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Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam a
a
a
Kim Bao Giang , Hoang Van Minh , Nguyen Van Hien , Nguyen Minh a
a
Ngoc & Nguyen Duc Hinh
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a
Hanoi Medical University, Institute for Preventive Medicine and Public Health, Hanoi, Vietnam Published online: 06 Dec 2014.
To cite this article: Kim Bao Giang, Hoang Van Minh, Nguyen Van Hien, Nguyen Minh Ngoc & Nguyen Duc Hinh (2015) Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam, Global Public Health: An International Journal for Research, Policy and Practice, 10:sup1, S120S130, DOI: 10.1080/17441692.2014.986157 To link to this article: http://dx.doi.org/10.1080/17441692.2014.986157
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Global Public Health, 2015 Vol. 10, No. S1, S120–S130, http://dx.doi.org/10.1080/17441692.2014.986157
Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam Kim Bao Giang*, Hoang Van Minh, Nguyen Van Hien, Nguyen Minh Ngoc and Nguyen Duc Hinh Hanoi Medical University, Institute for Preventive Medicine and Public Health, Hanoi, Vietnam
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(Received 6 September 2013; accepted 26 September 2014) There is a shortage of medical doctors in primary health care (PHC) settings in Vietnam. Evidence about the knowledge medical students have about PHC and their career decision-making is important for making policy in human resources for health. The objective of this study was to analyse knowledge and attitudes about PHC among medical students in their final year and their choice to work in PHC after graduation. A cross-sectional study was conducted among 400 final year general medical students from Hanoi Medical University. Self-administered interviews were conducted. Key variables were knowledge, awareness of the importance of PHC and PHC career choices. Descriptive and analytic statistics were performed. Students had essential knowledge of the concept and elements of PHC and were well aware of its importance. However, only one-third to one half of them valued PHC with regard to their professional development or management opportunities. Less than 1% of students would work at commune or district health facilities after graduation. This study evidences challenges related to increasing the number of medical doctors working in PHC settings. Immediate and effective interventions are needed to make PHC settings more attractive and to encourage medical graduates to start and continue a career in PHC. Keywords: human resources; career choice; primary health care; Vietnam; medical doctors
Introduction Primary health care (PHC) has been a central focus of health systems. The role of PHC is to provide essential health care services, increase community accessibility to health care services and organise health care services based on peoples’ needs. PHC has been the benchmark for most countries’ discourse on health precisely because the PHC movement tries to provide rational, evidence-based and anticipatory responses to health demand and social expectations. The main principles of PHC as identified in Alma Ata Declaration are equity in distribution of health care, health promotion and disease prevention, community participation, appropriate health technology and a multisectoral approach (WHO, 1978). In Vietnam, health staff at the commune health station are considered as the PHC team. This PHC team includes a medical doctor or medical doctor assistant, nurses and/or midwife, secondary pharmacist and supportive staff (Ministry of Labour and Invalid *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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Social Affaire, Ministry of Finance, & Ministry of Health, 1995). The PHC team is very important because the team has to organise and provide both curative and preventive services for people with common health needs in the community. Health staff require certain qualifications to work in the PHC team; these qualifications include good knowledge, attitude and competence. Within the PHC team in the commune health station, medical doctors often play a key role in providing curative care and in managing all activities of the station. For this reason, they have a substantial impact on the performance of PHC activities. In Vietnam, PHC is among the important strategies comprising the national health plan. The government emphasises the development of an effective and safe health care system which values and seeks to achieve health for all. In recent years, Vietnam’s government has emphasised essential health care which brings health services closer to all inhabitants in order to pursue the human values of ‘social justice, and the right to better health for all, participation and solidarity’ (Prime Minister, 2013). Although the number of students enrolled in and graduated from medical universities increased significantly in the past 10 years, from 6360 in 2004 to 16,900 in 2011, the proportion of communal health stations that have a medical doctor increased less than 3% over the three-year period from 2008 to 2011, from 65% to 67.7% (Ministry of Health & Hanoi School of Public Health, 2012). The quantity of university level medical doctors working in community health stations accounts for under a third of the total number of commune health stations in Vietnam. Furthermore, Vietnam has experienced the movement of physicians from health facilities at lower levels to the higher ones, creating a poor distribution of human resources by level and region. Low income, poor working conditions and lack of opportunities for career development are the reasons for the inappropriate distribution of health staff, especially medical doctors, at different levels, regions and areas of health care services (Ministry of Health & Health Partnership Group, 2009). Knowledge and awareness among medical students and graduates about the importance of PHC, as well as their responsibilities to work at the primary care setting, are essential to encourage them to make their career choice in the PHC setting. It has been several years since eight medical universities in Vietnam implemented a communityoriented curriculum for medical students (Hoat & Wright, 2001). According to the training curriculum for medical students, PHC is introduced and integrated in some modules (Ministry of Education and Training, 2012). However, how students and graduates perceive PHC and its relation to their career choices was not known. This study aimed to analyse final year medical students’ knowledge and attitudes about PHC, and how this influenced their decisions to work in PHC settings after graduation. Methods Setting This study was conducted in the Hanoi Medical University in Vietnam in 2012. Established in 1902, Hanoi Medical University is the oldest university in Vietnam and a leading medical university in Vietnam. Each year, the university recruits around 1000 undergraduate students and 1500 postgraduate students. With regard to undergraduate training, the university trains several medical-related categories, such as general medical doctor, doctor in odontology and stomatology, doctor in traditional medicine, doctor in preventive medicine and bachelor of public health, nursing and medical technology. The
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training curriculum for all undergraduate students is designed to be community-oriented; upon graduation, students are expected to have essential PHC knowledge and skills and be ready to work at different health facilities, including the PHC setting. Subjects All study subjects were final year general medical students of Hanoi Medical University. Study design This is a cross-sectional study using a quantitative approach.
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Sample size and sampling Sample size was estimated using the World Health Organization (WHO) formula for estimating the proportion of students who have essential knowledge of PHC as well as those aware of the importance of PHC in the health system. We assumed that the proportion of students who had essential knowledge of PHC was 50%; this was estimated based on a pilot study among 50 students before the survey. We used a level of significance of 5% and a relative precision of 10%. The required sample size was 385. A final sample of 400 students was selected to allow for non-response. Simple random sampling was employed to select 400 final year students from the list of all final year students. Main variables There were three main groups of variables used in this study; these were as follows: (1) (2)
Background information of study subjects (age, sex, place of birth, current place of residence and monthly income/allowance). Knowledge of and attitude towards PHC. This was divided into two areas: . Knowledge of PHC: ○ Knowledge about the concept of PHC was assessed by 5 statements about the key concepts of PHC, in which three items were true statements (Health care at the grass-roots level; Health care for the patients at the first access to health system; Other professions involved) and two items were false statements (Apply modern health technique and methods; Special health care to promote health for all). ○ Knowledge about 10 elements of PHC in Vietnam, which included (1) Health education, (2) Expanded immunisation, (3) Maternal and child health care and family planning, (4) Nutrition, food safety and security, (5) Provision of essential drugs, (6) Treatment of common diseases and injuries, (7) Clean water, hygiene and sanitation, (8) Prevention of local epidemics, (9) Management of community health and (10) Enhancement of grass-roots health care network. ○ Knowledge score: The number of correct answers regarding the concept and elements of PHC was counted, yielding a ‘knowledge score’. There were 15 statements about knowledge of PHC; thus knowledge scores could range from 0 to 15.
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. Awareness of values of PHC: ○ Six statements regarding the value and importance of PHC were introduced, and participants were asked whether they agree or not with the statement. ○ Awareness score: Each item was scored as 0 or 1. A score of 1 meant that the participant agreed with the statement. The total ‘awareness score’ could thus range from 0 to 6. Career choice to work at the PHC settings: . This included questions on (1) fields of health science that students planned to be involved in after graduation, (2) level of health facilities that students wanted to work in after graduation and (3) types of organisations students wanted to work after graduation.
Tools A self-administered questionnaire was developed by the research team which focused on three main sections of contents: (1) background information of participants, (2) knowledge of and attitude towards PHC and (3) career choice after graduation. Under each question about knowledge of PHC, several true and false statements were included. Students were requested to select whether each statement was true or false. The questionnaire was tested and revised to make sure the questions were understandable and appropriate to the participants. Data collection process Based on the training time tables of students, a data collection schedule was developed to make sure that all groups of students could participate at a convenient time. All selected students were invited to a classroom in order to perform the self-administered questionnaires with guidance from research team members. The purpose of this study and the right to refuse participation in this study were explained to all students. Research team members also explained each question in turn to help students understand the questions. The classrooms were large enough to give students private space and to ensure confidentiality. Selected students were divided into six groups, and data collection took place over a three-week period. For those students who could not come at the time stated in the invitation, they were invited to the second and/or third meetings. The response rate was 100%. Data management and analysis Data were cleaned and entered using EpiData 3.1 software (Lauritsen, 2005); check files were used to minimise illogical answers and errors. Data analysis was done using Stata 12 (StataCorp, 2011). Both descriptive and analytic statistics were used. In the analysis, the frequency and percentage of students who had correct answers for each statement about the concept and elements of PHC were calculated. Mean and standard deviation of knowledge score were estimated and at different levels were calculated. T-tests and chi-squared tests were used to compare the differences between groups. Because the knowledge and awareness scores had a normal distribution, we used multivariate linear regression models to analyse the differences in knowledge and awareness scores between subgroups of students while controlling for other variables. A significance level of α = 0.05 was used.
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Ethical clearance This study was approved by a scientific committee from the Hanoi Medical University. Informed consent was obtained before subjects were asked to fill in the self-administered questionnaire. They were informed that they could decide to participate in this study or to refuse to participate in this study and/or refuse to answer any of the questions. All identifying information about study subjects was kept confidential and only used for research purposes.
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Results Among 400 surveyed students, female students accounted for 45.5% and the mean age was 23.1 ± 0.76 years. Before enrolling in the university, 54.8% of students lived in an urban area and more female students lived in urban areas as compared to male students (59.3% vs. 50.9%). About 56.5% of students receive an allowance or have a monthly income of VND 1.5–2.5 million, and 33% of them received more than VND 2.5 million each month. The proportion of students with a grade point average of 7.0 and higher the previous year was 89.5% (see Table 1). Table 2 presents students’ knowledge about the concept of PHC as well as key elements of PHC in Vietnam. Students understood well that ‘other professions are involved in PHC’ (95.2%) and that ‘PHC is health care at the grass-roots level’ (77.3%). Students also knew that PHC is not to ‘apply modern health technique and methods’ (90%). Less than half of students knew that PHC is ‘health care for the patients at the first access to health system’ (43.3%). With regard to the elements of PHC, the proportion of those students who had correct answers were very high, except for ‘provision of essential drugs’ which was known by 69.5% of surveyed students. In general, female students tended to have better knowledge Table 1. Background information of surveyed students.
Age Place of residence before entering university Current place of residence
Monthly income/ allowance
Grade point average
Male, n = 218
Female, n = 182
Total, N = 400
23.2 ± 0.97 50.9
23.0 ± 0.35 59.3
23.1 ± 0.76 54.8
Rural (%) On campus (%)
49.1 27.5
40.7 42.3
45.2 34.2
Renting house (%) Living with family (%) Less than VND 1.5 million (%)
50.0 22.5 6.4
24.7 33.0 15.4
38.5 27.3 10.5
VND 1.5–2.5 million (%) More than VND 2.5 million (%) 8.0 and above (%) 7.0 to less than 8.0 (%) 5.0 to less than 7.0 (%)
52.3 41.3
61.5 23.1
56.5 33.0
9.6 74.3 16.1
30.2 65.9 3.9
19.0 70.5 10.5
Mean (year) Urban (%)
Global Public Health Table 2. PHC.
Knowledge of final year general medical students about the concept and elements of Male, Female, n = 218 (%) n = 182 (%)
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Correct answers about PHC concept Correct statements successfully recognised by students Health care at the grass-roots levela 72.9 Health care for the patients at the first 43.1 access to health system Other professions involved 94.0 Wrong statements successfully recognised by students Apply modern health technique and 98.2 methods Specialised health care to promote health 74.8 for all Correct answers about elements of PHC Health promotion and education 96.8 Food security and safety 92.7 Supply of safe water and basic sanitation 96.3 Maternal and childcare and family planning 98.2 Expanded immunisation programme 98.6 Prevention of epidemics 94.0 Treatment of common diseases and injuriesa 63.8 Provision of essential drugs 83.9 Management of community health 93.1 Improvement of the grass-roots health 92.7 network
Total, N = 400 (%)
p-value
82.4 43.4
77.3 43.3
0.05
96.7
95.2
>0.05
87.3
90.0
>0.05
81.2
77.7
>0.05
100.0 92.9 95.1 99.5 98.9 97.8 76.4 85.7 95.6 93.4
98.3 92.8 95.8 98.8 98.8 95.8 69.5 84.8 94.3 93.0
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 0.05 >0.05 >0.05
a
Statistically significant difference between female and male students.
of PHC. However, statistically significant differences were found only in the statements ‘PHC is health care at the grass-roots level’ and ‘PHC includes treatment of common diseases and injuries’ (see Table 2). Almost all students (99%) were aware of the importance of PHC. However, only half of them thought that ‘PHC is highly appreciated in Vietnam’ (51.8%) and that ‘You can make your own selection about work approach in providing curative and preventive care’ (54.8%). The percentages of students who were aware of opportunities in PHC to have an important management role and to be able to master their professional activities were lower (33.3% and 37.3%, respectively; Table 3). Table 4 shows that 68.5% of students would enrol in a postgraduate programme, that is specialised medical training. This was significantly higher among female students (74.2% vs. 63.8%). Only 23% of students would apply for a health-related job (both clinical and non-clinical) after graduation. About 85% of students desired to work as a specialised medical doctor, while only 6.5% and 3.7% of them wanted to become a general medical doctor and preventive medicine doctor, respectively. A large proportion of students wanted to work for governmental organisations (84.2%). The percentage of students who would work at communal or district health facilities accounted for only 0.8%. Stratified analyses of choices after graduation by living location of students before entering the university found no difference between those from urban and rural areas (data not shown).
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K. Bao Giang et al. Students’ awareness of the importance and values of PHC.
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1. PHC is very important 2. PHC is highly appreciated in Vietnam 3. You can master your professional activities better than that at other work places 4. You can make your own selection about work approach in providing curative and preventive care 5. Have stable and controllable work time table 6. Have an important management role at work place
Table 4.
Male, n = 218 (%)
Female, n = 182 (%)
Total, N = 400 (%)
98.6 51.8 37.6
99.4 51.6 36.8
99.0 51.8 37.3
52.3
57.7
54.8
45.4 34.4
39.6 31.9
42.8 33.3
Career choices after graduation. Male, n = 218 (%)
Intended activity after graduation Enrol in postgraduate 63.8 programme* Apply for a health-related job 26.6 Apply for another job 1.8 No plan yet 7.8 Field of medicine students intend to work in Specialised MD 85.8 General MD 7.3 Preventive medicine 3.2 Research and training 3.7 Level of health facilities Commune level 0.9 District level 0 Provincial/city level 36.2 Central level 62.8 Type of organisation Governmental organisation 84.0 Private organisation 8.3 NGOs/INGOs 7.7
Female, n = 182 (%)
Total, N = 400 (%)
74.2
68.5
18.7 1.1 6.0
23.0 1.5 7.0
84.1 5.5 4.4 6.0
85.0 6.5 3.7 4.8
0 0.6 39.0 60.4
0.5 0.3 37.5 62.7
84.6 3.8 11.6
84.2 6.3 9.5
*Statistical significance with p < 0.05.
Table 5 shows that mean scores of knowledge about PHC were significantly higher among groups of students who chose health facilities at provincial and central levels to work after graduation. No difference between sexes and other subgroups of students was found. No difference between student subgroups regarding awareness scores was found. Regression models for knowledge scores and awareness scores found similar results (see Table 5). Discussion The results from our study show that the majority of the final year medical students have essential knowledge about the concept and key elements of PHC. Students understood
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Table 5. Mean scores and results from linear regression model for knowledge and awareness of PHC in each social demographic group. Knowledge score
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Variable
Mean ± SD
Coefficient from regression model
Age NA Sex Male 12.8 ± 1.6 Female 13.1 ± 1.5 Place of residence before entering university Urban 13.1 ± 1.5 Rural 12.8 ± 1.7 Choice of place of work after graduation Commune/district level 9.7 ± 3.2 Provincial level 13 ± 1.5* Central level 12.9 ± 1.5* Field of medicine Specialised MD 13 ± 1.5 General MD 12.8 ± 2.2 Public health and 12.9 ± 1.5 preventive medicine Research and training 12.9 ± 1.5 Constant NA p-value for model NA R2 NA
−0.14
Awareness score Mean ± SD
Coefficient from regression model
NA
0.07
1 0.29
3.2 ± 1.5 3.2 ± 1.4
1 −0.01
1 −0.20
3.1 ± 1.4 3.2 ± 1.5
1 0.10
3.3 ± 1.5 3.3 ± 1.4 3.1 ± 1.4
1 0.21 0.11
1 −0.24 0.02
3.2 ± 1.4 3.3 ± 1.1 3.5 ± 1.7
1 0.17 0.42
−0.15
Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam a
a
a
Kim Bao Giang , Hoang Van Minh , Nguyen Van Hien , Nguyen Minh a
a
Ngoc & Nguyen Duc Hinh
Click for updates
a
Hanoi Medical University, Institute for Preventive Medicine and Public Health, Hanoi, Vietnam Published online: 06 Dec 2014.
To cite this article: Kim Bao Giang, Hoang Van Minh, Nguyen Van Hien, Nguyen Minh Ngoc & Nguyen Duc Hinh (2015) Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam, Global Public Health: An International Journal for Research, Policy and Practice, 10:sup1, S120S130, DOI: 10.1080/17441692.2014.986157 To link to this article: http://dx.doi.org/10.1080/17441692.2014.986157
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Global Public Health, 2015 Vol. 10, No. S1, S120–S130, http://dx.doi.org/10.1080/17441692.2014.986157
Knowledge of primary health care and career choice at primary health care settings among final year medical students – Challenges to human resources for health in Vietnam Kim Bao Giang*, Hoang Van Minh, Nguyen Van Hien, Nguyen Minh Ngoc and Nguyen Duc Hinh Hanoi Medical University, Institute for Preventive Medicine and Public Health, Hanoi, Vietnam
Downloaded by [ECU Libraries] at 07:34 22 April 2015
(Received 6 September 2013; accepted 26 September 2014) There is a shortage of medical doctors in primary health care (PHC) settings in Vietnam. Evidence about the knowledge medical students have about PHC and their career decision-making is important for making policy in human resources for health. The objective of this study was to analyse knowledge and attitudes about PHC among medical students in their final year and their choice to work in PHC after graduation. A cross-sectional study was conducted among 400 final year general medical students from Hanoi Medical University. Self-administered interviews were conducted. Key variables were knowledge, awareness of the importance of PHC and PHC career choices. Descriptive and analytic statistics were performed. Students had essential knowledge of the concept and elements of PHC and were well aware of its importance. However, only one-third to one half of them valued PHC with regard to their professional development or management opportunities. Less than 1% of students would work at commune or district health facilities after graduation. This study evidences challenges related to increasing the number of medical doctors working in PHC settings. Immediate and effective interventions are needed to make PHC settings more attractive and to encourage medical graduates to start and continue a career in PHC. Keywords: human resources; career choice; primary health care; Vietnam; medical doctors
Introduction Primary health care (PHC) has been a central focus of health systems. The role of PHC is to provide essential health care services, increase community accessibility to health care services and organise health care services based on peoples’ needs. PHC has been the benchmark for most countries’ discourse on health precisely because the PHC movement tries to provide rational, evidence-based and anticipatory responses to health demand and social expectations. The main principles of PHC as identified in Alma Ata Declaration are equity in distribution of health care, health promotion and disease prevention, community participation, appropriate health technology and a multisectoral approach (WHO, 1978). In Vietnam, health staff at the commune health station are considered as the PHC team. This PHC team includes a medical doctor or medical doctor assistant, nurses and/or midwife, secondary pharmacist and supportive staff (Ministry of Labour and Invalid *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Downloaded by [ECU Libraries] at 07:34 22 April 2015
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Social Affaire, Ministry of Finance, & Ministry of Health, 1995). The PHC team is very important because the team has to organise and provide both curative and preventive services for people with common health needs in the community. Health staff require certain qualifications to work in the PHC team; these qualifications include good knowledge, attitude and competence. Within the PHC team in the commune health station, medical doctors often play a key role in providing curative care and in managing all activities of the station. For this reason, they have a substantial impact on the performance of PHC activities. In Vietnam, PHC is among the important strategies comprising the national health plan. The government emphasises the development of an effective and safe health care system which values and seeks to achieve health for all. In recent years, Vietnam’s government has emphasised essential health care which brings health services closer to all inhabitants in order to pursue the human values of ‘social justice, and the right to better health for all, participation and solidarity’ (Prime Minister, 2013). Although the number of students enrolled in and graduated from medical universities increased significantly in the past 10 years, from 6360 in 2004 to 16,900 in 2011, the proportion of communal health stations that have a medical doctor increased less than 3% over the three-year period from 2008 to 2011, from 65% to 67.7% (Ministry of Health & Hanoi School of Public Health, 2012). The quantity of university level medical doctors working in community health stations accounts for under a third of the total number of commune health stations in Vietnam. Furthermore, Vietnam has experienced the movement of physicians from health facilities at lower levels to the higher ones, creating a poor distribution of human resources by level and region. Low income, poor working conditions and lack of opportunities for career development are the reasons for the inappropriate distribution of health staff, especially medical doctors, at different levels, regions and areas of health care services (Ministry of Health & Health Partnership Group, 2009). Knowledge and awareness among medical students and graduates about the importance of PHC, as well as their responsibilities to work at the primary care setting, are essential to encourage them to make their career choice in the PHC setting. It has been several years since eight medical universities in Vietnam implemented a communityoriented curriculum for medical students (Hoat & Wright, 2001). According to the training curriculum for medical students, PHC is introduced and integrated in some modules (Ministry of Education and Training, 2012). However, how students and graduates perceive PHC and its relation to their career choices was not known. This study aimed to analyse final year medical students’ knowledge and attitudes about PHC, and how this influenced their decisions to work in PHC settings after graduation. Methods Setting This study was conducted in the Hanoi Medical University in Vietnam in 2012. Established in 1902, Hanoi Medical University is the oldest university in Vietnam and a leading medical university in Vietnam. Each year, the university recruits around 1000 undergraduate students and 1500 postgraduate students. With regard to undergraduate training, the university trains several medical-related categories, such as general medical doctor, doctor in odontology and stomatology, doctor in traditional medicine, doctor in preventive medicine and bachelor of public health, nursing and medical technology. The
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training curriculum for all undergraduate students is designed to be community-oriented; upon graduation, students are expected to have essential PHC knowledge and skills and be ready to work at different health facilities, including the PHC setting. Subjects All study subjects were final year general medical students of Hanoi Medical University. Study design This is a cross-sectional study using a quantitative approach.
Downloaded by [ECU Libraries] at 07:34 22 April 2015
Sample size and sampling Sample size was estimated using the World Health Organization (WHO) formula for estimating the proportion of students who have essential knowledge of PHC as well as those aware of the importance of PHC in the health system. We assumed that the proportion of students who had essential knowledge of PHC was 50%; this was estimated based on a pilot study among 50 students before the survey. We used a level of significance of 5% and a relative precision of 10%. The required sample size was 385. A final sample of 400 students was selected to allow for non-response. Simple random sampling was employed to select 400 final year students from the list of all final year students. Main variables There were three main groups of variables used in this study; these were as follows: (1) (2)
Background information of study subjects (age, sex, place of birth, current place of residence and monthly income/allowance). Knowledge of and attitude towards PHC. This was divided into two areas: . Knowledge of PHC: ○ Knowledge about the concept of PHC was assessed by 5 statements about the key concepts of PHC, in which three items were true statements (Health care at the grass-roots level; Health care for the patients at the first access to health system; Other professions involved) and two items were false statements (Apply modern health technique and methods; Special health care to promote health for all). ○ Knowledge about 10 elements of PHC in Vietnam, which included (1) Health education, (2) Expanded immunisation, (3) Maternal and child health care and family planning, (4) Nutrition, food safety and security, (5) Provision of essential drugs, (6) Treatment of common diseases and injuries, (7) Clean water, hygiene and sanitation, (8) Prevention of local epidemics, (9) Management of community health and (10) Enhancement of grass-roots health care network. ○ Knowledge score: The number of correct answers regarding the concept and elements of PHC was counted, yielding a ‘knowledge score’. There were 15 statements about knowledge of PHC; thus knowledge scores could range from 0 to 15.
Global Public Health
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. Awareness of values of PHC: ○ Six statements regarding the value and importance of PHC were introduced, and participants were asked whether they agree or not with the statement. ○ Awareness score: Each item was scored as 0 or 1. A score of 1 meant that the participant agreed with the statement. The total ‘awareness score’ could thus range from 0 to 6. Career choice to work at the PHC settings: . This included questions on (1) fields of health science that students planned to be involved in after graduation, (2) level of health facilities that students wanted to work in after graduation and (3) types of organisations students wanted to work after graduation.
Tools A self-administered questionnaire was developed by the research team which focused on three main sections of contents: (1) background information of participants, (2) knowledge of and attitude towards PHC and (3) career choice after graduation. Under each question about knowledge of PHC, several true and false statements were included. Students were requested to select whether each statement was true or false. The questionnaire was tested and revised to make sure the questions were understandable and appropriate to the participants. Data collection process Based on the training time tables of students, a data collection schedule was developed to make sure that all groups of students could participate at a convenient time. All selected students were invited to a classroom in order to perform the self-administered questionnaires with guidance from research team members. The purpose of this study and the right to refuse participation in this study were explained to all students. Research team members also explained each question in turn to help students understand the questions. The classrooms were large enough to give students private space and to ensure confidentiality. Selected students were divided into six groups, and data collection took place over a three-week period. For those students who could not come at the time stated in the invitation, they were invited to the second and/or third meetings. The response rate was 100%. Data management and analysis Data were cleaned and entered using EpiData 3.1 software (Lauritsen, 2005); check files were used to minimise illogical answers and errors. Data analysis was done using Stata 12 (StataCorp, 2011). Both descriptive and analytic statistics were used. In the analysis, the frequency and percentage of students who had correct answers for each statement about the concept and elements of PHC were calculated. Mean and standard deviation of knowledge score were estimated and at different levels were calculated. T-tests and chi-squared tests were used to compare the differences between groups. Because the knowledge and awareness scores had a normal distribution, we used multivariate linear regression models to analyse the differences in knowledge and awareness scores between subgroups of students while controlling for other variables. A significance level of α = 0.05 was used.
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Ethical clearance This study was approved by a scientific committee from the Hanoi Medical University. Informed consent was obtained before subjects were asked to fill in the self-administered questionnaire. They were informed that they could decide to participate in this study or to refuse to participate in this study and/or refuse to answer any of the questions. All identifying information about study subjects was kept confidential and only used for research purposes.
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Results Among 400 surveyed students, female students accounted for 45.5% and the mean age was 23.1 ± 0.76 years. Before enrolling in the university, 54.8% of students lived in an urban area and more female students lived in urban areas as compared to male students (59.3% vs. 50.9%). About 56.5% of students receive an allowance or have a monthly income of VND 1.5–2.5 million, and 33% of them received more than VND 2.5 million each month. The proportion of students with a grade point average of 7.0 and higher the previous year was 89.5% (see Table 1). Table 2 presents students’ knowledge about the concept of PHC as well as key elements of PHC in Vietnam. Students understood well that ‘other professions are involved in PHC’ (95.2%) and that ‘PHC is health care at the grass-roots level’ (77.3%). Students also knew that PHC is not to ‘apply modern health technique and methods’ (90%). Less than half of students knew that PHC is ‘health care for the patients at the first access to health system’ (43.3%). With regard to the elements of PHC, the proportion of those students who had correct answers were very high, except for ‘provision of essential drugs’ which was known by 69.5% of surveyed students. In general, female students tended to have better knowledge Table 1. Background information of surveyed students.
Age Place of residence before entering university Current place of residence
Monthly income/ allowance
Grade point average
Male, n = 218
Female, n = 182
Total, N = 400
23.2 ± 0.97 50.9
23.0 ± 0.35 59.3
23.1 ± 0.76 54.8
Rural (%) On campus (%)
49.1 27.5
40.7 42.3
45.2 34.2
Renting house (%) Living with family (%) Less than VND 1.5 million (%)
50.0 22.5 6.4
24.7 33.0 15.4
38.5 27.3 10.5
VND 1.5–2.5 million (%) More than VND 2.5 million (%) 8.0 and above (%) 7.0 to less than 8.0 (%) 5.0 to less than 7.0 (%)
52.3 41.3
61.5 23.1
56.5 33.0
9.6 74.3 16.1
30.2 65.9 3.9
19.0 70.5 10.5
Mean (year) Urban (%)
Global Public Health Table 2. PHC.
Knowledge of final year general medical students about the concept and elements of Male, Female, n = 218 (%) n = 182 (%)
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Correct answers about PHC concept Correct statements successfully recognised by students Health care at the grass-roots levela 72.9 Health care for the patients at the first 43.1 access to health system Other professions involved 94.0 Wrong statements successfully recognised by students Apply modern health technique and 98.2 methods Specialised health care to promote health 74.8 for all Correct answers about elements of PHC Health promotion and education 96.8 Food security and safety 92.7 Supply of safe water and basic sanitation 96.3 Maternal and childcare and family planning 98.2 Expanded immunisation programme 98.6 Prevention of epidemics 94.0 Treatment of common diseases and injuriesa 63.8 Provision of essential drugs 83.9 Management of community health 93.1 Improvement of the grass-roots health 92.7 network
Total, N = 400 (%)
p-value
82.4 43.4
77.3 43.3
0.05
96.7
95.2
>0.05
87.3
90.0
>0.05
81.2
77.7
>0.05
100.0 92.9 95.1 99.5 98.9 97.8 76.4 85.7 95.6 93.4
98.3 92.8 95.8 98.8 98.8 95.8 69.5 84.8 94.3 93.0
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 0.05 >0.05 >0.05
a
Statistically significant difference between female and male students.
of PHC. However, statistically significant differences were found only in the statements ‘PHC is health care at the grass-roots level’ and ‘PHC includes treatment of common diseases and injuries’ (see Table 2). Almost all students (99%) were aware of the importance of PHC. However, only half of them thought that ‘PHC is highly appreciated in Vietnam’ (51.8%) and that ‘You can make your own selection about work approach in providing curative and preventive care’ (54.8%). The percentages of students who were aware of opportunities in PHC to have an important management role and to be able to master their professional activities were lower (33.3% and 37.3%, respectively; Table 3). Table 4 shows that 68.5% of students would enrol in a postgraduate programme, that is specialised medical training. This was significantly higher among female students (74.2% vs. 63.8%). Only 23% of students would apply for a health-related job (both clinical and non-clinical) after graduation. About 85% of students desired to work as a specialised medical doctor, while only 6.5% and 3.7% of them wanted to become a general medical doctor and preventive medicine doctor, respectively. A large proportion of students wanted to work for governmental organisations (84.2%). The percentage of students who would work at communal or district health facilities accounted for only 0.8%. Stratified analyses of choices after graduation by living location of students before entering the university found no difference between those from urban and rural areas (data not shown).
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K. Bao Giang et al. Students’ awareness of the importance and values of PHC.
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1. PHC is very important 2. PHC is highly appreciated in Vietnam 3. You can master your professional activities better than that at other work places 4. You can make your own selection about work approach in providing curative and preventive care 5. Have stable and controllable work time table 6. Have an important management role at work place
Table 4.
Male, n = 218 (%)
Female, n = 182 (%)
Total, N = 400 (%)
98.6 51.8 37.6
99.4 51.6 36.8
99.0 51.8 37.3
52.3
57.7
54.8
45.4 34.4
39.6 31.9
42.8 33.3
Career choices after graduation. Male, n = 218 (%)
Intended activity after graduation Enrol in postgraduate 63.8 programme* Apply for a health-related job 26.6 Apply for another job 1.8 No plan yet 7.8 Field of medicine students intend to work in Specialised MD 85.8 General MD 7.3 Preventive medicine 3.2 Research and training 3.7 Level of health facilities Commune level 0.9 District level 0 Provincial/city level 36.2 Central level 62.8 Type of organisation Governmental organisation 84.0 Private organisation 8.3 NGOs/INGOs 7.7
Female, n = 182 (%)
Total, N = 400 (%)
74.2
68.5
18.7 1.1 6.0
23.0 1.5 7.0
84.1 5.5 4.4 6.0
85.0 6.5 3.7 4.8
0 0.6 39.0 60.4
0.5 0.3 37.5 62.7
84.6 3.8 11.6
84.2 6.3 9.5
*Statistical significance with p < 0.05.
Table 5 shows that mean scores of knowledge about PHC were significantly higher among groups of students who chose health facilities at provincial and central levels to work after graduation. No difference between sexes and other subgroups of students was found. No difference between student subgroups regarding awareness scores was found. Regression models for knowledge scores and awareness scores found similar results (see Table 5). Discussion The results from our study show that the majority of the final year medical students have essential knowledge about the concept and key elements of PHC. Students understood
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Table 5. Mean scores and results from linear regression model for knowledge and awareness of PHC in each social demographic group. Knowledge score
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Variable
Mean ± SD
Coefficient from regression model
Age NA Sex Male 12.8 ± 1.6 Female 13.1 ± 1.5 Place of residence before entering university Urban 13.1 ± 1.5 Rural 12.8 ± 1.7 Choice of place of work after graduation Commune/district level 9.7 ± 3.2 Provincial level 13 ± 1.5* Central level 12.9 ± 1.5* Field of medicine Specialised MD 13 ± 1.5 General MD 12.8 ± 2.2 Public health and 12.9 ± 1.5 preventive medicine Research and training 12.9 ± 1.5 Constant NA p-value for model NA R2 NA
−0.14
Awareness score Mean ± SD
Coefficient from regression model
NA
0.07
1 0.29
3.2 ± 1.5 3.2 ± 1.4
1 −0.01
1 −0.20
3.1 ± 1.4 3.2 ± 1.5
1 0.10
3.3 ± 1.5 3.3 ± 1.4 3.1 ± 1.4
1 0.21 0.11
1 −0.24 0.02
3.2 ± 1.4 3.3 ± 1.1 3.5 ± 1.7
1 0.17 0.42
−0.15
