Education for Health

: 2018  |  Volume : 31  |  Issue : 2  |  Page : 114--118

Community-based learning enhances doctor retention

Pairoj Boonluksiri1, Hathaitip Tumviriyakul1, Rajin Arora2, Win Techakehakij2, Parinya Chamnan3, Nawapat Umthong4,  
1 Hatyai Medical Education Center, Songkhla, Thailand
2 Lumpang Medical Education Center, Lumpang, Thailand
3 Sunpasitthiprasong Medical Education Center, Ubon Ratchathani, Thailand
4 Office of Collaborative Project to Increase Production of Rural Doctor, Ministry of Public Health, Bangkok, Thailand

Correspondence Address:
Pairoj Boonluksiri
Hatyai Medical Education Center, Songkhla 90110


Background: Rural doctor shortage is a problem in many countries. Factors associated with doctor retention were reported such as colleagues, workload, accommodations, transportation, proximity of family and friends, incentives and career path. Rural background recruitment, increasing the quantity of doctor production to supply in rural and remote areas, and regulation are claimed to alleviate doctor scarcity in rural communities. Many programs have been developed, but an imbalance in physician distribution persists. Community-based learning (CBL) is recommended by the WHO to promote doctor retention. The longer contact time of CBL is practical, but it is uncertain that this results in greater retention. The objective of this study is to determine the association between contact time of CBL and retention of doctor with rural background recruitment. Methods: A cohort study was performed. The study population was 10,018 doctors graduated during 2001–2010 and followed up at least to 2014. Of the 10,018 physicians, 2098 doctors (21%) were recruited from rural backgrounds by the Collaborative Project to Increase Production of Rural Doctor (CPIRD). Contact time of CBL was calculated to the proportion of total curricular credit hours. The primary outcome was retention rate in government health-care system over 4 years. Statistical analysis was performed using multiple logistic regression. Results: A total of 5774 doctors (57.6%) were retained in the government health-care system. Higher percentages of CPIRD doctors were retained than normal track (72.1% and 53.8%, P < 0.001), especially in rural hospitals (60.3% and 38.4%, P < 0.001). Based on univariate analysis, CBL was slightly higher in retention than resignation group with statistical significance (2.97% and 2.90%, P = 0.045). Multiple logistic regression results showed that CBL, graduate entry, and geographic location of workplace were significantly associated with retention. Discussion: CBL can enhance doctor retention. It should incorporate meaningful experience such as rural exposure together with classroom teaching to focus concepts and integrating service to the community. Graduate entry and geographic location of workplace also have an impact on decision-making regarding retention.

How to cite this article:
Boonluksiri P, Tumviriyakul H, Arora R, Techakehakij W, Chamnan P, Umthong N. Community-based learning enhances doctor retention.Educ Health 2018;31:114-118

How to cite this URL:
Boonluksiri P, Tumviriyakul H, Arora R, Techakehakij W, Chamnan P, Umthong N. Community-based learning enhances doctor retention. Educ Health [serial online] 2018 [cited 2020 Sep 26 ];31:114-118
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Full Text


Doctor shortage is a problem in many countries, causing maldistribution in rural and remote areas and imbalance of supply and attrition. Doctor scarcities threaten health-care delivery in many rural communities.[1] There are many factors related to retention such as proximity of family and friends, working in a family-friendly environment, general living conditions, quality of children schools, social and recreational opportunities, safety and access to rapid transport to other cities, having access to social networks, infrastructure of the community hospital, managerial support, workload, professional support, and professional isolation. Rural background recruitment, increasing the quantity of doctor production to supply in rural and remote areas, and regulation are claimed to alleviate doctor scarcity in a rural community.[2] Many programs have been developed to increase doctor supply, but maldistribution persists.[2],[3],[4] While no single approach guarantees success, community-oriented medical education is a method which is recommended by the WHO to promote skills of community approach and enhance retention.[5],[6],[7] Community-based learning (CBL) is an intentional pedagogical strategy to integrate student learning in academic courses with community engagement, attachment by rural exposure. At the same time, it challenges them to develop a range of intellectual and academic skills to understand and take action on the issues they encounter in everyday life. Rural exposure is believed that it encourages students to deeply understand rural lifestyles, a sense of belonging in a community and adjust themselves to the community context.[8],[9],[10] In Thailand, The Collaborative Project to Increase Production of Rural Doctor (CPIRD) by Ministry of Public Health (MoPH) has been operating since 1994 in order to increase rural doctor supply. Student admission with rural background recruitment is used for a selection method. Rural background is determined by finishing from high school in a rural community and having a parent's rural background for at least 5 years. This project is affiliated with many medical faculties of universities. All CPIRD students study on campus like normal track students during three preclinical years. They have clinical rotations during their last 3 years at regional and rural hospitals of MoPH network which are located at all parts of Thailand. In the meanwhile, medical students in normal track have clinical rotations mostly in university hospitals and urban communities. CBL with rural exposure is arranged and led by staff from each medical education center (MEC). It focuses on service in which the students are under supervision to engage in caring for the patients and managing their illness in the context of their families and community. Community management includes medical illness and mental health, early detection of disease, population health surveillance, acute and chronic care management, and general practice within the wider health-care network. A cohort study of graduated CPIRD doctors during 2000–2010 showed that rural doctor retention of CPIRD is higher than normal track.[11] However, it is difficult to track which factors are yielding increases in retention because each MEC is unique and therefore has unique programming depending on its' affiliating university. Not all CBL programs are the same and vary in areas such as staff's preparedness, meaningful learning experience, different charm of community, level of community engagement, rural community environment, and contact time of rural exposure. If we assumed that all CBL programs were standard including learning environment and staff, the longer contact time of rural exposure would be one of the essential factors to promote longer rural retention.


The objective of this study is to determine the association between doctor retention and contact time of CBL with rural background recruitment.


A cohort study was performed. The study population was 10,018 doctors graduated 2001–2010 and followed up at least to 2014. Of the 10,018 graduates in this cohort, 2098 doctors (21%) were recruited from rural backgrounds by CPIRD. CPIRD doctors were allocated in their hometowns. Graduates from the normal track were allocated in any provincial and rural hospitals needed during their 3-year commitment by regulation for practice in the Thai government health-care system. CBL programs and contact time were collected from 37 MECs from where CPIRD programs are offered. A quantitative measurement of contact time of CBL was transformed to the proportion of total curricular credit hours. One credit of discipline was assumed as 42 h. The mean curriculum credit was 251.8 credits (range 242–265). It was assumed that all credits and learning experience in CBL did not change for this cohort. Data collection was performed for doctor characteristics, types of recruitment, and geographic location of workplace. The primary outcome was doctor retention rate in the government health-care system over 4 years after graduation. Resignation is defined as moving out of government health-care system. Data analysis was performed to determine the association between retention and contact time of CBL in CPIRD cohort using univariate analysis and multiple logistic regression.


Overall, 5774 of 10,018 doctors (57.6%) were retained. CPIRD retained at a higher rate (1514 of 2098 doctors; 72.1%) than normal track (4260 of 7919 doctors; 53.8%; P < 0.001). Graduate entry CPIRD also were retained at a higher rate than normal track; 108 of 128 doctors (84.4%) and 1406 of 1971 doctors (71.3%), respectively (P = 0.001). There were no statistically significant differences in size and experienced MEC by geographic locations (P = 0.23 and 0.40, respectively). The most common workplace was rural community hospitals for at least 2 years due to regulatory requirement. CPIRD doctors work in rural areas at a higher rate than normal track physicians (62.3% and 49.0%, P < 0.001) as shown in [Figure 1]. Most doctors resigned after a 3-year commitment. The doctor characteristics that are associated with retention in the government service system are being male, graduate entry, and rural background recruitment (i.e., CPIRD track). Doctors working in rural community hospitals resigned more often than those in others [Figure 2].{Figure 1}{Figure 2}

Analysis of association between community-based learning and retention in doctor with rural background recruitment

CBL was mainly arranged by staff in discipline of community medicine and family medicine. There are 6 (range 1–18) staffs in the family medicine department in average per each MEC that CPIRD doctors are graduated from. The mean contact time of CBL was 292.2 h. There were 76.8 h for classroom sessions that focused on integrating service to the community. The contents were presented through workshop, small group discussion, and interactive lectures. There were 215.4 h for rural exposure through practice under supervision in inpatient wards, outpatient clinic, mobile outpatient clinic, home visits, and community activities. The mean proportion of CBL was 2.8% (range 1.1–4.2). The contact time was different among geographic locations of MEC (3.2% in the North, 2.8% in the Central, 2.8% in the Northeast, and 2.4% in the South respectively, P < 0.001), but not by the size of and experience in MEC (P = 0.352 and 0.617, respectively). Extracurricular activities in the community were arranged such as volunteering (big cleaning day, medical service, and participation in community and social activities), education (leadership in exercise for health, clean and healthy food, and traffic accident prevention), and lifestyles (meditation and local herbal medicine). Rural exposure in all MECs was as high as 69.8% (range 53.7–83.8) of total CBL. Univariate analysis showed that the proportion of contact time of CBL in retention group is higher than in the resignation group (305.9 h (2.97%) versus 312.5 h (2.90%), respectively, P = 0.046) [Figure 3]. Multiple logistic regression showed that CBL, geographic location of workplace, and graduate entry were significantly associated with retention [Table 1].{Figure 3}{Table 1}


Rural background recruitment and graduate entry are also influencing factors to promote retention in rural areas than normal track because most of them return to work in their hometown or nearby after graduation.[11] Many barriers of recruitment and rural retention of healthcare staff are reported such as poor working conditions, professional isolation, lack of services in the general living environment, and higher mobility of health professionals associated with globalization.[12],[13],[14] More than half of doctors in this cohort resigned after 3-year commitment. It implies that a policy regulation has direct impact to improve retention. A previous survey revealed that retention duration for generalists in rural health professional shortage areas (HPSAs) was identical to or slightly shorter than for those in rural non-HPSAs.[15] This might be related to both regulation and distribution management. Shortage areas are first served to balance supply and resignation like in Thailand. Regarding CBL, there are reports showing competency of CBL is not different from the standard curriculum and enhances retention.[16],[17],[18],[19],[20],[21] Practical and political aspects of CBL have an impact on retention depending on context, learners' experiences, tutors, and peer setting.[22] The difficulty of the CBL arrangements were students attending a practice without feeling of community bonding, no organized patients, and teachers complaining of being too busy or not having sufficient time to give a classroom teaching during a busy consulting session. Changing the attitude toward rural exposure to promote community attachment in mind and appropriate approach by a role model and enough community encounter together with classroom teaching for accurate concept will empower students a sense of belonging in community and retaining in their rural hometowns longer.

A limitation of this cohort study is that learning experience in CBL was assumed to be standard and that no major changes occurred in MECs during the time frame studied. Analysis of contact time of CBL is performed for clinical year rotation because CPIRD is responsible only for last 3-clinical-year students. However, there is low proportion of early rural exposure during preclinical years in Thai medical curriculum, so minimal bias is expected. According to the results of this study, early rural exposure in preclinical years can be arranged in order to increase the total contact time of CBL. We would like to suggest that rural medicine program would be considered not only for learning experience but also contact time. CBL consists of a wide variety of instructional methods and programs of community-oriented medical education that integrates meaningful community engagement with instruction and reflection to enrich the learning experience with a greater emphasis on reciprocal learning and reflection. Not only meaningful learning experience but also long enough contact time is important to encourage student sense of community belonging in order to work in rural as long as possible supported by this study.


Adequate CBL enhances retention. However, preparedness should be basically arranged with meaningful experiences by rural exposure together with classroom teaching concept integrating service to the community. Graduate entry and geographic locations of workplace have also an impact on the decision-making of retention.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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