Factors influencing students' choices in considering rural radiography careers at Makerere University, Uganda

Introduction 

Rural areas face a continuing deficit of trained manpower in health service and this inequitable distribution of health workers has been a continuing challenge for policy makers.1, 2, 3 Uganda, is a land-locked state in Eastern Africa with total land area of 236,040 square kilometers. It has a total population of about 28.3 million, 87.7% of whom live in rural areas.4 Uganda's health care delivery has been decentralized in order to bring services nearer to people from the general health services at health centre I to more specialist services in referral hospitals (see Fig. 1).5 However, health workers, but radiographers in particular, have shunned rural areas leaving some health facilities with no radiographers at all.

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Figure 1 Showing Uganda's decentralized health care structure.

Several countries are experiencing a similar challenge of attracting health workers to rural areas. For example, Vietnam averages just over one health provider per 1000 people with 37 of Vietnam's 61 provinces falling below the national average.6 Countries, such as India, Indonesia, Fiji, Samoa, Tonga and the Philippines, have specifically trained health professionals for export to developed countries. However, though this is planned, the loss of health workers this way is becoming extremely costly creating scarcity mostly felt in rural settings where most health workers migrate from.7 In the Pacific region, doctors are generally employed in hospitals in urban areas leaving rural areas with scarcity of these health care providers. For example, more than 50% of all doctors in Papua New Guinea work for the National Department of Health (including urban clinics in the National Capital District), approximately 37% work in hospitals and less than 10% work in the provincial rural areas.8

In Cambodia, a similar observation is encountered where there is a poor distribution of doctors as well as an acute shortage of midwives outside the capital city, particularly in remote areas and sparsely populated rural communities.9, 10 Attempts made to encourage more health professionals to practice in rural areas have included financial incentives and offers for further training.11

In East Timor, the Ministry of Health set out to explore the use of incentives to compensate staff for working in remote areas.12 But it is virtually impossible for developing countries to compete with the salaries of developed nations. For example, specialist doctors in Sri Lanka were paid 45 000 rupees a year while their counterparts in Australia were paid the equivalent of 1.5 million rupees a year.13

Countries have adopted various initiatives to mitigate the low remuneration in the public sector. In Papua New Guinea, there is a Domestic Market Allowance, intended to assist in retaining doctors and nurses in rural areas where public service salaries are substantially lower than those prevailing in the domestic labour market.14, 15 Sempowski (2004), a medical Doctor and researcher, however cautions that financial incentives have a greater effect on short-term recruitment than on long-term retention.16 Other factors like safe working and living conditions also contribute to worker satisfaction as reported in Papua New Guinea.14

A study of rural midwives in Australia illustrates that continuing Professional Development is an important motivator.17 Studies in the United States and Canada have also shown that health workers with a rural background are likely to work in rural communities.18, 19 Conversely, it has been reported that although rural background may predict interest in rural practice, some rural practitioners actually did not spend any of their formative years in rural areas and there is therefore need to encourage professionals raised in urban settings to practice in rural settings as well.20

Another predictor of rural practice cited in the literature is exposure to community based training. It has been observed that graduates exposed to community based training are more likely to consider working in rural areas.21, 22, 23, 24 However, the influence of all these factors on student radiographers raised in rural and urban areas remains to be clarified. The dearth of literature in the Ugandan situation examining this issue warrants attention.

The purpose of this study was to assess factors that influence radiography students' choices in considering rural practice. It is hoped that this study will yield valuable data for both training institutions and policy makers. Permission to carry out this study was obtained from the Radiology Department Education Committee and confidentiality of all participants was observed throughout the study.

Methodology 

Results 

Quantitative results 

Socio-demographics 

Of the total respondents, 61.3% (n=19) were male and 38.7% (n=12) were female. Year III had the least number of students while Year II had the majority (see Table 1). 83.9% (n=26) were between 18 and 24 years, and 16.1% (n=5) between 25 and 30 years. 96.8% (n=30) were single and only 3.2% (n=1) was married. 51.6% (n=16) had spent part of their lives in a rural area while 48.4% (n=15) had not. 100% (n=31) expressed that a community qualifies to be rural in relation to its distance away from an urban area.

Table 1. Showing the distribution of students by year of study.

	Year	Frequency	Percentage
	I	11	35.4%
	II	11	35.4%
	III	9	29.2%

Rural radiography practice 

Respondents were asked about their interest in practising radiography in a rural area. 58% (n=18) agreed that that they would consider practising radiography in rural areas, while 42% (n=13) disagreed. 80.6% (n=25) agreed that rural radiography practice would promote the profession in those areas while 19.4% (n=6) disagreed with this. On whether being born in a rural area could stimulate one to work there, 64.5% (n=20) agreed while 35.5% (n=11)were negative about this.

Motivational factors for considering rural radiography practice 

Respondents were also asked for the factors that would motivate them to consider rural radiography practice. Key motivational factors sited included; Attractive salaries, professional independence, good social life, equipped rural centres, training opportunities and community based training (see Graph 1). However, there was a significant rating of attractive salaries and community based training as key motivating factors to consider rural practice. Further analysis across year groups showed a variation in response to community based training being a motivating factor to work in rural areas. All 20s and third year students combined rated community based training highly as a motivator to consider rural radiography practice, while all the 11 first year students disagreed with this.

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Graph 1. Showing motivational factors to practice radiography in rural areas.

Relationship between respondents' socio-demographics and interest of practising rural radiography 

45.1% (n=12) of the respondents between 18 and 24 years reported that they would consider practising radiography in rural areas. Alternatively, 54.9% (n=14) respondents of the same age group reported that they had no interest in practising radiography in the rural areas. 40% (n=2) of respondents between 25 and 30 years considered working in rural areas while 60% (n=3) of that age group reported no interest in working in rural areas. Further analysis showed that 63.1% (n=12) of all male respondents reported that they would at one time consider practising radiography in the rural areas, and 36.9% (n=7) of them reported no interest. 66.7%8 of females reported that they would also consider practising radiography in rural areas while, 33.3%4 of them did not.

Using both the Pearson Chi-square test and Fischer's exact test for these characteristics (age and gender) showed no statistical significance with p-value of 0.0915 and 0.0614 respectively. This means that there is no association between age or gender with choosing to practice radiography from a rural area.

Discussion 

This study has shown that students would actually consider rural radiography practice. There is need for health service and training institutions to create an enabling environment that will motivate and attract young professionals into rural practice. Attractive remuneration, training opportunities and social amenities like recreation facilities and entertainment were a common thread in this study that policy makers need to address if radiographers are to wholeheartedly consider rural practice. Like studies in Samoa, Tonga, Vanuatu, Papua New Guinea, Vietnam and Thailand revealed, attractive salaries are important motivators to work in rural areas.7

However, this remains a daunting challenge in a developing and resource-constrained country like Uganda. But as it was observed in a study carried out in Vietnam, motivation of a worker is much more than just finances and it should include aspects like appreciation, recognition and opportunities for further professional development. Similarly, developing nations should adopt other motivational factors (other than only increasing salaries) to build capacity of the rural health workforce16 Absence of these incentives has contributed to the migration of health workers from rural areas and the few remaining in those areas are not motivated to work efficiently.

Community based training has been highlighted in several studies as being a powerful stimulant to practice in rural areas.21, 22, 23, 24 This finding was identified in this study as well. Most responses to the questionnaire statements and from focus group discussions indicated that students raised the same issue of community based training being a stimulating factor for them to consider rural radiography practice. This could be attributed to the fact that through community based education, students get in touch with situations in which they are most likely to work. This seems to have a profound positive effect on their choices to consider rural practice.

It should be noted that from both the questionnaire responses and focus groups, second and third year students agreed that community based training stimulated them to consider rural radiography careers while first year students disagreed. The explanation to this is that, by the time of this study, second and third year students had actually had some community based placements while first years had not yet had this opportunity. This could explain the variation in the responses. It actually justifies that community based training can change students' perceptions as evidence from second and third year students.

Attracting and keeping health personnel in rural areas is still a major challenge not only in Uganda, but world wide.26 Uganda in particular still faces a major shortage of radiographers to efficiently address the health needs of her population. In some health facilities, X-ray/Ultrasound machines are lying redundant with no one to operate them. This was clearly illustrated by one student who said:

“In one up-country centre I visited during my holidays to do some practice, the X-ray machine was around but there was no radiographer to operate it since no one had responded to several advertisements made.”

At the same time, Uganda still has few radiography training institutions which also accommodate few students due to limited training resources and therefore cannot adequately meet the demand for radiographers needed in rural centres. This study has also shown that students would only consider rural practice to get confidence and experience rather than a long-term venture. This leaves rural areas vulnerable as they only act as stepping stones for these professionals. Miles et al. (2004), described this as rural regions becoming ‘professional nurseries’.27 For radiography rural workforce to become better, it is useful to focus on factors that attract and keep those who willingly choose to be in rural areas rather than putting all efforts in recruiting those already in urban centres. Security and family factors like spouse preferences and proximity to family members are pertinent factors that should be addressed.

From this study, it has been identified that there are several ways in which Radiographers can be motivated to work in rural areas for example increasing salaries, offering opportunities for professional development programmes, putting into consideration their family responsibilities when deploying them and offering scholarships for further training. With the current shortage of radiographers in developing countries, the above motivational factors need to be addressed in addition to probably think of training Assistant Radiographers who can help with work, equipping rural centres with radiography facilities, professional recognition, establishing a rotational scheme between working in rural and urban centres, establishing new training institutions and training radiographers from rural communities in order to arouse their interests in returning to those very areas upon completion of their studies.

Conclusion 

This study has shown that students would consider rural radiography practice. However, all stakeholders are called upon to motivate these health professionals through good remuneration, training opportunities, provision of social amenities as well as emphasizing community based training courses in students curricular in health training institutions.

Conflict of interest 

We declare that we have no conflict of interest.