Perception of medical student regarding factors influencing the decision to serve in rural health services of Uttarakhand

Background: Many countries in the developing world are plagued with challenges of inadequate and inequitable distribution of the health workforce. The Paucity of qualified health workers in rural areas is a critical challenge for India’s Health Sector. In view of the continuing challenges of Physician shortage in India, an understanding of our medical students’ attitude and perception towards rural medical practices is essential for appropriate planning of human resources. Objective: To assess the attitude and perception of medical students towards rural medical practices and identified the associated factors in order to fill these information gaps. Materials and Methods: A descriptive cross-sectional study was conducted among 282 MBBS students of the Government Medical College in Uttarakhand state, India. First, Third and Fifth semesters MBBS students were the study participants. Participants were enrolled by convenient sampling method. Ethical approval was sought and obtained from the Institutional Ethics Committee. Data was entered and analyzed with SPSS Software Version 22. Result: Among 282 MBBS Students, 68% females showed willingness to work in rural area compared to 57.6% of males. All the reasons for willingness as well as non-willingness to work in rural areas of Uttarakhand had statistically significant difference. Conclusion: Medical student’s attitude and perception to work in rural health services need much improvement towards positive side by intervention and implementation by joint collaborative efforts of Medical Education Department, Health department and State Government. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
Many countries in the developing world are plagued with challenges of inadequate and inequitable distribution of the health workforce. 1 Manpower for health services has been described as "the heart of the health system in our country". 2 The Paucity of qualified health workers in rural areas is a critical challenge for India's Health Sector. As on 31 st March 2018, 5.9% of the PHCs are without a doctor. For Allopathic doctors at PHC, there is a shortfall of 14.3% of the total requirement for existing infrastructure as compared to manpower in position. 3 Uttarakhand is mainly mountainous (86%) and 65% of its area is covered by forest. 4 There is a presence of only 31 doctors per 1 lakh population which is very low as compared to WHO standard of 100 per 1 lakh population. 4 As on 31 st March 2018, there was deficiency of 184 Medical officers and 239 specialist doctors in Uttarakhand. 3 In view of the continuing challenges of Physician shortage in India, an understanding of our medical students' attitude and perception towards rural medical practices is essential for appropriate planning of human resources. The present study was done to assess their attitude and perception towards rural medical practices and identified the associated factors in order to fill these information gaps.

Materials and Methods
A descriptive cross-sectional study was conducted among 282 MBBS students of the Government Medical College in Uttarakhand state, India. First, Third and Fifth semesters MBBS students were the study participants. Participants were enrolled by convenient sampling method. Data collection was carried out for a period of 3 months (October to December 2018). Before framing the questions, the need for the study was discussed with the student fraternity and their opinions were considered. Questionnaire items were developed after consulting the experts and validated appropriately. Each question was framed in such a way that the responses were graded from most appropriate to least appropriate. Ethical approval was sought and obtained from the Institutional Ethics Committee. Data was entered and analyzed with SPSS Software Version 22, International Business Machines (IBM). Individual Component wise analysis was done using tables with Percentages. Proportions were computed for Categorical variables and p value < 0.05 was considered to be significant.

Results
Majority of Students (164/282) were in the age group of 20-22 years and out of them 64.0% showed interest to work in rural area. Among Participants, 68% females showed willingness to work in rural area compared to 57.6% of males. 69.3% first Semester Medical Students were inclined towards service in rural area as compared to Fifth Semester Students (55.9%). About four-fifth of study Participants belonging to rural areas showed interest to join rural health services compared to three-fifth belonging to Urban Area. About two-third of medical students who have opted for rural health service bond during admission were willing to work in rural areas as compared to 28.6% of those who have not opted for it. 69.1% participants whose parents working place was rural had inclination for working in rural health as shown in Table 1.
All the reasons for willingness to work in rural areas of Uttarakhand, i.e. will do private practice and earn more, join Government health facility and secure job, own house and settle, contribute for betterment of State health system, compulsory bond service, job satisfaction, build confidence as a clinician and supportive people in rural areas had statistically significant difference ( Table 2). Table 3 shows the reasons and their association for non-willingness to work in rural areas of Uttarakhand had statistically significant difference. The reasons were limited infrastructure in health facilities, delay in post-graduation, limited professional growth, less salary, lack of recreational facilities, connectivity with cities not good and isolation from family, relatives and medical colleagues.
Statistically significant difference was found between participants response for improvement in rural health services by regular salary and incentives, reservation in PG seat for doctors serving in rural area, improvement in hospital and residential facilities, posting in rural health services to 2 years and compulsory after MBBS completion for every Indian Medical Graduate. No difference was observed for compulsory posting in rural health services for MBBS Graduates who are bonded (Table 4).

Discussion
At present, our Government is facing an uphill task of providing adequate, trained health workforce, especially trained doctors for rural health care delivery system.
In this study, the maximum number of participants were in the age group of 20-22 years and out of them 64% showed their willingness to work in rural area which is more than the study done by Bartwal et al 4 where 51.8% of same age group showed their willingness to work in rural area.
More females (68%) were inclined to work in rural areas as compared to males (57.6%) in the present study while Bartwal et al. 4 and Choudhary et al 5 reported opposite findings in their respective studies.
Among study participants, 69.3% first semester medical students and 55.9% fifth semester medical students were willing to work in rural area which is comparable to finding by Bartwal et al. 4 in which 72.1% first semester and 51.6% fifth semester medical students showed their willingness.
In the present study, 78.9% students belonging to rural areas showed interest to join rural health services compared to 57.8% belonging to urban area. This finding is similar to findings by Bartwal et al, 4 Choudhary et al. 5 and Saini et al. 6 which showed that rural background students were more likely to practice in rural areas.
This study observed that 69.1% of students whose parents were working in rural areas had inclination towards working in rural health while 60.7% of students whose parents were working in urban areas had interest in joining rural health which is similar to findings of study by Bartwal et al 4 on medical students of Uttarakhand.
Factors which promotes students to work in rural health of Uttarakhand had statistically significant association which is similar to findings by other studies. [4][5][6][7][8] In our study, reasons for non-willingness to work in rural Uttarakhand were limited infrastructure in health facilities, delay in post-graduation, limited professional growth, less salary, lack of recreational facilities, connectivity with cities not good and isolation from family, relatives and medical colleagues. All these reasons had statistically significant difference which had also been reported by studies of Saini et al. 6 in NCR region, Jain et al. 2   Statistically significant difference was found between participants response for improvement in rural health services by regular salary and incentives, reservation in PG seat for doctors serving in rural area, improvement in hospital and residential facilities, posting in rural health services to 2 years and compulsory after MBBS completion for every Indian Medical Graduate. These findings were comparable to various studies which suggested that these factors can address doctors shortage in rural areas. 6,9,10

Conclusion
The current government strategies to address the shortfall of health workers in rural settings may be ineffective without the infusion of some inducements, and unless these jobs are made lucrative for the physicians. With the present state of affairs, recruitment and retention of physicians in rural areas appear to remain a perpetual challenge for the government. Medical student's attitude and perception to work in rural health services need much improvement towards positive side by intervention and implementation by joint collaborative efforts of Medical Education Department, Health department and State Government.

Limitations of the Study
The study was restricted to only one medical college and not representative of pan Uttarakhand. Another limitation being a cross-sectional study, the future change of behavior or behavior persistence cannot be elicited now. Most of the medical students in the study had little exposure to rural areas, which limited their ability to perceive rural health services and its characteristics.

Source of Funding
None.

Conflict of Interest
None.