The Collaboration of Health Equity and Education in Research
CHEER & THE CASE-CONTROL STUDY

The shortage of health professionals in rural areas, particularly senior experienced generalist practitioners, is a major problem in South Africa. Amongst the important factors that influence health professionals’ career choices, the role of undergraduate and post-graduate education is significant. The selection criteria used for entry, the timing, duration and type of exposure to rural and community-based educational opportunities during the under-graduate phase, as well as the availability of post-graduate programmes that are supportive of rural practitioners, all play a significant part in influencing the eventual career choices of health science graduates.

The Collaboration for Health Equity in Education and Research (CHEER) is a research team formed in 2003 that investigates these issues. With seed funding from the MRC, it has brought together a representative from each university in the country with a Health Science Faculty, all of whom are involved in community-based education or rural health in some form. The universities are: Walter Sisulu, Stellenbosch, UCT, Free State, Wits, KwaZulu-Natal, Limpopo and Pretoria.

Collaboratively thus far, four distinct CHEER research projects have arisen: a peer review process, a systematic literature review (through the Cochrane collaboration), a qualitative study; and a case-control study evaluating the educational factors that could improve the supply and retention of health professionals in rural and underserved areas.

The national case-control study came about, as it was recognised by CHEER that undergraduate and post-graduate training is significant in influencing health professionals’ career choices, but that the extent of this had not been demonstrated in this region. The applicability of international studies on these issues has been questioned in the South African context. Consequently, a cross-sectional case-control study design was employed, with cases being rural medical practitioners and controls being urban medical practitioners, in the public service. A questionnaire was developed from the results of a previous qualitative study of the same question, in which fifteen in-depth interviews were conducted with rural practitioners and fifteen urban-based practitioners, around the question of their choice of the site of their practice.

The results of the study show that among the multitude of factors that influence and determine health professionals’ career choices, the educational component is significant. Most health professionals spend from four to six years as undergraduates, and their values and aspirations are shaped and moulded intentionally and unintentionally by the people and experiences that they encounter, both within the curriculum and outside of it.

The findings that rural respondents were significantly more likely to be black could be a reflection of the greater likelihood of graduates of rural origin returning to work in rural areas. Another major factor is that the sense of accountability to the communities that the rural practitioners serve, was found to be significantly higher than their urban counterparts, which was deepened by the qualitative data, and may reflect their relative idealism. The most important results were the highly significant differences between cases and controls (Odds ratio 4.1, p<0.05) in response to questions as to whether community-based and rural experiences within the undergraduate curriculum had influenced their choice of where they now practice. Rural respondents were more inclined to agree that this had influenced them than urban respondents, which is an extremely strong association and seems to suggest a direct causal relationship. That financial considerations of site of practice showed no difference between rural and urban groups probably relates to the positive impact the RA has had in reducing dissatisfaction amongst rural doctors. Finally, urban respondents rated professional and career development, as well as experiences as post-graduate students, much higher than rural respondents in making the choices that they did. While this is probably one of the commonest reasons cited for moving from rural to urban areas, it does point to the need for greater postgraduate training and career opportunities to be made available in rural areas.

This study provides some evidence for the association of preceding undergraduate and postgraduate educational experiences with the choice of site of practice of doctors in South Africa. This data gives credibility to the notion that exposing students to community-based and rural situations during their period of training is worthwhile, and deserves the extra resources that it demands, due to the added time and distances involved in these activities.