Interventions for increasing the proportion of health professionals practising in under‐served communities
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To assess the effectiveness of interventions aimed at increasing the proportion of health care professionals working in rural and other underserved communities.
Background
The World Health Organisation's Health for All policy posits the enjoyment of the highest attainable level of health as a fundamental human right to which all citizens are entitled (Strasser 2003; WHR 2003). The shortage of health care professionals in rural and urban under‐served communities, in both developed and developing countries is an important obstacle to the achievement of this goal (WHR 2003).
While the lack of health care professionals in certain communities may result from actual personnel shortages, the inequitable distribution of health care professionals is also an important factor (Stratton 1995). For example, in the United States of America, only 9% of registered physicians practice in rural areas where 20% of the population live (Ricketts 2000). In rural areas of Australia, the average doctor: patient ratio was reported to be 1:707 (Laven 2003). In developing countries inequities in health care service provision are even greater. For instance, in 1996, 46% of the South African population lived in rural communities (Statistics SA 1996) and were served by only 27% of general practitioners; 25% of medical specialists; 7% of dentists and 6% of psychologists (van Rensburg 1999). Statistics from Ecuador in 1991 reveal that one doctor was responsible for the care of approximately 3226 people (Cavender 1998).
Possible reasons contributing to the reduced number of health care professionals in rural and urban underserved communities include demanding working conditions, substandard medical equipment and facilities, inadequate financial remuneration, inadequate opportunities for personal and professional growth, lack of job opportunities for spouse and educational opportunities for children. While it has been suggested that a country's ability to recruit or retain health care professionals in underserved communities ultimately depends upon the provision of a stable, rewarding and fulfilling personal and professional environment for the health care professional (Hart 2002), the provision of such an environment continues to elude most developed and developing countries.
In developing countries, rural and other under‐served communities are generally worst afflicted by problems such as unemployment, poverty, malnutrition, lack of clean drinking water and poor sanitation (Boulle 1997). These factors contribute to the poor health status of people living in these communities (Strasser 2003). The spatial maldistribution of health workers means that those who have the greatest need have the poorest services thus fulfilling Hart's "inverse care law" (Hart 1971). Recent literature from sub‐Saharan Africa shows that treatment of patients with HIV/AIDS has been severely hampered not merely by the lack of financial resources or medical supplies but by the shortage of health care personnel needed to deliver the treatment (WHR 2003). In Uganda, lack of skilled staff at the primary care level is one of the reasons why pregnant women do not utilise community maternity services. These women invariably resort to traditional birthing practices, which result in higher rates of maternal mortality (Kyomuhendo 2003).
While some health care professionals choose to work in rural and urban under‐served communities, additional strategies are required to persuade more health care professionals to do so. These can generally be grouped into educational, financial and regulatory interventions. As previous research suggests that health care professionals originating from rural areas are more likely to practise in a rural health care environment (Rabinowitz 1993; Rabinowitz 1998; Stearns 2000), educational outreach programmes exist that promote the health care profession as a career choice among rural high school students. Furthermore, the selection criteria of medical schools and universities have, in some instances, been modified to ensure the recruitment of greater numbers of individuals from rural communities. Financial, cultural and academic support is provided for their medical training in the hope that once qualified they will return to work in rural areas (Crandall 1990; Rabinowitz 2000).
Some medical school curricula specifically involve greater exposure of undergraduate students to medically deprived areas (Moores 1998) and concentrate on the development of health care skills relevant to these communities (Rabinowitz 1999). Both these factors are believed to influence the choice of health care professionals to practise in under‐served communities once qualified (Brooks 2002; Rabinowitz 2001; Tavernier 2003).
Financial mechanisms that have been implemented to reduce inequitable distribution include scholarships and loan repayment schemes for medical students who in return must fulfil service obligations in rural and under‐served communities (Pathman 2000; Scammon 1994). In addition, higher salaries for individuals working in the public health sector as well as rural allowances (Reid 2001) and retention grants (Humphreys 2001) have also been introduced in some countries, but the effectiveness of these interventions has not been evaluated.
A number of developing countries have instituted a mandatory period of service in an underserved community in an attempt to distribute health professionals in a more equitable manner (Cavender 1998; Ezenwa 1986; Fadayomi 1984; Reid 2001). It is uncertain whether this increases or reduces the chances of health care professionals voluntarily choosing to practise in these areas in the longer term. Many countries attempt to address the problem by simply recruiting foreign health professionals to work in areas that appear to be unattractive to indigenous practitioners (Kiesouw 1996; Reid 2001).
Given the wide array of strategies that have been adopted to influence locality of practice, it is important for educationalists and policy makers to be aware of scientific evidence supporting the effectiveness and impact of the various interventions. This knowledge will promote informed decisions that should help in effectively addressing the problem of inequitable distribution of health care professionals.
Objectives
To assess the effectiveness of interventions aimed at increasing the proportion of health care professionals working in rural and other underserved communities.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials, controlled trials (not strictly randomised), controlled before‐after studies and interrupted time series studies that have evaluated the effects of various interventions on at least one of the outcomes listed below. Studies with historical controls and those that do not include a control or comparison group will not be considered.
Types of participants
All qualified health care professionals, for example, doctors (general practitioners and specialists), nurses, occupational therapists, physiotherapists, speech and hearing therapists, pharmacists, dieticians, clinical psychologists and dentists.
Types of interventions
Educational interventions (e.g. student selection criteria, undergraduate and postgraduate teaching curricula, exposure to rural and urban underserved communities), financial interventions (e.g. undergraduate and postgraduate bursaries/scholarships linked to future practice location, rural allowances, increased public sector salaries) and regulatory strategies (e.g. compulsory community service, relaxing work regulations imposed on foreign medical graduates who are willing to work in rural or urban underserved communities). Any other appropriate interventions, not listed above, targeting health care professionals' choice to work in under‐served communities will also be assessed. We will include studies that have compared one of the above strategies with either no intervention or an alternative strategy as a control.
Types of outcome measures
Primary
Studies should report on at least one of the following primary outcomes:
* The proportion of health care professionals who choose to work in rural or urban under‐served communities as a consequence of being exposed to the intervention (recruitment).
* The proportion of health care professionals who continue to work in rural or urban under‐served communities as a consequence of the intervention (retention).
There are no internationally agreed upon definitions for what constitutes "rural underserved" and "urban under‐served" communities, however, the following definitions are illustrative:
"rural underserved community" = areas in which there are less than a thousand people per square kilometre (Statistics SA 2004).
"rural communities" = areas where there is no ready access to specialists, intensive or high technology care (Hall 2003).
"rural areas" = areas in which both human and material resources are lacking (Hall 2003).
"urban underserved community" = inner‐city or urban community where the majority of the population is of a low socio‐economic status (Hall 2003).
These terms tend to be relative and their meaning will vary from country to country. Thus, for each study, we will accept the definitions as provided by the authors, recording their particular use in the "table of included studies."
Secondary
When provided we also collect information on the following outcomes:
* Patient satisfaction with care provided
* Impact on health status of patients
Search methods for identification of studies
We will search the following electronic databases:
(1) The EPOC Register (and the database of studies awaiting assessment)
(2) The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness
(3) MEDLINE, EMBASE, CINAHL and LILACS
Hand‐searching of high‐yield journals (Rural Nursing and Health Care, Canadian Journal of Rural Medicine, Journal of Rural Health, Australian Journal of Rural Health, Journal of Rural and Remote Environmental Health, Journal of Rural Medicine and Medical Education, Rural and Remote Health), although a potential source of relevant trials, is not a feasible option at this stage.
Furthermore we will search the following conference proceedings and abstracts for relevant trials.
* World Rural Health Congress
* National Rural Health Association (NRHA) Annual Conference (United States of America)
In addition we will:
(4) search reference lists of all papers and relevant reviews identified;
(5) contact authors of relevant papers regarding any further published or unpublished work;
(6) contact authors of other reviews in the field of effective professional practice regarding relevant studies that they may be aware of.
We will contact the following organisations for relevant trials:
* World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (Wonca)
* Canadian Rural Health Research Society
* International Association of Agricultural Medicine and Rural Health
* Institute of Rural Health (United Kingdom)
* Services for Australian Rural and Remote Allied Health
* World Health Assembly
* Australian College of Rural and Remote Medicine (ACCRM)
* Australian Rural and Remote Workforce Agencies Group (ARRWAG)
* European Rural and Isolated Practitioners Association (EURIPA)
* Rural Doctors' Association of Southern Africa (RuDASA)
* National Rural Health Alliance Annual Conference (Australia)
We will also contact experts in the field of rural health care for relevant information from unpublished or on‐going studies. We will also screen reference lists of all articles to look for additional studies.
Search strategies for electronic databases are being developed using the methodological component of the EPOC search strategy combined with selected MeSH terms and free text terms relating to printed educational materials. The following are the printed educational materials data terms that will be used in the MEDLINE search strategy. We will translate this search strategy into the other databases using the appropriate controlled vocabulary as applicable.
Search Strategy:
1 Nurse
2 Nursing staff
3 Nurse's aid
4 Physician
5 Physicians, family
6 Physician assistant
7 Dentist
8 Dental staff, hospital
9 Medical staff, hospital
10 Nursing staff, hospital
11 Pharmacist
12 Pharmacist's aides
13 Dietician
14 Nutritionist
15 Psychologist
16 Occupational therapist
17 Physiotherapist
18 Speech therapist
19 Language therapist
20 Audiologist
21 Allied health personnel
22 Health care professionals
23 Primary health care
24 Primary nursing care
25 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #51 OR #52
26 Rural health services
27 Rural health care
28 Medically underserved area
29 Underserved community
30 Physician‐shortage area
31 #26 OR #27 OR #28 OR #29 OR #30
32 Recruitment
33 Retention
34 Distribution
35 Maldistribution
36 Community service
37 Community‐based education
38 Equity
39 #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR 53
40 #25 AND #31 AND #39
41 Randomised controlled trial OR controlled clinical trial
42 Clinical trial OR (Clinica* trial*)
43 Randomised controlled trials OR Clinical controlled trials
44 Controlled before‐after
45 Interrupted time series
46 Single‐blind method OR double‐blind method
47 ((Singl* OR doubl* OR tripl* OR trebl*) AND mask* OR blind*))
48 Placebo OR Placebos
49 #41 OR #42 OR #43 OR #44 OR #45 OR #46
50 #40 AND #41
51 Logopaedist
52 Speech pathologist
53 Migration
54 Internist
55 Paediatrician
56 Opthalmologist
57 Surgeon
Data collection and analysis
Selection of the studies
Two reviewers (LG and PM or SM) will screen the titles and abstracts of all articles obtained from the search. We will retrieve full copies of all reports deemed eligible by either of the reviewers for closer inspection. The reviewers will independently determine if studies meet the inclusion criteria. Those that appear to meet the inclusion criteria but are later deemed unsuitable for inclusion will be listed in the "table for excluded studies", together with the reasons for their exclusion. We will resolve disagreement between the two reviewers through discussion with a third reviewer (JV).
Data extraction
One reviewer (LG) will extract the data and the process will be independently cross‐checked and confirmed by a second reviewer (PM or SM). We will use a data extraction form based on those used by the Effective Practice and Organisation of Care (EPOC) review group, but modified for this review. We will extract information on study design, the intervention evaluated (including process), participants (including number in each group), length of intervention and follow‐up, and the proportion of health care professionals who choose to work in rural or urban under‐served communities. Consensus will be reached by discussion and consultation with a third reviewer, if necessary.
Methodological quality
We will use the Effective Practice and Organisation of Care Group's (EPOC) quality checklists for randomised controlled trials (RCT), controlled trials, interrupted time series (ITS) and controlled before‐after (CBA) trials to assess all eligible studies. These checklists account for study design, method of randomisation, characteristics of control groups, method of data collection, confounding factors, appropriate statistical methods, selection of outcome variables and risk of bias.
Data analysis
We will analyse the studies separately depending on whether the intervention was aimed at the initial recruitment or subsequent retention of health professionals. Dichotomous and continuous data will be analysed separately. For dichotomous outcomes we will calculate the relative risk (RR, adjusted for baseline differences if possible), the risk difference (RD) and the numbers needed to treat (NNT), together with their respective 95% confidence intervals (CI). For studies reporting continuous outcomes we will calculate the percentage change (i.e. the percent improvement relative to the post intervention average in the control group).
We anticipate substantial variation in the study findings due to various sources of heterogeneity such as differences in the type of intervention, the type of health care professional, the study setting (rural versus urban underserved), study design and methodological quality and the income/development status of the country in which the study took place. Provided there are sufficient studies, we will explore the heterogeneity using meta‐regression analysis. If sufficient studies are not identified, we will explore the heterogeneity visually by means of bubble plots and box plots (displaying medians, interquartile ranges and ranges).
In addition, we plan to explore heterogeneity by conducting the following sub‐group analyses:
* Type of intervention (educational, financial, regulatory)
* Type of health professional (doctor, dentist, nurse, allied health professional)
* Country income/development status (as defined by the World Health Organisation according to burden of disease and mortality)
If we find two or more studies that we consider to be measuring essentially the same outcomes, using the same intervention in a similar population, we will pool the results of these studies. For conducting meta‐analyses we plan to use the inverse variance method in Review Manager 4.1. We will use a random effects model to pool the crude estimates of effect (unless adjusted estimates are provided) to calculate combined relative risks for binary data and weighted mean differences for continuous data. For continuous outcome data expressed in different units, across different studies, we will calculate standardised mean differences.
In order to determine how robust and consistent the results are, we will conduct sensitivity analyses based upon study design (RCT versus other) or risk of bias in study (high, medium, low ‐ according to the Effective Practice and Organisation of Care Group's (EPOC) quality checklists).
