Skip to main content

Table 1 The characteristics and findings of included studies in the review

From: Determining factors in the retention of physicians in rural and underdeveloped areas: a systematic review

No

Title and Authors

(Reference No)

Country and Date

Type of study

Study population

Data collection method

Quality appraisal

Effect of the context on how the factors influence the retention of physicians in rural and underdeveloped areas

1

Recruitment and Retention of General Practitioners in Rural Canada and Australia (Marco Viscomi, Hon BSc) [18]

2013

Canada and

Australia

review

n = 86

sources for review/ Canada Astralia

MEDLINE/Ovid

High

-Further follow-up of the highlighted educational programs is warranted to ensure continued refinement of socially accountable policies and initiatives.

2

Sustaining Family Physicians in Urban Underserved Settings (Anne Getzin MD, BennIe L) [19]

2016

United States

qualitative

study

N = 16family physicians

Semi-Structured Interviews/multi-step process

High

-Training in the personal and professional skill sets identified may improve physician retention in urban underserved settings.

3

Retention of General Practitioners in Rural Nepal: A qualitative study (Katrina Butterworth, Bruce Hayes) [20]

2008

Nepal

qualitative study

n = 86 General practitioner Questionnaire

n = 11 Semi structured interviews

Questionnaire/ semi structured interview and focus group

discussions

High

-Career development is considered as a key issue that must be addressed by the government of Nepal. GPs need to have a clear career ladder, with recognition of the value of service in rural areas.

-A multifaceted, holistic response is necessary. From the level of community awareness, a career structure and financial remuneration to adequately set up hospitals, functional teams, family support, continuing professional development and a secure working environment – each area must be addressed for the whole to function.

4

Factors Affecting Leave out of General Practitioners from Rural Family Physician Program(

Amiresmaili M, Khosravi S, YazdiFeyzabadi V) [16]

2014

Kerman, Iran

Survey cross-sectional

n = 271

Family Physicians

Questionnaire

High

-Educating native manpower has been one of the main strategies of medical education system in Iran in order to increase physicians’ retention in deprived areas.

-General practitioners cooperate with the educational programs as part time physicians and seek further education to gain a competitive advantage and better social position and income.

5

Analysis of a survey on young doctors’ willingness to work in rural Hungry (Edmond Girasek) [9]

2010

Hungary

Survey

n = 785 four Hungarian medical

universities

Questionnaires and focus group interviews

 

-The current system of medical training in Hungary tends to produce doctors who want to live in big cities and work in central hospitals. Rural regions and non-in-patient service alternatives seem either not to be targeted or seen as unattractive work places. More doctors would be willing to work in smaller towns and villages if in-hospital training was altered and if doctors were offered adequate incentives as part of a comprehensive human resource strategy (high salaries, high professional standards, good working environment, reasonable workload). If these changes do not occur, the existing geographical and structural imbalances will not be improved.

6

Rural Physician Satisfaction: Its Sources and Relationship to Retention (Donald E. Pathman, Eric S. Williams, Thomas R. Konrad) [14]

1996

United States

Survey/ Cross-sectional

n = 620 prima y care physicians

Mail questionnaires

High

-Physicians’ satisfaction with their communities and their opportunities to achieve professional goals predicted longer retention. Satisfaction with income also tended to predict longer retention.

7

Retention of Primary Care Physicians in

Rural Health Professional Shortage Areas (Donald E. Pathman, MD, MPH, Thomas R. Konrad, PhD, Rebekkah Dann, MS, and Gary Koch, PhD) [21]

1991

United States

Survey/ Cross-sectional

n = 505 physicians/

randomly selected

Questionnaire

High

-Retention is related to modifiable characteristics of work, whereas recruitment is related to the relatively immutable characteristics of physicians’ backgrounds and professional and lifestyle preferences, as well as the socioeconomic features of communities.

-To promote retention, local, state, and federal programs can promote practice ownership through low-interest loans and start-up income guarantees. Practice administrators can build a sense of personal investment and control among employed physicians by offering leadership opportunities and providing a greater voice in clinic policies and work schedules.

-Local hospitals and practice networks can reduce on-call frequency by coordinating cross-coverage arrangements. Work demands while on-call can be lessened by providing telephone call triage systems and full-time physician staffing in local emergency rooms.

8

Why do Junior doctors not want to work in a Rural location and What would induce them to do so? (Mary E. Rogers, Judy Searle and Peter A. Creed) [22]

2009

Australia

Survey/ Cross-sectional

n = 190 Junior doctors

Questionnaire

High

-Infrastructure and professional development opportunities are the influential factors.

-Women gave more importance to partner and family factors than men.

9

What Factors Contribute most to The Retention of General Practitioners in Rural and Remote areas? (Deborah J. Russell, Matthew R. McGrailB,, John S. Humphreys,

and John WakermanB,) [23]

2008

Australia

Survey/ Cross-sectional

n = 1189 general Practice

Questionnaire

High

-Ideally such factors would be supported by an existing evidence base, be amenable to measurement and able to be influenced by management policy (such as remuneration, availability of suitable housing, paid locum relief, work culture and perceptions of work life balance). Such information may facilitate the further ‘unpacking’ of factors that have been demonstrated to be important for Australian rural and remote GP retention.

10

Physician Shortages in Rural Vietnam: Using a labor market approach to inform policy. (Marko Vujicic, Bakhuti Shengelia,, Marco Alfano, Ha Bui Thu) [7]

2009–2010

Vietnam

Survey

n = 292 Physicians (rural n = 57 and urban n = 235)

Questionnaire/

multistage sampling

High

-Providing preferential access to short term training and paying financial bonuses in rural areas are policies that the government of Vietnam should seriously consider. For short-term training, the government might consider a program where physicians in rural areas are guaranteed access to short-term training courses that are most in demand. In terms of bonuses, these can be implemented either as separate allowances or by revising the current salary points system to reward locating in a rural area much more.

11

Factors and Outcomes in Primary Care Physician Retention in Rural areas (Glasser M, PhD MacDowell M, DrPH, MBA Hunsaker M, MD Salafsky B, PhD Nielsen K, MPH Peters K, DrPH Meurer M, MS) [13]

1997

United States

Survey

n = 107 Primary care and Specialty care

Non structured interview

Medium

-Keys to success in rural physician retention seem to include identifying and recruiting medical students of rural origin and focusing on a healthy practice environment. Policy makers need to work with local government; schools and employers to offer programmers that provide information on health careers in rural areas and begin to identify local youth for induction in rural health care.

12

Relationship Between Personal Characteristics of Specialist Physicians and Choice of Practice Location. (Taati Keley E, Ravaghi H, Salehi M, Nasiripour A, Abdi Z, Meshkini A) [24]

2013

Iran

Survey/cross-sectional

n = 3825 physicians who graduated from all public medical schools across the country between 2009 and 2012

 

High

-Increasing the enrollment of physicians with a rural background in residency programs may solve the problem of uneven distribution of specialist physicians in Iran. Because female physicians are less willing to work in the underdeveloped areas than male physicians, increasing the number of male student admissions to residency programs, particularly in certain specialties that are more in demand in the underdeveloped areas, could alleviate the problem of uneven distribution of physicians in the short run. Further, programs that support raising the admissions of female students with a rural background into local medical universities along with providing incentives to encourage them to live and work in rural areas should be put on the policy agenda.

13

Attracting and Retaining Doctors in Rural Nepal (Shankar PR) [8]

2010

Nepal

Review

Original research articles, reviews, magazine articles and project reports dealing with Nepal and other developing countries during the period 1995 to 2010

PubMed/Google scholar/ WHO’s HINARI database

Medium

-A range of strategies developed elsewhere could be used in Nepal, especially community-oriented medical education that involves rural doctors in training medical students. The reimbursement of tuition fees, assistance with relocation, and provision of opportunities for academic and professional advancement for rural doctors should also be considered. Government investment in improving working conditions in rural Nepal would assist rural communities to attract and retain doctors.

14

Factors affecting the work of physicians in rural areas of Turkey (Mollahaliloglu S, Ugurluoglu Ö) [25]

2009

Turkey

Survey

n = 1340 physicians working in urban areas

Questionnaire

High

-Medical residents working in the university hospitals, their willingness to work in rural areas can be related to their continuing education with temporary status and their obligation to go to another healthcare institution for a long-term employment option. Physicians who are in the early stages of their careers can be thought to be more open to changing location compared with more experienced ones who have an established career path.

-Financial incentives, non-monetary incentive policies that consider the physicians’ views should be developed to achieve permanent success.

-Regulations that make the physician’s life easier, such as housing provision, better service infrastructure and flexible working regimes, can motivate young and single physicians to work in rural areas.

15

Factors Affecting Willingness to Practice Medicine in Underserved Areas (Borracci RA, Arribalzaga EB) [12]

2013–2014

Argentina

Survey/ cross-sectional descriptive

n = 400 Argentine Medical students

Questionnaire

High

-Government policy-makers must recommend changes in resource allocation to better promote official proposals and opportunities to work.

16

Factors Influencing the Geographic Distribution of Physicians (Ravaghi H, Taati E, Abdi Z) [26]

2012

Iran

qualitative study

n = 82 key officials from medical universities

Open-ended Questionnaire

High

-Policies such as providing more financial and non-financial incentives, reducing disparities between physicians’ income in rural and metropolitan areas, selection of students with rural background, and supportive measures for physicians working in underserved areas were recommended.

17

Key factors leading to reduced Recruitment and Retention of Health Professionals in Remote areas of Ghana (Rachel Cnow, KwesiAsabir) [27]

2010

Ghana

qualitative study

n = 84 doctors and medical leaders

In-depth interviews

High

-Expanding opportunities for post-graduate specialization may offer a significant return on investment; establishment of postgraduate training in Obstetrics and Gynecology in Ghana in 1989 led to high retention rates among graduates of the program. Graduates cited the appeal of adding a chance for specialization in their own country to their continued service in Ghana.

-Career advancement incentives will be critical to any successful incentive package. Proposed incentives include guaranteed promotion or study opportunity after service in hardship areas contact with mentors through rural rotation of specialists or remote learning centers, and reliable terms of appointment with fixed end-points.

18

What Factors Influence the Choice of Urban or Rural Location for Future Practice of Nepalese Medical Students? (Bhim Prasad Sapkota, Archana Amatya) [28]

2015

Nepal

Cross-sectional descriptive

n = 393 medical students from four medical colleges

Questionnaire/

In-depth structured interviews

High

-The government should attract the students from a rural place of rearing and rural secondary education for medical education.

-Newly established medical college by the Nepal government (Patan Academy of Health Sciences) has started to enroll students having a rural rearing and rural schooling in MBBS.

19

A systematic review of strategies to recruit and retain primary care doctors (Puja Verma, Arabella Stuart) [29]

January 2015

England

review

n = 42 studies

MEDLINE, EMBASE, CENTRAL

High

 

20

Factors That Influence the Turnover Intention of Chinese village Doctors based on the Investigation Results of Xiangyang City in Hubei Province (Pengqian Fang, Xiangli Liu) [30]

July and August in 2012

China

Survey

n = 1889 Doctors

Questionnaire

High

-The government should raise the income of village doctors and provide them with suitable promotion opportunities and security insurance, such as health insurance and pension insurance. In addition, low education levels of village doctors, as a barrier to achieve the educational goals for the village doctors set by the government, should also be tackled through further on the-job training or by recruiting more college medical graduates into the village clinics.

21

Physicians’ retention rate and its effective factors in the Islamic Republic of Iran (Ehsani-Chimeh E, Majdzadeh R, Delavari S, et al) [31]

2000–2001

Iran

Survey

/cross-sectional

n = 5482

physicians

Questionnaire

High

-About three-fourths of Iranian physicians would work in underserved areas if there were some special privileges for them, mainly income and employment relationship. Younger males and those who belonged to the Medical Student Boom Generations had more inclination.

22

Assessment on causes of physicians’ abdication from Rural Family Physician Plan in 2012 (Sadighi S, Amini M, Pourreza A) [32]

2012

Iran

Analytical descriptive study

n = 26 Family physicians

Questionnaires

High

-With regard to the effective components in social and cultural resignation and leave family physicians in the main step of implementing this national plan, optimally between the two sides in a suitable provider of service and recipient country according to current laws will be.

23

Factors influencing desertion of family physicians working in rural areas with deprivation index less than 1.4 (prosperous) in 2010 (Atefi A, Aghamohammadi S) [33]

2010

Iran

cross-sectional descriptive

n = 6618 Family physicians

Questionnaire/

interviews

High

-There was an increasing trend on dropping out of family physician program. To seize this trend, some actions could be done, including: to promote authorization for hiring family physicians, to reform the amount of payments, to ensure timely payments, to develop residency program on family physicians and dedicate an admission priority to active family physicians to enroll in the program, and finally to set a higher salary for family physicians practicing in rural areas.

24

Factors Influencing Retention of Rural Pennsylvania Family Physicians. Esther M, Forti, Kenneth E. Martin, Robert L. Jones, and Herman, J [34]

1993

United State

Cross-sectional descriptive

n = 398 Family Physicians

Questionnaire/

Mail Survey

High

-Health system should use the strategies that minimize perceptions of professional isolation and policy efforts that address reimbursement differentials and compliance issues in order to minimize many complaints of rural family physicians.

25

Determining the Causes of Discontinuation of Family Physicians Working in Mashhad University of Medical Sciences (Ehsan Mosa Farkhany, Hosein Khooban, Behruz Dahrazama, Vahid Reza Arefi,Fariba Saadati) [35]

2012

Iran

Analytical study

n = 156 Family physicians

Questionnaire

High

-The Ministry of Health and Medical Education should focus on increasing annual per capita and credit The Rural Family Physician Program has taken serious action and also revised the plan to reduce the responsibilities of members of the health team.

26

Physician preferences for working in deprived areas: a systematic review of discrete choice experiment(Hamouzadeh P, Akbarisari A, Olyaeemanesh A, Yekaninejad MS) [36])

2017

Iran

Systematic review

n = 14 studies

PubMed, Embase, Web of Science Core Collection

High

-Financial attributes are not the only significant attributes considered by the physicians for deciding where to practice, but also the other non-financial attributes are important. It is suggested that based on the economic, social and cultural conditions of each country, a specific incentive package, including a set of financial and non-financial incentives, is developed to attract physicians to the deprived areas.

27

Factors influencing turnover intention among primary care doctors: a cross-sectional study in Chongqing, China (Tong Wen, Yan Zhang) [37]

2013

China

a cross-sectional study

n = 440 doctors

Interviewed

High

-Improving job satisfaction, in terms of salary, promotion and job safety, is crucial for reducing turnover intention among primary care doctors. Therefore, we suggest that the government increase its financial investment in primary care facilities, especially in less-developed areas, and reform incentive mechanisms to improve the job satisfaction of primary care doctors. The government should consider policies such as establishing a social pension programme for village-level doctors and providing more opportunities for job promotion among primary care doctors, especially township-level doctors.

28

The role of rural communities in the recruitment and retention of women physicians (Paladine HL, et al) [38]

2019

United States

Qualitative study

n = 25 women family physicians

Interview

High

-Resident selection based on a predisposition to work in underserviced areas, related to either interest or family ties, and immersing them in family practice in these areas, can enhance recruitment and retention in underserviced areas.

-Positive residency experiences, established relationships with local specialists, health professionals and community services, and opportunities to practice as they had trained and how they preferred to practice, contributed to physicians’ decision to practice in the same geographical area in which they train.

29

Keeping family physicians in rural practice (JTB Rourke) [39]

2003

Canada

Cross-sectional mailed survey

n = 276 physicians and 210 residents

Survey questionnaire

High

-It is important to facilitate referrals and provide specialist support

-Availability of locums can make a big difference in continuing patient care and allowing time off for CME, family holiday time, maternity leave, and so on.

-A comprehensive package based on highly rated solu- tions is more likely to be successful than politically expedient measures.

30

Retaining Doctors in Rural Bangladesh: A Policy Analysis

(Taufique Jourder et al) [40]

2018

Bangladesh

Qualitative study

n = 11 relevant policy elites

Group discussions

High

-Applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected.

-Facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practicing allowance in exchange of strict monitoring, and no political interference in compulsory service is assured.

- Specific policy guidelines should be developed to establish rural medical colleges.

-Commitment from the highest level of political hierarchy is the key to the successful implementation of the rural retention policies of the government.

31

Physician recruitment and retention in Manitoba: results from a survey of physicians’ preferences for rural job

(Witt, Julia) [41]

2017

Canada

survey

N = 561 physicians

Questionnaires

High

-Several of the attributes that reflected the need for professional and social inclusion were found to be important: group practice, community incentives (during the first year) and access to clinic technology, particularly telehealth.

32

Recruitment and retention of physicians in rural Alberta: The spousal perspective (Myroniuk, L., Adamiak, P., Bajaj, S., Myhre, D.L.) [42]

2016

Canada

Qualitative study

N = 84 physicians

Semi-structured interviews

High

-Considerations to accommodate the educational, professional and cultural needs of the physician spouse must be highlighted in policy if large areas of underserved rural communities continue to rely on international recruitment.

-Leveraging new technologies to provide online access to education, jobs and connection to family and friends may offer a solution to some of the challenges faced by spouses of physicians that practice medicine rurally.

33

Physician recruitment and retention in rural and underserved areas

(Lee DM, Nochols T) [43]

2014

Canada

and USA

review

n = 86

sources for review/ Canada USA

Academic Search Complete, PubMed and The Cochrane Collaboration

High

-The first strategy is to get the chief executive officer (CEO) involved in physician recruitment, who must: first, develop a recruiting team and meet the team at least quarterly to monitor progress and offer guidance; second, participate in developing marketing and recruiting strategies; third, interview all promising candidates; fourth, financially support the recruiting team’s recommended financial incentives for physicians; fifth, hold the recruiting team members accountable by tying their compensation and advancement in the organization to their recruiting performance; and sixth, request the recruiting team to brief candidates regarding abrasive personalities on the existing medical staff.

34

The role of distributed education in recruitment and retention of family physicians (Lee, J; Walus, A; Billing, R; Hillier, LM) [44]

2016

Canada

Qualitative

Study

N = 32 family physicians who graduated from a DME residency training programme.

Semi structured in person interviews

High

-Resident selection based on a predisposition to work in underserviced areas, related to either interest or family ties, and immersing them in family practice in these areas, can enhance recruitment and retention in underserviced areas.

-Positive residency experiences, established relationships with local specialists, health professionals and community services, and opportunities to practice as they had trained and how they preferred to practice, contributed to physicians’ decision to practice in the same geographical area in which they train.

35

Rural physician supply and retention: factors in the Canadian context

(Fleming, Patrick; Sinnot, Mari-Lynne) [45]

2018

Canada

Review

n = 42 studies

PubMed, Embase, CINAHL and ERIC

High

-Overall strategies to improve retention will ensure a stable physician supply and, therefore, will have benefits for population health over the long term. Locally trained physicians practice longer in their home province than out-of-province graduates and international medical graduates. It is important to ensure that there are rural educational opportunities for learners in undergraduate and postgraduate medical training.31 ultimately, enhanced, forward-thinking retention strategies will improve community health and help correct rural disparities for Canadians.