Employment intentions among rural order-oriented medical students in inner mongolia autonomous region,China

Abstract

BACKGROUND:

The program of the “Free Training of Chinese Rural Order-Oriented Medical Students” is a plan to train general practitioners who can work at rural medical institutions. However, many students have been unwilling to fulfill their commitments and actually work in their assigned locations.

OBJECTIVE:

This study aimed to provide some explanation by exploring factors influencing the employment intentions of rural order-oriented medical students in Inner Mongolia Autonomous Region of China to provide a basis for formulating relevant supporting policies to help increase the fulfillment rate of medical students.

METHODS:

We conducted a cross-sectional study with a stratified cluster sampling method at four medical universities in Inner Mongolia using a survey questionnaire. Multivariate logistic regression was used to identify factors that were significantly associated with employment intentions.

RESULTS:

Approximately 67% of students were willing to work in rural areas, whereas 33% were not. Order-oriented medical students who were dissatisfied with, or indifferent to, training, were unclear about policy, were of Han ethnicity, or came from an urban area, had lower intentions to accept employment in rural areas. The training satisfaction in particular had the greatest predictive effect.

CONCLUSION:

The implementation of the program “Free Training of Chinese Rural Order-Oriented Medical Students” has been affected by the low actual employment intentions. This study may provide a useful basis on which medical educators and health policy makers can formulate relevant supporting policies and develop strategies to increase the number of order-oriented medical students who working in rural areas where they are most needed.

Keywords

Health practitioner human resources rural area medicine work education

1 Introduction

Many rural areas in China currently suffer from a lack of primary healthcare providers [1 –4]. In order to increase the number of rural primary healthcare providers, the National Development and Reform Commission of China promulgated the “Implementation Opinions on Carrying out the Free Training of Rural Order-Oriented Medical Students” in 2010 and officially started training order-oriented medical students. The term “order-oriented medical students” refers to those recruited from rural areas and expected to return to work in the rural areas after graduation. Order-oriented medical students sign a directional employment agreement with their training schools and local rural health administration departments before obtaining admission and promise to return to the relevant rural medical and health institutions to work after graduation. In exchange for this promise, these directional medical students are exempted from tuition and accommodation fees and receive living allowances during their studies. In 2015, six Chinese governmental departments including the Ministry of Education jointly issued the “Opinions on the Further Free Training of Medical Students in Rural Areas”, which stated arrangements for the enrollment of order-oriented students, the implementation of training funds, the reform of the health labor training scheme, and the employment of graduates in the rural area.

The program of the “Free Training of Chinese Rural Order-Oriented Medical Students” is a plan to train general practitioners who can work at primary-level health institutions, which is a key project of China’s higher medical education reform policies [5], and it relies on medical universities across the country. Students are recruited according to the needs of health programs in different regions of China and are then trained and directed to work in these health programs’ primary-level health institutions, and the program has laid a foundation for the implementation of China’s hierarchical medical system [6]. In addition, Japan has a similar program that enrolls medical students from rural areas on a full scholarship from the Japanese government after which they must return to work in rural areas for a period of nine years [7], and this kind of program has also been implemented in the United States [8 –10], Australia [11] and Thailand [12, 13].

Studies have shown that the default rate in the primary-level employment of order-oriented Chinese medical students is relatively high [14, 15] but that employment intentions are an important indicator that reflect the default rate among targeted students [16]. However, some researchers have reported that order-oriented medical students have a low willingness to work at rural primary-level health institutions [17, 18]. Juan [19] described that 54.5% of rural order-oriented medical students in the Shaanxi province of China intended to break the contract during their standardized training. Xiaoyan et al. [20] showed that only 34.7% of order-oriented medical students in China’s Guangxi Zhuang Autonomous Region were willing to work at rural health institutions. Furthermore, He Zhang et al. found that the job satisfaction of rural orders-oriented physicians was low, with only 37.26% expressing satisfaction [21].

A number of previous studies have attempted to provide reasons for the low willingness to work at rural primary-level health institutions. For example, some researchers have argued that low income is an important factor in the reluctance of medical students to work at rural health institutions [22, 23]. In addition, lack of knowledge about policy specifics such as recompense for nonperformance and reputational factors such as loss of credibility for breach of contract on the part of medical students [24], can further influence their employment intentions [16, 25].

The low level of the actual employment intentions (the students’ true intentions to fulfill their contracts) of order-oriented medical students and the high default rate in their rural employment assignments have a great influence on the quality of the capacity of health services in rural China, and various factors can affect these employment intentions. In addition, the Inner Mongolia Autonomous Region is one of the five ethnic autonomous regions of China, and is an area with one of the most severe shortages of health provider resources. We therefore conducted this study to identify factors that affect the willingness of the order-oriented medical students to find jobs in rural areas and to provide a basis for formulating relevant supporting policies to help increase the fulfillment rate of order-oriented medical students and their job performance.

2 Methods

2.1 Study design and setting

This was a cross-sectional study undertaken in four different cities in the Inner Mongolian Autonomous Region, People’s Republic of China. Stratified cluster sampling method was conducted in this study.

The study protocol was approved by the local ethics committee (Number YKD202201083). The study was conducted in accordance with the Declaration of Helsinki. Support and permission were obtained from the four sample universities, and before the survey, the objectives and benefits of this study were explained in written form attached to the questionnaire given to the students in each setting. Prior to conducting the survey, written informed consent was obtained from all those who agreed to participate in the study.

2.2 Participant demographics

The total respondent sample consisted of 608 order-oriented medical students of four universities across the Inner Mongolia Autonomous Region, 251 males (41.3%) and 357 females (58.7%). The average age was 21.75±1.97 years, the youngest was 18 years, and the oldest was 31 years. We had 311 respondents who were of Han ethnicity (51.2%), 282 (46.4%) who were of Mongolian ethnicity, and 15 (2.5%) respondents who belonged to other, minority ethnicities. Those respondents who described their hometown as rural amounted to 88.8% of the total, and 11.2% came from urban areas. There were 259 medical students (42.6%) who came from an only-child family and 349 (57.4%) who had at least one sibling. Furthermore, 272 medical students (44.7%) majored in clinical medicine, 225 (37.0%) majored in Mongolian medicine, and 111 (18.3%) majored in traditional Chinese medicine. Finally, 236 (38.8%) respondent’s proposed working places were the same as their hometowns, and 372 (61.2%) were not.

2.3 Data collection and analysis

A half-day training course on data collection was provided for all research assistants before the data collection. This training aimed to ensure that all assistants fully understood their responsibilities and respective roles. The surveys were undertaken in the period from May 7, to June 22, 2020. The participating medical students were asked to complete the questionnaires after they understood the purpose, significance, and proper filling-out method. A total of 627 questionnaires were distributed and 608 valid questionnaires were returned. The effective response rate was 97.0%. We excluded the invalid questionnaires, which included respondents who gave incomplete, unrealistic, or inconsistent answers.

Data from the survey questionnaire were “double-entered” into a database using EpiData version 3.1. From this, we used Stata statistical software to analyze the data (Stata version 14.1, StataCorp, College Station, TX, USA). We used descriptive statistics such as frequencies and percentages to describe the employment intentions of order-oriented medical students at the rural level as well as their understanding of pertinent policies. For the outcome of employment intention, we used Chi-squared tests or Fisher Exact tests [26] to compare categorical variables between different groups (such as the clinical medicine group, the Mongolian medicine group, and the traditional Chinese medicine group, or between different ethnicities). Chi-squared tests were used when expected values were at least 5 in each category and Fisher tests were used when expected values were less than 5 in each category [27]. We then used a multivariate logistic regression model to identify the magnitude of the associations of the students’ employment intentions with potential independent variables. We set our threshold for a statistically significant test result at P < 0.05.

2.4 Survey instruments

Based on the relevant previous research [28 –30], a questionnaire titled “Employment Intentions Survey Questionnaire of Rural Order-Oriented Medical Students” was written, which had three parts and was self-administered. The first part included items on sociodemographic variables, such as gender, age, ethnicity, school type, household registration type, medical school major, and only-child-family status.

The second part included items on employment intentions and related issues, such as willingness to work in rural health institutions, whether the place of work was the same as the student’s hometown, whether the student participated in a rural internship, and knowledge of policies.

The third part explored training satisfaction using the “Training Satisfaction Questionnaire” created by Zhao Xin [31]. This questionnaire comprises 17 items representing five domains that measure general satisfaction, satisfaction with training courses, with daily management, with clinical practice, and with practice in rural institutions. These items were scored on a five-point Likert scale ranging from 1 (very dissatisfied) to 5 (very satisfied), and the average score was used for the evaluation (≤3 was unsatisfied;>3 was satisfied). The Cronbach’s Alpha value of the satisfaction survey in the scale was 0.954, the correlation between items and the total score was above 0.91, and the internal correlation between items was above 0.81 [31].

3 Results

3.1 The employment intentions of order-oriented medical students

Among the 608 respondents, 160 and 247 were “very willing” and “quite willing” to work in primary health institutions, accounting for 26.3% and 40.6% of the total number, respectively. The number of “unwilling” and “average” was 201, accounting for 33.1% of the total, which indicates that one third of order-oriented medical students in rural areas of Inner Mongolia were not willing to get jobs at rural health institutions. Therefore, the possibility of default risk is not negligible.

3.2 Demographic factors associated with employment intentions

In order to explore the influencing factors of order-oriented medical students’ employment willingness in rural areas, we conducted univariate analysis of the students’ demographic characteristics and the rural level employment willingness (Table 1). There were no significant differences in employment intentions according to gender, practice in rural area, only-child, or match of work location and household registration. However, order-oriented medical students who were of Han ethnicity, majoring in clinical medicine, or coming from an urban area, had lower willingness to work in rural medical institutions.

Table 1
Demographic characteristics of students and univariate analysis of employment intentions

Characteristic n Employment Intention in Rural Area χ ² p

Unwillingness Willingness

n(%) n(%)

Major

Clinical medicine 272 105 38.6 167 61.4^a 7.952 0.019

Mongolian medicine 225 60 26.7 165 73.3^b

Traditional Chinese medicine 111 36 32.4 75 67.6^a,b

Gender

Male 251 78 31.1 173 68.9 0.76 0.383

Female 357 123 34.5 234 65.5

Ethnicity

Han 311 122 39.2 189 60.8^a 10.949 0.004

Mongolia 282 75 26.6 207 73.4^b

Others 15 4 26.7 11 73.3^b

Only-child/Non-only-child

Only-child 259 96 37.1 163 62.9 3.273 0.070

Non-only-child 349 105 30.1 244 69.9

Household registration type

Rural 540 167 30.9 373 69.1 9.929 0.002

Urban 68 34 50.0 34 50.0

Whether work location matches household registration

household registration

Yes 236 71 30.1 165 69.9 1.542 0.214

No 372 130 34.9 242 65.1

Practice in rural area or not

Yes 131 35 26.7 96 73.3 3.304 0.082

No 477 166 34.8 311 65.2

Understand the policies or not

Indifferent/Unclear 232 130 56.0 102 44.0 89.483 <0.001

Clear 376 71 18.9 305 81.1

Training satisfaction

Indifferent/Dissatisfied 403 180 44.7 223 55.3 72.748 <0.001

Satisfied 205 21 10.2 184 89.8

Characteristic	n	Employment Intention in Rural Area	χ ²	p
Major
Clinical medicine	272	105	38.6	167	61.4^a	7.952	0.019
Mongolian medicine	225	60	26.7	165	73.3^b
Traditional Chinese medicine	111	36	32.4	75	67.6^a,b
Gender
Male	251	78	31.1	173	68.9	0.76	0.383
Female	357	123	34.5	234	65.5
Ethnicity
Han	311	122	39.2	189	60.8^a	10.949	0.004
Mongolia	282	75	26.6	207	73.4^b
Others	15	4	26.7	11	73.3^b
Only-child/Non-only-child
Only-child	259	96	37.1	163	62.9	3.273	0.070
Non-only-child	349	105	30.1	244	69.9
Household registration type
Rural	540	167	30.9	373	69.1	9.929	0.002
Urban	68	34	50.0	34	50.0
Whether work location matches household registration
household registration
Yes	236	71	30.1	165	69.9	1.542	0.214
No	372	130	34.9	242	65.1
Practice in rural area or not
Yes	131	35	26.7	96	73.3	3.304	0.082
No	477	166	34.8	311	65.2
Understand the policies or not
Indifferent/Unclear	232	130	56.0	102	44.0	89.483	<0.001
Clear	376	71	18.9	305	81.1
Training satisfaction
Indifferent/Dissatisfied	403	180	44.7	223	55.3	72.748	<0.001
Satisfied	205	21	10.2	184	89.8

Notes: ^a,b,c Values within the table that do not have a superscript in common differ significantly (P < 0.05, Chi-Squared Test). *P-values from Chi-Squared Test.

3.3 The relationship between awareness of policies and employment intentions

Approximately 61.9% of students understood the policies of rural order-oriented medical students, and 38.1% of students were vague or unclear about the policies. We carried out Chi-squared tests on the awareness of relevant policies and the willingness to enter rural level employment. The results show that there was a significant difference between students who were “clear” and those who were “indifferent/unclear” (χ² = 89.483, P < 0.001). That is, medical students who understood the relevant policies for order-oriented students were more willing to work in rural medical institutions, as shown in Table 1.

3.4 The relationship between training satisfaction and employment intentions

About 33.7% of order-oriented medical students were “satisfied” with their training, and 66.3% of the students showed that they were either “indifferent” or “dissatisfied”. Chi-squared tests show that there was a significant difference between those who responded with “satisfaction” and those who responded with “indifferent” / “unsatisfactory” (χ² = 72.748, P < 0.001). Order-oriented medical students who were highly satisfied with their training were more willing to choose rural medical institutions for employment.

3.5 Factors associated with employment intentions identified by multivariate binary logistic regression

We entered the independent variables that potentially influence the employment intentions of order-oriented medical students into a multivariate logistic model that was refined by the backward removal method. “Training satisfaction” appeared to be the greatest predictor of employment intentions, followed by a medical student’s understanding of relevant policies, ethnicity, and household registration type (Table 2). The odds of students who were “satisfied” with their training being willing to work in a rural area were more than five times (OR = 5.42, 95% CI: 3.23–9.09) that of students who were “dissatisfied” with, or indifferent to, the training. Compared with the order-oriented medical students who were unclear about policies, the students who understood the policies were more likely to show higher employment intentions toward rural areas (OR = 4.62, 95% CI: 3.10–6.88). In addition, Mongolian medical students had stronger employment intentions than Han medical students toward working in rural areas of Inner Mongolia (OR = 2.08, 95% CI: 1.39–3.12). Household registration type (OR = 1.59) was also a predictor of medical students’ employment intentions (P < 0.05).

Table 2
Multivariate logistic regression on rural employment intentions (Willingness vs. Unwillingness)

Variables Adj. OR (95% CI). p

Household registration type

Urban (Ref.)

Rural 1.59 (1.05, 2.39) 0.028

Training satisfaction

Indifferent/Dissatisfied (Ref.)

Satisfied 5.42 (3.23, 9.09) <0.001

Understand the policies or not

Indifferent/Unclear (Ref.)

Clear 4.62 (3.10, 6.88) <0.001

Ethnicity

Han (Ref.)

Mongolia 2.08 (1.39, 3.12) <0.001

Variables	Adj. OR	(95% CI).	p
Household registration type
Urban (Ref.)
Rural	1.59	(1.05, 2.39)	0.028
Training satisfaction
Indifferent/Dissatisfied (Ref.)
Satisfied	5.42	(3.23, 9.09)	<0.001
Understand the policies or not
Indifferent/Unclear (Ref.)
Clear	4.62	(3.10, 6.88)	<0.001
Ethnicity
Han (Ref.)
Mongolia	2.08	(1.39, 3.12)	<0.001

4 Discussion

Our cross-sectional study conducted at four medical universities from four different cities (Hohhot, Chifeng, Baotou, and Tongliao) explored the employment intentions of order-oriented medical students in the Inner Mongolia Autonomous Region of People’s Republic of China and their influencing factors. Most provinces in China have already begun to carry out the training of order-oriented medical students for later employment in rural areas, and there are 113 universities across the country in charge of the training [32]. We found that the proportion of order-oriented medical students who were unwilling to work at rural medical institutions was high. Nearly one third of medical students did not want to go to rural areas. Hong Liu et al. [18] reported similar results, showing that 44.5% of order-oriented medical students were unwilling to return to rural areas to work in Chengdu City in the Sichuan Province of China. Another finding was that rural employment intention of order-oriented medical students was significantly positively associated with training satisfaction, medical students’ understanding of policies, Mongolian ethnicity, and rural household registration type. Satisfaction was the most significant predictor of rural employment intentions. Zhou et al. [33] have also reported that medical students’ satisfaction with the quality of teaching has an impact on order-oriented students’ employment at the grassroots level after graduation. Li [34] indicated that optimizing the training curriculum, such as setting up medical courses related to primary medical treatment from different perspectives can help to ensure both the basic clinical skills of medical students and their satisfaction with their training. Moreover, the diversification of teaching methods, such as the use of case teaching [35] and problem-based learning methods [36], can also increase the learning interest of medical students, and improve training satisfaction. In addition, application of online-learning in medical education can also be considered when offline teaching is limited such as during the COVID-19 pandemic [37]. Medical students showed higher satisfaction with online and offline teaching mode, which is reported by Hao Lei [38]. Therefore, we propose that the training programs of order-oriented medical students should include an assessment of the capacity of the medical universities, including the evaluation of the training schedules and teaching methods for order-oriented medical students, and that the training satisfaction should be regularly evaluated as an indicator of quality control.

This study showed that there was no significant difference in employment intentions by experience of medical practice in rural area. In contrast, a study by Jasmin et al. [39] reported that the choice to pursue a medical career was based on prior exposure to the medical practice, self-efficacy, and the perceived prestige of the vocation, which came from the survey of British South Asian medical students and junior doctors. However, many socioeconomic characteristics differ between different countries including aspects of salaries, social identity, and human resources for health. Moreover, the practice of working in an urban medical institution is obviously different from that of working in a rural one. In particular, Inner Mongolia Autonomous Region located in the north of China has a relatively backward economic development, and differences are not unexpected.

Medical students’ understanding of policies was another predicting factor that affected rural employment intentions. Order-oriented medical students with an unclear understanding of the policies were less willing to work in rural medical institutions. In order to ensure that order-oriented medical students work in rural areas, the Chinese government has set up incentive policies that include salary incentives, employment arrangements, and housing arrangements, among others. Moreover, the order-oriented medical students who fail to fulfill their commitments would be recorded [40]. This study found that 38.1% of order-oriented medical students had an unclear or vague understanding of the policies governing their schooling and later employment. Accordingly, the related policy of publicity, such as preferential policies for order-oriented medical students in terms of welfare benefits, professional titles, and housing should be made when formulating policies. In this way, medical students will be aware of the preferential policies to stay in rural areas, so they will be willing to return [41].

In this study, compared with urban students, those whose household registration type was rural were associated with a higher ratio of employment intentions toward rural areas. One possible reason is that the students’ families and friends already live in these rural areas so they were more willing to return or stay there to work. Xiaoyun Liu et al. also mentioned that the students who grew up in rural areas were more familiar with rural environments, had a stronger social identity, and were more likely to return to work in rural areas after graduation [42]. In addition, our study showed that Mongolia ethnicity medical students were more likely to choose to work in rural areas than were those of Han ethnicity (P < 0.001). Similar results were found in a study by Xing [43], where the educational level of medical students’ parents, ethnicity, grade level, understanding of policy, and interest in general practice all had a substantial influence on employment intentions toward rural areas. Our study also showed that compared with the students who majored in clinical medicine, the students in Mongolian medicine were more willing to choose to work at rural medical institutions. The Chinese government has recently begun to promote the development of ethnic medicine vigorously [44]. Kong et al. [45] reported that the advantages of Mongolian medicine in primary medical institutions in Inner Mongolia included policy support, resource advantages, and people’s existing cultural background in Mongolian medicine. For these reasons, the students of Mongolian medicine had higher employment intentions toward work in rural areas. In fact, all students of Mongolian medicine were of Mongolian ethnicity in our study. Based on the above discussion, we suggest that policymakers should consider increasing the proportion of medical students from rural areas and of Mongolian ethnicity in their admissions when formulating policies.

5 Conclusion

The program of the “Free Training of Chinese Rural Order-Oriented Medical Students” was put in place in an attempt to cultivate medical workers for rural areas, in an effort to relieve the shortage of primary care medical workers in rural China. However, implementation of the policy has been affected by the low actual employment intentions. Using a cross-sectional study in Hohhot, in the Inner Mongolia Autonomous Region of People’s Republic of China, we found that lower employment intentions in rural areas were seen for students who were of Han ethnicity, were dissatisfied with, or indifferent to, training satisfaction, were unclear about the policy, and whose household registration type was urban. Training satisfaction in particular had the greatest predictive effect. Therefore, enhancing the training satisfaction, improving the understanding of policies, increasing the strength of policy preferences, and optimizing the percentage of students recruited may be potential ways to increase these employment intentions. We propose that the results of this study are generalizable for the other areas especially the ethnic minority areas of China. Moreover, this study may provide a useful basis on which health policy makers and administrators can formulate relevant supporting policies and develop strategies to increase the number of order-oriented medical students working in rural areas where they are most needed.

This study, however, has some limitations. Firstly, data collected through self-reported questionnaires are particularly susceptible to inappropriate or careless responding, and such invalid data increase noise and attenuate true statistical relationships. To reduce such bias, we eliminated some invalid questionnaires. However, the number of invalid questionnaires was very low and unlikely to substantially affect the overall findings. A second limitation is that only quantitative data were collected in this study. In order to explore the reasons that order-oriented medical students do not want to work in rural areas better, qualitative research, such as in-depth interviews with more stakeholders, may be necessary in future studies. Thirdly, this study only explored factors influencing the employment intentions from medical students’ perspective. There was no attempt at exploring the implications of the various levels of training satisfaction reported by medical students. Further study should consider more questions, such as the reasons why medical students are not satisfied with training and how the training can be improved to retain the medical students’ intention to work in rural areas. Lastly, the study was only conducted in one province in China. The results need to be replicated in other provinces, and the issue of follow-up studies should be taken into consideration by future researchers.

Funding

The research was funded by the Education Department of Inner Mongolia Autonomous Region (Grant number NJSY21620).

Ethics statement

The study was approved by the Medical Ethic Committee of Inner Mongolia Medical University (Number: YKD202201083). All participants completed an informed consent document in accordance with the university’s Institutional Review Board.

Footnotes

Acknowledgments

The authors thank AiMi Academic Services () for the English language editing and review services.

Conflict of interest

None to report.

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