|Year : 2022 | Volume
| Issue : 1 | Page : 95-102
Indian rural lands and shortages of healthcare professionals: A burning issue
Abhishek Singh Nayyar
Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani, Maharashtra, India
|Date of Submission||01-Mar-2022|
|Date of Decision||16-Mar-2022|
|Date of Acceptance||26-Mar-2022|
|Date of Web Publication||25-Jul-2022|
Dr. Abhishek Singh Nayyar
Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani, Maharashtra
Source of Support: None, Conflict of Interest: None
Context and Aim: The shortage of healthcare professionals in rural areas contributes toward discriminatory healthcare delivery. The present study was planned with similar intent and aimed to evaluate the perception of dental students regarding their future in rural areas. Materials and Methods: The present study was designed as a cross-sectional study comprising a 30-item questionnaire survey instrument distributed among a total of 550 dental students, while the results obtained were subjected to statistical analysis. Statistical Analysis Used: Statistical analysis was done using SPSS version 12.0 (SPSS Inc., Chicago, IL, USA). Independent Student's t-test and one-way analysis of variance were used for comparison among the variables, while Chi-square test was used to determine the association between the variables. P < 0.05 was considered statistically significant. Results: No significant difference was observed in the attitudes based on gender (P = 0.43), though a statistically significant difference was observed in the attitude of students based on the year of their education with a positive attitude toward rural dental practice generally noted in the 1st-year Bachelor of Dental Surgery students, which significantly declined with the increasing level of education (P = 0.01). Conclusions: Dental students are more influenced by the negative aspects of rural dental practice though they have, in their mind, a positive approach to the same at the beginning of their education, this significantly declined with the increasing level of their education.
Keywords: Career and educational advancement, census, dental healthcare crisis, dental healthcare professionals, dental healthcare services, discriminatory healthcare delivery, employment prospects, healthcare community, rural areas
|How to cite this article:|
Nayyar AS. Indian rural lands and shortages of healthcare professionals: A burning issue. J Datta Meghe Inst Med Sci Univ 2022;17:95-102
| Introduction|| |
Healthcare professionals are people engaged in actions whose primary intent is to enhance health. At present, the scarcity of healthcare professionals and their inequitable distribution in urban and rural areas has been reported by many developing and developed countries. These shortages contribute to discriminatory healthcare delivery. Typically, from an Indian census point of view, the word rural has been defined with a “deprivation” orientation with the rural population being devoid of majority of the advanced facilities. Accessibility of health services is a multidimensional concept that refers to geographical, economic (affordability), organizational, and cultural factors that can either facilitate or hinder the use of services (and development) in rural areas. Large metropolitan regions, on the other hand, are the centers of development since they offer plenty of opportunities for career and educational advancement, better employment prospects, and lifestyle-related services and amenities. In addition, the low status often conferred to those working in rural areas, further, contributes to healthcare professionals' preference for settling in urban areas.
Oral health is an integral part of general health. Microbial infections in the oral cavity affect the overall health status of an individual. In addition to diseases such as dental caries, a growing body of research suggests that poor oral health is linked to destabilizing of the general health in conditions such as type II diabetes mellitus, cardiovascular diseases, bacterial pneumonia and related complications, and complications during pregnancy. Oral diseases are, in fact, the most common chronic diseases among all age groups; however, accessing help from dental healthcare professionals is particularly hard for people from underserved and rural areas. The impact of this dental healthcare crisis has been and continues to be even greater in rural areas. Even this dental healthcare crisis involves issues or concerns such as the lack of adequate access to dental healthcare services in rural areas, a general lack of appreciation for the importance of maintaining good oral health by other members of the healthcare community, lack of knowledge or realization of the importance of good oral health by the general masses with this problem being rampant even in the educated masses and the situation being even more worse in people from the lower socio-economic strata. To further worsen this situation is the paucity of dental healthcare professionals practicing in rural areas with the preference of upcoming professionals to locate their practices in urban areas. In India itself, the dentist-to-population ratio has been reported as 1:10,000 in urban areas and around 1:250,000 in rural areas.
The willingness of dental students toward practicing in rural areas and their perception regarding future in rural areas play an important role in determining the future dental workforce in rural areas, and this can best be described in three major types of concerns that they might have including the professional, personal, and general concerns.,,,, With this background, the present study aimed to evaluate the perception of dental students regarding their future in rural areas.
| Materials and Methods|| |
The present study was a descriptive, observational study that was based on a cross-sectional study design, comprising a 30-item questionnaire survey instrument distributed among a total of 550 under- and post-graduate dental students who were enrolled in the present study via a randomized selection method. For the present study, all the participants who expressed their willingness to participate in the study voluntarily with written informed consent were included, while the research protocol was approved by the institutional review board and ethical clearance was obtained from the institutional ethics committee before the conduct of the study. Furthermore, the 30-item questionnaire survey instrument used in the present study comprised four parts including the first part which focused on information regarding the demographic details and opinion of the participants regarding the rural dental practice, the second part which dealt with the professional concerns of the participants (item No. 1–16) perceived regarding the rural dental practice, while the third and fourth parts which dealt with the personal and general concerns (item No. 17–27) of the participants, respectively. The data obtained were, then, entered into excel sheets and subjected to statistical analysis. Anonymity and confidentiality of the participants was duly taken care of and given the utmost priority for ensuring correct and unbiased results while participation in the study was kept voluntary.
Statistical analysis used
Statistical analysis was done using SPSS version 12.0 (SPSS Inc., Chicago, IL, USA). Independent Student's t-test and one-way analysis of variance were used for comparison among the variables, while Chi-square test was used to determine the association between the variables. P < 0.05 was considered statistically significant.
| Results|| |
From a total of 550 under- and post-graduate dental students who were enrolled in the present study, 428 students responded completely to the questionnaire with a total response rate of 77.8%, while 67 students (12.2%) were absent during the survey and 55 students (10%) returned incomplete questionnaires. [Table 1] lists the demographic details of the students (respondents) in terms of gender and the year of study which were the two most important criteria in the present study. [Table 1] also highlights the general perception of the respondents in terms of the meaning they implied from the word “rural” and the “additional opportunities” they associated and assumed in practicing in rural areas. More number of females (75.9%) participated in the present study with the maximum response obtained from the students who were in their 1st year (19.9%) of professional education. The next, in order, were the 2nd-year (15.9%) Bachelor of Dental Surgery (BDS) students, while the least number of responses came from the 3rd-year (10%) students. The mean age of the respondents was 20.94 ± 2.75 years. Among these, 62.4% of the respondents considered “distance, local facilities, type of people, and the size of population” as the important determinants to describe a population “rural,” while 78% of the respondents believed both the “community involvement and continuity of care” as the additional opportunities present in a rural scenario.
[Table 2] represents the perception of dental students regarding professional concerns based on gender wherein a significant number of female respondents (78.2%) agreed that rural areas provided opportunities to practice a variety of skills, while only 21.8% of the male respondents agreed that such opportunities are there in rural practice, with the difference being statistically significant (P = 0.01). In addition, a significant number of female respondents (70.3%) had the belief that there are good opportunities for employment in rural areas compared to the male respondents (29.7%) (P = 0.03). Majority of female respondents (80.7%), also, felt that staff is more supportive in rural areas, while only 19.3% of the male respondents had a similar opinion (P = 0.004). Furthermore, 79.0% of the female respondents believed that rural dental practice offered more diverse working experience than as compared to practice in urban areas against only 21.0% of the male respondents who had a similar opinion (P = 0.04).
|Table 2: Perception of dental students regarding professional concerns based on gender|
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Longer working hours and poor working conditions were the major deterrents perceived by around 73.7% of the female respondents against rural dental practice which were, also, the reasons cited by 26.3% of the male respondents as to why they did not want to opt for rural practice (P = 0.00). To add to this, 71.5% of the female respondents expressed worries about their future career prospects in entering into rural practice in the early stages of their career. Likewise, 28.5% of the male respondents, too, had a similar worry for their future and career advancement in life ahead (P = 0.06). A significant fact that was highlighted in the present study was that 71.1% of the female respondents assumed that remote and rural option prepares a student better for rural practice, while 28.9% of the male respondents had a similar opinion (P = 0.007).
[Table 3] compares the perception of dental students regarding professional concerns based on the year of education wherein 21.2% of the 1st-year BDS students presumed that working in a rural area provided more opportunity to practice a variety of skills, whereas 21.6% of the interns disagreed with this statement. Again, 19.1% of the postgraduate students accepted that there are good opportunities for employment in rural areas in dental profession while 19.1% of the 1st-year BDS students considered that rural dental practice provided greater opportunity for autonomy in work practice as against 13.5% of the interns and 12.5% of postgraduate students (P = 0.007). The study found 20.5% of the 1st-year BDS students worried that entering into rural practice in the early stages of their career could negatively impact their status as healthcare practitioners, while similar concern was expressed by 16.0% of the postgraduate students and 10.7% of the interns (P = 0.01).
|Table 3: Perception of dental students regarding professional concerns based on the year of education|
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As a contradictory finding, 19.9% of the 1st-year BDS students as well as 16.7% of the postgraduate students and 10.7% of the interns considered that remote and rural option prepares a student better for rural practice while a similar number of 1st-year BDS students (19.8%), also, disagreed with this statement (P = 0.07). Shockingly, 21.8% of the postgraduate students and 17.9% of the 1st-year BDS students as well as an equal number of interns (17.9%) had a fear that they will not be able to easily move from rural practice back to an urban practice, highlighting the main fear why most of the dental professionals are reluctant to take-on with their rural postings (P = 0.000).
[Table 4] gives an overview of the perception of dental students regarding personal and general concerns based on gender and the year of education wherein 21.4% of the 1st-year BDS students considered that people in rural areas were very friendly and that settling in rural areas was easy because of this (P = 0.001*), while 18.2% of the 1st-year BDS students and 17.5% of the postgraduate students, also, had a fear that working in rural settings carried a negative impact on spouse/children (P = 0.02). Likewise, poor recreational facilities were considered to be the major hindrance, while free accommodation was considered to be a major advantage for working in a rural setup and the results were found to be statistically significant, both gender-and year-wise. Pair-wise comparison of the perception of dental students toward working and living in rural areas according to the year of education revealed significant differences in the personal concerns among the 1st- and 5th-year BDS students (P = 0.01) and interns with 3rd- (P = 0.002) and 5th-year BDS students (P = 0.001). Similarly, significant difference was noted for general concerns among the postgraduate students with 3rd-year (P = 0.01) and 5th-year BDS students (P = 0.04).
|Table 4: Perception of dental students regarding personal and general concerns based on gender and the year of education|
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To conclude, the mean attitude scores for professional concerns among the male and female respondents were 60.7 ± 14.1 and 60.4 ± 13.6, respectively (P = 0.83), while with regard to personal concerns, the mean attitude scores were 61.6 ± 14.1 for male and 63.8 ± 16.1 for female respondents, respectively (P = 0.21). Likewise, no significant difference was noted for general concerns among the male and female respondents (P = 0.58), thereby helping us conclude that the present study did not find a significant difference in the attitude of the male and female respondents based on gender (P = 0.43). Nevertheless, a significant positive attitude was noted among the 1st-year BDS students toward rural dental practice as compared to the other years of education (P = 0.01).
| Discussion|| |
The quality and availability of specialist healthcare vary greatly among the different socioeconomic groups and by geographical variations such as urban versus rural areas. Despite a high annual output of specialist graduates, specialist care has conventionally been very poor in India due to a persistent phenomenon of highly educated Indians emigrating to western countries. Unsatisfactory employment opportunities in rural areas, further, adds to this problem with most of healthcare professionals migrating to urban areas in search of better opportunities. In this context, when access to dental services is already limited and has become a grave issue, the present students or upcoming dental healthcare professionals should offer benefits to the community. The present questionnaire-based study was based on previous international research which shed light on the perception of students regarding their future in rural areas. The Cronbach's alpha coefficient for the questionnaire came out to be 0.71, which was considered to be acceptable.
In the present study, data demonstrated that there was no significant difference in the attitude of the male and female respondents based on gender. This finding, however, was not found to be consistent with the previous studies where females were less likely than males to indicate their preference for practice in rural areas. The present study, also, revealed that 1st-year BDS students showed a significant positive attitude toward rural dental practice compared to the other years of education in accordance with the findings of similar other studies conducted by Deaville et al. and Kaye et al. The reasons behind this could be due to a more ethical approach to profession and limited prior exposure to rural health facilities and other associated factors. On the whole, the perceptions of dental students in the present study about rural dental practice, at first glance, were not found to be very encouraging. Most of the students appeared to have quite traditional views of what the term “rural” exactly meant and had their own perception of distance, the connectivity and overall facilities available, and the type and size of the population residing in rural areas. The major factors that made dental students reluctant to work in rural areas included poor recreational facilities, longer working hours, and poor working conditions along with difficulty in moving back from rural to an urban practice and negative impact on spouse/children and career.
Despite these restrictions, the students were found positive about the accommodation provided, more diverse work experience, the rural locations, and the community support with kind people and staff as the most important positive aspects of practicing in rural areas in accordance with the findings obtained in the study conducted by Mullei et al. However, another study conducted by Johnson and Blinkhorn reported missing friends, partners, and the number of available job opportunities as the major barriers cited to working in rural locations. Kotzee and Couper reported that professional development, ongoing training, and style of health service management were important factors influencing retention of healthcare professionals in underserved areas in South Africa, while in another study in Viet Nam by Dieleman et al., low salaries and poorer working conditions were found to be the major deterrents that discouraged public health workers to work in rural areas.
Schofield et al. concluded based on the findings of their study that the decision to practice in rural areas was the result of a complex interaction between a number of factors including ethnicity, discipline, age, sex, and type of work followed by career opportunities and challenges. Most of the other similar studies noticed a strong relationship between a student's rural background and the student's subsequent intention to train and work in rural areas., Agyepong identified lack of essential equipment, nonavailability of resources such as electricity, safe water, communication system, and isolation from other units as the major hardships of working in a rural area. Similar observations were made by Lehmann et al. who concluded that extremely demanding working conditions, substandard medical equipment and facilities, inadequate opportunities for personal and professional growth, safety concerns, and lack of job opportunities for spouse and educational opportunities for children were the major constraints of practicing in rural areas.
Some experts such as Khattak have, also, suggested remedies, however, to the situations including establishment of a rural health academy at divisional level to impart training and refresher courses to doctors working in rural areas, priority in postgraduate education and training, grant of rural and nonpracticing allowance and regular linkages with administration, and management and academic activities for the upliftment of the professionals posted in rural areas. Kristiansen and Førde, also, advocated the need for a proper education facility for the children of the doctors and staff working in rural areas as one of the priority concerns.
In addition to this, Anderson and Rosenberg emphasized the role of governments to solve the situation in this regard by using the government machinery to improve the geographical distribution of healthcare professionals. It has been suggested that a country's ability to retain healthcare professionals in rural areas ultimately depends upon the provision of a stable, rewarding and fulfilling personal and professional environment. Taking all these measures of differential rewards and provision of relief from the hardships involved, the healthcare professionals might accept to work in rural areas providing solution to the discriminatory healthcare delivery in the rural backdrops which is a standing problem worldwide despite availability of healthcare resources in the present scenario.
Limitations of the present study
The present study has to be depicted with certain limitations as well including single institutional data which may not be representative. Although dental students may have had limited experience of the underserved and rural areas, during their college education years, once acquainted with rural practice, per se, might have an impact on their opinion. In addition, background information was not taken into consideration which plays a major role in decision-making about rural practice.
| Conclusions|| |
Dental students were more influenced by the negative aspects of practicing in underserved and rural areas since they had many unattended queries and fears for rural dental practice, especially, for the longer working hours and poor working conditions, as well as difficulty in moving back from rural to urban practice. In addition, a negative impact on spouse/children and their own and spouse's/children career were, also, the major concerns. The present study, thus, adds to the understanding of the challenges that are faced by dental professionals in rural practice. It was, also, clear from the present study that many dental students, even, had a poor understanding of what the term “rural” actually meant and of the actual situation there. The present study, thus, adds to the existing literature regarding this grave problem of discriminatory healthcare delivery, especially, in the underserved and rural areas, and mandates the need for the issues to be resolved so as to have an equitable distribution of the healthcare professionals and upgrading healthcare facilities in the underserved and rural areas.
We would like to all the patients who contributed in the study without whom this study would not have been feasible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]