Discussion
The current study was designed to assess the knowledge, attitudes, and skills among primary healthcare workers in health promotional settings and to determine the managerial interventions needed in health promotional settings in the Kalutara RDHS division.
The knowledge among 70% (215) of the study participants of this study were categorized as 'poor' and only 30% (92) of study participants were identified as having 'good' knowledge according to the scoring system. According to the self-assessed level of knowledge on health promotional settings, 87.8% (257) of primary health care workers declared that they had 'good' knowledge of healthy settings. This difference in the self-assessed level of knowledge and calculated value suggested that most primary health care workers can't identify their level of actual knowledge on health promotion settings accurately. This wrong perception may prevent them being participating in training programs. A study conducted among PHMM in Kandy District revealed that 65.4% of PHMM had 'poor' knowledge on health promotion (16).
The highest achieved educational level (P ± 0.012) and ability to read English (P ± 0.021) were the background characteristics that were significantly associated with knowledge on health promotion settings. The basic qualification to enter PHMM training changed from GCE OL to GCE AL during the last decade. The significant association may be due to recently passed out PHMMs were trained in health promotion during their basic training which can have a confounding effect on the level of knowledge on health promotion. There were no books on health promotion written in either Sinhala or Tamil languages. Therefore, the ability to read English might have helped the primary health care workers to improve their knowledge. Whether or not residing in their field (P ± 0.962) area was not significantly associated with knowledge on health promotion settings. Perera (16) in his study conducted in the Kandy district had found that the highest achieved educational level, ability to access the internet, and ability to read English were significantly associated with knowledge on health promotion.
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The year of qualifying as a PHM, the year 2004 or after was not significantly associated with knowledge of health promotion settings (P ± 0.061), or not they obtained basic PHM training from Colombo NTS or other centers was not significantly associated with knowledge on health promotion settings (P ± 0.881). This finding indicated that the PHMM who were trained on health promotion had a similar level of knowledge and probably that the quality of training on health promotion was not differing to in larger extent between training centers. The PHMM who had public health work experience of fewer than five years had a good level of knowledge compared to those who had public health experience of more than five years (P ± 0.002). These results may be due to the confounding effect of recently passed-out PHMMs being trained recently in health promotion during their basic training. Perera (16) explained that the qualifying year as a PHM, the year 2004 or before significantly associated with knowledge on health promotion.
A decade after the introduction of health promotion to the curriculum of primary health care workers in Sri Lanka and conducting the larger number of training programs, knowledge in health promotion was not satisfactory. This fact raised the question about the quality of training in health promotion and that should be taken into serious consideration.
The level of attitudes among primary healthcare workers in developing health promotion settings was good (69.4%, 204) which is in line with the findings of other international research. Peltzer (8) researching South African primary care nurses and midwives found that 63.3% of them were good in attitudes. In another study, the majority of them expressed positive attitudes about health promotion as a core aspect of primary care (9). According to the study conducted by Geensi et al (17) attitudes of primary care nurses toward health promotion were rated as good.
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