Article Text

Original research
Challenges and outcomes of implementing a national syphilis follow-up system for the elimination of congenital syphilis in Cambodia: a mixed-methods study
  1. Thérèse Delvaux1,
  2. Vichea Ouk2,
  3. Sovannarith Samreth2,
  4. Socheata Yos3,
  5. Romain Tep4,
  6. Chamroen Pall5,
  7. Vannak Keo4,
  8. Serongkea Deng6,
  9. Win Htin Khin Cho7,
  10. Sivantha Hul8,
  11. Somnang Chhorn3,
  12. Sovannary Tuot5,
  13. Rattana Kim3
  1. 1Department of Publich Health, Institute of Tropical Medicine, Antwerp, Belgium
  2. 2National Centre for HIV/AIDS Dermatology and STD, Phnom Penh, Cambodia
  3. 3National Maternal and Child Health Center, Phnom Penh, Cambodia
  4. 4EpiC/FHI360, Phnom Penh, Cambodia
  5. 5KHANA Center for Population Health Research, Phnom Penh, Cambodia
  6. 6WHO, Phnom Penh, Cambodia
  7. 7UNAIDS, Phnom Penh, Cambodia
  8. 8Clinton Health Access Initiative, Phnom Penh, Cambodia
  1. Correspondence to Dr Thérèse Delvaux; tdelvaux{at}


Objectives We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia.

Design Operational study; quantitative cohort data and cross sectional qualitative data.

Setting Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia.

Participants Pregnant women screened for syphilis; MCH health care providers and managers.

Methods We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used.

Outcome measures Syphilis testing and treatment results and perceptions regarding these services.

Results A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019–2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners’ lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants.

Conclusions Study results contributed to informing improvements to syphilis management in MCH services in Cambodia.

  • Infection control
  • Public health
  • Prenatal diagnosis

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

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  • Contributors Conceived and designed the study: VO, SS, TD, RK, SH, SD, SC, ST. Conducted data collection: RT, SY, VK, CP, ST. Performed data analysis and presentation of results: RT, SY, TD, SS, VO. Wrote the manuscript: TD, VO, CP, ST, SS. All authors provided input in manuscript writing and approved the final manuscript. TD is responsible for the overall content as the guarantor.

  • Funding This study was funded by the Belgian Development Cooperation (DGD) through the Framework Agreement 4 (FA4) between the Institute of Tropical Medicine, the National Centre for HIV/AIDS, Dermatology and STD (NCHADS), and the National Maternal and Child Health Center (NMCHC).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.