Primary health care (PHC) is considered as a whole-of-society approach to health and well-being of individuals, families and communities based on their needs and preferences. The concept of primary health care varies from; provision of ambulatory or first-level of personal health care services to a set of priority health interventions for low-income populations. However primary health care has been an essential component of human development, focusing on the economic, social and political aspects. 

Trained and competent human resources are essential for an effective primary health care. Unfortunately, there is huge shortage of human resources in our country and on the top of this; their hesitation and low preference to work in remote and rural areas has worsen things for delivering effective primary health care [1-2]. Limited resources tend to give rise to the practices of quackery and use of alternative forms of medicine which are mostly primitive and far from evidence-based medicine [3]. 

To combat these problems the Ministry of Health and Family welfare, Government of India, came up with the idea of increasing mid level health care providers and cabinet approved the introduction of 3 and ½ year bachelor of science in Community Medicine course in November 2013 [4].

However, the uptake of this course has been slow and after many rationalizations, a bridge program in community Health was devised. Already qualified Ayurvedic doctors or BSc Nurses (which are already available in the system) are to be trained in public health and primary health care through suitably designed bridge program. These qualified human resources then can function as mid-level health care provider and are called as Community Health officers. In Himachal Pradesh the second batch of this bridge program has been introduced in September 2020 in seven designated institutes through Indira Gandhi National Open University (IGNOU). All these aspirants have minimum of 4 year training as BSc Nursing Student in health care and some may even have much more experience after taking jobs in the same field. They are supposed to be having some baseline knowledge of primary health care and may have developed a certain attitude toward primary health care.

So, in order to assess their understanding of primary health care, a cross-sectional study has been planned in the Zonal Hospital Dharamshala, Himachal Pradesh, India. We tried to ascertain their baseline knowledge of and attitude towards primary health care approach in health care delivery system. Observations from this study may help the training providers to remodel their approach accordingly and may also help in monitoring their progress after the completion of course.

A cross-sectional study was done in IGNOU accredited institute for Bridge Program in Community Health i.e Zonal Hospital, Dharamshala. All the willing students who were enrolled for the bridge course were included in study. A semi-structured, self-administered proforma was designed with the help of faculty of Community Medicine which is loosely inspired from Primary Health Care Questionnaire (PHCQ); an instrument developed and validated by Chalmers et al. [5] 1997. It has 30 questions (with True or False response) to record information on the knowledge of primary health care, its principles, components and utility in current health care system. In order to assess their attitude a four-point likert scale including 30 different items, has been used where each item has been rated from strongly agree (4) to strongly disagree (1). For ease of interpretation and comparison, the knowledge and attitude scores were converted to percentages (0–100%). Higher scores indicate more positive attitudes toward Primary health care. All the students were provided with these proforma at their introductory class. They were explained the objective of filling these proformas and its further implications. After completion of proforma, they were imparted orientation towards Bridge providing primary health care.

Data was transferred to MS Excel Spread sheet for further processing and analysis. Descriptive statistics (Proportions, Means and standard deviations) were calculated and difference in knowledge and attitudes score were determined between different sub-groups using student t-test or ANOVA. P-value less than 0.05 was considered statistically significant.

A total of 60 participants were studied. All participants were female, majority (65%) being in the age group of 26-30 years. 80 % (n-48) participants belonged to rural locality and 71.7% of them had prior job experience of less than five years in health field (Table 1).       

Table 1: Demographic profile of study participants (n=60)

Table 2:  Knowledge score among study participants (n=60)

Table 3:  Attitude score among study participants (n=60)

Mean knowledge score (as calculated in the scale of 0-100%) was found to be 62.7% with Standard deviation of 11.2%. Mean knowledge score among younger aspirants (20-25 Years) was observed to be statistically higher than both of other comparison groups (p-value 0.03, 0.07 as determined by Post hoc ANOVA test (Table 2).

Mean attitude score calculated (in the scale of 0-100%) was 68.6% with a standard deviation of 9.4%. Mean attitude score were comparable in all age groups, localities, institutes and experience groups without any statistically significant difference (p-value >0.05.) (Table 3).

Sixty (60) participants have been studied from an IGNOU accredited institute for the bridge program in Community Health in Himachal Pradesh. All participants were females, majority being in the age group of 26-30 years with rural background and job experience of less than five years. Aspirants in current study were quite young (mean age 27.2+/-4.65 years), who may be seeing this program as a better career opportunity. Investing on existing young potential to strengthen the depleted human resource for health in India is a welcome step and is in accordance to WHO global strategy for human resource in health by 2030 [6]. 

Mean knowledge score (as calculated in the scale of 0-100%) was found to be 62.7%+/-11.2%. In a similar study done in Australia [7] among nursing student mean knowledge score was found to be 69.2% +/- 9.4% which is slightly better than what we observed in current study. Still a baseline score above 60% has to be considered positive with the fact that they are going to undergo an intensive training program for next six month to improve their understanding.

Mean knowledge score among younger aspirants (20-25 Years) was higher as they are fresh from their studies and may have retained theoretically aspect better than older counterparts. Overall, an average score above 60% is encouraging and important considering the vision of policy makers to provide primary health care through community health officers. Mean attitude score calculated was 68.6%+/-9.4%. Mean score observed by Sandra Mackey et al was 70.4%+/-8.1% which is almost similar to our finding. High mean score represents positive attitude of aspirants towards primary health care which has be approached and handled carefully in order to expect better response from them as a community health officer. High attitude score in all age groups, localities, institutes and experience groups may be reflecting their present enthusiasm to play the role of CHO in primary health care system. A sustained encouragement needs to be maintained for keeping their inclination toward primary health care approach especially when they are to be working in remote and rural areas.

If we carefully observe their best knowledge response these are basically theoretical knowledge (accessibility to health care is a basic concept of PHC, WHO considers PHC to be the best way to achieve Health for All, Health promotion is a key in PHC and nurses have role in prevention and promotion). More complex elements like role of PHC in palliative and rehabilitative care, centralization or de-centralization of health services, mid-level health-care personnel replacing health professionals in PHC got the   worst    knowledge    response. These are 

somewhat expected responses and with more understanding of PHC approach in six-month program are supposed to be getting corrected.

Knowledge of aspirants regarding primary health care was found to be good. There is still a lot of scope for the improvement in their knowledge specially in understanding some of the complex elements of primary health care like role in palliative or rehabilitation health care, decentralization of health services and synergistic role of mid level workers and health professionals. Similarly attitude towards primary health care was found to be on the positive side which has to be sustained throughout the program and thereafter also by regular encouragement and skill development.

1. Sharma, D.C. "India still struggles with rural doctor shortages." Lancet, vol. 386, 2015, pp. 2381–2.

2. Sinha, P. and Sigamani, P. "Key challenges of human resources for health in India." Global Journal of Medicine and Public Health, vol. 5, no. 4, 2016, pp. 1–10.

3. Watts, K. "Quackery: an epidemic in India?" Accessed on 15 November 2020, https://www.healthissuesindia.com/2019/10 /04/quackery-an-epidemic-in-india.

4. NHSRC India. Bridge programmes in community health for nurses and for Ayurveda practitioners. Delhi, 2019. Accessed on 15 November 2020, http://nhsrcindia.org/sites/default/files/ Revisedguidancenoteonbridgeprogrammesinommunityhealth-may-17.

5. Chalmers, K. "Development and testing of the Primary Health Care Questionnaire: results with students and faculty in diploma and degree nursing programs." Canadian Journal of Nursing Research, vol. 29, 1997, pp. 79–96.

6. World Health Organization. Health workforce 2030: a global strategy on human resources for health. Geneva, 2019. Accessed in November 2019, <http://www.who.int/hrh/document s/strategy_brochure9-20-14 pdf?ua=1>.

7. Mackey, S. et al "Australian student nurse's knowledge of and attitudes toward primary health care: a cross-sectional study." Nurse Education Today, vol. 60, 2017, pp. 127–32.