ABSTRACT
Background:
Rural general practitioners (GPs) play a vital role in providing healthcare to populations in remote areas, yet there is a significant shortage of doctors willing to work in these regions. Despite the critical need, a strong preference for urban practices persists among young GPs in Europe, exacerbating the lack of healthcare providers in rural settings. Understanding the motivation factors influencing young GPs’ decisions to work in rural areas is essential to address this workforce distribution problem.
Objectives:
This study aims to identify the main motivating factors that drive young GPs to work in rural areas across four European countries. Additionally, the study seeks to propose strategies to enhance recruitment of young GPs in rural healthcare settings.
Methods:
A key informant survey was conducted across four member countries of the European Rural and Isolated Practitioners Association (EURIPA). The EURIPA Motivating young EuropeAn DOctors for rural Work (MEADOW) study utilized a semi-structured questionnaire. The survey targeted young GPs in Denmark, Norway, Turkey, and the Czech Republic, collecting data from 350 respondents.
Results:
Our survey revealed that 64.14% of young GPs expressed an interest in rural practice, with major motivating factors including accessibility of schooling for their children, income profitability, and employment opportunities for partners.
Conclusion:
The study highlights that financial incentives alone are insufficient to motivate young GPs to work in rural areas. Instead, a comprehensive approach that includes improving rural medical education, ensuring access to quality schools for children, and providing employment opportunities for partners is crucial. Addressing these multifaceted needs can enhance rural recruitment and retention efforts across Europe.
Keywords: Motivating factors, primary care, rural retention, rural, young doctors
Introduction/Background
A rural general practitioner (GP) is a primary, and often the only connection to healthcare services for those who live in rural locations. In Europe, there is a strong relationship between young GPs and metropolitan practices, which contributes to a notable scarcity of healthcare providers in rural areas.[1,2] Lack of GPs in these distant places presents a considerable issue, resulting in limited access to healthcare services and consequent challenges for local people. According to the Organization for Economic Co-operation and Development (OECD), 30% to 50% of GPs provide rural healthcare, with the proportion varying among nations.[3]
Studies from some countries show that a substantial 62% of individuals considering a career in rural general practice asserted that they would unequivocally commit to it if all their top three factors were met. This underscores the critical role these factors play in the decision-making process for aspiring rural practitioners.[4,5] However, a noteworthy concern emerged regarding rural practice, primarily centered around the accessibility to subsequent secondary care facilities. Addressing this concern could prove pivotal in attracting and retaining talent in rural healthcare settings. Identifying strategies to enhance access to secondary care resources may be crucial in furthering the appeal of rural general practice among potential practitioners.[5]
Our study aims to evaluate two key questions: What are the primary motivators that drive young GPs to work in rural areas? How can the current situation be enhanced or improved to attract and retain young GPs in rural healthcare settings?
Material and Method
A key informant survey was undertaken throughout four member countries of the European Rural and Isolated Practitioners Association (EURIPA) for the purpose of this study. The EURIPA MEADOW (Motivating young EuropeAn DOctors for rural Work) study’s steering committee created a semi-structured multiple-choice questionnaire. Although the questionnaire consisted of 13 main questions, many included multiple selectable options, sub-items, and free-text fields. When all individual items, sub-questions, and coded responses used in the analysis are considered, the total number of variables reaches 68. Therefore, the reference to 68 questions refers to the complete set of analyzed variables rather than the count of individually numbered questions presented in the appendix.
Twenty-one of these questions allowed respondents to offer free-text responses. The goal was to simplify the questionnaire as much as possible so that it could be completed within 2 or 3 min, even during the time-constrained work of a GP.
The questionnaire was distributed in a paper format at educational seminars for pre-certification preparation of GPs, and further in electronic form through the mailing list of young GPs organizations in individual countries [Appendix 1].
In the formulation of this comprehensive survey, a “rural area” is distinctly characterized as any district or settlement lacking a local hospital or accessibility to a hospital by a city’s public transportation system. The questionnaire focused on a specific demographic group—young GPs, which includes doctors in specialty training aspiring to become GPs, as well as GPs who have successfully passed their certified specialization exam within the last 5 years. The questionnaire was distributed from March to June 2019.
The study ambitiously spans across four diverse countries, namely, Denmark, Norway, Turkey, and the Czech Republic. To encapsulate the varying geographical and healthcare landscapes, participants are intelligently divided into three distinct groups: Scandinavia (North), Turkey (South), and the Czech Republic (Central).
Following the meticulous distribution and collection process, a robust dataset of 350 questionnaires has been compiled for in-depth analysis. This research endeavors to uncover critical insights into the primary motivators influencing young GPs to opt for roles in rural areas and proposes potential strategies to enhance the current scenario, fostering improved recruitment and retention of young GPs in rural healthcare settings across the studied countries.
The hypothesis of independence in the contingency table was tested using the Chi-squared test of independence. In case the assumptions for the Chi-squared test were not met (minimum expected frequency of at least 5), Fisher’s exact test was used.
This study did not require formal ethical approval, as it was an anonymous, non-interventional survey involving adult medical professionals, with no collection of sensitive personal data or any impact on clinical care. Participation was entirely voluntary, and completion of the questionnaire was considered as implied consent. In accordance with standard ethical guidelines for non-invasive survey research in public health and social sciences, the absence of identifiable data meant that referral to an institutional ethics committee was not necessary. Nevertheless, the study protocol was reviewed and approved by the Scientific Board of EURIPA, which assessed and endorsed the ethical aspects of the project.
Results
In total, 350 participants were evaluated: Scandinavia (Denmark + Norway) 100 (28.57%), the Czech Republic 124 (35.43%), and Turkey 126 (36.00%). Most of them were female (227: 65.23%). The mean age of the participants was 35.17572 (Std: 7.134544, Standard Error: 0.4032682, min: 25, max: 64, range: 39) [Table 1].
Table 1.
Characteristics of GPs participating in the EURIPA MEADOW study—What motivates young European doctors for rural work (2019)
| GP characteristic, n=350 (%) | ||
|---|---|---|
| Country | ||
| Scandinavia | 100 | (28.57) |
| Turkey | 126 | (36.00) |
| Czech Republic | 124 | (35.43) |
| Gender | ||
| Female | 227 | (64.85) |
| Male | 121 | (34.57) |
| Not indicated | 2 | (0.57) |
| Age (years) | ||
| Average | 35 | |
| Min | 25 | |
| Max | 64 | |
GP=general practitioner, EURIPA=European Rural and Isolated Practitioners Association, MEADOW=Motivating young EuropeAn DOctors for rural Work
Most participants (64.14%) were considering a career as a rural GP, and more than one-third had decided against it (35.86%). The main concern about the rural practice was the accessibility to subsequent secondary care facilities. The three most motivating factors are: quality and accessibility of schooling for doctor’s children (64,90%), income of the practice (63,00%), and securing a qualified work for the partner (58%). The main motivators identified are summarized in Table 2.
Table 2.
The main motivating factors for rural work, EURIPA MEADOW study—What motivates young European doctors for rural work (2019), n=350
| Motivating factor | Percentage |
|---|---|
| Accessibility of schooling for your children | 64.90% |
| Income, profitability of the practice | 62.00% |
| Accessibility of qualified jobs for your partner | 58.00% |
| Accessibility of culture | 31.70% |
| Environmental issues | 27.40% |
| Accessibility of sport facilities | 25.70% |
| City life | 20.60% |
| Country life | 20.00% |
| Desire to work where you grew up | 12.60% |
| Subsidies (by the state, local administration) | 12.00% |
EURIPA=European Rural and Isolated Practitioners Association. MEADOW=Motivating young EuropeAn DOctors for rural Work
Respondents were also asked about their current workplace and whether they grew up in a rural or urban area during their childhood. Those who grew up in rural areas also work in rural areas more (P = 0.00001), rural origin is more interesting for rural work (P < 0.00139) [Table 3].
Table 3.
The relationship between growing up in rural areas and subsequent work or interest to rural practice – percentage of respondents, EURIPA MEADOW study - What motivates young European doctors for rural work (2019), n=350
| Work in a rural area | |||
|---|---|---|---|
|
| |||
| No | Yes | Total | |
| Grow up in a rural area | |||
| No | 76.75% | 23.25% | 100.00% |
| Yes | 54.10% | 45.90% | 100.00% |
| Total | 68.86% | 31.14% | 100.00% |
| P=0.00001 | |||
|
| |||
| Find work in a rural area interesting | |||
|
| |||
| No | Yes | Total | |
|
| |||
| Grow up in a rural area | |||
| No | 41.83% | 58.17% | 100.00% |
| Yes | 22.92% | 77.08% | 100.00% |
| Total | 35.86% | 64.14% | 100.00% |
| P<0.00139 | |||
EURIPA=European Rural and Isolated Practitioners Association, MEADOW=Motivating young EuropeAn DOctors for rural Work, GP=general practitioner
In addition, we found that 60.57% of respondents felt they did not have access to relevant information on rural practice during university studies and as a part of the general practice training program [Table 4].
Table 4.
Education on rural practice, EURIPA MEADOW study—What motivates young European doctors for rural work (2019), n=350 (%)
| Did you have access to information on rural healthcare during university and GP training? | |||
|---|---|---|---|
|
| |||
| No | Yes | Total | |
| Denmark + Norway | 49 (49.00) | 51 (51.00) | 100 (100.00) |
| Czech Republic | 99 (79.84) | 25 (20.16) | 124 (100.00) |
| Turkey | 64 (50.79) | 62 (49.21) | 126 (100.00) |
| Total | 212 (60.57) | 318 (39.43) | 350 (100.00) |
| P<0.0001 | |||
EURIPA=European Rural and Isolated Practitioners Association, MEADOW=Motivating young EuropeAn DOctors for rural Work, GP=general practitioner
By country
In Turkey, fewer doctors grew up in rural areas (P = 0.00208), in Scandinavia most people work in rural areas (P = 0.00009), and more grew up in rural areas (P = 0.00208).
The greatest interest in working in rural areas was found in the Czech Republic, significantly less interest in rural work is in Turkey (P < 0.0001). In Scandinavia, most rural-origin people work in rural areas (P = 0.01846). In Turkey, they have significantly less interest in providing schools (P = 0.00075) and employment for a partner (P = 0.0357), but financial incentives are more appealing (P = 0.0261) [Table 5]. The Czech Republic has the worst education in rural medicine (P < 0.0001) [Table 4].
Table 5.
Respondents by country, EURIPA MEADOW study—What motivates young European doctors for rural work (2019)
| No | Yes | Total | |
|---|---|---|---|
| Did you grow up in a rural area? n=350 (%) | |||
| Denmark + Norway | 53 (53.00) | 47 (47.00) | 100 (100.00) |
| The Czech Republic | 80 (64.52) | 44 (35.48) | 124 (100.00) |
| Turkey | 95 (75.40) | 31 (24.60) | 126 (100.00) |
| Total | 228 (65.14) | 122 (34.86) | 350 (100.00) |
| P=0.00208 | |||
| Do you work in a rural area? n=350 (%) | |||
| Denmark + Norway | 52 (52.00) | 48 (48.00) | 100 (100.00) |
| The Czech Republic | 95 (76.61) | 29 (23.39) | 124 (100.00) |
| Turkey | 94 (74.60) | 32 (25.40) | 126 (100.00) |
| Total | 241 (68.86) | 109 (31.14) | 350 (100.00) |
| P=0.00009 | |||
| If you do not work in a rural area, would you find the idea interesting? n=304 (%) | |||
| Denmark + Norway | 21 (29.17) | 51 (70.83) | 72 (100.00) |
| The Czech Republic | 22 (20.00) | 88 (80.00) | 110 (100.00) |
| Turkey | 66 (54.10) | 56 (45.90) | 122 (100.00) |
| Total | 109 (35.86) | 195 (64.14) | 304 (100.00) |
| P<0.00000 | |||
| The number with at least one missing value is 46. | |||
| Rural origin people working in rural areas by a country. n=122 (%) | |||
| Denmark + Norway | 18 (38.30) | 29 (61.70) | 47 (100.00) |
| The Czech Republic | 27 (61.36) | 17 (38.64) | 44 (100.00) |
| Turkey | 21 (67.74) | 10 (32.26) | 31 (100.00) |
| Total | 66 (54.10) | 56 (45.90) | 122 (100.00) |
| P=0.01846 | |||
| Would securing a qualified job for your partner in rural area increase your motivation for working in rural work? n=350 (%) | |||
| Denmark + Norway | 7 (7.00) | 93 (93.00) | 100 (100.00) |
| The Czech Republic | 9 (7.26) | 115 (92.74) | 124 (100.00) |
| Turkey | 20 (15.87) | 106 (84.13) | 126 (100.00) |
| Total | 36 (10.29) | 314 (89.71) | 350 (100.00) |
| P=0.0357 | |||
| Securing accessebility to schooling for your children in rural area increase your motivation for working in rural work? n=350 (%) | |||
| Denmark + Norway | 9 (9.00) | 91 (91.00) | 100 (100.00) |
| The Czech Republic | 8 (6.45) | 116 (93.55) | 124 (100.00) |
| Turkey | 27 (21.43) | 99 (78.57) | 126 (100.00) |
| Total | 44 (12.57) | 306 (87.43) | 350 (100.00) |
| P=0.00075 | |||
| Would one time financial support increase the change of you working in rural area? n=350 (%) | |||
| Denmark + Norway | 44.00% | 56.00% | 100.00% |
| The Czech Republic | 40.32% | 59.68% | 100.00% |
| Turkey | 27.78% | 72.22% | 100.00% |
| Total | 36.86% | 63.14% | 100.00% |
| P=0.0261 |
EURIPA=European Rural and Isolated Practitioners Association, MEADOW=Motivating young EuropeAn DOctors for rural Work, GP=general practitioner
Discussion
For young doctors across the surveyed countries, finance is not the only or main motivating factor. In addition to the long-term profit and income of the practice, the quality and availability of schools for the doctor’s children and securing a qualified work for the doctor’s partner rank among the top three motivating factors. For many, a combination of these factors played a more substantial role in their decision-making process, indicating that financial support alone may not be as attractive.
Doctors who grow up in rural areas are more likely to work in rural areas later on. Therefore, targeting recruitment specifically on these young doctors strongly suggests itself.
A surprising result is the evaluation of the quality of education in the field of general practice, particularly rural medicine, at medical schools. Sixty percent of surveyed young doctors reported that they did not receive enough information about rural medicine during their medical studies. We suffer from a shortage of doctors in rural areas, but during their studies, we are unable to provide students enough information about this field, making it difficult to motivate them for this specific type of work.
Rural curriculum at medical schools plays a significant role in the choice of location for young doctors’ professional careers. Ideally, the rural medical curriculum should include an internship in a rural practice. The longer the internship, the better. Additionally, motivational factors influenced by either national or local authorities, which are not directly related to healthcare, also influence this choice. While financial incentives such as funding for setting up a practice, housing assistance, or land for building a house are motivational, let alone not sufficient. Respondents emphasized that the most important factors for them are adequately qualified work opportunities for their partners and the quality of education for their children. These factors are linked to the long-standing debt of rural areas and depend on efforts to alleviate this debt and promote quality of life. Local authorities should primarily contribute to this endeavor.
It is thus the comprehensive, overall perspective on rural life and its quality that serves as a motivating factor.
Among the participating countries, statistically significant differences were found in some areas. Scandinavian countries generally have more doctors working in rural areas and a higher proportion of doctors who grew up in rural environments. In the Czech Republic, young doctors were least likely to exclude working in rural areas, while the least interest was shown by young doctors in Turkey. The financial aspect as a motivating factor was the most influential in Turkey, where, conversely, other motivational factors, such as the availability of schooling for children or employment opportunities for a partner, had a lower motivating effect. Doctors in the Czech Republic rated the quality of education at medical schools as the worst.
One of the main limitations of the study is the limited number of respondents; the responses came only from those willing to participate. The study focused only on basic motivational factors and did not track the actual impact of these factors on young GPs’ decisions to become rural doctors. Further studies with larger cohorts of respondents and the involvement of more countries could yield more detailed results.
The maldistribution of the medical workforce globally, particularly across regional and remote locations, remains a significant concern that impacts the health and well-being needs of underserved populations. These workforce issues are most acutely experienced by smaller rural and remote communities, where recruitment and retention are generally poorer.[6]
There is a growing body of evidence about the effectiveness of interventions to improve the retention of rural health professionals. The best available evidence suggests that policy makers can be confident that selecting health professional students based on rural background supporting training based in rural and remote areas during their basic and subsequent training and removing barriers to rural health professionals for further development of skills (both professional and personal) and qualifications is associated with longer rural retention.[7] Many young GPs are drawn to rural practice because they find it personally and professionally rewarding. They can make a significant impact on the health and well-being of underserved communities, often serving as the primary healthcare provider (Professional Fulfillment).[8,9,10] In rural settings, GPs have the opportunity to develop deeper and more meaningful relationships with their patients (Strong Doctor-Patient Relationships). The smaller patient load allows for more personalized care.[11,12] Rural GPs often encounter a broader range of medical cases and gain experience in various areas of medicine. They may need to be more versatile and resourceful due to limited specialist resources.[9,13,14] Working in a rural area allows GPs to become a vital part of the community they serve. They can build strong connections with local residents, making them trusted healthcare providers (Community Integration).[15,16] Some rural settings offer opportunities for GPs to engage in research or teach medical students, which can be intellectually stimulating (Research and Teaching Opportunities).[17,18]
Conclusion
The findings from the survey reveal that a significant proportion, 64% of young GPs, express an interest in rural work.
When contemplating the location of their future practice, respondents were asked to identify the most crucial factors influencing their decision. The survey underscores the importance of addressing multifaceted considerations. The top considerations include the accessibility of schooling for children, the income and profitability of the practice, and the availability of qualified job opportunities for their partners.
Notably, there is variation among countries in the perceived quality of rural education, both at the medical school level and in GP training. A significant 81% of young GPs expressed appreciation for a short-term training period in a rural practice as part of their GP training program. This suggests a positive inclination towards gaining practical experience in rural settings.
Conflicts of interest
There are no conflicts of interest.
Appendix 1 – Questionnaire
What motivates young European doctors for rural work?
EURIPA MEADOW (Motivating young EuropeAn DOctors for rural Work)
For those living in the country, a rural general practitioner (GP) is the main (and often exclusive) link to healthcare.
The fact is, however, that young GPs in Europe are mostly associated with practices in large cities, and a lack of rural GPs is emerging.
Their absence in rural areas can consequently lead to inaccessibility of healthcare and the population‘s suffering.
To what extent are young general practitioners in Europe interested in working in rural areas?
What are the main motivating factors for young GPs to work in rural areas?
How could the situation be improved?
According to the available data, rural healthcare is provided by 30–50% of all general practitioners, varying from country to country (OECD).
For the purposes of this questionnaire, a “rural area” is defined as any district or settlement without a local hospital or without a hospital accessible by a city public transportation system.
This questionnaire is intended for Young GPs:
Doctors in specialty training who want to become GPs.
GPs who passed their certified specialization exam no longer than 5 years ago.
Where are you from?
In which country do you work right now?
Czech Republic
Denmark
Turkey
Sex:
female – male
Age:
-
Did you grow up in a rural area?
yes – no
-
Do you work in a rural area?
yes – no
-
If you do not work in a rural area, would you find the idea interesting?
yes – no
-
When considering the location of your future practice, which factors do you find most important? (check off the three most important factors)
- income, profitability of the practice
- subsidies (by the state, local administration, or other)
- environmental issues
- city life
- country life
- accessibility of schooling for your children
- accessibility of qualified jobs for your partner
- accessibility of culture (theaters, cinemas, or others)
- accessibility of sport facilities
- desire to work where you grew up
- others specify: …………………………….
-
Would securing a qualified job for your partner in a rural area increase the chance of you working there too?
yes – no
-
Would securing accessibility to schooling for your children in a rural area increase the chance of you working there too?
yes – no
-
Where do you see obstacles stopping you from working in a rural area?
(check off the three most important factors)
- increased amount of work
- bigger responsibility
- work interfering with your leisure time (being asked for help outside your office hours)
- GP‘s core skills (the fully fledged nature of the work)
- lesser accessibility to doctors other than GPs
- lesser accessibility to emergency services
- lesser accessibility of education
- paperwork
- life in the country with its specifics
- lesser accessibility of schools for your children
- lesser accessibility of jobs for your partner
- the solitude in your office (feelings of isolation)
- others specify:……………………………….
-
Which factors do you find motivating to work in a rural area:
(check off the three most important factors)
- environmental issues
- permanent and continuous contact with people (including times outside the office hours)
- long term nature of care (monitoring individuals or families for up to decades)
- the doctor‘s role in the local community
- diversity of work, performing a higher number of tasks, the necessity of being self reliant
- greater responsibility
- closer relationships
- availability of leisure time activities (e.g. gardening, raising animals, gamekeeping, etc.)
- availability of leisure time activities for your family (e.g. gardening, raising animals, gamekeeping, etc.)
- others specify:……………………………….
-
Would one time financial support for new rural practice increase the chance of you working there too? (subsidies by the state or local administration, f.e. grant of the Ministry of Health, financial support for practice equipment,….)
yes – no
-
Did you have access to information on rural healthcare during your studies at medical school or during your GP training?
yes – no
-
Is there any educational support for rural doctors in your country?
yes – no
-
Would you appreciate a short term training period in a rural practice as part of the GP training program?
yes – no
-
Is there anything you would like to share that could increase your interest in a rural practice?
……………………………….
Funding Statement
Cooperatio UK-Health Sciences - This work was supported by the project SVV-2024-260776. Dedicated to the memory of Berit Hansen (1984–2022).
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