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 Table of Contents  
BRIEF COMMUNICATION
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 174-177

Identifying motivations and personality of rural doctors: A study in Nusa Tenggara Timur, Indonesia


1 Department of Medical Education, Faculty of Medicine, University of Nusa Cendana, Kupang, Nusa Tenggara Timur, Indonesia
2 Department of Public Health, Faculty of Medicine, University of Gadjah Mada, Yogyakarta, Indonesia
3 Department of Medical Education, Faculty of Medicine, University of Gadjah Mada, Yogyakarta, Indonesia

Date of Web Publication23-May-2019

Correspondence Address:
Nicholas Edwin Handoyo
Jl. Adi Sucipto, Penfui, Kupang, Nusa Tenggara Timur 850001
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_106_14

  Abstract 


Background: One of the health issues faced worldwide is the misdistribution of health practitioners resulting in a lack of physicians working in rural and remote areas. We identified the motivations of rural doctors and the personality that contribute to motivation to stay in rural communities. Methods: A qualitative phenomenological approach was used for which 35 rural general practitioners were interviewed in focus group discussion and one-to-one in-depth interview using a list of structured open-ended questions. Results: Family relationships and self-actualization play important roles in choosing a rural career. Personality also contributes to the decision to work as a rural doctor. We identified nine types of rural doctors, of which it is proposed that five could be encouraged and further developed in medical training. Discussion: The study results suggest that more attention should be devoted to developing certain characteristic in medical students. This would hopefully result in rural doctors gaining increased job satisfaction and being more likely to be retained for a longer duration in rural locations.

Keywords: Career choice, medical education, personality, rural, undergraduate


How to cite this article:
Handoyo NE, Prabandari YS, Rahayu GR. Identifying motivations and personality of rural doctors: A study in Nusa Tenggara Timur, Indonesia. Educ Health 2018;31:174-7

How to cite this URL:
Handoyo NE, Prabandari YS, Rahayu GR. Identifying motivations and personality of rural doctors: A study in Nusa Tenggara Timur, Indonesia. Educ Health [serial online] 2018 [cited 2019 Jul 19];31:174-7. Available from: http://www.educationforhealth.net/text.asp?2018/31/3/174/258918




  Background Top


The province of Nusa Tenggara Timur (NTT) in Indonesia is inhabited by 4.7 million people. Sixty-nine percent of the population are considered to be economically poor and served by a low ratio of general practitioners (1/10,000 population) in 2013 compared to the national rate (2/10,000), Japan (23/10,000), and Australia (32.7/10,000).[1]

The Indonesian Government has implemented a range of policies aimed at recruiting doctors to rural communities based on compulsory rural service and on incentives. Since 1991, there has been a compulsory rural contract for new graduates with high financial incentive. While this program may have increased recruitment, retention has been poor.[2] Most have served a 1-year contract, some extended for an additional 1 or 2 years. Very few have worked >5 years.

A medical school was established in Kupang, the capital city of NTT, in 2008 with a mission to increase the number of doctors working in NTT. To catch up with the national rate of 2/10,000 population, we targeted the graduates to stay 10 years (50 graduates × 10 years = 500 doctors serving 4.7 million people).

Special effort of retaining the graduates is needed. There were, however, a group of doctors who stayed in rural for long periods who can be seen as role models. The reasons for staying and their personality have not previously been studied in Indonesia.


  Methods Top


A qualitative approach was used. Ethical approval was granted by the University of Gadjah Mada. Each participant gave informed verbal consent.

Participants

Potential participants of general practitioners working in NTT for >10 years were identified using the records of the Provincial Indonesian Doctor Association and a snowball sampling technique. To ensure diverse P articipants were represented, the participants were chosen purposively based on a combination of variables: gender (male/female), origin (rural/urban), previous education (rural/urban), marital status (married/single/divorce), and job (private/public). A total of 35 participants volunteered, consisting of 33 who stayed and 2 who had left NTT after serving for a minimum of 10 years.

Data collection

A total of 40 invitations were sent to potential participants living around Kupang. Focus group discussion (FGD) was conducted with nine participants by the main researcher, guided by a list of open-ended questions and audiorecorded. Every participant was given the opportunity to answer the open-ended questions and share experiences. Every participant had to respect and not argue with other participants' opinions.

Face-to-face in-depth interviews were conducted with the other 24 identified participants across NTT and the 2 participants from the leaving group. The interviews were held at places and times convenient for the participants. The interviews were audiorecorded, and all were conducted by one researcher to ensure consistency of technique and reduce inter-rater bias.

The same questions were used in the FGD and the in-depth interviews. [Table 1] presents the list of questions.
Table 1: List of open-ended questions for interviews of physicians remaining in and leaving rural areas

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Data analysis

The same technique of analysis was applied to data from the FGD and the in-depth interviews. Transcriptions of all interviews were checked twice to ensure the accuracy of transcription and then analyzed independently by two researchers with discussion on any differences until agreement was reached.


  Results Top


A total of 35 participants volunteered, consisting of 33 who stayed and 2 who had left NTT. The first group consisted of 19 females and 14 males aged 40–76-years with an average age of 51.8 years. Eighteen were native NTT, and of these, 17 received their primary or secondary education in NTT. Fifteen had come from other provinces of which 14 received their previous education outside of NTT. The second group consisted of one native female who received her education in NTT and one nonnative male who received his education outside NTT.

The following three themes were identified:

  1. Motivation to come and stay
  2. Motivation to leave
  3. Types of rural doctor based on their motivation.


Theme 1: Motivation to come and stay

Family factor was the only motivation found in every participant. For natives, the presence of their family in a rural setting brought them back and helped to keep them there. For those not native to the rural area, having their family present with them in the rural area was an important factor as they did not feel isolated or lonely. However, having family outside of the rural area motivated doctors to leave, in part because of the high travel cost to visit their family.

I have my family here. If they weren't here I wouldn't be able to cope … I couldn't even imagine not having them here, I wouldn't be able to live here … nonnative NTT).

Self-actualization is a strong motivation to come and to stay. Self-actualization involves setting out to achieve one's greatest potential and satisfaction through achieving good patient outcomes, making useful community changes, having time to spend with the family, and achieving the respect of the community. Those achievements are seen as more important than wealth.

Theme 2: Motivation to leave

Personality trait plays a role in the decision to leave. Those strongly motivated by making money, those who fail to adapt to a rural lifestyle, and those seeking higher professional education are more likely to leave.

Family, education for children, career development, and cultural factor also contribute to the decision to leave. For example, obligation to contribute in every event held by the extended family, including marriage, first communion, graduation, and death may cause one to end up in no savings.

Family is a big thing in NTT and this could be a problem. I am glad I live away from my family in Atambua… otherwise we'll spend all our money on our family get together (native NTT).

Theme 3: Types of rural doctor based on their motivation

By grouping similar responses of the participants, nine types of rural doctors emerged during analysis. These are described and presented in [Table 2].
Table 2: Nine types of rural doctor based on motivation

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A spiritualist-type participant offered a unique definition of success which contributed to him staying longer in rural.

To me, success is when I do what God wants me to do … those who work and work only are in fact poor people. The rich ones are the ones who donate and spare their time for others … if someone has this attitude, the person would be able to cope being posted anywhere …” (native NTT, Christian).

On the other hand, a different reason was stated by the rationalist type:

Why have I been there for that long?… Ideally we probably want to contribute. People generally talk that way, but back to the financial issues … if my private practice didn't run very well, I'd have to think it over (native NTT).


  Discussion Top


We must comment on limitations of this study. First, the location of participants is limited to NTT province where the majority of the population is Christian. This region might have attracted health professionals with a similar background compared to other Moslem populated areas of rural Indonesia. The implications of results to other rural areas with a different culture remain to be determined. Second, this study only had a small sample of 35 participants. Third, there was no comparison group with physicians who had left the area prior to 10 years.

Motivation

Considering intrinsic motivations in retaining health workforce in rural is very important. Financial incentives tend to improve recruitment but do not necessarily address retention.[2],[3] Overall, there are similarities between the motivations to come and to stay. The family factor was the intrinsic motivation which emerged the most during analysis and influenced the participants to come, to stay, or even to leave rural. This is consistent with previous studies.[4],[5],[6] Family factors such as job for spouse, proper education for children, and other privileges for doctor's family need to be considered when designing health policies.[4]

The motivations to leave were similar to previous studies: family factor, education for children, financial and political problems, facilities, career change, and work comfort.[4] This study added personality traits as another contributing factor.

Types of rural doctors based on motivation

There were nine types of rural doctors found. We postulate that these types contributed in retaining doctors in rural. Among those, five types were recommended: spiritualist, idealist, adventurer, family, and agent of change. It is assumed that if these five types could be fostered during training, it would help in improving misdistribution of medical workforce.

Motivation has a strong relationship with personality. In terms of personality traits, Erikson's theory of psychosocial development has contended that social interactions influence the development of personality and continue to develop and grow throughout life.[7] Character can be assessed and developed through experience, training, mentoring, and education.[8] Students from rural backgrounds are generally more likely to have the intended traits developed through rural experience. Character education for both rural and urban origins is suggested along with intervention in student admission.

The role of character education is consistent with previous studies. Examining humanistic and intrinsic factors in the selection process may be an important strategy for identifying physicians who are motivated to practice in rural.[5] Some strategies for character education could be: developing community-oriented curriculum by giving students more rural experiences and community services,[4],[8] teaching values through religious belief,[9] role modeling,[10] and guided reflection. However, the best way to inculcate those values, the impact of rural experience on the development of the intended traits, and how to assess this remain to be determined.

Acknowledgment

The authors thank the rural doctors who participated in the study, Dr. Ika Febianti Buntoro who helped the transcription process of this study, and HPEQ Project which funded the study.

Financial support and sponsorship

This research was funded through research grant of Higher Professional Education Quality Project, Ministry of Higher Education of Indonesia.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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World Health Organization. World Health Statistics 2015. Luxembourg: World Health Organization; 2015.  Back to cited text no. 1
    
2.
Efendi F. Health worker recruitment and deployment in remote areas of indonesia. Rural Remote Health 2012;12:2008.  Back to cited text no. 2
    
3.
Hall DJ, Garnett ST, Barnes T, Stevens M. Drivers of professional mobility in the northern territory: Dental professionals. Rural Remote Health 2007;7:655.  Back to cited text no. 3
    
4.
Hancock C, Steinbach A, Nesbitt TS, Adler SR, Auerswald CL. Why doctors choose small towns: A developmental model of rural physician recruitment and retention. Soc Sci Med 2009;69:1368-76.  Back to cited text no. 4
    
5.
Odom Walker K, Ryan G, Ramey R, Nunez FL, Beltran R, Splawn RG, et al. Recruiting and retaining primary care physicians in urban underserved communities: The importance of having a mission to serve. Am J Public Health 2010;100:2168-75.  Back to cited text no. 5
    
6.
Laven G, Wilkinson D. Rural doctors and rural backgrounds: How strong is the evidence? A systematic review. Aust J Rural Health 2003;11:277-84.  Back to cited text no. 6
    
7.
Cherry K. Personality Development: Major Theories of Personality Development. (online). Available from: http://www.psychology.about.com/od/personalitydevelopment/a/personality-dev.htm. [Last retrieved on 2015 Sep 03].  Back to cited text no. 7
    
8.
Woloschuk W, Tarrant M. Does a rural educational experience influence students' likelihood of rural practice? Impact of student background and gender. Med Educ 2002;36:241-7.  Back to cited text no. 8
    
9.
Barlow CB, Jordan M, Hendrix WH. Character assessment: An examination of leadership levels. J Bus Psychol 2003;17:563-84.  Back to cited text no. 9
    
10.
Sivalingam N. Teaching and learning of professionalism in medical schools. Ann Acad Med Singapore 2004;33:706-10.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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