Backgrounds: In India, fewer doctors work in rural areas than urban locations, despite having greater health needs for rural populations. At the same time, living conditions and work environment present many challenges in rural and underserved areas. Therefore, fostering and creating a congenial work environment is of paramount importance in rural areas. This study analyses living conditions, work environment, and the factors that influence the intention to stay among doctors in current posts of work in rural areas of Odisha state, India. Materials and Methods: A nonexperimental cross-sectional study design was conducted to collect data from 233 doctors working in rural health facilities in Odisha, India. The data were collected through a structured questionnaire and analyzed using SPSS version 18. The statistical significance of the association between variables was assessed using logistic regression. Results: The study of the investigated doctor showed that 57.6% of doctors wanted to stay and continue working in rural areas for the next 36 months. The logistic regression outlined that age, time travel (one way) to workplace, and work environment were the significant factors that are associated with intent to stay in rural areas. Conclusions: Formulating effective strategies to bring about improvement in work environment for doctors community working in rural regions should form a critical component of rural retention efforts.
Keywords: Doctors, India, intention to stay, living condition, Odisha, rural areas, work environment
|How to cite this article:
Behera MR, Prutipinyo C, Sirichotiratana N, Viwatwongkasem C. Living conditions, work environment, and intention to stay among doctors working in rural areas of Odisha state, India. Ann Trop Med Public Health 2018;11:70-7
|How to cite this URL:
Behera MR, Prutipinyo C, Sirichotiratana N, Viwatwongkasem C. Living conditions, work environment, and intention to stay among doctors working in rural areas of Odisha state, India. Ann Trop Med Public Health [serial online] 2018 [cited 2020 Aug 10];11:70-7. Available from: https://www.atmph.org/text.asp?2018/11/3/70/272549
Acute shortage of health-care professionals, especially physicians in rural and underserved areas, has become a key discussion among social and political circle of most countries. There is also geographic maldistribution of physicians within countries leading to poor functioning of health systems., Research evidence indicates that the availability of adequacy of health workforce is important for improving population health and better health outcomes.,, It is widely recognized that the physicians are the backbone of the health systems as they are frontline health managers for primary health care, yet the global deficit of physicians continues with significantly skewed distribution within the states of many countries.,,
The evidence suggested that the urban populations access more health care than rural areas.,, About 50% of the population in the world reside in rural areas, which is served by only 38% of nursing workforce and 24% of the medical doctors’ workforce. Further, the Sub-Saharan Africa has the lowest density of health-care professionals per capita of any region with the highest burden of disease., Moreover, the World Health Report of 2006 estimated that around 4.3 million health workers deficit worldwide combined with uneven geographical distribution of health workforce in underserved, remote, and rural areas., Such issues of iniquities in the rational distribution of physician workforce increase the global burden of disease and decrease performance of health system functions. The World Health Organization (WHO) has described “underserved areas” as: “geographical areas where populations have limited access to qualified health-care providers and quality health-care services. They include remote and rural areas, small or remote islands, urban slums, conflict and postconflict zones, refugee camps, minority and internally trained communities, and any place that has been severely affected by a major natural or man-made disaster (p. 10).” Further, there are 57 countries in the world that face critical shortage of human resources for health as indicated by the WHO, 2006 report. These countries have fewer than 2.3 doctors, nurses, and midwives per 1000 populations, which is believed to be too few to deliver basic health services that are needed to serve rural populations. In addition, evidence showed that many doctors prefer to work in city areas, thus leaving the remote locations that are underserved.,,, This raises the concern about the enormous differences in accessing health-care facilities in urban versus rural areas, highlighting the need for thorough research on the issue of remote, underserved, and rural areas.
To address the global shortage of medical doctors more effectively, concerted attention needs to be given in the improvement of living conditions and work environment at workplaces in rural areas. Creating and fostering decent living condition for doctors and solving their work-related issues are critical, especially where these issues pose many challenges in rural and remote areas., Therefore, thoughtful consideration of the various factors is needed that might impact improved rural retention and offer feasible solutions to address physicians’ shortage in rural areas. Various studies stated that physicians’ retention in rural areas is related to their living condition, practice situation, economics, and work satisfaction., Therefore, the current study aims to determine doctors’ living conditions and work environment and to identify factors that influence intention to stay in their current post of work in rural areas.
In India, several policy documents and reviews have highlighted the severe shortage of doctors in rural and remote areas across the country., For example, in 2005, there were about ten qualified physicians in urban and one physician in rural areas per 10,000 populations. The rural space of India is highly occupied with unqualified practitioners: national surveys have indicated that about 63% of doctors practicing in rural areas have inadequate training. This shortage of physicians in the country has become a matter of concern to various state governments of India. Odisha, one of the low health indicator states of India, faces severe shortage of doctors. Approximately 24% of physician’s vacancy has been found at various levels in most of the districts. The availability of doctors in Odisha is 1.3/10,000 population which is lower than other states of India such as Goa (5.8 doctors/10,000) and Kerala (3.2/10,000). Recognizing the need for additional doctors in rural hospitals, the Odisha government has taken concerted efforts by providing rural incentives and enhancing recruitment drive. However, available physicians in remote and underserved locations are still very low at peripheral health structures mainly at the primary health centers (PHCs).
There is a dearth of literature in the world and in the South Asian countries about living and work circumstances among doctors in rural areas. In general, national and international literatures suggest that doctors working in supportive working environment in urban locations of health facilities tend to stay more and less intend to leave., Job satisfaction has also been associated with work environment among health workers., Further, several descriptive studies have been undertaken to investigate the retention of doctors in rural areas showing that there is no single factor responsible, but rather a combination and complex factors impact on and influences where doctors work.,, According to Dolea et al., these factors can be categorized into education, regulatory, financial, and professional/personal support. A qualitative study in South Africa has shown that an increase in financial incentives would attract doctors to work in underserved areas. According to McGregor, the crucial issue in human resource management is to interlink the organizational needs with the individual needs. Organizational needs may be developed by the employer such as deployment policy (transfer and placement); however, the employee will make their own decisions to stay or leave the organization based on the work condition, living facility, career development, and professional satisfaction. Therefore, it is necessary to have deployment policy (recruitment and transfer) that fulfills organizational need, at the same time, policies being effective toward retaining, attracting, and motivating the staff to work in rural areas. It is also equally crucial to improve living and work conditions while making decisions at top level.
In this article, we examined the perception of medical doctors toward their living conditions, work environment, and intention to stay in their current posts. This would benefit to the policy makers and administrators in designing feasible strategies toward better work environment for improved rural retention of doctors.
|Materials and Methods|
The data investigated in the present study were drawn from the cross-sectional survey of physicians. This study is part of larger state project of the first author.
The study is conducted in Odisha (formerly known as Orissa) state of India. There are 30 districts of Odisha, with a total population of around 42 million. The state is categorized into two parts based on the socioeconomic indicators; 11 districts belong to Koraput, Bolangir, and Kalahandi (KBK) that comprise 25% of the population and the rest 19 districts are non-KBK (75% of the population). The southern part of Odisha represents that the KBK region is among poorest regions in the country, mostly tribal population with underdeveloped economy, low health indicator, and poor living conditions in comparison to non-KBK regions. All districts of KBK regions are designated as tribal.
Each district has a three-tier health-care structure: at the district level, district hospital (DH) and subdivisional hospitals (SDHs) that cater 1.3 million populations, at the block level, community health center (CHC) for 100, 000 populations, and at the village level, PHCs for 30, 000 populations. The DH and SDH provide specialist services while the rural health facilities (PHCs and CHC) provide primary health care.
A sample size of 255 was estimated, including 10% of nonresponse rate. Therefore, the study employed multistage sampling to select study participants. At the first stage, six districts were selected, three randomly from KBK and three from non-KBK regions. The second stage was proportionate sampling where estimated sample size of each district was calculated based on the real estimation of doctors working in PHCs and CHC. The third stage involved simple random sampling to select sampled rural doctors from each district. A total of 233 doctors responded to the questionnaire. The investigation was conducted during the period of October 2016–February 2017.
A structured self-administered questionnaire was utilized for data collection. The questionnaire comprised the basic sociodemographic characteristics such as age, gender, marital status, religion, and distance from workplace (one way). The other parts included living condition and work environment inventories of doctors. After investigation on the situation of doctors in Odisha, we developed 10 items (4 items for living conditions and 6 items for work environment). Physicians were asked about their living conditions satisfaction in the following aspects: (1) the amenities and infrastructure available in the current place of stay, (2) the housing allocated from the government, (3) availability of schools and childcare facilities at work, and (4) the prospects of employment of the spouse in the current place of work. These aspects were rated in a five-point (number ranging from 1 to 5) Likert scale that ranged from “least satisfied” to “very satisfied.” “1” represents least satisfied, “2” represents slightly satisfied, “3” represents moderate (not too bad), “4” represents very satisfied, and “5” represents extremely satisfied. The Cronbach’s alpha coefficient for the scale was 0.59.
For work environment satisfaction, doctors were asked the following aspects: (1) the adequacy of support services (such as patient transport, clerks, and personnel) provided to them for quality care of the patients, (2) the adequacy of time and opportunity to discuss various health-care issues of patient with experienced doctors or those who are working in allied disciplines, (3) the adequacy of drugs, medical supplies, and up-to-date equipment for provision of quality patient care, (4) getting regularity of suggestions and support from colleagues/seniors working in urban areas for providing better health services through personal/team visits or through telehealth (distance-based technology) to improve knowledge and skills, (5) the accessibility to any professional network and rural health professional associations that consisted of doctors working in rural areas, and (6) have received any award or recognition while working in rural areas based on performance. Each aspect was measured on a five-point Likert scale (ranging from 1 to 5 from “least satisfied to very satisfied”). “1” represents least satisfied, “2” represents slightly satisfied, “3” represents moderate (not too bad), “4” represents very satisfied, and “5” represents extremely satisfied. The Cronbach’s alpha coefficient for the scale was 0.80.
Intention to stay was measured by one question, “Do you intend to stay and continue to work in rural areas for at least next 3 years?” was asked to each physician. They replied with “Yes” or “No” to the statement. A value 1 was set for doctors who was said “yes” and 0 for those who said “No”.
Data collection and ethical clearance
The ethical approval of the study granted by the Institutional Review Committees of the Mahidol University, Bangkok. The study was also approved by the Research and Ethics Committee, Department of Health and Family Welfare, Government of Odisha. The objectives of the study were explained to all respondents. They were reminded that their responses were voluntary and confidential. They have right to withdraw the study at any point of time if they wish to do so, and their refusal in participating the study would not negatively affect them. Questionnaires were offered by hand to doctors and it took around 20–30 min to complete the questionnaires.
Data were entered using SPSS 18.0 (SPSS;http://www.spss.com) for statistical analysis. The descriptive statistical analysis was used for the sociodemographic information’s of the investigated doctors. Further, logistic regression was computed to assess significantly related factors that influence intention to stay among doctors. The odds ratio (OR) and 95% confidence interval (CI) were reported as strength of association. The significance level was set at P ≤ 0.05.
Sociodemographic characteristic of study sampling
A total of 233 doctors completed the questionnaire in this study. The average mean age of participants was 36.7 years (SD = 10.6), ranging from 24 to 62 years. Nearly 82% of participants were male and 55.4% of them were married. The mean of the total years of work experience in rural areas was 7.6 (SD = 8.1). Nearly 95% of study participants belong to Hindu religion. Nearly 68.2% of participants took ៲ min to reach their workplace (one way). The sociodemographic characteristics of the study group are shown in [Table 1] (n = 233).
|Table 1: Sociodemographic characteristics of the doctors (n=233)
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Intention to stay of doctors
The results of the study among investigated doctors conducted in Odisha state showed that 56.7% of the doctors working in government health systems intend to stay and continue to work in rural areas for the next 3 years.
Degree of satisfaction in living conditions and work environment of doctors
The statistical results of living condition scores of the investigated doctors indicated that doctors were least satisfied with four items asked to them.
The mean score of satisfaction of each item was such as satisfaction with the amenities and infrastructure (water, telephones, internet etc.) available in the current place of stay (1.55 ± 0.593), with the housing allocated from government (1.44 ± 0.655), with the availability of schools or childcare in the current place posting (1.33 ± 0.642), and with the prospects of employment for your spouse in the current place of posting (1.12 ± 0.775). Whereas, in work environment degree scores, doctors were found moderately satisfied with the adequacy of support services (such as patient transport, clerks, and personnel) provided to them for quality care of the patients (1.84 ± 0.608), the adequacy of time and opportunity to discuss various health-care issues of patient with experienced doctors or those who are working with allied disciplines (1.73 ± 0.674), the adequacy of drugs, medical supplies, and up-to-date equipment for provision of quality patient care (1.78 ± 0.533), getting regularity of suggestions and support from colleagues/seniors working in urban areas for providing better health services through personal/team visits or through telehealth (distance-based technology) to improve knowledge and skills (1.77 ± 0.679), the accessibility to any professional network and rural health professional associations that consists of doctors working in rural areas (1.62 ± 0.619), and any award or recognition received while working in rural areas based on performance or any other relevant indicators (1.42 ± 0.618).
[Table 2] showed the degree of satisfaction in living conditions and work environment of the investigated doctors. A score of more than 2 in each component of living condition and work environment was classified as the “satisfactory” group. A score of “1.5–2” represented moderate (not too bad); the ɣ.5 or rest was classified as the “unsatisfactory.”
|Table 2: Degree of satisfaction in living conditions and work environment of the investigated doctors
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Logistic regression analyses examining factors associated with the intention to stay among doctors
The binary logistic regression was carried out to analyze the predictor variables that influence the intention to stay among doctors. We analyzed the factors which are significantly associated (P< 0.05). The dependent variable “intention to stay” was measured categorically which is replied with “Yes” or “No.” The sociodemographic characteristics, living conditions, and work environment were the independent variables. The results showed that age, time travel (one way) to workplace ៲ min, and work environment were significantly related to intention to stay of doctors at work. Age was significant predictor (OR = 0.94, 95% CI = 0.89–0.97; P = 0.043), the odds of doctors reporting an intention for rural retention decreases by 0.06 times with every 1 year increase in their age. Doctors who stated that it took ៲ min to reach their workplace were 2.59 times more likely to intend to stay (OR = 2.59, 95% CI = 1.14–5.91; P = 0.023). Work environment was also significantly associated with greater odds of expressing intention to stay (OR = 1.11, 95% CI = 1.02–1.20; P = 0.009). This means that the odds of a doctor expressing intention to stay are 1.11 times higher for doctors who are satisfied with their works. The binary logistic regression results are summarized in [Table 3].
|Table 3: Binary logistic regression examining factors associated with the intention to stay of doctors
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This is a unique study to examine the perception of medical doctors toward their living conditions, work environment, and intent to stay in rural and underserved areas.
The findings of the study suggested that doctors were least satisfied with the living conditions, and they perceived their work environment as unsupportive or moderately satisfied. It can be believed that life in rural and underserved areas is negative, often associated with various factors such as housing, schooling, and safety being perceived as substandard in rural areas. In the present study, doctors have shown the least satisfaction with housing allocated by government, schooling, and employment of the spouse. Such results are consistent with the previous findings as conducted by Dolea et al. and Ojakaa et al., In addition, poor quality health care in rural areas persists as indicated by doctors, problems of inadequate infrastructure and amenities (water, telephones, internet etc.) were reported and shown to be at borderline of moderately satisfied in the present study which is corroborated by the previous findings conducted by van Rensburg. Despite such results, the study participants have shown a high level of intention (56.7%) toward rural service. This might be due to the fact that doctors working in underserved and rural areas either belong to their home location, thus feeling settled down, or from the other regions in which they wanted to complete the rural service period and they agreed to come and work in rural areas because of additional financial incentives given by the state governments for rural service. Nonetheless, further studies may be carried out to investigate other predictors that might have an impact toward intent to stay in rural and underserved locations.
The results of logistic regression illustrated that age, time travel to workplace (one way), and work environment were predictor variables of intention to stay in rural and remote areas. Such results were corroborated with other findings that were reported in international and national studies of medical workers. Age was one of the predictor for the level of intention to stay in rural areas. For every 1 year increase in age, doctors’ intention to stay in rural areas gradually decreases which means that the younger doctors are more likely to stay and work in rural areas for few years which is corroborated by the previous findings. This finding suggests that medical administrator and policy planner should be designed targeted retention strategies for younger doctor and new fresh graduates in underserved communities. Such strategies must be aligned with more engaging way to involve fresh graduates and younger doctor in planning and implementation. Further, time travel (one way) to workplace ៲ min was associated with the level of intention to stay in rural areas, which is consistent with the findings of EI-Jardali et al. The study found that not communing for over an hour among nurses was associated with intent to stay in rural areas. In addition, doctors who perceived that their work environment as satisfied was intend to stay more in rural areas than other doctors. This supports the findings of other literatures that state that the supportive work environment has the positive impact toward improved rural retention.,
Limitations of the study
There were few limitations of the study. First, this was a cross-sectional survey design, so it is difficult to establish causality. Second, this study was undertaken only 6 districts out of total 30 districts of Odisha. Therefore, the findings cannot be broadly generalized. Finally, more detailed qualitative views from the respondent could have facilitated better interpretation of the results.
The findings of the present study illustrated that the doctors of Odisha were least satisfied with the items of living condition domain; however, they were moderately satisfied with the items of work environment at their workplace. In spite of such results, more than half of the study participants (56.7%) considered to stay and work in rural areas for the next 36 months. This prompts the policymakers and administrators to design bundle of interventions that support medical doctors to work in underserved areas. Further, age, time travel (one way) to workplace, and the work environment were significantly associated to the intent to stay in rural areas.
The study findings necessitate the improvement of work environment for doctors working in rural hospitals. Further, a tailor-made intervention for young doctors to attract and work in rural areas is needed. These results may also be interested to policy maker at health department considering the fact that severe shortage of doctors in rural and underserved areas. This study highlighted the living conditions, work environment, and intent to stay of doctors who devote themselves to health-care services in underserved areas.
This study is part of the graduation requirement of first author Manas Ranjan Behera as mandated under doctoral curriculum at the Faculty of Public Health, Mahidol University, Thailand. The authors would like to thank all medical doctors for their participation in the study. They also acknowledge the assistance received from Department of Health and Family Welfare (DOHFW), Odisha and extend their thanks to Dr. B.P. Mohapatra, Team Leader State Human Resource Management Unit, DOHFW, Odisha, for his support in data collection for this study.
Financial support and sponsorship
This study was partially supported by the China Medical Board, Faculty of Public Health, Mahidol University, Bangkok, Thailand.
Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]