Factors influencing choice of site for rural clinical placements by final year medical students in a South African university

Background Most of South Africa’s citizens who live in rural or underserved communities rely on the public health care sector to access quality health care. The value of rural exposure through clinical placements is well documented. Medical schools in South Africa have a responsibility to provide solutions that address the prevailing human resources challenges. Despite this commitment, medical students do not necessarily appreciate their role in resolving South Africa’s human resources challenges. This study aimed to assess the factors that influenced the choice of clinical learning sites in a self-selection process undertaken by Wits final year medical students for the compulsory 6-week integrated primary care block rotation. Methods Qualitative data related to reasons for choice of service learning site were gathered from 524 pre-placement questionnaires completed by final year medical students entering the rotation over a 3-year period (2012–2014). Thematic analysis was performed using the MAXQDA software. Results Eight themes emerged from the study indicating that the majority of participants were in favour of local urban underserved placement. Contextual factors, such as work commitments or family responsibilities, being compromised socially and losing academic standing were the main reasons for seeking urban placement. Good supervision, opportunistic learning, skills development and moral support were reasons for seeking rural placements. Previous voluntary exposure to rural practice or being of rural origin was a strong indicator for uptake of rural placement. Conclusion This study has demonstrated the challenges faced by coordinators in balancing personal and institutional needs with country needs and the contextual factors that must be considered when implementing medical education programmes that respond to social challenges.


Introduction
South Africa is a developing country with many of its citizens residing in rural or underserved communities dependent on the public health care sector to access quality health care. Universities across the country are tasked with the responsibility to provide solutions for prevailing challenges such as the shortage of health care workers, especially in the rural areas of South Africa. 1,2 In the first 20 years of post-apartheid, South African universities had an opportunity to select a diverse group of health sciences students and adopt curricula that focused on reforms to benefit communities. 3,4 Reflecting on some of these initiatives, Lehmann et al. refer to a full spectrum of reforms that brought changes and innovations in many of the medical schools. 5 Although these initiatives varied from institution to institution, from student selection as an entry point right up to faculty development to incorporate a diverse body of staff members, the ultimate goal has always been to produce a graduate who will respond to the needs of South Africa. It is for these reasons that rural exposure through clinical placements has gained prominence amongst policy makers, faculty members and clinical educators based on perceived benefits in familiarising students with the needs of rural communities and an opportunity to address the cumulative shortage of health care workers. 6,7,8 The question remains, however, whether these initiatives are having the impact that is desired, and whether medical students are changing in their attitudes to the perceived needs.
Research has shown that being of rural origin is positively associated with having intentions to work in a rural community. 6,7,9 There is a body of work suggesting that rural clinical placements for medical students could create interest in working in a rural setting. 4,6,10 A Background: Most of South Africa's citizens who live in rural or underserved communities rely on the public health care sector to access quality health care. The value of rural exposure through clinical placements is well documented. Medical schools in South Africa have a responsibility to provide solutions that address the prevailing human resources challenges. Despite this commitment, medical students do not necessarily appreciate their role in resolving South Africa's human resources challenges. This study aimed to assess the factors that influenced the choice of clinical learning sites in a self-selection process undertaken by Wits final year medical students for the compulsory 6-week integrated primary care block rotation.

Methods:
Qualitative data related to reasons for choice of service learning site were gathered from 524 pre-placement questionnaires completed by final year medical students entering the rotation over a 3-year period (2012-2014). Thematic analysis was performed using the MAXQDA software.
Results: Eight themes emerged from the study indicating that the majority of participants were in favour of local urban underserved placement. Contextual factors, such as work commitments or family responsibilities, being compromised socially and losing academic standing were the main reasons for seeking urban placement. Good supervision, opportunistic learning, skills development and moral support were reasons for seeking rural placements. Previous voluntary exposure to rural practice or being of rural origin was a strong indicator for uptake of rural placement.

Conclusion:
This study has demonstrated the challenges faced by coordinators in balancing personal and institutional needs with country needs and the contextual factors that must be considered when implementing medical education programmes that respond to social challenges.

Factors influencing choice of site for rural clinical placements by final year medical students in a South African university
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positive relationship between such placements and later work in rural areas has also been found. 6,11,12 Amongst the many reforms adopted by the Faculty of Health Sciences at the University of the Witwatersrand (Wits) was the launch of the Graduate Entry Medical Programme (GEMP) in 2003 as a 4-year training programme that complemented the existing traditional approach to medical training, with both streams being combined in the clinical years. Within that, the integrated primary care (IPC) block, which is a compulsory 6-week placement in a range of primary health care settings, was launched in 2006 as one of the initiatives that would strengthen the university's and students' commitment to rural and underserved communities. 8 Through the IPC block, district facilities in underserved communities of the Gauteng, North West and Mpumalanga provinces provide the context for final year medical students to achieve some of the core competencies of an integrated curriculum. This allows students to understand not only the disease profile but also the health care needs of that particular community. 8,12 Students are able to select the sites at which they wish to undergo the IPC rotation in small groups of 3-4 within a range of rural, peri-urban and urban sites offered for each block, comprising 30 to 36 students. The reasons for their choices of site are unknown.
This study aimed to assess factors that influenced the choice of sites in the self-selection process undertaken by final year medical students at Wits for the compulsory 6-week IPC block in the period 2012-2014.

Setting
In preparation for the IPC block placement, final year medical students are required to attend an hour's briefing session on a Friday afternoon 4 weeks prior to the rotation. Students are briefed on the objectives of the block, site availability and the number of students that can be accommodated in each site. Following the briefing, 30-36 final year medical students have an opportunity to choose where they wish to be based from any of the 7-9 sites available to host students per rotation. Students have to negotiate their choice with their peers, taking into account issues such as students who have special needs, such as personal or family circumstances or having to work to pay tuition fees. Academic coordinators are required to support special case requests from the Office of Student Support, such as a student who requires remediation or is ill.
As part of the IPC block orientation on the first day of each rotation, students complete a pre-placement questionnaire that evaluates their expectations of the block.

Data analysis
Thematic content analysis was performed using the MAXQDA software (Version 11). This provided a detailed account of participants' responses. An inductive analysis approach was used to generate codes and identify themes. The initial analysis was conducted by M.G.M. and was finalised by N.O.M. with consensus from the co-authors. Informed consent was obtained from all students who participated. The data were anonymised and confidentiality was maintained throughout the research process.

Results
The majority of participants were in favour of urban underserved local placements in Gauteng province. In terms of the factors influencing choice of site, eight themes emerged from the study. These are reported below under the two subheadings as factors that led to interest in either rural or urban placements. The researchers excluded 19 students' responses in the final analysis as their allocation to rural sites was for space reasons and not in keeping with their stated preference for urban sites. Their comments did not fit either of the main themes as they focused on the fact that they did not get their choice.

Demographics
Female students constituted 63% (325) of the total population. The large majority of the students (477; 91%) reported themselves to be South African citizens. At the time of completing the questionnaire, 309 (59%) students were aged between 20 and 24 years. Students were admitted mostly as undergraduates, at MBBCh 1 level (299; 64%) with most of them indicating no prior work experience (250; 53%) (see Table 1). Only 21% of the class reported themselves to be of rural origin.

Factors leading to interest in rural placements
The three themes that were mentioned by students who prioritised rural placement, were academic learning, interest in rural practice and rural environment.

Academic learning in a rural facility
Amongst the reasons that influenced the students to choose a rural site were good supervision and also the ability to complete the requirements of the block. Students also cited professional development as having an important influence. 'The range of clinical scenarios I am likely to encounter. Working in a non-academic hospital to learn and work with colleagues in an expected way (i.e. maintaining punctuality, confidentiality) etc. and respect for people I will be working with.' (Participant 68, rotation 3,2013) This development occurs because rural facilities provide an opportunity for students to assume responsibility for their patients and engage in teamwork. Managing the undifferentiated patient, a key outcome of the rotation, was cited a number of times in relation to skills acquisition and the corresponding professional responsibility in relation to the context. 'Working at the clinics, seeing undifferentiated patients it will be so exciting to see if I can truly make decisions about patient's pathology and management.' (Participant 95, rotation 3,2013) The role of the primary health care setting was also relevant, in relation to the set outcomes of the medical curriculum.

Interest in rural practice
Previous exposure to the facility was a strong motivator for repeated experience, as well as a commitment to rural practice.
'I was exposed to rural medicine during my GEMP

The rural environment
There were some students whose choice of a rural site was influenced by the accommodation and on-site hospitality. One such site was complimented for its comfortable accommodation, the three meals a day that were provided at no cost to the student and the fact that students were treated like doctors, based on information passed on by previous students. Other factors that influenced students were the support they would receive as a group if they were all based in one site together and an appreciation of the social learning in a primary health care setting. The opportunity to spend time with their primary or extended families was also mentioned.

Factors leading to an interest in urban placements
Factors that motivated the students' preference of an urban site were identified as academic learning, environment, personal health, family responsibility and religion.

Academic learning in an urban facility
Some students requested to be accommodated locally in undeserved sites in and around the Gauteng Province based on reports they have received from their peers about on-site tutorials and a structured learning approach in a particular site. '

Personal health
The students in this category were considered to have special health needs and for that reason needed to be accommodated locally and often had permission from faculty.

Family responsibility and financial challenges
Many students in this group cited family commitments as reasons for requesting local placement as they were either single parents or recently married with or without children.
'It is within reasonable distance to home; because I am a mother to a 1 year old child; in case anything should happen at home.' Others indicated that they did not have financial assistance and had to work part-time to finance their studies.
'…Financial obligations do not permit me to work away from home as I am currently working to earn money to pay monthly loans and day to day living expenses.' (Participant 442, rotation 7, 2013) 'Financial matters -I have a student loan and need to pay monthly and I need to work to earn.' (Participant 13, rotation 1, 2013)

Urban environment
There were students who were not willing to venture out of Johannesburg. They cited relationships, comfort and access to resources as their main reasons.

Ethical considerations
This study is part of an ongoing evaluation of the IPC block. The protocol for this was approved by the Wits Human Research Ethics Committee (M131162).

Discussion
This study revealed that the rural platform is preferred by many medical students as it facilitates opportunities for them to gain confidence, manage the patient holistically, and is also considered to be a place to integrate learning and facilitate social and cultural competencies. 8,11 Interestingly, the competency in speaking the local language was embraced as a benefit in the same way that it presented a challenge to those who were likely to be linguistically compromised by the setting. 13 From this study, the factors that seem to have the greatest influence on the choice of rural placement, namely previous positive academic experiences and being of rural origin, are widely reported. 1,2,6,7,11,14,15 Alternatively, it is the opportunity to have a different academic experience in a rural setting, and to be in a different location 'to see more of South Africa'. Rose and Van Rensburg-Bonthuyzen make reference to a sense of belonging, socialisation and lifestyle factors as some of the factors that influence health care workers' choice to remain in rural practice, 16 so it is not surprising that these may be motivating factors for students. Similarly, being of rural origin does influence future practice as some of the students related their choice of site to their obligations of giving back to their own community, which fits with international evidence about the influence of rural origin. 1,2,9,11,14,15 Previous research around the IPC rotation has noted that students value the opportunity to engage with communities and to understand their health needs, and this was echoed in the reasons for choosing rural sites mentioned in this study. 8,12 An interesting finding is the extent to which medical students influenced their peers in choosing a rural site based on their experiences of the IPC block.
This study revealed that not all final year medical students are keen to take up placement in rural areas despite a progressive preparatory exposure from GEMP 1 to GEMP 3. An interesting tension of a kind can be seen in the students' responses between those favouring a rural site from an academic perspective -they believe the learning will be better, because of the practical skills and context-based learning that occurs there -versus those who see the rural sites as important in terms of clinical practice and the contribution they may make, now and in the future. This 'workforce versus education' tension is a recognised issue in rural programmes internationally. 10 This has been described particularly in longitudinal rural programmes. 17 Therefore, it is interesting to see it reflected even in a short rotation such as IPC. It is important to hold this tension in balance; the challenge for rural placements is that if students all choose them only for one or the other reason, they will either be written off as not being academically sound (workforce focus) or will not achieve their desired long-term impact (education focus). Contextual factors were cited as the main reasons for seeking urban placement by the medical students who selected these. In contrast, contextual factors have been found to be some of the primary motivators that influence a health professional's decision to work and stay in a rural area. 1,2,6,8,16 However, the choices made by the students are supported by the fact that the majority of Wits students are raised and schooled in urban communities. In a study undertaken by Price and Weiner, 18 76% of Wits graduates surveyed had set up practice in urban-based settings, in line with a more recent study of career intentions of African medical students, 19 thus supporting, albeit negatively, the association between childhood upbringing and affinity for rural practice. 15 With only 21% of the class claiming to be of rural origin, limited exposure to public health and primary health care as career options and the majority of the undergraduate teaching being delivered by urban-based specialists, it is not surprising that Wits students favour urban-based medical practice.
There is no doubt that South Africa is dependent on its universities to produce the kind of graduate that will help alleviate the workforce challenges in rural areas. 1,2 The fact that a number of students have to work to meet their financial needs calls for a review on the funding allocation to consider the country's needs. In a similar study conducted in Nepal, the economic pressure was mentioned as one of the reasons students opted for an urban placement. 15 It is possible that a number of students may be persuaded to take up rural placement in their final year if an offer is made to cover their tuition. 14 This study has revealed a need for the society at large, including the medical fraternity, to support universities in their efforts to make rural practice a lot more appealing, especially to young doctors.

Limitation
The study did not explore third-party influence on choice of site and this requires further exploration.

Conclusion
Medical training presents unique challenges as academic staff have to balance personal and institutional interests with country needs. Although the primary responsibility of the academic coordinators is to deliver on the latter, some students have genuine reasons for objecting to rural placement that must be supported. It is incumbent on programme coordinators to identify ways to make rural placements more attractive and feasible for all students.
Although the majority of Wits students are raised and schooled in urban settings, it is possible that early socialisation to primary health care settings may influence the number of students who would not have otherwise ventured out of Gauteng Province. At the same time, however, increasing the number of rural origin students selected into the medical programme, should also be pursued, as this is known to be a motivating factor for rural placement. 11