The mental health status of the female entertainment workers and their children in cambodia

The mental health status of the female entertainment workers and their children in cambodia The mental health status of the female entertainment workers and their children in cambodia

VIETNAM NATIONAL UNIVERSITY, HANOI

College, Vanderbilt University

Dr Khanh Ngoc Do,

Professor, University of Education, Vietnam National University

HANOI – 2021

UNIVERSITY OF EDUCATION

THIS DOCTORAL DISSERTATION WAS COMPLETED AT

THE UNIVERSITY OF EDUCATION, VIETNAM NATIONAL

The dissertation can be found at:

- Vietnam National Library

- Information and Library Center, Vietnam National Unviersity, Hanoi

Acknowledgments

I would like to sincerely pay my respect and be thankful to all the professors in the doctoral program at the Vietnam National University for their profound time and effort to share their knowledge, professional experiences during the entire course that I have been involved till the end My special thanks, in addition, to Professor Dr Amie Alley Pollack, and Professor Dr Khanh Ngoc Do for their tirelessness time and energy

to supervise my dissertation Without their friendly but meaningful support this dissertation could not have existed I really appreciate that,

My heartful appreciation also goes to the top management team of the Cambodian Women for Peace and Development for the official approval and their support on my data collection especially to H.E Meach Sotheary, Executive Director, Mr Chhorn Ann, Program Manager, and Mr Heng Tola, Monitoring & Evaluation Manager I would also like to thanks to their core team at the provincial levels who were offering their support

in the field

Special thanks to my wife, Tep Sopheawatey, for her time and energy to enable

me to fully taking part in the whole course while she has to take lots of her time to take care of the kid I also appreciated my son, Tep Rattanak Mongkol for his enjoyable time and being patient I’m really proud of them

Last but not least, all my total appreciation is to my mother, Saro Vanny, and my deceased father, Ean Nhim, for giving my birth and for their forever unconditional regards and affection

Abstract

Introduction: Freelance and brothel-based entertainment workers have been found

highly suffering from mental health problems Many of them have children whose are living in very distressed, traumatized, and unsafe environment Paper addresses psychiatric symptoms-related disorders of female samples and their offspring’s mental health are still limited and scientifically undocumented well This paper is going to explore better understanding on their mental health situation and possible

interrelationships Method: 160 female entertainment workers (FEWs) and 60 children

from four different areas of Cambodia participated in the study FEW’s mental health, mother-children relationship, children’s mental health, and child-mother relationship were assessed Descriptive, correlational, and linear regression analysis were executed

Result: From moderate to severe level of depression and anxiety symptoms severity

were found among the total FEWs (67% and 60.7%), and 54.38% met the symptoms criteria of Post-traumatic stress disorder (PTSD) Of 60 children, 46.7% have functional impairment, 18.33% suffered from psychological distress, and 36.67% have PTSD Childhood traumatic experience and current mental health problems of the FEWs, FEWs’ anxiety and PTSD and their children’s psychological distress were found statistically significant Mother’s PTSD predicts children’s psychological distress [ß = 0.282, R2 = 0.079] and functioning [ß = 0.285, R2 = 0.081] and anxiety predicts child-mother conflict relationship [ß = 0.314, R2= 0.325] Conclusion: Mental health problems

among FEWs are still the main concern PTSD was found among vulnerable children in the current study These psychological problems contribute to the impairment of the children’ functioning Mother’s PTSD predicts children’s psychological distress, functioning but anxiety worsen the mother-child relationship Mental health professional and further study should focus more on this finding for the best interest of the vulnerable

groups and further prevention strategy development

List of Abbreviations

ACE Adverse Childhood Experience

APA American Psychological Association

ASSIST The Alcohol, Smoking and Substance Involvement Screening Test ATS Amphetamine Type Stimulant

BSS Behavioral Surveillance Survey

CWPD Cambodian Women for Peace and Development (CWPD)

DFSW Direct Female Sex Worker

EE/EV Entertainment Establishment/v=Venue

FEW Female Entertainment Worker

IFSW Indirect Female Sex Worker

MARPs Most at Risk Populations

MoEYS Ministry of Education Youth and Sports

NCHADS National Center for HIV/AIDS, Dermatology and STDs

NGO Non-Governmental Organization

PTSD Post-Traumatic Stress Disorder

SUD Substance Use Disorder

UNAIDS United Nations Program on HIV/AIDS

UNICEF United Nations International Children’s Emergency Fund

UNODC United Nations Office on Drugs and Crime

VNU Vietnam National University

WHO World Health Organization

List of Tables

Table 3.3 : Life-time Duration of the FEWs’ Work in the Entertainment

Table 3.9 : Post-Traumatic Stress Disorder (PTSD) Symptoms of the

Table 3.10 : Adverse Childhood Experiences (ACE) Score of FEWs 88 Table 3.11 : Adverse Childhood Experiences by Categories 89

Table 3.13 : Patterns and Severity of Substance Use Disorders (SUD) of

Table 3.15 : Daily Functioning of the Children of the FEWs 95 Table 3.16 : Functioning Impairment of the Children of the FEWs by Gender 96 Table 3.17 : Mental Health Status of the Children of the FEWs on SDQ 97 Table 3.18 : SDQ and Subscale Descriptive Statistic of Children of the

Table 3.22 : Correlations between Demographic Information and Mental

Health Problems and Mother-child Relationship 104 Table 3.23 : Correlation between Demographic Information and Substance

Use Disorders (inhalants and opioids are excluded) Variables 107 Table 3.24 : Correlations Between Adverse Childhood Experiences (ACE),

Mental Health Disorders and Substance Use Disorders 112 Table 3.25 : Correlation Between Children of FEWs’ Demographic

Information, Functioning and Mental Health Problems 117 Table 3.26 : Correlation Matrix between FEWs’ Mental Health and

Table 3.27 : Means, Standard Deviations, and Inter-correlations for the

Outcome and Predictor Variables (Children Psychological

Table 3.28 : Multiple Regression Analysis Summary for Variables

Table 3.29 : Correlation Matrix between Age, Duration in Business and

Educational Background of the FEWs and Children’s Mental

Table 3.30 : Correlation Matrix between FEWs History of Trauma

Experiences and Children Psychological Distress & PTSD 124 Table 3.31 : Correlation Matrix between the Substance Use Disorders of the

FEWs and the Children’s Mental Heal Problems 125 Table 3.32 : Correlations Matrix between the Children’s Functioning and the

FEW’s Mental Health Problems 127 Table 3.33 : Means, Standard Deviations, and Inter-correlations for the

Outcome and Predictor Variables (Children’s Functioning Vs

Table 3.34 : Single Regression Analysis Summary for Variables Predicting

Table 3.35 : Correlation between Children’s Functioning and FEWs’

Table 3.36 : Means, Standard Deviations, and Inter-correlations for the

Outcome and Predictor Variables (CRPBI-Conflict Vs FEWs’

Table 3.37 : Multiple Regression Analysis Summary for Variables

Predicting Relationship with Children on Conflict Subscale 130

1.1.2 Physical Health Problems of Female Entertainment Workers 21 1.1.3 Mental Health Problems of Female Entertainment Workers 22 1.1.4 Substance Abuse among Female Entertainment Workers 24

1.1.8 Children of Female Entertainment Workers in Cambodia 36

1.2.4 Key Concepts of Trauma and Post-traumatic Stress Disorder 45

1.2.10 Hypothetical Conceptual Framework of the Current Study 52

2.2.3.2 Measures for Children of Female Entertainment Workers 67

INTRODUCTION

Mental health problems affect millions of people on earth About 30% of the world’s population suffer from some kinds of mental disorders (World Health Organization, World Bank, 2016) Depression and anxiety are the most common mental disorders among the world population An estimation from the World Health Organization (WHO), there are about 322 million of people in the world are suffering from depression which half of this figure are represented those who are living in the South East Asian and Western Pacific regions (WHO, 2017) Depression leads 800,000 persons to die every year by committing suicide predominantly young adult ranges from age 15 to 29 years of old (WHO, 2017) Depression has been also detected among younger age even under 15 years of old However, the prevalence is low (WHO, 2017)

Anxiety is also a prevalent psychiatric disorder among human being An estimated percentage from the WHO in 2015 of people with anxiety disorder across the world was 3.6% which is about 264 million people respectively The figure showed a dramatic increase of about 20% of the world population for a decade since the year 2005 (WHO, 2017) A recent and large study done in 27 European countries, two specific anxiety disorders, specific phobia, and separation anxiety disorder (SAD), are the most common among the population in these countries (Wittchen et al., 20011) Women are two times higher than man suffer from this particular psychiatric disorder (WHO, 2017) A systematic review and meta-analysis were done by Steel and colleagues drew similar attention and concern over mood and anxiety disorder among both populations in the high-income countries and low- and middle-income countries The review and analysis were conducted from 174 surveys in 63 countries (26 from high-income countries and 37 others from low- and middle-income countries) by following epidemiological study guidelines The results showed mood and anxiety disorder are very common mental disorders among all the population (Steel et al., 2014)

Different types of substances are being abused differently from one region of the world to another One in twenty adults (about 247 million people) age ranges from 15 to

64 years old does at least used one drug in 2014 (UNODC, 2016) Across the world, cannabis was found as the first drug of abuse while amphetamine-type stimulants (ATS) were the second most frequently abused substances in 2014 Amphetamine-type stimulants in both crystal and tablet forms are the most concerning type of drug use in many countries in East and South-East Asia (UNODC, 2016) Men are three times more likely than women found to abuse drugs But women were found to misuse some forms for prescribed medicine such as opioids and tranquilizers (UNODC, 2015) Persons who inject drugs (PWID) are riskier to be infected by HIV/AIDS than persons who use drugs (PWUD) (UNODC, 2016)

Many people who are misusing drugs are also living with other types of mental problems A very recent systematic review in Australia found remarkable results of comorbidity of drug users with different forms of mental ailments The authors did a thorough review into eighteen-well published articles and found mood disorder (depression ranges from 27-85%) and anxiety disorder (generalize anxiety disorder ranges from 1-75%) are the most common disorders among the clients with substance use who come to seek for treatment services at different clinics in Australia (Kingston,

et at., 2017) In another review done in Jane-Llopis and Matytsina in 10 high-income countries found alcohol has a higher rate with a comorbid anxiety disorder (5%) and personality disorder (39%) Drug use disorder comorbid with at least one psychiatric disorder was also found in the same review (Jane-Llopis & Matytsina, 2006)

Exposure to traumatic experience brings tremendous impacts physically and mentally throughout the later life of survivors A national mental health survey had been conducted in a war-torn country in Asia, Afghanistan, found common forms of mental health problems as a consequence of war There was about 62% of 699 eligible

respondents from 15 to 34 years of age in the survey reported they have experienced at least 4 traumatic events The most common traumatic events for women respondents were: ill health without access to medical care, lack of food and water, and need to flee suddenly whereas the most common traumatic events for male respondents were: lack of food and water, lack of shelter, ill health wither access to medical care, and need to feel suddenly Depression (female=73%, male =59%), anxiety (female=84%, male=59%) and post-traumatic stress disorder (PTSD) (female=48%, male=32%) were found as common mental health problems among surveyed participants Women showed more social functional problems than the male counterpart (Cardozo et al., 2005) Another systematic review from published studies in low- and middle-income countries addressed common forms of mental health problems of the survivors from domestic violence and their relationship The ratio of depression and anxiety symptoms of women victims of domestic violence are 3.2 times higher comparing to non-victims of domestic violence (Rebeiro et al., 2009)

Traumatic experience not only cause survivor’s but also their offspring’s mental health during their developmental stage Pregnancy complications (warning sign of miscarriage or follow-up of abnormalities), and prematurely born baby have been found among Palestinian women in Gaza Strip in a study done by Punamaki and colleagues From an in-depth pathway model, structural equation, the authors found 48% of the respondent’s infant has developmental problem in their sensorimotor and language (Punamaki et al., 2017) Social and emotional development were also found affected by the parents who are under critical psychological distress (Mensah and Kiernan, 2010) Mental problems of children and adolescent in Middle East countries as consequences of traumatic experience related to arm conflict society have been revealed in a systematic review study done by Dimitry In the review, the author overlooked into 71 published studies in 4 countries (Israel, Palestine, Lebanon and Iraq) with sample sized ranged from

29 to 4054 The total participants to these studies were 52977 The prevalence rate of the

common mental disorders among study participants were: posttraumatic stress disorder (PTSD) in children ranges from 5-8% and major depression in adolescent was 3.3% were found in Israel In Palestine, the PTSD rate ranged from 23-70%, high anxiety ranged from 40-100%, and depression was 11.3% In Iraq the PTSD rate ranged from 10-30%, separation anxiety disorder 4.3% and specific phobia was 3.3% (Dimitry, 2011)

Mental health problems have relationship with dysfunctional parenting as found

in many studies Anxiety, major depression and PTSD has significantly correlated with the socio-occupational functioning of survivors from a natural disaster, Tsunami (Hussain et al., 2011) Untreated mental health ailment impacts the parenting and the strong bond relationship Mother with depressive disorder view herself with low ability

to control and unable to positively raise up their children (WHO, UNFPA 2008) Mother with mental health problems have difficulty to give reasonable explanation relation to the child negative behavior comparing to normal mother (Cornah et al., 2003) Low quality of parenting related to spending time playing with their children have been found affected by mother’s recent mental health symptoms (symptoms related to dissociation, depression and trauma) (Fujiwara et al., 2011) Irritable parents are more often use negative and hostile communication with their children (Leinonen et al., 2003)

1 Context and Background

Entertainment work has been a public health concern in many countries in the world HIV/AIDS transmission has been detected among injection drug users include women who work in the sex business (Burack, Bangsberg, 1998) The evidence suggests that female drug users are specifically at risk for health-related problems and discrimination, and more at-risk for developing different mental health problems at the same time The same report shows inadequate efforts to provide suitable health services

to female drug users compared to male drug users (UNODC, 2016) The world

epidemiological report highlights about 14% (around 1.6 million) of 12 million intravenous drug users (IDU) across the world are living with HIV/AIDS, particularly the infection rates in the Asia Pacific region are approximately 18% (UNAIDS, 2016) Sexually transmitted diseases (STDs), abortion, miscarriage, particularly related to virginal transmitted diseases, hepatitis etc were very common among this population who are seeking health services (UNAIDS, 2008)

Mental health problems have been addressed in many studies among Entertainment workers A study conducted by Rossler and colleagues in Zurich, Switzerland found that women sex workers have about a 63% lifetime prevalence of all types of mental illnesses (Rossler et al., 2010) One of the early studies in Israel also found psychosocial problems were very comment among this population Seventeen percent of respondents met criteria of posttraumatic stress disorder (PTSD) symptoms and nineteen percent of them reportedly having symptoms of depression (Chudakov, Ilan, and Belmaker, 2002) Prevalence of depression among female sex workers in China has also brought into concern in the recent study Sixty-two percent of the 278 respondents in the Guangxi reported having highly symptoms of server depression A concern strong correlation with this mental health problem is about having riskier sexual behavior with partners comparing with others who have less severe symptoms of clinical depression (Hong et al., 2007) Mood disorder, anxiety disorder and substance abuse have also been found among female sex workers in Bangladesh (Hengartner et al., 2015)

Children of FEWs have been put in risky situation of different form of abuses as adult does They are known as one of the vulnerable groups to violence and abuses in the country The most common forms of abuses, sexually and physically have been reported across the country This vulnerable group has been found more than 50 percent

of the study samples both male and female who were victims of physical abuse at least one time before they reached 18 years of age (UNICEF, 2014) Emotional and sexual

abuses have also been addressed in the same finding The male children are more reported suffering from the emotional abuse (M=1/5) and sexual abuse (5.6%) than female (F=1/4) and (4.4%) (UNICEF, 2014) Perpetrators more often were identified as those who are in close relationship with them, they are adult relative, parents and intimate partners

The physical health problems of the FEW’s offspring have been subjected in recent studies but not much on their mental health problems (Beard, 2010) Remarkable consequences from violence and abuses bring concerns for child victims Girls who suffered from sexual abuse are more likely to have symptoms of suicidal ideation while symptoms of sexual transmitted diseases (STIs) have been found in victims of male children Comparing to children who haven’t been physically abused, those who were the victims were reported with considerable symptoms of mental health problems and suicidal thought (UNICEF, 2014) More forms of mental disorders have also been found from another study in Brazil among early childhood experience of stress full situation and violence The finding addresses depression, bipolar, schizophrenia and substance abuse as major concern of the mental development problems among children (Brietzke

et al., 2012)

2 Statement of the Problem

Scientific evidences have its limitation to map out an overall picture of mental health situation of the FEWs and their children particularly in the context of Cambodia Only a couple of published papers have been addressed the psychological distressed among female samples who are working in the field of entertainment industries but not

in depth about their psychiatric symptomatology link to psychosocial related disorders Mental health status of this particular population’s offspring and the interrelationship with the mother’s mental health problems are still unknown and scientifically undocumented

This paper is going to bring out another piece of jigsaw to contribute to more understanding on the FEWs’ and their children’s mental health status and their inter-relationships from one to another

3 Purposes and Objectives of the study

There are several objectives for this research as in the following;

- Understanding more about severity of mental health problems of the Cambodian female entertainment workers

- Understanding more about common mental health issues and functioning of the children of the Cambodian female entertainment workers

- To explore more whether is there any relationship between the mother and the children’s mental health among these groups

- To explore relationships between mother’s mental health problems and

functioning

- To provide more insight about possible relationship and prediction among

female entertainment workers’ and their children’s mental to mental health professionals and stakeholders in this field

4 Research Hypotheses

4.1 Research Questions

Questions for the study are listed in the following;

Q1 Is there any relationship between the history of traumatic experience and the current mental health problems of the FEWs?

Q2 Does the severity of the Cambodian FEWs’ mental health problem have any relationship with the severity of their children’s mental health problems?

Q3 Is there any relationship between the FEWs’ age, duration of time working in the sex business, and educational level with their children’s mental health?

Q4 Does FEWs’ history of traumatic experiences have a relationship to their children’s mental health?

Q5 Does the severity of drug use of FEWs have any relationship with the severity of their children’s mental health?

Q6 Do FEWs’ anxiety, depression and PTSD have any relationship with the children’s functioning?

Q7 Is there any relationship between the children’s functioning and the mother’s functioning?

Q8 Is there any relationship between the children’s psychological distress and their relationship with their mother?

4.2 Hypothesis

Eight hypotheses are drawn to answer the above questions They are;

Ha1: FEWs’ history of traumatic experience significantly and positively correlates

with their mental health problems

Ha2: There will be a positive correlation between mother FEW mental health severity

and child mental health severity indicating that mother’s mental health problems predict to child mental health problems

Ha3 FEWs’ age and duration in their business will have a positive correlation but

FEWs’ educational level will have a negative relationship with their children mental health problem severity

Ha4: FEWs history of traumatic experiences positively correlate with their children’s

mental health indicating that the mother’s traumatic experience predicts to child mental health problems

Ha5: FEWs with severe drug use problem has a positive relationship with their

children’s mental health

Ha6: FEWs’ mental health problems have significantly positive relationship with the

children’s functioning indicating that mother’s mental health problems predict

to their children’s functioning

Ha7: The children’s functioning has relationship with their mother’s functioning

Ha8: FEWs’ psychological distress predicts level of relationship with their children

5 Significance of the Study

This study helps to understand more deeply about the mental health situation of the female entertainment workers and their children as in the following;

For the FEWs It would give us more explanation on the relationship between their adverse childhood experiences and the current severity of mental health problems particularly on depression, anxiety, Post-traumatic Stress Disorder (PTSD), and as well

as substance misuses For the offspring of the FEWs, in addition, early mental health problems of the children would be identified Possible recommendations from the findings would be discussed among concerned mental health practitioners and

government and non-governmental institutions The result of the study would contribute

to the development of better mental health services and program not only for the FEWs and also for their children

These outcomes would be a new pathway to get to know more insight about the nature of risk and protective factors among Cambodian female entertainment workers and the possible relationship between their mental health problems and being a mother

It is also an alarm for mental health professionals and policymakers to identify vulnerable groups among the population and providing suitable mental health treatment services Last but not least, it would also contribute to the prevention of future outbreak

of young population with possible mental health problems in the country, particularly to this vulnerable group

CHAPTER 1 THEORETICAL FRAMEWORK

1.1 Literature Review

1.1.1 Female Entertainment Workers in Cambodia

Commercial sex workers have been defined as a member of vulnerable groups (WHO, 2010) The term for a female working in the sex business has been defined differently from one country to another In many countries the general term “sex worker” has been used to name those who are working in the sex business for the purposes of exchange of money (Cambridge University Press, 2019) Historically, the term

“prostitute” has been used to label those females who are working in the same setting in Cambodia More recently, the term was changed from “prostitute” to “sex worker.” However recently Cambodian government institutes, non-governmental organizations and private sectors came to a consensus that Cambodian females working for the purpose

of exchanging sex for money, goods, drugs and services are referred to “entertainment workers” (NCHADS, 2013)

The term “entertainment workers” was divided into two different types, direct entertainment workers or direct female sex worker (DFSW) and indirect entertainment workers (IDEW) Direct entertainment worker referred to females based in a brothel setting or freelance venues such as public parks, while indirect entertainment workers refer to females having a different job as primary source of income Indirect entertainment workers, therefore, include those working at a karaoke or massage parlor,

or in beer garden or night club settings (Sokhom et al., 2002) The term female entertainment workers (FEW) will be used throughout this document

Different reasons bring women in Cambodia to end up their job in the entertainment business A national survey in Cambodia showed that women started to have sex in exchange for money and goods at the average age of 22 years (Chhorvann, 2010) However, this is not the only cause that brings Cambodian females into sex work Studies conducted by Boden (2012) and Hengartner and colleagues (2015) show poverty and social economic problems were found to be additional reasons for young women to engage in sex work Sexual exploitation and human trafficking can also be a reason why some girls and women end up in involuntary prostitution

1.1.2 Physical Health Problems of Female Entertainment Workers

HIV/AIDs and health-related problems found in HIV/AIDs epidemic studies among most-at-risk population includes FEWs in Cambodia 13.9% of them were found

as a high prevalence of HIV/AIDS transmission comparing to other groups of the MARPs (Chorvann, 2012) Unprotected sex is a crystal factor in rates of HIV/AIDS One study on Cambodian FEWs’ risky behaviors indicates an increase in use of condoms with money partners (Gorbach, 2006) Contextually, violence from intimate partners puts FEWs at even more risk of unprotected sex The more vulnerable the victims they are more likely not to be able to protect themselves from sexual intercourse and possible virus transmission from their partners

FEWs are at a much higher risk of being abused by their non-paying partner (husband or boyfriend) when under the effects of a drug or ‘high’ In this respect, a recent study found among 220 Cambodian women sex workers in Phnom Penh 16% have been physically abused whereas 18% have been sexually abused (Drughon Moret et al., 2016)

Health services for FEWs are even more inaccessible than other at-risk populations compared to the normal population The accessibility of the venue of health service

provision, self-discrimination and health staff’s attitude and behavior toward this target group have been found challenges for hard-to-reach population to get access to the suitable health services Cracking down from the law enforcement officer to meeting the demand of the commune/village safety policy across the country also play additionally contributive role in putting barrier for them to have equal opportunity for health care and

treatment (Schneider, 2013)

Health problems, including mental health problems, of FEWs exist but accessibility

to health care and treatments is limited particularly during the time of crackdown from the local police authority in early 2008 As they are afraid of being arrested, at least 26%

of this population was reported less accessing to STI care and treatment from the local clinics While many health consequences have been reported among Cambodian females working directly and indirectly in sex work, social discrimination particularly from

health service providers has been found to be a barrier to health care (Schneider, 2013)

1.1.3 Mental Health Problems of Female Entertainment Workers

Mental health is an area of particular needs among FEWs A recent study in 2016

of FEWs in two of the biggest cities of Cambodia, Phnom Penh and Siem Reap, found a mental health treatment demand for workers in the entertainment sector Of 657 of the identified hotspots (the venue where the entertainment workers can be reached) in the study found 43.2% are having general mental health distress Experiences of abuses emotionally and physically in early childhood have also been addressed in the finding 25.3% of respondents reported with experience of being insulted or verbally abuse by members in the family and 26% have been physically abuse that need medical care Furthermore, rating scores of suicidal ideations (19.5%) and attempt (7.3%) were found among this population (Brody et al., 2016)

Mental health services and proper treatment programs are limited in Cambodia Regarding mental health infrastructure, only about 50% of the eighty-four referral hospitals in the country are available with mental health care and treatment services Furthermore, Cambodia is also rated in the lowest level of mental health service provision among the Asian nations where there are only two in-patient unit from two different hospital provide fourteen beds for psychiatric patients across the country In smaller facilities in the community setting, such as health centers, only a small number

of well-trained mental health practitioners are available For instance, not more than twenty mental health staff were found in about 967 health centers across the country Professional mental health resources are highly limited and unable to respond to the tremendous mental health care and treatment needs of the Cambodian population (McLaughlin & Wickeri, 2012)

Since mental health services and resources are often unavailable or restricted in the context, optional cultural and traditional treatments are considered by for many Cambodians including FEWs Many persons with mental health problem seek treatment from local traditional healers or “Kru Khmer” including monks This is found particularly among those living in the country side and rural areas where mental health understanding is poor (TPO, 2004) Contextually, Kru Khmer is known as someone who has learnt how to treat health problems by using variety of natural and traditional remedies and magic from spirits They can be those who have learnt and kept spiritual beliefs as their routine on a daily basis of treatment (Community Partner Program, 2010) Many community programs that have been working in the mental health field in Cambodia still cannot discount the positive contribution of these traditional resources in the mental health sector in Cambodia (Somasundaram et al., 1999; TPO, 2004) The accessibility of traditional healing services in rural areas influences the rate of persons with mental health problems, including FEWs, seek health care from scientifically based

treatments

1.1.4 Substance Abuse among Female Entertainment Workers

Increasing numbers of drug users has been found among Cambodian FEWs A national report from the NCHADs show an increasing number of drug users among this target population in a period of 5 years from 2003 (about 7%) to 2007 (about 19%) (NCHADS, 2007) Later study showed a concern on the increased trend The lifetime prevalence rate of Cambodian FEWs misused ATS was from 42.5 % in 2007 but increased to 30.1 % in 2009 Assessing the most recent misuse of ATS in the last 3 months the mentioned FEWs reported 26.6 % in 2007 and 23.5 % in 2009 (Page et al., 2013)

The Behavioral Sentinel Surveillance across the country in 2010 show female populations who are working both in the direct and indirect sex business are using more amphetamine type stimulant drug Tablet (“yama” or “yaba”) and crystal (ice) forms of ATS are the most comment drug of abuse among this most-at-risk population (Chhorvann, 2010) Recent qualitative findings among Cambodian FEWs revealed common purpose of misusing ATS The finding addressed occupational functions involuntarily demand the women to stay alert and being on duty in order to be available for late at night male customers (Dixon et al., 2015; Maher et al., 2011)

Certain group of the FEWs are putting themselves even more at risk than the other one Freelance and brothel based of entertainment workers have been found with a higher proportion of abusing illicit drugs more than those who are working at the entertainment establishment based such as beer garden, Karaoke or massage parlor (Couture et al., 2011b) The same author has also found an increasing number of drug users of the same forms of abuse among the target population Crystalized from of drug has been abused 23.1% and the table form “yama” or “yaba” has been found more as 40.6% among the FEWs Alcohol abuses (23.7%) (Couture et al., 2011a) and ATS abuse (Kab et at., 2012) are also comment among this group

1.1.5 Mental Health of Children

Children was globally defined by the United Nation’s convention on their rights since 1989 as the person who is under the age of eighteen years unless under the law applicable to the child, majority is attained earlier (United Nations of Human Rights, 1989) Children’s rights are also the human being’s rights which each and everyone of the child has to be guaranteed to obtained his/her basic rights From a developmental perspective, healthy children need to growth up in an environment where it provides full

of care, love, support, responsively to the needs in order to develop to the fullest it could

be and appropriate nutrition (World Health Organization, 2018)

While some children have been raised up to fulfill this fundamental development, unfortunately some others are struggling with their life during their developmental stage due to culture, political situation, life condition, family situation, parental condition, economic status and so on Many children have been reported living in poverty and risky situation and even threatens to their life Globally, about 450 million children are living

on with less than USD 1.90 a day The United Nation’s data in 2013 showed that there were about 124 million under age children (including adolescents) were not accessed to education Up to 2014, there was also reported that nearly 160 million of children were stunted and remarkable about 250 million of children of the world are living in areas and countries where arm conflicts or civil wars are still being taken placed (United Nations, 2018)

Children are more prone to different forms of violence and exploitation domestically and communistically Every year, about one billion of children are suffered from violence across the globe (WHO, World Bank, 2017) In a large sample size (N=1966) study among students from grad 4 to 8 in Taiwan found that there are about 34% of them have experienced of physical abuse (Chou et al., 2011) Children and youth

particularly in were putting at a greater risk of poverty, sexual abuse, trafficking and exploitation, and forced labors (WHO, 2012) From a global report of the United Nation Office on Drug and Crime (UNODC) on the situation of the human trafficking highlighted that about 20% of victims of this crime are children predominately women and girls (79%) (UNODC, 2009)

In an eleven-year reviewed study on published literatures from 1995 to 2006, Children and younger age who live in family with violence were putting at more risk to develop emotional and behavior problems (Holt, Buckley, Whelan, 2008) A meta-analysis from 60 different published articles related to impact of domestic violence on the children’s mental health found their childhood experience has an association with three main symptoms; internalizing, externalizing and traumatic symptoms (Evans, Davies, DiLillo, 2008) Another systematic review on a larger sample of published studies among 19 nations across the lower- and middle-income countries also found some correction of mental health problems of children in the same context The review looked in deep into 233 published articles which 25 were cross-sectional studies found that externalizing is the most comment mental problems among children and adolescents Furthermore, the highest association between exposure to violence at home with externalizing problems and sexual abuse with suicide ideation was also highlighted in the review (Rebeiro, Andreoli, Perri, Prince, Mari, 2009)

Mental health of the child and adolescent is prevalent across the world A global estimation from the World Health Organization (WHO) of the mental health problems among this particular population is about 20% Noticeably, about 50% of them are living

in the lower- and middle-income countries (WHO, UNPF, 2005) From a children developmental point of view, there are about 200 million of children under 5 years of age haven’t been able to development mentally and cognitively to the best that they could (Grantham-McGregor et al., 2007) Experiencing common mental disorders in early

childhood have a significantly relationship with low cognitive development in later life

of the children (Bennett, Schott, Krutikova, Behrman, 2015)

From a mental health etiology foundation, there is no an extinct factor contribute

to the development of the mental abnormality or psychopathology Scientific studies to date confirmed at least three main factors rooted in the causes of the mental instabilities

of humankind They are environmental, biological, social and psychological factors Due to the limitation of the review, only social and psychological factors are addressed

and discussed later in this section Social factor, by definition, is factors (e.g., attitudes)

that affect thought or behavior in social contexts or that affect self-concept vis-à-vis other individuals or groups On one more hand, psychological factor is defined as functional factors—as opposed to biological (constitutional, hereditary) factors—that contribute to the development of personality, the maintenance of health and well-being, and the etiology of mental and behavioral disorder A few examples of psychological factors are the nature of significant childhood and adult relationships, the experience of ease or stress in social environments (e.g., school, work), and the experience of trauma

(APA, 2018)

Recent studies have given us better understanding about common types of mental abnormality or disorders among children Among all the children in the world, there are about 10% to 20% of them are living with mental health illnesses, remarkably about half

of these illnesses have started in early adolescent years around fourteen years of age and most of them are living in low- and middle-income countries (WHO, 2018) Some forms for particular mental disorders among this vulnerable population are; attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), depressive disorder (DD), anxiety disorders including post-traumatic stress disorder (PTSD) (Raphael, Stevens, & Pedersen, 2006) Substance misuse, in addition, particularly tobacco, alcohol and marijuana have been found among school age

adolescent (Bauman, Phongsavan, 1999) In a very recent finding from the Lancet report, among these common disorders, children are more at risk of developing depression when moving up to their adolescent age The same report also highlighted that moving up to their early adulthood, many of them affected by at least one of the mental disorders (Lancet, 2014)

Children has their rights - the same rights and equal to others - to be protected and developing to the best that they could Some children have been grown up in very supportive, care, affection, and responsive environment which are scientifically found being positive foundation to become a health and functioning human new generation However, some other children are, unfortunately, living in very distressed, traumatized, and unsafe environment which endanger their life to early starting point to struggle with unwanted symptomatology and abnormality from one stage to another of their development fulfillment, physiologically and psychologically The differences between these two groups of children can be understood more by addressing on the risk factors and protective factors which are going to be described in the following section

1.1.6 Risk Factors for Children’s Mental Health

Before moving on to address in more detail about what the risk factors for the development of the children’s mental health problems and disorders is, it is worthwhile

to understand, first, about the term “Risk Factors” Based on the online dictionary of psychology from the American Psychology Association (APA) website, the term “Risk

Factors” is defined as “a clearly defined behavior or constitutional (e.g genetic),

psychological, environmental, or other characteristic that is associated with an increased possibility or likelihood that a disease or disorder will subsequently develop

in an individual” (American Psychological Association, 2018) Researches in the field

of social sciences have been contributing a lot in the last decades to understand possible

factors contributing to worsen the mental health stability of the children after exposing

to the abnormal situations in their day-to-day life

First and one of the foremost factors which has been encompassed the way how theorists, researchers, clinicians and practitioners in the field of mental health to change the focus of their traditional attention on predominately the root causes of many of the child mental disorders is the concept of the attachment John Bowlby, a British psychologist and psychiatrist, who has originated the attachment theory and spent most

of his professional time in this field has found a few main attachment partners hidden behind the development of each and every of the child Developed in the 1990s, the attachment theory has been set the ground based on the foundation of various concepts

of ethology, developmental psychology, cybernetic, psychoanalyst, and the information

processing (Bretherton, 1992) By definition, “attachment” is described as the emotional

bond between a human infant or a young nonhuman animal and its parent figure or caregiver (APA, 2018) From the mile stone development of the theory, John Bowlby

and Mary Ainsworth, also known as an important contributor to and a co-founder of the theory development, introduced four different kinds of attachment patterns which the children can develop eventually throughout the early stage of their development They are; secure attachment, anxious ambivalent attachment, anxious avoidant attachment, and disorganized/disoriented attachment (Holmes, 2014)

Overwhelms of evidences from scientific communities up to date show different patterns of the attachment contribute to the different consequences of personal development psychologically of a child Insecure attachment pattern, in this respect, lay down a negatively foundation of early onset of child psychiatric problems and last onto later life was also found in children who raised up by parents with mental illness (Manning, Gregoire, 2009) In a longitudinal study from Glazerbrook and colleagues amplified that insecure-attached adolescents are more likely to repeated self-harm

behavior comparing to their counterpart The authors were trying to look into the association between the negative effect of the insecure attachment on the self-harm behavior outcome of the adolescent participants Study participants ages from 13 to 17 were invited to voluntarily take part in the study (n=52) Certain measures have been administered to rate the level of self-harm severity, peer attachment, and mental health symptomatology of depression and anxiety A post assessment in 6-month period for following up the participants has also been set in their research methodology The result

of the study indicates that participants with insecure attachment both with mother and peer were significantly found having relationship with self-harm behavior at their base line assessment (p = 0.35, p = 0.50 < 0.05) respectively (Glazerbrook, Townsend, and Sayal, 2015)

Relationship between attachment during the developmental stage with eating disorder has also been highlighted in another recent study Milan and Acker (2014) conducted a study in order to seek for any association between insecure attachment in early childhood with the risk of eating disorder among adolescent girls in the United State of America The sample were driven from the national survey known as the National Institute of Child Health and Human Development Study of Early Child Care Adolescent samples of 659 or equal to 49% (N=1364) of the total sample in the survey have been put into the analysis From their in-depth analysis, one of the finding support their hypothesis that the low quality of attachment in early childhood experience predict

as a risk factor for eating disorder with unhealthier response (Milan, and Acker, 2014)

In another most recent study in a war-torn area, Palestine, relationship between children with insecurely attachment and mental health outcomes have been addressed Eloranta and colleagues (2017) have invited 428 school children with their ages range from 10 to

13 years (M=11.29, SD=0.68) to take part in their study Base on their result, the authors

highlighted that anxious/avoidant insecurely attached children perform lower mental

health outcomes based on their measure particularly on the emotional regulation scale (Eloranta, Peltonen, Palosaari, Qouta & Punamaki, 2017)

Another risk factor contributes to the anticipation of the children mental health problems is known as childhood adversities and life threating events exposed by children during their developmental stage A worldwide report on violence and health indicated children who have been left neglected behind and abused in their early stage of mental development tend to develop emotional problems and distressed in later life (Krug et al., 2002) In a recent systematic review and thorough meta-analysis on childhood maltreatment done by Li and colleagues, the result gives amount of indication that effected children are risking to development of depression and anxiety in later life From their conclusion, the authors pointed out that, at the policy making level, having reduced the cases of maltreatment among the children from 10 – 25%, it contributes to the financial saving for the world from 31.4 – 80.3 million dollars which would need to be spent on treating depression and anxiety (Li, D’Arcy, and Meng, 2015)

Exposing to adverse experiences in childhood such as violence, abuse, neglect or even living with malfunctioning member in family can be predicted instability and abnormality physically and mentally in late adulthood A very first publication from Felitti and his colleagues in 1998 gave a surprisingly notion about how long-term relationship between adverse childhood experiences (ACEs) and development of major health diseases among the US population In this study, the authors tried to look for the association between seven major childhood experiences related to abuses (psychological, physical, or sexual), domestic violence against mother, live with member(s) dysfunction in the family (drug user, having mental disorder, or suicidality) and having any member in the family imprisoned and with the risky behaviors, health status and common disease in adult life The result showed that among all the adult respondents (N=13,494) more than 50% of them reported having at least experience with

one major adversity in their childhood and about 25% have experienced more than two major adversities Remarkably, respondents experienced equal or more than four majors

of the adversity have 4 to 12 time of risky behavior such as alcoholism, abusing drugs, depression and having suicidal attempt In their general conclusion, the authors addressed that the association between these adverse childhood experiences and health outcomes is strong and has long term effects in later life which contribute to the major causes of earlier deaths (Felitti et al., 1998)

Building up from the ground breaking finding of the first ACEs study, later researchers have been expanding their work to get to know more about relevant and other possible impacts of the adversities to other health related problems and disorders In a long cohort study published in 2009, Flaherty and associates found that the more adversity the children exposure in their early years of life the more health complaints they have including somatization This finding came from the sample of children from their age of 4 and keep tracking their health record up to 12 years old The authors concluded that previous experiences especially exposing to maltreating in their early life should be including in a comprehensive assessment (Flaherty et al., 2009) In another study among Mexican population, a group of researchers addressed the relationship between childhood adversities and the onset of the development of the psychiatric disorders among three different courses of life; childhood, adolescence and adulthood Different types of adversities in childhood such as abuse and neglect, loss of parents, mental illnesses of family members, physical illness and economic adversity were measured Four major types of mental disorders; mood, anxiety, substance abuse, and externalizing, have also been measured during the data collection from the adult respondent age ranges from 18 – 65 years old (N=5826) The finding from this national study indicated that, sever childhood adversity, particularly with those who have family members with mental illness, has a relationship with the all the four types of psychiatric

disorders (mood, anxiety, substance abuse and externalizing) (Benjet, Borges, Mora, 2010)

Medina-Parental mental instability is being held accountability as another risk factor contribute to the development of their offspring’s mental health in many researches recently A meta-analysis published in 2007 by McLeod at al highlighted the relationship between parental dysfunction with their children’s anxiety disorder The analysis was executed from 47 published articles with three main types of study categories; cross-sectional, longitudinal and experimental study The result showed that parenting plays a crucial role in the development of the children’s mental health problems In this respect, the parental control pattern is found having stronger association than the rejection one with their offspring’s anxiety (McLeod, Wood, Weisz, 2007) In

a cross-sectional study done by Atwoli and colleagues (2014) indicated in their published article that there is a statistically significant finding on the relationship between parental psychopathology and their children’s suicidal behavior among South African population (n=4,315) In this large sample study, five major types of mental illness of parent such

as major depression, generalized anxiety disorder, panic disorder, substance use disorder and personality disorder and children’s suicidal behaviors by using structured interviews were measured respectively Notable findings addressed that panic disorder, substance use disorder and personality disorder among parents have an association with their offspring’s suicidal attempt In addition, parental suicidality and generalized anxiety disorder are also found statistically significant correlate with their children’s suicidal ideation (Atwoli, Nock, Williams, and Stein, 2014)

Preliminary finding and conclusion from Williamson and colleagues (2017) in their systematic review addressed the linkage between specific parenting behaviors of parents and their children’s post-traumatic stress symptoms (PTSS) In their review, the authors intended to look for confirming evident among fourteen published articles dated back

from the year 1996 to 2014 on the association between the way of parenting and the symptoms of post-traumatic stress disorder in childhood of the offspring The age of participants in the mentioned study ranged from 9 to 16 years old The finding revealed that negative parenting behavior has a statistically significant relationship with children’s PTSS (Williamson et al., 2017)

Exposing to horrified experiences in early stages of life has put the young children

at an enormous risk of developing early mental ailments Some main risk factors have been documented by promising studies including cross-sectional, longitudinal and experimental design addressed the role of attachment formation between the primary caregiver and children, early childhood traumatic experiences effected by adversities and maltreatment and the impact of parental mental disorders on the children’s mental health outcome

1.1.7 Protective Factors for Children’s Mental Health

While risk factors contribute to the development of negative outcomes of children’s and adolescents’ mental health have been addressed in various studies, protective factors

have also been explored Protective factors, in this respect, are defined as a clearly

defined behavior or constitutional (e.g., genetic), psychological, environmental, or other characteristic that is associated with a decreased probability that a particular disease

or disorder will develop in an individual, that reduces the severity of an existing pathological condition, or that mitigates the effects of stress generally (APA, 2018)

Protective factors have been found from several contributing factors such as; the child, parent, relationship between the two – the child and the parent, and the external environment (Shulman, 2016, p.125)

Various studies attempted to identify the particular effect of the different types of protective factors on mental health development among children Secure attachment

child growths up with authoritarian parenting developed more sense of self, high esteem and self-reliance and self-control behaviors (Wilmshurst, 2005, p.18) The good quality of the caring from the primary figure to the child from the very early age of live contributes to the adaptive response in case of distress in later life particularly from positive attachment parenting (Miller, Commons, 2010) In day-to-day communication and interaction, caregiver and family also play as the most crucial role for the children

self-to growth and develop self-to the best that they could (WHO, UNICEF, 2012)

In a national mental health survey done in Germany among 2,863 families and children The total number of child and adolescent respondents in the survey was 1,903 ages ranged from 7 to 17 The survey indicated that mental health problems was found higher in children with low resources (personal, family and social) than children with higher resources The protective factors from family and society were identified by the young respondents in the survey (Wille, Bettge, Ravens-Sieberer, and the BELLA study group, 2008) Miller-Lewis and colleagues found additional and particular factor which also develop coping ability of the children to be more resilience to life distress From a thorough analysis of the study among a sample of 474 Australian children, they found that, relationship with parent and teach, play as a role to build mental resources for young children It is positively correlate with their resilient mental health outcome (Miller-Lewis, Searle, Sawyer, Baghurs, and Hedley, 2013)

Another study in Germany also verified the relationship between the quality of the foster care parenting and the attachment security of the small children who have been replaced to live in foster care program In this study, Gabler and associate analysis data collected from 48 children respondents age from 9 to 66 months old who are living with their foster caregivers The children’s attachment security and behavioral problems and the caregivers’ stress level have been measured accordingly Their result indicated that there is a negative correlation between the stress level of the parent and the children’s

attachment security This particularly means that children with high level of attachment security are being taken care by foster parent with low level of stress (Gabler at al., 2014) The positive outcome as a consequence of healthy interaction between the parent and the child has also been highlighted recently in another study done by Van Loon and colleagues The authors were trying to identify any factors preventing children from developing behavioral problems among children who are living parents with and without mental health problems In their design, children age from 11 to 16 from 132 families have met the selection criteria and been voluntarily invited to take part in the interview The children’s coping strategies, self-esteem, and behavioral problems and the parent’s mental health, monitoring, and support have been measures From the study analysis, the result pointed out that the communication between parent and children and the children’s coping strategies play an important role in preventing the development of the internalizing behavior of the children (Van Loon, Van De Ven, Van Doesum, Hosman, Witteman, 2015)

Though children are at possible risks to mental health problems as they live in adversity situations or being maltreated inside and outside the family, there are positive factors have been found to protect some of them from developing them Internal – from the child – and external – from parent and peer – protective factors have been addressed

in many recent studies

1.1.8 Children of Female Entertainment Workers in Cambodia

Many children in Cambodia have been maltreated not far different from the others

in another part of the world particularly in low- and middle- income countries From a study among school adolescents in Battambang province (a city located in the Western part) of Cambodia indicated prevalence of violence and its consequence on their mental health problems 27.9 % of male and 21.5% of female students have reported at least one

time they have been a victim of domestic violence This victimization was related to the increase of depressive symptom Moreover, being a witness to community and family violence among female student had a positive relationship with depressive symptoms (Yi, Poudel, Yasuoka, Yi, Palmer, Jimba, 2013) Ong and colleagues also conducted a study to understand more insight about the mental health well-being of a particular most-at-risk children who are known as orphan and vulnerable children (OVC) There were six-hundred and six community sample children (50% is girl) age ranges from 11 to 18 years (Mean=13.4, SD=1.7) have been asked to take part in the study Various measures have been administered to rate depressive symptoms, adverse childhood experiences, family dysfunction and school attachment The finding of this study highlighted that girl respondents who are with older age, lacking of daily food and having separated parents

or passed away have higher level of depressive symptoms comparing to their counterparts (Ong, 2015)

Young age Cambodian adolescents have been found being vulnerable to violence and abuses Many children aged from 15 to 17 years old have exposed to domestic violence and lacked of family care which contribute to concerned suicidal cases among the population Sexually abused cases have also been reported among older children who are working as entertainment workers and garment factory workers (UNICEF, 2009) In

a very recent prevalence study conducted by Sumner and colleagues also addressed a remarkable representative rate of sexual abuse among children in Cambodia The study analysis data collected from seven countries; Cambodia, Haiti, Kenya, Malawi, Swaziland, Tanzania and Zimbabwe with a sample of children and youth from 13 to 24 years of age The data collection was done from 2007 to 203 The result on the prevalence

of the lifetime experiencing sexual abuse among Cambodian respondents are 4.4% for female and 5.6% for male (Sumner et al., 2015)