ABSTRACT
Objective
To investigate the trends in the perceived social isolation and improved wellbeing of Australian medical students over a 6‐year period (2017–2022) during their rural clinical school (RCS) placements.
Methods
Data were analysed using descriptive statistics and multinomial logistic regressions to identify the trends and factors contributing to perceived social isolation and improved wellbeing during RCS placements.
Design
This is a retrospective, cross‐sectional study of the 2017–2022 FRAME (Federation of Rural Australian Medical Educators) dataset.
Participants
Data were collected from 2915 Australian medical students who completed RCS placements.
Setting
Respondents were located at RCS placements across 19 Australian universities.
Main Outcome Measures
The main outcomes were self‐reported social isolation and improvement in wellbeing.
Results
Over 30% of respondents reported experiencing social isolation. Factors contributing to social isolation were preference to practice in a capital city and lack of financial or overall support from the RCS, while lack of academic isolation was protective. More than 80% of respondents perceived the RCS placement had a positive impact on their wellbeing. Positive influences on wellbeing were associated with active role‐modelling of self‐care, support services and mentorship by a rural‐based clinician. The COVID‐19 years did not significantly impact perceived social isolation or improved wellbeing.
Conclusions
Most medical students on RCS placements reported positive impacts on their wellbeing, while over 30% experienced social isolation. Targeted support strategies that reduce social isolation and enhance student wellbeing on rural placements may help improve rural workforce retention and address healthcare shortages.
Keywords: medical education, medical school, mental health, rural placement, social connectedness
Summary
What is already known on this subject
Over half of medical students indicated that their rural clinical school (RCS) placements had a positive impact on their wellbeing. Approximately one‐third of medical students reported feeling socially isolated during their RCS placements.
Financial concerns and the COVID‐19 pandemic were associated with an increased likelihood of wellbeing decline, whereas feeling connected and supported by the university were protective factors.
Factors associated with lower social isolation included the RCS being the first choice for clinical training, feeling overall well supported and positive experiences with supervision. Gender, rural background and perceived financial support did not have a statistically significant association with social isolation.
What this paper adds
An exploration of trends in wellbeing and social isolation across multiple cohorts of medical students on RCS placements. Over 83% of medical students perceived that the RCS placement had a positive impact on their wellbeing and over 30% reported experiencing social isolation.
Academic isolation, lack of academic, financial or overall support from the RCS, and a preference to practice in a capital city contributed to social isolation and lack of improved wellbeing.
Whereas active role‐modelling of self‐care, support services and mentorship by a rural‐based clinician was associated with reduced social isolation and improved wellbeing. COVID‐19 did not have a significant impact on social isolation or wellbeing.
1. Introduction
The demanding nature of medical education, including its academic, emotional and social pressures, increases medical students' risk of poor wellbeing and social isolation [1]. The World Health Organisation (2021) defines wellbeing as ‘quality of life and the ability…to contribute to the world with a sense of meaning and purpose’ and is ‘determined by social, economic and environmental conditions’ [2]. Medical associations and regulatory bodies remain concerned about medical students' wellbeing due to training stressors such as exposure to illness, suffering and death [3], and a high academic workload [4].
Medical students in both metropolitan and rural settings experience a greater burden of mental health problems than their non‐medical counterparts, making them more likely to experience lower levels of mental wellbeing [5]. Despite this, previous studies of individual medical cohorts and during the COVID‐19 pandemic found that most medical students felt that their rural placements positively impacted their wellbeing [6, 7]. These contrasting findings underscore the complexity of medical students' wellbeing dynamics during rural placements, suggesting a nuanced relationship between their mental health challenges and the potential benefits derived from rural clinical experiences.
Social isolation refers to ‘having objectively few social relationships or roles and infrequent social contact’ [8]. Approximately one‐third of medical students reported experiencing social isolation during their rural placements [7, 9], which is associated with decreased interest in a future rural career [9]. Studies have shown that factors contributing to social isolation among medical students include enforced segregation from non‐medical peers [10], geographical isolation from existing social support [11], and lower levels of self‐efficacy [9]. Effective interventions addressing social isolation could promote interest in future rural career choices and help alleviate the shortage of rural and remote doctors across Australia [12].
According to the current literature, factors that are positively associated with wellbeing include younger age, academic support, access to support services, communication with staff, and having the rural placement as their first preference [13]. Whereas factors associated with social isolation and poor wellbeing were reported to include academic demands and competition and being female [14]. While the COVID‐19 pandemic was found to negatively impact medical students' wellbeing and increase perceived social isolation broadly [15], it is unclear whether rural placements specifically intensified or buffered these negative effects.
While prior studies have examined wellbeing and social isolation in individual cohorts [4, 16, 17], few have explored patterns over multiple years to assess whether these experiences vary across different cohorts, particularly in rural and remote settings. This study aims to assess the trends in medical students' self‐reported social isolation and improvement in wellbeing during rural clinical school (RCS) placements across multiple cohorts over 6 years (2017–2022), and to identify the factors contributing to these trends. Findings from this study will guide medical schools and policymakers to develop targeted, evidence‐based strategies that enhance medical students' wellbeing and social connectedness during rural placements.
2. Materials and Methods
2.1. Setting
RCS placements are training programs delivered by Australian medical schools in a rural area defined by the Australian Statistical Geography Standard—Remoteness Areas (ASGS‐RA) 2–5 [18, 19], which aim to improve medical students' intentions to practise rurally [20]. RCS placements are funded by the Australian Government's Rural Clinical Training and Support (RCTS) program, which was established by the Department of Health in 2000 [21]. As of 2022, there is a national network of 19 RCSs under 22 universities across all 6 states in Australia [22].
The Federation of Rural Australian Medical Educators (FRAME) is a peak body representing 19 Australian universities with RCSs funded by the Australian Government Rural Health Multidisciplinary Training (RHMT) Program [23]. FRAME conducts annual rural placement evaluations by distributing cross‐sectional surveys to medical students who have completed RCS placements [23]. The 2017–2022 surveys are available on the FRAME website (https://ausframe.org/publications‐and‐resources/) [24].
2.2. Participants
2915 medical students met the inclusion criteria of completing their RCS placement between 2017 and 2022 and responding to the two questions identified as the dependent variables in the FRAME surveys.
2.3. Ethical Consideration
Participants provided written informed consent for the survey. Ethics approval was obtained from the University of Notre Dame Australia (UNDA) (2020‐196S) and from each of the participating universities. The custodian of the FRAME data also gave approval for the use of the data set for the purpose of this study. The study was conducted in accordance with the tenets of the Declaration of Helsinki.
2.4. Survey Design
The FRAME survey included 28 broader questions, of which 12 were chosen as both relevant to the aims of this study and with consistent data across the 6 years. The chosen survey items comprised 9 sociodemographic items including the calendar year, gender, rural background, history of residence outside of a major Australian city, rural health club membership status, year at the RCS, placement type, type of location in Australia with the longest residence, and location in Australia they were most likely to practise after training.
2.5. Dependent Variables
Social isolation was measured by students' responses to the statement ‘I felt socially isolated during my RCS placement’. Improvement in wellbeing was evaluated by students' responses to the statement ‘Overall, my RCS placement impacted positively on my well‐being’. Responses were assessed on a five‐point Likert scale, dichotomised from 1 = ‘Strongly disagree’, 2 = ‘Disagree’, 3 = ‘Neutral’, 4 = ‘Agree’ to 5 = ‘Strongly agree’. The responses were recategorized into three levels (agree, neutral, and disagree) to address sparse cells at the extreme ends of the spectrum and ensure sufficient statistical power for the multinomial logistic regression. Student responses to wellbeing ‘Strongly agree’ and ‘Agree’ were merged into a single category ‘Agree’. Similarly, the responses ‘Strongly disagree’ and ‘Disagree’ were merged into a single category ‘Disagree’. The ‘Neutral’ responses were treated as a third response option.
2.6. Independent Variables
In addition to the sociodemographic variables, other independent variables included students' perceptions of academic, financial, and overall support, as well as academic isolation. The study investigated the effect of COVID‐19 through the variable ‘COVID‐year’, which was defined as a year in which medical students experienced lockdowns (2020 and 2021), or restricted access to hospitals or hospital teaching (2020–2022). Additionally, the study considered factors related to the services and programs provided by the medical school such as a mindfulness course, structured support activities and rural‐specific interventions.
2.7. Data Analyses
Statistical analyses were performed using SPSS Version 29 (SPSS IBM, New York, USA). Data were combined in Microsoft Excel (Microsoft Corporation, USA), and responses with missing data from any question were discarded entirely to create one analytical dataset. Data were presented using descriptive statistics showing frequencies, proportions, and graphs. Chi‐square analysis was conducted to examine differences between variables.
Multinomial logistic regression was conducted to allow for the simultaneous comparison of ‘Neutral’ and ‘Disagree’ or ‘Agree’ states against a baseline reference. This approach was preferred over ordinal regression as it does not assume proportional odds across the levels of the dependent variables, providing a more granular understanding of how specific factors influence students' perceptions. Odds ratios and their 95% confidence intervals were determined, with the level of statistical significance set at 1% to ensure the robustness of our findings and minimise the risk of Type I errors given the large sample size (n = 2915). Categorical variables included those with ≥ 2 categories in no significant order.
The coding of variables was carried out to consider those who experienced social isolation or did not experience a positive impact on their wellbeing. For ‘social isolation’, the ‘disagree’ responses were set as a baseline (0 in coding), and these were compared with ‘agree’ (coded as 2) and ‘neutral’ (coded as 1) responses. Whereas for ‘improved wellbeing’, ‘agree’ was the baseline, compared with ‘disagree’ and ‘neutral’ responses.
3. Results
3.1. Characteristics of Respondents
Table 1 summarises the socio‐demographic characteristics of the 2915 respondents. The lowest student participation in the survey was in 2020 (n = 388, 13.3%) and the highest in 2017 (n = 611, 21.0%). More than half of respondents were female (57.4%), in their first year at the RCS (65.2%), had a non‐rural background (55.3%), and were not members of their university's rural health club during preclinical years (53.1%). Most respondents had a Commonwealth Supported (HECS) Place (65.2%) or Bonded Place (30.1%), with very few Australian Fee‐paying Places (3.2%) or International Fee‐paying Places (2.4%).
TABLE 1.
Socio‐demographic characteristics of the students in the FRAME survey (2017–2022) (n = 2915).
| Variables | Frequency (n, %) | |
|---|---|---|
| Year | 2017 | 611 (21.0) |
| 2018 | 540 (18.5) | |
| 2019 | 528 (18.1) | |
| 2020 | 388 (13.3) | |
| 2021 | 432 (14.8) | |
| 2022 | 416 (14.3) | |
| Age groups | 19–22 years | 442 (15.2) |
| 23 years | 545 (18.7) | |
| 24 years | 545 (18.7) | |
| 25–26 years | 663 (22.7) | |
| ≥ 27 years | 720 (24.7) | |
| Gender | Male | 1229 (42.2) |
| Female | 1674 (57.4) | |
| Other | 12 (0.4) | |
| Placement type | Commonwealth Supported (HECS) Place | 1900 (65.2) |
| Medical Rural Bonded Scholarships (MRBS) | 58 (2.0) | |
| Bonded Medical Place (BMP) | 763 (26.2) | |
| Commonwealth Bonded Place | 18 (0.6) | |
| State Bonded Place | 10 (0.3) | |
| International Fee‐paying Place | 70 (2.4) | |
| Australian Fee‐paying Place | 92 (3.2) | |
| Other | 4 (0.1) | |
| Rural background | No | 1611 (55.3) |
| Yes | 1304 (44.7) | |
| Type of location in Australia lived longest | Capital city | 1370 (47.0) |
| Major urban centre | 352 (12.1) | |
| Regional city/large town | 447 (15.3) | |
| Smaller town | 330 (11.3) | |
| Small rural community | 362 (12.4) | |
| Remote centre/area | 54 (1.9) | |
| Lived outside major city in Australia for 10 years cumulatively or 5 years consecutively | No | 1516 (52.0) |
| Yes | 1399 (48.0) | |
| Year at RCS | First year | 1902 (65.2) |
| Second consecutive year | 626 (21.5) | |
| Other | 387 (13.3) | |
| Upon entry to RCS, geographical location in Australia mostly likely to practise after training | Capital city | 1323 (45.4) |
| Major urban centre | 846 (29.0) | |
| Regional city/large town | 420 (14.4) | |
| Smaller town | 147 (5.0) | |
| Small rural community | 103 (3.5) | |
| Remote centre/area | 76 (2.6) | |
| Member of university's student rural health club during preclinical years | No | 1548 (53.1) |
| Yes | 1367 (46.9) | |
3.2. Change in Perceived Social Isolation and Improved Well‐Being of Medical Students
Figures 1 and 2 present the percentage of respondents who disagreed, felt neutral, or agreed with the statements ‘I felt socially isolated during my RCS placement’ and ‘Overall, my RCS placement impacted positively on my well‐being’ respectively between 2017 and 2022.
FIGURE 1.
Social Isolation (derived from ‘I felt socially isolated during my RCS placement’).
FIGURE 2.
Improved well‐being (derived from ‘Overall, my RCS placement impacted positively on my wellbeing’).
3.3. Change in Perception of Social Isolation Among Medical Students
A yearly average of 30.3% of respondents reported feeling socially isolated during their RCS placement, with an increase of almost 2% from 2017 to 2022, which approached but did not reach statistical significance (p = 0.010). On average across the years, 13.0% of respondents reported feeling neutral about their social isolation, and this proportion decreased by around 4% from 2017 to 2022.
3.4. Change in Perception of Improved Wellbeing Among Medical Students
Across all years, a yearly average of 83.2% of respondents agreed that their RCS placement positively impacted their wellbeing. The proportion of respondents who reported a positive impact on their wellbeing decreased by 14.3% from 2017 to 2022; however, this trend was not statistically significant (p = 0.059). A yearly average of 9.9% of respondents felt neutral about their placement's positive impact on their wellbeing, and this proportion increased by 1.5% from 2017 to 2022.
3.5. Univariate Analysis of Student Perceptions of Social Isolation During Their RCS Placement
Table 2 shows the percentage distribution of student responses to the statement ‘I felt socially isolated during my RCS placement’ by the independent variables.
TABLE 2.
Students responses on feeling of social isolation during RCS placement (derived from the statement ‘I felt socially isolated during my RCS placement’) (n = 2915).
| Variables | Outcome (n, %) | p | r (p) | |||
|---|---|---|---|---|---|---|
| Disagree | Neutral | Agree | ||||
| Year | 2017 | 336 (55.0) | 100 (16.4) | 175 (28.6) | 0.010 | 0.016 (p = 0.384) |
| 2018 | 301 (55.7) | 64 (11.9) | 175 (32.4) | |||
| 2019 | 264 (50.0) | 75 (14.2) | 189 (35.8) | |||
| 2020 | 196 (50.5) | 40 (10.3) | 152 (39.2) | |||
| 2021 | 225 (52.1) | 56 (13.0) | 151 (35.0) | |||
| 2022 | 238 (57.2) | 51 (12.3) | 127 (30.5) | |||
| Age groups | 19–22 years | 208 (13.3) | 65 (16.8) | 169 (17.4) | 0.002 | −0.005 (p = 0.438) |
| 23 years | 301 (19.3) | 78 (20.2) | 166 (17.1) | |||
| 24 years | 323 (20.7) | 53 (13.7) | 169 (17.4) | |||
| 25–26 years | 370 (23.7) | 82 (21.2) | 211 (21.8) | |||
| ≥ 27 years | 358 (22.9) | 108 (28.0) | 254 (26.2) | |||
| Gender | Male | 660 (42.3) | 174 (45.1) | 395 (40.8) | 0.319 | 0.014 (p = 0.806) |
| Female | 896 (57.4) | 209 (54.1) | 569 (58.7) | |||
| Other | 4 (0.3) | 3 (0.8) | 5 (0.5) | |||
| Placement type | Commonwealth Supported (HECS) Place | 1027 (54.1) | 243 (12.8) | 630 (33.2) | 0.149 | −0.007 (p = 0.687) |
| Medical Rural Bonded Scholarships (MRBS) | 33 (56.9) | 8 (13.8) | 17 (29.3) | |||
| Bonded Medical Place (BMP) | 390 (51.1) | 107 (14.0) | 266 (34.9) | |||
| Commonwealth Bonded Place | 11 (61.1) | 2 (11.1) | 5 (27.8) | |||
| State Bonded Place | 5 (50.0) | 2 (20.0) | 3 (30.0) | |||
| International Fee‐paying Place | 32 (45.7) | 12 (17.1) | 26 (37.1) | |||
| Australian Fee‐paying Place | 62 (67.4) | 10 (10.9) | 20 (21.7) | |||
| Other | 0 (0.0) | 2 (50.0) | 2 (50.0) | |||
| Rural background | No | 880 (56.4) | 203 (52.6) | 528 (54.5) | 0.336 | 0.019 (p = 0.297) |
| Yes | 680 (43.6) | 183 (47.4) | 441 (45.5) | |||
| Aus location lived longest | Capital city | 748 (54.6) | 178 (13.0) | 444 (32.4) | 0.671 | 0.016 (p = 0.389) |
| Major urban centre | 188 (53.4) | 41 (11.6) | 123 (34.9) | |||
| Regional city/large town | 232 (51.9) | 65 (14.5) | 150 (33.6) | |||
| Smaller town | 170 (51.5) | 54 (16.4) | 106 (32.1) | |||
| Small rural community | 191 (52.8) | 44 (12.2) | 127 (35.1) | |||
| Remote centre/area | 31 (57.4) | 4 (7.4) | 19 (35.2) | |||
| Lived outside major Aus city 10 years or 5 years consecutively | No | 841 (53.9) | 186 (48.2) | 489 (50.5) | 0.065 | 0.034 (p = 0.068) |
| Yes | 719 (46.1) | 200 (51.8) | 480 (49.5) | |||
| Year RCS | First year | 1008 (64.6) | 250 (64.8) | 644 (66.5) | 0.559 | −0.005 (p = 0.778) |
| Second consecutive year | 352 (22.6) | 82 (21.2) | 192 (19.8) | |||
| Other | 200 (12.8) | 54 (14.0) | 133 (13.7) | |||
| RCS entry Aus location most likely practise | Capital city | 662 (50.0) | 168 (12.7) | 493 (37.3) | 0.002 | −0.066 (p < 0.001) |
| Major urban centre | 481 (56.9) | 104 (12.3) | 261 (30.9) | |||
| Regional city/large town | 229 (54.5) | 65 (15.5) | 126 (30.0) | |||
| Smaller town | 86 (58.5) | 19 (12.9) | 42 (28.6) | |||
| Small rural community | 56 (54.4) | 14 (13.6) | 33 (32.0) | |||
| Rural or remote community | 46 (60.5) | 16 (21.1) | 14 (18.4) | |||
| Academically supported by RCS | Disagree | 67 (28.8) | 25 (10.7) | 141 (60.5) | < 0.001 | −0.188 (p < 0.001) |
| Neutral | 48 (34.5) | 30 (21.6) | 61 (43.9) | |||
| Agree | 1445 (56.8) | 331 (13.0) | 767 (30.2) | |||
| Financially supported by RCS | Disagree | 187 (37.7) | 64 (12.9) | 245 (49.4) | < 0.001 | −0.155 (p < 0.001) |
| Neutral | 292 (53.2) | 79 (14.4) | 178 (32.4) | |||
| Agree | 1081 (57.8) | 243 (13.0) | 546 (29.2) | |||
| Academically isolated | Disagree | 1173 (73.2) | 175 (10.9) | 255 (15.9) | < 0.001 | 0.460 (p < 0.001) |
| Neutral | 150 (35.5) | 110 (28.5) | 163 (38.5) | |||
| Agree | 237 (26.7) | 101 (11.4) | 551 (62.0) | |||
| RCS informed health counselling services | Disagree | 160 (41.2) | 53 (13.7) | 175 (45.1) | < 0.001 | −0.118 (p < 0.001) |
| Neutral | 230 (47.0) | 91 (18.6) | 168 (34.4) | |||
| Agree | 1170 (57.4) | 242 (11.9) | 626 (30.7) | |||
| Well supported by RCS | Disagree | 44 (26.5) | 16 (9.6) | 106 (63.9) | < 0.001 | −0.219 (p < 0.001) |
| Neutral | 49 (24.1) | 40 (19.7) | 114 (56.2) | |||
| Agree | 1467 (57.6) | 330 (13.0) | 749 (29.4) | |||
| Rural‐based clinician as mentor | Disagree | 274 (49.3) | 71 (12.8) | 211 (37.9) | 0.008 | −0.059 (p < 0.001) |
| Neutral | 255 (49.9) | 80 (15.7) | 176 (34.4) | |||
| Agree | 1031 (55.8) | 235 (12.7) | 582 (31.5) | |||
| Mindfulness course | Disagree | 570 (49.2) | 156 (13.5) | 432 (37.3) | < 0.001 | −0.067 (p < 0.001) |
| Neutral | 300 (55.6) | 82 (15.2) | 158 (29.3) | |||
| Agree | 690 (56.7) | 148 (12.2) | 379 (31.1) | |||
| Formal wellbeing/resilience training | Disagree | 532 (47.5) | 152 (13.6) | 437 (39.0) | < 0.001 | −0.110 (p < 0.001) |
| Neutral | 376 (53.2) | 109 (15.4) | 222 (31.4) | |||
| Agree | 652 (60.0) | 125 (11.5) | 310 (28.5) | |||
| Structured support activities | Disagree | 366 (44.1) | 102 (12.3) | 362 (43.6) | < 0.001 | −0.149 (p < 0.001) |
| Neutral | 380 (51.6) | 122 (16.6) | 235 (31.9) | |||
| Agree | 814 (60.4) | 162 (12.0) | 372 (27.6) | |||
| Informal/optional wellbeing activities | Disagree | 249 (41.4) | 68 (11.3) | 284 (47.3) | < 0.001 | −0.158 (p < 0.001) |
| Neutral | 382 (48.5) | 112 (19.2) | 188 (32.2) | |||
| Agree | 1028 (59.4) | 206 (11.9) | 497 (28.7) | |||
| Active role modelling of self‐care | Disagree | 324 (44.0) | 92 (12.5) | 320 (43.5) | < 0.001 | −0.152 (p < 0.001) |
| Neutral | 395 (49.3) | 132 (16.5) | 274 (34.2) | |||
| Agree | 841 (61.0) | 162 (11.8) | 375 (27.2) | |||
| Formal tuition on rural career options | Disagree | 497 (50.5) | 122 (12.4) | 366 (37.2) | < 0.001 | −0.065 (p < 0.001) |
| Neutral | 302 (50.0) | 108 (17.9) | 194 (32.1) | |||
| Agree | 761 (57.4) | 156 (11.8) | 409 (30.8) | |||
| Informal information on rural career options | Disagree | 129 (49.8) | 27 (10.4) | 103 (39.8) | < 0.001 | −0.062 (p < 0.001) |
| Neutral | 131 (41.6) | 68 (21.6) | 116 (36.8) | |||
| Agree | 1300 (55.5) | 291 (12.4) | 750 (32.0) | |||
| Work with rurally‐training junior doctors | Disagree | 113 (41.1) | 37 (13.5) | 125 (45.5) | < 0.001 | −0.101 (p < 0.001) |
| Neutral | 86 (43.7) | 36 (18.3) | 75 (38.1) | |||
| Agree | 1361 (55.7) | 313 (12.8) | 769 (31.5) | |||
| Rural health club preclinical years | No | 811 (52.4) | 198 (12.8) | 539 (34.8) | 0.155 | −0.032 (p = 0.091) |
| Yes | 749 (54.8) | 188 (13.8) | 430 (31.5) | |||
| COVID‐19 year | No | 901 (53.7) | 239 (14.2) | 539 (32.1) | 0.107 | 0.016 (p = 0.369) |
| Yes | 659 (53.5) | 147 (13.2) | 430 (33.2) | |||
A larger proportion of respondents aged 27 years or older reported social isolation compared with the younger age groups (26.2% vs. < 22%, p = 0.002). Compared to other locations, a greater proportion of respondents who nominated a ‘capital city’ as the location they would most likely practise after training upon entering the RCS also reported feeling socially isolated (37.3% vs. < 32% for other locations, p = 0.002). The percentage of respondents feeling socially and academically isolated was four times larger than those who felt socially isolated but not academically isolated (62.0% vs. 15.9%, p < 0.01). The proportion of respondents who did not feel academically, financially or overall supported by the RCS and also felt socially isolated was higher than those who did feel supported but were socially isolated (p < 0.01).
Higher levels of social isolation were reported by respondents who also agreed that their RCS did not provide support services such as a mindfulness course, wellbeing or resilience training, and active role modelling of self‐care (p < 0.01). Greater percentages of social isolation were reported by respondents who also agreed that they did not have a rural‐based clinician as a mentor (p = 0.008), did not work with rurally‐training junior doctors (p < 0.01) and were not informed of health and counselling services by their RCS (p < 0.01). No significant associations were found for gender, rural background or COVID‐19 years (p > 0.01).
3.6. Univariate Analysis of Student Perceptions of Improved Wellbeing During Their RCS Placement
Table 3 presents the percentage distribution of student responses to the statement ‘Overall, my RCS placement impacted positively on my well‐being’ by the independent variables.
TABLE 3.
Students responses on how the rural clinical school placement years impacted their wellbeing (derived from the statement ‘RCS placement impacted positively on my wellbeing’) (n = 2915).
| Variables | Outcome (n, %) | p | r (p) | |||
|---|---|---|---|---|---|---|
| Disagree | Neutral | Agree | ||||
| Year | 2017 | 38 (6.2) | 53 (8.7) | 520 (95.1) | 0.059 | −0.22 (0.226) |
| 2018 | 44 (8.1) | 58 (10.7) | 438 (81.1) | |||
| 2019 | 59 (11.2) | 63 (11.9) | 406 (76.9) | |||
| 2020 | 32 (8.2) | 41 (10.6) | 315 (81.2) | |||
| 2021 | 37 (8.6) | 32 (7.4) | 363 (84.0) | |||
| 2022 | 38 (9.1) | 42 (10.1) | 336 (80.8) | |||
| Age groups | 19–22 years | 47 (19.0) | 57 (19.7) | 338 (14.2) | 0.004 | −0.006 (p = 0.740) |
| 23 years | 38 (15.3) | 50 (17.3) | 457 (19.2) | |||
| 24 years | 36 (14.5) | 43 (14.9) | 466 (19.6) | |||
| 25–26 years | 49 (19.8) | 63 (21.8) | 551 (23.2) | |||
| ≥ 27 years | 78 (31.5) | 76 (26.3) | 566 (23.8) | |||
| Gender | Male | 111 (44.8) | 139 (48.1) | 979 (41.2) | 0.042 | 0.030 (p = 0.112) |
| Female | 134 (54.0) | 149 (51.6) | 1391 (58.5) | |||
| Other | 3 (1.2) | 1 (0.3) | 8 (0.3) | |||
| Placement type | Commonwealth Supported (HECS) Place | 165 (8.7) | 191 (10.1) | 1544 (81.3) | 0.051 | 0.014 (p = 0.464) |
| Medical Rural Bonded Scholarships (MRBS) | 1 (1.7) | 2 (3.4) | 55 (94.8) | |||
| Bonded Medical Place (BMP) | 71 (9.3) | 74 (9.7) | 618 (81.0) | |||
| Commonwealth Bonded Place | 0 (0.0) | 2 (11.1) | 16 (88.9) | |||
| State Bonded Place | 0 (0.0) | 1 (10.0) | 9 (90.0) | |||
| International Fee‐paying Place | 6 (8.6) | 14 (20.0) | 50 (71.4) | |||
| Australian Fee‐paying Place | 5 (5.4) | 4 (4.3) | 83 (90.2) | |||
| Other | 0 (0.0) | 1 (25.0) | 3 (75.0) | |||
| Rural background | No | 130 (52.4) | 164 (56.7) | 1317 (55.4) | 0.581 | −0.011 (p = 0.555) |
| Yes | 118 (47.6) | 125 (43.3) | 1061 (44.6) | |||
| Aus location lived longest | Capital city | 116 (8.5) | 126 (9.2) | 1128 (82.3) | 0.297 | 0.006 (p = 0.738) |
| Major urban centre | 27 (7.7) | 47 (13.4) | 278 (79.0) | |||
| Regional city/large town | 47 (10.5) | 46 (10.6) | 354 (81.2) | |||
| Smaller town | 27 (8.2) | 35 (9.1) | 268 (83.7) | |||
| Small rural community | 26 (7.2) | 33 (9.1) | 303 (83.7) | |||
| Remote centre/area | 5 (9.3) | 2 (3.7) | 47 (87.0) | |||
| Lived outside major Aus city 10 years or 5 years consecutively | No | 119 (48.0) | 159 (55.0) | 1238 (52.1) | 0.261 | −0.013 (p = 0.499) |
| Yes | 129 (52.0) | 130 (45.0) | 1140 (47.9) | |||
| Year RCS | First year | 167 (8.8) | 178 (9.4) | 1557 (81.9) | 0.120 | −0.017 (p = 0.386) |
| Second consecutive year | 41 (6.5) | 66 (10.5) | 519 (82.9) | |||
| Other | 40 (10.3) | 45 (11.6) | 302 (78.0) | |||
| RCS entry Aus location most likely practise | Capital city | 138 (10.4) | 154 (11.6) | 1031 (77.9) | 0.005 | 0.068 (p < 0.001) |
| Major urban centre | 57 (6.7) | 78 (9.2) | 711 (84.0) | |||
| Regional city/large town | 29 (6.9) | 33 (9.2) | 358 (84.0) | |||
| Smaller town | 13 (6.9) | 10 (7.9) | 124 (85.2) | |||
| Small rural community | 8 (8.8) | 9 (6.8) | 86 (84.4) | |||
| Rural or remote community | 3 (7.8) | 5 (8.7) | 68 (83.5) | |||
| Academically supported by RCS | Disagree | 112 (48.1) | 43 (18.5) | 78 (33.5) | < 0.001 | 0.461 (p < 0.001) |
| Neutral | 29 (20.9) | 35 (25.2) | 75 (54.0) | |||
| Agree | 107 (4.2) | 211 (8.3) | 2225 (87.5) | |||
| Financially supported by RCS | Disagree | 110 (22.2) | 69 (13.9) | 317 (63.9) | < 0.001 | 0.247 (p < 0.001) |
| Neutral | 50 (9.1) | 72 (13.1) | 427 (77.8) | |||
| Agree | 88 (4.7) | 148 (7.9) | 1634 (87.4) | |||
| Academically isolated | Disagree | 43 (2.7) | 75 (4.7) | 1485 (92.6) | < 0.001 | −0.344 (p < 0.001) |
| Neutral | 21 (5.0) | 71 (16.8) | 331 (78.3) | |||
| Agree | 184 (20.7) | 143 (16.1) | 562 (63.2) | |||
| RCS informed health counselling services | Disagree | 79 (20.4) | 53 (13.7) | 256 (10.8) | < 0.001 | 0.203 (p < 0.001) |
| Neutral | 47 (9.6) | 81 (16.6) | 361 (73.8) | |||
| Agree | 122 (6.0) | 155 (7.6) | 1761 (86.4) | |||
| Well supported by RCS | Disagree | 105 (63.3) | 28 (16.9) | 33 (19.9) | < 0.001 | 0.562 (p < 0.001) |
| Neutral | 54 (26.6) | 70 (34.5) | 79 (38.9) | |||
| Agree | 89 (3.5) | 191 (7.5) | 2266 (89.0) | |||
| Rural‐based clinician as mentor | Disagree | 84 (15.1) | 66 (11.9) | 406 (73.0) | < 0.001 | 0.129 (p < 0.001) |
| Neutral | 42 (8.2) | 65 (12.7) | 404 (79.1) | |||
| Agree | 122 (6.6) | 158 (8.5) | 1568 (84.8) | |||
| Mindfulness course | Disagree | 115 (9.9) | 136 (11.7) | 907 (78.3) | < 0.001 | 0.072 (p < 0.001) |
| Neutral | 49 (9.1) | 54 (10.0) | 437 (80.9) | |||
| Agree | 84 (6.9) | 99 (8.1) | 1034 (85.0) | |||
| Formal wellbeing/resilience training | Disagree | 137 (12.2) | 146 (13.0) | 838 (74.8) | < 0.001 | 0.140 (p < 0.001) |
| Neutral | 50 (7.1) | 70 (9.9) | 587 (83.0) | |||
| Agree | 61 (5.6) | 73 (6.7) | 953 (87.7) | |||
| Structured support activities | Disagree | 129 (15.5) | 113 (13.6) | 588 (70.8) | < 0.001 | 0.198 (p < 0.001) |
| Neutral | 56 (7.6) | 88 (11.9) | 593 (80.5) | |||
| Agree | 63 (4.7) | 88 (6.5) | 1197 (88.8) | |||
| Informal/optional wellbeing activities | Disagree | 97 (16.1) | 97 (16.1) | 407 (67.7) | < 0.001 | 0.198 (p < 0.001) |
| Neutral | 51 (8.7) | 79 (13.6) | 453 (77.7) | |||
| Agree | 100 (5.8) | 113 (6.5) | 1518 (87.7) | |||
| Active role modelling of self‐care | Disagree | 136 (18.5) | 112 (15.2) | 488 (66.3) | < 0.001 | 0.270 (p < 0.001) |
| Neutral | 71 (8.9) | 95 (11.9) | 635 (79.3) | |||
| Agree | 41 (3.0) | 82 (6.0) | 1255 (91.1) | |||
| Formal tuition on rural career options | Disagree | 100 (10.2) | 115 (11.7) | 770 (78.2) | < 0.001 | 0.065 (p < 0.001) |
| Neutral | 47 (7.8) | 71 (11.8) | 486 (80.5) | |||
| Agree | 101 (7.6) | 103 (7.8) | 1122 (84.6) | |||
| Informal information on rural career options | Disagree | 32 (12.4) | 36 (13.9) | 191 (73.7) | < 0.001 | 0.069 (p < 0.001) |
| Neutral | 29 (9.2) | 42 (13.3) | 244 (77.5) | |||
| Agree | 187 (8.0) | 211 (9.0) | 1943 (83.0) | |||
| Work with rurally‐training junior doctors | Disagree | 32 (11.6) | 39 (14.2) | 204 (74.2) | < 0.001 | 0.072 (p < 0.001) |
| Neutral | 22 (11.2) | 29 (14.7) | 146 (74.1) | |||
| Agree | 194 (7.9) | 221 (9.0) | 2028 (83.0) | |||
| Rural health club preclinical years | No | 147 (9.5) | 174 (11.2) | 1227 (79.3) | 0.003 | 0.058 (p = 0.002) |
| Yes | 101 (7.4) | 115 (8.4) | 1151 (84.2) | |||
| COVID‐19 year | No | 141 (8.4) | 174 (10.4) | 1364 (81.2) | 0.632 | 0.004 (p = 0.827) |
| Yes | 107 (8.7) | 115 (9.3) | 1014 (82.0) | |||
An increase in the percentage of respondents who agreed that their RCS placement positively impacted their wellbeing was associated with an increase in age groups from 19 to 22 years (14.2%) to 27 years or older (23.8%) (p = 0.004). The proportion of respondents who nominated a ‘capital city’ as the location in which they were most likely to practise after training upon entry to the RCS and agreed with a positive impact on their wellbeing was lower than those who similarly agreed with the statement but chose other locations (77.9% vs. > 83% for other locations, p = 0.005). Over 87% of respondents who felt academically, financially or overall supported by their RCS also agreed that their placement positively impacted their wellbeing (p < 0.01). The proportion of respondents who agreed with this statement and reported not feeling academically isolated was nearly one and a half times higher than those experienced a positive impact on wellbeing but also felt academically isolated (92.6% vs. 63.2%, p < 0.01).
Over 80% of respondents who worked with rurally‐training junior doctors or had a rural‐based clinician as a mentor also agreed that their placement had a positive impact on their wellbeing (p < 0.01). A similar trend was seen among respondents who agreed that their RCS provided services such as informal or optional wellbeing activities, structured support activities, and active role modelling of self‐care (p < 0.01). More respondents who were part of their university's rural health club agreed with a positive impact on their wellbeing compared with those who were not part of the club (84.2% vs. 79.3%, p = 0.003). No significant associations were found for gender, rural background or COVID‐19 years (p > 0.01).
3.7. Multivariable Analysis of Factors Associated With Social Isolation and Well‐Being of Rural Medical Students
Table 4 displays the results of the multinomial logistic regression with ‘social isolation’ as the outcome variable and ‘year’ as the controlled variable. The model was statistically significant (χ 2 = 1020.51, p < 0.001). Unless otherwise specified, all associations reported below were significant (p < 0.001, see Tables 4 and 5).
TABLE 4.
Multinomial logistic regression of factors associated with students' feeling of social isolation during their RCS placement. Reference category is ‘Disagree’.
| Variables | Agree with feeling socially isolated | Neutral about the feeling of social isolation | ||||
|---|---|---|---|---|---|---|
| B | p | OR (95% CI lower, upper) | B | p | OR (95% CI lower, upper) | |
| Male | −0.37 | 0.66 | 0.69 (0.13, 3.62) | −0.90 | 0.29 | 0.41 (0.08, 2.13) |
| Female | −0.32 | 0.70 | 0.73 (0.14, 3.79) | −0.98 | 0.25 | 0.38 (0.07, 1.96) |
| 19–22 years | −0.03 | 0.84 | 0.97 (0.71, 1.32) | 0.06 | 0.77 | 1.06 (0.72, 1.55) |
| 23 years | −0.04 | 0.78 | 0.96 (0.72, 1.28) | 0.02 | 0.91 | 1.02 (0.71, 1.46) |
| 24 years | −0.12 | 0.41 | 0.88 (0.66, 1.18) | −0.44 | 0.03 | 0.65 (0.44, 0.95) |
| 25–26 years | −0.15 | 0.27 | 0.86 (0.65, 1.13) | −0.19 | 0.27 | 0.83 (0.59, 1.16) |
| No rural background | 0.17 | 0.35 | 1.18 (0.83, 1.67) | −0.05 | 0.84 | 0.96 (0.62, 1.48) |
| Lived longest capital city | 0.07 | 0.84 | 1.08 (0.51, 2.27) | 1.02 | 0.08 | 2.77 (0.87, 8.78) |
| Lived longest major urban centre | 0.20 | 0.59 | 1.23 (0.58, 2.60) | 0.77 | 0.20 | 2.16 (0.67, 6.92) |
| Lived longest regional city/large town | 0.09 | 0.81 | 1.09 (0.53, 2.25) | 0.95 | 0.10 | 2.59 (0.84, 8.01) |
| Lived longest smaller town | 0.20 | 0.60 | 1.22 (0.58, 2.55) | 1.06 | 0.07 | 2.90 (0.93, 9.03) |
| Lived longest small rural community | 0.32 | 0.39 | 1.38 (0.66, 2.85) | 0.74 | 0.20 | 2.10 (0.67, 6.58) |
| Didn't live outside major Aus city 10 years or 5 years consecutively | −0.25 | 0.09 | 0.78 (0.58, 1.04) | −0.23 | 0.23 | 0.80 (0.55, 1.16) |
| First year at RCS | 0.28 | 0.06 | 1.33 (0.99, 1.78) | 0.13 | 0.50 | 1.13 (0.78, 1.64) |
| Second consecutive year at RCS | 0.16 | 0.35 | 1.17 (0.84, 1.64) | 0.03 | 0.88 | 1.03 (0.68, 1.56) |
| RCS entry most likely practise capital city | 1.19 | < 0.001 | 3.30 (1.64, 6.65) | −0.42 | 0.22 | 0.66 (0.34, 1.28) |
| RCS entry most likely practise major urban centre | 0.95 | 0.01 | 2.58 (1.27, 5.24) | −0.59 | 0.09 | 0.56 (0.28, 1.09) |
| RCS entry most likely practise regional city/large town | 0.79 | 0.03 | 2.20 (1.06, 4.56) | −0.43 | 0.23 | 0.65 (0.32, 1.32) |
| RCS entry most likely practise smaller town | 0.60 | 0.14 | 1.82 (0.82, 4.06) | −0.58 | 0.16 | 0.56 (0.25, 1.26) |
| RCS entry most likely practise small rural community | 1.07 | 0.01 | 2.92 (1.27, 6.72) | −0.27 | 0.55 | 0.77 (0.32, 1.82) |
| Not academically supported | −0.27 | 0.22 | 0.77 (0.50, 1.18) | −0.31 | 0.31 | 0.73 (0.40, 1.34) |
| Neutral academically supported | −0.50 | 0.03 | 0.60 (0.38, 0.96) | 0.00 | 0.99 | 1.00 (0.58, 1.74) |
| Not financially supported | 0.55 | < 0.001 | 1.73 (1.33, 2.27) | 0.17 | 0.33 | 1.19 (0.84, 1.69) |
| Neutral financially supported | 0.05 | 0.67 | 1.06 (0.82, 1.36) | −0.01 | 0.96 | 0.99 (0.73, 1.36) |
| Not academically isolated | −2.23 | < 0.001 | 0.11 (0.09, 0.14) | −0.91 | < 0.001 | 0.40 (0.30, 0.55) |
| Neutral academically isolated | −0.69 | < 0.001 | 0.50 (0.38, 0.67) | 0.51 | 0.01 | 1.66 (1.16, 2.37) |
| RCS did not inform health counselling services | 0.03 | 0.83 | 1.03 (0.77, 1.40) | 0.28 | 0.17 | 1.32 (0.89, 1.95) |
| RCS informed health counselling services | 0.00 | 1.00 | 1.00 (0.77, 1.30) | 0.33 | 0.03 | 1.40 (1.03, 1.90) |
| Not well supported by RCS | 0.65 | 0.01 | 1.91 (1.15, 3.18) | 0.13 | 0.73 | 1.14 (0.55, 2.37) |
| Neutral well supported by RCS | 0.69 | < 0.001 | 1.99 (1.31, 3.03) | 0.73 | 0.01 | 2.08 (1.24, 3.48) |
| No rural‐based clinician as mentor | −0.06 | 0.67 | 0.95 (0.74, 1.22) | −0.04 | 0.79 | 0.96 (0.69, 1.33) |
| Neutral rural‐based clinician as mentor | 0.15 | 0.25 | 1.16 (0.90, 1.50) | 0.13 | 0.43 | 1.14 (0.83, 1.56) |
| No mindfulness course | 0.08 | 0.56 | 1.08 (0.84, 1.40) | 0.10 | 0.56 | 1.10 (0.79, 1.54) |
| Neutral mindfulness course | −0.20 | 0.18 | 0.82 (0.61, 1.10) | −0.10 | 0.61 | 0.91 (0.63, 1.31) |
| No formal wellbeing/resilience training | −0.06 | 0.70 | 0.94 (0.69, 1.28) | 0.13 | 0.51 | 1.14 (0.77, 0.69) |
| Neutral formal wellbeing/resilience training | 0.07 | 0.64 | 1.07 (0.80, 1.44) | 0.06 | 0.73 | 1.07 (0.74, 1.54) |
| No structured support activities | 0.01 | 0.96 | 1.01 (0.74, 1.37) | −0.08 | 0.69 | 0.92 (0.62, 1.37) |
| Neutral structured support activities | 0.07 | 0.62 | 1.07 (0.82, 1.41) | 0.05 | 0.78 | 1.05 (0.75, 1.46) |
| No informal/optional wellbeing activities | 0.42 | 0.01 | 1.52 (1.12, 2.05) | −0.06 | 0.76 | 0.94 (0.63, 1.41) |
| Neutral informal/optional wellbeing activities | 0.00 | 0.99 | 1.00 (0.76, 1.33) | 0.33 | 0.05 | 1.40 (1.00, 1.95) |
| No active role‐modelling of self‐care | 0.07 | 0.67 | 1.07 (0.79, 1.44) | 0.03 | 0.89 | 1.03 (0.70, 1.51) |
| Neutral active role‐modelling of self‐care | 0.15 | 0.27 | 1.16 (0.89, 1.50) | 0.13 | 0.42 | 1.14 (0.83, 1.57) |
| No formal tuition on rural career options | −0.03 | 0.82 | 0.97 (0.77, 1.23) | −0.05 | 0.72 | 0.95 (0.70, 1.28) |
| Neutral formal tuition on rural career options | −0.05 | 0.70 | 0.95 (0.73, 1.24) | 0.16 | 0.32 | 1.18 (0.86, 1.61) |
| No informal info on rural career options | −0.22 | 0.23 | 0.81 (0.56, 1.15) | −0.35 | 0.17 | 0.71 (0.43, 1.16) |
| Neutral informal info on rural career options | 0.13 | 0.45 | 1.13 (0.82, 1.57) | 0.50 | 0.01 | 1.64 (1.13, 2.38) |
| Didn't work with rurally training junior doctors | 0.45 | 0.01 | 1.56 (1.13, 2.16) | 0.30 | 0.16 | 1.35 (0.88, 2.06) |
| Did work with rurally training junior doctors | 0.19 | 0.34 | 1.21 (0.82, 1.78) | 0.27 | 0.25 | 1.31 (0.83, 2.07) |
| No rural health club preclinical years | 0.11 | 0.28 | 1.11 (0.92, 1.35) | −0.08 | 0.53 | 0.93 (0.73, 1.18) |
| Not COVID‐19 year | −0.15 | 0.14 | 0.86 (0.70, 1.05) | 0.13 | 0.34 | 1.14 (0.87, 1.49) |
Abbreviations: CI, 95% confidence intervals of adjusted odd ratios; OR, adjusted odd ratios; RCS, rural clinical school.
TABLE 5.
Multinomial logistic regression of factors associated with students' perceptions of positive impact on their wellbeing during their RCS placement. Reference category is ‘Agree’.
| Variables | Disagree with positive impact on wellbeing | Neutral about positive impact on wellbeing | ||||
|---|---|---|---|---|---|---|
| B | p | OR (95% CI lower, upper) | B | p | OR (95% CI lower, upper) | |
| Male | −0.24 | 0.81 | 0.79 (0.12, 5.31) | 0.85 | 0.47 | 2.34 (0.24, 23.30) |
| Female | −0.49 | 0.62 | 0.62 (0.09, 4.12) | 0.55 | 0.64 | 1.73 (0.17, 17.18) |
| 19–22 years | −0.13 | 0.64 | 0.88 (0.52, 1.50) | 0.16 | 0.48 | 1.17 (0.76, 1.79) |
| 23 years | 0.09 | 0.75 | 1.09 (0.64, 1.87) | 0.14 | 0.53 | 1.15 (0.75, 1.75) |
| 24 years | −0.31 | 0.27 | 0.73 (0.42, 1.27) | −0.12 | 0.57 | 0.88 (0.57, 1.36) |
| 25–26 years | −0.43 | 0.10 | 0.65 (0.39, 1.08) | −0.05 | 0.82 | 0.96 (0.65, 1.42) |
| No rural background | 0.02 | 0.96 | 1.02 (0.55, 1.87) | 0.06 | 0.79 | 1.07 (0.66, 1.73) |
| Lived longest capital city | −0.01 | 0.98 | 0.99 (0.26, 3.78) | 0.79 | 0.32 | 2.19 (0.47, 10.23) |
| Lived longest major urban centre | −0.28 | 0.68 | 0.75 (0.19, 2.93) | 1.25 | 0.11 | 3.50 (0.75, 16.32) |
| Lived longest regional city/large town | −0.09 | 0.89 | 0.91 (0.25, 3.32) | 1.05 | 0.18 | 2.85 (0.62, 13.01) |
| Lived longest smaller town | −0.32 | 0.64 | 0.73 (0.19, 2.73) | 1.12 | 0.15 | 3.05 (0.66, 14.06) |
| Lived longest small rural community | −0.48 | 0.48 | 0.62 (0.16, 2.35) | 1.07 | 0.17 | 2.92 (0.64, 13.46) |
| Didn't live outside major Aus city 10 or 5 years consecutively | −0.22 | 0.41 | 0.80 (0.47, 4.35) | 0.28 | 0.20 | 1.32 (0.87, 2.01) |
| First year at RCS | 0.41 | 0.12 | 1.51 (0.89, 2.55) | −0.06 | 0.77 | 0.94 (0.63, 1.42) |
| Second consecutive year at RCS | 0.03 | 0.94 | 1.03 (0.55, 1.90) | −0.01 | 0.96 | 0.99 (0.62, 1.57) |
| RCS entry most likely practise capital city | 1.39 | 0.07 | 4.01 (0.88, 18.23) | 0.58 | 0.27 | 1.79 (0.64, 5.03) |
| RCS entry most likely practise major urban centre | 1.04 | 0.18 | 2.83 (0.61, 13.12) | 0.39 | 0.47 | 1.47 (0.52, 4.20) |
| RCS entry most likely practise regional city/large town | 0.84 | 0.29 | 2.32 (0.48, 11.15) | 0.03 | 0.96 | 1.03 (0.35, 3.06) |
| RCS entry most likely practise smaller town | 1.08 | 0.20 | 2.96 (0.56, 15.76) | −0.07 | 0.91 | 0.93 (0.27, 3.17) |
| RCS entry most likely practise small rural community | 0.92 | 0.31 | 2.52 (0.43, 14.94) | 0.44 | 0.49 | 1.55 (0.44, 5.40) |
| Not academically supported | 1.06 | < 0.001 | 2.89 (1.72, 4.84) | 0.20 | 0.45 | 1.22 (0.73, 2.04) |
| Neutral academically supported | 0.40 | 0.21 | 1.49 (0.80, 2.76) | 0.26 | 0.33 | 1.30 (0.77, 2.18) |
| Not financially supported | 1.04 | < 0.001 | 2.84 (1.87, 4.31) | 0.33 | 0.07 | 1.39 (0.97, 2.00) |
| Neutral financially supported | 0.32 | 0.18 | 1.38 (0.87, 2.19) | 0.29 | 0.10 | 1.34 (0.95, 1.89) |
| Not academically isolated | −1.61 | < 0.001 | 0.20 (0.13, 0.31) | −1.22 | < 0.001 | 0.30 (0.21, 0.41) |
| Neutral academically isolated | −1.32 | < 0.001 | 0.27 (0.16, 0.46) | −0.18 | 0.33 | 0.84 (0.59, 1.20) |
| RCS did not inform health counselling services | 0.08 | 0.75 | 1.08 (0.67, 1.74) | 0.01 | 0.98 | 1.01 (0.66, 1.52) |
| RCS informed health counselling services | 0.05 | 0.84 | 1.05 (0.66, 1.68) | 0.45 | 0.01 | 1.57 (1.12, 2.21) |
| Not well supported by RCS | 3.03 | < 0.001 | 20.71 (11.16, 38.44) | 1.61 | < 0.001 | 4.98 (2.61, 9.51) |
| Neutral well supported by RCS | 1.79 | < 0.001 | 6.00 (3.63, 9.93) | 1.55 | < 0.001 | 4.70 (3.07, 7.20) |
| No rural‐based clinician as mentor | 0.42 | 0.04 | 1.53 (1.02, 2.30) | 0.05 | 0.79 | 1.05 (90.74, 1.49) |
| Neutral rural‐based clinician as mentor | 0.11 | 0.66 | 1.11 (0.69, 1.81) | 0.27 | 0.14 | 1.30 (0.92, 1.85) |
| No mindfulness course | −0.33 | 0.17 | 0.72 (0.45, 1.15) | −0.12 | 0.53 | 0.89 (0.61, 1.29) |
| Neutral mindfulness course | 0.42 | 0.13 | 1.53 (0.89, 2.62) | −0.03 | 0.88 | 0.97 (0.62, 1.50) |
| No formal wellbeing/resilience training | −0.17 | 0.55 | 0.84 (0.48, 1.47) | 0.23 | 0.32 | 1.26 (0.80, 1.97) |
| Neutral formal wellbeing/resilience training | −0.38 | 0.20 | 0.68 (0.38, 1.23) | −0.13 | 0.56 | 0.87 (0.56, 1.37) |
| No structured support activities | 0.07 | 0.80 | 1.08 (0.62, 1.89) | −0.14 | 0.53 | 0.87 (0.56, 1.35) |
| Neutral structured support activities | 0.05 | 0.86 | 1.05 (0.62, 1.79) | 0.15 | 0.46 | 1.16 (0.78, 1.72) |
| No informal/optional wellbeing activities | −0.13 | 0.63 | 0.88 (0.52, 1.48) | 0.47 | 0.03 | 1.59 (1.05, 2.43) |
| Neutral informal/optional wellbeing activities | −0.19 | 0.45 | 0.82 (0.49, 1.37) | 0.34 | 0.08 | 1.41 (0.96, 2.08) |
| No active role‐modelling of self‐care | 1.18 | < 0.001 | 3.25 (1.87, 5.63) | 0.40 | 0.07 | 1.49 (0.97, 2.28) |
| Neutral active role‐modelling of self‐care | 0.89 | < 0.001 | 2.43 (1.44, 4.10) | 0.26 | 0.19 | 1.29 (0.88, 1.90) |
| No formal tuition on rural career options | −0.29 | 0.19 | 0.75 (0.49, 1.15) | 0.03 | 0.88 | 1.03 (0.73, 1.45) |
| Neutral formal tuition on rural career options | −0.05 | 0.85 | 0.95 (0.58, 1.56) | 0.13 | 0.50 | 1.14 (0.78, 1.66) |
| No informal info on rural career options | −0.34 | 0.29 | 0.71 (0.39, 1.32) | −0.08 | 0.74 | 0.92 (0.57, 1.49) |
| Neutral informal info on rural career options | −0.36 | 0.24 | 0.70 (0.39, 1.26) | −0.15 | 0.49 | 0.86 (0.56, 1.33) |
| Didn't work with rurally training junior doctors | −0.12 | 0.69 | 0.89 (0.50, 1.57) | 0.34 | 0.12 | 1.41 (0.92, 2.16) |
| Did work with rurally training junior doctors | 0.09 | 0.77 | 1.10 (0.58, 2.08) | 0.12 | 0.63 | 1.13 (0.68, 1.87) |
| No rural health club preclinical years | 0.17 | 0.34 | 1.19 (0.833, 1.70) | 0.20 | 0.16 | 1.23 (0.92, 1.63) |
| Not COVID‐19 year | 0.09 | 0.65 | 1.09 (0.75, 1.58) | 0.07 | 0.65 | 1.07 (0.80, 1.44) |
Abbreviations: CI, 95% confidence intervals of adjusted odd ratios; OR, adjusted Odd ratios; RCS, rural clinical school.
The multinomial regression analysis controlling for the survey year revealed that respondents who reported being most likely to practise in a ‘capital city’ after training were over three times more likely to experience social isolation during their RCS placement (OR = 3.30, 95% CI: 1.64–6.65). Self‐reported lack of financial support by the RCS was associated with higher odds of feeling socially isolated (OR = 1.73, 95% CI: 1.33–2.27). Whereas respondents who did not feel academically isolated were over nine times less likely to experience social isolation (OR = 0.11, 95% CI: 0.09–0.14).
Respondents who felt neutral about their academic isolation were two times less likely to report social isolation (OR = 0.50, 95% CI: 0.38–0.67). A neutral response to feeling well supported by the RCS was associated with almost double the odds of feeling socially isolated (OR = 1.99, 95% CI: 1.31–3.03). The absence of academic isolation was associated with decreased odds of feeling neutral about social isolation (OR = 0.40, 95% CI: 0.30–0.55).
Table 5 presents the variables associated with the outcome ‘improved wellbeing’ after controlling for the survey year in the multinomial regression analysis. The model was statistically significant (χ 2 = 885.97). The variables associated with students feeling neutral about their social isolation and improved wellbeing have been shown in Tables S1 and S2 respectively.
From Table 5, lack of overall support by the RCS was correlated with over 20 times higher odds of disagreeing with the statement of a positive impact on wellbeing (OR = 20.71, 95% CI: 11.16–38.44). Lack of academic isolation was associated with five times reduced odds of disagreeing with a positive impact on wellbeing (OR = 0.20, 95% CI: 0.13–0.31). Respondents who reported that their RCS did not provide active role‐modelling of self‐care had three times higher odds of disagreeing with the statement of improved wellbeing. Respondents who did not feel academically or financially supported were nearly three times more likely to disagree that their RCS placement positively impacted their wellbeing (OR = 2.89, 95% CI: 1.72–4.84, and OR = 2.84, 95% CI: 1.87–4.31 respectively).
Respondents who felt neutral about their academic isolation were less likely to disagree that their placement had a positive impact on their wellbeing. Whereas feeling neutral that they were overall supported by the RCS was associated with six times higher odds of disagreeing with the statement of improved wellbeing. A neutral response to active role‐modelling of self‐care by the RCS was correlated with increased odds of disagreeing with the statement. Not feeling academically isolated was associated with over three times reduced odds of feeling neutral about a positive impact on wellbeing. Not feeling overall supported by the RCS or feeling neutral about this support was correlated with almost five times higher odds of feeling neutral that their placement positively impacted their wellbeing.
According to the multinomial regression analysis, age group, gender, preference of rural practice and COVID‐19 years did not significantly affect respondents' perceptions of social isolation or positive impact on their wellbeing during their RCS placement.
4. Discussion
This study examined medical students' perceptions of improved wellbeing and social isolation during their RCS placements over a 6‐year period (2017–2022) using the FRAME dataset. Similar to previous studies on rural placements [6, 7, 9], the present study found that, for over 80% of respondents, their RCS placement had a positive impact on their wellbeing. The consistency of this positive impact across a 6‐year period, including the disruptive COVID‐19 years, underscores the robustness of the RCS model. The unique features of RCS placements, such as smaller cohort sizes, more hands‐on clinical time or closer relationships with clinicians, may provide a stable, protective effect on student wellbeing by facilitating a sense of belonging and professional identity formation that may be difficult to achieve in high‐volume metropolitan centres.
However, while the 80% threshold indicates broad success of the RCS model, the stability of the figure highlights a persistent minority for whom the placement does not yield wellbeing benefits. This suggests that current wellbeing strategies may have reached a ‘ceiling’ of effectiveness and further improvements in student outcomes will require more targeted interventions for high‐risk cohorts, especially those expressing a strong preference for urban practice. Additionally, while the 14.3% decrease in respondents reporting improved wellbeing between 2017 and 2022 is not statistically significant (p = 0.059), the magnitude of this shift is of practical significance. In the context of rural workforce retention, a double‐digit decline in positive placement perceptions may signal emerging pressures on student mental health that require proactive institutional attention.
A yearly average of over 30% of respondents felt socially isolated during their RCS placements. This figure is lower than previous reports [6, 7] but still represents a significant proportion of medical students. According to the results of our study, academic isolation was associated with higher levels of social isolation and lower levels of improved wellbeing. The large academic workload of medical students, comprising a vast syllabus and long hours of study, is well documented in the literature [4, 25]. Previous research has reported that medical students may spend less time with friends and family due to the academic demands of their course [10]. The academic rigour of medicine combined with geographical challenges of living rurally such as limited access to existing social networks, and fewer recreational opportunities may hinder the ability to develop new relationships and engage in meaningful social interactions, contributing to perceived social isolation and poor wellbeing.
Financial support by the RCS was correlated with reduced levels of social isolation and higher odds of agreeing with the statement of improved wellbeing by respondents. Past research has reported that two‐thirds of medical students found financial concerns very or extremely stressful [26] and medical students' concerns about their financial situation were associated with increased odds of a decline in wellbeing [27]. Subsidised accommodation provided by universities [28, 29] and financial aid in the form of scholarships and grants [30, 31, 32] help to alleviate the financial burden faced by medical students on rural placements.
Active role‐modelling of self‐care was associated with increased odds of respondents agreeing that the RCS placement positively impacted wellbeing in this study. This finding aligns with previous reports of the effectiveness of peer support programs in promoting self‐care among medical students [33] and the importance of a ‘healthy role‐model’ in medical schools [34]. Having peers, professors, and supervisors demonstrate effective self‐care practices is vital to equip medical students with healthy habits and techniques to improve their wellbeing.
The COVID‐19 years (2020–2022) did not have a significant impact on respondents' reports of social isolation and improved wellbeing. This result is contrary to previous studies, which found that the pandemic detrimentally affected medical students' psychological wellbeing and increased social isolation while on rural placements [35, 36, 37]. In one study that reported increased workload and stress among rural frontline community staff during the pandemic, organisational responses, rather than COVID‐19 itself, were the primary drivers of stress [38]. One potential reason for this discrepancy is the geographic variation in public health restrictions. While metropolitan students faced prolonged, stringent lockdowns, many rural and regional areas in Australia experienced shorter or less restrictive mandates [39]. Another possibility is that the small, close‐knit medical student cohorts established in RCSs provided consistent, high‐quality peer support and a sense of community resilience that was unavailable to their metropolitan counterparts [23]. Finally, the continuation of small‐group clinical placements in rural settings compared with the complete shift to online learning in urban settings may have contributed to better wellbeing and less isolation among rural medical students [6].
Respondents who reported that they were most likely to practise in a capital city after training upon entry to their RCS were more likely to also report experiencing social isolation. This finding suggests that medical students' inherent bias towards urban practice and preconceived notions of rural medicine may hinder social connectedness on rural placements. Future research should address the perceived social isolation of urban‐preferencing students as negative placement experiences could deter future rural practice among a cohort with pre‐existing urban‐centric biases.
In this study, the proportion of respondents feeling neutral about their social isolation or placement positively impacting their wellbeing in this study was lower than previous 2016 reports [7]. Institutions may need to regularly check in with students to better understand the specific challenges they are facing and ways to better support them.
4.1. Strengths and Limitations
The study's representation of medical students from 19 Australian medical schools is a major strength as it allows for a comprehensive national evaluation of social isolation and improvement in wellbeing. The study is the first 6‐year trend analysis of medical students' perceptions of social isolation and improved wellbeing. The inclusion of rural‐specific variables in the survey allows the study to evaluate social isolation and improved wellbeing in a rural‐specific context.
The study also had several limitations that should be considered when interpreting or comparing the findings with other studies. The lack of a clear definition of ‘wellbeing’ in the FRAME surveys may result in inconsistent interpretations among the students. Additionally, there is ambiguity surrounding whether disagreeing with the statement of improved wellbeing indicates stable or declining levels of wellbeing. The relatively low response rate for the FRAME surveys (13%–20%) and potential selection bias associated with voluntary survey participation may affect the representativeness of the data.
Restrictions accompanying the FRAME data‐sharing agreement prevent comparison between participating universities such as the proportional response from each RCS. The FRAME dataset also does not include students in metropolitan clinical schools, preventing comparisons with medical students in metropolitan settings. Lastly, there is a lack of qualitative data accompanying the respondents' survey responses to contextualise the quantitative findings of this study.
5. Conclusions and Recommendations
This six‐year analysis demonstrates that RCS placements consistently benefitted the wellbeing of over 80% of medical students. However, more than 30% of medical students experienced social isolation, which is a critical concern for medical educators. Wellbeing and social isolation are influenced by various factors such as academic and financial support, active role‐modelling of behaviours and prior career intentions. Addressing the identified risk factors for social isolation and lack of a positive impact on wellbeing could help ensure that rural placements contribute to greater retention of medical students as future doctors in rural and remote areas, where there is a shortage of medical practitioners.
Based on our findings, we recommend that universities prioritise students with a rural interest or background for RCS placements as they may be more resilient to the geographic challenges of rural settings. Implementing ‘rural readiness’ orientations that address the transition for urban‐origin or preference students could help them build coping strategies prior to their placements. Investment into university‐subsidised accommodation and external scholarships and grants should be maintained, and government funding of the RHMT program potentially expanded to cover the hidden costs of rural life such as return travel to urban homes and the rising cost of rural living. Universities should invest in mentorship programs where older students, professors and doctors are incentivised to role‐model healthy wellbeing strategies to incoming medical students.
Author Contributions
Sari Dewi: conceptualization, validation, writing – review and editing, visualization. Minha Lee: conceptualization, methodology, investigation, formal analysis, writing – original draft, writing – review and editing, data curation, resources, validation, project administration, visualization. Peter Simmons: conceptualization, validation, data curation, writing – review and editing, visualization. Jodie Bailie: validation, visualization, investigation, writing – review and editing. Zelda Doyle: conceptualization, methodology, software, data curation, investigation, formal analysis, supervision, validation, visualization, project administration, resources, writing – original draft, writing – review and editing. Uchechukwu Levi Osuagwu: conceptualization, methodology, software, data curation, investigation, validation, formal analysis, supervision, visualization, project administration, resources, writing – original draft, writing – review and editing. Tracy McFarlane: conceptualization, methodology, validation, investigation, data curation, writing – original draft, writing – review and editing, visualization.
Funding
This research did not receive any funding.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Likelihood ratio tests of the multinomial regression of factors associated with self‐reported social isolation during RCS placement.
Table S2: Likelihood ratio tests of the multinomial regression of factors associated with self‐reported positive wellbeing during RCS placement.
Acknowledgements
The authors acknowledge all students who participated in the FRAME surveys that were used in this research. The authors confirm that no generative artificial intelligence tools were used in the writing or preparation of this manuscript.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Likelihood ratio tests of the multinomial regression of factors associated with self‐reported social isolation during RCS placement.
Table S2: Likelihood ratio tests of the multinomial regression of factors associated with self‐reported positive wellbeing during RCS placement.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.