Hrev_master [Healthcare in Low-resource Settings 2013; 1:e4] [page 11] Willingness and professional motivations of medical students to work in rural areas: a study in Alexandria, Egypt Aida M. Mohamed Community Medicine Department, Faculty of Medicine, Alexandria University, Egypt Abstract Retaining health workers in rural areas is challenging for a number of reasons, e.g. per- sonal preferences, difficult work conditions and low remuneration. Our aim was to deter- mine the effect of motivational factors on will- ingness to accept postings to rural under- served areas in Alexandria, Egypt and to iden- tify perceived attributes of rural service.,A cross-sectional survey involving 302 4th-year medical students was conducted in March-July 2012. Logistic regression analysis was used to assess the association between students’ will- ingness to accept rural postings and their pro- fessional motivations, rural exposure and fam- ily parental professional and educational sta- tus (PPES). Perceived attributes to rural serv- ice were also assessed. Over 85% students were born in urban areas and 41.4% came from affluent backgrounds. More than half students reported strong intrinsic motivation to study medicine. After controlling for demographic characteristics and rural exposure, motivation- al factors significantly influenced willingness to practice in rural areas. High-family PPES was consistently associated with lower willing- ness to work in rural areas. A sizable portion of medical students are motivated to study and practice medicine in rural areas. Efforts should be made to build on motivation during medical training and designing rural postings, as well as favor lower PPES students for admission and improving organizational and contextual issues of rural service. Introduction The World Health Organization (WHO) esti- mates that more than 4 million health workers are needed to fill the health workforce gap globally.1 This includes 2.4 million physicians, nurses and midwives. Fifty-seven countries are defined as having a critical shortage of health staff; of these, 36 are in Sub-Saharan Africa. Medical services in Egypt greatly suffer shortage of healthcare workers; however, sta- tistics from Egypt concerning this is lacking. Africa has only 3% of the the total world’s health work force (59.2 million people), in spite of having 25% of the global burden of dis- ease.1,2 The shortage of health staff cripples the health delivery system. It is also a threat to pro- vision of essential, life-saving interventions such as childhood immunizations, provision of safe water, safe pregnancy and childbirth serv- ices for mothers as well as access to treatment for AIDS, tuberculosis and malaria. Health workers are critical to the global preparedness for and response to threats posed by emerging and epidemic-prone diseases. Different inter- ventions have been tried to address these shortages. Four main downstream interven- tions have been implemented by developed and developing countries: financial incentives, pro- vision of education opportunities, interven- tions supporting the work of health profession- als and regulatory mechanisms, such as com- pulsory services in underserved areas.2 Health worker shortages in rural areas have been identified as one of the biggest chal- lenges to the health sector and a barrier to reaching the country’s health-related Millennium Development Goal targets.3 While the public sector has made considerable efforts to place doctors (and a variety of other health workers) in rural areas, issues like absen- teeism, ghost doctors, and dual practice have compromized the effectiveness of this effort. Retaining health staff in rural areas has proven extremely difficult as young profession- als increasingly prefer urban postings and health systems do not reward rural service.4 Qualitative research has also shown the importance of healthcare providers’ personal characteristics and value systems, such as reli- gious beliefs and socio-political convictions, to their motivation towards rural practice. Emigration of skilled professionals to high- income countries is another barrier to ade- quate staffing of health facilities.5 A study in Ghana in 2006 on trainee physicians and nurs- es revealed that the majority had considered emigrating. More physicians (68%) than nurs- es (57%) considered emigration.6 These find- ings imply that achieving improvements in the health status of people living in low-income countries, and particularly, in rural areas, will be extremely difficult.7 This highly uneven distribution between urban and rural areas is rooted in the fact that cities offer better incomes (e.g. the potential for private practice), more opportunities for career progression, better infrastructure and more social amenities than rural areas.8 While previous research has looked at incentives and working conditions to promote uptake of rural posts, few studies have focused on motivation crowding and its effect on willingness to accept postings to rural area. Motivation crowding is the conflict between external fac- tors (extrinsic), such as monetary incentives or punishments, and the underlying desire or willingness to work (intrinsic) in areas need- ed most. Students may have a mix of extrinsic and intrinsic motivations for studying medi- cine.9 Relatively little research has been con- ducted on effective strategies to promote rural practice, particularly in low-income coun- tries.10 To tackle the uneven distribution of human resources for health, understanding the factors that motivate medical students to study and practice medicine and their willing- ness to accept postings to rural underserved area is essential. This study was conducted to determine the effect of motivational factors on stated willing- ness to accept postings to rural underserved areas in Alexandria, Egypt and to identify per- ceived attributes of rural service. Materials and Methods Study design, setting and target population This descriptive cross-sectional survey was conducted between March and July 2012 in the Alexandria Faculty of Medicine. Medical edu- cation consists of three years of basic sciences (BSc), and three years of clinical training at a Healthcare in Low-resource Settings 2013; volume 1:e4 Correspondence: Aida M. Mohamed, Community Medicine Department, Faculty of Medicine, Alexandria University, Al-Khartom square, Alexandria, Egypt. Tel./Fax: +203.12792.9039. E-mail: aida_mohey@yahoo.com Key words: health manpower, motivation, rural health services, Egypt. Acknowledgments: I am greatly indebted and grateful to Alexandria medical students who made this study possible. They devoted some of their precious time in helping me to collect the data. Contributions: the authors contributed equally. Conflict of interests: the authors declare no potential conflict of interests. Received for publication: 12 December 2012. Revision received: 10 February 2013. Accepted for publication: 16 February 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright A.M. Mohamed., 2013 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2013; 1:e4 doi:10.4081/hls.2013.e4 No n- co mm er cia l u se on ly [page 12] [Healthcare in Low-resource Settings 2013; 1:e4] teaching hospital in rotating housemanship. A stratified random sample of medical students was invited to participate in the study. Stratification is based on the clinical round rotations (4 groups in 4 clinical rounds of dif- ferent departments). Fourth-year medical stu- dents were selected because they had complet- ed the BSc, and had also been exposed to field work, but had not yet made their final deci- sions about rural or urban practice. The total number of fourth year students was 960. Sex distribution reflects that males (n=576) outnumbered females (n=384) (fac- ulty registration year: 2012). With the assump- tion that students’ willingness to work in rural areas was 30% and using a significant level of 0.05, a sample size of 355 fourth-year Alexandria medical school was selected with equal proportionate to clinical round size (n=120), a sample of approximately 45 stu- dents from each clinical round (n=8) was ran- domly enrolled. Data collection Data collection was preceded by approvals from the heads of the involved departments, who were informed of the content of the ques- tionnaire and provided access to the student population. The data collection instruments were developed after three-focus group discus- sions of 6-8 participants facilitated by the trained investigator. The themes for the focus group discussion were motivation, willingness to work in deprived areas, and the influence of background characteristics on willingness to work in deprived areas. The survey instrument – which included structured questions – was then pre-tested and finalized for the study. The questionnaires were administered to the stu- dents in their clinical departments at the Faculty of Medicine. The survey format took 30 min to be filled on average. The questionnaires covered the following domains. i) Students were asked to rate how likely they were to work in a deprived area (at any time in their careers) on a scale from 1-4, where 1 represented I will definitely not work in a deprived area; 2 I am unlikely to work in a deprived area; 3 I am likely to work in a deprived area; and 4 I will definitely work in a deprived area. This response set was collapsed to a dichotomous willing (groups 3 or 4) vs unwilling (groups 1 or 2) to practice in a deprived area. Deprived area was defined as a rural area that is distant from the big cities with few social amenities such as schools, roads, pipe-borne water, etc.2 ii) Students were also asked to identify any of the 12 factors (identified as important by the focus group discussions) that motivated them to study and practice medicine. The five intrin- sic motivations included: desire to help others, desire to give back to their home community or country, interest in medicine as a subject mat- ter, inspiration by a role model, and loss of a loved one. The seven extrinsic motivation fac- tors included: income of physicians, job securi- ty and lifestyle, social status/prestige, proposed by parents, opportunities to travel and work internationally, ability to use new cutting-edge technologies, and research opportunities. Motivation factors were coded as no=0 and yes=1. Respondents were coded as having strong intrinsic or extrinsic motivation if total score was ≥3. Thus, strong intrinsic and extrin- sic motivation groups were mutually exclusive. iii) Socio-demographic factors included: sex, age, marital status and parental profes- sional and educational status (PPES). High PPES was defined as having a mother and/or father who is a university-trained professional (e.g. doctor, lawyer, engineer, accountant, tech- nical, etc.) and low PPES was defined as hav- ing neither mother nor father as a university- trained professional. iv) Rural (an area with a population less than 5000) exposure factors included: birth location (urban vs rural), having ever lived in rural area (from the age of 5 onwards), and exposure to rural service in medical training (for a minimum of 6 months). v) The students were also asked to indicate the strength of a set of important organization- al and contextual attributes and conditions for rural practice. These identified through a liter- ature review and discussions with physicians from the Ministry of Health and practicing physicians. Ethical considerations The study received ethics approval from the Ethical Review Committee at the Alexandria Faculty of Medicine. All respondents voluntari- ly participated after the intent and design of the study were explained to them and signing informed consent forms. The study partici- pants were assured of anonymity and confi- dentiality, in responding to the questions. Confidentiality of the data was maintained throughout the study. Statistical analysis The study used SPSS version 18.0 for data entry and statistical analyses. Descriptive sta- tistics such as frequency, percentage, mean and standard deviation (SD) were conducted to describe socio-demographic characteristics and rural exposure as well as perceived attrib- utes to rural service. Bivariate associations and 95% confidence intervals (CIs) were esti- mated using multivariate logistic regression analysis. The main outcome of interest was the willingness to work in a deprived area after graduation. Predictors of interest included motivation (intrinsic and extrinsic), demo- graphic characteristics, and rural exposure variables. Significance was set at 0.05 level. Results Socio-demographic characteristics and rural exposure Of the 355 eligible medical students, 302 par- ticipated in the survey (85.0% response rate). The socio-demographic characteristics of respondents are presented in Table 1. Of the 302 respondents recruited for the study, the majori- ty were male (60.6%), with a mean age of 20.9 (SD 1.4). Only 5.6% of them were married or engaged. Most respondents were born in or around urban areas (87.4%) and had never lived in rural underserved area (75.8%). In terms of socio-economic status, more than half of stu- dents (58.6%) came from low PPES families and the rest (41.4%) came from affluent back- grounds. About one fifth of the respondents (20.2%) were exposed to rural service (rural outreach or service during medical studies). Professional motivation and likeli- hood of working in an underserved area Willingness to work in underserved area according to the intensities of current motiva- tional factors is presented in Table 2 and Figure Article Table 1. Socio-demographic characteristics and rural exposure of Alexandria medical students (n=302). Variable Frequency (n) % Sex Male 183 60.6 Female 119 39.4 Age mean (SD) 20.9 (1.40) Family PPES Low° 177 58.6 High# 125 41.4 Marital status Married or engaged 17 5.6 Not in a relationship 285 94.4 Birth area Urban§ 264 87.4 Rural^ 38 12.6 Ever lived in rural area$ Yes 73 24.2 No 229 75.8 Exposed to rural service°° Yes 61 20.2 No 241 79.8 SD, standard deviation; PPES, parental professional and educational status. °Low-family PPES, neither mother nor father is a university- graduated professional; #high-family PPES, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.); §urban area defined as a place with more than 5000 residents; ^rural area defined as a place with less than 5000 residents; $from age five onwards; °°participated in out- reach or service in a deprived area during medical studies. No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e4] [page 13] 1. Overall, 158 (52.3%) students stated that they were likely to or definitely would work in an underserved area. More than half of students (181, 59.9%) had strong intrinsic motivation to study medicine. A significantly higher propor- tion of respondents who had strong intrinsic motivation (61.3%) indicated willingness to work in a rural area, compared to those with weak intrinsic motivation (38.8%) (χ2=7.952, P=0.008). Significantly higher proportions of those motivated to study medicine by the desire to give back to their home community or coun- try (64.0%) were willing to work in an under- served area as compared to 36.0% who would not like to work in rural area (P=0.007). More than two-thirds of students (203, 67.2%) had strong extrinsic motivation to study medicine. The results were reversed for those with strong extrinsic motivation. A significantly lower pro- portion of respondents who had strong extrinsic motivation (35.0%) indicated willingness to work in a rural area, compared to those with weak extrinsic motivation (87.9%) (χ2=8.121, P=0.003). Article Table 2. Willingness and current motivations of Alexandria medical students (n=302) to work in an underserved area according to fac- tors that motivated them to study and practice medicine. Factors motivating Alexandria medical Total (n) Willingness to work in an underserved area χ2 test students to study and practice medicine° (P value) Unlikely Likely Domain Items n % n % Intrinsic motivation Desire to help others 284 135 47.5 149 52.5 3.764 (0.836) Desire to give back to their 114 41 36.0 73 64.0 7.942 home community or country (0.007)* Interest in medicine as a subject matter 118 62 52.5 56 47.5 3.968 (0.802) Inspiration by a role model 84 60 71.4 24 28.6 8.032 (0.003)* Loss of a loved one 13 12 92.3 1 7.7 FE(0.000)* Weak motivation# 121 74 61.2 47 38.8 7.952 (0.008)* Strong motivation§ 181 70 38.7 111 61.3 7.952 (0.008)* Extrinsic motivation Income of physicians 216 174 80.6 42 19.4 7.523 (0.009)* Job security and lifestyle 119 76 63.9 43 36.1 6.236 (0.028)* Social status/prestige 212 192 90.6 20 9.4 9.612 (0.000)* Proposed by parents 59 32 54.2 27 45.8 2.754 (0.814) Opportunities to travel and work internationally 181 112 61.9 69 38.1 6.034 (0.033)* Ability to use new cutting-edge technologies 109 100 91.7 9 8.3 8.632 (0.002)* Research opportunities 23 22 95.7 1 4.3 FE(0.000)* Weak motivation# 99 12 12.1 87 87.9 8.121 (0.003)* Strong motivation§ 203 132 65.0 71 35.0 Total 302 144 47.7 158 52.3 - FE, P value of Fisher exact test; * significant at 0.05 level. Categories are not mutually exclusive. °Motivation factors were scored as 0=no, 1=yes. Maximum possible score for intrinsic factors=5 and that for extrinsic factors=7; #score<3 ; §score ≥3. Figure 1. Willingness of Alexandria medical students (n=302) to work in an underserved area according to strength of factors that motivated them to study medicine. No n- co mm er cia l u se on ly [page 14] [Healthcare in Low-resource Settings 2013; 1:e4] Multivariate analysis of motivations and the willingness to accept post- ings in a rural underserved area after graduation Multivariate logistic regression results for strength of intrinsic motivation and willing- ness to work in a rural underserved area after graduation are presented in Table 3. Variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. In the final adjusted model, having a strong intrinsic moti- vation increased the odds of being willing to accept a job in an underserved area [adjusted odds ratio (AOR)=2.6, 95% CI 1.3-8.2]. In the model adjusting for demographics, high PPES were associated with reduced willingness to practice in underserved areas (AOR=0.4, 95% CI 0.2-0.8). While a higher age was associated with greater willingness to practice in a rural area (AOR=3.1, 95% CI 1.8-7.5). Living in a rural area was significantly associated with greater willingness to practice in a rural area (AOR=3.2, 95% CI 1.8-7.4). These variables constituted 80% of factors influencing the will- ing to work in a deprived area (R2=0.798) with an overall model (Likelihood ratio χ2=33.48, P=0.000). Table 4 shows the multivariate logistic regression results for the strength of extrinsic motivation and willingness to work in a rural underserved area after graduation. Variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. In the final adjusted model, a strong extrinsic motivation reduced the odds of being willing to accept a job in an underserved area (AOR=0.5, 95% CI 0.3-0.9). Demographic factors, female gender (AOR=0.4, 95% CI 0.3-0.8), and high PPES (AOR=0.4, 95% CI 0.2-0.7) were associated with reduced willingness to practice in a deprived area while a higher age was associat- ed with greater willingness to practice in a rural area (AOR=3.8, 95% CI 1.9-8.4). Living in a rural area was significantly associated with greater willingness to practice in a rural area (AOR=3.4, 95% CI 1.7-7.0). These variables constituted 83% of factors influencing the will- ing to work in a deprived area (R2=0.826) with an overall model (Likelihood ratio χ2=31.33, P=0.000). Perceived attributes of rural service Table 5 shows students’ perceived organiza- tional and contextual factors pertaining to liv- ing in a rural area. Organizational factors Financial attributes The vast majority of students (96.7%) felt that a substantially higher salary is a strong attribute if they are to take up a rural job. Facilities One of the strong issues that medical stu- dents have with working in a rural area is the availability of infrastructure (staff, drugs, equipment, diagnostics, and physical structure of the health center) to treat patients: this was felt by 69.5% of students. Moreover, a good physical work environment (e.g. clean sur- roundings, good furniture) and having men- tors were perceived to be important attributes by 65.6% and 62.9% of students, respectively. Organizational culture, policies and management Many students expressed their need for hav- ing clarity in the process for taking leave (60.3%), and transfer policies (59.6%). Career growth opportunities The vast majority of medical students (93.7%) aspire to further specialize. Lower proportions felt that following graduation they were inadequately learned or trained to treat patients. The need for learning opportunities was perceived by 66.2% and for training oppor- tunities by 65.6%. Contextual factors Expectedly living facilities (housing, elec- tricity, water, access to the market, hygiene) are felt as a strong attribute by almost the entire number of students except two (99.3%). Moreover, a lower proportion (71.9%) felt the need for security (physical security, legal pro- tection against political interference). Article Table 3. Multivariate logistic regression analysis of strength of intrinsic motivation and the willingness of Alexandria medical students (n=302) to accept postings to rural under- served area after graduation. Independent variables Willingness to accept postings to rural underserved area after graduation OR CI P value Strong intrinsic motivation to study medicine 2.6 1.3-8.2 0.001* Socio-demographics Female 0.5 0.3-1.09 0.634 Age (years) 3.1 1.8-7.5 0.000* High-family PPES° 0.4 0.2-0.8 0.011* Married or in a relationship 0.9 0.5-1.7 0.621 Rural exposure Born in a rural area 1.4 0.5-4.3 0.321 Lived in a rural area 3.2 1.8-7.4 0.009* Exposed to rural service 1.5 0.8-2.8 0.467 R2 0.798 Likelihood ratio χ2, P 33.48, P=0.000* OR, odds ratio; CI, confidence interval; PPES, parental professional and educational status. °High-family PPES, mother and/or father is a uni- versity-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). Table 4. Multivariate logistic regression analysis of strength of extrinsic motivation and the willingness of Alexandria medical students (n=302) to accept postings to rural under- served area after graduation. Independent variables Willingness to accept postings to rural underserved area after graduation OR CI P value Strong extrinsic motivation to study medicine 0.5 0.3-0.9 0.001* Socio-demographics Female 0.4 0.3-0.8 0.016* Age (years) 3.8 1.9-8.4 0.000* High-family PPES° 0.4 0.2-0.7 0.012* Married or in a relationship 0.9 0.5-1.7 0.583 Rural exposure Born in a rural area 1.4 0.5-4.3 0.264 Lived in a rural area 3.4 1.7-7.0 0.012* Exposed to rural service 1.5 0.8-2.8 0.531 R2 0.826 Likelihood ratio χ2, P 31.33, P=0.000* OR, odds ratio; CI, confidence interval; PPES, parental professional and educational status. °High-family PPES, mother and/or father is a uni- versity-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e4] [page 15] Connectivity (transport availability, no sense of isolation) is expressed by 69.9% of students. Discussion The present study found that more students reported strong intrinsic motivation compared to high extrinsic motivation to study medicine. This may reflect the underlying altruistic moti- vation for many students entering a profession focused on serving others.6,7 Moreover, despite the fact that study participants were assured of anonymity and confidentiality in responding to the questions, 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. For this reason, a meas- ure of high intrinsic and extrinsic motivation was selected for use in the regression models. Research comparing students stated inten- tions with their actual career choices during internship is urgently needed as few studies on matched follow-ups are available. In addi- tion, most students participating in the study were young and had not yet tasted the rigors of working in a rural area, which may have affect- ed their job preferences. Thus, the findings of this study may not be applicable to practicing physicians. From the work of Serneels11 and Hanson,12 it appears that these two groups may differ in their preferences for rural practice. In this study, a strong extrinsic motivation was associated with reduced reported willing for rural practice and the reverse was true for high intrinsic motivation. Similar results were reported in other studies.13,14 Interestingly, this association remained statistically significant at the 95% CI in models with demographic and rural exposure confounders. Studies conducted outside Egypt have found rural origin to be an important motivator for rural practice.15-17 In contrast to this, the pres- ent study found that rural origin did not influ- ence students’ willingness to work in rural areas after controlling for intrinsic/extrinsic motivation and demographic characteristics. The difference could be due to the socio-cultur- al differences between different locations. This study highlights the importance of locally- relevant data for decision making. High socio-economic status, measured using parental education and profession, was consistently associated with lack of willing- ness to work in rural areas. This finding sug- gests that admission policies favoring well-to- do applicants may reduce 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 motivation and rural exposure variables. This is consistent with similar studies which revealed that women are less likely to accept positions in remote areas due to varying fami- ly reasons; they would like to live where their husbands’ jobs are, have difficulties convinc- ing their husbands to follow them to rural areas and want their children to have better education in urban areas.18-20 The studies fur- ther explained that female doctors rarely live in the same village as their assigned post and have higher overall absentee rates in rural practice.20,21 With increasing representation of female healthcare professionals,18 it is likely that the supply of health staff to rural under- served areas will remain a major setback if professional motivations are designed to attract more female students to rural practice. More research is urgently needed to determine how female healthcare professionals’ motiva- tions towards rural practice can be better engaged by policy-makers. The present study examined the perceived factors that encourage graduates to work in a Article Table 5. Perceived attributes of rural service by Alexandria medical students (n=302). Attributes Student perception Weak attribute Strong attribute n % n % Organizational factors Financial attributes Increase in salary 10 3.3 292 96.7 Facilities Good clinic infrastructure 92 30.5 210 69.5 Good physical work environment 104 34.4 198 65.6 Availability of monitoring staff 112 37.1 190 62.9 Availability of support staff 140 46.4 162 53.6 Adequate workload 142 46.0 160 53.0 Organizational culture, policies and management Regulatory policies 152 50.3 150 49.7 Policies on leave 120 39.7 182 60.3 Transfer policies 122 40.4 180 59.6 Job security 241 79.8 61 20.2 Management 132 43.7 170 56.3 Career growth opportunities Learning opportunities on the job 102 33.8 200 66.2 Training opportunities 104 34.4 198 65.6 Research opportunities 212 70.2 90 29.8 Post-graduation opportunities 19 6.3 283 93.7 Contextual factors Living facilities 2 0.7 300 99.3 Proximity to family 123 40.7 179 59.3 Children development (education) 258 85.4 44 14.6 Family well-being and comfort 190 62.9 112 37.1 Security 85 28.1 217 71.9 Connectivity (transport) 91 30.1 211 69.9 Social life 164 54.3 138 45.7 Community type 202 66.9 100 33.1 Categories are mutually exclusive. No n- co mm er cia l u se on ly [page 16] [Healthcare in Low-resource Settings 2013; 1:e4] rural area. It was found that the students val- ued rural job attributes with appropriate salary, that enabled them to perform well clinically (improved infrastructure, physical work envi- ronment and monitoring staff), to grow profes- sionally (career growth opportunities, espe- cially for post-graduation), and that provided adequate living facilities, security and connec- tivity. This is consistent with what has emerged from focus group discussions with Ghana students, who expressed doubts about being able to apply their clinical skills to help patients in poorly equipped rural hospitals where basic inputs such as electricity and sup- ply of medicines were unreliable.22 These findings are consistent with the results of studies in Ghana23 and Ethiopia12 in which housing facilities and security were scored as the most important determinants for accepting postings to rural areas. Moreover, in several case studies in middle- and low-income countries, supportive supervision has been noted to improve motivation among health work- ers to rural practice and quality of care.24-26 In Uganda, Kaye et al. found that a community based training experience of graduates signif- icantly influenced their choice to work in a rural and underserved area, compared with their counterparts from the traditional curricu- lum.27 An interesting experiment is under way in Zambia, where the government, with sup- port from development partners, has instituted several measures to recruit and retain physi- cians in rural areas. Interventions included the refurbishment of government housing, school fees, car loans, improved hospital equipment and assistance with placement for post-gradu- ate training at the end of a 3-year contract.28 This study has certain implications. First, the majority of students have high intrinsic motivation for rural service. More research is needed to determine the potency of this moti- vation source in real-life decision making and how to best engage it in health policy. It is pos- sible 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 favor of rural areas. In addi- tion, 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 rota- tions is likely to depend heavily on having ade- quate local infrastructure and mentorship.17 Second, the current results suggest that effective strategies to promote and support rural practice after graduation should be implemented and evaluated. It was suggested that students may be willing to commit to short-term placements of 2 years or less in rural areas.29 The Ministry of Health may want to consider the possibility of short contracts that rotate physicians in and out of difficult staff rural areas. Conclusions A sizable portion of students reported high intrinsic motivation and therefore it is impor- tant to appeal and build on this in medical school curricula and in designing rural post- ings. However, extrinsic motivation and, per- haps most importantly, gender and socio-eco- nomic status, will likely continue to be impor- tant factors in deciding on job postings. The present research also suggests that increasing efforts to recruit medical students from low socio-economic backgrounds may be the most effective current pathway to increasing the yield of physicians willing to practice in under- served areas. Financial incentives from central or local governments would attract health workers to rural areas. Well planned strategies can help identify effective and efficient human and non-human resources for meeting the health needs of underserved rural populations in Alexandria. References 1. World Health Organization. The world health report 2006: working together for health. Geneva: World Health Organization ed.; 2006. 2. Grobler L, Marais BJ, Mabunda SA, et al. Interventions for increasing the propor- tion of health professionals practicing in rural and other underserved areas. Cochrane Db Syst Rev 2009;1:CD005314. 3. Asante AD, Zwi AB. Factors influencing resource allocation decisions and equity in the health system of Ghana. Public Health 2009;123:371-7. 4. Nadeem N, Muhammed A. Brain drain: causes and implications. Karachi: DAWN; 2004. 5. Garbarino S, Lievens T, Quartey P, Serneels P. Ghana qualitative health work- er study: draft report of preliminary descriptive findings. Accra: Oxford Policy Management Publ.; 2007. 6.United Nations Development Programme. Country fact sheets: Ghana. Geneva: UNDP ed.; 2009. 7. Anarfi JK. Migration expectations of trainee health professionals in Ghana. Accra: Institute of Statistical, Social and Economic Research and the University of Ghana Publ.; 2006. 8. Dussault G, Franceschini MC. Not enough there, too many here: understanding geo- graphical imbalances in the distribution of the health workforce. Hum Resour Health 2006;4:12. 9. Frey BS, Reto J. Motivation crowding theo- ry: a survey of empirical evidence. J Econ Surv 2001;15:589-611. 10. Wilson NW, Couper ID, De Vries E, et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural Remote Health 2009;9:1060. 11. Serneels P, Lindelow M, Montalvo JG, Barr A. For public service or money: under- standing geographical imbalances in the health workforce. Health Policy Plann 2007;22:128-38. 12. Hanson K, Jack W. Health worker prefer- ences for job attributes in Ethiopia: results from a discrete choice experiment (work- ing paper). Washington, DC: Georgetown University Publ.; 2008. 13. Munga M, Mbilinyi D. Non-financial incentives and retention of health workers in Tanzania. Dar es Salaam: National Institute for Medical Research ed.; 2008. 14. Kuehn BM. Global shortage of health work- ers, brain drain stress developing coun- tries. JAMA-J Am Med Assoc 2007;298: 1853-5. 15. Dovlo D. The brain drain and retention of health professionals in Africa. Accra: Medact ed.; 2003. 16. Akerlof GA. Labor contracts as partial gift exchange. Q J Econ 1982;97:543-69. 17. Ghana Ministry of Health. The Ghana health sector 2009 programme of work: change for better results: improving maternal and neonatal health. Accra: Ministry of Health Publ.; 2009. 18. Fritzen SA. Strategic management of the health workforce in developing countries: what have we learned? Hum Resour Health 2007;5:4. 19. Kletke PR, Marder WD, Silberger AB. The growing proportion of female physicians: implications for US physician supply. Am J Public Health 1990;80:300-4. 20. Knaul F, Frenk J, Aguilar A. The gender composition of the medical profession in Mexico: implications for employment pat- terns and physician labor supply. J Am Med Women Assoc 2000;55:32-5. 21. White CD, Willet K, Mitchell C, Constantine S. Making a difference: edu- cation and training retains and supports rural and remote doctors in Queensland. Rural Remote Health 2007;7:700. 22. Kruk ME, Johnson JC, Gyakobo M, et al. Rural practice preferences among medical students in Ghana: a discrete choice experiment. B World Health Organ 2010; 88:333-41. 23. Snow R, Asabir K, Mutumba M, et al. Policy talk: how Ghanaian doctors would improve Article No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2013; 1:e4] [page 17] retention in rural service. In: Proceedings of the Ghana Health Summit 2010: From Strategy to Action, 2009 Apr 26-30, Accra, Ghana. 24. Hole AR. Modelling heterogeneity in patients’ preferences for the attributes of a general practitioner appointment. J Health Econ 2008;27:1078-94. 25. Loevinsohn BP, Guerrero ET, Gregorio SP. Improving primary health care through systematic supervision: a controlled field trial. Health Policy Plann 1995;10:144-53. 26. Bosch-Capblanch X, Garner P. Primary health care supervision in developing countries. Trop Med Int Health 2008;13:369-83. 27. Douglas M. Supervision of rural health centres in Papua New Guinea: consolida- tion of the delivery of health services. Papua New Guinea Med 1991;34:144-8. 28. Kaye DK, Mwanika A, Sewankambo N. Influence of the training experience of Makerere University medical and nursing graduates on willingness and competence to work in rural health facilities. Rural Remote Health 2010;10:1372. 29. Koot J, Martineau T. Mid term review. Zambian health workers retention scheme (ZHWRS) 2003-2004. Lusaka: Ministry of Health Publ.; 2005. Article No n- co mm er cia l u se on ly