Abstract
There is an ongoing shortage of rural healthcare providers relative to urban healthcare providers worldwide. Many strategies have been implemented to increase the distribution of rural healthcare providers, and financial incentives such as loan repayment programs have become popular means to both recruit and retain healthcare providers in rural communities. Studies detailing the effects of such programs on rural provider recruitment and retention are limited. The objective of this study was to assess the influence of loan repayment and other factors on the recruitment and retention of healthcare providers in rural Colorado, USA, and to compare the motivations and attitudes of these rural providers with their urban counterparts. A survey was sent to 122 healthcare providers who had participated in one of three loan repayment programs in Colorado between the years of 1992 and 2007: the Colorado Health Professional Loan Repayment Program; the Colorado Rural Outreach Program; and the Dental Loan Repayment Program of Colorado. Differentiation between rural and urban communities was accomplished by using the Rural Urban Commuting Area Codes developed by the University of Washington's Rural Health Research Center and Economic Research Service. Statistical analysis was performed using STATA from StataCorp. Of the 93 respondents included in the study, 57 worked in rural communities and 36 worked in urban communities during their programs. Of the rural participants, 74% were already working in or intending to work in an eligible community when they were made aware of the loan repayment program. Of those planning to work in a rural community regardless of any loan repayment option, 42% reported that the loan repayment program had an important influence on the specific community in which they chose to practice. Of the rural participants already working in a rural community, 38% reported loan repayment as being an important factor in their retention. The most important factors the rural providers cited for their recruitment were the location of the community, scope of practice, and family fit with the community. The most important factors for the urban providers were the location of the community, salary, and scope of practice. Of the rural providers, 36% attended rural high schools, while 9% of urban providers attended rural high schools. Of the rural providers who were planning on practicing in a rural area regardless of any loan repayment option, 37% had attended rural high schools. Rural participants most often left their communities because their families wanted to move, personal or professional isolation, and dissatisfaction with the medical community. Of rural participants 22% cited the desire for a higher income as an important reason to leave their communities, while the desire for a higher income was the most commonly cited reason for the urban providers. Rural retention rates were not influenced by past attendance at rural high schools or by intention to practice in a rural community regardless of loan repayment. Loan repayment programs targeting rural Colorado usually enroll providers who would have worked in a rural area regardless of loan repayment opportunities, but are likely to play a role in providers' choice of specific rural community for practice. They also appear to have a limited but important influence on rural provider retention, though financial concerns are generally less influential for non-retained rural providers than are family preferences and professional dissatisfaction.
Highlights
There is an ongoing shortage of rural healthcare providers relative to urban healthcare providers worldwide
In 2000, over half of all US frontier counties with hospitals were classified as nurse shortage counties, while only 30% of non-frontier counties carried this designation[9]; the population density of dentists in non-metropolitan areas is less than half of what it is in metropolitan areas[12]; and for every 100 000 people in 2005, there were 210 physicians in urban locations but only 52 in more remote rural areas[8]
Loan repayment programs have increased in popularity as a means to enhance recruitment and retention of healthcare providers in medically underserved areas
Summary
There is an ongoing shortage of rural healthcare providers relative to urban healthcare providers worldwide. In 2000, over half of all US frontier counties with hospitals were classified as nurse shortage counties, while only 30% of non-frontier counties carried this designation[9]; the population density of dentists in non-metropolitan areas is less than half of what it is in metropolitan areas[12]; and for every 100 000 people in 2005, there were 210 physicians in urban locations but only 52 in more remote rural areas[8]. Financial incentives have become a popular intervention to enhance recruitment, given the rising debt levels of US medical graduates (the median debt level of indebted 2008 medical school graduates was US$155,000, up 53% from 1998 after inflation adjustment)[39] Examples of such incentives include direct financial incentives, resident support, scholarships, and loan repayment programs (LRPs), all with or without associated service commitments[31]
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