|ORIGINAL RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 1 | Page : 11-18
Factors Influencing the completion of 2 years of rural service by MBBS graduates at an Indian medical college – A qualitative study
Verna Mauren Amy, Nachiket Shankar
Department of Anatomy, St. John's Medical College, Bengaluru, Karnataka, India
|Date of Submission||31-Oct-2017|
|Date of Decision||08-Jun-2020|
|Date of Acceptance||07-Mar-2021|
|Date of Web Publication||30-Jun-2021|
Department of Anatomy, St. John's Medical College, Sarjapur Road, Bengaluru-. 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Physician shortage in rural areas is a global problem that is one of the contributors to disparities in health indicators between rural and urban areas. The medical college to which the authors are attached has a 2-year mandatory rural service requirement which medical graduates are expected to fulfil. However, some students choose the option of paying off rather than completing the service requirement. The objective of this study was to explore the facilitating factors and barriers for MBBS graduates from the above medical college to complete the mandatory rural service requirement. Methods: This was a qualitative study in which data was collected through in-depth interviews with 15 alumni of the college who were pursuing their postgraduate courses or working as junior residents. The participants in the study comprised those who completed or partially fulfilled the rural service requirement as well as those who chose to opt out of it. Data collection and analysis were done in August and September 2016 after obtaining ethical clearance from the Institutional Ethics Committee. Purposive sampling was done to ensure the diversity of responses. A semi-structured interview guide was used to conduct the interviews after pilot testing. Transcripts of the interviews were then analyzed for emergent themes related to the objective of the study. Results: Certain themes were identified as both facilitating and inhibiting factors for completing the rural service requirement. These included financial aspects, utilization of time, and peer influences. Facilitating factors included the need to acquire clinical and practical skills, moral considerations, the influence of the college, and the need to broaden perspectives. Unforeseen exigencies served as a barrier. Discussion:: The identified facilitating factors and barriers will serve as a useful starting point to initiate measures to encourage MBBS graduates to work in rural areas.
Keywords: Barriers, facilitating factors, India, medical graduates, qualitative study, rural service, rural service requirement
|How to cite this article:|
Amy VM, Shankar N. Factors Influencing the completion of 2 years of rural service by MBBS graduates at an Indian medical college – A qualitative study. Educ Health 2021;34:11-8
| Background|| |
Health for all is the national goal in India and the government of India expects medical training to produce competent physicians of the first contact toward meeting this goal. Currently, health care in India is facing serious challenges, with a high burden of both communicable and non-communicable diseases, health disparities between different states, different levels of access to medical services in rural and urban areas, inadequate resources, physician shortages to name a few. In India, the doctor to population ratio is 1:1700 as against the world average of 1.5:1000. Annually, more than 30,000 doctors pass out of medical colleges in India. Studies show that 73% of doctors practice in urban areas as compared to 17% in rural areas. Various factors such as lack of amenities, social isolation, and inability to adjust to rural life are reasons cited for doctors not preferring to practice in rural areas. The government of India has taken many steps to address this issue, one among which is the institution of a compulsory 1-year rural service for MBBS graduates. The MBBS refers to the undergraduate medical degree in India. The Government of Karnataka (one of the states in India where our medical college is located) has recently passed an act making it mandatory for medical students to do rural service. However, many graduates exercise the option to pay a penalty and forgo the service requirement.
Although the number of health facilities in rural areas of India has increased during the past decade, convincing doctors to work in them remains a challenge. Indian medical education is geared to train doctors to work in tertiary care and specialized hospitals despite the curriculum including primary care as a key component. This undue focus on specialized care in undergraduate medical training results in the neglect of primary health care and family care components, thereby rendering young doctors ill-equipped to serve in rural areas. In a study about the predictor characteristics of medical students which were associated with them staying to practice in the country and its rural areas in Nepal, it was found that many characteristics like paramedical background, rural birthplace, and lower academic rank were associated. For Nepalese graduate doctors, this association between various characteristics and eventually working in an underserved area was suggested to be used by policymakers in health education to revise entrance criteria for medical school. Another study conducted in Canada on the relationship between rural practice and educational and personal characters of medical students showed that rural experience during residency training was a key factor in determining the subsequent choice of rural medical practice.
Undergraduate medical education in India does not focus enough on primary care, as envisioned by the curriculum developers. Added to this is the reluctance of medical graduates to work in rural areas. This is one of the many reasons for the glaring disparities in the health indicators between urban and rural areas. The current study focuses on one facet of this complex issue, namely the perceptions of medical graduates about serving in rural areas. The results of the present study will be compared to studies conducted in India and other countries that have explored the perceptions of medical students and graduates about working in rural areas.,,,,,,,,
In a study conducted in India, it was found that of the 390 students (290 from government colleges and 100 from private colleges) who participated, most preferred pursuing the immediate career goal of landing a postgraduate seat rather than opting for rural service. About 17% of government and 9% of private students showed willingness to work in rural areas. Incentives suggested for joining rural service were good housing, higher salaries, improved infrastructure, opportunities for career growth and having an advantage for admission to post graduate studies. Another study from Delhi examined the inclination of medical students towards rural service. Of a total of 201 students, 110 (54.7%) indicated an interest to work in rural areas for some time after graduation. Factors like lack of poor infrastructure, low salaries, and sub-standard living conditions were found to be potential barriers to a rural health career. One of the objectives of the research conducted in Madhya Pradesh exploring the motivations and career aspirations of medical students was to compare the willingness to work in a rural area, between public and private sector medical college students. The authors concluded that though there was little difference in background characteristics, motives, and aspirations between the students, public medical school students were more willing to work in a rural area after graduating with the influencing factors being altruistic reasons, to gain experience and earn money.
To get a global perspective, we will now explore studies conducted in other countries. An interesting finding from a study conducted in Ghana was that though most medical students were motivated to study medicine by the desire to help others, it did not necessarily translate to willingness to work in rural areas. However intrinsic motivation during medical training and rural postings favored the retention of health staff in rural areas. Research conducted in Uganda found that the preferences of trainee health professionals for working in rural clinics were influenced by better quality facilities and supportive managers. This study also added the insight that salary was not the only important factor for deciding where to work. A large majority of recently graduated Thai medical, dental, and pharmacy students attended the Ministry of Public Health selection meeting for rural service. However, 20% of the total graduates did not attend, including those who opted out of mandatory rural service due to various reasons by paying the fine. Overall the attitudes towards rural work were positive or neutral in most cases. Of a total of 185 1st and 2nd year medical students from Nepal, 134 (72.4%) opined that they would work in rural Nepal after graduation. They felt the barriers to performing rural service included inadequate facilities, low salary, problems with professional development, decreased contact with family, and difficulty in communication with the rural population and also suggested curriculum changes and better facilities for rural doctors to change the scenario. In another study on the factors influencing Argentine medical students to practice medicine in underserved areas, 21% showed strong willingness to work in deprived areas while 57.5% showed weak willingness and 21.5% unwillingness. They also concluded that better remuneration and assurance of a position at an urban hospital in the future acts in favor of serving in underprivileged regions.
One of the goals of the institution to which the authors are attached is to provide health care services to the underprivileged, especially in rural areas. In keeping with this goal, the medical graduates are expected to do 2 years of rural service after completing their MBBS. There are nearly 300 rural centers in most states across India that are affiliated with the medical college for the MBBS graduates to complete their rural service. These centers are run by religious institutions or nonprofit organizations. Around 75% of these centers provide outpatient services, 20% include both outpatient and inpatient services, with about 5% providing specialist services. All the centers are in rural areas, most of them around 50 kilometers from the nearest city. Some of these centers are in remote areas which are inaccessible by public transport. Most centers provide treatment for common medical and dermatological conditions, while basic surgeries are performed in a few others. Some centers are designated maternity centers providing pregnancy-related care. One center is a mobile unit that travels from village to village providing outpatient services, including some minor procedures. The role of the graduate in the centers varies from being the sole medical officer in charge of the center to being part of a healthcare team providing services. Accommodation and food are provided for by the respective centers.
Thousands of patients have benefitted from the services provided by these graduates. Despite this noble tradition, a significant proportion of students prefer to take up the option of paying off the rural service requirement. This tendency negates the objectives with which the graduates obtained admission into the institution. An important consideration in this regard are the perceptions of graduates about the rural service requirement, as these are likely to have a bearing on whether they fulfil the requirement. With this in the mind, the research question that the authors sought to answer was “What are the perceived facilitating factors and barriers for graduates completing their MBBS degree from a medical college in South India to fulfil a 2-year rural service requirement?”
| Methods|| |
This was a qualitative study conducted at the medical college to which the authors are attached. Ethical clearance for this study was obtained from the Institutional Ethics Committee. Data was collected in the workplace of the participants by the first author and subsequently analyzed in the months of August and September 2016. Interviews with 20 subjects were scheduled. Those who refused consent were excluded. Junior doctors who were alumni of the medical college and who were working either as junior residents or postgraduates were included as subjects in the study. Purposive sampling was done to include those who had completed the rural service requirement, those who had not completed the rural service requirement and those who had left the service requirement midway. The graduating class has 60 doctors with 30 females and 30 males. Of the 30 female graduates, 15 are religious sisters. All the religious sisters go on to fulfil the 2 year rural service requirement. Among the remaining 45 graduates, around 30 on average opt for rural service. A quarter of the graduating class pay off the bond. The sample for this study included representatives from all the subsets mentioned above. Of the 15 subjects who were eventually interviewed, four were female and 11 were male. Fourteen of them were postgraduate students, while one of them was a junior resident. At the time of the interviews, the departments where the subjects were working included anesthesia, general surgery, obstetrics and gynecology, orthopedics, general medicine, pediatrics, gastroenterology, and nephrology. The time after graduation of the interviewees ranged from 1 to 7 years.
A phenomenological approach was utilized, as the authors wanted to understand the reasons why medical graduates chose to fulfil the rural service requirement or otherwise. The method used to collect data was in-depth interviews using a semi-structured interview guide which was prepared by both the authors after studying the literature. The interview guide [Appendix 1] included questions related to the following factors for those who completed their service requirement: (a) need for experience; (b) to get a postgraduate seat; (c) inability to pay off the bond; (d) genuine interest in rural service; (e) the need to earn immediately after graduating. Open-ended questions related to the following factors were formulated for those who paid off the bond or stopped midway: (a) got a postgraduate seat immediately; (b) need to study for the postgraduate entrance examinations; (c) family pressure or pressure to get married; (d) lack of interest in doing rural service; (e) had enough money to pay off the bond; (f) lost interest halfway through the bond. The first author used this interview guide to conduct two pilot interviews before collecting the data. The participants were approached before the study and rapport established. The participants were fully aware of the personal goals of the researcher and the reasons for doing the research. All the interviews were conducted by the first author.
Prior written informed consent was obtained from each participant before the interview. All interviews were audio-recorded. The questions asked to open the interviews were open-ended and aimed at exploring the possible reasons that were identified before the study as well as those that emerged during the interview. At all times there was an attempt to allow the interviewee to speak with minimal interruption. Appropriate probes were utilized during the interviews to further explore the perceptions of the subjects. The duration of the interviews varied based on the participants' responses and lasted between 45 min to one and a half hours. Each interview was transcribed soon after it was conducted, to identify new themes that emerged and hence modify the questions asked in the next interview. Participants were recruited until data saturation occurred. The transcripts were manually coded following which a thematic analysis was conducted to identify emergent themes. If there was any doubt about the identification of a theme from the transcripts, a consensus was reached after discussions between the authors.
| Results|| |
One of the participants was excluded, as the request for audio recording was declined. Data saturation was reached on interviewing 15 subjects. Some of the themes were those that were identified before the interviews as possible influencers of the completion of the rural bond, whereas the remaining themes emerged from the transcripts. The themes were grouped as facilitating factors and barriers in alignment with the objectives of the study. The themes and excerpts from the interviews substantiating these themes are mentioned below after summaries of the facilitating factors and barriers.
Financial constraints leading to the inability to pay off the bond were identified as one of the reasons for completing the 2-year rural service. Others cited that the financial independence that doing the rural service conferred, would motivate them to complete the service requirement. Some of the participants mentioned that the time doing the rural service would be well spent. This time was an opportunity to identify areas of interest for post-graduation, to study for the post-graduate entrance examination, as a buffer time in case they did not enter a post-graduate course of their choice and as a period for reflection. Seniors' and faculty members advice had a motivating influence on taking up rural service. The need for clinical experience and opportunities for practical application of knowledge was put forth as reasons for doing the rural service. Religious sentiments influenced the decision of some of the participants to complete the rural service. Others felt a moral obligation to comply with the service requirement. The need to serve the community was another motivating factor. The motivation provided by the college for postgraduate entrance in terms of marks for completing the bond, motivated some students to take up rural service. An attachment to the alma-mater was another reason to do the rural service requirement and return to the college. Rural postings during the MBBS course served as an inspiration for some to take up rural service. The need to understand and explore rural life was proposed as another reason to do the bond. The themes identified as being facilitatory are mentioned below along with the relevant extracts from the interviews.
- ”I never thought of paying off the bond because of the financial resources, as I'm not from a well-to-do family”
- ”Obviously the 6-lakh penalty for bond motivated me”
- ”At that point in time, I could not afford to pay off the bond, so I had no choice but to do the bond”
- ”The pay for the bond was definitely a perk as it gave a lot of financial independence”
- ”My plan was clear. do the bond, make enough money, attend coaching and get PG.”
Utilization of time
- ”I wasn't really sure in which direction I was moving in, but after the bond I realized what my strengths were”
- ”… Wanted my time to study, so that at least my 2 years were not spent just sitting and working”
- ”I couldn't see myself going to a coaching centre and cracking an entrance exam just after MBBS, I felt completely underprepared”
- ”… Didn't want to start studying immediately after my MBBS and realized that it's not such a major race I have to take part in”
- ”It was really hard as the work in the centre was crazy, I had to work for 12–14 h a day and spend the nights studying. But I wanted that field in PG and not getting it was my worst fear, so that kind of motivated me to study”
- ”I was thinking that I would get a 2-year window to study for my entrances.”
- ”Whenever we spoke to seniors and interacted with others, everything pointed towards doing the bond”
- ”Then I spoke to some senior doctors who were telling me why I should be doing the bond and why I shouldn't be thinking of entrances right now.”
Clinical and practical exposure
- ”I didn't want to become a very narrow-minded doctor, I wanted that broad experience”
- ”…Because as interns we don't do much clinical work, it's mostly clerical work. So, I wanted to get that proper exposure clinically before starting practice”
- ”….Decided to do it, to put theory and whatever little I had learnt during internship into practice”
- ”So this 2 years is a good thing. First year you tend to learn a lot of new things and 2nd year you implement those things.”
- ”My religion gave me the motivation of going out and doing something”
- ”MBBS seat was a blessing from God, I wouldn't have betrayed that trust”
- ”I didn't want to break my word. I had signed a legal document saying it”
- ”I could not betray my word which I had given initially, so I had to respect that”
- ”When I joined I thought about service”
- ”We're doing the bond as our motto is to do service”
- ” was not by nature a selfish person and I wanted to give back to the institution that had given me so much through this service.”
Influence of college
- ”Because of bond marks, by doing the bond we had hope that we will get in”
- ”College did provide a cushion while doing the bond as an advantage, so I thought it was worth the shot”
- ”I always wanted to come back here and knowing that I would be still be associated with my college was very important to me.”
- ”I was interested in doing the rural bond, after our rural orientation program”
The financial wherewithal to pay off the bond was also a factor that influenced students on their rural service commitment. Fulfilling the rural service requirement was considered an inefficient use of time for those intending to get into a post-graduate course at the earliest. Gaining admission into a postgraduate course during the rural service period necessitated leaving the rural service requirement before completion. The fear of getting left behind in the race to gain admission to a postgraduate course was a demotivating factor for completing the service requirement. Seniors', some of whom had completed their rural service advised against opting for the bond. This was because they felt that paying off the bond would enable one to study for and obtain a post-graduate admission earlier. Unexpected life events sometimes came in the way of fulfilling the service requirement. The father of one of the interviewees had a serious illness when she was about to commence the rural service requirement. She, therefore, opted out of the requirement to care for her ailing father. The themes identified as barriers are mentioned below along with the relevant extracts from the interviews.
- ”I come from an upper-middle-class family, so it was okay to pay off the bond”
- ”I was not very eager to return here. I was thinking of PG abroad, so I paid.”
Utilization of time
- ”For me it was about getting a PG seat at the end of 2 years, so I paid off the bond and started studying”
- ”Didn't want to spend time as an MBBS doctor, I wanted to become a specialist as soon as I could, purely because of my interest in the subject”
- ”… I feel 2 years is very long, did not want to invest 2 years in that”
- ”I cannot study and work at the same time, I don't think I would have done well in the entrances if I had been working and studying”
- ”The timing of the bond itself played a role. If it had not been after my UG when I was running after something I needed but maybe after PG it would have been better”
- ”I got the PG seat after that 1 year, I had to leave the bond.”
- ”lot of my batch mates were paying the bond and were studying, it was scary how competitive it was, so I paid it off too”
- ”I was getting a lot of negativity from people who did the bond”
- ”Seniors' said if I could afford it, it was better to pay off and start studying. Some of them who had done it without any questions told me to pay it off and study.”
- ”I was very passionate about the bond. I had even chosen the bond centre. But I had to pay it off in the last minute as dad was sick and I had to take care of him. It was a very personal decision.”
| Discussion|| |
The present study identified factors which could act either as facilitators or as barriers. These included financial aspects, utilization of time and peer influences. While the former two factors have been alluded to in previous studies, peer influence has not specifically been cited as being a contributory factor or otherwise in taking up rural service.,, As seen from the facilitating factors mentioned in the results section, moral considerations, the requirement for practical and clinical exposure, role of the college and the need to broaden one's perspectives were perceived as positive influences to do the rural bond. While altruistic reasons have been identified as a reason for working in rural areas, it has not been explored as extensively as other factors. This study suggests that religious beliefs and ethical perspectives too serve as facilitators to serve in rural areas. The need to gain practical and clinical experience as a reason to work in rural areas has also been mentioned previously. Several studies confirm that prior rural experience during the medical course influence decisions of graduates to work in these areas.,,, This, along with motivation provided by giving preference for graduates who complete the rural bond to enter postgraduate courses, was a facilitating factor in the present study. Finally, broadening of perspectives as a reason for working in rural areas has not received mention in previous literature. It was especially felt that the 1-year internship done as part of the MBBS course was inadequate to develop the range of skills required by a basic doctor. However, a previous study showed that outgoing students were more likely to seek placements in rural areas.
This study has some limitations. First, this study was conducted in a medical college whose admission criteria are different from most other medical colleges. The medical college is a religious minority institution where a majority of students are Christians. This could have limited the perspectives that might have emerged in a more heterogeneous group of subjects. Second, only junior doctors were interviewed. Other graduates who were working elsewhere after graduating and more senior doctors were not interviewed. Another limitation could be that despite assuring anonymity and confidentiality to the participants, there was some hesitation in answering certain questions, such that the actual perspectives may have been missed. Finally, certain methodological inadequacies due to feasibility issues such as lack of triangulation and verification of the transcripts with the subjects could have had a bearing on the quality of the data collected.
The findings of this study represent a starting point to understand what goes on in the mind of a student when confronted with the choice of serving in a rural area. The emergent themes from this study provide insights to institute interventions to encourage more students to complete their rural service. An increased compliance with the rural bond must necessarily occur by changing the mindset of students during the undergraduate medical course. During the undergraduate medical course, encouragement needs to be provided to the students to take up rural service by exposing them to well-run rural healthcare centres. Periodic inspirational interactions with doctors rendering yeomen service to underprivileged sections of the society can be organized by the management. Those who complete the rural service requirement must be held as role models for the undergraduate students by highlighting their role in upholding the vison and mission of the institution. During their rural service period, doctors could be provided access to study material or coaching classes to help them study for entrance examinations. Additionally, they could be given dedicated time off from their duties to enable them to study for these examinations. Medical college management could consider providing a postgraduate course tuition fee waiver for those students who complete their rural service. A decrease in the rural service period from 2 years to 1 year is also likely to increase compliance with the bond.
The aim of this study was to understand the reasons for medical graduates to serve in rural areas, the specific objective being the exploration of the facilitating factors and barriers for graduates from an Indian medical college to complete their rural service requirement. This study showed that the subjects who chose to do the service requirement did so because of financial reasons, gaining clinical experience, peer influences, religious and moral considerations, needing the time for reflection on the future, college-related considerations and to broaden one's perspectives. The students who chose not to do the rural service requirement cited the ability to pay off, the need to get into a postgraduate course at the earliest, peer influences, and unforeseen emergencies. The findings of this study can be used by medical college managements across the country to devise strategies to ensure that a greater proportion of graduates complete their rural service requirement, thus fulfilling the vison and mission of undergraduate medical training as proposed by the Medical Council of India.
We would like to thank the Indian Council of Medical Research for approving this research project for the Short-Term Studentship program for the year 2016–2017. Our gratitude to Dr. Maria Pauline for help with piloting the interview guide. We are grateful to Dr. Sanjiv Lewin for his support and encouragement during this project. Last but not the least, we would like to place on record the technical help received from Dr. Lazar in the preparation of the manuscript.
Financial support and sponsorship
Indian Council of Medical Research Short-Term Studentship.
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Appendix 1: The Interview Guide
After the initial introduction of the interviewer and participant, informed consent was obtained, after which the interview commenced with the questions mentioned below.
- What are your thoughts about rural service requirement implemented in our college?
- Did you complete the rural service or not?
- What were the main factors or reasons that influenced you in taking the decision?
The remaining questions were then dependent on whether the participant had completed the rural service requirement or not.
For those who had completed the rural service requirement
- Could you elaborate more on the specific reason (once they stated the reason)?
- Need for experience - What experience were you were looking for (for example clinical exposure, learning to manage patients' alone, independent decision-making etc.)?
- To get a postgraduate seat – What was the influence of the preference given by the institution to graduates who completed the rural service requirement for postgraduate admissions?
- Genuine interest in rural service – What was the specific reason that triggered your interest? What part did moral obligations play while making your decision? What role did the Rural Orientation Program and Community Health Action Program conducted by the college have?
- Need for money for further studies – What influence did your financial situation have on your decision?
- To find out their line of interest for specialization - Did you feel the clinical exposure provided during internship was adequate? If you already knew your field of interest, what were you looking to gain from the rural service requirement? How did this play a part in choosing your center?
- Were there any other reasons other than the ones you have mentioned?
- What role did seniors' opinions have on your decision? (if they did not mention the role of opinion of seniors). What role did family have in your decision-making?
- What were the characteristics you looked for when you searched for a rural service center? Based on the participant's answers, this question was probed further.
For those who had paid off to forgo the rural service requirement
- What was the main reason for choosing not to do the rural service requirement?
- Were you interested in rural service or not? If interested, what made you to pay the penalty instead?
- How did the postgraduate entrance exams influence your decision?
- What was the role of family or any family pressures in your decision?
- Were there any financial constraints for paying off? Why was the decision taken to pay the penalty despite financial constraints?
- Were there any unforeseen circumstances that forced you to pay off? If so, could you elaborate more on that?
- How did the opinion of seniors influence your decision?
For those who had started rural service and left midway
- What made you choose to do the rural service requirement initially (same questions posed to those who completed the rural service requirement)?
- Why did you have to leave the rural service in the middle? Please elaborate. The following factors were probed:
- Loss of interest
- Securing a postgraduate seat during the bond
- Lack of proper remuneration
- Any unforeseen situations
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