Medical students’ willingness to work in post-conflict areas: A qualitative study in Sri Lanka

Abstract

Background: The north-east (NE) region of Sri Lanka observed a critical health workers' shortage after the long-lasting armed conflict. This study aimed to explore medical students' attitudes towards working in the NE and to identify factors determining such attitudes. Methods: A semi-structured, self-administered questionnaire survey was conducted in two medical schools, one in the NE and the other near the capital, in October 2004. Data were qualitatively analysed using the framework approach. Results: Three main themes were identified: 1) Professional motives and career plans; 2) Students' perceptions of the healthcare situation in the NE; and 3) Students' choice of the NE as a future practice location. It was found that familiarity with the difficulties faced by the NE people was a major motivation for medical students to work in the NE in the future. For NE students, familiarity was linked to their sense of belonging. For non-NE students, their personal experience of the NE familiarized them with the difficult situation there, which positively influenced their willingness to work there. Demotivations to work in the NE were poor working and living conditions, fewer opportunities for postgraduate education, language differences, insecurity, and fear of an unpleasant social response from the NE communities. Conclusions: NE local medical students had a sense of belonging to the NE and compassion for the Tamil people as members of the ethnic group. They were willing to work in the NE if their concerns about difficult working and living conditions and postgraduate education could be solved. Non-NE students who were familiar with the NE situation through their personal experience also showed a willingness to work there; thus, early exposure programmes in medical education might help to increase the health workforce in the NE. It is also expected that non-NE physicians working for the NE people would facilitate reconciliation and the rebuilding of trust between two ethnic groups.

Measuring the reasons that discourage medical students from working in rural areas

“…The earlier few studies have either considered a limited spectrum of items in the questionnaire or were conducted in developed nations. [ 4 , 12 , 16 , 17 , 35 , 36 ] After rigorous literature review and expert Delphi consultations, a questionnaire consisting of 33 items was developed which was named the MSDRI questionnaire. Interestingly, our analyses highlight 5 factors/subscales for the items listed in the questionnaire.…”

“…Gadi, [ 4 ] Kotzee and Couper, [ 5 ] Manongi et al, [ 6 ] Shankar and Thapa, [ 12 ] Henderson and Tulloch, [ 37 ] Lori et al, [ 35 ] Kaye et al, [ 38 ] and Steinhaeuser et al [ 39 ] have mentioned items related to professional challenge as the barriers for medical students to serve in rural areas. Few studies in the context of the social segregation subscale are Gadi, [ 4 ] Saini et al, [ 16 ] Sinha, [ 17 ] Shankar and Thapa, [ 12 ] Lori et al, [ 35 ] and Kaye et al [ 38 ] who concluded that low standard of living impedes medical students for working in rural areas. A study by Henderson and Tulloch [ 37 ] has reported that items related to hostile professional environment were responsible barriers for health workers for accepting rural postings.…”

“…Another study by Kaye et al [ 38 ] reported that heavy workload, inadequate opportunities for continuing graduate training are the factors that make medical students not to work in rural areas. Other references in this context are Kotzee and Couper [ 5 ] and Saini et al [ 16 ] A study by Gadi in 2012 [ 4 ] stated that language differences, insecurity, and fear of an unpleasant social response, which fall under the socio-cultural gap subscale, are demotivators to medical students for working in the North East Sri Lanka.…”

“…Lack of financial rewards, limited training opportunities, limited professional interaction with peers, heavy workload, social isolation, poor social services, poor living and working conditions, lack of education opportunities for children, and limited opportunities for income-generation through a second job or private practice are often cited as the main factors. [ 4 – 7 ] If the expectations of health workers are not met then they tend to migrate within countries (to urban areas) or to developed countries. [ 8 – 11 ] Governments in low- and high-income countries alike are struggling to attract and retain health workers in underserved areas by offering a package of incentives that covers an array of salary and non-salary related factors.…”

“…Few studies have been conducted worldwide to report factors which deter medical students from working in rural areas. A study by Gadi [ 4 ] in 2012 conducted in Sri Lanka and another study by Shankar and Thapa [ 12 ] in Nepal reported that poor working and living conditions, fewer opportunities for postgraduate education, language differences, insecurity, lack of financial incentives were barriers identified by medical students to work in rural area.…”