Introduction
There is a shortage of doctors globally, especially in rural and remote areas, which hinders the progress towards improving the health of people in these areas.1, 2 This global challenge has been accorded high priority by the World Health Organization (WHO). Current data document that more than 44% of WHO member states have fallen short of the WHO standard of one physician per 1,000 populations. 3
In order to achieve effective training, good quality supervisors, effective supervision, adequate opportunities to experimental learning, conductive environment, good support system, personal attributes and reasonable workload are essential factors. 4 Satisfaction is enhanced by a perceived good training, and internship training remains very important in preparing doctors for their future careers. 5 The Government of India recognizes ‘Health for All’ as a national goal and expects medical training to produce competent “Physicians of First Contact” towards meeting this goal. Post Graduate examination is a major distraction for internship. Interns give more priority for securing a postgraduate seat than to learning the clinical skills during internship. 6
Theories about career choice are concerned with the fact that career goals will change as a response to claims and opportunities in the environment or as a response to learning experiences. Studies demonstrate how rural exposure as a part of medical education leads to a greater likelihood of working in a rural area after graduation. 7, 8 A lesson from this is that the longer the exposure to training in a rural context, the greater the impact on interest in future rural practice and, particularly, the greater the likelihood that doctors make important life decisions in a rural context. 9
After the period of internship, the interns are expected to acquire competencies to deal effectively with an individual and the community in the context of primary health care during their posting in government-funded primary or secondary care hospitals. 9
MBBS interns after their successful completion of internship program are posted in Primary/ Community health centres to provide health services, thus it is important for MBBS interns to understand basic concept of public health and its various aspects. Visit to the institutes that work for public health, helps broaden vision of interns so that they feel motivated to work for rural health care. Therefore this study was planned to evaluate the effect on the minds of MBBS interns of Pt. J. N. M Medical College, Raipur, after visiting such places with objectives.
Material and Methods
Study design
It was a cross-sectional descriptive qualitative study. MBBS interns had to visit NGO`s or institutes that were known to work for public health. The visits were carried out by the department of Community Medicine after necessary approval from the Pt. JNM Medical College. So, after the completion of the Interns interstate visit, a Focus Group Discussion was conducted to understand the things they have learnt during their visit.
Study setting
Interns visited the institutes of Public Health importance that worked for the betterment of health and society. Depending upon the feasibility and nearness to Raipur some of the institutes of Public health importance were chosen in Maharashtra and in Chhattisgarh. These institutes not only played vital role in providing health care but also in the upliftment of communities by imparting awareness about Health, Hygiene, solving nutrition and livelihood problems and working for their rights.
Study areas
Some of the selected public health institutes in Wardha, Gadchiroli in Maharashtra and Narayanpur, Bilaspur and Mungeli Districts in Chhattisgarh.
Study population
MBBS interns of Pt. J.N.M Medical College, Raipur (C.G) that visited the above mentioned institutes of public health importance.
Inclusion criteria
All the interested interns that participated in the interstate visit program and gave their consent for FGD were included in the study.
Exclusion criteria
Those interns that were ill during the day of FGD, those who remained absent during the FGD and those were not willing to participate were excluded from the study.
Study tool
Focus group guidelines with open ended questions were developed based on the existing literature. 10 FGD were conducted by trained facilitators who used pre-prepared topic list of questions to understand what these interns learnt during the visit to various places of public health importance.
Questions asked during focus group discussions to identify important points that they learnt during this visit at Institutes that worked for Public Health
Data collection
A prior written informed consent was taken from the participants. The participants were ensured about their anonymity and confidentiality while reporting the results. Necessary permissions were obtained by the institutes prior to the visit. After the completion of the visit, interns were asked to assemble in the department of Community Medicine for conduction of a Focus Group Discussion. The research team conducted the FGD who were well versed in qualitative research methods. The FGD was conducted in local language. It was held at a suitable time and place which was convenient to the participants. Study purpose and objectives were well explained to the participants. Initially setting up the induction with icebreaker questions began which generated interest for the topic among the participants followed by the questions meant for focus group discussions were asked. The researcher asked each one of the participants the things they learnt during the visit and finally concluded the session with key statements obtained during the focus group discussions to ensure the participants validation.
Results
28 interns participated in the study including 6 (21.42%) females and 22 (78.57%) males. The age range was 23 to 27 years and all were unmarried. More than 2/3rd interns belonged to Chhattisgarh and few from outside the state.
After the analysis the major important points were noted.
Theme 1: These institutes had clear goals and objectives for patient care.
Some of the highlights of the responses are shown below;
“These institutes had clear ideals and objectives to serve the rural population in terms of health care”
“Patient centric approach”
“Series of methods such as low cost registration, low priced but high quality investigations”
“Dedicated specialists in rural area”
“Encouraging community to participate in health care”
“They also worked for livelihood”
“A few of these institutes also provided education to children”
Theme 2: Newer methods were used for patient care
“Administration was organised”
“Staffs were well aware of their responsibility, friendly environment”
“Use of Hospital Management Information System (HMIS), to reduce work load & save time of the patients”
“Establishment of clinics in periphery to help reduce patient`s burden in their tertiary hospital.”
“Involving community to learn their problems and solve them”
“Development of newer techniques and models to solve the patients and community problem example: Encouraging development of dried products rich in vitamin C (Indian gooseberry), calcium based products and application of oils on body which acted as mosquito repellents”.
Theme 3: Based on learning acquired
They said they learnt many new things about dedicated health professionals working in rural area. After visiting these institutes they felt the staffs were very cooperative and friendly in nature. Interns must be sent to these places for better understanding how to maintain human resources in difficult areas and learn enormous amount of public health work done by these institutes. Following observations were made;
“These institutes provided curative, diagnostic and rehabilitative services at low cost”,
“The staffs here are very dedicated, co-operative and patient centred”
“These institutes encourage Community Participation to understand their problem and guide them to solve it by themselves”
“Some of these institutes also provide education and trained the villagers that worked locally as Mid level health worker”
“Most of the people are poor and hence such institutes are needed in rural areas to provide health care services”
“Learnt new concept of community problem solving by opening weekly Kiran clinics/community arranged and managed clinic in Sevagram village”
“Rotation basis duty of mothers to handle children of that Phoolwari or crèches in a village in Bilaspur”
“Appropriate technology can solve many problems”
Even though these institutes work in remote and difficult to reach areas, high motivation factor to serve for the rural health care and their development keeps them going. Infrastructure of this institute was quite impressive with use of computers, centralised networking and use of less paper. Even most of the specialist doctors used to help in handling general outpatient department facilities that reduced the burden and only the needy patients were further sent to specialist doctors. Use of modern technology & medicine dispensing system was appreciated by the interns. Government Insurance schemes were utilized to serve the needy and some of the schemes were also run by these institutes themselves by collecting minimum annual payment which helped insure the whole family.
Table 1
Major findings from the visit to various public health institutes
Discussion
Very few studies have been conducted in Chhattisgarh on improvement in medical internship through outreach visits to public health institutes. Compulsory internship program is successfully being conducted in all the medical colleges but most of these interns were posted in various clinical departments or in rural health centres.
Most of these students were impressed by the “General OPD” concept started by a Medical college in Wardha. The system and mechanism this institute developed where the Community Medicine Physician checks the patients and if required sends them to specialists or else sends them back home after prescribing necessary medications if there is no need for specialists. This institute has its own insurance cards and also utilizes various government schemes for delivering services to patients as far as Telangana who reach there for speciality services. “Kiran clinic” concept in a village near Sevagram, where the villagers through the community participation concept demanded a need for doctor in the village and a doctor from the Community Medicine department visits the village every week. In the remote and inaccessible area in Gadchiroli in Maharashtra providing health care, teaching farming methods and education to children was appreciated by interns, similarly it was also being done in a public health institute in Chhattisgarh by the totally dedicated hard working team was noticed by the interns.
Development of various appropriate technologies such as mosquito repellent oils, nutritious calcium supplements and vitamins, “Phoolwari” or crèches concept in a renowned public health institute in Chhattisgarh for the children was appreciated and liked by the interns. Registration and record keeping of the patients, dispensing low cost generic drugs, and low cost latest technology fast reporting diagnostic reports, intervention in form of medicine or surgeries in these remote areas was learnt by the interns. They took help of nearby specialist doctors for surgeries once a week that came on voluntary basis to perform various surgeries either free of cost or minimum honorarium. Apart from intervention these institutes also worked in the field of rehabilitation. For leprosy patients a very famous institute of Chhattisgarh issued special footwear, had various reconstructive surgeries and rehabilitation as well as they worked for their rights and all round development of nearby children and communities.
Exposure of the interns to institutes out of the states and learning by visiting them is a new concept which was appreciated by the interns is very much apparent from this study. The above findings indicate that interstate visit has affected the cognitive domain of the interns in terms of acquiring knowledge about the existing health care delivery system in the institutes of Public Health importance. By visiting different remote parts of India it changed their view and mindset which affected the affective domain and generated a different perspective for rural people and the rural health care in inaccessible and remote areas. Communication skills while dealing with the community and involving them for community participation is very important. Thus importance of this skill was learnt during the community orientation visit by the interns.
Conclusion
This study helped us understand the factors that lead the interns to appreciate the visit to institutes of public health importance. It changed their view about health care needs in rural area and motivated them to work for rural health care. Rural health care service is challenging and that lead to a change in intern’s views and affected their affective domain of learning. They were also oriented about the needs of the strong dedicated field workers working in the peripheral clinics.
Various factors that were enumerated by the interns such health insurance schemes, peripheral or satellite clinics, team of dedicated skilled health and trained Para health professionals were some of the new things learnt during the visit. Interns were motivated to work for rural health care and were sensitized about the health care needs work challenges in remote inaccessible areas.
Majority of participants liked the visits. They acquired knowledge of various innovation techniques to solve health and social problems and came to know about public health and its related activities done by these institutes which relates to the cognitive domain of learning.
Recommendations
More time should be allotted for such type of visits which helps in better understanding the rural health care needs and motivates the medical interns to serve in these remote areas. Prior to visits, orientation about these institutes must be provided, so that these interns must be aware of the place they are going to visit and the things that they must focus to learn from these places. MBBS Students, interns & medical officers should also visit such institutes.
