Perception about Working in Rural Area after Graduation and Associated Factors: A Study among Final Year Medical Students in Medical Schools of Southeast Nigeria

Aims: Aim of study was to determine the perception of rural medical practice among final year medical students in medical schools of southeast Nigeria and the associated factors. Study Design: Descriptive cross-sectional study. Methodology: All the final year medical students in southeast Nigeria were recruited and were eligible for voluntary participation in the study. The students were interviewed using a pretested, self-administered questionnaire. Data analysis was done using STATA statistical software; version 13 and level of significance was determined at a p value of less than 0.05. Results: Four hundred and fifty seven medical students participated in the study representing a response rate of 86.7%. The mean age of the students was 25.5±2.9 years and majority (57.1%) were male. A minor proportion of the students (13.6%) were willing to practice in the rural area after graduation. Majority of the students (80.1%) were of the opinion that doctors working in rural area should earn more than their urban counterparts. Factors associated with willingness to practice in rural area included family residence in an urban area (AOR= 0.4, 95% CI: 0.2 – 0.9); work experience before admission into medical school (AOR= 2.0, 95% CI: 1.1- 3.9); intention to specialize in Community Medicine (AOR= 3.1 95% CI: 1.2- 7.7) and satisfaction with rural community posting, (AOR=2.1, 95% CI: 1.2- 3.9). Conclusion: Majority of the students were unwilling to work in rural area after graduation. Knowing the need for doctors in rural practice, a re-orientation of the students on rural practice through adequate community exposure during rural posting is essential. There is also need for increased allowances for doctors working in rural areas and opportunities for training and or further studies should be encouraged.


INTRODUCTION
Globally there is an uneven distribution of all cadres of health workers, leaving countries in dire need of health services with the least number of health workers [1]. Similarly, within regions and countries, there is an urban-rural disparity in the distribution of health workers. For example, while about 55% of all people in the world reside in urban area, as much as 75% of the global doctor population render their services there [2]. This has prompted global policy recommendations by the World Health Organization (WHO) on how to increase access to health workers to rural areas through improved retention [3].
The WHO has emphasized that 57 countries of the world have a critical shortage of health workers and 36 of these countries are in sub-Saharan Africa including Nigeria [2]. This shortage of health workers has serious implications in the realization of the healthrelated Millennium Development Goals [4][5][6]. Consequently, these shortages have been found to be associated with high maternal mortality ratio and high infant and under five mortality rates. This situation appears unchanged as doctors are continually attracted more to the urban than the rural areas because of better income, good career opportunities, good infrastructure and social amenities [7]. Perhaps this constant deficit in distribution of health workers with regards to rural areas necessitated the suggestion on the need to attract and retain health workers in rural areas [8].
In Nigeria, 54% of the populace reside in rural area [9] where the health workers including the doctor-population are fewer resulting in poorer health indices when compared to the urban [10]. With all these in mind, it is not surprising that urban inhabitants have a three-fold greater access to doctors compared to those in rural area [11]. Also, bearing in mind that final year medical students will in no distant time be part of the total doctor population, this study was conducted among final year medical students in medical schools of southeast Nigeria to determine their willingness to practice in the rural area after graduation and the associated factors.

Setting
The study was conducted in medical schools in southeast Nigeria, which is one of the six geopolitical zones in Nigeria. It is made up of five states including Abia, Imo, Ebonyi, Anambra and Enugu states. It has a population of 16, 381, 729 people [12] within a total area of 28, 987 square kilometer [13]. The inhabitants are mostly of Igbo ethnic nationality and are predominantly Christians.
Medicine is accredited for study in six universities in the zone and two of these universities belong to the Federal Government of Nigeria. They include Nnamdi Azikiwe University Awka and the University of Nigeria Nsukka which was established in 1960 and is Nigeria's second oldest university. The state owned universities that offer medicine include that of Abia, Imo, Ebonyi and Enugu states.

Study Design
The study employed a cross-sectional descriptive study design using self-administered questionnaires.

Study Participants
The study population consisted of all final year medical students in medical schools of southeast Nigeria who gave consent to participate in the study.

Study Instrument
The study instrument was a pre-tested, semistructured questionnaire which was developed by the researchers. Information was obtained on the socio-demographic characteristics of the students, their willingness to practice in rural area after graduation, the reasons why doctors were unwilling to work in rural area, whether doctors working in rural area should earn more and their suggestions on what should be done to encourage doctors to work in rural area.

Data Analysis
The analysis was performed using STATA statistical software, version 13. Frequency tables and cross tabulations were generated and level of significance was based on a p-value of less than 0.05. Multivariate analysis using binary logistic regression was used to determine the factors predictive of willingness of the students to practice in rural area after graduation. Variables that had a p-value of less than 0.2 in bivariate analysis were entered into the logistic regression model to determine the predictors of students' willingness to practice in rural area after graduation. The results are reported using Adjusted Odds Ratio (AOR), and 95% Confidence Interval (CI).

Ethical Consideration
Ethical approval for the study was obtained from Research and Ethics Committee of University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu. The students were required to sign a written informed consent form before participating in the study. The nature of the study, its relevance and the level of their participation were well explained to them. They were also assured that all information as would be provided in the questionnaire will be treated confidentially and anonymously. Above all, participation in the study was voluntary and participants were assured that there would be no victimization of anyone who refused to participate or who decided to withdraw from the study after providing consent. Table  1 shows the socio-demographic characteristics of the students. The mean age was 25.5±2.9 years with the majority (51.6%) within the age group of 25-29 years. A higher proportion (57.1%) were male while majority of the parents of the students had tertiary education. Most of the students had their families residing in urban areas (88.4%) and also had their secondary education in the urban (82.7). Table 2 shows the willingness of the students to practice in rural area after graduation. A minor proportion of the students (13.6%) were willing to practice in rural area after graduation. The major reason for the unwillingness was lack of interest in rural area (32.9%). Majority of the students (80.1%) were of the opinion that doctors working in rural areas should be paid more than their urban counterparts. Table 3 shows the factors affecting the willingness of the students to practice in rural area after graduation. The students whose families reside in urban areas were 2.5 times less likely to be willing to practice in rural area after graduation when compared with those whose family residence were in the rural. The students who had a paid work experience before gaining admission to study medicine were twice more likely to be willing to practice in rural area when compared with those who had no work experience. Also, the students who were satisfied with rural community posting were twice more likely to be willing to practice in rural area after graduation when compared with those who were not satisfied. Likewise, the students whose intention is to specialize in Community Medicine after graduation were three times more likely to be willingly to practice in rural area when compared with other students who did not have such intention.

DISCUSSION
Majority of the students had an urban background (88.4%) and also attended secondary schools in urban area (82.7%).
Bearing in mind that majority of the students are of Igbo ethnic nationality who are the major inhabitants of southeast Nigeria, it could be that students with rural background and those that attended secondary schools in rural areas show less interest in studying medicine or that they are not adequately prepared and motivated for that purpose. Previous studies have demonstrated that students in secondary schools in urban areas perform better than their rural counterparts in the Senior School Certificate examination in Nigeria [14,15] and there are a lack of teachers in most junior secondary schools in the rural area [16]. This has led to the conclusion that children in rural areas of developing nations are educationally disadvantaged hence the call for the establishment of Rural Education Programme in developing countries [17].
Also bearing in mind the complex and rigorous academic procedures in gaining admission to study medicine in Nigeria and elsewhere, there is a tendency that whatever admission process in place at present does not favour students who reside and attend secondary schools in rural areas since they are not adequately prepared for examinations [17]. This is because the cut off mark for admission to study medicine in the university entrance examination has consistently been the highest in each of the universities in Nigeria as compared with that for other courses.
A minor proportion of the students (13.6%) were willing to practice in rural area after graduation and this has serious implications on the health of rural dwellers since majority of the populace reside there [9]. Also, that this proportion who were willing to practice in rural area were lower than that from similar studies elsewhere [18][19][20][21] is of concern and should attract the attention of policy makers.
For the students who were willing to practice in rural area, the major reason for that decision was to provide service to the underserved and this was similar to a finding from India [20] and Uganda [22] where the major reasons were to provide medical services to the poor and the vulnerable respectively. This is a reflection of prior contact with rural area or its health care system by the students and at the same time, it demonstrates their appreciation of the gap in health needs of its inhabitants.
From the results of this study, the reasons why doctors were unwilling to practice in rural area included amongst others poor social amenities, poor financial remuneration and inadequate hospital facilities. These results are similar to that from other regions [20,21]. This to an extent paints the same picture of other rural and underserved areas of the world with regards to health service delivery and the need for concerted action in-order to improve delivery of services and patient care in these areas.
Majority of the students (80.1%) were in support of doctors working in rural areas earning more than their urban counterparts. Also, majority of the students who shared this opinion opted for 150% of the salary of doctors working in urban for rural medical practitioners. The WHO in its policy document recommended appropriate financial incentives for doctors who ply their trade in rural areas [3] as a way of retaining their services. In Nigeria, there is a policy for the payment of rural allowance to health workers working in rural areas. However, this rural allowance for doctors is the equivalent of 20% of basic salary [23] and as such, falls short of the expectations of the student doctors. There is every reason to increase this allowance in the light of recent developments. It is interesting to note that what the students suggested as possible measures to be adopted by the government to encourage doctors to work in rural areas include provision of social amenities, increased financial remuneration, training opportunities for rural doctors and good hospital facilities as suggested in the global policy recommendations of WHO [3].
From the logistic regression results, students with urban background were about three times less likely to be willing to practice in rural area after graduation when compared with those with rural background. The significant association between students with rural background and willingness to practice in rural area has never ceased to attract global recognition. The WHO policy recommendations strongly advocated targeted admission policies to enroll students with rural backgrounds for entry into medical schools on the premise that there is an increased likelihood that majority of them will be willing to serve in rural areas after graduation [3]. Also, a study in South Africa recommended an admission policy that will favour students with rural background to gain admission into medical schools based on same assumption [24].
The Cochrane systematic review regarded this concept of students with rural background as the strongest factor associated with willingness to practice in rural area after graduation [25] which is well supported by recent studies [20,[26][27][28][29].
From the results of this study, admission into medical schools is tilted in favour of urban residents, hence the need for a policy that will encourage candidates with rural backgrounds to gain admission into medical schools like lower cut off marks in the university entrance examination. This is because a study in Australia revealed that students with rural background had low academic entry scores for admission into medical schools [26].
The students who had work experience before entry into medical schools were also found to be more willing to practice in rural area after graduation when compared with those who did not. This finding is peculiar to this study, however, having a work experience before admission into medical school could be an indication of the intricate admission procedures in the quest to study medicine in Nigeria. It could also be due to financial reasons since a minor proportion of the students (2.4%) were responsible for their training in the medical school. Since majority of the students were sponsored by their parents, scholarship awards to indigent students who intend to study medicine and willing to practice in rural area after graduation will be of relevance as the possibility of rise in tuition fees in Nigerian universities is increasingly becoming obvious.
From the results of our study, students who were satisfied with rural community posting were twice more likely to be willing to practice in rural area after graduation when compared with those who were not. This is at variance with the result of a study from South Africa [30] however there has also been calls for repeated rural exposures and postings in rural hospitals for medical students [21]. It is important to note that studies from Australia and Democratic Republic of the Congo found a significant relationship between exposure to a rural clinical school and willingness to practice in rural area [27,31]. In Nigeria, no medical school is located in a rural area, however all the medical schools adopt a compulsory rural community posting as part of its training programme for doctors.
One of the objectives of the rural community programme in medical schools in Nigeria is to teach medical students through practical work the principles and practice of community medicine [32]. Based on the finding that students who were satisfied with rural community posting were more willingly to practice in rural area, there is need to ensure that the rural community posting is student oriented. Also, since among the urban areas in Nigeria, some differences can exist hence there may be the need to designate at least one medical school (preferably a federal university) in each geo-political zone in Nigeria as a rural medical school. These schools may specifically serve for the purpose of training of doctors for rural practice with emphasis on good community experiences.
Another significant factor that affected the willingness of the students to practice in rural area after graduation were students whose intention were to specialize in Community Medicine or Public Health after graduation. This finding may be related to that on satisfaction with rural community posting. It may also be seen as falling in line with the objective of setting up the rural community programme in Nigerian universities. It is also worthy of mention that in the postgraduate training programme for Community Medicine/ Public Health, the concept of rural posting and rural community experiences receives higher attention and greater emphasis hence the need for a focus on this rural community experiences for student doctors.

CONCLUSION
Majority of the students were unwilling to work in rural area after graduation and were of the opinion that doctors working in rural area should earn more than their urban counterparts. This was based on the perception of the students that the rural areas lack social amenities, their health facilities are poorly equipped and the doctors working in these areas are not adquately remunerated.. Satisfaction with rural community posting which is a mandatory and rotational two to three months rural community experience by medical students during the period of training was significantly associated with willingness to practice in rural area after graduation. Knowing the need for doctors in rural practice, a reorientation of the students on rural practice, through adequate community exposure during rural posting is essential. There is also need for increased allowances for doctors working in rural areas, availability of better social amenities and opportunities for training and, or further studies. Our study has demonstrated a need for earlier intervention during the medical school curriculum to overcome these perceptions and attitudes of the students towards practice in rural area inorder to reverse this disparity.

Introduction
Socio-demographic characteristics