Abstract
Background
The shortage of health personnel facing China, particularly in rural areas, has posed a great obstacle to the sustainable development of its health system. The Chinese government has, therefore, implemented the Rural-Oriented Tuition-Waived Medical Higher Education (ROTWMHE) program to address this issue, which recruits and trains medical students (oriented medical students) with contracts to serve in designated areas. This study attempts to identify the contract compliance intention of medical students in the ROTWMHE program and investigate the influencing factors and mechanisms.
Methods
From May to June 2023, a total of 1130 oriented medical students engaged in the ROTWMHE program were selected from oriented medical student educational institutions in Hubei Province to conduct questionnaire surveys. The questionnaire, based on the Theory of Planned Behavior, consisted of four parts: demographics, attitudes, subjective norms, and perceived behavioral control. Descriptive analysis, chi-square test, and multivariate logistic regression analysis were employed to identify the factors influencing the contract compliance intention of oriented medical students.
Results
A total of 1114 (98.58%) valid questionnaires were included, and the contract compliance intention rate of oriented medical students in Hubei Province was 75.31%. Regression analysis showed that attitudes, subjective norms, and perceived behavioral control all had statistically significant effects (P < 0.05). Specifically, the gender, the matriculation year, whether you apply for the RDTWME program voluntarily, attitude toward the education program, whether rural medical work holds value, whether rural healthcare systems require high-level medical professionals, maternal education attainment, family attitude toward the ROTWMHE program, compliance rate among peers, and whether you acquaint with rural healthcare work environment were all associated with contract compliance intention.
Conclusions
The contract compliance intention among oriented medical students in Hubei Province was relatively positive, but negative attitudes and the adverse effects of subjective norms have weakened their intention. Policymakers and medical educational institutions should formulate differentiated enrollment policies, reinforce integrity mechanisms in the employment sector, strengthen practice-based education and value cultivation related to rural healthcare, leverage new media platforms to enhance policy outreach, and improve the benefits and compensations to further enhance the contract compliance intention in oriented medical students.
Keywords: Oriented medical students, Contract compliance intention, Attitudes, Subjective norms, Perceived behavioral control
Background
Primary healthcare institutions remain the weakest link in China’s healthcare system. Rural facilities demonstrate particularly pronounced disparities, lagging behind urban counterparts in terms of infrastructure capacity and service coverage, with medical personnel shortages being the critical constraint [1, 2]. Despite approximately 45% of China’s population residing in rural areas, the number of licensed healthcare professionals per 100,000 urban residents is nearly twice that in rural regions [2]. These impede the efforts to improve health outcomes among rural residents.
Since 2010, in response to the developmental difficulties of rural healthcare, China has issued and prompted the Rural-Oriented Tuition-Waived Medical Higher Education (RDTWMHE) program. The program mandates regional health commissions to annually recruit and train a predetermined number of rural students through partnerships with local medical education institutions (designated medical educational institutions). In turn, students participating in the RDTWMHE program (oriented medical students) must contract with local health commissions to enroll at designated medical educational institutions and serve as rural physicians in designated areas for at least 3–6 years upon graduation (mandatory service period), in exchange for their free medical education and living allowances. By 2021, more than 70,000 oriented medical students have already entered rural work through this program [3]. Hubei Province, which serves as one of the first provinces to implement the RDTWMHE program, adopts multiple measures including optimizing the medical education system for oriented medical students through diverse channels and expanding the recruitment scope for rural healthcare workers to encourage the flow of medical professionals to the rural. However, Hubei Province exhibits substantial regional development disparities, with a pronounced imbalance in the allocation of medical resources between urban and rural areas. Despite progressive policy enhancements, challenges such as limited working conditions and restricted career development opportunities at the grassroots level have considerably diminished the attractiveness of the RDTWMHE program [4, 5], resulting in persistently high turnover rates among rural health workforce [6], especially in low intention to comply with contractual obligations among oriented medical students being a key manifestation [7].
Current research on the contract compliance intention of oriented medical students and its influencing factors mainly focuses on individual characteristics and attitudes, as well as the institutional framework of the RDTWMHE program. Literature indicates that factors such as gender, matriculation year, and household income significantly influence the contract compliance intention of oriented medical students [8, 9]. Meanwhile, individual cognition—including voluntary application, attitude toward the mandatory service period, and the education program—also plays a crucial role in shaping contract compliance intention [10–12]. In addition, institutional factors such as healthcare policies, compensation packages, and career advancement mechanisms have been identified as key variables affecting contract compliance intention [12–14]. While the prior research provides valuable insights into contract compliance intention and its determinants, they predominantly examine these elements in isolation and fail to integrate factors related to interpersonal relationships, and social environments, making it difficult to systematically explain the influencing mechanisms of contract compliance intention.
Oriented medical students represent a critical reserve of human resources for underserved rural healthcare institutions, and research on their intention to comply with contracts holds immediate relevance for achieving sustainable primary healthcare development. The Theory of Planned Behavior establishes an analytical framework integrating individual, interpersonal, and societal dimensions, with demonstrated predictive validity for the behavioral intention of healthcare professionals [12, 13]. It aligns with the research objectives and provides a systematic framework for investigating contract compliance intention. Accordingly, this study applies the Theory of Planned Behavior to survey the contract compliance intention of oriented medical students in Hubei Province, aiming to identify key influencing factors and provide suggestions for policymakers to refine relevant policies and strengthen the development of oriented medical talent.
Methods
Study design
The present cross-sectional survey was conducted across designated medical education institutions for the ROTWMHE program in Hubei Province from May to June 2023. The sampling frame encompassed all three undergraduate and ten vocational colleges authorized for oriented medical student training in the Province. This study employed a stratified cluster sampling method. Institutions were stratified into two tiers based on academic level (undergraduate vs. vocational colleges). Considering the overall proportion of institution types in Hubei Province, one undergraduate college (Hubei University of Traditional Chinese Medicine) and four vocational colleges (Hubei University of Science and Technology, Huanggang Polytechnic College, Jingchu University of Technology, and Xiangyang Polytechnic College) were selected using a random number table. This sampling frame ensured a proportional representation of oriented medical students across the Province. All enrolled oriented medical students at the five selected institutions were eligible participants. On-site research staff administered paper questionnaires, provided standardized instructions, and conducted immediate quality checks upon collection. Incomplete responses were rectified through follow-up verification during the survey session. The exclusion criteria are: (1) < 1 year of oriented medical education; (2) inability to complete surveys due to health/time constraints. The sample size is calculated by the formula N = Zα/2 × p(1 − p)/ δ2, Zα/2 = 1.96, p = 0.70 [17], δ = 0.05. The initial calculation yielded a minimum required sample size of 323. To account for potential invalid responses and non-participation (attrition rate ≤ 10%), the final target sample size was adjusted to 359. Anonymous surveys were adopted, and all respondents signed an informed consent form. Ultimately, 1130 students participated in this survey. Following the exclusion of incomplete, inconsistent, or non-compliant responses, 1114 valid questionnaires were retained (response rate was 98.58%). The study has followed the Declaration of Helsinki and was approved by the ethics committee at Wuhan University School of Medicine.
Theoretical framework
Ajzen (1985) proposed the Theory of Planned Behavior (TPB) as a theoretical framework for explaining and predicting individual behavioral intention [18]. It posits that behavioral intention—the immediate determinant of behavioral choice—is shaped by three key factors: (1) attitudes (personal evaluation of the target behavior), (2) subjective norms (perceived pressure from influential referents, including parents and peers), and (3) perceived behavioral control (self-efficacy and perceived external constraints). Contract compliance intention among oriented medical students exemplifies a multifactorial behavioral intention amenable to TPB analysis. Empirical studies have demonstrated the theory’s applicability in health domains and its strong predictive validity for healthcare professionals [15, 16, 19]. Therefore, this study employs TPB to systematically investigate the factors influencing the contract compliance intention of oriented medical students (Fig. 1).
Fig. 1.
Theoretical framework of the theory of planned behavior
Questionnaire
Based on the Theory of Planned Behavior, the Compliance Intention Survey for Oriented Medical Students was developed by synthesizing relevant literature and consulting both medical educators and experts in the field of rural medical service. The questionnaire underwent pilot testing to evaluate and refine its items and response options. It comprised four main sections: (1) demographics, including gender, age, matriculation year, major, residential regions, etc. (2) questions about attitudes [20, 21], including whether you apply for the RDTWMHE program voluntarily, contract compliance intention, attitude toward the education program, attitude toward mandatory service period, and whether rural medical work holds value, etc. (3) questions about subjective norms [22, 23], including family attitude toward the RDTWMHE program, compliance rate among peers (observed contract compliance rates in the oriented medical student cohort), etc. (4) questions about perceived behavioral control [24, 25], including the designated employment location, whether you acquaint with the rural healthcare work environment, and whether you acquaint with the policies related to the rural healthcare, etc. All questionnaire items were measured using a 3-point Likert scale, with response options, including: “Satisfied/Neutral/Dissatisfied”, “Support/Neutral/Do not support”, and “Yes/Neutral/No”. Given evidence that socioeconomic status moderates behavioral intention [26], Hubei Province’s 16 prefecture-level cities were categorized into three tiers based on their 2022 regional GDP, regarding the two issues of residential regions and designated employment location, namely, the Tier-1 regions (GDP ≥ 500 billion CNY), including Wuhan, Xiangyang, and Yichang; the Tier-2 regions (GDP between 500 billion CNY and 200 billion CNY), including Jingzhou, Xiaogan, Huanggang, and other six cities; Tier-3 regions (GDP ≤ 200 billion CNY), including Xianning, Enshi, Suizhou, and Ezhou [27]. The grouping was determined using the natural breaks method (Jenks optimization) to maximize within-group homogeneity and between-group heterogeneity. GDP data from province-directly-administered counties were consolidated for analysis. The Cronbach’s α coefficient of the questionnaire was 0.769, and Kaiser–Meyer–Olkin was 0.84, confirming its reliability and structural validity.
Statistical analysis
The database was constructed using EpiData 3.1 to ensure standardized data entry, followed by data cleaning and statistical analysis performed in SPSS 23.0. Descriptive statistics were computed to characterize respondents’ demographics and attributes, along with the distribution of contract compliance intention levels. Categorical variables were expressed as frequencies (%). Intergroup comparisons were conducted using chi-square tests. In addition, multiple logistic regression analysis was conducted to identify the critical factors influencing contract compliance intention of oriented medical students. A p value < 0.05 was considered as statistically significant.
Results
Demographic characteristics
Among the 1114 oriented medical students surveyed, 63.82% (n = 711) were female and 36.18% (n = 403) male, with a mean age of 20.14 ± 1.57 years. Most respondents (n = 827, 74.24%) majored in clinical medicine, and the remainder (n = 287, 25.76%) studied in Traditional Chinese Medicine. In addition, there were 820 (73.61%) respondents enrolled in undergraduate college and 294 (26.39%) attended vocational college. The majority were one-child or unmarried, with 691 (62.03%) and 1105 (99.19%), respectively. Plus, the matriculation year of 2021 and 2022 accounted for 37.43% (n = 417) and 35.82% (n = 399), the remaining were divided into 3.05% (n = 34) in 2018, 8.80% (n = 98) in 2019 and 14.90% (n = 166) in 2020. Regarding residential regions, 20.83% (n = 232) of participants were from Tier-1 regions, 60.06% (n = 747) from Tier-2 regions, and 12.12% (n = 135) from Tier-3 regions of Hubei Province. In annual household income, 56.73% (n = 632) reported incomes below 50,000 RMB, 33.30% (n = 371) between 50,000 RMB and 100,000 RMB, and only 9.96% (n = 111) above 100,000 RMB. 839 (75.31%) oriented medical students demonstrated positive compliance intention, while 275 (24.69%) held negative intention toward complying with their contract obligations.
Univariate analysis
Table 1 depicts the contract compliance intention of oriented medical students across different characteristics. Demographic factors significantly associated with contract compliance intention included gender (P = 0.011), matriculation year (P < 0.001), and residential regions (P < 0.001). Regarding attitudinal factors, whether you apply for the RDTWMHE program voluntarily (P < 0.001), whether you recognize the RDTWMHE program (P < 0.001), whether you recognize your major (P < 0.001), attitude toward the education program (P < 0.001), attitude toward mandatory service period (P < 0.001), and whether rural medical work holds value (P < 0.001) or rural healthcare systems require high-level medical professionals (P < 0.001) were found to be meaningful. For the Subjective Norms, maternal education attainment (P = 0.034), family attitude toward the RDTWMHE program, and compliance rate among peers (P < 0.001) all demonstrated significant associations. Perceived behavioral control, including the designated employment location (P < 0.001), whether you acquaint with the rural healthcare work environment (P < 0.001), and the policy relevant to the RDTWMHE program (P < 0.001) or rural healthcare (P < 0.001) were all significantly related to the contract compliance intention (Table 1).
Table 1.
Univariate analysis of contract compliance intention among oriented medical students
| Items | N | Unmotivated n (%) |
Motivated n (%) |
χ2 | P | |
|---|---|---|---|---|---|---|
| Demographics | Gender | |||||
| Male | 403 | 117 (29.03) | 286 (70.97) | 6.416 | 0.011 | |
| Female | 711 | 158 (22.22) | 553 (77.78) | |||
| Matriculation year | ||||||
| 2018 | 34 | 20 (58.82) | 14 (41.18) | 109.020 | < 0.001 | |
| 2019 | 98 | 56 (57.14) | 42 (42.86) | |||
| 2020 | 166 | 55 (33.13) | 111 (66.87) | |||
| 2021 | 417 | 86 (20.62) | 331 (79.38) | |||
| 2022 | 399 | 58 (14.54) | 341 (85.46) | |||
| Residential regions | ||||||
| Tier-1 regions | 232 | 40 (17.24) | 192 (82.76) | 144.547 | < 0.001 | |
| Tier-2 regions | 747 | 188 (25.17) | 559 (74.63) | |||
| Tier-3 regions | 135 | 47 (34.81) | 88 (65.19) | |||
| Attitudes | Whether you apply for the RDTWMHE program voluntarily | |||||
| No | 335 | 153 (45.67) | 182 (54.33) | 113.480 | < 0.001 | |
| Yes | 779 | 122 (15.66) | 657 (84.34) | |||
| Whether you recognize the RDTWMHE program | ||||||
| No | 150 | 106 (70.67) | 44 (29.33) | 238.618 | < 0.001 | |
| Neutral | 456 | 123 (26.97) | 333 (73.03) | |||
| Yes | 508 | 46 (9.06) | 462 (90.94) | |||
| Whether you recognize your major | ||||||
| No | 99 | 72 (72.73) | 27 (27.27) | 165.044 | < 0.001 | |
| Neutral | 467 | 131 (28.05) | 336 (71.95) | |||
| Yes | 548 | 72 (13.14) | 476 (86.86) | |||
| Attitude toward the education program | ||||||
| Dissatisfied | 167 | 116 (69.46) | 51 (30.54) | 252.077 | < 0.001 | |
| Neutral | 488 | 124 (25.41) | 364 (74.59) | |||
| Satisfied | 459 | 35 (7.63) | 424 (92.37) | |||
| Attitude toward mandatory service period | ||||||
| Dissatisfied | 373 | 187 (50.13) | 186 (49.87) | 207.026 | < 0.001 | |
| Neutral | 313 | 57 (18.21) | 256 (81.79) | |||
| Satisfied | 428 | 31 (7.24) | 397 (92.76) | |||
| Whether rural medical work holds value | ||||||
| No | 78 | 61 (78.21) | 17 (21.79) | 190.099 | < 0.001 | |
| General | 352 | 124 (35.23) | 228 (64.77) | |||
| Yes | 684 | 90 (13.16) | 594 (86.84) | |||
| Whether rural healthcare systems require high-level medical professionals | ||||||
| No | 68 | 51 (75.00) | 17 (25.00) | 107.507 | < 0.001 | |
| Neutral | 330 | 90 (27.27) | 240 (72.73) | |||
| Yes | 716 | 134 (18.72) | 582 (81.28) | |||
| Subjective norms | Maternal academic attainment | |||||
| Elementary school or below | 322 | 84 (26.09) | 238 (73.91) | 8.688 | 0.034 | |
| Middle school | 424 | 93 (21.93) | 331 (78.07) | |||
| High school/secondary vocational school | 271 | 81 (29.89) | 190 (70.11) | |||
| College/associate degree or above | 97 | 17 (17.53) | 80 (82.47) | |||
| Family attitude toward the RDTWMHE program | ||||||
| Disapprove | 116 | 74 (63.79) | 42 (36.21) | 150.450 | < 0.001 | |
| Neutral | 221 | 82 (37.10) | 139 (62.90) | |||
| Approve | 777 | 119 (15.32) | 658 (84.68) | |||
| Compliance rate among peers | ||||||
| < 50% | 211 | 116 (54.98) | 95 (45.02) | 139.223 | < 0.001 | |
| 50–80% | 499 | 109 (21.84) | 390 (78.16) | |||
| ≥ 80% | 404 | 50 (12.38) | 354 (87.62) | |||
| Perceived behavioral control | Designated employment location | |||||
| Tier-1 regions | 231 | 42 (18.18) | 189 (81.82) | 13.043 | < 0.001 | |
| Tier-2 regions | 749 | 186 (24.83) | 563 (75.17) | |||
| Tier-3 regions | 134 | 47 (35.07) | 87 (64.93) | |||
| Whether you acquaint with rural healthcare work environment | ||||||
| No | 503 | 169 (33.60) | 334 (66.40) | 39.370 | < 0.001 | |
| Neutral | 420 | 75 (17.86) | 345 (82.14) | |||
| Yes | 191 | 31 (16.23) | 160 (83.77) | |||
| Whether you acquaint with the policy related to the RDTWMHE program | ||||||
| No | 278 | 119 (42.81) | 159 (57.19) | 72.251 | < 0.001 | |
| Neutral | 482 | 106 (21.99) | 376 (78.01) | |||
| Yes | 354 | 50 (14.12) | 304 (85.88) | |||
| Whether you acquaint with policies related to rural healthcare | ||||||
| No | 263 | 83 (31.56) | 180 (68.44) | 13.510 | < 0.001 | |
| Neutral | 494 | 125 (25.30) | 369 (74.70) | |||
| Yes | 357 | 67 (18.77) | 290 (81.23) | |||
RDTWMHE the Rural-Oriented Tuition-Waived Medical Higher Education
Multiple logistic regression analysis
To further identify determinants of contract compliance intention among oriented medical students, multivariable logistic regression incorporated all factors that demonstrated statistical significance in univariate analyses as independent variables. The model with the best goodness-of-fit (Nagelkerke R2 = 0.74) was selected as the final model. Multicollinearity diagnostics indicated tolerance (Tol) values > 0.3 and variance inflation factors (VIF) < 3.5 for all included variables, confirming the absence of significant collinearity. The Hosmer–Lemeshow test yielded a non-significant result (P = 0.843), suggesting robust model calibration.
Table 2 summarizes the multivariate predictors of contract compliance intention. Oriented medical students with male gender (OR = 0.688), earlier matriculation year (enrollment in 2018: OR = 0.246, in 2020: OR = 0.292), non-voluntary application to the RDTWMHE program (OR = 0.524), dissatisfied with the education program (OR = 0.212), considering rural medical work holds no value (OR = 0.232) or neutral (OR = 0.443), maternal education attainment of college/associate degree or above (OR = 0.403), family disapproval of the RDTWMHE program (OR = 0.449), and peer compliance rates below 50% (OR = 0.392), and those unfamiliarity with the rural healthcare work environment (OR = 0.480) were exhibited lower intention to comply with the contract (P < 0.05). Conversely, those who with neutral attitudes regarding the need for high-level medical professionals in rural healthcare systems (OR = 1.791) had higher intention to comply with the contract (P < 0.05) (Table 2, Fig. 2).
Table 2.
Multiple logistic regression analysis of contract compliance intention among oriented medical students
| Items | Reference | β | P | OR | 95% CI | |||
|---|---|---|---|---|---|---|---|---|
| LL | UL | |||||||
| Demographics | Gender | |||||||
| Male | Female | − 0.374 | 0.046 | 0.688 | 0.476 | 0.994 | ||
| Matriculation year | ||||||||
| 2018 | 2022 | − 1.400 | 0.005 | 0.246 | 0.094 | 0.650 | ||
| 2019 | − 1.229 | 0.000 | 0.292 | 0.152 | 0.564 | |||
| 2020 | − 0.490 | 0.091 | 0.613 | 0.347 | 1.082 | |||
| 2021 | − 0.315 | 0.173 | 0.730 | 0.464 | 1.148 | |||
| Attitudes | Whether you apply for the RDTWMHE program voluntarily | |||||||
| No | Yes | − 0.646 | 0.001 | 0.524 | 0.358 | 0.767 | ||
| Attitude toward the education program | ||||||||
| Dissatisfied | Satisfied | − 1.553 | 0.000 | 0.212 | 0.102 | 0.438 | ||
| Neutral | − 0.519 | 0.092 | 0.595 | 0.325 | 1.089 | |||
| Whether rural medical work holds value | ||||||||
| No | Yes | − 1.460 | 0.000 | 0.232 | 0.104 | 0.518 | ||
| Neutral | − 0.815 | 0.001 | 0.443 | 0.270 | 0.727 | |||
| Whether rural healthcare systems require high-level medical professionals | ||||||||
| No | Yes | − 0.447 | 0.310 | 0.640 | 0.270 | 1.517 | ||
| Neutral | 0.583 | 0.020 | 1.791 | 1.096 | 2.927 | |||
| Subjective norms | Maternal academic attainment | |||||||
| Middle school | Elementary school or below | − 0.724 | 0.098 | 0.485 | 0.206 | 1.143 | ||
| High school/secondary vocational school | − 0.336 | 0.417 | 0.715 | 0.318 | 1.608 | |||
| College/associate degree or above | − 0.909 | 0.028 | 0.403 | 0.179 | 0.906 | |||
| Family attitude toward the RDTWMHE program | ||||||||
| Disapprove | Approve | − 0.800 | 0.006 | 0.449 | 0.252 | 0.799 | ||
| Neutral | − 0.122 | 0.592 | 0.885 | 0.567 | 1.382 | |||
| Compliance rate among peers | ||||||||
| < 50% | ≥ 80% | − 0.937 | 0.000 | 0.392 | 0.234 | 0.657 | ||
| 50% ~ 80% | − 0.079 | 0.724 | 0.924 | 0.595 | 1.434 | |||
| Perceived behavioral control | Whether you acquaint with rural healthcare work environment | |||||||
| No | Yes | − 0.734 | 0.019 | 0.480 | 0.260 | 0.886 | ||
| Neutral | 0.040 | 0.900 | 1.041 | 0.559 | 1.937 | |||
OR Odds Ratio, CI Confidence Interval, LL lower limit, UL Upper limit, RDTWMHE the Rural-Oriented Tuition-Waived Medical Higher Education
Fig. 2.
Multivariate analysis of demographic, attitudinal, and social factors influencing contract compliance intention among oriented medical students
Discussion
Contract compliance intention rate is relatively good, while negative factors existed
The overall contract compliance intention rate of oriented medical students in Hubei Province was 75.31%, surpassing rates reported in comparable studies from Inner Mongolia Autonomous Region (66.90%) [28] and Shandong Province (71.30%) [17], which may be attributable to Hubei’s enhanced institutional safeguards for the RDTWMHE program. Its policy innovations such as permitting primary healthcare institutions to exceed standard public institution salary caps for performance-based compensation, coupled with preferential promotion criteria (including direct senior title conferral) for rural health workers, mitigated economic and career progression barriers—thereby multi-dimensionally incentivizing compliance.
While academic degree (undergraduate vs. vocational college) did not significantly predict contract compliance intention in univariate analysis, likely due to equivalent policy incentives across educational tiers, gender emerged as a critical determinant, with male students demonstrating only 0.68 times the contract compliance intention of female counterparts. This disparity aligns with established social role theory [29], wherein traditional male breadwinner expectations may prioritize higher-paying career opportunities despite instability risks, whereas female comparatively reduced economic pressures and stronger familial responsibilities may foster greater alignment with the characteristic features of rural healthcare positions [30], including contained work hours, job stability. These dynamics were empirically evidenced by significantly higher valuations of rural medical work (63.00% vs. 51.20% for males) and stronger policy endorsement (49.93% vs. 38.75%) among female respondents, confirming that external expectations based on gender systematically shape attitudes toward the RDTWMHE program. Notably, earlier enrollment respondents exhibited markedly lower contract compliance intention, likely stemming from two systemic factors. First, penalty structures for contract breaches remain weak, limited primarily to the integrity system, while during hiring processes, employers typically verify only diplomas and medical licenses [8]. Concurrently, expanding urban employment opportunities enhance perceived behavioral control by reinforcing oriented medical students' confidence in accessing socioeconomic resources particularly [27, 28]. Thus, as approaching graduation, escalating financial pressures combined with reduced barriers to accessing social resources appear to erode initial service commitments [31]. Senior students create negative tendencies in their contract compliance, enticing some of them into other careers [9]. Policymakers should thus implement gender-differentiated admission strategies accounting for observed contract compliance intention disparities, and reinforce integrity mechanisms in the employment sector to ensure the effectiveness of punitive measures (Fig. 3).
Fig. 3.
TPB-based analysis of contract compliance intention among oriented medical students
Attitudes with lower occupational identity affected contract compliance intention
Research showed that negative attitudes toward both the RDTWMHE program application and the education program significantly undermined contract compliance intention among oriented medical students. While 69.93% of respondents voluntarily applied to the RDTWMHE program, most cited extrinsic motivations (academic admission advantages, financial subsidies, or employment guarantees), with only 4.10% (n = 32) reporting intrinsic motivation to serve rural communities. This trend highlighted a fundamental lack of professional interest in rural medical careers [11]. The training program, as the cornerstone of rural-oriented medical student cultivation, was rated satisfactory by fewer than half of respondents, underscoring systemic deficiencies in the policy’s educational attractiveness during training phases [32]. Owing to this inadequacy, oriented medical students struggled to develop proactive interest in rural medical careers or motivation to explore policy related to rural during medical school, and ultimately impeded the formation of positive occupational cognitions and a sense of mission-driven responsibility toward rural service [33]. Simultaneously, it is noteworthy that recognition of both rural healthcare work value and the need for highly skilled professionals demonstrated a strong positive association with contract compliance intention, further confirming the pivotal role of professional identity in sustaining commitment [14, 34]. Despite Hubei's progressive policy refinements, the education paradigm remains structurally indistinguishable from conventional medical education—maintaining discipline-based teaching models without specialized adaptations for rural practice. This missed curricular differentiation design fails to cultivate appropriate occupational cognition [32, 35]. To address these challenges, policymakers should develop practice-oriented training modules focused on rural healthcare requirements, and strengthen value-based education to enhance professional recognition formation (Fig. 3).
Significant others showed limited awareness and provided minimal support
Maternal education attainment has been suggested as an influencing factor on contract compliance intention. This may be attributed to the influence of family relational dynamics, particularly in households with highly educated mothers who invest greater time and resources in child-rearing, thereby strengthening intergenerational bonds and exerting greater influence over their children’s intention [36]. Beyond that, previous relevant studies have verified that contract compliance intention among oriented medical students exhibited congruent trends with familial and peer attitudes [8, 37]. About 70.83% enrolled in the RDTWMHE program dictated mainly with familial advice, and respondents embedded in social networks with higher contract compliance rates among peers demonstrated significantly greater recognition of rural healthcare value (70.79%) compared to those in networks with lower rates (18.48%), which attests that the stance of others could be in on the decision-making psychology and intention of oriented medical students. Current RDTWMHE policy primarily focuses on recruitment, training, and service fulfillment components, lacking clear provisions for effective policy dissemination and interpretation. Reliance on official channels, such as government and university websites and social media accounts, resulted in limited and unidirectional information flow, contributing to inadequate public awareness. This deficit has fostered negative perceptions toward the policy [17]. Eventually, community members exert external pressure through close-knit social networks, imposing their subjective perceptions on oriented medical students and thereby affecting their contract compliance intention [38]. To address this, relevant authorities should leverage new media platforms (e.g., Weibo, Douyin) to enhance policy outreach, foster comprehensive public understanding, and rebuild trust and support for the RDTWMHE program among key stakeholders, including family and friends (Fig. 3).
Perceived availability of social resources influenced contract compliance intention
Contrary to prior studies identifying limited living conditions and suboptimal work environments as deterrents to compliance [39], our survey revealed higher contract compliance intention among oriented medical students familiar with rural healthcare work environment. This discrepancy may reflect socioeconomic-mediated perceptual differences [40]. Hubei Province exhibits marked regional economic disparities, with Tier-2 and Tier-3 regions demonstrating nearly ¥10,000 lower per capita disposable income than Tier-1 urban centers [41]. Significantly, 76.43% of students with higher familiarity regarding rural healthcare environments originated from these less developed regions (Tier-2 and Tier-3), while 57.10% reported annual household incomes below ¥50,000, and 67.39% had parents with junior high education or lower. As an underprivileged group, students who familiarized with the rural healthcare work environment were inclined to have lower household incomes and parental educational attainments, making their families less likely to have means to independently provide extra social opportunities and resources. Consequently, constrained social capital (e.g., professional networks, family financial support) heightens risk aversion and lowers career expectations among socioeconomically disadvantaged students from less developed regions, thereby structurally inhibiting the formation of contract breach intention, which was in coherence with the research of Goel [42]. To transform this passive compliance into genuine retention, authorities should enhance welfare provisions for rural practitioners (e.g., housing subsidies, childcare support) and institutional safeguards against post-graduation uncertainties, which facilitate a stable transition from academic commitment to professional practice while addressing fundamental livelihood concerns (Fig. 3).
Limitations
The findings of this study encompassed the potentially pivotal factors influencing oriented medical students to abide by contracts related to working in rural healthcare institutions; however, several limitations still existed. Initially, while all oriented medical students constituted the potential study subjects, the survey excluded some upper-year students who were completing mandatory off-campus clinical rotations at assigned practice sites. This sampling constraint may have introduced bias, as the later matriculation year (2021–2022) demonstrated significantly higher baseline contract compliance intention than the earlier, potentially inflating aggregate compliance intention estimates in more recent cohorts. In addition, although considerable efforts were exerted when developing the questionnaire, certain theoretical constructs of the Theory of Planned Behavior were not comprehensively measured and need further enrichment. Similar to other studies regarding the intention of oriented medical students to work in rural areas, it elucidated self-reported attitudes rather than observed career choices. Thus, further research should explore the influence of significant factors on the final decision through a follow-up survey.
Acknowledgements
Not applicable.
Author contributions
LX, lead author, participated in data collection, conducted the analysis, and wrote the manuscript. WC, corresponding author, designed the topic of this paper, and participated in questionnaire preparation, manuscript writing, and revision. YXX, co-corresponding author, participated in the manuscript revision and provided suggestions. JH, co-author, offered suggestions for the manuscript revision. LSS, co-author, designed the questionnaire and took data collection. All authors have reviewed and approved the manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, or publication of this article. The work of Wang C was supported by the Hubei Provincial Educational Science Planning Project (NO. 2022GB003), the Guangdong Basic and Applied Basic Research Foundation Project (NO. 2023A1515110672), and the Hubei Provincial Education Department, Philosophy and Social Science Project (NO. 22G001). The work of Yin XX was supported by the National Natural Science Foundation of China (NO.72074092). The other authors received no external funding for the research, authorship, and/or publication of this article.
Data availability
The data used and/or analyzed during the study are not publicly available due to privacy and data protection concerns but are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
All methods and procedures in this research were conducted in accordance with the ethics guidelines of the Declaration of Helsinki and were approved by the Biomedical Ethics Committee of Wuhan University. Informed consent was provided for all participants and they were only allowed to participate in the survey after signing the consent.
Consent for publication
Not applicable.
Competing interest
The authors declare no competing interest.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Wang Chao, Email: wangch@whu.edu.cn.
Yin Xiaoxv, Email: yxx@hust.edu.cn.
References
- 1.Hou J, Liang Y, Tong L, et al. Targeted enrollment of medical students for rural China: prospects and challenges. Adv Med Educ Pract. 2019;10:1021–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.National Health Commission of the PRC. Statistical Bulletin on the Development of China's Health Care Program. 2022. http://www.nhc.gov.cn/guihuaxxs/s3585u/202309/6707c48f2a2b420fbfb739c393fcca92.shtml. Accessed 26 Jun 2024.
- 3.Revitalizing higher Education and Serving High-quality Development in Central and Western China. 2024. http://www.moe.gov.cn/fbh/live/2021/53921/sfcl/202112/t20211227_590326.html. Accessed 24 Jun 2024.
- 4.Esu EB, Chibuzor M, Aquaisua E, et al. Interventions for improving attraction and retention of health workers in rural and underserved areas: a systematic review of systematic reviews. J Public Health. 2021;43(Suppl):i54–66. [DOI] [PubMed] [Google Scholar]
- 5.Budhathoki S, Zwanikken P, Pokharel P, et al. Factors influencing medical students’ motivation to practise in rural areas in low-income and middle-income countries: a systematic review. BMJ Open. 2017;7:e013501. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Yan W, Gao X, Wang W, et al. Job satisfaction of graduates of rural oriented medical students training project in Jiangsu Province, China: a cross-sectional study. BMC Med Educ. 2022;22(1):9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ao WH, Lin CM, Zhang YC, et al. Progress and practice of policies related to the use and incentive of order-oriented general practitioners in rural areas in China. Chin Fam Med. 2025;06:1–9. [Google Scholar]
- 8.Gill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical students’ choice of family medicine: effects of rural versus urban background. Can Fam Physician. 2012;58(11):e649–57. [PMC free article] [PubMed] [Google Scholar]
- 9.Liu J, Zhu B, Mao Y. Association between rural clinical clerkship and medical students’ intentions to choose rural medical work after graduation: a cross-sectional study in western China. PLoS ONE. 2018;13(4):e195266. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Playford D, Ngo H, Gupta S, et al. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med J Aust. 2017;207:154–8. [DOI] [PubMed] [Google Scholar]
- 11.Wang L, Yang Y, Zhu J, et al. Professional identity and mental health of rural-oriented tuition-waived medical students in Anhui Province, China. BMC Med Educ. 2019;19(1):199. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Brutting C, Herget S, Bauch F, et al. Factors promoting willingness to practice medicine in rural regions and awareness of rural regions in the university’s catchment area - cross-sectional survey among medical students in central Germany. GMS J Med Educ. 2023;40(4):c52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bao M, Huang C. Job preferences of medical and nursing students seeking employment in rural China: a discrete choice experiment. BMC Med Educ. 2021;21(1):146. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Arscott-Mills T, Kebaabetswe P, Tawana G, et al. Rural exposure during medical education and student preference for future practice location—a case of Botswana. Afr J Prim Health Care Fam Med. 2016;8:a1039. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Przymuszała P, Szmelter J, Zielińska-Tomczak Ł, et al. Future physicians’ behavioral intentions towards collaborative practice - a qualitative study on polish final-year medical students guided by the Theory of Planned Behavior. BMC Med Educ. 2023;23:151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Sussman R, Gifford R. Causality in the Theory of Planned Behavior. Pers Soc Psychol Bull. 2019;45(6):920–33. [DOI] [PubMed] [Google Scholar]
- 17.Wang Y, Xie MQ, Cui XX, et al. Willingness to comply with contract and its relationship with motivation, policy perception and career planning of oriented-service medical students in Shandong Province. Health Dev Policy Res. 2022;2(25):205–9. [Google Scholar]
- 18.Ajzen I. The theory of planned behavior. Organ Behav Hum Dec. 1991;50(2):179–211. [Google Scholar]
- 19.Godin G, Kok G. The theory of planned behavior: a review of its applications to health-related behaviors. Am J Health Promot. 1996;11(2):87–98. [DOI] [PubMed] [Google Scholar]
- 20.Samoggia A, Rossi G, Fantini A, et al. What drives consumers’ intention towards fairness-oriented products purchasing? An emotion-extended model of theory of planned behaviour. Heliyon. 2025. 10.1016/j.heliyon.2024.e41285. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Zhang R, Fu MSC, Yuan J, et al. Colonoscopy screening behavior in first-degree relatives of colorectal cancer patients: a qualitative study based on the theory of planned behavior. Inqu J Medical Care Organ Provis Finan. 2024. 10.1177/00469580241305344. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Chen Q, Ma J, Wu R, et al. Factors influencing hepatitis B vaccination intention and behavior among college students in Tibet: Insights from the expanded theory of planned behavior. Hum Vaccin Immunother. 2025;21(1):2452026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Zhu P, Xu X, Zhai C, et al. Turnover intentions among rural-oriented medical students in Western China: a constructivist grounded theory study. Prim Health Care Res Dev. 2025;26:e28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Talbert N, Wong N. In Whom we trust: the effect of trust, subjective norms, and socioeconomic status on attitudes and COVID-19 vaccination intentions. Health Commun. 2025;40(11):2375–88. [DOI] [PubMed] [Google Scholar]
- 25.Singh N, Rawat B, Chaubey D, et al. Understanding the dynamics of consumer behavior and purchase intentions for green cosmetic products in North India: a gender-neutral approach. F1000Research. 2025;13:611. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Goel S, Angeli F, Dhirar N, et al. What motivates medical students to select medical studies: a systematic literature review. BMC Med Educ. 2018;18:16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Statistical Bulletin of National Economic and Social Development of Hubei Province. Hubei Provincial Bureau of Statistics. 2022. http://tjj.hubei.gov.cn/tjsj.
- 28.Qiao T, Geater AF, Du H, et al. Employment intentions among rural order-oriented medical students in inner Mongolia autonomous region. China Work. 2023;76(1):393–401. [DOI] [PubMed] [Google Scholar]
- 29.Chuenkongkaew W, Negandhi H, Lumbiganon P, et al. Attitude towards working in rural area and self-assessment of competencies in last year medical students: a survey of five countries in Asia. BMC Med Educ. 2016;16:238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Ziegler S, Zimmermann T, Krause-Solberg L, et al. Male and female residents in postgraduate medical education–a gender comparative analysis of differences in career perspectives and their conditions in Germany. GMS J Medical Educ. 2017;34(5):53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Guilfoyle C, Huang PH, Forster L, et al. Factors predicting rural location employment intent and choice among medical students and graduates. Korean J Med Educ. 2022;34(4):273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Fan G, Lin Z, Luo Y, et al. Role of community health service programs in navigating the medical ethical slippery slope—a 10-year retrospective study among medical students from southern China. BMC Med Educ. 2019;19(1):240. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Knight E, Andrew J, Mahomed O. Developing primary health care and public health competencies in undergraduate medical students. South African Fam Pract. 2017;59(3):103–9. [Google Scholar]
- 34.Kaye D, Mwanika A, Sekimpi P, et al. Perceptions of newly admitted undergraduate medical students on experiential training on community placements and working in rural areas of Uganda. BMC Med Educ. 2010;10:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Mcgrail M, Woolley T, Pinidiyapathirage J, et al. Exploring recent trends (2014–21) in preferencing and accepting Queensland medical internships in rural hospitals. BMC Health Serv Res. 2024;24(1):236. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Ostovarfar J, Kaveh M, Vardanjani H, et al. Improving family health climate, effect of role modeling and maternal support in female students. BMC Prim Care. 2023;24(1):70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Zhang L, Bossert T, Mahal A, et al. Attitudes towards primary care career in community health centers among medical students in China. BMC Fam Pract. 2016;17:75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Hai M, Tian YY, Kang YH, et al. The influence of college students’ identity expectations on behavior choices in different social contexts. Psychol Res. 2023;16(5):467–73. [Google Scholar]
- 39.Kolie D, Van De Pas R, Codjia L, et al. Increasing the availability of health workers in rural sub-Saharan Africa: a scoping review of rural pipeline programs. Hum Resour Health. 2023;21(1):20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Kotha S, Johnson J, Galea S, et al. Life course factors and likelihood of rural practice and emigration: a survey of Ghanaian medical students. Rural Remote Health. 2012;12:1898. [PubMed] [Google Scholar]
- 41.Hubei Provincial Bureau of Statistics. Tianmen Statistical Yearbook. 2022. https://tjj.hubei.gov.cn/tjsj/sjkscx/tjnj/gsztj/tms/202403/P020240313474824427730.pdf.
- 42.Goel S, Angeli F, Dhirar N, et al. Factors affecting medical students’ interests in working in rural areas in North India-a qualitative inquiry. PLoS ONE. 2019;14(1):e210251. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and/or analyzed during the study are not publicly available due to privacy and data protection concerns but are available from the corresponding author upon reasonable request.