In fact, a woman who has already lost her virginity is considered "kouc", meaning broken (Derks, 1998). Children in this position are vulnerable to sex trafficking and many times, prostitution is their only option (Sutton, 2020; Tumlin, 2000).
Derks, A. (1998). Trafficking of Cambodian women and children to Thailand. International Organization for Migration and Center for Advanced Study.
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Gay, D. (2018). Facts about girls' education in Cambodia illustrate its progress. BORGEN. https://www.borgenmagazine.com/top-10-facts-about-girls-education-in-cambodia/
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Khim, K., & Andermann, A. (2021). Challenges and opportunities in addressing social determinants of Child health in Cambodia: Perspectives and experience of frontline providers in two health districts. Canadian Journal of Public Health, 112(2), 317-330. https://doi.org/10.17269/s41997-020-00442-y
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Little, K. (2020). Alleviating child poverty in Cambodia. The Borgen Project. https://borgenproject.org/child-poverty-in-cambodia/
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Nag, O. S. (2017, April 25). What language is spoken in Cambodia? WorldAtlas. https://www.worldatlas.com/articles/what-language-is-spoken-in-cambodia.html
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Overseas Security Advisory Council [OSAC]. (2020). Cambodia 2020 crime & safety report. https://www.osac.gov/Country/Cambodia/Content/Detail/Report/4205bb26-6e00-46a1-b468-181219a75c2
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Overseas Security Advisory Council [OSAC]. (2021). Cambodia country security report. https://www.osac.gov/Content/Report/4c264015-35ea-4977-9fb6-1c5bab6c8b18
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Scroope, C. (2017). Cambodian Culture. Cultural atlas. https://culturalatlas.sbs.com.au/cambodian-culture
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Sutton, A. (2020). The truth behind Cambodia’s virginity trade: Hidden factors. Women Going Beyond.
https://www.womengoingbeyond.org/post/virginity-trade-in-cambodia
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The World Bank. (2021). The world bank in Cambodia. https://www.worldbank.org/en/country/cambodia/overview
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Tumlin, K. C. (2000). Trafficking in children in Asia: a regional overview. Institute for Asian Studies. Chulalongkorn University.
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UNICEF. (n.d.). Cambodia. https://www.unicef.org/cambodia/education
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United Nations World Food Programme [WFP]. (2021). Cambodia. https://www.wfp.org/countries/cambodia
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U.S. Agency for International Development [USAID]. (2021). Agriculture and food security. https://www.usaid.gov/cambodia/agriculture-and-food-security
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U.S. Department of State. (2020). 2020 trafficking in persons report: Cambodia. https://www.state.gov/reports/2020-trafficking-in-persons-report/cambodia/
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U.S. Department of State. (2021). 2021 Trafficking in persons report: Cambodia. https://www.state.gov/reports/2021-trafficking-in-persons-report/cambodia/.
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Wetzel, L. (2014). Cambodian. EthnoMed. https://ethnomed.org/culture/cambodian/
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World Health Organization. (2019). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1