Table 2 Influential factors on retention of physicians in rural and underdeveloped areas

Financial factors

➢ Improved earning potential (18)

➢ Individual incentive programs (18)

➢ Financial incentives (20, 23, 18, 25, 27, 29, 41, 43, 45)

➢ Adequate and fair pay scale (20)

➢ Transparency of the payment system (16)

➢ High salaries (9, 24)

➢ High Earnings from the practice (9)

➢ Bolstering incomes for employed physicians (14)

➢ Favorable salary levels (14)

➢ Increasing reimbursement levels (14) Remuneration (12,18, 23, 27)

➢ Desirable average monthly payments (7)

➢ Various allowances (7)

➢ Financial bonus (7)

➢ Good revenues/patient volume (13)

➢ Financial support (8)

➢ Increase in physicians’ income (25, 30)

➢ Guarantee of a position (12)

➢ Opportunities to perform research (12)

➢ Financial compensations (26)

➢ Loan repayment (29)

➢ Scholarship throughout their medical education (29)

➢ Wages (36)

➢ Future tuition (36)

➢ An alternate payment plan (39)

➢ Comprehensive payment plans (39)

➢ Increased funding (39)

➢ Direct financial support for overhead expenses (39)

➢ Special funding for rural clinics, including facilities, support staff, and administration, regardless of compensation model (39)

➢ Financial support for travel and accommodation (39)

➢ Financial motivations (40)

➢ Funding for continuing medical education (45)

➢ Having a partner who wants to live and work in a metropolitan environment (18)

➢ Desire for a metropolitan lifestyle (18)

➢ Unsuitable requirements of salary (16)

➢ Irregular payments (16)

➢ High deductibles (16)

➢ Lower financial bonus (7)

➢ Lower income (7)

➢ Willingness to pay for working in an urban area (7)

➢ Low remuneration (8)

➢ High tuition fees (8)

➢ Lack of economic incentives (26)

➢ Differences between private and public sector payments (26)

➢ Lack of rewards (27)

➢ supplementary income from locum (27)

➢ Economic problems (32)

➢ High fuel costs (45)

➢ Inappropriate payment (33)

➢ Inappropriate salary (33)

➢ Lower reimbursements (34)

➢ Influence of monitoring score on salary (35)

➢ Delay in payments (35)

➢ Low salary(37)

➢ Income sources (22)

➢ Income expectations (26)

➢ Financing Method (32)

➢ Monthly payment time (33)

➢ Rate of payment (37)

➢ Income (41)

Career and professional factors

➢ Group practice arrangement with other clinicians (18)

➢ Opportunities for leadership (18)

➢ Job growth opportunities (19)

➢ Working toward health equity (4)

➢ Promotion prospects status (20)

➢ Providing facilities for phone or email contact with seniors or specialist colleagues for advice (20)

➢ Career development (20)

➢ Professional development opportunity (20)

➢ Functional teams (20)

➢ Autonomy on clinical issues (14)

➢ Professional support (22)

➢ Career opportunities (22)

➢ High professional expectations (22)

➢ Training opportunities (7)

➢ Skills Development (7)

➢ Longer work experience (7)

➢ Scholarship obligation (13)

➢ Autonomy/freedom in the rural practice setting (13)

➢ Recruiting and developing students with an ‘affinity’ for rural communities and services (13)

➢ Educational strategies (8)

➢ Reservation of post-graduate seats for doctors who have served in rural areas (8)

➢ Involving rural doctors in teaching medical students (8)

➢ Arranging continuing education programs for rural doctors (8)

➢ Introduction of compulsory rural service after graduation (8)

➢ Educational investment (8)

➢ Offering professional development opportunities (8)

➢ Educational initiatives to create doctors for rural areas (8)

➢ Selecting medical students who have a rural background (8)

➢ Community-based medical Education (8)

➢ Providing a partial or complete tuition fee waiver in return for rural service (8)

➢ Career Development (27)

➢ Professional or career incentives (27)

➢ Chance to learn new procedures (43)

➢ Rural or underserved postgraduate training (29)

➢ Retainer schemes (29)

➢ Continuing medical education workshops (29)

➢ Initiative Zone Educational Incentive scheme (29)

➢ Financial investment (29)

➢ Graduate in family medicine (31)

➢ Early rural exposure for trainees (45)

➢ Training local students (45)

➢ Educational opportunities (45)

➢ Increasing the number of rural students in local schools (45)

➢ Increasing admissions for rural students (45)

➢ Training and education (36)

➢ Training and purchase of patient-record and information systems (39)

➢ Providing forms of licensure to provide services (39)

➢ Provide forms of licensure to permit rural physicians to cross provincial borders to provide locum services (39)

➢ Career Development Programs (40)

➢ Absence of proper system or policy (40)

➢ Expanding education services (40)

➢ Provision of post-graduation and in-service training (40)

➢ Establishment of medical colleges in rural areas (40)

➢ Continuing medical education (41)

➢ National medical graduate (42)

➢ Accessing higher education (42)

➢ Emphasize on the social aspect of recruitment (42)

➢ Lack of collegial support among rural general practices (18)

➢ Lack of opportunity to take vacations for personal reasons or continuing medical education (18)

➢ High Professional standards (9)

➢ Specialty and educational requirements and infrastructure (22)

➢ Procedural skills (23)

➢ Shorter job history (7)

➢ Barriers to career advancement (13)

➢ Increasing specialization (25)

➢ Professional isolation (27)

➢ Not having continuing education opportunities (27)

➢ Professional imprisonment (27)

➢ Study leave or international opportunities (27)

➢ Lack of career development guidelines (27)

➢ Educational problems (32)

➢ Poor transportation infrastructure (45)

➢ professional isolation (35)

➢ Lack of promotion opportunities (37)

➢ Feel negative to current job prospects (37)

➢ Seeking better career development (37)

➢ Lack of chance of promotion (37)

➢ Low education level (37)

➢ Limited professional ability (37)

➢ Limited or distant access to specialists and technological support (39)

➢ International medical graduate (42)

➢ Practice size and type (23, 41)

➢ Long term education (7)

➢ Lack of promotion opportunities (13)

➢ Having an established career path (25)

➢ improvement opportunities (28)

➢ Educational factors (28)

➢ Type of secondary education, and type of higher secondary education (28)

➢ working expertise (31)

➢ Enhanced skills programs (45)

➢ Longer postgraduate training (45)

➢ Midlevel practitioners (34)

➢ Age (37)

➢ Lack of opportunity to use the abilities (37)

➢ Medical training (42)

➢ Changing the medical education model (42)

Working conditions factors

➢ Low workload (18)

➢ Regular work hours (18)

➢ level of collegial support (18)

➢ Supervisor level of support (18)

➢ Improvements in information technology (18)

➢ Job flexibility (25, 34, 19)

➢ Supporting systems (19)

➢ Staff function as team (19)

➢ Supportive family and work/life balance (19)

➢ Supportive administration (19)

➢ Effective support staff (19)

➢ Social justice (19)

➢ Developing a locum service to allow rural doctors to take annual leave and sabbaticals (20)

➢ A reasonable level of infrastructure (20)

➢ Working security (16, 20)

➢ A secure working environment (20)

➢ Opportunities for continuing medical education (20)

➢ Compulsory services commitment (16) Educating native manpower (16)

➢ Workplace with a high level of progressive healthcare (9)

➢ Good working environment (9)

➢ Good infrastructure (9)

➢ Rich instrumental background (9)

➢ Reasonable workload (9)

➢ Incentive benefits (9)

➢ Good equipment (9)

➢ Access to medical information and consultations (9)

➢ Opportunities to achieve professional goals (9)

➢ Modifiable characteristics of work (21)

➢ Offering leadership opportunities (21)

➢ Promoting practice ownership (21)

➢ Coordinating cross-coverage arrangements (21)

➢ Professional work (21)

➢ Preference for a location (22) Lack of educational opportunities for children (22)

➢ Work commitments (22)

➢ High career pathways (34) Annual leave opportunities (23)

➢ Business structure (23)

➢ Paid locum relief (23)

➢ Good relations with the supervisor (7)

➢ Increasing level of the facility (7)

➢ Call coverage (13)

➢ Provision of improved working conditions (8)

➢ Improving living and working conditions and environment (8)

➢ Good service infrastructure (25) Educational incentives to promote working (12)

➢ Personal security at workplace (12)

➢ Access to online information technology for bibliographic search (12)

➢ Ability to use new cutting edge technologies (12)

➢ Access to specialist referral network via telephone and web (12)

➢ Adequate infrastructure at workplace (12)

➢ Access to high-complexity regional hospital to refer patients (12)

➢ Contact with medical technology (12)

➢ Rewards and promotion system (27)

➢ support or supervision (27)

➢ Access to the scholarships (27)

➢

➢ No possibility for contacting a colleague for advice (27)

➢ Organizational incentives (27)

➢ Infrastructure development (27)

➢ Recruiting rural students (29)

➢ Support for professional development or research marketing (29)

➢ Wellbeing or peer support initiatives (29)

➢ Chances for advancement on this job (30)

➢ Appropriate work conditions (30)

➢ The chance to do something that makes use of their abilities (30)

➢ Competence of the manager in making decisions (30)

➢ Work stability (30)

➢ Employment relationship (31)

➢ Fixed office instructions (32)

➢ The specified working hours (32)

➢ Quantity and quality of feedback (32)

➢ Fewer working hours (45)

➢ Immigration policies (45)

➢ Broad scope of practice (45)

➢ Practice opportunities (30)

➢ Positive clerkship experiences (30)

➢ Specific practice opportunities such as teaching, hospital work (30)

➢ Lack of access to electronic medical records (30)

➢ Established relationships with specialists (30)

➢ Security at work (33)

➢ Change management (33)

➢ Political support of the government (33)

➢ Provide needed infrastructure (33)

➢ Organization of practice (35)

➢ Equipment (36)

➢ Social welfare benefits (37)

➢ Growth rate of investment in human resources (37)

➢ Devise retirement incentives specific to rural physicians (39)

➢ Clinical support program (39)

➢ Support staff (41)

➢ Ability to take time off (41)

➢ Group practice (41)

➢ No opportunity for working part-time

➢ Remaining located far from family and friends over an extended period (18)

➢ Less opportunity for private practice (19)

➢ Inadequate food service equipment (20)

➢ Minimal facilities (20)

➢ Lack of operating room facilities, equipment and blood transfusion services or even basic essential drugs (20)

➢ Mismatch between doctors’ skills and hospital facilities (20)

➢ Long working hours (16)

➢ Lack of job security (16)

➢ High working responsibilities (16)

➢ Local authorities’ bad behavior (16)

➢ Staff’s bad behavior (16)

➢ Improper facilities (16)

➢ Inefficient performance monitoring and evaluation (16)

➢ International medical school graduate (21)

➢ Restrictions on practice location (23)

➢ Lack of labor mobility among physicians (7)

➢ Distance from specialists and medical testing facilities (13)

➢ Adequate equipment (7)

➢ Hard work/long hours (13)

➢ Minimal laboratory and technical support (8)

➢ Lack of enough technological facilities (25)

➢ Socioeconomic characteristics of the designated areas (26)

➢ Income disparities between underserved areas and large cities (26)

➢ Inadequate accommodation facilities (26)

➢ Lack of recreational services (26)

➢ Higher workload (27)

➢ Lack of Mentoring (27)

➢ Absence of library facilities or technical resources (27)

➢ Lack of enough transportation facilities (27)

➢ Inability to use in-service training (27)

➢ Lack of clear incentives (27)

➢ Weak information systems (27)

➢ Systemic and organizational problems (32)

➢ Long working hours (33)

➢ Sharing on-call with only one other physician (34)

➢ Lack of job security (35)

➢ Low amenities (35)

➢ Long working hours (35)

➢ High work risk (37)

➢ Work pressure (37)

➢ Poor work condition (37)

➢ Lack of job safety (37)

➢ Lack the freedom to choose their own method of working (37)

➢ Amount of variety in the job (37)

➢ Industrial relationship between management and workers (37)

➢ Feeling of unsafe job (37)

➢ Continuing medical education (39)

➢ Limiting on-call duty (27)

➢ Compulsory services of doctors in rural health facilities (40)

➢ High ours worked and on-call frequency (40)

Work schedules (21)

➢ Workload (23)

➢ Work hours (23)

➢ Work culture (23)

➢ Hospital Infrastructure (27)

➢ Amount of work (30)

➢ Organization policies (30)

➢ Level of attention by leaders (30)

➢ Workload (45)

➢ Number of referrals for services (35)

➢ Poor work environment (37)

➢ Work hours (37)

Personal factors

➢ Supportive family (20)

➢ Self-care while working in high pressure settings (20)

➢ Political stability and security (20)

➢ Desirable family situations (21)

➢ having a personal and family rural background (18)

➢ Older age (22)

➢ Having a rural background (26, 22, 7, 31, 42, 45)

➢ Having a feel for the area (22)

➢ Perceptions of work life balance (23)

➢ Family ties to the community (13)

➢ Being able to help and feelings of patients’ appreciation of the physician (13)

➢ Good partners (13)

➢ Dependence on rural community (13)

➢ Place of residence (13)

➢ Exposure to rural practice before residency program (24)

➢ Marriage to a person from a rural area (24)

➢ Negative opinions about working in rural areas (25)

➢ Family physicians’ reluctance to change locations (25)

➢ Non-monetary incentive policies (25)

➢ Older age (12)

➢ Not having a university-trained professional parent (12)

➢ Previous exposure or service in a poor area (12)

➢ Willingness to practice medicine in rural or underprivileged areas (12)

➢ Interest in serving vulnerable people (12)

➢ Religious beliefs (26)

➢ Positive attitude towards working in remote areas (26)

➢ Lifestyle-related issues (26)

➢ Interest in serving rural setting (27)

➢ Less experience (27)

➢ Rural-origin graduates (28)

➢ Rural place of birth (28)

➢ Parent’s occupation (28)

➢ Occupation of father (28)

➢ Rural health related work experience (29)

➢ Family ties to the region (45)

➢ Residency experiences (30)

➢ knowledge gained during residency of the local community programmers (30)

➢ Being native (33)

➢ Job opportunities for spouses (39)

➢ Work-life balance (41)

➢ Professional interaction (41)

➢ Rural training (41)

➢ Spousal employment opportunities (41)

➢ Importance of finding spousal employment (42)

➢ Raising a family in a rural environment (42)

➢ Alignment of personal culture and skill set with that in the community or practice (42)

➢ Unsatisfactory rural elective experiences (18)

➢ Family pressure (16)

➢ Having high professional expectations (22)

➢ Placing a high value on prestige (22)

➢ Being bonded and clinical experience (22)

➢ Family and friend closeness (22)

➢ Seeking new employment (7)

➢ Wish to change employment (7)

➢ Being female (12)

➢ Anxiety about the unfamiliarity of rural life (27)

➢ The turnover intention (30)

➢ Being away from family (35)

➢ Willingness to continue education (35)

➢ Spousal and family concerns (39)

➢ Considerations of children (39)

➢ Personal and professional characteristics (21)

➢ Gender (22)

➢ Specific demographic (23)

➢ Gender (23)

➢ Age (23)

➢ Parental education levels (7)

➢ Birthplace (24)

➢ Year of graduation (24)

➢ The rank of the university attended (24)

➢ Place of residence (24)

➢ Marital status (26, 31)

➢ Individual preferences (26)

➢ Number of children (31)

➢ Year of University entrance (31)

➢ Age (31, 39, 42, 45)

➢ Gender (26, 24, 31, 42, 32, 39, 42, 45)

➢ Family member (37)

➢ Spouse’s career (42)

Cultural factors

➢ Gaining an understanding of the needs of people living in rural areas (18)

➢ Patient communication (19)

➢ Patient trust (19)

➢ Quality of doctor patient relationships (14)

➢ Nice people or community (13)

➢ Values (26)

➢ Personal incentives (27)

➢ Target population culture (32)

➢ Deep mutual trust and communication (37)

➢ Lack of social networks and investment in the community (38)

➢ The misconception that rural practitioners are less qualified than urban specialists (18)

➢ Poor culture of people (16)

➢ Inappropriate treatment of people (33)

➢ Social problems (37)

➢ Cultural differences (38)

➢ Lack of cultural opportunities (42)

➢ High cultural expectations (42)

➢ Degree of respect and recognition (27)

➢ Relationship with patients (37)

Living conditions factors

➢ Suitable housing and access to facilities (18, 23)

➢ Completion of satisfactory electives in rural areas (18)

➢ Provision of adequate schooling for their children or scholarships for boarding school (20)

➢ Jobs for spouses (9)

➢ Suitable places for their children in schools (9)

➢ free housing or subsidized house purchases (9)

➢ Opportunities to enjoy outdoor sports (14)

➢ Access to cultural activities (14)

➢ Lifestyle goals (22)

➢ Having a placement in a rural area (22)

➢ Free housing (25, 7)

➢ Lack of private paying patients (13)

➢ Lack of shopping or restaurants (13)

➢ Access to good schools for children (24)

➢ Social and recreation opportunities (30)

➢ Services in the area and lifestyle opportunities afforded by the location (30)

➢ Education facilities for children (36)

➢ Fit with the community; spouse/partner fit with the community (38)

➢ Appropriate relationships with individuals/community (38)

➢ Attractiveness of a rural location to the spouse (39)

➢ Recreational opportunities (39)

➢ Housing availability (41)

➢ Community incentives (41)

➢ Adequate housing availability (41)

➢ Strong education system for children (42)

➢ Safety of the community (42)

➢ Access to recreational facilities (42)

➢ Activities and proximity to an urban center (42)

➢ Proximity of the location for work and personal lives in a rural environment (42)

➢ Few social and recreational activities to enjoy (18)

➢ Inadequate accommodation facilities (18)

➢ Separation from partner and family (18)

➢ The absence of phone networks and other forms of communication even post (20)

➢ Lack of opportunities for a social life (20)

➢ Lack of vacation requirements or vacation leave (16)

➢ Region insecurity (16)

➢ Distrust to local authorities (16)

➢ Region depravity (16)

➢ Partner and family considerations (22)

➢ Geographic location (23)

➢ Limiting food choices (8)

➢ Unavailable Telephone services (8)

➢ Social and cultural problems (32)

➢ Environmental problems (32)

➢ Welfare problems (32)

➢ Inappropriate behavior of the people of the area (35)

➢ Political differences (38)

➢ Size of town

➢ Higher socioeconomic background (7)

➢ Wealth ranking (28)

➢ Population covered area (33)

➢ population growth and urbanization progress (37)

➢ Community size (39)

➢ Current community of residence (42)

➢ Able to grow in [a supportive] environment (42)