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

Article Outline

• Abstract
• Introduction
• Methodology
  • Study setting
  • Study design
  • Sample size
  • Data analysis
  • Study limitations
• Results
  • Quantitative results
    • Socio-demographics
    • Rural radiography practice
    • Motivational factors for considering rural radiography practice
    • Relationship between respondents' socio-demographics and interest of practising rural radiography
  • Qualitative results
    • Promotion of rural radiography practice
    • Benefits of practising radiography in rural communities
• Discussion
• Conclusion
• Conflict of interest
• References
• Copyright

Abstract 

Introduction

The Faculty of Medicine, Makerere University is the oldest health professions training institution in East Africa having started in 1924. The radiography degree course started in 2001 and Makerere remains the only institution in the East African region offering this degree course. The faculty adopted a Problem based Learning/Community based education curriculum in order to stimulate students' interests to consider working in rural areas. Attracting and retaining radiographers and other health professionals in rural areas is a recognized problem in Uganda and overseas and strategic actions to enhance the rural health workforce and its ability to deliver the required services are paramount. A range of factors in different domains can be associated with recruitment and retention. By consulting students, some of these factors can be identified and addressed.

Methodology

It was a descriptive exploratory study involving 31 students. Data was collected through a questionnaire and focus group discussions.

Results

58% of the students reported that they would consider rural radiography practice while 42% would not. Key motivational factors cited to work in rural areas were; attractive salaries/incentives, community based training curricular, opportunities for further training and well equipped rural health facilities.

Conclusion

This study has shown that students would consider working in rural areas provided the working conditions are improved upon.

Key words: Students' choices, Rural radiography, Makerere University, Uganda

Back to Article Outline

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.

• 
  • View Large Image
  • Download to PowerPoint

• 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.

Back to Article Outline

Methodology 

Study setting 

This study was conducted at the Faculty of Medicine, Makerere University.

Study design 

It was a descriptive exploratory study in which questionnaires were administered and focus group discussions conducted. The questionnaire involved a section seeking consent which also assured the participant of anonymity and confidentiality, socio-demographic factors (gender and age), close-ended statements to which each participant was expected to respond by grading each statement on a scale of 1–4 (1 being strongly disagree, 2-disagree, 3-agree and 4 being strongly agree').

Focus group discussions were tape-recorded and transcribed. There were 4 questions for the focus groups exploring opinions on what factors would motivate students to consider rural radiography practice. There were two focus groups of 6 members in each group and two members of the research team, one asking questions and the other taking notes. Verbal consent was obtained from all members of the focus groups. Anonymity and confidentiality of the opinions were also assured to members in the focus groups. The use of focus groups in addition to the questionnaire was to obtain triangulation of data in order to reduce intrinsic biases that would arise from using only the questionnaire.

Sample size 

There were 31 participants of which 9 were first year, 11 were second year and 11 were third year undergraduate radiography students. This represents 100% of the total undergraduate radiography student population at the Faculty of Medicine.

Data analysis 

Data was both quantitative and qualitative. The quantitative part was analyzed by a Statistician in the presence of members of the research team. For interpretation using a 2-tailed test, ‘strongly disagree’ and ‘disagree’ were coded as ‘Disagree’, while agree and strongly agree were coded as ‘Agree’. It involved tallying and then coding. Codes were counted and entered into the Computer. Using SPSS statistical package, percentages were then obtained. A level of significance of p=0.05 has been adopted for this study.

Qualitative data was analyzed by the researchers since the investigator of qualitative research becomes the instrument in both data collection and analysis. It involved content analysis to extract the meaning given by informants and transcription. This raw data was proof-read against audio-taped interviews. Data was manually coded into categories of similar meaning. Relationships between categories were established resulting into content themes since thematic content analysis is a valued method for analyzing qualitative data.²⁵ These themes summarized the meaning of the data which addressed the purpose of the study.

Study limitations 

Back to Article Outline

Results 

Quantitative results 

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.

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.

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.

• 
  • View Large Image
  • Download to PowerPoint

• Graph 1. 

  Showing motivational factors to practice radiography in rural areas.

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.

Qualitative results 

Two key themes were identified:

Respondents were asked to suggest ways of promoting rural radiography practice: The following opinions were expressed in order of descending frequency: Increasing salaries, introducing a community based education module during training, equipping rural facilities with modern equipment, provision of other incentives like free housing and allowances as well as training more radiographers. One second year student who had just returned from the community based training internship at a rural hospital had this to say during the focus groups:

“The experience of Community based training in Lira Hospital has changed my perception about rural areas although I did not grow up from there. I would actually consider working in such an area now if posted there”.

Similarly, a third year student who had had two Community based internships had this to say:

“When the Community placement came to a closure, I felt like not leaving the Health Centre as the whole experience was interesting. With this exposure, I would seriously consider working in a rural hospital or health centre”.

However, there was a strong variation when it came to responses from all the first year students who participated in the focus groups as to whether community based training would motivate them to work in rural areas. One first year student expressed:

“Even if I train from a rural setting, I would not even think of working there.”

This was a common response from all first year students. With the absence of attractive incentives therefore, students expressed no interest to work in rural areas as one of them explicitly put it:

“Unless things change from the way they are now, I would never even think of working in a rural area.”

As if to demystify the former statement, another student contended:

“Working in a rural area is like burying you alive since the pay is poor and yet you may have dependants. In town, I may get many jobs to juggle to supplement what government pays me which is not possible in the village.”

Respondents were also asked about the benefits they would get when they practice from rural areas and these were a common thread in all responses: Getting experience from a different setting, attaining confidence without seniors who are mostly in towns, low cost of living, challenges make one get confidence and raising awareness about radiography and imaging services among the local leaders and the community. This was reflected in the comment below:

“While practising radiography in an up-country centre as a professional, I can be in better position to engage the local and district leaders to equip at least big health centres with X-ray and Ultrasound machines”.

Back to Article Outline

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.

Back to Article Outline

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.

Back to Article Outline

Conflict of interest 

We declare that we have no conflict of interest.

Back to Article Outline

References 

1. Hicks LL. Social policy implications of physician shortage areas in Missouri. American Journal of Public Health. 1984;74:1316–1321
   • View In Article
   • MEDLINE
   • CrossRef
2. Wilkinson D. Inequitable distribution of general practitioners in Australia. Analysis by state and territory using census data. Australian Journal of Rural Health. 2000;8:87–93
   • View In Article
3. Krup LK, Chan BTB. Canadian rural family medicine training program. Growth and variation in recruitment. Canadian Family Physicians. 2005;51:852–853
   • View In Article
4. State of Uganda Population Report 2007. Available (online): http://www.popsec.org/documents/State%20of%20Uganda%Population%20Report%202007.pdf(accessed 20 December 2008)
   • View In Article
5. Health Sector Strategic Plan II (HSSP II: 2005/2006-2009/2010). vol. 1. Kampala-Uganda: Ministry of Health; June, 2005;
   • View In Article
6. Prasad A, Tandon A, Sousa A, Ebener S, Evans DB. Measuring the efficiency of human resources for health in attaining health outcomes across provinces in Vietnam. WHO Background papers for the World Health Report 2006.
   • View In Article
7. World Health Organization . The migration of skilled health personnel in the Pacific region. WHO Western Pacific Region; 2004;
   • View In Article
8. World Bank: Papua New Guinea Human Development Strategy. 2005.
   • View In Article
9. Oum S, Keat P, Saphonn V, Oum P. Human Resources for Health and Child Survival in Cambodia. sia Pacific Action Alliance on Human Resources for Health country reviews 2005.
   • View In Article
10. Soeters R, Griffiths F. Improving government health services through contract management: a case from Cambodia. Health Policy Plan. 2003;18(1):74–83
    • View In Article
    • MEDLINE
    • CrossRef
11. Szafran O, Crutcher RA, Chaytor RG. Location of family medicine graduates practice. What factors influence Albertan's choices?. Canadian Family Physicians. 2001;47:2279–2285
    • View In Article
12. Timor-Leste Ministry of Health: health care priorities and proposed sector investment program. MoH, MoEC, MoNRMEP 2006.
    • View In Article
13. Adkoli BV. Migration of health workers: perspectives from Bangladesh, India, Nepal, Pakistan and Sri Lanka. WHO South-East Asia Regional Health Forum; 2006;
    • View In Article
14. Papua New Guinea Public Services Conciliation & Arbitration Act: National Doctors and Dentists Agreement. 1998.
    • View In Article
15. Papua New Guinea Public Services Conciliation & Arbitration Act: Memorandum of Agreement governing the terms and conditions of the nursing personnel in the health service. 2001.
    • View In Article
16. Sempowski IP. Effectiveness of financial incentives in exchange for rural and under-serviced areas in return for service commitments. Systematic review of literature. Canadian Journal of Rural Medicine. 2004;9(2):82–88
    • View In Article
17. Daniels ZM, Vanleit BJ, Skipper BJ, Sanders ML, Rhyne RL. Factors in recruiting and retaining health professionals for rural practice. Journal of Rural Health. 2007;23(1):
    • View In Article
18. Bushy A, Leipert BD. Factors that influence students in choosing rural nursing practice: a pilot study. Rural and Remote Health. 2005;5(2):387
    • View In Article
    • MEDLINE
19. Chan B, Degani N, Crichton T, Pong R, Rourke J, Goertzen J, et al. Factors influencing family physicians to enter rural practice. Canadian Family Physicians. 2005;51:1246–1247
    • View In Article
20. Laven GA, Belby JJ, Wilkinson D, Mc-Elroy HJ. Factors associated with rural practice among Austrian-trained general practitioners. Medicine. August 2003;179(2):75–79
    • View In Article
21. Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. A program to increase the number of physicians in rural and underserved areas. Impact after 22 years. JAMA. 1999;281(3):255–260
    • View In Article
    • MEDLINE
    • CrossRef
22. Costa DA. Impact of rural training on physician workforce: the role of post residency education. Rural Health. 2000;16:254–261
    • View In Article
23. Rosenthal TC, Guigan MH, Anderson G. Rural residency track in family practice: graduate outcomes. Family Medicine. 2000;32(3):174–177
    • View In Article
    • MEDLINE
24. Carter RG. The relation between personal characteristics of physician and practice location in Manitoba. CMAJ. 1987;136:559–563
    • View In Article
25. Sorreli JM, Redmond GM. Interviews in qualitative nursing research: differing approaches for ethnographic and phenomenological studies. Journal of Advanced Nursing. 1995;11:122–171
    • View In Article
26. Best J. Rural Health Stocktake Advisory Paper. Canberra: Commonwealth Department of Health and Aged Care; 2000;
    • View In Article
27. Miles RL, Marshall C, Rolfe J, Noonan S. The attraction and retention of professionals to regional areas. Queensland Health Report. Brisbane: Queensland Government; 2004;
    • View In Article