Assessment of the Reasons for Specialization in Public Health among Students of All India Institute of Hygiene & Public Health, Kolkata

Introduction:

Public Health as defined classically by CEA Winslow ^[1] refers to "The science and art of disease prevention, prolonging life, and promoting health and well-being through organized community effort for the sanitation of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health.(1920)" is well known to all of us. World Health Organization (WHO) also similarly defined^[2] it as "All organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole.” However, in practice, the so called "Organized Community Effort" seems to be a myth in Indian situation. Probably, the basic reason is that the effect of improvement of public health is not immediately visible as those of clinical problems tackled by "Doctors." The same also applies to other social determinants of health like income, education, occupation etc. which have vast role in public health. In India or similar developing countries, people and policy makers very often organize for political power with possible immediate gains but not for public health issues like sanitation, safe water, immunization education etc. Till now, the field practice of public health basically lies in the hands of the "Medical Graduates" posted in peripheral public health institutions besides a few non- govt. organizations (NGOs) working there. For obvious reasons of non/minimal profit, the private sector has negligible presence here. The situation is probably not going to be changed in the near future.

Medical Education in India has traditionally been having a clinical/curative orientation as part of British legacy. The subject of public health has been variously named from "Hygiene" to "Preventive & Social Medicine" to "Community Medicine" in the recent past. Whatever be the name, the public health component was a rudimentary one in undergraduate medical curriculum all over India as part of the clinical/curative mind set not only of the planners and policy makers but also for the people in general. It is only since the last revision of curriculum in 1997^[3], the subject is given little more importance at par with the adoption of primary health care strategy since eighties and nineties. There were very few postgraduate (PG) seats in public health compared to clinical subjects until recently when National Health Policy 2002^[4] announced that among all newly created PG medical seats, 25% will go to public health disciplines with the noble idea that more public health experts will change the public health scenario of India by leading, organizing and managing the public health institutions as it is often said that India is a country full of resources with poor management.

But what about the medical graduates? Do they really feel and agree with the necessity as thought by our policy makers? Do they believe that specialization in public health disciplines is as important as to clinical disciplines? Does specialization in public health disciplines will help them to build a good and respectable career? Do the people in general recognize and respect the public health specialists similar to the clinicians? The answers to all these questions in general still remain on the negative although no such authentic study is readily available. The common perception is that medical graduates opt for public health disciplines in their PG curriculum only after being sure that they shall not be eligible for clinical subjects usually at a higher age often sponsored from their respective employers for organizational necessities. Moreover, in Indian situation, specialization in public health requires a lot of "Internal Motivation" as compared to clinical subjects where there are a lot of obvious "External Motivators" like money, respect, fame etc. which public health specialist usually do not have till now.

In spite of these, presently there are about 475 medical graduates doing specialization in public health subjects each year in India.^[5] Their motivation is not known to us. Any motivational factor other than desirable ones like "Loves the subject" or "Good professional demand of the subject" is definitely not going to fulfill the objectives of our policy makers to improve public health scenario of India by them. With this background, a study was done among newly admitted students of All India Institute of Hygiene & Public Health,(AIIH&PH) Kolkata with the objective of identifying the reason(s) for joining Postgraduate Public Health Courses.

Materials & Methods:

It was a cross-sectional, observational institution based study done in AIIH&PH, Kolkata. It is the premier public health institute of India running since 1932 with many public health speciality courses both for medical and non-medical graduates. Till the beginning of 21^st century, it was the only institute in West Bengal having opportunities for specialization in public health subjects. The important courses of AIIH&PH for medical graduates in 2013 are MD (Community Medicine) with 11 seats and DPH (Diploma in Public Health) with 70 seats. Two other courses e.g. DMCW (Diploma in Maternity & Child Welfare) and DIH (Diploma in Industrial Health) for medical graduates were taught till last year but for recognition related issues, no students were admitted in these courses in 2013.

The study was conducted among all 63 newly admitted students in the institute in 2013 by predesigned and pretested self-administered anonymous questionnaire after prior briefing and informed consent with full right not to respond. Variables included in the study were age, sex, religion, caste, residence (rural / urban) and state of domicile (West Bengal or outside), socio-economic status (determined by per capita family income: Prasad scale, inflation updated to 2013),^[6] education of the parents, occupation of the parents (whether doctor or not), years since completion of MBBS, number of attempts to pass MBBS examinations, sponsorship of students (open/sponsored), reasons for joining public health PG courses (primary reason and others), desire for "other PG courses"(whether leave the course if gets PG chance in non-public health subjects). Reasons like "likes/loves the subject" and "good professional demand of the subject" were considered as desirable reason in this study. Data collected were analyzed by statistical procedures like tabulation, proportion (percentage), mean/standard deviation etc. Help of data analysis softwares were taken e.g. Program for Epidemiologists (PEPI), version 4.0, windows compatible and Statistical package for Social Sciences (SPSS) version 17.0 windows compatible.

Results:

In the year 2013 (for the session 2013-15/16), total students admitted in AIIH&PH, Kolkata were 63; MD (Community Medicine) 10 and DPH 53. Out of this, 42 students responded for this study with a non-responses rate of 33.3%. For certain responses, even less number of students responded e.g. 32 students for income and 39 students for leaving the course after getting chance in non-public health diploma/degree. Majority of the students (27, 64.3%) belong to 20-29 years age group. The mean age of the students was 30.8 years, higher than students having post-graduations in other disciplines (about 25-26 yrs.) without any major loss of years in between. This was little higher for the male compared to female (31.0 yrs. vs 21.8 yrs.) and DPH students compared to MD (30.9 yrs. vs 28.7 yrs.) but considerably higher for the sponsored students (39.8 yrs. vs. 27.5 yrs.) than non sponsored students.

Regarding socio-demographic characteristics the majority of the students are Unmarried (59.5%), Hindu (85.6%), belonging to General Caste (59.5%), residing in Urban area (64.3%) in West Bengal (about 62%) but good number of students are married (about 40%), belonging to rural areas (35.7%), residing outside West Bengal (38%). Education of the parents show that majority of the fathers are Graduate & PG (76%) but for mothers the majority had education within Class XII (57%) with Graduate & PG being 35.7%. Parents as doctors are rarity esp. for mothers (fathers 14.3% and mothers 4.8%). Income wise, majority (78.1%) belong to Social Class I with none belonging to Social Class V.

The academic characteristics of the students show that Non- MBBS graduation before MBBS is a rarity (2.4%) as also special performance during MBBS course (4.8%). Just 50% students have passed all MBBS examinations in first attempt. Majority of students (76.2%) are Non-sponsored and joined the course within 1-2 years of internship (40.5%) although about 1/3^d students joined the course 5 or more years after internship. Only 50% students have done housestaffship.

The reasons for doing post graduations in public health disciplines are depicted in Table 1. The major primary reasons are to add some qualification(s) after MBBS (31%) and no chance in other subjects (21.3%). These are not desirable reasons. Only 28.6% students had desirable reasons e.g. loves/likes the subject and good professional demand which is more for MD (55.5%) compared to DPH students(21.2%) & Non-sponsored students (34.4%) compared to sponsored student(10.0%) Almost same picture prevails when data analysed for choices (multiple choices).

The unfavourable situation is better reflected in their desire to leave the course after getting chance for PG in other non-public health subjects. Even chance in non-public health DIPLOMA will take away 51.3% students, more for diploma course students (60%) than MD (22.2%) student. For non-public health DEGREES, it was about 90.0%,93.3% for diploma course students and 77.8% for MD students!!

Discussion:

Present study revealed the reasons for doing specialization (post-graduation) in public health subjects as stated by the newly admitted students in 2013 of AIIH&PH, Kolkata. Results show that major primary reasons are to add some qualification(s) after MBBS (31%) and no chance in other subjects (21.3%). These are not desirable reasons. Only 28.6% students had desirable reasons e.g. loves/likes the subject and good professional demand which is more for MD (55.5%) than DPH student (21.2%) & Non-sponsored students (34.4%) compared to non sponsored students (. Almost same picture prevails when data analysed for choices (multiple choices). Because of non-availability of any similar study in Indian setting(s), these figures could not be compared.

However, these figures are not showing any change of doctors' attitude towards public health as subject as well as a profession. Therefore, the basic philosophy of our planners to improve our public health services by medical public health experts only remain questionable. Till now, doctors in general and possibly the community also believe in clinical and curative aspect of medicine and doctors resort to public health specialities only when clinical avenues are closed or appeared impossible. With this philosophy, one should not expect much commitment and dedication from our public health experts with remote chance of improvement of public health services by them.

The major limitation of this study is that it was done in one institution for one year only which may not be representative of the whole situation. However, Present author decided to continue the study over the years to find any change in the trend in this regard. Another limitation is that the responses are completely subjective with about 33.3% non-response which may not reflect the true picture esp. regarding sensitive issues like income, occupation etc.

Conclusion & recommendations :

More and more similar studies need to be conducted in different parts of India to know the country-wise situation. A serious thinking need to be exercised by the planners and policy makers with more insight in this regard so as to improve the situation.