Factors that influence the choice to work in rural township health centers among 4,669 clinical medical students from five medical universities in Guangxi, China

Purpose: To produce competent undergraduate-level medical doctors for rural township health centers (THCs), the Chinese government mandated that medical colleges in Central and Western China recruit rural-oriented, tuition-waived medical students (RTMSs) starting in 2010. This study aimed to identify and assess factors that influence the choice to work in rural township health centers among both RTMSs and other students from five medical universities in Guangxi, China. Methods: An internet-based self-administered questionnaire survey was conducted with medical students in Guangxi province. Multinomial logistic regression was used to identify factors related to the attitudes toward work in a rural township health center. Results: Among 4,669 medical students, 1,523 (33%) had a positive attitude and 2,574 (55%) had a neutral attitude toward working in THCs. Demographic characteristics, personal job concerns, and knowledge of THCs were associated with the choice of a career in THCs. The factors related to a positive attitude included the following: three-year program, a rural-oriented medical program, being male, an expectation of working in a county or township, a focus on medical career development, some perceived difficulty of getting a job, having family support, sufficient knowledge of THCs, optimism toward THC development, seeking lower working pressure, and a lower expected monthly salary. Conclusion: Male students in a three-year program or a rural-oriented tuition-waived medical education program were more likely to work in THCs. Selecting medical students through interviews to identify their family support and intentions to work in THCs would increase recruitment and retention. Establishing favorable policies and financial incentives to improve living conditions and the social status of rural physicians is necessary.


INTRODUCTION
The unequal distribution of health workers between urban and rural or remote areas is a global concern.Lack of access to health workers in rural regions often leads to comparatively high costs for rural residents in seeking care at urban health facilities [1,2].In China, the rural primary medical institutions consist of a three-tier system including village clinics, township health centers (THCs), and a county hospitals.THCs play an essential role in providing rural medical services [3].It has been well documented that a shortage of qualified medical professionals in THCs is one of the major challenges of the current Chinese healthcare system.The Chinese tertiary medical education system offering bachelor's degrees or above was expanded in 1998, mostly in larger cities.At the same time, secondary medical technical schools offering three years of basic medical training have been left behind [4].Almost all graduates with a university level of education choose to work in big cities.Consequently, rural health institutions such as http://jeehp.orgJ Educ Eval Health Prof 2015, 12: 40 • http://dx.doi.org/10.3352/jeehp.2015.12.40 THCs must employ health workers with limited education [5].To produce competent undergraduate-level medical doctors for rural THCs, the Chinese government started a rural-oriented tuition-waived medical education (RTME) program in 2010.The aim has been to enroll students from rural areas to work in THCs for six years after their graduation [6].The government waived tuition for these students and gave them a certain living allowance during their studies in a medical university.Apart from this, the government has set many other policies favorable to producing competent doctors to serve rural THCs [7].However, there is still a large shortage of doctors in THCs.Therefore, gaining an understanding of current medical students' intent to work in rural THCs is necessary.
The Guangxi Zhuang Autonomous Region is a Southwest province with 82% of the 51.59 million population that lives in rural areas.Currently, there are four medical institutions offering five-year undergraduate-level medical education: Guang xi Medical University (GXMU), Guilin Medical University (GLMU), Youjiang Medical University for Nationalities (YM-UN), and Guangxi Traditional Chinese Medical University (GTCMU).There is one medical institute providing threeyear junior degree education, the Medical College of Guangxi University of Technology (GUT).When the RTME program was established in Guangxi in 2010, the first three medical universities qualified to enroll students were Guangxi Medical University, Guilin Medical University, and Youjiang Medical University for Nationalities.The three universities were geographically located in the south, north, and west of the province.Every year, GXMU was eligible to enroll 100 rural-oriented, tuition-waived medical students (RTMS), and the other two universities were each eligible to enroll 50 students.In addition, all five medical universities matriculate 100 to 400 normal track students according to the quota set by the Ministry of Education for over twenty provinces in China.Whether these students' varying characteristics such as demographic data, perceptions on their career, and knowledge of THCs have an influence on their intention to work in rural THCs has not, to our knowledge, been studied in a large sample of students in multiple universities.
This study aims to survey the intention to work in THCs of medical students in all of the five medical universities in Guangxi province and to identify potential factors contributing to their choices.

Study design
This survey was conducted from May to August 2012 via an internet-based self-administered questionnaire developed by the Department of Education of Guangxi Province.The Em-ployment Guidance Centers in each medical university organized the survey and ensured quality control.

Study population
All third-, fourth-, and fifth-year students in the five-year programs and first-, second-, and third-year students in the three-year program in the five medical schools in Guangxi province were included in the study.

Questionnaire
The questionnaire included four parts: demographic information, personal job concerns and factors influencing them, knowledge of THCs and related factors, and intention to work in a THC.A small pilot study was conducted with paper questionnaires for the first-year medical students in Guangxi Medical University to verify suitability of the questions.Two epidemiologists, a statistician, and two other specialists from the Department of Education reviewed the questionnaires to ensure their validity.

Dataset and ethical clearance
The data was retrieved from Internet centers in all of the medical universities in Guangxi.All personal identification was encrypted.The Ethics Committee of the Guangxi Medical University approved the study protocol.

Data analysis
All data analyses were performed using R version 3.1.3(http: //www.r-project.org) and EpiCalc package 2.15.1.0(http://CR-AN.R-project.org/package= epicalc).The willingness to work in THCs was classified into four levels: (1) I am very willing to work in a THC; (2) I am willing to work in a THC; (3) I will consider working in a THC if I cannot find a job; (4) I will not go to work in a THC even if I cannot find a job.To analyze the data, the first two levels were labeled as a positive attitude, the third level as a neutral attitude, and the fourth level as a negative attitude.The chi-square test was use to study the association of demographic characteristics, personal job concerns, and knowledge of THCs with the three different attitudes toward working in THCs.A multinomial logistic regression model was used to identify the factors related to the attitudes toward working in THCs adjusted for potential confounders.The statistical significance level was set at < 0.05.

RESULTS
Among 5,256 medical students invited to participate in the survey, 4,669 responded, yielding a response rate of 88.8%.Out of the total of 4,669 medical students, 1,523 (33%) of them had positive attitudes, 2,574 (55%) had neutral attitudes, and http://jeehp.orgJ Educ Eval Health Prof 2015, 12: 40 • http://dx.doi.org/10.3352/jeehp.2015.12.40 572 (12%) had negative attitudes toward working in THCs.Table 1 summarizes the demographic characteristics related to different attitudes toward working in THCs.Gender, a one-child family of origin, place of birth, and years of one's educational program, major, and school were found to be significantly related to the type of attitude.Female students, those  not from a one-child family, and those born in a village or county were more likely to have positive attitudes toward working in THCs.
Table 2 shows that the students' personal job concerns and factors influencing them contributed to their attitudes toward working in THCs.The students who expected to work in a county and were focused on relevant studies were more likely to have positive or neutral attitudes.In contrast, those who intended to work in a city were less likely to be willing to work in a THC.As shown in Table 3, the students' knowledge of THCs and THC-related perceptions had a great bearing on their attitudes and choices.The students with optimistic attitudes and somewhat knowledgeable were more willing to work in THCs; meanhttp://jeehp.orgwhile, they had a comparatively lower expected salary compared with the negative and neutral attitude groups.Favorable policies were regarded as the most important facilitating factor, while the three most common inhibiting factors were difficulty of developing skills, low salary and benefits, and poor living conditions.Table 4 shows the adjusted relative risk ratios using a multinomial logistic regression model.The reference group was those students with negative attitudes toward working in THCs.A three-year program and major in rural-oriented medicine were factors promoting intention to work in a rural area.Female students were less positive about rural medical service.The students who expected to work in a county or township and who perceived getting a job to be somewhat difficult were more likely to accept rural work.The most important factors influencing their choice were personal career development, relevance of work to one's major, family support, and salary.Lower working pressure and more opportunities to practice were facilitating factors, whereas poor living conditions and low social status were factors inhibiting work in THCs.

DISCUSSION
Shortages and an uneven distribution of the health workforce have been global issues for a long time .In order to produce more health workers, China has expanded its higher medical education [4,8] and has increased the total number of health workers in the past decade, but this has not resulted in better rural-urban equity [9].Meanwhile, the aging and brain drain of the rural health workforce are making the situation much worse.One study reported that 1,523 out of 4,669 (33%) med-ical students had a positive attitude toward working in rural THCs, and 2,574 (55%) students had a neutral attitude toward working in THCs.It would be feasible to reach the goal of "one doctor, one township hospital" for all of the 1,294 THCs in Guangxi based on the number of graduates produced by medical universities.However, the high rate of mobility of rural doctors to high-level health facilities means that measures to increase retention rather than simple recruitment should be taken [10].
The finding that male students from three-year programs and those majoring in rural-oriented medicine were more likely to choose to work in THCs has important implications.The students from the RTME program were 6.58 times more likely to plan to work in THCs.The three-year program in Guangxi University of technology was another factor promoting rural service.The current RTME program is a five-year bachelor's degree program with a major in clinical medicine.If this program were shifted into a three-year junior college, it would be more likely to produce students with an intention to work in a rural area.
This study also suggested that family support and medical career development were important factors influencing intention to work in a rural area.Other studies have shown similar results-that family and community support were essential to recruitment and retention for rural physicians because of the professional and living isolation involved in rural service [11].In selecting medical students, many countries have used interviews as a non-academic measure to assess students' suitability, which would take students' values and personal characteristics into account [12].An interview process to select those medical students with good family support and interest in developing a http://jeehp.orgJ Educ Eval Health Prof 2015, 12: 40 • http://dx.doi.org/10.3352/jeehp.2015.12.40 career in township hospitals would be recommended.
The fact that students with sufficient knowledge about THCs and optimism towards THC development would be more likely to work in rural THCs has important implications.The World Health Organization has recommended educational interventions to increase recruitment and retention of rural health workers such as recruiting students of rural origin, locating medical schools outside major cities, bringing students to rural communities, and matching curricula with rural health needs.These measures were found to increase medical students' knowledge of and capability to perform rural medical service and have proved to be effective in reality [2].Taking these measures would be helpful in improving the curriculum design and clinical placement of rural-oriented medical education programs.
In addition, providing the appropriate infrastructure and competitive remuneration are necessary strategies to retain a rural health workforce [13,14].This study has revealed that the students who were optimistic about the potential development of THCs had positive attitudes toward rural service.Their expected salary was from 1,000 RMB to 3,000 RMB, which was comparatively low.Meanwhile, poor living conditions and low social status were inhibiting factors.Therefore, the government should continuously offer favorable policies and financial incentives to attract and retain a rural health workforce, while at the same time, to improve the living conditions and social status of rural physicians.
In conclusion, male students in three-year programs or rural-oriented tuition waiver medical education programs were more likely to choose to work in THCs.Selecting medical students through interviewing to identify their family support and intentions to work in THCs would increase recruitment and retention.Designing a proper curriculum and offering rural clinical placement in medical education would increase medical students' knowledge of and capability to perform rural service.Favorable policies and financial incentives to improve the living conditions and social status of rural physicians will be necessary in the long term.

Table 1 .
Demographic characteristics related to attitudes toward working in township health centers a)P-value < 0.001.