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Digitally Signed by: Content manager’s Name
DN : CN = Weabmaster’s name
O= University of Nigeria, Nsukka
OU = Innovation Centre
Nwamarah Uche
FACULTY OF HEALTH SCIENCES AND
TECHNOLOGY
DEPARTMENT OF NURSING SCIENCES
PERCEIVED FACTORS AFFECTING NON STAY OF
HEALTH WORKERS IN RURAL AREAS OF ENUGU
STATE
CHUKWUNWENDU, IFEOMA
PG/MSC/07/46902
2
PERCEIVED FACTORS AFFECTING NON STAY OF HEALTH
WORKERS IN RURAL AREAS OF ENUGU STATE
BY
CHUKWUNWENDU, IFEOMA
PG/MSC/07/46902
MSC DISSERTATION
DEPARTMENT OF NURSING SCIENCES
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY
UNIVERSITY OF NIGERIA, ENUGU CAMPUS.
DR (MRS) I.L OKORONKWO
JULY, 2014
3
PERCEIVED FACTORS AFFECTING NON STAY OF
HEALTH WORKERS IN RURAL AREAS OF ENUGU
STATE
BY
CHUKWUNWENDU, IFEOMA F.
PG/MSC/07/46902
M.SC DISSERTATION
SUBMITTED TO THE
DEPARTMENT OF NURSING SCIENCES, FACULTY OF HEALTH
SCIENCES AND TECHNOLOGY,UNIVERSITY OF NIGERIA ENUGU
CAMPUS
IN PARTIAL FULFILMENT FOR THE AWARD OF MASTER OF SCIENCE
DEGREE IN NURSING ADMINISTRATION.
SUPERVISOR: DR I.L OKORONKWO
JULY, 2014
4
Approval
This dissertation: Perceived factors affecting non stay of health workers in rural areas of
Enugu state has been approved for the award of masters of science degree in nursing, in the
department of Nursing sciences, Faculty of Health Sciences and Technology, University of
Nigeria Enugu Campus
By
DR.(MRS) OKORONKWO, I.L
Supervisor Date ----------------------------------------------------
DR (MRS) OKOLIE, U.
Head of Department Date---------------------------------------------------
--
PROF. EZENDUKA,
External Examiner Date ----------------------------------------------------
PROFESSOR OBINNA ONWUJEKWE
Dean FHST, UNEC Date ----------------------------------------------------
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Certification
This is to certify that this dissertation is the original work of Chukwunwendu, Ifeoma of the
department of Nursing sciences, faculty of health sciences and technology, University of
Nigeria, Enugu Campus.
…………………………..
Chukwunwendu, Ifeoma F
Student Date…………………………..
………………………….
Dr.(Mrs) I.L Okoronkwo
Supervisor Date……………………….
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DEDICATION
This project work is dedicated to my dad Pa Charles Chukwu of blessed memory who wished
to be alive to see me conclude this programme.
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Acknowledgement
My profound gratitude goes to Almighty God for His abundant grace, wisdom, guidance,
provision and protection throughout the course of this programme.
I acknowledge my noble and versatile supervisor, Dr I.L Okoronkwo for her directions,
useful and constructive criticisms, her motherly advice and for investing her time and energy
to see that this work is completed. I also wish to appreciate other staff of the Department of
Nursing Sciences who contributed to the success of this work. Worthy to mention are: Dr.
Nwaneri, A. and Dr. Ogbonnaya, N.P.
To my love Chika Ndubuisi, my lovely triplets, my son and kid sister who supported me
throughout the period of this study, I say a big thank you and may God bless you abundantly.
I sincerely thank you all.
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TABLE OF CONTENT
Page
Cover page i
Title page ii
Approval iii
Certification iv
Dedication v
Acknowledgement vi
Table of content vii
List of tables viii
List of figures ix
List of appendix x
Abstract xi
Chapter One: Introduction
Background to the study 1
Statement of problem 3
Purpose of the study 4
Objectives of the study 4
Research Questions 5
Significance of the study 5
Scope of the study 5
Operational definition of terms 6
Chapter Two: Literature Review
Conceptual review 8
Recruitment and retention of health workers 8
Predictors to recruitment and retention in rural areas 11
Barriers to retention in rural areas 12
Attractors to rural posting 14
9
Community factors contributing to non-stay 15
Incentives to motivate health workers 16
Theoretical Review 19
Hertzberg’s two factor theory 19
Contingency theory 22
Conceptual framework 24
Empirical Review 26
Summary of Literature review 30
Chapter Three: Research Method
Research design 31
Area of study 31
Population of the study 31
Sample 31
Sampling technique 32
Instrument for data collection 32
Validity of instrument 33
Reliability of instrument 33
Ethical consideration 33
Procedure for data collection 33
Method of data analysis 34
Chapter four: Presentation of Result 35
Summary of Findings 47
Chapter five: Discussion of Findings 48
Conclusion 53
Limitation of the study 53
Summary 54
Recommendation 54
Suggestion for further studies 55
References
Appendices
10
List of Tables
Page
Table 1: Demographic data of the respondents 35
Table 2: Personal factors affecting non-stay of health workers
in rural areas 36
Table 3: Institutional factors affecting non-stay of health
workers in rural areas 38
Table 4: Community factors contributing to non-stay of health
workers in rural areas 40
Table 5: Strategies to retain health workers in rural areas 42
11
List of figures
Page
Figure 1: Hertzbergs two factor theory of job satisfaction 20
12
List of Appendix
Appendix 1 Number of professional health workers in Enugu State
Appendix 11 Sample size calculation
Appendix 111 Sample of questionnaire
Appendix 1V Measure of reliability test
Appendix V Ethical approval letter
Appendix VI Sample of the informed consent form
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ABSTRACT
A major challenge to the achievement of Millennium Development Goals is the shortage
of health workers in the remote areas, especially in the developing countries where
preventable disease burden is high. The aim of the study was to determine perceived
factors contributing to non-stay of professional health workers in rural areas of Enugu
state and strategies to retain them. The study was a descriptive, cross-sectional,
questionnaire-based study carried out in randomly selected health districts of Enugu state.
A total of 236 consenting professional health staff with at least two years working
experience were randomly selected. A validated researcher developed questionnaire was
used to obtain information from the respondents. Data were analysed using descriptive
statistics and facilitated by the Statistical Package for the Social Sciences (SPSS version
17.0). Findings revealed that there were 70.8% females and 29.2% males in the study.
Age distribution showed a mean age of 33.8 with a standard deviation of 8.23. Family tie
was the most significant personal factor identified as contributing to non-stay of health
workers (P<0.0005). Among the institutional factors affecting non-stay of health workers
in rural areas, poor organizational policy and inadequate reward/ recognition were
considered very strong reasons for non-stay (P<0.005). None of the community factors
had a significant relationship with the staff decision to stay or not stay in the rural areas.
Suggested strategies identified by respondents to retain health workers in rural areas
included paying more to professionals working in rural areas (92.79%), provision of
adequate security in the health centres (88.56%) and provision of rural allowance
(92.79%). It is therefore recommended that the observed factors should assist
stakeholders and government of Enugu State in formulating effective strategies that
would improve retention of health workers in the rural areas. Postings to the rural areas
should be rotational and preferably staff family locations should be considered. In
addition, adequate remuneration and motivation for staff working in the rural areas should
be considered as ways of improving shortage of professional health workers in the remote
areas.
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CHAPTER ONE
INTRODUCTION
Background to the study.
The shortage of healthcare professionals in rural communities remains an intractable problem
that poses a serious challenge to equitable healthcare delivery. Both developed and
developing countries report geographically skewed distributions of healthcare professionals,
favouring urban and wealthier areas (Wilson, Couper & De Vries, 2009). Rural communities
are on the average poorer, less educated and have higher disease burden; they also have
worse access to health care than people in urban areas (Wilson, Reid, Fish, & Marais, 2009).
This discrepancy between health care needs and service provision has been captured by
Hart’s ‘inverse care law’, which states that those with the greatest health needs usually have
the worst access to healthcare services (Flament, 2012). Rapid urbanization is a global
phenomenon but it also poses particular health problems in developing countries with poor
infrastructural development (Wilson, Reid, Fish & Marais, 2009). Improved access to
healthcare should therefore be seen as an indicator of the level of development of any nation.
International attention has recently been drawn to the problems of attracting, retaining and
motivating health workers in developing countries particularly in remote areas, which has
created human resource for health (HRH) crisis (Williams, 2007). Health workers form the
foundation of health service delivery and therefore the staff strength, skill and level of
commitment are critical for the delivery of good, quality and effective health care (Serneels,
Montalvo & Lievens, 2010). Renewed attention is being given to the role of geographical
imbalances in the health workforce, a feature of nearly all health systems. This raises
concerns about the equity in access to health care as well as the efficiency of allocation of
human resources bearing in mind the impact on health outcomes (Petterson, Serneels, Aklilu
& Butera, 2010). The issue is particularly relevant for developing countries with limited
resources and poor health outcomes. Ultimately, the difficulties to attract and retain staff in
rural facilities may also stem from the preferences and choice made by the health workers.
Furthermore, a growing body of evidence shows that apart from wages, other job attributes
like training opportunities, career development prospects, living and working conditions may
also play a role (Hays, Veitch, Cheers & Crossland, 2007).
15
The challenges in maintaining an adequate workforce that meets the needs of a population
with social, demographic, epidemiological and political transitions require a sustained effort
in addressing workforce planning, development and financing. Skilled health workers are
increasingly taking up job opportunities in the global labour market as the demand for their
expertise rises in high income areas. It has been suggested that the rural to urban and
international migration of health workers in African countries inevitably leaves poor, rural
and remote areas underserviced and disadvantaged (Bach, 2003). Developing countries often
experience ‘urban-bias’ where the political and economic forces support the provision of
services and investment in urban areas to the detriment of rural areas. This increases the
disparities in health worker distribution, access to services and health outcome (Zurn, Dal
Poz, Barbara & Orvill, 2004).
A regression of data for 117 countries found a significant relationship between health worker
density and maternal mortality rates (Gerein, 2006). Nigeria has high numbers of healthcare
providers, who together make up the largest human resource for health in Africa. There are
52,408 doctors, 219,399 nurses and midwives, and 19,268 community health workers
practicing in the public sector (Professional Regulatory Agencies, 2008). However, these
values translate to only 23 doctors, 112 nurses, and 64 community health workers per
100,000 people. To put these figures into context, European health worker density values are
332 doctors and 780 nurses per 100,000 people (World Health Organisation [WHO], 2008).
Poor, rural communities experience the lowest health worker densities, with three times as
many doctors and two times as many nurses practicing in urban areas as opposed to rural.
These figures imply that the number of women in rural areas giving birth unaccompanied by
skilled birth attendants is directly impacted by the understaffed rural health facilities.
Maternal mortality continues to be the leading cause of death of women of reproductive age
in developing countries. Maternal death is primarily a result of the health care system’s
inability to deal effectively with complications during and shortly after childbirth (World
Health Report, 2005). Recruitment and retention of skilled workers, particularly midwives,
nurses, doctors, and obstetricians, are essential to the provision of quality antenatal, delivery,
emergency obstetric and postnatal services. It is necessary to realize both the United Nations
millennium development goals (MDG) 4 (Reduce under 5 mortality) and MDG 5 (reduction
of maternal mortality) (MDG Report, 2006). Nigerian policy-makers are looking for
solutions. Researchers and development agencies agree that the disproportionate rates in the
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developing world, particularly Sub-Saharan Africa, are as a result of high rate of births
unaccompanied by a skilled birth attendant (WHO, 2005).
To achieve the MDGs for health by 2015, improving access to key interventions such as anti-
retroviral therapy, immunizations, tuberculosis and malaria treatments are top priorities for
most health system (Adano & Vicks, 2008). However, in addition to financial resources for
commodities, improving access requires a well-functioning health system and adequate
workforce capable of delivering interventions at a large scale (Drager, Gedik & DolPoz,
2006). The 2004 joint learning initiative report on human resource for health and others have
concluded that shortage and skewed distribution of health personnel especially in the rural
areas undermine the scaling up efforts, particularly in low income countries (Bloom &
Barnighausen, 2009). It is against this background that this study sought to determine
perceived factors that affect non stay of health workers in rural areas of Enugu State.
Statement of problem
Survey report has shown that more than 75% of Nigerian population live in rural areas and
are left at the mercy of untrained personnel (Demographic and health survey, 2007). Studies
have also shown that the five commonest causes of maternal and child mortality is
preventable in most cases with the presence of qualified and skilled attending health
personnel (WHO, 2006).
With a population of more than 140 million people (National Population Commission [NPC],
2007), Nigeria is the most populous country in Africa. The latest estimates also put life
expectancy in Nigeria at 44 years (NPC 2007). Seventy two (72) % of the urban population
and just forty nine (49) % of rural population have access to safe drinking water. The
shortage of health workers in the areas where they are most needed is an important problem
for health systems. Patients who have the greatest need for health care tend to live in remote
and rural areas, but attracting skilled health workers to such areas and retaining them there
has proved difficult. Such an uneven distribution of health workers contributes directly to the
global burden of ill health and inequity in health outcomes. Improvements in key health
indicators have been slow and today Nigeria ranks among the countries with the highest child
and maternal mortality: the Under-five mortality rate is two hundred and one (201) per 1,000
live births, and the maternal mortality ratio is estimated at eight hundred and forty (840) per
100,000 live births (United Nations Children Emergency Fund [UNICEF], 2010). Many
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Nigerian doctors and nurses have emigrated to North America and Europe. In 2005, two
thousand three hundred and ninety two (2,392) Nigeria doctors were practicing in the United
States alone; in United Kingdom the number was one thousand five hundred and twenty nine
(1529). Retaining these expensively-trained professionals in their countries of training has
been identified as an urgent goal (United Nations Population Fund [UNPF], 2005). Most
developing countries face shortages of health workers in rural areas. This has profound
consequences for health service delivery and ultimately for health outcomes.
In 2003, Enugu State adopted the district health system and tried to meet the 5km distance
approved by WHO for citing of health care facilities in order to improve access. However,
the 2009 survey by State Ministry of health showed that these facilities are underutilized
primarily due to the dearth of qualified health care workers in these rural health facilities
(Partnership for transforming Health systems [PATHS2], 2009). The State has 482 nurses, 25
pharmacists, 80 medical doctors, and 24 medical laboratory scientists. Out of these only 127
nurses, 10 pharmacists, 22 doctors and 5 medical laboratory scientists are posted to the rural
areas (State health board statistics office, 2010). In 2010 the Ministry of Health recruited 96
nurses to make up for this shortage, but their nominal roll in 2012 revealed that 27 nurses had
absconded, while 11 resigned officially.
Personal visits to rural health facilities by the researcher showed that there is inadequate staff
in these health facilities. This has raised some basic questions in the researcher’s mind: Are
there personal factors responsible for non-stay of health workers in rural areas? Do
institutional factors contribute to non-stay of health workers in rural areas? What are the
community factors responsible for non-stay of health workers in rural areas? This study
attempted to answer the above questions.
Purpose of the study.
The purpose of this study was to determine the perceived factors that contribute to non-stay
of professional health workers in rural areas of Enugu State and strategies to retain them.
18
Objectives
The specific objectives were to;
1. Identify personal factors contributing to non-stay of health workers in rural areas.
2. Determine institutional factors contributing to non-stay of health workers in rural
areas.
3. Assess community factors contributing to non-stay of health workers in rural areas.
4. Identify strategies that will motivate workers to live and work in the rural areas of
Enugu state.
Research Questions
1. What are the personal factors that negatively affect the decision of health
professionals to live and work in the rural areas?
2. What are the institutional factors that negatively affect the decision of health
professionals to live and work in the rural areas?
3. What are the community factors that negatively affect the decision of health
professionals to live and work in the rural areas?
4. What are the incentives/resources/strategies available to motivate workers to stay in
the rural areas?
Significance of the study
The result from this study would help health administrators to understand the peculiar local
factors that contribute to non-stay of health professionals in rural areas in Enugu State. This
information would equip health administrators better on how to handle issues regarding rural
postings of health care professionals in Enugu state. This is an important step in boosting
rural health care delivery services since effective policy formulation and implementation
based on the findings from this research will help to address the needs of health care
providers in the rural areas and ensure that staff are committed to assigned jobs. This in turn
may help to reduce the currently unacceptable high rate of preventable maternal and infant
19
morbidity and mortality since staff will always be on ground to attend to preventable life
threatening emergencies in the rural areas.
In addition, the result of this study will provide a basis for policy makers to know what to put
in place in health care facilities to serve the elderly who stay in the rural areas to achieve
optimum health care.
The result of this study will also assist policy makers to determine and design strategies to
attract and retain health workers in rural areas in order to achieve the health related
Millennium Development goals (MDG 4 and 5).
Scope of the study
This study is delimited to skilled health workers comprising of doctors, nurses, pharmacists
and medical laboratory scientists posted and working in health centres in Enugu state. It is
also confined to variables such as institutional, community and personal factors that
contribute to non-stay of health workers in the rural areas of Enugu state.
Operational definition of terms.
Professional health workers refer to doctors, nurses, pharmacists and medical laboratory
scientists who are currently working in Enugu State Ministry of Health who have been duly
registered and licensed to practice by their respective professional bodies.
Perceived factors that contribute to non-stay of health workers refer to such factors like
personal, institutional, community that health workers feel may affect their decision not to
live and work in rural areas
Personal factors refer to certain individual constraints that may influence a decision to live
and work in a rural area. This may include marriage status, family ties, low standard of rural
schools and future academic ambitions.
Institutional/administrative factors are those hindrances in/from the institution or
administrative issues that discourage trained staff from working in rural areas. This may
20
include relationship with senior staff, lack of or unacceptable quality of accommodation
provided for the staff, inadequate medical instruments, security concerns in the work place,
quality of supervision and remuneration.
Community factors will include the community’s belief, language barrier and the attitude of
the host community towards strangers.
Strategies to retain health workers refer to necessary resources and incentives that will
motivate or enhance health workers stay in rural areas e.g. rural allowance, offering
scholarships to children of staff, provision of working materials, accommodation and car
allowances.
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CHAPTER TWO
LITERATURE REVIEW
This chapter dealt with the review of related literature on the topic. It was discussed under
conceptual, theoretical and empirical reviews. A summary of literature was also highlighted.
Conceptual Review
Health professionals are highly skilled workers, in professions that usually require extensive
knowledge including university-level study leading to the award of a first degree or higher
degree. This category includes physicians, dentists, nurse practitioners, pharmacists,
physiotherapists, optometrists and others. They are often recruited to function in the
hospitals, health care centers and other service delivery points. The practice of health
professionals and operation of health care institutions is typically regulated by national or
state/provincial authorities through appropriate regulatory bodies for purposes of quality
assurance.
Two important functions of human resources department are recruitment and selection.
Although linked together in what is generally called the employment discipline of human
resources, they are two distinct functions. Recruitment is a continuous process whereby the
firm attempts to develop a pool of qualified applicants for the future human resource needs
even though specific vacancies do not exist. Usually, the recruitment process starts when a
manager initiates an employee requisition for a specific vacancy or an anticipated vacancy. It
refers to the process of attracting, screening and selecting qualified people for a job (Evans &
Anand, 2006). The recruitment phase is the initial step for all applicants. Once the applicant
presents the skill, knowledge base and qualifications, she moves into the category of
candidacy for a position. In all, recruitment refers to the problem of attracting the qualified
health workers while retention refers to the decision of the staff to stay in practice.
Effective employee retention is a systematic effort by employers to create and foster an
environment that encourages current employees to remain employed by having policies and
practices in place that address their diverse needs. Also of concern are the costs of employee
22
turnover (including hiring costs, training costs, productivity loss). Replacement costs usually
are 2.5 times the salary of the individual. “The costs associated with turnover may include
lost customers, business and damaged morale. In addition there are the hard costs of time
spent in screening, verifying credentials, references, interviewing, hiring, and training the
new employee just to get back to where you started” (Workforce Planning for Wisconsin
State Government, 2005).
The growing gap between the supply of health care professionals and the demand for their
services is recognised as a key issue for health and development worldwide. The WHO
(2010) reports a global shortage of 4.3 million health workers, including approximately 3
million health professionals. Many countries are affected by the shortage, and fifty-seven
have been identified as ‘in crisis.’ Health human resources are now a high priority on the
political agenda. In most countries, imbalances in labour supply stem from a number of
causes. These include: poor human resource (HR) planning and management and
unsatisfactory working conditions characterised by heavy workloads, lack of professional
autonomy, long working hours, unsafe workplaces and unfair pay (Gerein, 2006). It is within
this context that policy makers, planners and managers have turned their attention to
identifying and implementing incentive systems which will be effective in improving the
recruitment and retention of health care personnel.
In developing countries, low motivation among health workers is a serious human resource
problem in the health sector (Ahamed, Urassa, Gherardi & Game, 2006). The low motivation
stems from a poorly equipped health care system that lacks the means and supplies to
facilitate high quality health care delivery and a deficient human resource management
system. This deficiency is as a result primarily of poor leadership, lack of communication and
lack of feedback to evaluate health workers performance.
The severe shortage of health workers in Pacific and African countries is a critical issue that
must be addressed as an integral part of strengthening health systems. Health workers are
vital to health systems but are often neglected. Factors that contribute to the shortage of
skilled health workers include a lack of effective planning, limited health budgets, migration
of health workers, inadequate number of students entering and/or completing professional
training, limited employment opportunities, low salaries, poor working conditions, weak
support and supervision, and limited opportunities for professional development (Muula,
2006). The shortage of workers often results in inappropriate skill mixes in the health sector
23
as well as gaps in the distribution of health workers (Needleman, 2005). This is especially so
in rural and remote areas where the provision of services is difficult because of limited health
budgets and scattered populations living in isolated villages or islands. In developing
countries like Nigeria, there are great disparities in health status and access to health care
among different population groups. For example, the under-five mortality rate in rural areas
is estimated at two hundred and forty three (243) per 1000 live births, compared to one
hundred and fifty three (153) per 1000 live births in urban areas. About fifty nine (59%)
percent of women in urban areas deliver with a doctor, nurse or midwife in contrast to 26% of
women in rural areas (DHS, 2004 in Aminu, 2010). The 2010 maternal mortality rate per
100,000 births for Nigeria is 840 (UNICEF, 2010). This figure shows an increasing trend
when compared with 608 in 2008 and 473 in 1990. The high maternal mortality rate implies
that there is high rate of unattended child deliveries especially in rural areas.
The magnitude of the shortage can be seen in health worker density rates and workforce
vacancy rates. Its impact is reflected in health system performance indicators, including
maternal and child health indicators, which correlate with health worker density. A threshold
of 2.5 health workers (including doctors, nurses and midwives) per 1000 people has been
recommended by the Joint Learning Initiative on Human Resources for Health (2004) in
order to achieve a package of essential health interventions and the health-related Millennium
Development Goals. Several countries in Asia and Africa fall well below this threshold.
WHO (2006) has reported an association between health worker density and health outcomes
and it is generally accepted that, where health workers are scarce, health services and health
outcomes suffer. For example, countries (Vietnam, Papau New Guinea, and Nigeria) with
low ratios of health workers to population are among the countries with high mortality rates
for children under-five years of age.
The challenges in maintaining an adequate health workforce that meets the needs of a
population with social, demographic, epidemiological and political transitions require a
sustained effort in addressing workforce planning, development and financing (WHO, 2008).
Further examination and analysis are needed to better understand the factors that contribute to
health worker retention in resource-constrained settings and the initiatives that have the
potential to maintain a competent and motivated health workforce in rural areas.
24
Predictors to recruitment and retention in rural areas
McDonald, Bibby and Carroll, (2005) identified the following as predictors of potential
individuals for recruitment and retention in rural areas:
Rural Background
Various studies have reported that health practitioners with a predominantly rural childhood
background are up to four times more likely to enter rural practice than those who grew up in
urban areas. The sub-predictors associated with a rural background that increase the
likelihood of entering rural practice include: having a rural primary school education (this
appears to be more important than rural secondary education) for rural health workers with
partners. The strongest independent predictor is having a partner who grew up in the country
(rural health practitioners have been found to be 3 times more likely to have a partner with a
rural background than urban health practitioners); having family living in a rural area has
been found to be significantly associated with long-term plans to practice in a rural area i.e.
the view of one’s partner or spouse about living and working in a rural area.
Gender considerations
In the majority of countries, women are the primary caregivers. As women make up an
increasingly large proportion of the health profession, it is important to consider the different
needs of female health workers when developing incentives. Flexible and/or part-time
working hours, flexible leave/vacation time, access to child care and schools, and planned
career breaks are a few of the incentives that may be important to female health workers. A
survey of 271 female general practitioners and 31 specialists in rural Australia found that
36% of general practitioners and 56% of specialists would prefer to work fewer hours
(Wainer, 2004). Results indicated that incentives to attract and retain women in rural practice
include flexible practice structures, acceptance of the rural area by the doctor's family,
mentoring by women doctors, and financial and personal recognition.
Rural Medical Training
Undergraduate and postgraduate clinical experience in a rural setting is the second strongest
predictor of rural practice. A research carried out by McDonald (2006) found significant
25
associations between a decision to do further residency training in the country and length of
time spent in a rural hospital, a perception that previous rural hospital experience had
enhanced theoretical knowledge, a belief that rural training has a positive influence on a
future career in rural medicine and an expressed desire for a career in rural medicine.
Other predictors of rural practice include: being a male, having children less than 18 years of
age, lower reimbursements and professional isolation is associated with considerations about
leaving rural practice.
Barriers to recruitment and retention
The barriers are complex and overlapping. The barriers are sometimes reported as
disincentives for entering rural practice; others are clearly triggers for leaving rural practice,
or reasons for moving to a larger town.
A research conducted by McDonald, Bibby and Carroll (2002) on recruitment and retention
of health workers in rural areas of Australia identified professional isolation and lack of
organizational support, inadequate access to hospitals, unreasonable workloads,
unsatisfactory levels of procedural work, and the lack of availability of good social and
cultural facilities as barriers to rural practise. They further stated that market forces affecting
the distribution of the medical workforce are mediated by a complex interplay of individual,
familial and environmental factors. These factors include access to continuing education,
employment for one’s partner, children education, lack of suitable housing, family and social
ties and lifestyle preferences. Rural communities do have the capacity to influence these
factors by ensuring that these facilities are available for those posted and working in their
communities. These barriers have been grouped into three main issues: professional practice
issues, personal, family and community related issues.
Professional Practice Issues
Professional isolation: The main aspects of isolation are not having access to information,
specialists or professional colleagues with whom to discuss medicine, exchange ideas or refer
complicated cases to. Other aspects include: restricted access to continuing medical
education; a feeling that health policies and programs are city based and do not adequately
represent rural health professionals (HPs’) situation; and a lack of respect and support by
medical authorities and teaching institutions.
26
Income is important to the quality of life of rural Health Practitioners (HPs), but it is far from
being the most important. Inadequate financial reward is mainly related to non-payment for
over time and rural allowance. Other professional practice issues include the ever-increasing
burden of bureaucratic paperwork, a perceived lack of respect from urban colleagues, and a
lack of appropriate training in rural practice
Community Issues
A research by Wainer (2007) has identified that the particular concerns of female rural HPs
are: poor community resources and facilities, lack of recreational, shopping and trade services
are reasons for leaving or considering leaving rural area. A spouse’s opinion about rural life,
their general happiness, and opportunities for professional employment are highly influential
factors in recruitment and retention.
Personal and Family Issues
The most significant issue for health professionals leaving or considering leaving rural
practice is dissatisfaction with the standard of secondary schooling for children. Secondary
schooling is much more of a concern than primary schooling; it is often a trigger to leave
rather than just a disadvantage. Isolation from family and friends, and geographical isolation
from social and cultural activities in the city are important problems associated with rural
practice.
Attractors to Rural Practice
While it is valuable to examine why health professionals leave rural practice or do not enter it
in the first place, it is also important to assess the reasons why they choose rural practice. By
doing so, one can preserve and enhance the desirable attributes of rural practice. Evidence
from a study by Wainer (2007) indicated that the most important attractors to rural practice
are: scope and variety of work, comprehensiveness and continuity of care, rural lifestyle,
rural placements.
Scope and Variety of Work
The most important aspect of professional practice for rural health professionals appears to be
the scope and variety of work. HPs are expected to become multi-skilled, and they encounter
a greater range of medical conditions than urban HPs. In professional practice, rural HPs have
27
to rely heavily on their own knowledge, skills and medical preparedness. The inherent
challenge and responsibility of rural medical practice is widely reported as an advantage. The
capacity to practice procedural medicine and/or do hospital work is also an attractor to rural
HPs.
Comprehensiveness and Continuity of Care
The sense of community in country towns is highly valued by rural HPs. The key elements of
this include connectedness, the degree of community recognition and appreciation, and a
feeling that they were making a difference to the community. Rural HPs, report valuing the
opportunity to practice ongoing, whole patient care and whole family care within a
community context.
Rural Lifestyle
Not surprisingly, the love of the rural lifestyle and environment was the most salient personal
attraction of rural practice. This love of a rural lifestyle encompasses the cleaner country
environment, a more relaxed way of life, outdoor living, and increased safety for family
members. Spouse and family happiness, including the availability of employment for
spouses, and proximity to family and friends, was considered an attraction or reason for
staying in rural practice.
Rural Placements
Rural placement has also improved recruitment to rural practice. Medical and nursing
students in the United States who undertake a rural placement are more likely to practise in a
rural area, although it is unknown if this greater likelihood is statistically significant. In
Australia, this program is too early to determine the effect of rural placements on medical
students due to the short period of time the policy has been in operation. At this stage, those
students that have participated in rural placements have responded positively and indicated a
greater intention to practice in rural areas than those students who have not completed a rural
placement.
Community factors that contribute to non-stay of health workers in rural areas
McLeroy, (2006) developed community capacity building approaches to recruitment and
retention in rural communities. Community capacity refers to the attributes of communities
28
that determine their capacity to identify, mobilize, and address social and public health
problems. Capacity- building aims to foster the conditions that strengthen the attributes of
communities that enable them to plan, develop, implement, and maintain effective
community programs (Poole, 2007). In the context of this project, community capacity-
building is an approach that rural communities can use to retain a Health practitioner posted
to their communities.
Capacity-building, when combined with an evidence-based approach to addressing barriers,
predictors and attractors, offers rural communities a strategic advantage in successfully
recruiting and retaining a health practitioner. Communities can develop and implement
strategies based on rigorous research knowledge about the most effective intervention
However, community capacity-building puts the community at the centre of the effort to
develop local solutions to identified barriers in a specific community thereby enhancing
retention of health practitioners in that community.
The justification for using this approach is that;
1. Communities have some degree of control in addressing many of the known barriers to
recruitment and retention.
2. Communities also have some degree of control over the known predictors of and attractors
to rural practice.
3. Community capacity-building has been used successfully to address a wide range of health
problems, including health professionals workforce issues (Veitch et al., 1999, Fleming,
McRae & Tegen, 2001).
Moreover, because capacity-building is lengthy and time-consuming, it is generally carried
out with only a small number of communities that are receptive to the idea. Therefore, there
is no definitive answer to the question about whether it works. However, the research
evidence on capacity-building reveals a number of consistent factors associated with
improved outcomes in health professionals’ recruitment and retention.
Amundson and Rosenblatt (2002) have identified some key factors that contributed to
positive outcomes for the six Pacific Northwest and Alaskan communities they worked with.
The factors include; the problems facing rural health systems (and their solutions) are local,
29
Community is the key. Working with (instead of for) communities, a high degree of
community commitment and investment in all stages of the process, Use of a flexible
methodology, Use of outside consultants, Demonstration that small, rural health care systems
can be efficient, Identification and development of local leadership and Enhancing teamwork
among local health care providers. Fleming, McRae and Tegen (2001) have worked with
South Australian communities to identify the key ingredients to developing sustainable,
community owned solutions to address rural medical workforce issues which are; need for a
driver or champion, community ownership, community awareness, a ‘multi-system’ response
and sharing the knowledge base capacity-building.
Incentives to motivate health workers
The World Health Organization (2000) defines incentives as “all the rewards and
punishments that providers face as a consequence of the organizations in which they work,
the institutions under which they operate and the specific interventions they provide.
Incentives can also be seen as the factors and/or conditions within health professionals’ work
environments that enable and encourage them to stay in their jobs, in their profession and in
their countries. Incentives are an important means of attracting, retaining, motivating,
satisfying and improving the performance of employees. They can be applied to groups,
organisations and individuals and may vary according to the type of employer. Incentives can
be positive, negative (as in disincentives), financial or non-financial, tangible or intangible
(International council of nurses [ICN] 2005). Financial incentives involve the transfer of
monetary values, such as salaries, pensions, bonuses, allowances and loans. Non-financial
incentives include work autonomy, flexible hours and scheduling, recognition of work,
coaching and mentoring structures, support for career development,
In economics and sociology, an incentive is any factor (financial or non-financial) that
enables or motivates a particular course of action, or counts as a reason for preferring one
choice to the alternatives (Sullivan & Steven, 2003). It is an expectation that encourages
people to behave in a certain way (Stevens, 2009). Since human beings are purposeful
creatures, the study of incentive structures is central to the study of all economic activity
(both in terms of individual decision-making and in terms of co-operation and competition
within a larger institutional structure). Ultimately, incentives aim to provide value for money
and contribute to organizational success (Armstrong, 2002).
30
Incentives can be classified according to the different ways in which they motivate agents to
take a particular course of action.
Lipinge et al; (2009), in their EQUINET Discussion Paper 78 on Policies and incentives for
health worker retention in east and southern Africa: Learning from country research
discussed in detail the classification of Incentives: financial and non-financial.
Financial incentives: are said to exist where an agent can expect some form of material
reward especially money in exchange for acting in a particular way. It may be direct or
indirect. Direct financial incentives include pay (salary), pension and allowances for
accommodation, travel, childcare, clothing and medical needs. Indirect financial benefits
include subsidized meals, clothing, transport, childcare facilities and support for further
studies.
In most countries, health worker salaries are poor, and financial incentives are essential
because most health workers want enough money to meet their living costs, arguably making
good remuneration the most influential factor for retaining health workers (Dovlo &
Martineau, 2004). Financial incentives tend to have dramatic and immediate results, either
slowing the exit of workers from the health sector or attracting them to the system. For
example, in Kenya raising doctors’ allowances led to hundreds of doctors applying for
government jobs (Matheau and Imhoff, 2006).
Non-financial incentives: include holidays, flexible working hours, access to training
opportunities, sabbatical/study leave, planned career breaks, occupational health counselling
and recreational facilities (Adams, 2000). Others include social needs support, solid human
resource and personnel management system. Non-financial incentives create a stabilizing
influence, after the more rapid effects of financial incentives, by sustaining health worker
commitment and sending signals that health workers are supported. Although non-financial
incentives are, ultimately, financial because they cost money to provide, they cater for longer-
term career, welfare and systems benefits that may provide greater stability. In many cases,
for example, training or workplace investments, non-financial incentives may cost nothing
because they can be created by more effectively organising and aligning existing resources to
meet the needs of health workers, the systems they work in and the communities they serve,
with wider gain to all.
31
These categories do not, by any means, exhaust every possible form of incentive that an
individual person may have. In particular, they do not encompass the many other forms of
incentive, which may be roughly grouped together under the heading of personal incentives
which motivate an individual person through their tastes, desires, sense of duty, pride,
personal drives to artistic creation or to achieve remarkable feats, and so on. Personal
incentives are set apart from these other forms of incentive because the distinction above was
made for the purpose of understanding and contrasting the social incentive structures
established by different forms of social interaction. Personal incentives are essential to
understanding why a specific person acts the way they do, but social analysis has to take into
account the situation faced by any individual in a given position within a given society which
means mainly examining the practices, rules, and norms established at a social, rather than a
personal, level.
Workers in any organization need something to keep them working. Most times the salary of
the employee is enough to keep him or her working for an organization. However, sometimes
just working for salary is not enough for employees to stay at an organization. An employee
must be motivated to work for a company or organization. If no motivation is present in an
employee, then that employee’s quality of work or all work in general will deteriorate.
While bonuses, paid holidays and other formal employee benefits are good for business, they
are not a guarantee of employee or team performance. In fact, studies have proved that “soft”
benefits, such as employee incentive programs, are directly responsible for driving increased
efficiencies and productivity among employees.
The movement of workers to act in a desired manner has always consumed the thoughts of
managers. In many ways, this goal has been reached through incentive programmes,
corporate pep talks, and other types of conditional administrative policy. The instilling of
satisfaction within workers is a crucial task of management. Some sectors have achieved this
through properly packaged employee motivation programmes.
THEORETICAL REVIEW
Two theories related to this study are Herzberg's two factor theory and the contingency
theory.
32
Herzberg's two-factor theory
Herzberg published the two-factor theory of work motivation in 1959. The theory was highly
controversial at the time it was published, and it was claimed to be the most replicated study
in this area, and provided the foundation for numerous other theories and frameworks in
human resource development (Herzberg, 1987). Herzberg analyzed the job attitudes of 200
accountants and engineers who were asked to recall when they had felt positive or negative at
work and the reasons why. From this research, Herzberg suggested a two-step approach to
understanding employee motivation and satisfaction. They include hygiene and motivator
factors.
Hygiene Factors
Hygiene factors are based on the need for a business to avoid unpleasantness at work. If these
factors are considered inadequate by employees, then they can cause dissatisfaction with
work. Hygiene factors include: Company policy and administration, wages, salaries and
other financial remuneration, quality of supervision, quality of inter-personal relations,
working conditions, feelings of job security.
Motivator Factors
Motivator factors are based on an individual's need for personal growth. When they exist,
motivator factors actively create job satisfaction. If they are effective, then they can motivate
an individual to achieve above-average performance and effort. Motivator factors include:
status, opportunity for advancement, gaining recognition, responsibility,
challenging/stimulating work, sense of personal achievement and personal growth in a job.
The theory states that job satisfaction and dissatisfaction are affected by two different sets of
factors. Therefore, satisfaction and dissatisfaction cannot be measured on the same
continuum.
Frederick Herzberg's two-factor theory, (intrinsic/extrinsic motivation), concludes that certain
factors in the workplace result in job satisfaction, but if absent, they don't lead to
dissatisfaction but no satisfaction. The factors that motivate people can change over their
33
lifetime, depending on the individuals’ status at a specific point in time. The theory is
sometimes called the "Motivator-Hygiene Theory" and/or "The Dual Structure Theory."
Source; Christina (2003). Herzberg’s Two-Factor Theory of Job Satisfaction: An Integrative
Literature Review
34
The Two-Factor theory implies that managers must stress the guaranteeing of the adequacy of
the hygiene factors to avoid employee dissatisfaction. Also, managers must make sure that
the work is stimulating and rewarding so that the employees are motivated to work and
perform harder and better. This theory emphasize on job-enrichment i.e making the work
interesting and stimulating in order to motivate the employees. The job must utilize the
employee’s skills and competencies to the maximum. Focusing on the motivational factors
can improve work-quality
Hertzberg’s theory when applied to this study implies that both motivator and hygiene factors
should be present in order to get a worker stay in a rural area where they are posted and still
get the best out of the worker. When this theory is properly applied, health workers will have
the incentive to stay and improve quality of service (reduction in maternal and child
mortality), reduce industrial disputes and make fewer complaints about pay and working
conditions
Management should therefore focus on rearranging work schedule and postings so that both
motivator and hygiene factors will reflect on all the policies and organization of the
environment to achieve the best possible outcome for the organization.
Contingency Theory
Contingency theory is a class of behavioral theory that claims that there is no best way to
organize a corporation, to lead a company, or to make decisions; rather, the optimal course of
action is contingent (dependent) upon the internal and external situation. Several contingency
approaches were developed concurrently in the late 1960s.
They suggested that previous theories such as Weber's bureaucracy and Taylor's scientific
management failed because they neglected that management style and organizational
structure were influenced by various aspects of the environment: the contingency factors.
There could not be "one best way" for leadership or organization.
Historically, contingency theory has sought to formulate broad generalizations about the
formal structures that are typically associated with or best fit the use of different
technologies. The perspective originated with the work of Joan Woodward (1958), who
35
argued that technologies directly determine differences in such organizational attributes as
span of control, centralization of authority, and the formalization of rules and procedures.
Gareth Morgan in his book Images of Organization describes the main ideas underlying
contingency in a nutshell:
Organizations are open systems that need careful management to satisfy and balance internal
needs and to adapt to environmental circumstances
There is no one best way of organizing. The appropriate form depends on the kind of task or
environment one is dealing with.
Management must be concerned, above all else, with achieving alignments and good fits
Different types or species of organizations are needed in different types of environments
Fred Fiedler's contingency model focused on a contingency model of leadership
effectiveness. This model contains the relationship between leadership style and the
favorableness of the situation. Situational favorableness was described by Fiedler in terms of
three empirically derived dimensions
1. The leader-member relationship, which is the most important variable in determining the
situation's favorableness
2. The degree of task structure, which is the second most important input into the
favorableness of the situation
3. The leader's position power obtained through formal authority, which is the third most
important dimension of the situation
Situations are favorable to the leader if all three of these dimensions are high. That is, if the
leader is generally accepted and respected by followers (first dimension), if the task is very
structured (second dimension), and if a great deal of authority and power are formally
attributed to the leader's position (third dimension), then the situation is favorable.
In recruitment and retention, it is worthy to note that the leader's ability to lead is contingent
upon various situational factors, including the leader's preferred style, the capabilities and
behaviours of followers and also various other situational factors. In rural areas an effective
leader should put into consideration the environment (housing, roads, availability of hospital
36
equipment} in which workers are posted and ensure that it is favourable to get the best out of
them. Another important factor to consider in this theory is that all environment and situation
differ therefore what works in a particular local government might not work in another and as
such each local government should be handled based on their unique nature.
Conceptual Framework
To better understand the role of factors affecting recruitment and retention of health workers
in rural areas, a conceptual framework developed by the researcher is presented in this
section.
Factors affecting recruitment and retention of health workers are numerous and complex, but
focusing on crucial elements should permit insight into the issue of health workforce
imbalances.
The independent variables as derived from the theories used in this study include; inadequate/
shortage of staff, Closure of health clinics, Increased attrition of health workers in rural areas,
reduced access to health care services by rural dwellers, increased maternal/infant morbidity
and mortality rate, challenging/stimulating work schedule, opportunity for advancement and
gaining recognition working condition, job security, quality of supervision and inter-personal
relationships, wages, salaries and other financial remuneration. The intervening variables
include living with family members in the area of assignment, good schools, positive
individual working goals/motives (personal factors), adequate rewards, positive policies,
adequate resources/incentives (institutional factors), adequate and safe work environment,
provision of social amenities (community factors). When all these intervening variables are
put in place, the likely outcome would be an adequate and motivated workforce who will
always be present at the clinic. This will eventually lead to improved access to quality health
care services for rural dwellers, reduced infant and maternal mortality, and overall
achievement of health related millennium development goals. The individual looks for a
better organisation with these factors in place which will inevitably lead to retention of health
workers.
37
Conceptual framework developed by the researcher
Empirical Review
Wafula et al, (2010) investigated reasons for poor recruitment and retention in rural areas and
potential policy interventions through quantitative and qualitative data collection with nursing
INTERVENING
VARIABLES
Adequate rewards
Positive policies
Adequate resources
Adequate and safe
work environment
Adequate
incentives: rural
allowance etc.
Positive individual
working
goals/motives
Job security
INDEPENDENT
VARIABLES
Inadequate/
shortage of staff
Closure of health
clinics
Increased attrition
of health workers in
rural areas.
Reduced access to
health care services
by rural dwellers
Increased maternal
morbidity and
mortality rate
Increased infant
mortality and
morbidity rate
DEPENDENT
VARIABLES
Adequate/motivated
staff in the rural area.
Reduced migration of
health workers from
rural to urban area.
Availability of staff in
the clinics at all times.
Increased access to
quality health care
services for rural
dwellers
Reduced infant and
maternal
morbidity/mortality
Achievement of health
related MDGs
38
trainees in Kenya, they interviewed 345 trainees from four purposively selected Medical
Training Colleges (MTCs) (166 pre-service and 179 upgrading trainees with prior work
experience). Each interviewee completed a self-administered questionnaire including likert
scale responses to statements about rural areas and interventions, and focus group discussions
(FGDs) were conducted at each MTC. They found that among the health workers used for the
99study there is mixed perceptions of both living and working in rural areas, with a range of
positive, negative and indifferent views expressed on average across different statements. The
analysis further revealed that their attitude to working in rural areas was significantly
positively affected by advancing age, but negatively affected by being an upgrading student.
Attitudes to living in rural areas were significantly positively affected by being a student at
the Medical and nursing Training Colleges furthest from Nairobi. Positive aspects included
lower costs of living and more autonomy at work. Negative issues included poor
infrastructure, inadequate education facilities and opportunities, higher workloads, and
inadequate supplies and supervision.
The results from their quantitative and qualitative data indicated that students believed
several strategies could improve rural recruitment and retention, with particular emphasis on
substantial rural allowances and the ability to choose their rural location. Other interventions
highlighted included provision of decent housing, and more rapid career advancement.
However, recently introduced short term contracts in named locations were not favoured due
to their lack of pension plans and job security.
Serneels et al, (2010) carried out a study on who wants to work in a rural health post? The
role of intrinsic motivation, rural background and faith based institutions in Ethiopia. They
carried out a cohort descriptive survey of 288 nursing students and 124 medical students
using a researcher developed questionnaire and they observed that, the analysis points to
three factors in the Rwanda context: intrinsic motivation, rural background and religious
affiliation related to participation in a local bonding scheme. When supplementing the
Rwanda data with similar data from Ethiopia, the results confirm two key determinants of
rural reservation wages: motivation to help the poor and religious affiliation, where the latter
reflects country specific activities by faith-based organizations: a local bonding scheme
operated by the Adventist community in Rwanda and training that encourages rural service
by a Catholic NGO in Ethiopia. Among these results, the effect of motivation stands out as a
particularly strong and robust finding.
39
However, Alihonou, Soudé, and Hounyé (1998) in their study on health workers' motivation
and performance in Benin, suggested introducing non-financial incentives while also
improving structural conditions. Stilwell (2001) shows, by reference to Zimbabwe, that health
workers based in remote areas, despite lack of financial incentives and hard working
conditions, frequently exhibited a high level of motivation to perform well. She traces this
motivation to good leadership and supportive management, among other factors. Her analysis
suggested that certain non-financial incentives can have a beneficial effect on motivation,
even under adverse conditions of insufficient pay and equipment, understaffing, etc. In a
review of theories and empirical evidence of health workers motivation, Dolea and Adams
(2005) equally stressed the importance of non-financial incentives.
In addition, Henderson and Tulloch, (2008) carried out a cross sectional survey of 234 health
professionals in rural pacific and Asian communities on incentives for retaining and
motivating health workers in pacific and Asian countries. They utilized a structured
questionnaire to elicit information from the respondents. They found that Health workers
migrate, leave the health sector, or use various coping strategies in response to difficult
circumstances such as poor or intermittent remuneration, inadequate working conditions,
limited training opportunities or weak supervision. They suggested that to minimize attrition
from the health workforce and the negative effects of coping strategies, efforts are required to
address the causes of health worker dissatisfaction and to identify the factors that influence
health worker choices. The challenges in maintaining an adequate health workforce require a
sustained effort in workforce planning, development and financing. This effort requires
innovative strategies – such as incentive packages – for retaining and motivating health
workers in resource-constrained settings.
Lian (2004) carried out a delphi analysis of the influence of human resource management
practices on the retention of employees of Australian organization, she found out that the five
(5) HRM factors influencing retention in order of importance, are; effective selection, reward
and recognition, training and career development, challenging employment structures and
opportunities and equity of compensation and benefits. She also found that there are also
organizational factors that affect retention; influential and sensitive leadership style, company
policies and culture, communication and consultation, effective integration, working
40
relationships, satisfactory working environment, good work mates, sound supervision and
direction, clear work standards, good instruction on how to do the job and above all objective
assessment.
Surveys of health workers in five Pacific countries examined reasons for leaving or staying in
their country of origin and demonstrated that there are common patterns among countries,
even though there is variation in the relative importance of factors influencing individuals
(WHO, 2004). Findings indicate that health workers commonly leave to obtain better
salaries, training opportunities and more desirable working conditions, to access education
for children, to find political stability, and because of family ties abroad. Evidence from the
same study indicates that health workers who remain in their countries of origin hold more
senior positions, receive good salaries and privileges, and work in favoured locations.
Studies in the United States and Canada have shown that health workers with a rural
background, a preference for life in smaller communities, and education in rural medicine are
likely to be both recruited for and retained in rural communities (Daniels, Skipper, Sanders,
& Rhyne, 2007). In Canada, recruiting midwives for remote areas is difficult. As a result, the
Ministry of Health has started a midwifery course where female nurses currently working in
(or with strong links to) rural areas with vacancies are selected and trained for an additional
year in midwifery and then posted to these priority areas.
There is a positive association between the performance of health workers and the clarity of
their job descriptions. A questionnaire based survey of Indonesian nurses and midwives by
WHO (2006) found that approximately 47% of them did not have job descriptions and 40%
were engaged in work other than nurses duties. Based on the survey results, clear job
descriptions and a performance monitoring system were developed and implemented. Staff
reported that the job descriptions together with standards of operation and procedures had
given them greater confidence about their roles and responsibilities. It is important that health
workers have their skills matched to their tasks.
McAuliffe and Barnett (2010) carried out a questionnaire study on perceptions towards rural
and remote practice: a study of 342 final year occupational therapy students studying in a
regional university in Australia. Quantitative data analysis was performed on responses. They
found out that students' perceptions towards rural and remote practice changed over the
course of their university programme. They suggested that greater focus on the academic staff
41
and fieldwork supervisors' perceptions towards rural and remote practice may be required in
the development of rural undergraduate programmes. Identification of students who have
family/close friends living in rural and remote areas may encourage occupational therapists to
work in rural areas.
Keane, Smith, Lincoln and Fisher (2011) carried out a survey of the rural allied health
workforce in New South Wales to inform recruitment and retention. They found out that the
New South Wales rural allied health workforce is strongly feminized, matured and
experienced. They suggested that recruitment should target rural high school students and
promote positive aspects of rural practice, such as diversity and autonomy and the retention
strategies should include flexible employment options and career development opportunities.
Ebuehi and Campbell (2011) carried out a study on attraction and retention of qualified health
workers to rural areas in Nigeria: a case study of four LGAs in Ogun State, Nigeria. Their
cross sectional survey measured health workers work experience, satisfaction with, and
reasons for undertaking their current work; as well as their reasons for leaving a work
location. They also gathered data on factors that attract health workers in rural settings and
retain them. They found that rural health workers were generally more likely to work in rural
settings (62.5%) than their urban counterparts (16.5%). Major rural motivators for both
groups included: assurances of better working conditions; effective and efficient support
systems; opportunities for career development; financial incentives; better living conditions
and family support systems. More urban than rural health workers expressed a wish to leave
their current job due to poor job satisfaction resulting from poor working and living
conditions and the lack of career advancement opportunities. The main de-motivator was
poor job satisfaction resulting from inadequate infrastructure. Rural health workers were
particularly dissatisfied with career advancement opportunities.
42
Summary of Literature Review
This chapter discussed the concepts relevant to the study which included; retention and
recruitment, health practitioners, incentives and other concepts in human resource for health.
The theories applied to this study are Hertzberg two factor theory propounded by Fredrick
Hertzberg and contingency theory propounded by Jean Woodward. Hertzberg discussed two
important concepts; the hygiene and motivator factors. Hygiene factors are based on the
need for a business to avoid unpleasantness at work while the motivator factor is an
individual’s desire for growth. He went further to state that if these factors are present, an
employer is assured to get the best from his employees.
Contingency theory is of the opinion that there is no best way to organize a corporation, to
lead a company, or to make decisions. Instead, the optimal course of action is contingent
(dependent) upon the internal and external situations.
Related literatures were reviewed and the researcher found that there is paucity of data on this
topic in developing countries like Nigeria. Most of the literatures related to this topic were
largely carried out in developed countries whose culture and certain characteristics are quite
different from those in developing countries. The personal, institutional and community
factors that affect non stay of health workers in rural areas that will be identified in this study
will be specific to developing countries like Nigeria. It is believed that the findings from this
work will provide the necessary information with regards to recruitment and retention of
health workers in rural areas of developing countries of which Nigeria is one, thereby closing
the gap created by lack of data.
43
CHAPTER THREE
RESEARCH METHOD
This chapter presented the research design, the study area, the population of study, sample
and sampling procedure, instrument for data collection, validity and reliability of instrument,
ethical consideration as well as the procedure for data collection and data analysis.
Research Design
This was a prospective, descriptive, cross-sectional study used to obtain information on
factors contributing to non-stay of health workers in rural areas. The design was considered
appropriate for this study because it permitted the observation, descriptions and
documentations of aspects of the situation as it naturally occurred.
Area of study
The study was undertaken in Enugu State, south east Nigeria. There are seventeen local
government areas (LGAs) in the State officially recognized by the federal government
besides development council areas created by the State Government. Five of these local
government areas are largely urban. Enugu state has an estimated population of about
3,257,298 (FRN Official Gazette No 24 Vol 94, 2007) and the inhabitants are mainly civil
servants and farmers. There are six district hospitals, 36 cottage hospitals and 407 primary
health care centres, including comprehensive health centres, health centres, and health posts
in the state (Ministry of Health, department of statistics 2009). The State is divided into seven
health districts for the purpose of health care delivery. Each health district is made up of
between one and three LGAs.
Population of the study
The population of study was made up of all the professional rural health workers in Enugu
State. This Population consisted of 611 professional health workers working in the State
Ministry of Health according to the data from Enugu State Ministry of Health in 2011. This
population excluded those working in Enugu State Teaching Hospital and the Poly District
Hospital in Enugu urban. See appendix 1.
44
Sample
The sample size of 236 professional rural health workers in Enugu state for the study was
determined using power analysis formular (Creative Research System Survey Software,
2010).
Sample size = n/ [1+(n/population)].
Where
n= Z2P(1-P)
d2
Z= Standard normal distribution at 95% which corresponds to the confidence interval 1.96.
P= 50 % (the prevalence rate is not known).
d= Allowable error which is taken as 0.05 or 5%.
Following this formular, a sample size of 236 professional health workers in Enugu state was
calculated. (See appendix II).
Inclusion criteria
1. Doctors, nurses, pharmacists and medical laboratory scientists working under the
Enugu State health board.
2. Staff must have been employed for at least two years.
3. Willingness to participate.
4. Those available at the time of the study.
Sampling Procedure
A multi stage sampling technique was employed.
The first stage employed the use of simple random sampling to select three health districts
out of the seven in the State. The health districts selected were Agbani, Udi, and Enugu
health districts.
45
Agbani and Udi health districts have two LGAs each while Enugu district covers three LGAs.
Each district has one district hospital while each LGA has two cottage hospitals. All the
district and cottage hospitals in the selected health districts were used. District and cottage
hospitals were chosen because they have more professional mix and have more staff.
The second stage was the use of stratified proportionate sampling to select the number of
health professionals in each group that formed an adequate representation of the group. Total
population in each group / total (Target) population X sample size. (see appendix 2).
The third stage was the use of convenience sampling to reach the 236 professional workers
used for the study.
Instrument for data collection
A researcher-developed questionnaire was used for data collection. Questions were drawn
based strictly on the stated objectives and literatures reviewed on factors contributing to non-
stay of health workers in rural areas. The structured questionnaire was a modified 4 point
Likert scale ranging from strongly agreed(1), Agree (2), disagree (3) to strongly disagreed(4)
and contained 31 items in five sections A, B, C, D, and E. Section A elicited information on
the demographic profile of the health workers: age, profession and years of service in the
rural areas. Section B dealt with questions on personal factors that contribute to non-stay of
health workers in rural areas and contains six (6) questions, section C dealt with institutional
factors with five (5) questions, section D contained six (6) questions that dealt with
community factors that contribute to non-stay of health workers in rural areas while section E
identified strategies that would potentially motivate health workers to stay in the rural areas.
(See appendix 111).
Validity of instrument
The instrument was submitted for face and content validity to the researchers’ supervisor and
two other experts- one specialist in measurement and evaluation, one community health
specialist- for vetting of the relevance of the instruments. The observations and corrections
were used to modify the final instrument.
46
Reliability of instrument
In order to ascertain the reliability of the instrument, a pilot study was conducted using test-
retest method. The developed test questionnaire was administered to 24 practicing health
professionals of comparable characteristics at Poly district hospital Enugu. The procedure
was done by administering the developed questionnaire to the same health professionals
twice with a two week gap. The two sets of scores were computed using Pearson product
moment correlation formula based on the different sections of the questionnaire. A
correlation (r) of 0.83 for section B, (r) of 0.96 for section C, (r) of 0.87 for section D, and (r)
of 0.92 for section E was obtained which was deemed appropriate. (See appendix IV).
Ethical consideration
Approval to conduct the study was obtained from the ethical committee of the Ministry of
Health, Enugu. (See appendix V).
Informed consent was obtained from the respondents and they were assured of confidentiality
and anonymity. (See appendix VI).
Procedure for data collection
With the ethical approval and the introductory letter from the Head of Department of Nursing
Sciences, University of Nigeria Enugu Campus, an administrative permit was obtained from
the Director of hospital services Ministry of Health, Enugu state. With this permit, all the
heads of the sampled health centers and cottage hospitals were notified to render the
necessary assistance.
The duty rooster of the health professionals was collected from each of the hospitals and
arrangements were made to administer the questionnaire on the clinic days. Two research
assistants were trained on the purpose of the study and how to collect data from respondents.
They assisted the researcher in administration and collection of data.
Each district was allocated two weeks for data collection. The whole exercise of data
collection lasted for six (6) weeks.
47
Methods of data analysis
Data collected were analyzed descriptively using percentages, means, frequencies, standard
deviations and presented in tables. The decision rule was determined as the mean value
obtained using the Likert 4-point scale. A cutoff point of 2.5 was derived. The responses were
compared with this mean value of 2.5 to ascertain to which extent the overall responses
differed from the mean. The item with a mean value less than 2.5 has a positive impact on the
respondent’s decision to stay in the rural area while items with a mean value greater than 2.5
have no impact on decision to stay. Analysis was done using the statistical package for social
science (SPSS 17.0 for windows Evaluation version).
48
CHAPTER FOUR
PRESENTATION OF RESULTS
This chapter presents the results of the data analysis. Two hundred and thirty six (236) copies
of the questionnaire were administered and all were returned, giving a 100% response rate.
Table 1: Demographic data of the respondents
n=236
Age 21-30 years
31-40 years
41-50 years
51years and above
Total
Mean
Standard Deviation
F
95
88
47
6
236
%
40.3
37.3
19.9
2.5
100
33.84
8.23
Sex Male
Female
Total
69
167
236
29.2
70.8
100
Marital status Single
Married
Total
128
108
236
54.2
45.8
100
Profession Medical Doctor
Nurse/midwife
Pharmacist
Medical laboratory scientist
Total
31
186
10
9
236
13.2
68.8
4.2
3.8
100
Years of experience 2-5 yrs
6 yrs & above
Total
207
29
236
87.7
12.3
100
Table 1 showed that 95 (40.3%) of the respondents were within the age range of 21-30 years
while 88 (37.3%) were within the age range of 31-40 years. Respondents within the age range
of 41-50 years were 47 (19.9%) while those that aged 51 years and above were 6 (2.5%).
49
Also 69 (29.2%) of the respondents were males while 167 (70.8%) were females. The table
showed that 128 (54.2%) of the respondents were single while 108 (45.8%) were married.
The table also showed that 60 (19.2%) of the respondents were medical doctors, 179 (68.6%)
were nurse/midwives, 19 (17.2%) were pharmacists and 13 (5.0%) were medical laboratory
scientists.
There were 207 (87.7%) respondents with 2 to 5years of working experience and 29(12.3%)
with working experience of more than 5 years.
50
Objective one: To identify personal factors that affect non-stay of health workers in
rural area.
Table 2: Personal factors affecting non stay of health workers in rural areas
n=236
Factor SA
F (%)
A
F (%)
D
F (%)
SD
F (%)
Mean SD P-
value
Never lived in rural
area all my life.
38(16.10) 95(40.25) 70(29.66) 33(13.98) 2.42 0.92 0.170
Quality of life in rural
area is poor.
2(0.85) 34(14.41) 152(64.41 48(20.34) 3.04 0.62 0.199
Housing is poor in rural
area.
6(2.54) 73(30.93) 107(45.34) 50(21.19) 2.85 0.78 0.919
Working in the rural
area is stressful.
22(9.32) 70(29.66) 122(51.69) 22(9.32) 2.61 0.78 0.177
My family prefers
living urban area.
47(19.92) 171(72.46) 8(3.39) 10(4.24) 1.92 0.63 0.000
Raising children in
rural area is difficult.
18(7.63) 33(13.98) 131(55.51) 54(22.88) 2.94 0.82 0.000
Table 2 showed that 95 (40.25%) agreed that having never lived in rural area would affect
on3es decision to stay and work in rural area, 38 (16.10%) strongly agreed to this, 70
(29.66%) disagreed and 33 (13.98%) strongly disagreed that having never lived in rural area
all their lives would affect their decision to live and work in the rural area with a mean value
of 2.42. (P = 0.170).
The table also showed that 152 (64.41%) of the respondents disagreed that quality of life in
rural area was poor, 48 (20.34%) strongly disagreed, 34 (14.41%) agreed and only 2 (0.85%)
strongly agreed with a mean value of 3.04. (P = 0.199).
51
The table also revealed that 107 (45.34%) disagreed that housing was poor in the rural areas,
50 (21.19%) strongly disagreed, 73 (30.93%) agreed and 6 (2.54%) strongly agreed with a
mean value of 2.85.
One hundred and twenty two (51.69%) of the respondents disagreed that working in the rural
area was stressful, 22 (9.32%) strongly disagreed, whereas 70 (29.66%) agreed and 22
(9.32%) strongly agreed that working in the rural area was stressful with a mean value of
2.61.
Table 2 also showed that 171 (72.46%) of the respondents agreed that the family preferring to
live in urban area could affect ones decision to live and work in the rural area, 47 (19.92%)
strongly agreed, 10 (4.24%) strongly disagreed while 8 (3.39%) disagreed with a mean value
of 1.97 (P = 0.000).
The table also showed that 131 (55.51%) of the respondents disagreed that raising children in
the rural area was difficult, 54 (22.88%) strongly disagreed while 33 (13.98%) agreed and
only 18 (7.63%) agreed strongly that raising children in rural area was difficult with a mean
value of 2.94.
52
Objective 2: To identify institutional factors contributing to non stay of health workers
in rural areas
Table 3: Institutional factors affecting non-stay of health workers in rural areas.
n=236
Factor SA
F (%)
A
F (%)
D
F (%)
SD
F (%)
Mean SD P-value
Not challenging due
to limited variety of
health problems.
16(6.78) 54(22.88) 120(50.85) 46(19.49) 2.83 0.82 0.302
Modern facilities
and equipment are
not available for use
in the rural areas.
6(2.54) 12(5.08) 135(57.20) 83(35.17) 3.25 0.67 0.512
There is inadequate
reward and
recognition for
health workers in
rural areas.
56(23.73) 143(60.59) 34(14.41) 3(1.27) 1.93 0.66 0.000
There is limited
training opportunity
and weak
supervision in rural
areas.
38(16.10) 44(18.64) 117(49.58) 37(15.68) 2.65 0.93 0.203
There are no
organizational
policies that will
affect workers
positively e.g.
incentives.
38(16.10) 127(53.81) 31(13.14) 40(16.95) 2.31 0.94 0.000
53
Table 3 above revealed that 120 (50.85%) of the respondents disagreed that limited variety of
health problems should not affect ones decision to stay and work in the rural area, 46
(19.49%) strongly disagreed to this, while 54 (22.88%) agreed and 16 (6.78%) strongly
agreed with a mean value of 2.83.
The table also showed that 135 (57.20%) and 83 (35.17%) of the respondents disagreed and
strongly disagreed respectively that non-availability of modern facilities for use in the rural
area should contribute to their decision not to live and work in the rural area, 12 (5.08%)
agreed that this factor could influence their decision not to live and work in the rural area
while only 6 (2.54%) respondents strongly agreed with a mean value of 3.25.
The table also showed that 143 (60.59%) of the respondents agreed that inadequate reward
and recognition for health workers in rural area was a factor that could affect ones decision
not to live and work in the rural area, 56 (23.73%) strongly agreed to this statement whereas
34 (14.41%) disagreed and only 3 (1.27%) strongly disagreed to this opinion with a mean
value of 1.93. (P=0.000).
One hundred and seventeen respondents (49.58%) disagreed that limited training opportunity
and weak supervision were significant factors that could affect the choice to live and work in
the rural areas while 37 (15.68%) of the respondents strongly disagreed to the statement.
Forty four (18.64%) agreed and 38 (16.10%) strongly agreed that limited training opportunity
and weak supervision was a factor that may affect their decision to live and work in the rural
areas with a mean value of 2.65.
Table two also showed that 127 (53.81%) of the respondents agreed that poor organisational
policies that affect workers in the rural areas positively could affect the staff decision to live
and work in the rural areas, 38 (16.10%) strongly agreed to this, 40 (16.95%) strongly
disagreed and 31 (13.14%) respondents disagreed with a mean value of 2.31. (P = 0.000).
54
Objective 3: To identify community factors contributing to non-stay of health workers
in rural areas.
Table 4: Community factors contributing to non-stay of health workers in rural areas.
n=236
Factor SA
F (%)
A
F (%)
D
F (%)
SD
F (%)
Mean SD P-
value
The host community is
not receptive to visitors.
61(25.85) 65(27.54) 76(32.20 34(14.41 2.35 1.02 0.023
There are no good
schools for the children
in rural areas.
14(5.93) 32(13.56) 143(60.59 47(19.92) 2.94 0.76 0.987
Posting to a community
with different belief
may scare staff.
33(13.98) 58(24.58) 101(42.80) 44(16.64) 2.66 0.94 0.859
There are no social
amenities (good roads,
electricity, pipe borne
water and access to
information).
22(9.32)
53(22.46) 92(38.98) 69(29.24) 2.88 0.94 0.502
Security in the
community is
inadequate and
unreliable.
53(22.46) 14(5.93)
101(42.80) 68(28.81) 2.78 1.10 0.588
Clients do not visit the
health centers.
13(5.51) 25(10.59) 134(56.78) 64(27.12) 3.06 0.77 0.894
Table 4 revealed that 76 (32.20%) and 34 (14.41%) disagreed and strongly disagreed
respectively that the host community’s receptiveness to visitors was a contributing factor to
non-stay of health workers in the rural area whereas 65 (26.4%) and 61 (24.6%) respectively
55
agreed and strongly agreed that the host community not being receptive to visitors may affect
ones decision to stay and work in the rural area with a mean value of 2.35.
The table also showed that 143 (60.59%) of the respondents disagreed, and 47 (19.92%)
strongly disagreed that the quality of schools for the children in the rural area would not
influence staff decision not to live and work in the rural area while 32 (13.56%) and 14
(5.93%) of the respondents agreed and strongly agreed respectively that the quality of schools
in the rural areas would influence their decision and a mean value of 2.94.
The above table revealed that 101 (42.80%) respondents disagreed that posting to a
community with a different belief could affect the individuals decision to live and work in the
rural area, 44(18.64%) strongly disagreed, 58 (24.58%) agreed and 33 (13.98%) strongly
agreed that posting to a community with a different belief from theirs would affect their
decision to stay and work in the rural area and a mean value of 2.66.
The table showed that 92 (38.98%) of the respondents disagreed that the quality of
infrastructure in the rural area was a significant factor affecting non-stay of staff in the rural
areas, 69 (29.24%) strongly disagreed, 53 (22.46%) agreed and 22 (9.32%) respondents
strongly agreed that inadequate infrastructure may be a contributing factor to non-stay of
health workers in the rural area with a mean value of 2.88.
The table also showed that 101 (42.80%) and 68 (28.81%) respectively disagreed and
strongly disagreed that inadequate security coverage in the community was a serious factor
contributing to non-stay of health workers in the rural area, while 53 (22.46%) and 14
(5.93%) strongly agreed and agreed respectively with a mean value of 2.78.
One hundred and thirty four (56.78%) and 64 (27.12%) of respondents disagreed and strongly
disagreed respectively that poor client visit to the health centre was a factor influencing the
non-stay of professionals in the rural area whereas 25 (10.59%) agreed and 13 (5.51) strongly
agreed with a mean value of 3.06.
56
Objective 4: To identify strategies to retain health workers in rural areas.
Table 5: Strategies to retain health workers in the rural areas. n=236
Factor SA
F (%)
A
F (%)
D
F (%)
SD
F (%)
Mean SD P-
value
Paying more to
professionals who work in
rural areas.
63(26.69) 156(66.10) 12(5.08) 5(2.12) 1.83 0.61 0.002
Making it compulsory for
fresh graduates to spend at
least one year in the rural
area.
47(19.92) 56(23.73) 107(45.34) 53(22.46) 2.81 0.89 0.506
Giving more opportunities
to health workers in rural
areas for career
development.
22(9.32) 54(22.88) 107(45.34) 53(22.46) 2.81 0.89 0.506
Provision of adequate
infrastructure e.g. housing,
electricity for health
workers.
16(6.78) 38(16.10) 119(50.42) 63(26.69) 2.97 0.84 0.991
Provision of adequate
security in health centres.
68(28.81) 141(59.75) 12(5.08) 15(6.36) 1.89 0.76 0.004
Provision of rural
allowance.
162(68.64) 57(24.15) 16(6.78) 1(0.42) 1.39 0.63 0.000
Giving scholarship to
children of health workers
in rural areas.
2(0.85) 11(4.66) 178(75.42) 45(19.07) 3.13 0.51 0.541
Table 5 above showed that 156 (66.10%) of the respondents agreed that paying more to
professionals who work in rural areas would improve the stay of health workers in the rural
areas, 63 (26.69%) strongly agreed too. On the other hand, 12( 5.08%) and 5 (2.12%) of the
respondents disagreed and strongly disagreed respectively that paying more to professionals
who work in rural areas would not affect their decision to stay and work in the rural area and
the mean value is 1.83. (P-value = 0.002).
57
One hundred (40.7%) and 33 (13.98%) of the respondents disagreed and strongly disagreed
respectively that making it compulsory for fresh graduates to spend at least one year in the
rural area would help retain health workers in rural area while 56 (23.73%) agreed and 47
(19.92%) strongly agreed with a mean value of 2.50.
Also 107 (45.34%) of the respondents disagreed that giving more opportunities to health
workers in rural areas for career development would not retain professionals in the rural area
and 53 (22.46%) of the respondents strongly disagreed to this; while 54 (22.88%) of the
respondents agreed and 22 (9.32%) strongly agreed that if more opportunities were given to
rural health worker for career development they would live and work in the rural area (mean
= 2.81).
In this table, 119 (50.42%) of the respondents disagreed that provision of adequate
infrastructure would be a significant factor that would help to retain health workers in the
rural areas and 63 (26.69%) strongly disagreed. However, 38 (16.10%) and 16 (6.78%) of the
respondents agreed and strongly agreed respectively that provision of adequate infrastructure
would help to retain health workers in rural areas with a mean value of 2.97.
The table also revealed that 141 (59.75%) of the respondents agreed that provision of
adequate security at the health centres might help to retain health workers in rural areas, 68
(28.81%) strongly agreed to this, whereas 15 (6.36%) and 12 (5.08%) respectively strongly
disagreed and disagreed that provision of adequate security at the health centres would not
improve the stay of health workers in the rural areas and a mean value of 1.89. (P-value
=0.004).
From the table, it was shown that 162 (68.64%) of the respondents strongly agreed that
paying rural allowance will help retain health workers in the rural area, and 57 (24.15) agreed
to this. Sixteen (6.78%) and 1 (0.42%) disagreed and strongly disagreed respectively that
paying rural allowance will not help retain health workers in the rural area and a mean value
of 1.39. (P-value = 0.000).
The table also revealed that 178 (75.42%) and 45 (19.07%) of the respondents disagreed and
strongly disagreed respectively that granting scholarship to children of health workers in the
rural areas was a good strategy that would retain health workers in the rural area while 11
(4.66%), 2 (0.85%) agreed and strongly agreed respectively that these scholarship schemes to
58
children of rural health workers would help to retain the staff in the rural postings with a
mean value of 3.13.
SUMMARY OF MAJOR FINDINGS
• Majority (40.3%) of the health workers were within the age range of 21 to 30 years
while 37.3% were within the age range of 31 to 40 years.
• Majority (70.8%) of the respondents were female and most of them were nurses
(68.8%).
• Family related factor was the most important (92.38%) personal factor affecting non-
stay of health workers in rural areas of Enugu state with a mean value of 1.92. (P-
value=0.000)
• Among the institutional factors affecting non-stay of health workers in rural areas,
majority of the respondents 84.32% felt that inadequate reward and recognition of
rural health workers affect their decision to either stay or not stay and work in rural
areas (mean=1.93). In addition, most of them (69.91%) felt that if there are no
organizational policies affecting rural health workers positively, with a mean value of
2.31. (P-value=0.000).
• None of the community factors had a significant relationship with their decision to
stay or not stay in the rural areas.
• Suggested strategies identified by respondents to retain health workers in rural areas
included paying more to professionals working in rural areas (92.79%), provision of
adequate security in the health centres (88.56%) and provision of rural allowance
(92.79%).
59
CHAPTER FIVE
DISCUSSION OF FINDINGS
This chapter presented the discussion of findings, implication of the study, limitation of the
study, suggestion for further studies, summary, conclusion, and recommendation.
Objective one: Personal factors contributing to non-stay of health workers
This study revealed that family related factors appeared to have the most significant impact
on the decision of a health worker to live and work outside the urban areas. Respondents
believed strongly that if the rest of the members of a family preferred to live in the urban
areas for one reason or the other, the health worker would rather live with the rest of the
family. McDonald, Bibby and Carroll (2002) also observed in a separate study that having a
family living in a rural area has been found to be significantly associated with long-term
plans by the health worker to practice in a rural area.
The indigenes of Enugu State, like most Igbos believe strongly in both the nuclear and
extended family systems and as such, family ties would strongly influence a staff’s decision
to be retained at a duty station that is far from daily contact with other family members. This
finding concerning family tie from this study is highly relevant especially considering that the
study population was made of mainly the unmarried and relatively young age group. This
situation appears particularly more pressing considering the fact that most medical staff in
our environment are ladies who are likely to get married and by cultural beliefs are expected
to live in a family system where the husband determines the major decisions including which
part of the State that the family eventually settles down. In the local culture too, gender roles
demand that the woman should oversee basic household duties and take care of her children
among other roles. This finding implies that social infrastructure and Government policies
that would encourage the man to live with the wife at remote areas of posting should be
enhanced. Definitely, a properly organised good road network, transport and housing scheme
may encourage the rest of family members to live in the rural areas with the health worker.
Interestingly, the challenge about child up-bringing in the rural area and the hitherto
perception of poor quality of life in the rural areas did not affect significantly the staff
decision to be retained in the rural areas. This may probably be explained by the fact that
most staff of the state Government are indigenes of the state and would probably have lived
60
in the rural areas at one time or other at a younger age. Daniels, Skipper and Sanders (2007)
in a study conducted in the United States and Canada also observed that health workers with
a rural background would more likely be retained in rural communities following
recruitment.
The respondents are also willing to raise their family in the rural areas if other incentives are
available since there may be more time for them to take care of the children and supervise
their academic activities. Moreover, affordable and standard private schools are springing up
in the remote areas of the State with manpower derived from unemployed graduates.
Therefore the quality of education in the rural areas is gradually meeting up with standards in
the urban areas and it may no longer matter much if a child schooled in the urban or rural
area.
The quality of life in the rural area was not shown to be significantly poor as to affect
decision of stay. This may be due to improvement of rural infrastructure and social amenities
in the rural areas which has significantly improved the quality of life in the rural areas. The
effect of this social support was also observed by Wainer (2001), whose study identified that
poor community resources and facilities, lack of recreational, shopping and trade services
were reasons for female health workers leaving or considering leaving the rural areas. Other
studies have also reported that poor quality of life in rural areas contributes significantly to
nurses’ reluctance to live and work in rural settings (Consortium for Research on Equitable
Health System [CREHS], 2009). Ajala et al. (2005) also observed that lack of basic social/
infrastructural facilities (water, schools, electricity, roads) in rural communities contribute to
non-stay of health workers in rural areas.
Interestingly housing in the rural area was not a significant infrastructure challenge in this
study. This may be because there are no active on going housing scheme in any part of the
state. It is also common for an average Igbo adult to build a standard house in the village as
status definition. Some of these houses are usually unoccupied and rented out since a greater
proportion of the owners live in the urban areas. Contrary to perception therefore, housing in
the rural areas may actually be more standard, affordable and with relatively less crowding
and pollution compared to the urban areas. McDonald (2002) found a contrary opinion in a
study he carried out to identify the barriers to retention. His study revealed that market forces
affecting the distribution of the medical workforce are mediated by a complex interplay of
individual, familial and environmental factors. These factors include access to continuing
61
education, employment for one’s partner, children educations, lack of suitable housing,
family and social ties and lifestyle preferences. Rural communities and Government have the
capacity to influence these factors by ensuring that these facilities are available for those
posted and working in their communities.
Objective Two: Institutional factors contributing to non-stay of health workers in rural
areas.
Among the institutional factors studied, it was identified that poor government policy and
inadequate reward mechanism for staff in rural area were the most significant factors leading
to non-stay of health workers posted to the rural areas. This is an important finding that
exposed the role of government in non-stay of health workers in rural areas. For example,
Enugu state government has one of the worst salary structures in the country and in addition
to this; there is a significant salary and allowance disparity in favour of staff working in state
teaching hospital and to the disadvantage of other staff under the payroll of the state ministry
of Health. To put it in its perspective, a newly employed nurse in the state teaching hospital
has been observed to earn seventy thousand naira (N70, 000.00) monthly while the same
person employed in the rural area under the state Ministry of Health would earn around forty
thousand naira (N40.000.00) monthly. This will obviously put a staff posted in a rural area at
a disadvantage. Worse still, private hospital practice thrives better in the urban area than in
the rural area, with the implication that the poorer earning staff posted to the rural area would
prefer to engage in private practice in the urban area in order to supplement his salary and
probably visit the rural hospital at convenient periods. This attitude may increase morbidity
and mortality as well as thriving of non-orthodox medical practices in the rural areas, since
emergency services in the rural areas would not be satisfactorily offered when necessary.
This finding is in line with what Henderson and Tulloch (2008) observed in their study on the
incentives for retaining and motivating health workers in Pacific and Asian countries. Health
workers migrate, leave the health sector, or use various coping strategies in response to
difficult circumstances such as poor or irregular remuneration, inadequate working
conditions, limited training opportunities or weak supervision. In addition, Lian (2004)
carried out a Delphi analysis of the influence of human resource management practices on
retention of employees in Australia, and found that influential and sensitive leadership style,
company policies and culture, compensation and benefits, sound supervision and direction,
62
clear work standards and above all objective assessment were some of the organisational
factors that affect retention.
This salary disparity may be a true reflection of government poor political will power towards
adequately rewarding health workers posted in rural areas. Positive incentives like rural
posting allowance, less working hour per month, improved equipping of health facilities and
more opportunities for rural practice-oriented conferences may improve staff morale and
attitudes in rural areas. Federal Ministry of Health (2006) revealed that factors such as
disparity in the remuneration packages and schemes of service among health workers at
federal, state and local government payrolls may also be a contributory factor in their
migration to urban areas, though in spite of these findings, nothing much has been done to
retain health workers in rural areas in an attempt to achieve the MDGs by 2015.
In addition, the Enugu state government has not instituted effective policy in the state to
ensure proper monitoring of staff posted to rural areas. Effective implementation of periodic
unannounced staff monitoring by external supervisors along with appropriate penalties should
be attached to staff absenteeism. These measures would certainly serve as negative incentive
that would encourage the staff to stay at their duty post when scheduled.
In spite of the fact that most tertiary institutions in this state are in the urban areas,
opportunity for educational advancement was not a significant factor in the decision of staff
to stay in rural areas. Unlike the finding in this study, Olumide et al (2007) observed that
isolation from social/professional life, lack of educational opportunities for career mobility,
and quality schools for children were significant factors that affect the stay of health workers
in the rural areas. The finding in our study may be a reflection that staff posting are not
adequately monitored in Enugu state. Apparently these staff may be exploiting the
opportunity of poor supervision and more liberal work schedule to attend post graduate
courses unofficially. As much as continuing education is commendable and should be
encouraged by policy makers, this however should be organised in such a way that it does not
affect the efficiency of the staff at the place of primary assignment.
63
Objective Three: Community factors contributing to non-stay of health workers
Although a poor community receptive attitude may have a tendency to increase non-stay of
health workers in the rural areas, this study did not find this factor to be statistically
significant. Furthermore, none of the community factors investigated had significant
relationship with the respondents’ decision on non-stay in the rural areas. This result is not
surprising because the state is quite homogenous in terms of culture, religious beliefs and
ethnicity. Indirectly, these findings may reflect the high level of acceptance of the practice of
orthodox medicine in the communities as well as the tolerance, receptive and accommodating
attitude of people of Enugu state to strangers. Wainer (2007) in her study found that rural
health practitioners feel connected to the community they are posted to if the community
shows some degree of recognition and appreciation.
Objective 4: Strategies that will motivate workers to live and work in the rural areas
In this study, suggested interventions that will support stay in the rural areas included
increasing pay package and rural allowance as well as the guarantee of security in the rural
areas. On the other hand, compulsory one year rural posting for fresh graduates, improvement
in infrastructure and opportunity for career development were not considered very useful
intervention to influence retention of health workers in rural areas. This finding implies that
although government has done a lot in terms of security, a lot still needs to be done by the
government to sustain it.
Financial reward is a strong positive incentive that should not be over looked. It seems from
this study that financial reward is one of the most important mechanisms that the state
government should deploy to improve both staff stay in rural areas and work output. This
financial incentive is also very important especially for nurses whose career promotions are
currently based on seniority. These nurses are not likely to be motivated by non-financial
incentives like career advancement and other secondary gains. This result is also in
consonance with the result of the study done by Ebuehi and Campbell (2011) in Ogun State,
Nigeria on attraction and retention of qualified health workers to rural areas in Nigeria which
also highlighted the usefulness of financial reward as one of the tools for improved staff
motivation and retention. In the researchers’ opinion, a compulsory one year attachment for
64
fresh graduates in the rural area will be a novel idea if a proper incentive like boosting the
chances of getting a permanent job after the service is attached to this scheme. It will serve as
part of internship and the national youth service corp (NYSC) programme for nurse graduates
who train in the hospitals. This will improve the quality of health services available to
majority of Nigerians who live in the rural areas on both short and long term.
IMPLICATIONS OF THE STUDY TO NURSING
The need to retain health workers in the rural areas is very important in our society today.
There are personal, institutional and community factors that may affect a health professionals
decision to either stay or not stay and work in rural areas.
This implies that if the identified factors are considered by Nurse Administrators before
posting professionals to rural areas, they will get the best out of the staff. This will encourage
professional health workers in the rural areas to be committed to duty and always be present.
This will inevitably promote positive health outcome in our rural areas
These identified factors will also help health administrators to know policies they will put in
place to encourage professional health workers to remain in the rural areas and provide
quality care to more than 75% Nigerians living in rural area and this will in turn help to
achieve the Millennium Development Goals by 2015.
LIMITATIONS OF THE STUDY
This prospective study is very useful in this environment since it tried to highlight important
peculiar factors influencing non-stay of health workers in rural areas of Enugu state. However
a few limitations were encountered during the course of the study.
• Limited number of other health professionals like pharmacists and medical laboratory
scientists, with a larger number of nurses and doctors which inevitably may have
affected the result of the study.
• Age, sex, specialty and length of service of the staff were not randomized in the study.
There is no doubt that these variables may have affected the result of this study.
65
• In addition, Enugu State government workforce is likely to be made up of indigenes
with almost similar cultural and demographic characteristics. Therefore the result may
be different if the study were extended to federal government hospitals where
considerable culture conflict may exist among staff of different ethnic backgrounds.
Suggestion for further studies
• Further studies to evaluate the impact of age, sex and work experience on non-stay of
health workers may be considered in future. Studies in the future may also target sub-
group analysis among the different professions in the health sector.
• This study may be replicated on respondents who are in the federal teaching hospitals
from different geo-political zones of the country.
SUMMARY
This study was carried to determine the perceived factors affecting non-stay of helth workers
in rural areas of Enugu State. Four (4) objectives were formulated for the study.
Extensive literature was reviewed based on conceptual, theoretical and empirical review.
Cross sectional descriptive survey design was used for the study. The study was carried out in
the rural areas of Enugu state. A sample size of 236 professional health workers was selected
from a population of 611 health workers using proportional stratified random sampling
technique.
Data generated were analyzed descriptively using frequencies, mean, and standard deviation,
and presented in tables.
Findings of the study revealed that family related factors were the common personal factors
that affected non-stay of health workers in rural area, whereas lack of adequate government
policy, poor financial remuneration and weak supervision were some of the institutional
factors that contributed to non-stay. None of the community factors had a significant
relationship with the staff decision to stay or not stay in the rural areas. Suggested strategies
identified by respondents to retain health workers in rural areas included paying more to
professionals working in rural areas, provision of adequate security in the health centres and
provision of rural allowance.
66
CONCLUSION
From the findings of this study
• Majority (40.3%) of the health workers were within the age range of 21 to years while
37.3% were within the age range of 31 to 40 years.
• Majority (70.8%) of the respondents was female and most of them were nurses
(68.8%).
• Family related factor was the most important personal factor affecting non-stay of
health workers in rural areas of Enugu state.
• Among the institutional factors affecting non-stay of health workers in rural areas
were: inadequate reward and recognition of rural health workers as well as poor
organizational policy affect the staff decision to either stay or not stay and work in
rural areas.
• None of the communities factors identified had a significant impact on decision to
stay or not stay in the rural areas.
• Suggested strategies identified by respondents to retain health workers in rural areas
included paying more to professionals working in rural areas, provision of adequate
security in the health centres and provision of special allowances.
RECOMMENDATIONS
Based on the findings; the following recommendations were made;
• There is need to examine closely and review the current policies concerning rural
health staffing so as to improve effectiveness. Staff working conditions and welfare
should be improved to comparable standards. Motivation in terms of financial
incentives for rural health workers is essential. The policy review should also be
extended to efficient supervision exercise for workers in the rural areas with the
appropriate penalty attached to absenteeism and neglect of duty.
67
• Postings to the rural areas should be rotational and preferably family dispositions,
marital status, age and staff LGA of origin may also be considered.
• A properly organised good road network and housing scheme may encourage health
workers to relocate and live with their family in the rural areas.
• One year compulsory posting of fresh graduates from schools of Nursing and
Midwifery to rural areas with adequate remuneration should be considered as a way
of providing adequate and constant health care to rural dwellers.
68
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Appendix 1
Enugu state core health staff profile
Cadre of health workers No in service Sample
Medical officers 80 31
Pharmacists 25 10
Nursing officers/ midwives 482 186
Medical laboratory
scientists
24 9
Total 611 236
Source: State Health board statistics office, Ministry of Health, 2010.
Appendix 11
75
Sample size calculation using power analysis
Formula:
Sample size = n/[1+(n/population)]
Where
n= Z2P(1-P)
d2
Z= Standard normal distribution at 95% which corresponds to the confidence interval 1.96
P= 50 % (the prevalence rate is not known)
d- Allowable error which is taken as 0.05 or 5%
Population = 611
First, calculate the value for "n".
n = Z2 [P (1-P) / (D
2)]
n = 1.960 * 1.960 [0.50(1 - 0.50)
(0.05 * 0.05)
n = 1.960 * 1.960 [0.50(0.50)
(0.0025)
n = 1.960 * 1.960 [.25)
(0.0025)
n = 1.960 * 1.960 [100]
n = 1.960 * 9.31
n = 384.16
Next, Calculate the Sample Size. (S = Sample Size)
S = n / [1 + (n / population)
S = 384.16 / [1 + (384.16 / 611)]
S = 384.16 / [1 + 0.6287]
S = 384.16/ 1.6287
S = 236
Appendix 111
76
Department of Nursing Science
Faculty of Health Sciences & Technology
University of Nigeria, Enugu Campus
Dear Respondent,
I am an MSc student of the above named Department conducting a research study for my
dissertation on the topic perceived factors affecting non stay of health workers in rural areas
of Enugu state. Kindly answer the questions in this questionnaire. Your honest answer to each
question will be highly appreciated.
Thanks for your co-operation
Chukwunwendu,I.F
PART A. – Tick in your appropriate option in the box provided.
1. What is your age?
21- 30
31-40
41-50
51 and above
2. Sex Male Female
3. Marital Status. Single
Married
. Divorced
Widowed
4. What is your profession?
√
77
Medical doctor
Nurse/midwife
Pharmacist
Medical laboratory scientist
5. How long have you been in the service of Enugu state?
……………………………..
6. How many years have you been in rural service?
2 to 5years
6years & above
7. What is the name of your cottage hospital
………………………………………………..
Section B. For each number tick the most appropriate option with regards to your opinion on
the Personal factors contributing to non -stay of health workers in rural areas of Enugu state.
SN
Items
Strongly
Agree
(1)
Agree
(2)
Disagree
(3)
Strongly
disagree (4)
8 Never lived in rural area all my life
9 Quality of life in rural area is very
poor
10 Housing is poor in rural areas
11 Working in the rural area is stressful
12 My family prefers living in urban
area
13 Raising children in rural area is
78
difficult
Section C; Institutional factors contributing to non-stay of health workers in rural areas
14 Not challenging, due to limited
variety of health problems.
15 Modern facilities and equipment
are not available for use in the rural
areas
16 There is inadequate reward and
recognition for health workers in
rural areas.
17
There is limited training
opportunities and weak supervision
in rural areas
18 There is no organizational policies
that will affect workers positively
e.g. incentives.
Section D; Community factors contributing to non-stay of health workers in rural areas
19 The host community is not receptive to visitors
20 There are no good schools for the children in
rural areas
21 Posting to a community with a different belief
may scare staff
22 There are no good roads, electricity, pipe borne
water and access to information in most
communities
23 Security in the community is inadequate and
unreliable.
24 Clients do not visit the health center
79
Section E Perception Of Strategies To Retain Health Workers In Rural Areas.
25 Paying more to professionals who work in
remote areas
26 Making it compulsory for fresh graduates to
spend at least one year in the rural area
27 Giving more opportunities to health workers
in rural areas for career development.
28 Provision of adequate infrastructure e.g
housing, electricity for health workers
29 Provision of adequate security in health
centers
30 Provision of rural allowance
31 Giving scholarship to children of health
workers in rural areas.
Appendix IV
80
MEASURE OF RELIABILITY TEST
( )( )
( ) ( )∑∑
∑
−−
−−=
22
yyxx
yyxxr
FACTORS NO OF RESPONDENTS CORR. COEF (r)
PERSONAL FACTORS 26 0.83
INSTITUTIONAL FACTORS 26 0.96
COMMUNITY FACTORS 26 0.87
STRATEGIES FOR RETENTION 26 0.92
APPENDIX V1
INFORMED CONSENT
81
Introduction: My name is Chukwunwendu, Ifeoma, a post graduate student of Department
of Nursing Sciences, Faculty of Health science and Technology, University of Nigeria Enugu
Campus.
Voluntary nature of participation: Subject participation in this study is entirely voluntary.
You have the right to with draw consent and discontinue participation in the study at any
given time.
Study procedure: I am carrying out a study on the perceived factors affecting non-stay of
health workers in rural areas of Enugu State.
In this study you will be required to fill the questionnaire. Please feel free to ask for
clarification on any question you do not understand.
Risk: The process of filling the questionnaire will not cause you any harm or injury.
Confidentiality: Please note that any information you give will be kept confidential. Your
name will never be used in connection with any information you give.
Feedback: In case of any clarification, you can contact me 08032613134.
Response: The study has been explained to me and I understood the consent of the study
process. I will be willing to participate in the study described above.
Signature of Participant Signature of Witness Signature of Researcher
.................................... ................................ .......................................
Date Date Date
82
