Strategies to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review

Background: Medical workforce shortages in rural and remote areas are a global issue. High-income countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs. Methods: The Arksey and O’Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates. Results: Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in HICs, with only eight studies from LMICs. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce. Conclusion: This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country’s commitment to act to improve the rural medical workforce shortage is most critical.


Woolley 2014 Australia
Multivariate logistic regression identified that the likelihood of JCU MBBS graduates practising in a rural location in PGY 5 was predicted by rural background (having a hometown at application categorised as an 'outer regional' or 'remote' location) (P<0.001; POR =3.9), having Aboriginal or Torres Strait Islander heritage (P= 0.031; POR=5.6) Memorial's pathways to rural practice (rural generalist focused)
Socially accountable medical school

Mian 2017 Canada
Positive changes, linked to collaboration with NOSM, included achieving a full complement of physicians in 5 communities with previous chronic shortages of 30%-50% of the physician supply, substantial reduction in recruitment expenditures, decreased reliance on locums and a shift from crisis management to long-term planning in recruitment activities. The magnitude of positive changes varied across communities, with individual leadership and communities' active engagement being key factors in successful physician recruitment In 2013, 62% were working in rural or regional areas, with 31% in the Northland DHB.
Socially accountable, community engaged medical school Halili 2017 Phillipine s ADZU-SOM medical graduates were more likely to work in their first position as a Rural/Municipal Health Officer than were comparator school graduates (p ¼ 0.001). ADZUSOM medical graduates were also more likely to be working in a Government tertiary hospital in their current position as a generalist Medical Officer/Resident/Consultant (p < 0.001) or working in a Rural Health Unit (p < 0.001) as Municipal Health Officers (p ¼ 0.003), while comparator school graduates were more likely to currently working in private hospitals (p ¼ 0.033) or Government specialist hospitals (p ¼ 0.040), often as surgical (p ¼ 0.010) or nonsurgical/medical specialists (p < 0.001). Phillipine s

Context (Recruitment/ development/retention)
Thirty-one percent of ADZU-SOM medical graduates practised in communities <100 000 population versus 7% of graduates from the conventional school in the Zamboanga region (p<0.001), while 61% of SHS-Palo medical graduates practised in communities <100 000 population versus 12% of graduates from the conventional school in the Visayas region (p<0.001). Twenty-seven percent of ADZU-SOM graduates practised in lower income category communities (categories 2-6) versus 8% of graduates from the conventional school in the same region (p<0.001), while 49% of SHS-Palo graduates practised in lower income category communities (categories 2-6) versus 11% of graduates from the conventional school in the same region (p<0.001). Sociallyaccountable, communityengaged medical education

Siega-Sur 2017
Phillipine s SHS-Palo graduates were also more likely to work in rural and remote areas (p < 0.001). Graduates also stayed longer in both their first medical position (p = 0.028, 3.7 years) and their current position (p < 0.001, 6.8 years), although not clearly in rural/remote posts p=.009. Men were 1.33 times more likely than women to select rural practices, but this difference was narrowing (Figure 2), perhaps related to increasing numbers of women from rural hometowns. Being older and having a rural hometown increased the odds of rural practice, and these two effects were synergistic, such that older rural hometown graduates were 3.65 times more likely to choose a rural practice than younger urban hometown graduates ( The two groups not participating in the RCSWA had 45.5% and 52.4% of subjects in outer regional/very remote locations, respectively. In comparison, 78.7% of those who had participated in the RCSWA were currently practicing in outer regional/very remote locations. When the 3 groups were compared, the significant predictors of working in a more remote practice compared to working in an inner regional area were being female (OR 1.75 95% CI 1.13, 2.72, P = 0.013) and participating in the RCSWA (OR 4.42, 95% CI 2.26, 8.67, P < 0.001). In multivariate logistic regression that corrected for gender and remoteness of rural address before entry to medical school, participation in the RCSWA still predicted a more than 4-fold increase in the odds of practicing in a more remote area (OR 4.11, 95% CI 2.04, 8.30, P < 0.001).
Socially accountable, community engaged medical school

Woolley 2017 Australia
Forty-seven (9%) of JCU Bachelor of Medicine and Bachelor of Surgery graduates in the first seven cohorts had practised for at least 1 year in a remote location between PGY 4 and 10. Practice in a 'remote' town was predicted by undertaking rural generalist training (p<0.001; prevalence odds ratio (POR)=17.0), being awarded an 'above average' interview score at medical school selection (p=0.006; POR=5.1), attending the Darwin clinical school

Type of strategy/initiative Substrategy Program Name Study Country Study outcomes
in years 5-6 (p=0.005; POR=4.7), being female (p=0.016, POR=3.6) and undertaking an outer-regional or remotely based internship (p=0.006; POR=3.5). CART analysis identified Indigenous graduates as another key subgroup of remote practice graduates.

Shires 2015 Australia
Students who had spent a year at the UTAS RCS were five times more likely to be working in RA3 to RA5 than those who hadn't spent a clinical year there (28% vs 7%, χ2 (1) =59.5, p<0.0001) (odds ratio (OR) 4.9, 95% confidence interval (CI) 3.2-7.6). Using the Modified Monash Model, it was found that UTAS RCS graduates were nine times more likely (OR 9.0, 95%CI 4.7-17.2) to be working in the regional cities and smaller towns of Tasmania.

Moore 2018 Australia
The percentage of graduates working in rural areas was highest in the later postgraduate years -PGY6 and above. More than twice as many rural stream graduates were working in RA2-5 locations in PGY6-11 (34.7%) than in PGY1-5 (16.1%; = 10.73, P <0.001).

Type of strategy/initiative Substrategy Program Name Study Country Study outcomes
Longitudinal Integrated Clerkship (LIC)

Campbell 2019 Australia
After accounting for key covariates, LIC participants who had additional rural training of >6 weeks in years 3 and/or 5 of the course (group A) had the strongest odds of working in rural areas (OR 5.04, 95%CI 2.80-9.09). In contrast, LIC participants for whom LIC was their only rural training (group B) were no more likely to take up rural practice than the metropolitan-only group (OR 1.66, 95%CI 0.75-3.68). Among the non-LIC participants with year 4 rural training, students with longer rural exposure (>1 year in years 3 and/or 5 of the course, group C) also had higher odds of working in rural locations than students with shorter rural training (=1 year, group D) (OR 3.68, 95%CI 2.58-5.23 and OR 2.39, 95%CI 1.48-3.87, respectively) Students who had participated in the LIC group with additional rural training in years 3 and/or 5 of the course (group A) had the strongest odds of working in smaller regional or rural towns (population size<50 000) (OR 5.62, 95%CI 2.81-11.20). Students in this group (group A) also had strong odds of working in large regional centres (=50 000 population) as did the non-LIC year 4 rural group (group C) (OR 4.11, 95%CI 1.32-4.95 and OR 4.49, 95%CI 2.81-7.19, respectively). Overall, rural work was consistently positively associated with rural background, being an international student and having a BMP or MRBS return of service obligation, but negatively associated with being in a later career stage (=PGY 7) ( Table 4). Working in a smaller rural town was positively associated with being a graduate entry student or having an interest in rural practice when commencing medical school.

McGirr 2019 Australia
Students with a rural background were 4.1 times more likely to be practising in a rural location according to ASGC (p<0.001) and students who participated in extended RCS placement were 1.9 times as likely to be practising in a rural location (p<0.001). After rural background was controlled for, students who attended an RCS were 1.6 times more likely to be in rural practice (p=0.004). After extended RCS placement was controlled for, students with a rural background were 3.8 times more likely to be practising in a rural location (p<0.001). According to the MMM (3-7), students with a rural background were 3.1 times more likely to be in rural practice than students with a metropolitan background (p<0.001). Students who participated in extended RCS placement were 3.1 times as likely to be practising in a rural location (p<0.001). After rural background was controlled for, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (p<0.001). After extended RCS placement was controlled for, students with a rural background were 2.6 times more likely to be practising in a rural location (p<0.001). In bivariate analysis, site of training was correlated with practice location/population served, with those training in the Metro Vancouver based sites more likely to serve an urban or inner-city population and those in the distributed sites more likely to serve a regional or rural population (Fig2). When regional and rural practice populations are combined, the relationship between training site and practice location is even more pronounced (Fig3). This relationship persists at 5 and 10 years after graduation (χ 2=31 and 33 respectively, df=1, p Student selection

Ray 2015 Australia
Graduates having either a rural or a remote home town at application were more likely to practise in rural (RA 3-5) towns than graduates from metropolitan/inner regional centre across all postgraduate years. For example, the prevalence odds ratios (POR) for graduates practising in a rural town at postgraduate year 1 (PGY 1) having either a rural or remote hometown were 2.6 and 1.8, respectively, times that of graduates having a metropolitan/inner regional hometown, while at PGY 9 the PORs had increased to 4.2 and 9.5, respectively. Bonded medical place students showed lower engagement in rural practice in the 5 years of data available. A rural background (of the Francophone doctors) was positively associated with the establishment of a first medical practice in a rural community. This relationship was only significant among family physicians. There was no statistically significant relationship between rurality of community of origin and rurality of current community of practice among either family or specialty physicians.

Rabinowi tz 2012 USA
A logistic regression showed that all three predictors were independently related to rural practice (P .001). Of graduates with all three predictors, 45% (45/99; CI 35%-55%) practiced in rural areas; of those with two predictors, 33% (48/145; CI 25%-41%) practiced rural; of those with one predictor, 21% (42/198; CI 15%-27%) were rural; and of graduates without any predictors, only 12% (37/320; CI 8%-15%) practiced in rural areas (Figure 1). Compared with the reference group of graduates with no predictors, the RR of practicing rural was 3.9 (CI2.7-5.7, P .001) for those with three predictors, RR 2.9 (CI 2.0 -4.2, P .001) for those with two predictors, and RR 1.8 (CI 1.2-2.8, P .01) for those with one predictor. RMED graduates were 14.4 times more likely than non-RMED graduates to choose family medicine; 6.7 times more likely to choose a primary care practice specialty; 17.2 times more likely to be currently practicing in a rural location; and 12.8 times more likely to be currently practicing in a primary care shortage zip code. Analysis of current RMED graduates' practice locations indicates that 41.9% were within 90 miles of their fourth-year preceptorship community. Among RMED graduates practicing in Illinois, 62.1% and 73.3% were located within 60 and 90 miles, respectively, of their hometown. In terms of length of time in practice, the mean number of years is 5.3 years, with a range from 0.5 to 11.3 years. A total of 110 (68.8%) have remained in their original practice location. For these, the mean length of time in the community is 4.3 years, with a range of 0.58 to 10.6 years.

Rural Medical Education (RMED) Program
Glasser 2010 USA Most rural physicians in this study decided to practise in rural areas because of family ties. Eighty per cent of the physicians participating in the interviews mentioned no negative personal or family factors related to their community of practice. Outcome data on graduates from the rural medical education programme are encouraging. Over 70% opt for primary care and rural practice. Over 80% have remained in their original rural practice location. 75 (70%) are in practice in rural areas. The percentage of graduates going into rural primary care slightly increases from 64 to 70% when comparing longer term to short-term programme graduates.