We found that twice as many students reported high intrinsic motivation compared to high extrinsic motivation to study and practice medicine. This may reflect the underlying altruistic motivation for many students entering a profession focused on serving others [12, 13]. There may also be an element of social desirability bias in the students' responses as intrinsic motivation may be thought to be more socially acceptable than extrinsic motivation. Nonetheless, we found that high extrinsic motivation was associated with low self-reported likelihood of rural practice and that the converse was true for high intrinsic motivation [2, 3]. Interestingly, this association lost statistical significance at the 95% confidence level in models with demographic and rural exposure confounders, whereas socioeconomic status (PPES) retained a highly influential role, as discussed below.
In this study, rural origin did not influence students' willingness to practice in rural areas after controlling for intrinsic/extrinsic motivation and demographic characteristics. This is in contrast with studies which have found rural origin to be an important motivator for rural practice [8, 17, 23]. Our findings highlight the heterogeneity of trends in motivation dynamics for rural practice and the importance of locally-relevant data for decision making. High PPES, measured using parental education and profession, was consistently associated with lack of willingness to work in rural areas. This is concerning as nearly 6 in 10 medical students in this cohort were from high PPES backgrounds--which is typical for Ghanaian medical schools . These findings suggest that admission policies that favour well-to do applicants may be reducing the pool of students willing to consider rural practice. Female gender was also strongly associated with reduced interest in rural practice for women even after controlling for extrinsic/intrinsic motivation and rural exposure variables. This is consistent with similar studies among health staff which revealed that women are less likely to accept positions in remote areas due to varying family reasons; they would like to live where their husbands jobs are, have difficulties convincing their husbands to follow them to rural areas and want their children to have better education in the urban areas [10, 11, 22]. The studies further explained that female doctors rarely live in the same village as their assigned post and have higher overall absentee rates in rural practice [19, 20]. With increasing representation of female healthcare professionals in many places in sub-Saharan Africa, [10, 11], it is likely that the supply of health staff to rural underserved areas will remain a major setback if professional motivations are designed to attract more female students to rural practice. Although our study showed a lower proportion of female medical students in Ghana compared to other areas, they are likely to become a more important cadre in the coming years [11, 19]. More research is urgently needed to determine how female healthcare professionals' motivations towards rural practice can be better engaged by policy-makers.
The limitations of this study include the possibility of social desirability bias in responses on motivation and likelihood of rural practice, as noted above. Despite the fact that study participants were assured of anonymity, confidentiality, in responding to the questions, some social desirability bias is likely. For this reason, we selected a measure of high intrinsic and extrinsic motivation for use in the regression models. Research comparing students stated intentions with their actual career choices during internship is urgently needed as few studies on matched follow-ups are available. In addition, most the students participating in the study were young and had not yet tasted the rigors of working in a rural area, which may affect their job preferences. Thus the findings of this study may not be applicable to practicing physicians. Finally, these findings are only generalizable to students in the current medical education system. The findings may be different if selection criteria for medical school admission change.
The major strengths of this study are its high response rate of 99% and that its ability to capture an entire population of young medical students who are one of the targets for addressing the rural-urban health staff recruitment imbalance. Surveying practicing physicians would have missed out those who had migrated.
This study has several implications. First, the majority of students profess high intrinsic motivation for rural service. More research is needed to determine the potency of this motivation source in real-life decision making and how to best engage it via HRH policy. It is possible that emphasizing the community service aspect of medical practice and elevating the status of rural primary care in under-graduate and post-graduate training may help narrow the gap between motivation and eventual career choice in favour of rural areas. In addition, well-supervised and supported rural placements in which students experience the rewards of rural practice may help to persuade students who are largely unfamiliar with rural life. However, the success of these rural rotations is likely to depend heavily on having adequate local infrastructure and mentorship [13, 23].
Second, admission criteria may need to be reconsidered in light of the strong relationship between high PPES and lack of interest in rural practice. For example, medical school admission slots might be reserved for qualified students from poorer families. These students may not need to come from rural areas as we found that none of the rural exposure factors were significant after controlling for motivation and demographics.
Third, our results suggest that programmes to promote and support rural practice after graduation may have some success. Our focus groups and discrete choice experiment suggested that students may be willing to commit to short-term placements of 2 years or less in rural areas . The Ministry of Health may want to consider the possibility of short contracts that rotate physicians in and out of difficult to staff rural areas.