ADDIS ABABA UNIVERSITYCOLLEGE OF HEALTH SCIENCESCHOOL OF PUBLIC HEALTH Intention of medical student to work in rural areas and its associated factors among the three public University undergraduate medical students in Ethiopia

ADDIS ABABA UNIVERSITYCOLLEGE OF HEALTH SCIENCESCHOOL OF PUBLIC HEALTH Intention of medical student to work in rural areas and its associated factors among the three public University undergraduate medical students in Ethiopia, 2018By ADVISORS:BERHAN TASSEW (MPH) WONDIMU AYELE (MSc PHD candidate)i ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCE SCHOOL OF PUBLIC HEALTH Intention of medical student to work in rural areas and its associated factors among the three public University undergraduate medical students in Ethiopia, 2018 By: BERHANU ACHISO (B.A) ADVISORS: BERHAN TASSEW (MPH) WONDIMU AYELE (MSc PHD candidate) Addis AbabaIntention of medical student to work in rural areas and its associated factors among the three public University undergraduate WONDIMU AYELE (MSc PHD candidate) June, 2018 Addis Ababa

Intention of medical student to work in rural areas and its associated factors among the three public University INVESTIGATOR: BERHANU ACHISOBERHAN TASSEW (MPH)WONDIMU AYELE (MSc PHD candidate)A Thesis submitted to school of graduate studies College of Health Sciences, School of Public Health, in partial fulfillment of the requirements for the degree of Masters in health economics ii Intention of medical student to work in rural areas and its associated factors among the three public University undergraduate medical students in Ethiopia, 2018 INVESTIGATOR: BERHANU ACHISO (B.A)ADVISORS: BERHAN TASSEW (MPH) WONDIMU AYELE (MSc PHD candidate) A Thesis submitted to school of graduate studies Addis Ababa University, Sciences, School of Public Health, in partial fulfillment of the requirements for the degree of Masters in health economicsADDIS ABABAIntention of medical student to work in rural areas and its associated factors undergraduate medical students in (B.A) Addis Ababa University, Sciences, School of Public Health, in partial fulfillment of the requirements for the degree of Masters in health economics JUNE, 2018 ADDIS ABABA

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iii ACKNOWLEDGEMENT I would like to thank my advisors Wondimu Ayele (MSc, PHD candidate) and Berhan Tassew (MPH) for their unreserved advice and unlimited support for this proposal development, finally I am very thankful to AAU University School of public Health and Tikur Anbesa teaching Hospital School of medicine Director for their kindly giving information for proposal preparation.

iv ACRONYMS AAU Addis Ababa University AOR Adjusted Odds Ratio C.I Confidence Interval COR Crude Odds Ratio C.P Cumulative percent ERG Existence Related Growth FGD Focus Group Discussion GH General Hospital GP General Practitioner GPs Graduate Programs HR Human Resource HRH Human Resource for Health IRBCHS Institutional Review Board of College of Health Science LIC Low Income Countries MDG Millennium Development Goal NGO Non-governmental Organization NIMEI New Innovative Medical Education Initiative PH Primary Hospital REC Review of Ethical Committee SD Standard Deviation SSA Sub-Saharan Africa SPSS Statistical Package for Social Science TASH Tikur Anbessa Specialized Hospital TH Tertiary Hospital THC Township Health Center USA United State of America WHO World Health Organization WSU Wolayita Sodo University WU Wachemo University

v ABSTRACT BACKGROUND: In Ethiopia, about 84% of the country’s total populations live in rural areas. However, there are major Human Resources for Health (HRH) management challenges including shortage, urban/rural and regional disparities, poor motivation, and low retention of physicians. Shortages and imbalances in physician workforce distribution between urban and rural areas among different regions are enormous. The intentions of the majority of medical students from capital city towards practicing medicine in rural areas were found to be poor and they intent to migrate urban areas after completing their medical training. This study was done to assess the intention of undergraduate medical students towards rural settings work and to identify factors associated with their willing to work in the rural areas. METHODS: A cross-sectional study was carried out in February 2018 among 342 (254 male Vs 88 female) medical students (Year IV to Year V) of faculty of medicine at Addis Ababa, Wolayita Sodo and Wachemo Universities. Simple random sampling method was applied. The pretested self-administered questionnaires were used. Data was entered into EPI-data version 3.1 and exported to Statistical Package for Social Science (SPSS) version 24 for analysis. Descriptive statistics employed for data summarization and presentation. Bivariate and multivariate analyses of logistic regression were used with 95% of confidence interval. RESULTS: This study found that, 32.2% of participants are willing to work in rural areas. The intention of willing to work in the rural area was lower among male (AOR (C.I) = 0.392(0.191, 0.806)), Orthodox (AOR C.I =0.0770.011, 0.526) and Protestant religion (AOR C.I = 0.0980.015, 0.659) follower medical students. Out of the study participant, nearly half of them were interested to work in the tertiary hospitals, however; only 20.8% and 30.7% respondents were willing to work in the primary and general hospitals respectively. Career advancement (AOR C.I = 0.3480.159, 0.765) was encouraging factor which is significantly associated with medical students intention to work in the rural settings. CONCLUSION: Greater part of undergraduate medical students was dislike to work in the rural areas. It creates serious shortage of senior physicians in the rural part of the community in case of rural to urban migration. Career guidance about rural health work during medical education period promotes their awareness. Accessibility for career advancement is more likely to encourage working in the rural area. Finally, recruiting more female medical students into medical schools is expected to produce more likely to work in rural areas. Key words: medical students, intention, rural area, urban area, motivation, health facility, career advancement, push and pull factors

vi CONTENTS ACKNOWLEDGEMENT …………………………………………………………………………………………………………… iii ACRONYMS …………………………………………………………………………………………………………………………….. iv ABSTRACT ……………………………………………………………………………………………………………………………….. v LIST OF TABLES ……………………………………………………………………………………………………………………. viii LISTS OF FIGURES ………………………………………………………………………………………………………………… viii LISTS ANNEX ………………………………………………………………………………………………………………………….. ix 1. INTRODUCTION …………………………………………………………………………………………………………………… 1 1.1. BACKGROUND ………………………………………………………………………………………………………………. 1 1.2. STATEMENT OF THE PROBLEM ……………………………………………………………………………….. 2 1.3. SIGNIFICANCE OF THE STUDY …………………………………………………………………………………. 3 2. LITERATURE REVIEW ……………………………………………………………………………………………………… 4 2.2. THE CONCEPT OF MIGRATION AND MOTIVATION …………………………………………………. 4 2.2.1. MIGRATION OF HEALTH WORKERS …………………………………………………………………. 4 2.2.2. MOTIVATION OF HEALTH WORKERS ……………………………………………………………….. 5 2.2.3. SOME THEORIES OF MOTIVATION ……………………………………………………………………. 5 2.3. THE ROLE OF MEDICAL STUDENTS FOR THE RURAL COMMUNITY ……………………… 7 2.4. INTENTIONS OF MEDICAL STUDENTS IN THE WORLD CONTEXT …………………………. 7 2.5. INTENTIONS OF MEDICAL STUDENTS IN SUB-SAHARAN AFRICAN CONTEXT …….. 9 2.6. INTENTIONS OF MEDICAL STUDENTS IN ETHIOPIAN CONTEXT …………………………. 11 2.7. FACTORS THAT INFLUENCE MEDICAL STUDENTS TO PRACTICE RURAL AREA .. 12 3. THE OBJECTIVES ……………………………………………………………………………………………………………. 15 3.2. GENERAL OBJECTIVE ……………………………………………………………………………………………… 15 3.3. SPECIFIC OBJECTIVES …………………………………………………………………………………………….. 15 4. METHODS ……………………………………………………………………………………………………………………….. 16 4.1. STUDY AREA AND PERIOD …………………………………………………………………………………….. 16 4.2. STUDY DESIGN ………………………………………………………………………………………………………… 17 4.3. SOURCES OF POPULATION …………………………………………………………………………………….. 17

vii 4.4. STUDY POPULATION ………………………………………………………………………………………………. 17 4.5. VARIABLES OF THE STUDY ……………………………………………………………………………………. 18 4.5.1. INDEPENDENT VARIABLES …………………………………………………………………………….. 18 4.5.2. DEPENDENT VARIABLE …………………………………………………………………………………… 18 4.6. OPERATIONAL DEFINITIONS ………………………………………………………………………………….. 19 4.7. SAMPLE SIZE DETERMINATION …………………………………………………………………………….. 20 4.8. SAMPLING PROCEDURE …………………………………………………………………………………………. 20 4.9. DATA COLLECTION TOOLS AND PROCEDURE ……………………………………………………… 21 4.10. D ATA QUALITY MANAGMENT ………………………………………………………………………….. 22 4.11. DATA ANALYSIS PROCEDURE ……………………………………………………………………………. 22 4.12. ETHICAL CONSIDERATION …………………………………………………………………………………. 23 4.13. DISSEMINATION OF THE STUDY FINDINGS ……………………………………………………….. 23 5. RESULTS …………………………………………………………………………………………………………………………. 24 5.1. Socio-demographic characteristics of the study participants ……………………………………………… 24 5.2. The study participants according to their sex distribution …………………………………………………. 26 5.3. Factors that inspire medical students to choose medicine …………………………………………………. 27 5.4. Existing feeling of medical students on medical education ……….. Error! Bookmark not defined. 5.5. Factors that encourage medical students to work in the rural area ……………………………………… 28 5.6. Factors that discourage medical students to work in the rural area …………………………………….. 29 5.7. Awareness of medical students about rural area ………………………………………………………………. 31 5.8. The areas of intention to work after graduation ……………………………………………………………….. 31 5.9. Factors that associated with intention of medical students to work in the rural area ……………… 33 6. DISCUSSION ……………………………………………………………………………………………………………………. 36 7. LIMITATION OF THE STUDY ………………………………………………………………………………………….. 37 8. CONCLUSIONS AND RECOMMENDATIONS ………………………………………………………………….. 38 8.1. CONCLUSIONS …………………………………………………………………………………………………………. 38 8.2. RECOMMENDATIONS ……………………………………………………………………………………………… 38 9. REFERENCES ………………………………………………………………………………………………………………….. 40

viii LIST OF TABLES Table 1 Sample size calculation with different variables for study of intention to work in rural areas and associated factors among public University undergraduate medical students in Ethiopia, 2018 ……………. 20 Table2. Socio-demographic characteristics of medical students in AAU, WSU, and WU, Ethiopia, in April, 2018 ……………………………………………………………………………………………………………………………….. 25 LISTS OF FIGURES FIG. 1 SCHEMATIC REPRESENTATION OF SAMPLING PROCEDURE—————————————-21 FIG.2 GENDER DISTRIBUTION OF MEDICAL STUDENTS AMONG THREE UNIVERSITIES——————26 FIG.3 YEARS OF INTENTION TO WORK IN RURAL AREA—————————————————-33 FIG.4 CONCEPTUAL FRAME WORK FOR INTENTION TO WORK IN THE RURAL AREA——————-51

ix LISTS ANNEX INFORMATION SHEET/INFORMED CONSENT—————————————————46 QUESTIONNAIRES—————————————————————————————-47 CONCEPTUAL FRAME WORK————————————————————————-51 DECLARATION SHEET———————————————————————————-52

1 1. INTRODUCTION 1.1. BACKGROUND Qualified and motivated human resources (HR) are essential for adequate health service provision, but HR shortages have now reached critical levels in many in rural areas(1)worse in developing countries(2) particularly in Africa(3). As a result, the shortage of doctors and their mal-distribution between urban and rural areas contribute to inequitable health care delivery(4). Ethiopia is the second most populous sub-Saharan country in Africa next to Nigeria. About 84% of the country’s total populations live in rural areas(5). The number of medical schools is more than 24 and the annual undergraduate medical students were more than 2000 currently and it was more than 3000 per year after 2018 from the level of only 336 in 2010(6). However, there are major HRH management challenges including shortage, urban/rural and regional disparities, poor motivation, retention and performance hence enhancing human resources management practice including motivation , and retention schemes is the main component (7). Shortages and imbalances in physician workforce distribution between urban and rural areas among the different regions in Ethiopia are enormous(8).The doctor to population ratio is 0.7 per 1000 population (7). Studies identified that medical students have low positive attitudes towards to work in rural area as well as low confidence in overall competency to work in the rural area in five Asian countries(9). In Uganda, medical students had a negative perception about the rural areas and did not intend to practice medicine in rural area after their qualification(10). The intentions of the majority of Ethiopian medical students in the capital city towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high (5) Different intrinsic example work itself and extrinsic factors like financial and non-financial incentives that pull or push affect the attitude of medical students towards rural area practicing after their graduation (3, 11-13).

2 However, limited evidences are available on intentions of medical students to work in rural area and influential factors that associate with practicing rural area after their qualification in Ethiopia. 1.2.STATEMENT OF THE PROBLEM The health workforce crisis is a worldwide phenomenon. It includes: difficulties in attracting and retaining health professionals to work in rural and remote areas, geographical mal?distribution and high turnover of health staff particularly physicians(14, 15) and serious shortage of these workers in the rural area particularly high in sub-Saharan Africa(16). Most of the medical students were expected to migrate abroad, rural to urban but small number of students anticipated a rural career and then increase physician shortage in rural areas(17, 18). Similarly, medical students with urban background were hate rural area work (8, 19-21). The staffing of public sector health facilities in remote rural areas is a serious challenge for many ministries of health because medical doctors left the rural public health sector mainly male, young and less experienced physicians (8, 22, 23). Low production capacity of medical doctors, limited health workforce management systems, which include lack of adequate retention and motivation mechanisms, Limited capacity of enrolling students remain responsible in most and the consequence has been geographical imbalances (urban/rural, interregional and Male/Female) (24). To improve the urban-rural distribution of physicians’ measures were introduced to increase the uptake of medical students considered quotas from different disadvantaged regions; medical education schools outside of regional capitals and emphasis of the curriculum on family and community medicine. National health systems response included accelerated (NIMEI) training program requires an undergraduate degree in natural science for program and candidates selected on the basis of entrance exam result(6). However, the magnitude of the problem is still high. Accordingly, the aim of this study was to assess the intention to work in the rural area, identify major associated factors with their intention and to explore factors to motivate to work in the rural area.

3 1.3.SIGNIFICANCE OF THE STUDY Different findings from different studies on the same topic were indicated but they were contradicting each other. Very few studies were conducted among medical students regarding their intention to work rural area and factors that associated in Ethiopia. Hence, there is limited availability of evidence. Therefore; the findings of this research add new information and knowledge regarding this area and give direction for the other researchers interested on this area. The finding of the study will also help to provide equitable health service for rural community and increase the interest of medical students to work in the rural settings. Moreover, the new message come through the study will help to fill the gap of motivation. Furthermore, the findings of this study will help Universities to give focus on rural health program for producing motivated medical students and Ministry Of Health to design motivating strategies for medical doctors in order to attract towards rural area. Finally, this paper will give new knowledge for program developers and policy formulators regarding this area.

4 2. LITERATURE REVIEW 2.2.THE CONCEPT OF MIGRATION AND MOTIVATION 2.2.1. MIGRATION OF HEALTH WORKERS Migration is a phenomenon where health workers leave from rural to urban regions within a country, from developing to developed countries or from public to the private sector. It can be defined as a form of relocation diffusion (the spread of ideas, innovations, behaviors, from one place to another) involving a permanent move to a new location. The World Health Organization estimates the current global shortage of health workers at more than 4 million(25). Because, health professionals migrate from rural to urban, from low to middle and middle to high-income countries, from developed countries with lower wages to those with higher ones. Less developed countries are most likely to be net suppliers, and although other developed countries are also net recipients the main receiver appears to be the US(9, 26). The Global pattern reflects the importance of migration from less developed countries to more developed countries. Migrants from countries with relatively low-income and high natural increase rate tend to head for wealthier countries where job prospects are higher (27). The migration of health workers from developing countries to developed ones is a well-recognized contributor to weak health systems in low income countries and is considered a primary threat to achieving the health-related millennium development goals (28-30). The emigration of doctors from developing countries to developed countries could be considered deleterious for the low income countries of departure but more associated with the amount of remittances sent home by migrants(31). From a global perspective, therefore, the medical brain drain could be seen as a matching process through which workers are allocated to places and jobs where they are most productive(25). The drain of health resources from low income countries to richer ones is not a new phenomenon, and Ethiopia is one of the countries with the lowest density of physicians in the world ; health migration is a problem in several categories of health workers in Ethiopia(12).

5 The literature shows that the brain drain of medical professionals is threatening the very existence of the countries’ health services. The problem of brain drain has reached quite disturbing proportions in certain African countries, with Ethiopia ranked first in the continent in terms of rate of loss of human capital, followed by Nigeria and Ghana(13) 2.2.2. MOTIVATION OF HEALTH WORKERS Motivation is a driving force that influences individuals to act in a certain way in their workplace. It can be defined both intrinsically and extrinsically. Intrinsically, self-generated like self- feeling, the freedom to act, to choose the goals, to develop one’s goals, interesting and stimulating tasks, promotion and development opportunities. But extrinsically, comes from outside, to motivate the employees such as incentives as raising the salary, recognition of one’s work(32). The increased focus on health workers’ motivation as vital to ensure good quality health services is a very important shift from seeing quality of service delivery in the health sector as a function of the number of health workers and their qualifications(33). Human resources management focuses on recruitment as per the need, deployment of staff, performance management and motivation. In order to improve development and management of human resources for health-enhancing human resources management practice including motivation and retention schemes can be taken as a strategy(7, 34). The motivation of health professionals is one of the key ways to ensuring efficient provision of health services. Improving the motivation of health workers in rural and remote areas is of greatest concern to all countries worldwide(18). 2.2.3. SOME THEORIES OF MOTIVATION It is better to state different theories of motivation in order to confirm the study finding whether agree or disagree with them because the study approach was deductive. Behavioral theories, such as those developed by Maslow and Herzberg, show a more complex decision-making process regarding the movement of labour (32, 35) with a particular emphasis on the importance of job satisfaction. They stated as follows Maslow’s Hierarchy of Need: Maslow (1954) postulated a hierarchy of needs that progresses from the lowest, subsistence level needs to the highest level of self-awareness and self-

6 actualization. The five levels of Maslow’s are Physiological, Safety, belonging, Esteem, and Self-actualization. The movement from one level to another level is satisfactory progress according to the theory(35). Alderfer’s ERG Theory: the three components (Existence, Relatedness, and Growth) identified by Alderfer (1972) drew upon Maslow’s theory, but also suggested that individuals were motivated to move forward and backward through the levels in terms of motivations. The three levels are: 1Existence related to Physiological and Safety needs 2. Relatedness addresses the belonging needs 3. Growth pertains to the last two needs, thereby combining Esteem and Self-actualization(36). Herzberg’s Two Factors Theory: Herzberg (2003) further modified Maslow’s needs theory and consolidated down to two areas of needs that motivated employees. These were characterized as lower level motivators called Hygiene’s and higher level factors and focused on aspects of works known as motivators. This theory easily understood the approach that suggests that individuals have desire beyond the Hygiene’s and that motivators are very important to them(32). McClelland’s Acquired Needs Theory (1985): the idea here is that needs are acquired throughout life. That is, needs are not innate but are learned or developed as a result of one’s life experiences. This theory focuses on three types of needs for achievement, affiliation, and power. The above theories of motivation were understood employees’ motivation on the basis of needs. But from other considerations is an extrinsic and intrinsic theory of motivation(37). Reinforcement Theory: B.F. Skinner (1953) studied human behaviors and proposed that individuals are motivated when their behaviors are reinforced which are associated with desirable and undesirable(38). These theories deal with a particular aspect of motivation, it seems unrealistic to address them in isolation, since these factors often do come into play in and are important to employee motivation at one time or another. Other approaches to motivation are driven by aspects of management, such as productivity, human resources, like Scientific Management Theory, McGregor’s Theory X and Theory Y, Ouch’s Theory Z these theories are helpful in understanding management and motivation from the conceptual perspective, it is important to recognize that most managers draw upon a combination of needs, extrinsic factors and intrinsic

7 factors in an effort to help motivate employees, to help employees meet their own personal needs and goals. Managers should focus on expectancy, goal setting, performance, feedback, equity, satisfaction, commitment, and other characteristics(39-41). 2.3.THE ROLE OF MEDICAL STUDENTS FOR THE RURAL COMMUNITY The healthcare sector at the rural community level is important for many reasons. Living in a rural area is appealing to many people, primarily for the quiet lifestyle and strong community relationships. These "quality of life" variables are important not only to those who want to continue living in a rural area, but also to urban residents that are searching for a change. However, for a rural community to survive, the local economy must be sustainable which will allow for the provision of important local services(16). Typically, rural communities pay little attention to their health care system until they need it. As a result, many people have little idea of the non-medical importance of the health care system to the local communities. The employment opportunities and the resulting wages and salaries make the health care system an extremely important part of the local economy and strong viable hospital must have support from local physicians to maintain sufficient utilization. Lack of local physician support will significantly impact the financial stability of the hospital. In addition to the inpatient visits, physicians can generate significant outpatient activity that increases hospital net revenue(28, 42). However, unpopularity for rural lifestyle indicated by medical students were: it is difficult or uncomfortable, it is backward, lack of social and family networks, poor accessibility of services and facilities, more fun and interesting in urban areas, financially is not as good, change from original lifestyle , and concern regarding children and schools(19). 2.4.INTENTIONS OF MEDICAL STUDENTS IN THE WORLD CONTEXT The Neoclassic Wage Theory, which suggests that the choice is driven largely by financial motives and by the probability of finding employment(17). On the other hand, people are motivated by a complex structure of rewards, in which non-financial benefits and move quickly to another job or place if their expectations are not met (43). Retention of health workers, particularly in rural areas of LICs (Low Income Countries), was great agenda, due to the severe staff shortages that hamper the attainment of the MDGs

8 (Millennium Development Goal). As a result, the study done on Germany and France24% of physicians were found in rural area(16), correspondingly in USA, Canada, South Africa, and Kenya, only 9% , 9.3% , 12% and 36% of physicians were found in rural areas respectively(43). So that ,there were fewer health workers in rural areas, loss of health workers in these areas will severely contribute to accessibility problems(44). Based on study done on China, among 4,669 medical students, (33%) had a positive attitude and (55%) had a neutral attitude toward working in rural THCs (Township Health Centers). Twenty-one per cent of medical students showed a strong willingness to work in a deprived area, 57.3% manifested weak willingness and 21.5% unwillingness to work in a low-resource setting(45). There was a significant increase in students’ perceptions of rural primary care physicians’ primary care service features and medical expertise. In the majority of countries, rural and remote areas are usually lacking sufficient numbers of health workers. Approximately one half of the global population lives in rural areas, but these areas are served by less than a quarter of the total physicians’ workforce and then at the country level, imbalances are even more prominent. Some countries have apparently a sufficient numbers on average, but with shortages in rural areas (Germany, France) as a result 24% and 76% of physicians were found in rural and urban areas respectively(43). Medical students preferring to work in rural areas were more likely to believe there are good opportunities for employment, to practice variety of skills, to get clinical practice autonomy in rural areas than those intending to work in urban areas. On the other hand, students preferring urban areas versus rural locations in the future were more likely to believe that working in rural areas would be more isolated(46, 47).But in Bangladesh 43% of medical students had positive attitude towards working in rural areas, and attitude about overall competency(9). Almost half the participant’s students chosen regional or rural practice, with the balance (majority) of the students preferring an urban Centre(46). Though, female students had negative attitude to practice rural area than male students. Students who lived in urban areas during their high school period had significantly lower positive attitude compared to those living in rural areas. Students whose parents lived in semi-urban areas had significantly higher positive attitude compared to those living in rural areas (9, 45, 48, 49).

9 Studies conducted in Bulgarian and Germany describes that, students prefer to specialize and to work in other European countries due to the better payment and they have intention to return and practice their profession in their country of origin(50). Conversely, Students perceived the physicians’ work demands more positively, and there was no change in students’ perceptions of the physicians’ income potential(51). The only factor significantly associated with positive attitudes towards their school in terms of preparing or inspiring them to work in rural areas is parents? residence. Factors significantly associated with intention to work in public sector five years after graduation includes residence during childhood and mode of admission into medical schools. Students living in urban areas during their childhood period had significantly less intention to work for public sector while (9, 45, 48, 49). Rural medical recruitment and retention through education and training, with important insights into the factors affecting preference for future rural practice was essential(34, 46). In Thailand, the government has aimed to annually produce 300 doctors specifically for rural areas(34). Selecting medical students through interviews to identify their family support and intentions to work in THCs would increase recruitment and retention(52). A rural background (i.e being brought up in a rural area) training with a community-based curriculum, was early exposure to the community during medical training and rural location of medical school motivate medical students to work in rural areas(53). 2.5.INTENTIONS OF MEDICAL STUDENTS IN SUB-SAHARAN AFRICAN CONTEXT Migration from and within sub-Saharan Africa (SSA) is an important macroeconomic issue for both sending and receiving countries. Amid rapid population growth countries, migration in sub-Saharan Africa has been increasing briskly over the last 20 years(22). Most of the medical students were expected to migrate abroad, but small number of students anticipated a rural career(18). From the African and Asian context, 28% expected to migrate abroad, while only 18% anticipated a rural career. There were more nursing than medical students desired professions abroad(54).

10 There are sub-Saharan African countries (Cote d’Ivoire, Mali, Democratic Republic of Congo), where there is large overproduction of health workers, with medical unemployment in urban areas, and at the same time with shortages in rural areas(43). For the reason that, a minor proportion of the students (13.6%) were willing to practice in the rural area after graduation and only (22.5%) were satisfied with rural community posting due to lack of interest in rural communities(55). Majority of the students (80.1%) were of the opinion that doctors working in rural area should earn more than their urban counterparts(56). Almost half (49.7% or 167/336) of all the respondents who answered the research questionnaire did not intend to work in rural health units after training. A quarter (25% or 84/336) of the respondents intended to work in rural facilities. Intention of medical students to work in rural health facilities decreased progressively from the first academic year to graduation even if, none of the fourth and fifth year respondents had any intention to work in rural units after training(2). In Malawi, medical students with rural background and small towns, and whose parents were ‘non-professionals’, were more likely to intend working in rural areas and small towns than students from urban and professional families(19). Medical students and young doctors were eager about working at district level, although this is curtailed by their desire for specialist training and frustration with resource shortages. There is currently little intention to move into the private sector. In Tanzania, the presence of family members in rural and remote areas also increases the probability that an individual will consider these areas for the establishment of his/her practice(47). Time spent in rural areas before matriculation predicted the preference for a rural career and against work abroad(54).Satisfaction with the rural rotation program was associated with increased likelihood of rural practice after graduation(47). So that, admissions standards favoring medical and nursing students with rural backgrounds could promote greater graduate retention in the country of training and in rural areas in Ghana (18).

11 2.6.INTENTIONS OF MEDICAL STUDENTS IN ETHIOPIAN CONTEXT The public health sector physician workforce largely constituted of male physicians, young and less experienced due to high turnover rate among females, the young and less experienced physicians, and those working in distant places (district hospitals) indicate the need for special attention in devising human resources management and retention strategies(8). Female physicians were 1.4 times more likely to move out from their duty stations compared to their counterparts. On the other hand, as the age of physicians increased, the incidence of physician turnover decreased. In terms of educational levels, Graduate Programs (GPs) had more incidence of turnover compared to specialists/subspecialists, in addition, turnover variations were observed between health service delivery settings that mean physicians working in referral hospitals and those working in the general hospitals were 1.39 times more likely to move out than physicians working in district hospitals. The incidence of physician migration was 2 times higher in Amhara region than capital AAU(8). In Ethiopia, physicians’ first placements occur through a lottery, leading to self-selection into the lottery while non-lottery participants apply mainly to private institutions. The authors argue that such random placement does not allow for efficient signaling of individual ability and therefore leads to adverse selection into the lottery, which is indeed what they find using career and wage records of physicians who remain in the public sector. They also find that within the group of lottery participants, the most able tend to leave and are likely to account for a substantial part (one third) of the physician brain drain out of Ethiopia(25). From the total respondents 67% (i.e. 63) of physicians express their wish to go abroad if they got the opportunity(13). The attitudes of the majority of Ethiopian medical students in the capital city, towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high among the study participants, creating a huge potential for brain drain(20). About 30% of the study participants would like to practice in rural areas of the country after completing their training, while 28% preferred to work in urban areas. However, 21% of the participants would prefer to work abroad following graduation, without serving in the country. Among the participants, (44%) of them preferred to initially practice medicine in public sector compared with NGOs (17%) or private sector (6%)(20).

12 2.7.FACTORS THAT INFLUENCE MEDICAL STUDENTS TO PRACTICE RURAL AREA Descriptive characteristics about medics’ migration designate, through the representative components for financial aspects, health system, and professional career, those important aspects that are relevant for a medic’s career, related to the migration phenomenon. The possibility of emigrating in more developed countries was mainly for economic reasons but also in search for better career advancement opportunities (57). Demographic characteristics, personal job concerns, and knowledge of THCs were associated with the choice of a career in rural THCs(52). Financial rewards as the number one motivator; followed by promotion, growth and development; job security; acknowledgment, praise, and recognition; and working environment in that order but doctors were motivated by their working environment mostly(18). Low salaries and unsatisfactory working conditions are often cited as reasons for not practicing in rural and remote areas(34). Motivational factors (satisfaction, intrinsically or content factors): events usually associated with positive attitudes regarding the workplace. These events are usually linked to the professional activities (realization, work itself, responsibility and promotion), which means they are intrinsic to the activity itself Hygiene factors (dissatisfaction, extrinsically or context factors). The events associated with negative attitudes regarding the workplace are extrinsically to the work itself and are more likely associated with the context of the activity (the organization’s administration and policy, job security, salary, management, interpersonal relationships and general work conditions) (18, 58). Factors associated with satisfaction with rural community posting included being a student in a federal institution, being a male student and intention to specialize in community medicine after graduation(55). Being female, of older age, not having a university-trained professional parent, previous exposure or service in a poor area, choice of pediatrics as a specialty and strong altruistic motivations were highly associated with the willingness to practice medicine in rural or underprivileged areas. Only 21.5% of respondents considered that medical schools encourage the practice of medicine in poor deprived regions. Likewise, only 6.2% of students considered that national public health authorities suitably stimulate physician distribution in poorer districts(45).

13 Factors associated with willingness to practice in the rural area included family residence in an urban area, work experience before admission into medical school, intention to specialize in Community Medicine and satisfaction with rural community posting(56). Marital status, some perceived difficulty of getting a job, having family support, sufficient knowledge of THCs, optimism toward THC development, seeking lower working pressure and a lower expected monthly salary affect intention of medical students to practice in rural area(52)however, another study opposed that medical students pursuit of postgraduate study rather than higher salaries(59). Exposure of facilitators to rural location, role models, working conditions; income, prestige, medical school environment, understanding of rural needs, intellectual challenge, attitude towards social problems, voluntary work, the influence of family, and length of residency impact the medical students to work in rural areas(60). Most of the existing literatures recognize that the decision to migrate is the result of the interaction between several identifiable factors both from home and abroad which are expressed as push and pull factors. Different kinds of literature like, (44, 61, 62)push factors are conditions that can drive people to leave their homes, they are forceful and relate to the country from which a person migrates. A few examples of push factors are not enough jobs in your country; few opportunities; "Primitive" conditions; desertification; famine/drought; political fear/persecution; poor medical care; loss of wealth; and natural disasters. low pay (absolute or relative), poor working conditions, lack of resources to perform work in an efficient manner, limited career opportunities, limited education and further training opportunities, the burden of infectious diseases such as HIV/AIDS, unstable and dangerous working environment, economic instability(13, 27, 35, 44). Examples of pull factors are; better living conditions; religious freedom; enjoyment; education; better medical care; and security. Higher payment, better working conditions, well-financed health systems, attractive career opportunities, further education opportunities, political stability, travel opportunities (27, 63). According to study conducted in public Hospitals of West Amhara, Northwest Ethiopia, Professional category, age, type of the hospital, non-financial motivators like performance evaluation and management, staffing and work schedule, staff development and promotion, availability of necessary resources, and ease of communication were found to be strong predictors of health worker motivation. Across the hospitals and professional categories, health

14 workers’ overall level of motivation with the absolute level of compensation was not significantly associated with their overall level of motivation (64). All job satisfaction subscales like professional training, autonomy, and work environment and cohesion, promotion, recognition at work, perceived alternative employment opportunity and leadership relationship except benefit and salary subscale were significant predictors of overall job satisfaction. Satisfactions with the work environment and group cohesion, single cohesion, and working in the hospital were the final significant predictors of anticipated turnover of Sidama zone nurses (65). Even though factors influencing health worker motivation are well established in the literature, little is known about the motivational factors that are of relevance to different categories of rural health workers in developing countries (18).

15 3. THE OBJECTIVES 3.2.GENERAL OBJECTIVE To identify the intention of rural medical practice among fourth and fifth year clinical level medical students in medical schools of AAU, WU, WSU Universities and the associated factors, 2018. 3.3.SPECIFIC OBJECTIVES To assess the intentions to work in the rural areas among Addis Ababa, Wachemo and Wolayita Sodo Universities undergraduate medical students, 2018. To identify factors associated with intention to work in the rural area among fourth and fifth year medical students in Addis Ababa, Wachemo and Wolayita Sodo universities undergraduate medical students, 2018 To explore factors those motivate fourth and fifth year undergraduate medical students to practice in rural area after their qualification at Addis Ababa, Wachemo and Wolayita Sodo Universities, 2018

16 4. METHODS 4.1. STUDY AREA AND PERIOD One of the study areas for the study was AAU University particularly Tikur Anbessa Specialized Hospital (TASH). TASH is the largest specialized hospital in Ethiopia from 1972, with over 700 beds, and serves as a training center for undergraduate and postgraduate medical students, dentists, nurses, mid wives, pharmacists, medical laboratory technologists, radiology technologists, and others who shoulder the health problems of the community and the country at large. The TASH has more than 400 doctors, 400 nurses and 115 other health professionals and also more than 950 permanent and administrative staff dedicated to providing health care services. Above 1300 medical students are actively learning in the school of medicine. WSU University (WSU) is another study area for this study. WSU is one of the new generation Universities found at a town Wolayita Sodo, which is around 390 kilometers away towards South from the capital city AAU, Ethiopia. The university was opened officially on March 24, 2007. The University started the school of medicine by accelerating program or New Innovative Medical Education Initiative (NIMIE) from last five years. Currently, above 200 medicine students are learning actively on medical education. WU University (WU) is among the third generation public Universities which commenced educating in 2011. it is located 230 km southwest of AAU, at Hosanna town in the area of over 200 hectares. Currently, the University has admitted over 18,000 students among these more than 175 are medical students. Recently the University runs 48 departments under 6 Colleges, namely 1) Engineering and Technology, 2) Natural and Computational Sciences, 3) Medicine and Health Sciences, 4) Agricultural Sciences, 5) Business and Economics, and 6) Social Sciences and Humanities. In addition to these, the university has launched 4 new programs at MSc level in 2016/17 academic year. The reason to choose such areas are the accessibility and the former researchers were not included such areas and also minimizing the cost of the study was considered. Hence, the study site was limited in such area and the study population was medicine students in the selected areas. The study was conducted from January to April 2018.

17 4.2. STUDY DESIGN A cross-sectional study design using quantitative approach was used to assess intention of fourth and fifth year medical students towards clinical practice in rural area after graduation and their associated factors. 4.3.SOURCES OF POPULATION All undergraduate medical students who are active in 2018 academic year at WU University, WSU University, and AAU University were source of population (year one to graduate year medical students). 4.4.STUDY POPULATION In order to infer the expected outcome of this research, all the fourth to fifth year (clinical level) medical students who are found in WU, WSU, and AAU Universities are considered to be the population of the study.

18 4.5.VARIABLES OF THE STUDY 4.5.1. INDEPENDENT VARIABLES Socio -demographic factors Variables such as age, sex, birth place, marital status, religion, place of high school or secondary school, work experience, academic year, father’s and mother’s highest educational status, father’s and mother’s occupation, current family residence area, source of family income, perceived economic status of family were determining variables. Factors that initiate medical students to choose medicine Self interest for life saving, demanding better income, social prestige, family or peer group pressure, senior medical students or health professionals advice were considered as independent variables. Factors that encourage working in the rural area Work autonomy or variety of skills, employment opportunity, career advancement, near to family or spouse or friends, new knowledge from diversity of cultures were also independent variables. Factors that discourage working in the rural area Inadequate financial incentives, professional isolation, family or social isolation, less availability of basic infrastructures, updated technologies, and lack essential medical equipment, language barrier, low par time work were other independent variables. Factors related to awareness about rural community Attending on rural health programs, rural career guidance, belief on rural community life style Factors related to areas to work: type of organization, type or level of health facility were considered as independent variables. 4.5.2. DEPENDENT VARIABLE The intention of medical students to work in rural areas was expected outcome of this research (where do you want to work? Rural/Urban)

19 4.6.OPERATIONAL DEFINITIONS RURAL AREA: Those areas other than major or biggest cities or towns recognized as polic, rajeo-polic and category one cities in Ethiopia. URBAN AREA: According to Ministry of urban development and housing, geographical area that incorporates the biggest cities or towns recognized as polic, rajeo-polic and category one in Ethiopia such as (Addis Ababa, Adama,Gonder, Mekele, Hawasa, Bahir Dar, Dire Dawa, Dessie, Jimma, Jijiga, Shashemane, Bishoftu, Sodo, Arba Minch, Hosaena, Harar, Dila, Nekemte, Debre Birhan, Assella) UNDER-SERVED AREA: geographical areas where relatively poorer populations reside – areas that have limited access to qualified health care providers and health services of adequate quality. It may include, for example, remote rural areas; areas that are in conflict or post-conflict; refugee camps; and areas inhabited by minority or indigenous groups HEALTH WORKERS MIGRATION is a well-known phenomenon where health workers move from rural to urban regions within a country. MEDICAL STUDENTS: learners who are following medicine courses from the fourth year to the fifth year. INTENTION: mental state that represents a commitment to carrying out an action in the future. PUSH FACTORS: circumstances that force physicians to leave their countries and rural area due to different reasons or factors. MOTIVATIONAL FACTORS: are attractive reasons for acting or behaving in a particular way” or a “desire or willingness to work in rural area. PULL FACTORS: circumstances that force to attract medical students to their countries due to different reasons or factors.

20 4.7.SAMPLE SIZE DETERMINATION The sample size was calculated by using estimation of single population proportion based on(20). As a result of this, P = 0.3, q = 0.70, Z = 1.96 from 95% confidence interval and 0.05 was the degree of precision (d) value. Therefore, sample size was calculated as follows n= (z ?/2)2x pq = (1.96)2(0.3) (0.7)/ (0.05)2 = 323 d2 TABLE 1 SAMPLE SIZE CALCULATION WITH DIFFERENT VARIABLES FOR STUDY OF INTENTION TO WORK IN RURAL AREAS AND ASSOCIATED FACTORS AMONG PUBLIC UNIVERSITY UNDERGRADUATE MEDICAL STUDENTS IN ETHIOPIA, 2018 Major factors Confidence level Power % of less likely to practice AOR Sample size Age 95% 80% 10.5 0.6 145 Gender 95% 80% 27.7 1.0 308 Family residence 95% 80% 11.5 0.4 157 Work experience 95% 80% 10.9 2.0 150 Finally, Maximum number of sample size is acceptable and 10% was considered non-respondents’ rate then the sample size of this study was 355 among this 342 were returned completed questionnaires and 0.8% were incomplete so that 96.33% respondents rate was made. 4.8. SAMPLING PROCEDURE The probability sampling particularly simple random sampling method was employed. First, the target population was stratified according to years of clinical practicum. Second, proportional allocation of participants to the size of clinical levels was done. Third, proportional allocation of participants to study areas and sampling frame was prepared from the list of medical students and finally, eligible participants were selected by simple random sampling from each level of medical students (see figure one below).

21 SAMPLING PROCEDUREBy proportional allocation to class levelProportional allocation to study areaUsing simple random sampling Fig1Schematic presentation of sampling frame of intention of medical students to work in rural area, 2018Total number of year four and year five medical students= 708Year four students= 320Year five students= 388Allocated Year 4 students = 160Allocated Year 5 students = 195Sodo21Yr3= 160AAU124Wachemo15Sodo34AAU140Wachemo21Sodo21AAU124Wachemo15Sodo34AAU140Year 5 students sample =195Total sample size for the study =355Wachemo21Year 4 students sample = 160 4.9. DATA COLLECTION TOOLS AND PROCEDURE The questionnaire for the participant was adapted from prior literature and modified to the study context. The tools comprise of questions related to Socio-demographic characteristics, reasons to choose medicine initially, factors that demotivate to practice rural area, factors that motivate to practice rural area and intention about working in the rural area after graduation. The expected relevant data was gathered by using self-administered English version questionnaires because English is media of instruction in higher education institutions in Ethiopia. The both closed and open-ended type of items was used in the form of Likert-scale by which the researcher has the chance to get a greater uniformity of responses of the respondents that was helped him to make it easy to be processed. Then the questionnaires were administered to sample medical students in the selected universities based on the agreement. The participants were allowed giving their own answers to each item independently as needed by the researcher. They were strictly assisted and supervised by the researcher himself. Finally, the questionnaires were collected back at the right appointment.

22 4.10. D ATA QUALITY MANAGMENT To ensure data quality, sufficient orientation was given to co-coordinators or data collectors and study participants on the objective of the study, on answering style of questionnaires, on the confidentiality of the data. The facilitators supported to collect data through provided questionnaires. Data collection process was strictly followed by the researcher. Checking the validity and reliability of data collecting instruments before providing to the actual study subject was the core activity to assure the quality of the data(66) through Pre-tested pilot study that was conducted in St. Paulos millennium Medical College among 24(6.8%) medical students prior to the final administration of the questionnaires to all respondents. Each questionnaire was checked for completeness, missed values and unlikely responses; those incomplete questionnaires were omitted from the analysis then final administration was started. As a result, Editing, coding and cleaning was carried out and also recoding, transforming, and re-categorizing of variables was done. 4.11. DATA ANALYSIS PROCEDURE After completion of data collection; Data was entered in to EPI-Data version 3.1, and it was exported to Statistical Package for Social Science (SPSS) version 24 for analysis. After checking, basic descriptive summaries of medical students’ characteristics and outcome of interest was computed. Accordingly, simple frequencies, measure of central tendencies and measure of dispersions were calculated. The prevalence of their intention to practice in rural area was determined and analysis was carried out for the determination of the relationship between predictor variables and intention to work in rural area by using crosstab. Binary logistic regression analysis was done to determine the effect of factors that associate with the outcome variable. During binary logistic regression analysis factors which have association at P-value less than 0.20 was entered into multinomial logistic regression analysis. Statistical significance was declared at P value less than 0.05 at final multinomial logistic regression. Finding of final model was reported using adjusted odds ratio at 95% confidence interval.

23 4.12. ETHICAL CONSIDERATION To make the research process professional, ethical consideration was made. Ethical permission was received from Review of Ethical Committee (REC) of the school of public health and the Institutional Review Board (IRBCHS) of College of Health Science at AAU. Ethical clearance was received from St. Paulos Millennium Medical College Ethical Review Board to do pretest before distributing the questionnaires. The researcher informed the respondents about the purpose of the study i.e. purely for academic, the purpose of the study also introduced in the introduction part of the questionnaires to the responsible participants. Participants were informed that their participation in the study was based on their consent and the purpose of the study was explained to them prior to the distribution of the questionnaires. Any identification of the students did not record anywhere on the questionnaire. In addition to this, the research has not personalized any of the respondent’s response during data presentations, analysis and interpretation. Furthermore, all the materials used for this research had been acknowledged. 4.13. DISSEMINATION OF THE STUDY FINDINGS The final edition (revision) was disseminated to AAU University; College of Health Science School of Public Health, School of Medicine, Ministry of Health and Ministry of Education through hard and soft copies. In addition, effort was exerted to publish the study findings on local/ international journal by preparing manuscript.

24 5. RESULTS 5.1. Socio-demographic characteristics of the study participants A total of 342 undergraduate medical students were participated in this study, of which 254(74.3%) were male. While 88(25.7%) were female. The mean age of study participant was 23.85 with S.D 3.02. Among them 184(53.8%) were born in Urban area but 158(46.2) were born rural area. Out of total participants, 292 (85.4%) were generic, 50(14.6%) were accelerated (NIMEI). Of which 157(45.9%) were fourth and 185(54.1%) were fifth years. Regarding to religion affiliation, 201(58.8%) were Orthodox, 41(12%) were Islam, 91(26.6%) were Protestant and 8(2.3%) were from Catholic religions. Concerning to current family residence, 199(58.2%) were live in urban and the rest 143(41.8%) were live in rural area. According to main income source of the family, 156(70.8%) from Salary, 100(29.2%) from Business and 86(25.1%) from Agriculture. Finally, out of total respondents 254(74.3%) were medium, 66(19.3%) were poor and 22(6.4%) were rich regarding to perceived economic status of their families (see table 2).

25 Table2. Socio-demographic characteristics of medical students in AAU, WSU, and WU, Ethiopia, in April, 2018 Variables Frequency Valid Percent Cumulative Percent Sex Female 88 25.7 25.7 Male 254 74.3 100.0 Age 20-25 284 83.0 83.0 Above 25 58 17.0 100.0 Birth place of respondents Urban 184 53.8 53.8 Rural 158 46.2 100.0 Religion of the respondents Orthodox 201 58.9 58.9 Islam 41 12.0 71.0 Protestant 91 26.7 97.7 Catholic 8 2.3 100.0 Academic year of respondents Fourth year 157 45.9 45.9 Fifth year 185 54.1 100.0 Medical education program Generic 292 85.4 85.4 Accelerated 50 14.6 100.0 Current family residence Urban 199 58.2 58.2 Rural 143 41.8 100.0 Main income source of family Agriculture 86 25.1 25.1 Salary 156 45.6 70.8 Business 100 29.2 100.0 Perceived economic status of family Poor 66 19.3 19.3 Medium 254 74.3 93.6 Rich 22 6.4 100.0

5.2. The study participants Majority of the study participants were from Addis Ababa University School of Medicine that means 182 males versus 75 females and total two hundred fiftyparticipants were from Wolayita Sodo accelerated program medical students (45 males’ vs. 5 females) and finally the least number (35) of respondents were selected from Wachemo new generation University among them 27 and 8 were males and females respectivelydirectly below). Figure2: The gender distributionfactors among the three public University undergraduate medical students1824527MALE
Number of respondents26 participants according to their sex distribution ajority of the study participants were from Addis Ababa University School of Medicine that means 182 males versus 75 females and total two hundred fifty-seven. Fifty out of total study om Wolayita Sodo accelerated program medical students (45 males’ vs. 5 females) and finally the least number (35) of respondents were selected from Wachemo new generation University among them 27 and 8 were males and females respectivelyThe gender distribution for study of intention to work in rural areas and its associated public University undergraduate medical students in Ethiopia7558FEMALE TOTAL Sex of respondentsAddis AbabaWolayita SodoWachemosex distribution ajority of the study participants were from Addis Ababa University School of Medicine that seven. Fifty out of total study om Wolayita Sodo accelerated program medical students (45 males’ vs. 5 females) and finally the least number (35) of respondents were selected from Wachemo new generation University among them 27 and 8 were males and females respectively (see the figure ntention to work in rural areas and its associated in Ethiopia, 2018 2575035TOTAL

27 5.3. Factors that inspire medical students to choose medicine Greater part of the respondents were chosen medicine department according to their interest in the field for life saving (mean score: 2.72) and the second inspiring factor to choose medicine initially was searching better income which means 239(69.9%) of respondents were agreed on searching income was basic reason to choose medicine (mean score: 2.56). In addition, among the total respondents 169(49.4%) of them were chosen medicine due to the presence of family or peer group influence (see table 3). Table3. Factors that inspire medical students to choose medicine of AAU, WSU, and WU, Ethiopia, April 2018 (n=342). Variables Frequency Percent Mean S.D My interest in the field for life saving Disagree 30 8.8 2.72 0.61 Neutral 35 10.2 Agree 277 81.0 In order to search better income Disagree 46 13.5 2.56 0.72 Neutral 57 16.7 Agree 239 69.9 Family or peer group influence Disagree 110 32.2 2.17 0.89 Neutral 63 18.4 Agree 169 49.4

28 5.4. Factors that encourage medical students to work in the rural area More than two third of the respondents were interested to work in rural area after their graduation (mean score: 2.53) due to the existence of high medical need, about half of total respondents were encouraged in order to practice variety of skills or to get work autonomy in the rural area which was mean score of 2.24. Nearly forty percent of respondents agreed that having better opportunity for career advancement encourage them. Furthermore, 120(35.1%) participants agreed on good opportunity for employment. Similar number of respondents 111(32.5%) were agreed on familiarizing different cultures or gaining cultural advantages, nearness for family or friends or spouse as an encouraging factor for them (see table 5). Table5.Factors that encourage medical students to work in rural area of AAU, WSU, and WU, Ethiopia, April 2018 (n=342). Variables Frequency Percent Mean S.D Opportunity to practice variety of skills or work autonomy Disagree 96 28.1 2.24 0.86 Neutral 67 19.6 Agree 179 52.3 Having better opportunity for employment in the rural area Disagree 145 42.4 1.93 0.88 Neutral 77 22.5 Agree 120 35.1 Having high medical need for rural area Disagree 50 14.6 2.53 0.74 Neutral 59 17.3 Agree 233 68.1 Having better opportunity for career advancement Disagree 139 40.6 1.98 0.89 Neutral 72 21.1 Agree 131 38.3 Locating near to the family or friends or spouse Disagree 178 52.0 1.80 0.89 Neutral 53 15.5 Agree 111 32.5 Adopting with different cultures or cultural advantages in the rural areas Disagree 133 38.9 1.93 0.84 Neutral 98 28.7 Agree 111 32.5

29 5.5. Factors that discourage medical students to work in the rural area Nearly ninety percent of respondents agreed that poor accessibility of essential infrastructures (like road, education, electricity, recreational facilities and other technologies) and low availability of essential medical equipment and laboratory facilities discouraged to work in rural area after their qualification (mean score: 2.87 and 2.83 respectively). The response of 272(79.5%) shown inadequate financial incentives such as salary, bonus, allowances, compensations, loans affected their intention to work in rural area (mean score: 2.71). Furthermore, seventy four percent of respondents agreed for language barrier and about sixty six percent of participants agreed for less access to par time work as discouraging factor for them (mean scores 2.61 and 2.51 respectively). Among total study respondents, 214(62.6%) of them decided that working in rural area might expose to family and professional isolations with their mean scores: 2.48 and 2.53 respectively (see table six below).

30 Table6 Factors that discourage medical students to work in rural area in AAU, WSU, and WU, Ethiopia, April 2018 (n=342). Variables Frequency Percent Mean S.D Poor accessibility of essential infrastructures in the rural area Disagree 13 3.8 2.87 0.44 Neutral 19 5.6 Agree 310 90.6 Low availability of medical equipment and laboratory facilities Disagree 17 5.0 2.83 0.49 Neutral 24 7.0 Agree 301 88.0 Inadequacy of financial incentives in the rural area Disagree 29 8.5 2.71 0.61 Neutral 41 12.0 Agree 272 79.5 Having language barrier in the rural area Disagree 43 12.6 2.61 0.70 Neutral 46 13.5 Agree 253 74.0 Professional isolation will face if the location to work after graduation is rural area Disagree 33 9.6 2.53 0.66 Neutral 95 27.8 Agree 214 62.6 Less access to par time work in the rural area Disagree 51 14.9 2.51 0.74 Neutral 66 19.3 Agree 225 65.8 Family or friends isolation Disagree 48 14.0 2.48 0.73 Neutral 80 23.4 Agree 214 62.6

31 5.6. Awareness of medical students about rural area Regarding on career guidance, 275(80.4%) of respondents were not properly received rural career guidance (mean score: 1.80). Among 342 respondents more than sixty percent respondents were not attending on different experimental rural health programs was (mean score: 1.64). Finally, below the average number of medical students were aware about rural community posting as well as the life style of rural community which is mean score of 1.58 (see table 7). Table7. Awareness of medical students about rural area or rural community in AAU, WSU, and WU, Ethiopia, April 2018 (n=342). Variables Frequency Percent Mean S.D Receiving rural career guidance while medical education carried out Yes 67 19.6 1.80 0.38 No 275 80.4 Attending on different experimental rural health programs Yes 124 36.3 1.64 0.48 No 218 63.7 Having good awareness about rural community posting Yes 145 42.4 1.58 0.49 No 197 57.6 5.7. The areas of intention to work after graduation About two third of respondents were chosen public or governmental health facility rather than private or Non-government organization. Which means 224(65.5%) study participants were intended to work in public facility and the rest 118(34.5%) were chosen private or Non-government health organization. Almost half of the study participants were wished for tertiary or teaching hospital, about thirty percent preferred general hospital and approximately twenty one percent of them were preferred primary hospital to work after their qualification. From the total respondents of the study 232(67.8%) respondents were preferred urban area but the rest 110(32.2%) of respondents intended to work rural area (71 males and 39 females) after their graduation (see table 8)

32 Table8. The areas of intention to work after graduation in AAU, WSU, and WU undergraduate medical students Ethiopia, April 2018 (n=342). Variables Frequency Percent C. P Organization Public or Government 224 65.5 65.5 Private or NGO 118 34.5 100.0 Total 342 100.0 Facilities that intended to practice after graduation Primary hospital 71 20.8 20.8 General hospital 105 30.7 51.5 Teaching hospital 166 48.5 100.0 Intended location after graduation Urban 232 67.8 67.8 Rural 110 32.2 100 About sixty percent of rural intended students were targeted maximum of two years but the rest forty percent of them were agreed to work more than two years in the rural areas. Fig3: Representation of years of intention to work in rural areas and undergraduate medical students in Ethiopia, 2018 050100150200250Zero year(Urban)one to two yearsAbove two years

33 5.8. Factors that associated with intention of medical students to work in the rural area Among all the study variables sex of the respondents,’ secondary school place of the respondents, religion of the respondents, marital status of the respondents, medical education program, current family residence, accessibility for work autonomy or exercising different skills, opportunity for employment, opportunity for career advancement, location near to the family or friends, exposure for professional isolation, availability of medical equipments, availability of essential facilities and infrastructures, sufficient career guidance for rural works and type of health facility were candidate variables because of p-value less than 0.2 during Bivariate analysis of logistic regression. Out of total candidate variables, only four variables such as sex, religion, opportunity for career advancement and type of health facility were significantly associated with intention of medical students to work in the rural area after their graduation while Multivariate analysis of logistic regression. However; the rest variables were not significantly associated with intention of medical students to work rural area. Regarding socio-demographic characteristics, sex or male medical students (AOR 95%CI = 0.3920.191, 0.806) were significantly associated with intended to work in the rural area. This result shown that, male medical students were less likely intended to work in the rural area after graduation than female students. According to religion of medical students, Orthodox (AOR 95%CI = 0.0770.011, 0.526) and Protestant (AOR 95%CI =0.0980.015, 0.659) religions were associated significantly. The odds of intention to work in the rural area among Orthodox and Protestant religion followers were less likely intended to work in the rural area. Concerning to factors that encourage medical students, only good opportunity for career advancement (AOR 95%CI = 0.3480.159, 0.765) associated significantly. This result told that the medical students disagreed on opportunity for career advancement as important encouraging factor were less likely intended to work in the rural area so that the variable is an encouraging factor. Among types of health facilities in the health sector tier system primary hospital (AOR

34 95%CI = 28.111.8, 67.3) and general hospital (AOR 95%CI = 2.481.22, 5.06) were considerably associated with intention of medical students to work in the rural area after qualification (refer table 9). Table9. Bivariate and multivariate analysis of logistic regression for associated factors with intention to work in rural area AAU, WSU, WU in Ethiopia, April 2018 (n=342). Variables Preferred location Bivariate analysis Multivariate analysis Urban n(%) Rural n (%) COR95%C.I p-value AOR95%C.I p-value Sex of respondents Male 183(78.9) 71(64.5) 0.487(0.295, 0.805)* .005 0.392(0.191, 0.806)** 0.011 Female 49 (21.1) 39(35.5) 1 1 Respondents School place Urban 135(39.5) 78(70.9) 1.751(1.076, 2.851)* 0.024 1.55(0.469, 5.097) 0.474 Rural 97(28.4) 32(29.1) 1 1 Religion of the respondents Orthodox 137(59.1) 64(58.2) 0.280(0.065, 1.209) 0.080 0.077(0.011, 0.526)** 0.009 Islam 25(10.8) 16(14.5) 0.384(0.080, 1.833) 0.230 0.131(0.017,1.008) 0.051 Protestant 66(28.6) 25(22.7) 0.227(0.051, 1.022) 0.053 0.098(0.015, 0.659)** 0.017 Catholic 3(1.3) 5(4.5) 1 1 Respondents Marital status Single 222(95.7) 98(89.1) 0.368(0.154, 0.880)* 0.025 0.825(0.159, 4.279) 0.819 Married 10(4.3) 12(10.9) 1 1 Education program Generic 193(83.2) 99(90.0) 1.819(0.893, 3.705) 0.100 2.09(0.586, 7.43) 0.257 accelerate 39(16.8) 11(10.0) 1 1 Current family residence Urban 127(54.7) 72(65.5) 1.567(0.979, 2.507) 0.061 1.07(0.327, 3.511) 0.908 Rural 105(45.3) 38(34.5) 1 1 practicing variety of skills or Disagree 80(34.5) 16(14.5) 0.290(0.157, 0.537) 0.000 0.51(0.213, 1.218) 0.129 Neutral 46(19.8) 21(19.1) 0.663(0.365, 1.203) 0.176 0.922(0.415,2.046) 0.842 Agree 106(45.7) 73(66.4) 1 1

35 opportunity for employment Disagree 114(49.1) 31(28.2) 0.332(0.195, 0.568)* 0.000 .478(0.215, 1.063) .07 Neutral 52(22.4) 25(22.7) 0.588(0.323, 1.068) 0.081 .642(0.280, 1.470) .29 Agree 66(28.4) 54(49.1) 1 1 Opportunity for career advancement Disagree 111(47.8) 28(25.5) 0.308(0.180, 0.528)* 0.000 0.348(0.159, 0.765)** .009 Neutral 49(21.1) 23(20.9) 0.573(0.313, 1.047) 0.070 0.443(0.190,1.035) .060 Agree 72(21.0) 59(53.6) 1 1 Locating near to the family or friends Disagree 123(53.0) 55(50.0) 0.707(0.430, 1.162) 0.172 1.38(0.63, 2.99) 0.42 Neutral 41(17.7) 12(10.9) 0.463(0.219, 0.978)* 0.044 1.02(.377, 2.773) 0.97 Agree 68(29.3) 43(39.1) 1 1 Professional isolation in the rural area Disagree 18(7.8) 15(13.6) 2.04(0.969, 4.308) 0.061 1.62(0.539, 4.854) 0.39 Neutral 62(26.7) 33(30.0) 1.30(0.779, 2.185) 0.321 1.38(0.663, 2.866) 0.39 Agree 152(65.5) 62(56.4) 1 1 Availability of medical equipments Disagree 8(3.4) 9(8.2) 2.680(1.002, 7.169)* 0.050 1.54(0.363, 6.557) .56 Neutral 12(5.2) 12(10.9) 2.382(1.031, 5.504)* 0.042 1.22(0.387, 3.849) .73 Agree 212(91.4) 89(80.9) 1 1 Infrastructure and other facilities Disagree 14(6.0) 14(12.7) 2.532(1.154, 5.560)* 0.021 3.21(0.95, 10.81) .06 Neutral 23(9.9) 1917.3) 2.092(1.079, 4.057)* 0.029 1.75(0.736, 4.152) .21 Agree 195(84.1) 77(70.0) 1 1 Rural career guidance Yes 40(17.2) 27(24.5) 1.561(0.899, 2.712) 0.114 1.62(0.694, 3.80) 0.26 No 192(82.8) 83(75.5) 1 1 Type of health facility PH 14(6.0) 57(51.8) 25.3(12.17, 52.62)* 0.000 28.1(11.8, 67.3)** .000 GH 75(32.3) 30(27.3) 2.5(1.35, 4.58)* 0.003 2.48(1.22, 5.06)** .012 TH 143(61.6) 23(20.9) 1 1 “*” Shown significant at p-value less than 0.2 “**” Shown significance at p-value less than 0.05

36 6. DISCUSSION The central purpose of this study was to identify factors associated with medical students’ intentions to work in rural area after graduation. The study also assessed factors that motivate medical students to work in rural area after qualification. The finding of this study was about one-third of the study participants were intended to work in rural area. Furthermore, male gender is the only notable socio-demographic variable that significantly associated or female medical students were more likely intended to work in rural area than male students. Better opportunity for career advancement was for effective significant motivator and type of health facility were motivating factors in order to work rural area after their graduation. This study found that 110(32.2%) of participants were willing to work medicine activities in rural areas after graduation among this about sixty percent of them were targeted for one or two years until receiving their license after completing obligation years. Similarly, the studies done regarding medical students intention to work rural area confirm that 40% in Australia, 52.0% in Chinese, 30% in Pakistan, 30% in Ethiopia were willing to work in the rural area(20, 67-69). However; about 60 % of students from Bangladesh and Thailand had positive attitude towards working in rural area(9). Finding from Uganda assured that few students who intended to work in rural areas hoped to stay for not more than three years, before going either for further studies or for self-employment in urban areas(2). On the other hand, new graduates of medicine face an obligation to serve the public to compensate for their training expenses and has become usual that most of the experienced medical specialists and even general practitioners move to the private sector and NGOs following the completion of the obligation(20) Another important result of this study, female medical students were more likely willing to work in rural area than male students. Likewise, different literatures verified that the intention of medical students to work in the rural area was higher among females that males (45, 70, 71). However; researches done in Nepal, Ghana, and South Africa contrary that male medical students were more interested to work in rural area than those female medical students (4, 49, 55, 72, 73).

37 Concerning religion, Orthodox and Protestants were shown significant association with intention of medical students to work in the rural area. Correspondingly, study finding reports from South Africa revealed a small subset of students objected to rural placements because of religious commitments, citing the fact that they were either fasting or were on a special diet wherein certain cooking ingredients would not be available in a rural site (74). Similarly, in Ethiopia Orthodox religion affiliation were significantly associated with intention to work in the rural area(20) An additional finding of this study, better opportunity for career advancement is an important factor to attract medical students to work in the rural area after their qualification. A study carried out in Pakistan, India and Uganda confirmed that the career development was the main factors identified by young doctors and a good motivator for work location preference (69, 75-77). Literatures in Ethiopian context also confirmed that limited career opportunities impact the intention of medical students to work in rural area (13). Out of the study participant, nearly half of them were interested to work in the tertiary hospitals, however; only 20.8% and 30.7% respondents were willing to work in the primary and general hospitals respectively. In Hungary, the majority of the young doctors preferred to work in large cities or major teaching or central hospitals (78). In Ethiopia the result of survey shown that physicians working in district or general hospitals were more likely to migrate out than physicians working in referral hospitals (8). The medical doctors profile study in Ethiopia also revealed accumulation of medical doctors in Addis Ababa(23). Majority of Ethiopian medical students in the capital city, towards practicing medicine in rural areas were found to be poor, creating(20). 7. LIMITATION OF THE STUDY Absence of adequate research papers was conducted by senior researchers regarding to intention of medical students to work in the rural area particularly in Ethiopia. Since the study is cross-sectional and only self administered questionnaire used it are not possible make inferences about the causal effects relationship. The sample consisted of more generic students than accelerated ones and, therefore, may have had a less proportion of students with experience before medical education, resulting in response of generic program students might have impact on the intention to practice medicine in rural areas. The proportion of both male and female students was not

38 equivalent. Finally, this study was based on self-reported data and possibly affected by a recall bias. However, all the above limitations may not have a negative effect on the validity of the findings, and data can be used for policy formulation and sustainable interventions to bring about positive changes in the attitudes of medical students towards location to medical practice and motivational factors. 8. CONCLUSIONS AND RECOMMENDATIONS 8.1. CONCLUSIONS This paper is among the few studies conducted on medical students’ intention to work in the rural area and their associated factors after graduation in Ethiopia. Greater part of undergraduate medical students was dislike to work in the rural areas. It creates serious shortage of senior physicians and inequitable health services in the rural part of the community in case of rural to urban migration. Rural career guidance during medical education activates their intention to work in the rural settings and expansion of career advancement produces students who are more interested to practice medicine in the rural areas. The female medical students were more likely voluntary to work in rural areas than males, therefore; recruiting more female medical students into medical schools is expected to produce more likely to work in rural areas. 8.2. RECOMMENDATIONS A range of activities should be targeted to shape the attitudes of medical students to practice in rural settings and provide interventions for medical students’ motivation. As WHO reported that strategies or bundles of interventions on education, regulation, financial incentives, professional and personal support policies to increase the availability of motivated and skilled health workers in remote and rural areas through improved attraction, recruitment, and retention of health workers in these areas should be considered(79). Because improving equipment in rural area facilities and providing long-term education for physicians who work in rural areas would increase the share of physicians willing to work in rural areas(80). As a suggestion, comprehensive interventions starting from enrolment and recruitment of medical students who

39 have the drive and motivation to be health professionals, to continuously engaging students of health science to reflect on what it means to be a health professional and inspiring practicing health professionals to demonstrate commitment to their country, people and care for their patients should be emphasized. In order to minimize the shortage of more experienced physicians in the rural settings, basic motivations like adequate salaries, private wing and other allowances to increase retention of medical students in the rural location should be improved from government point of view. Furthermore, opportunity for career advancement should be considered by different policy interventions. More centralized medical cases and activities in the tertiary hospitals should be decentralized into lower levels of health facilities because there were high accumulation of medical doctors particularly senior physicians in the teaching hospitals. The findings of this study also have important policy suggestions that the number of female students enrolled into medical schools should be increased to produce graduates who are more likely to practice in rural settings so that using different affirmative action’s for involving more female students into medical schools. Finally, in order to decrease the shortage of physicians in the rural part of the country a New Innovative Medical Education Initiative (NIMEI) launched in Ethiopia and the training of female medical doctors using a new approach and curriculum initiated should be expanded to all medical schools in the country.

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45 LISTS OF ANNEX INFORMATION SHEET This study was conducted on the assessment of intention to work in rural area after graduation among clinical year medical students in AAU University, WSU University, and WU University, 2018. Hello, my name is Berhanu Achiso I am from AAU University, Health Science College, School of Public Health, Graduate program of Health Economics. I would like to ask a few questions about intention of clinical year medical students to work in rural area after graduation and their associated factors. Your genuine information that you are going to provide will help educational policy makers to design strategy/give priority for improvement of rural community health. Your answers will remain confidential and your name will not be taken. Participation in this study is voluntary and you are not obligated to answer any questions that you do not want to answer and it takes at most 20 minutes. Title of the study: Intention of medical student to work rural areas and its associated factors among undergraduate medical students in public University, 2018 Objective of the study: To determine the intention of rural medical practice among clinical level medical students in medical schools of AAU, WU, WSU Universities and the associated factors, Ethiopia 2018. Rights of the participant: participating and not participating is the full right and the participant can stop from participation in the study at any time. And the participant can skip question which he or she does not want to respond. Participants can ask any questions, which is not clear for understanding. Confidentiality: – Any information forwarded was kept private. Data collector and the principal investigator will not know his /her name. INFORMED CONSENT I have read all this form or it has been read to me in the language I comprehend and understood all conditions stated above. Therefore, I am willing to participate in this study Yes. ? No. ? Signature of participant—————– Name of researcher: Berhanu Achiso Signature ——————————————–Address Tell (E-mail) 0910049019 or [email protected] Name of witness ________________________________Signature________________ Date______________ starting time _______________Ending time________________________Result of administration: 1. Completed 2. Respondents are not available 3. Respondents are refused. 4. Partially completed

46 QUESTIONAIRES N.B: Please, circle only one alternative given on choice questions whereas put (?) mark for questions part II to V listed below. Do not write your name anywhere in these questionnaire. No Part-I questions related to Socio-economic and demographic characteristics Response Skip 1 Age ————-year 2 Sex 1. Male 2. Female 3 Your birth place 1. Urban 2. Rural If Rural ?Q5 4 If your birth place is Urban Name of town or city———————- 5 Marital status 1. Single 2. Married 3. Divorced 4. widowed 6 Religion 1. Orthodox 2. Islam 3. Protestant 4. Catholic 5.Others 7 Place of your secondary school 1. Urban 2. Rural If Rural ?Q9 8 If your response is urban Name of town or city———————- 9 Medical education program 1. Generic 2.Accelerated If Generic ?Q11 10 If your response is accelerated How many years——————————– 11 Your academic year 1.Fourth year 2.Fifth year 12 Father’s educational status (1). Never educated (2). 1-4grade (3). 5-8 grade (4). 9-10 grade (5). 11-12 grade (6.) >12 grade If >12grade?13 If not >12grade?14 13 If your response is >12grades 1.Heath background 2.None health background 14 Father’s occupation 1. Farmer 2. Business man 3. Employee 4. Others 15 Mother’s educational status (1). Never educated (2). 1-4grade (3). 5-8 grade (4). 9-10 grade (5). 11-12 grade (6.) >12 grade If >12grade?16 If not >12grade?17 16 If your response is >12grades 1. Heath background 2. None health background 17 Mother’s occupation 1. Farmer 2. Business man 3. Employee 4. House wife 5. Others

47 18 Current family Residence place 1. Urban 2. Rural If Rural ?Q20 19 If your response is Urban Name of city or town————————————- 20 Main income source of your family 1. Agriculture 2. Salary 3. Business 4. Others 21 Perceived Economic status of your family 1. Poorest of poor 2. Poor 3. Medium 4. Wealthy (Rich). Part II questions related to factors that inspire medical students to choose medicine What initiated you to choose medicine primarily? Strongly disagree(1) Disagree(2) Neutral(3) Agree(4) Strongly agree(5) 22 My interest in the field for life saving 23 Searching better income 24 Getting social prestige 25 Family or peer group influence 26 Assignment of government 27 Advice of health professionals 28 If you have any other factors——————————————————————————————————- Part III questions related to the existing feeling of medical students No Currently, what kind of feeling do you have on medical education?
Bad

Poo
r

Goo
d

Ver
y
Exc
ellen29 Attractiveness or being role models of instructors 30 Punctuality of instructors in every practical activities 31 Equipment of facilities for practical sessions 32 Excitement or satisfaction of medical education 33 If you have another feeling—————————————————-

48 Part IV questions related to factors that encourage medical students to practice rural area What factors lead you to intend to practice in rural area after graduation? Strongly disagree(1) Disagree (2) Neutral(3) Agree(4) Strongly agree(5) 34 Opportunity to practice variety of skills or work autonomy 35 Opportunity for employment 37 Opportunity for career advancement 38 Better for enjoyable lifestyle 39 Near to family or friends or spouse 40 Family income potential is poor 41 Cultural advantages 42 High medical need of rural area 43 Similar to the community in which you grew up 44 If you have additional factors————————————————— Part V questions related to factors that discourage medical students to practice rural area Are the following factors discouraging you to practice in rural area after graduation? Strongly disagree(1) Disagree (2) Neutral(3) Agree(4) Strongly agree(5) 45 Inadequacy of financial incentives ( salary, bonus, remote, allowance, compensation, loans) 46 No opportunity for better social life 47 Less availability of recreational facilities and technologies

49 Part VI- questions related to awareness about rural area or community No What is your awareness about rural area or community? Response Skip 56 I have attended on different experimental rural health programs 1. Yes 2. No 57 I have good awareness about quality of rural community posting 1. Yes 2. No 58 Rural community postings could influence my decision negatively 1. Yes 2. No 59 I have received rural career guidance 1. Yes 2. No 60 I am ready to live with different society’s traditions, values, customs, and cultures if I was in the rural area after my graduation 1. Yes 2. No Part VII- questions related to locations that intend to practice after graduation Where do you prefer to practice after graduation? Response Skip 61 Where do you intend to practice after graduation? 1. Public/ Government 2. Private/NGO 62 Which health facility do you want to practice? 1. Health center 2.Primary Hospital 3. General Hospital 4. Tertiary or teaching Hospital 63 Which location do you anticipate to practice 1.Urban 2.Rural If Rural?64 64 If your response is Rural in Q#63 for how long ——————years Thank you very much! 48 Professional isolation 49 Family or friends isolation 50 Fear of weather condition or climate 51 Low availability of medical equipment and laboratory facilities 52 Poor accessibility of essential infrastructures like education, roads, electricity, telecom services etc 53 Poorness of the rural community 54 Less access to par time work 55 If you have any other factors———————————————————————————————–

50 FIG FOUR CONCEPTUAL FRAMEWORK Fig4. Conceptual frame work for intention of medical students to practice rural area among public university undergraduate medical students in Ethiopia, 2018 SOCIO-DEMOGRAPHIC CHARACTERISTICS KNOWLEDGE ABOUT COMMUNITY ENCOURAGING FACTORS LEAD TO CHOOSE MEDICINE DICOURAGING FACTORS LEADS TO INTENTION TO WORK INTENTION OF MEDICAL STUDENTS TO PRACTICE RURAL AREA

51 DECLARATION SHEET I, the undersigned, senior MPH in Health Economics student declare that this thesis report is my original work in partial fulfillment of the requirement for the degree of Master in Health Economics. Name: Berhanu Achiso Signature: _____________ Place of submission: AAU University, College of Health Sciences, School of public Health, Department of Health Economics. Date of Submission: ________________ This thesis has been submitted after approved by my advisors Advisors: Name Signature Wondimu Ayele ___________________ Birhan Tassew _________________

52 ASSURANCE OF INVESTIGATOR The undersigned investigator agrees to accept responsibility for the scientific, ethical and technical conduct of this research project and for provision of required progress reports and conditions of the research and Institutional Review Ethical Board of AAU University. Name of the Investigator: Berhanu Achiso Signature: ___________________________________ Date: _______________________________________ Approval of the advisors Advisors: Name Signature Date 1. Mr. Wondimu Ayele ____________ _______________ 2. Mrs. Birhan Tassew ____________ _______________

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