Oral health workforce in rural and remote Western Australia: practice perceptions

OBJECTIVE: In this study an analysis was undertaken to determine: (i) the major factors that influence oral health professionals to practise in rural areas and determine practice location; (ii) what assists the professional oral health workforce to remain in rural practice; and (iii) what the main reasons are for leaving rural practice. DESIGN: A postal survey was undertaken among all registered oral health professionals in Western Australia. SETTING: Rural and remote Western Australia. PARTICIPANTS: Registered dental therapists, dental hygienists and dentists in rural and remote Western Australia. RESULTS: Results indicated that there are various factors that attract people to rural and remote areas, other than financial incentives. Incentives to remain in rural practice include the need for professional development. The most common reason for leaving rural practice was to access children's educational facilities. CONCLUSIONS: This study emphasises that many factors contribute to recruitment and retention of dental professionals in rural practice. A broad integrated retention strategy is needed to address oral health workforce shortage issues in rural and remote Western Australia.     

Preparedness for rural community leadership and its impact on practice location of family medicine graduates

OBJECTIVE: To identify non-clinical dimensions of preparedness for rural practice and to determine whether preparedness for rural practice is predictive of rural practice location. DESIGN: Cross-sectional postal survey mailed in 2001. SETTING: Communities across Canada where graduates were practising. SUBJECTS: Graduates (n = 369) of the family medicine residency program at the universities of Alberta (U of A) and Calgary (U of C) between 1996 and 2000, inclusive. INTERVENTIONS: Using a 4-point scale, graduates rated the extent to which the residency program prepared them for eight dimensions of rural practice: clinical demands of rural practice, understanding rural culture, small community living, balancing work and personal life, establishing personal/professional boundaries, becoming a community leader, handling a 'fish bowl' lifestyle, and choosing a suitable community. MAIN OUTCOME MEASURE: Identification of non-clinical dimensions of preparedness for rural practice and whether scores on preparedness scales are predictive of rural practice location. RESULTS: The overall response rate was 76.4%. Factor analysis of the eight preparedness items produced two factors, 'rural culture' and 'rural community leader' which explained 72% of the variance. The alpha coefficient for each factor was 0.87. Odds ratios revealed that family medicine graduates prepared for rural community leadership roles were 1.92 (CI = 1.03-3.61) times more likely to be in rural practice. Rural physicians were also 2.14 (CI = 1.13-4.03) times as likely to have a rural background. CONCLUSIONS: Preparedness to be a rural community leader and having a rural background were predictive of rural practice. Educators should consider this in both family medicine residency admissions policy and practice and when designing and implementing family medicine residency curricula.     

Recruiting and Retaining Physicians in Very Rural Areas

Context: Recruiting and retaining physicians is a challenge in rural areas. Growing up in a rural area and completing medical training in a rural area have been shown to predict decisions to practice in rural areas. Little is known, though, about factors that contribute to physicians’ decisions to locate in very sparsely populated areas. Purpose: In this study, we investigated whether variables associated with rural background and training predicted physicians’ decisions to practice in very rural areas. We also examined reasons given for plans to leave the study state. Methods: Physicians in the State of Wyoming (N = 693) completed a questionnaire assessing their background, current practice, and future practice plans. Findings: Being raised in a rural area and training in nearby states predicted practicing in very rural areas. High malpractice insurance rates predicted planning to move one's practice out of state rather than within state. Conclusions: Rural backgrounds and training independently predict practice location decisions, but high malpractice rates are the most crucial factor in future plans to leave the state.     

The Reported Value of Rural Internal Medicine Residency Electives and Factors That Influence Rural Career Choice

This study examines how rural electives affect medical residents' opinions about rural practice and which factors encourage or discourage choice of rural practice. Participants in a one- to two-month rural elective and a matched group of randomly selected nonparticipants were surveyed. Seventy percent of the elective participants (n = 58) and 61% of the matched nonparticipants (n = 51) completed the questionnaire. The groups' responses to scaled response measures and open-ended questions were analyzed using t , chi-square and Mann-Whitney U tests. A majority of participants stated that the elective was a beneficial experience (n = 36), and participants' interest in rural practice increased significantly after the elective. Elective participants were more likely than nonparticipants to see breadth of practice, continuity of care, quality of life in rural areas, and experiences with mentors as encouraging rural practice. Elective participation did not demonstrably increase rural career choice, although this finding may be attributable to small sample size. Respondents identified means to encourage rural practice, as well as barriers to rural practice: Elective participants suggested that electives may be more effective if they occurred earlier in medical training, lasted for longer periods of time, and addressed the needs of spouses or partners. Generalizability is limited by several factors, including small sample size and the possibility of pre-existing differences between elective participants and nonparticipants.     

Why do junior doctors not want to work in a rural location,and what would induce them to do so?

Objective: Identify the most important factors associated with choosing rural medical practice. Design: Cross‐sectional design using a web survey to collect quantitative and qualitative data. Participants: One hundred and ninety junior doctors – 91 interns, 99 PGY2. Main outcome measures: Choice of practice location (urban/rural), reason for choosing location, enticement to a rural location. Results: Twenty‐seven per cent of junior doctors preferred a rural practice location. Preference to practice in a rural area was associated with medical placement bonding schemes, rural background, rural placement experience and being older. High levels of professional expectations and prestige were associated with a preference for an urban location. The most important reasons for choosing a practice location included consideration of partner, family and friends (35.3%), preference for a location (20.5%), lifestyle goals (19.5%) and career opportunities, specialty requirements and infrastructure (17.9%). Those who preferred an urban compared with a rural location gave more importance to factors concerning partner, family and friends. The factors that would entice a doctor to a rural location included partner and family considerations (27.0%), professional support (20.3%), and career opportunities, specialty requirements and infrastructure (16.3%). Women gave more importance to partner and family factors than men. Conclusions: Our findings support the continuation of policies that are known to encourage choice of rural practice, but highlight the need for additional strategies that consider the personal and professional needs of this generation of doctors.     

Rural Health Research: Demographic, Educational and Economic Factors Related to Recruitment and Retention of Physicians in Rural Pennsylvania

While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.     

Perceptions towards rural and remote practice: A study of final year occupational therapy students studying in a regional university in Australia

Background/aim: Rural and remote health education during undergraduate training is a strategy to alleviate the shortage of rural health professionals. Undergraduate rural exposure can be beneficial in improving students’ perceptions towards rural and remote practice as well as their decision to work rurally. This study examined James Cook University (JCU) final year occupational therapy students’ perceptions towards rural and remote practice and if their perceptions had changed over the course of their study. Methods: Questionnaires were administered to 58 final year occupational therapy students at JCU during a block class. Quantitative data analysis was performed on responses. Results: The change in the students’ career intentions from not considering to considering rural and remote practice over the duration of their study was found to be significant (exact P = 0.003). The influential factors identified in students considering rural employment included the rural location of their close family and friends (exact P = 0.006), the overall occupational therapy programme (U = 171.5, P = 0.045), good fieldwork experience (U = 144, P = 0.039) and inspiring fieldwork supervisors (U = 135.5, P = 0.01). The course curriculum was not found to influence the students’ perceptual change. Conclusion: This study has found that students’ perceptions towards rural and remote practice changed over the course of their university programme. A greater focus on the academic staff and fieldwork supervisors’ perceptions towards rural and remote practice may be required in the development of rural undergraduate programmes. Identification of students who have family/close friends living in rural and remote areas may encourage occupational therapists to work in rural areas.     

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural,Small Town America

ABSTRACT: Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. Methods: A survey mailed in 2004‐2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.     

Context counts: training health workers in and for rural and remote areas

Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.     

Factors in Recruiting and Retaining Health Professionals for Rural Practice

CONTEXT: Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce. PURPOSE: To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States. METHODS: A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations. FINDINGS: Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups. CONCLUSION: Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.     

Why doctors choose small towns: A developmental model of rural physician recruitment and retention

Shortages of health care professionals have plagued rural areas of the USA for more than a century. Programs to alleviate them have met with limited success. These programs generally focus on factors that affect recruitment and retention, with the supposition that poor recruitment drives most shortages. The strongest known influence on rural physician recruitment is a “rural upbringing,” but little is known about how this childhood experience promotes a return to rural areas, or how non-rural physicians choose rural practice without such an upbringing. Less is known about how rural upbringing affects retention. Through twenty-two in-depth, semi-structured interviews with both rural- and urban-raised physicians in northeastern California and northwestern Nevada, this study investigates practice location choice over the life course, describing a progression of events and experiences important to rural practice choice and retention in both groups.     

Cardiovascular risk levels in general practice patients with type 2 diabetes in rural and urban areas

OBJECTIVE: To investigate the change of cardiovascular risk factor from 2000 to 2002 in general practice patients with type 2 diabetes in urban and rural areas, and the association between cardiovascular risk (both single risk factors and coronary heart disease absolute risk (CHDAR)) and rurality in three years. METHODS: In total, 6305 patients were extracted from 16 Divisions (250 practices). Multivariate regression at Division, practice and patient levels was conducted with adjustment for age and gender. RESULTS: In each of the three years, most single individual risk factors and CHDAR were high. Comparing 2002 with 2000: for urban patients in 2002 total cholesterol (OR 0.85) and low-density lipoprotein (OR 0.81) significantly decreased, and high-density lipoprotein (HDL) (OR 1.16) significantly increased; for rural patients in 2002 HbA1c (OR 0.85) significantly decreased and HDL (OR 1.22) significantly increased; and CHDAR significantly improved only in urban patients (OR 0.93) in 2002. In 2002 rural patients were still more likely to be overweight/obese (OR 1.16), be current smokers (OR 1.36), and have worse HDL (OR 0.84) and triglycerides (OR 1.23) than their urban counterparts. CONCLUSION: Some key individual risk factors and CHDAR did not improve in rural patients with type 2 diabetes despite a number of programs designed to provide comprehensive care to rural patients with diabetes. More emphasis is needed on supporting access to lifestyle changes (such as smoking, diet and physical activity) in rural primary health care.     

WHY DOCTORS WOULD STAY IN RURAL PRACTICE IN THE NEW ENGLAND HEALTH AREA OF NEW SOUTH WALES

ABSTRACT: Retention of rural doctors is a critical factor in effectively addressing the well-documented maldistribution of the medical workforce. The present study explores the reasons why rural doctors working in northwestern New South Wales left their previous practice, moved to their current practice and have considered moving to another practice. In addition, these doctors were also asked as to the most effective strategies in retaining rural doctors and which organisations could make a valuable contribution in making rural general practice more attractive. As the doctors' choices concerning their practice locations involve judgements relating to a complex array of factors, there are a great number of priority actions involving many stakeholders that can impact positively on the retention of rural doctors. In addition to strictly professional issues, such as access to hospitals, a reasonable work load and a good level of procedural work, other issues, such as the availability of good social and cultural facilities, work opportunities for one's partner and good educational facilities for one's children, have a great bearing on the doctor's decision where to practise. Put differently, while the professional environment needs to be conducive to good rural practice, rural doctors are also human beings, requiring appropriate facilities to meet their 'quality of life' needs.     

Assessment of a Curricular Component Designed to Introduce Physical Therapy Students to Rural Practice Issues

A rural health curricular component was designed for students enrolled in a physical therapy program in Nevada to change student attitudes about rural practice and to encourage more physical therapy students to seek employment in rural areas postgraduation. Student attitudes and beliefs related to rural practice were investigated following participation in a rural health conference and a full-time rural clinical affiliation. Twelve students (N = 12) participated. All reported positive impressions of rural practice after participating in the rural clinical affiliation and nine (75%) were favorable toward seeking employment in a rural setting. Two (17%) accepted rural health positions following graduation. Clinical experience in a rural setting was found to have the greatest influence on student attitudes about rural practice.     

International Perspective: RURAL NURSING IN THE UNITED STATES: WHERE DO WE STAND AS WE ENTER A NEW MILLENNIUM?

ABSTRACT: Approximately one-fourth of all Americans live in rural communities; and, of the 50 States, 31 have more than 60% of their counties designated as rural. No matter what indicator is used, United States residents in non-metropolitan areas have less than metropolitan counterparts (e.g. per capita income, health status, access to care, level of education and employment opportunities) and are more likely to need help from human services and health professionals. Additionally, rural people often must confront unique obstacles not experienced by most urban residents to access those services. As nurses live and work in rural communities they, too, must be aware of and contend with similar factors in their practice settings. In some ways rural nursing practice has changed dramatically over the last decade but in other ways things remain much the same. This article will examine common nursing issues associated with caring for clients in a rural environment. The information in this article is based on a review of the literature and the author's personal and professional nursing experiences.     

Influences on doctors’ prescribing: is geographical remoteness a factor?

Objective: To identify factors influencing the prescribing of medicines by general practitioners in rural and remote Australia. Design: A qualitative study using a questionnaire to determine attitudes about prescribing, specific prescribing habits and comments on prescribing in ‘rural practice’. Setting: General practice in rural and remote Queensland. Subjects: General practitioners practising in rural and remote settings in Queensland (n = 258). Main outcome measures: The factors perceived to influence the prescribing of medicines by medical practitioners in rural environments. Results: A 58% response rate (n = 142) was achieved. Most respondents agreed that they prescribe differently in rural compared with city practice. The majority of respondents agreed that their prescribing was influenced by practice location, isolation of patient home location, limited diagnostic testing and increased drug monitoring. Location issues and other issues were more likely to be identified as ‘influential’ by the more isolated practitioners. Factors such as access to continuing medical education and specialists were confirmed as having an influence on prescribing. The prescribing of recently marketed drugs was more likely by doctors practising in less remote rural areas. Conclusion: Practising in rural and remote locations is perceived to have an effect on prescribing. These influences need to be considered when developing quality use of medicines policies and initiatives for these locations. What is already known: Anecdotal and audit based studies have shown that rural general practice differs to urban‐based practice in Australia, including some limited data showing some variations in prescribing patterns. No substantiated explanations for these variations have been offered. It is known that interventions to change prescribing behaviour are more likely to be effective if they are perceived as relevant and hence increasing our knowledge of rural doctors’ perceptions of differences in rural practice prescribing is required. What this study adds: Rural doctors believed that they prescribe differently in rural compared with city practice and they described a range of influences. The more remotely located doctors were more likely to report the ‘rural’ influences on prescribing, however, most results failed to reach statistical significance when compared to the less remotely located doctors. These perceptions should be considered when developing medicines policy and education for rural medical practitioners to ensure it is perceived rurally relevant.     

Rural pharmacy in New Zealand: effects of a compulsory externship on student perspectives and implications for workforce shortage

Objective: To explore student perceptions of rural pharmacy practice, factors affecting interest in rural work and effects of an educational intervention designed to raise awareness of rural practice. Design: Qualitative and quantitative survey questionnaire administered before and after a week-long rural externship. Setting: Undergraduate – rural pharmacy externship. Participants: Third-year Bachelor of Pharmacy undergraduate cohort (n = 123). Intervention: Week-long exposure to rural pharmacy practice Main outcome measures: Rural/urban origin of students, interest in working in rural practice, views held of rural practice and towards externship. Results: Rural-origin students were significantly more likely to report they would consider working in rural practice prior to the intervention than urban-origin students (77% rural origin versus 40% urban origin). The intervention significantly increased the overall proportion (48% pre-versus 73% post-externship), proportion of female students (48% pre versus 79% post-externship) and proportion of urban-origin students (38% pre-versus 67% post-externship) prepared to consider rural practice. Despite apprehension towards the externship, students reported overwhelmingly positive experiences of it. Negative aspects related mainly to travel and accommodation costs incurred. Conclusions: This targeted, experiential intervention affected perceptions of rural practice in a positive direction among urban-origin students by raising awareness and challenging their preconceptions of rural pharmacy practice. Further research is required to see whether this will affect recruitment and to investigate what appears to be a particular effect on female students.     

Job Satisfaction Among Rural Physician Assistants

Abstract: Because increasing numbers of physicians are being trained in specialized medicine, health professional shortage areas remain common in the United States, and the role of physician assistants (PAS) in health services provision is becoming increasingly important, especially in rural and underserved areas. By most accounts, there is a shortage of PAS in the United States, particularly in rural areas. A nationwide survey was conducted in 1994 to determine what attracted PAS to rural settings and what they found satisfying about their work and community. This study involved a random sample of 1,263 PAS who practiced in rural (nonmetropolitan) areas of the United States. A 15-item scale was developed to measure job satisfaction. A statistical model was tested for its ability to predict levels of job satisfaction using multiple regression analysis. Independent variables included demographics, practice, and community factors. Findings indicated that rural PAS were generally satisfied with their work. The most significant predictors of satisfaction included practice factors (e.g., importance of autonomy and a good relationship with the supervising physician), extent of practice responsibilities (e.g., regular and on-call hours and the percentage of PAS' patient load that was not discussed with the supervising physician), and community factors (e.g., community satisfaction).     

Sustainable rural practice for female general practitioners

An expert panel of female rural and remote doctors have nominated updating professional skills as the most important strategy for sustainable rural general practice for women. The panel was comprised of members of the Australian College of Rural and Remote Medicine (ACRRM). The panel was asked to identify and prioritise strategies they had used to make rural practice work for them. They identified and ranked the following eight groups of strategies: (i) structure medical practice to work for you; (ii) implement personal strategies; (iii) obtain and update professional skills; (iv) establish professional and personal boundaries; (v) gain exposure to rural practice; (vi) engage with the community; (vii) implement professional strategies; and (viii) engage with women. Detailed strategies within these groups have been identified and will form the basis of grounded knowledge about how to structure rural and remote practice to work for women. This will complement the work of ACRRM, the Rural Doctors Association and workforce agencies in developing models of sustainable rural medical practice.