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Turnover intention and continuing professional development of rural doctors from targeted admission medical education program in China: a cross-sectional study in the post-COVID-19 era

BMC Primary Care volume 25, Article number: 389 (2024) Cite this article

Abstract

Background

Turnover intention (TI) indicates an employee’s intention to depart from their current role within a defined timeframe. In China, the Targeted Admission Medical Education (TAME) program, initiated in 2010, offers tuition-free education to cultivate rural doctors. Despite continuous professional development (CPD) being considered a viable retention strategy, TI of alumni doctors from the TAME program remains high in recent years. This study aims to describe the prevalence of “turnover intention” among alumni doctors of the TAME program doctors in rural placements, and associated factors that predict high turnover intention.

Methods

A snowball sampling method was adopted to collect survey responses from 1,369 alumni doctors of the TAME program in Jiangxi Province, China. Based on the survey data, a binary variable was constructed to measure the turnover intention, and multivariate binary logistic regression models were used to investigate the relationship between doctors’ turnover intention and demographic characteristics, work environment characteristics, and CPD activities. Results were presented using adjusted odds ratios with 95% confidence intervals.

Results

Among the 1,369 alumni doctors of the TAME program surveyed in this study, 392 (28.6%) expressed intentions to leave their current positions. Of the respondents, 620 (45.3%) were female, and 930 (67.9%) were married. Additionally, 1,232 respondents (90%) indicated that their fathers were engaged in farm work. Strong associations with turnover intention were notably found among individuals who had undergone training at a higher-level healthcare institution for more than three months (aOR = 6.810, 95% CI: 3.333 to 13.909, p-value < 0.001), particularly those who had participated in CPD through a graduate degree program (aOR = 1.818, 95% CI: 1.272 to 2.597, p-value < 0.001).

Conclusion

Rural doctors in China from the tuition-free medical education program exhibit high turnover intention, especially those in graduate degree programs as CPD. To retain these highly qualified rural doctors, it is vital to offer competitive efficiency wages aligned with their skills and provide ample long-term career growth opportunities within the rural healthcare system.

Highlights

Retaining rural doctors in China who graduated from the tuition-free medical education program continues to pose a significant challenge.

High turnover intention is particularly prevalent among those enrolled in CPD graduate degree programs.

Offering competitive efficiency wages and creating abundant long-term career growth opportunities within the rural healthcare system are essential measures.

Peer Review reports

Background

Primary healthcare is a critical component of a country’s healthcare system [1, 2], but the shortage of primary care physicians (PCP) has become a major obstacle to providing high-quality healthcare services to residents [3,4,5]. WHO recommends that effective intervention strategies include medical education, economic incentives, professional support, and compulsory interventions [6], especially recruiting and cultivating medical students of rural origin to work in the rural areas as highly effective [7,8,9]. Policy implementations in countries like Japan and Australia offer compelling evidence in support of these approaches [10, 11].

By 2021 year, PCP density in China rural areas was just 1.81 per thousand population [12], significantly lower than 2.5 per thousand population, the recommended standard of the WHO. China has been implementing the Targeted Admission Medical Education (TAME) program since 2010. This unique program provided tuition-free medical education to students with rural origins, and requires them to commit to working in their rural hometown areas for a period of six years following graduation. However, over 80% of alumni doctors of the TAME program across different regions in China were unwilling to continue serving in rural areas after completing their contracted service years [13,14,15,16].The recent challenges presented by the COVID-19 pandemic have further exacerbated the high level of TI [17, 18].

Turnover intention(TI) is a key measure that reflects employees’ willingness of resigning from their current position [19], often serving as a reliable predictor of actual actions [20]. Major dissatisfactory factors include low pay, long working hours, limited opportunities for CPD, and restricted prospects for career advancement [21]. Continuing professional development (CPD) is the process through which “health professionals keep updated to meet the needs of patients, the health service, and their own professional development” [22], it fosters a sense of professional fulfillment and engagement [23, 24], playing a vital role in retaining rural healthcare professionals [25, 26]. CPD has received significant policy emphasis in China, but the existing literature on rural doctors in China is limited and offers mixed findings [27, 28].

The objective of the study was to determine the prevalence of TI [20] and predicting sociodemographic and occupation-related factors among rurally-placed alumni doctors of the TAME program in China.

Methods

Study settings

As a traditional agricultural province in inner land of southeastern China [29], Jiangxi has the shortage of healthcare professionals, especially in rural areas. In 2021, in rural areas of Jiangxi Province had 1.57 doctors, lower than the national average of 1.81 doctors [12]. Jiangxi Province has been a leading pioneer of implementing the TAME program in China since 2010. With approximately 4,199 medical students graduating through the TAME program in Jiangxi between 2010 and 2022, its success has positioned it as a model and exemplar in China.

Questionnaire

This study has adopted key questions of the questionnaire for the TAME, which was first developed by Liu and colleagues and has been widely adopted in relevant studies [30,31,32].The questionnaire consisted of 3 sections: socio-demographic characteristics, job characteristics, and turnover intention. The questionnaire was pre-tested for validity among a group of about 50 TAME graduates in Ganzhou City, Jiangxi Province. The reliability of the scales was estimated to be 0.91. (See Supplemental Document 1 for the full version of the questionnaire.)

Sampling

The questionnaire for this study was distributed through the alumni network of TAME program graduates in Jiangxi Province. Due to Jiangxi’s pioneering role in TAME, since 2015, its graduates have been invited to participate in a national research project for longitudinal studies tracking the long-term effects of the TAME program [33,34,35]. In the alumni social network, two student leaders from each class are elected to serve as contact persons. These class representatives set up contact networks, and are responsible for maintaining regular communication with other members of the alumni. The primary communication tool of this alumni network is WeChat, which is the most popular multi-media social communication app in China.

The inclusion criteria of rural doctors were: (1) graduation from a TAME program in Jiangxi Province, (2) a bachelor’s degree, and (3) primary care doctors in township health centers or village clinics; (4) five to ten years of work experience as rural doctors.

A snowball sampling method was employed to recruit rural doctors among the TAME program graduates in the cohort network above described. Initially, a sample of 100 graduates from the Class of 2012 in the TAME program in Jiangxi Province was selected, and 83 respondents completed the questionnaire. They were then asked to invite other eligible rural doctors in the TAME network to participate, and the process was repeated until a convenient sample size of at least 1000 respondents was reached to represent approximately one-quarter of the study population. The survey was conducted over four months, from February to May 2023, following a nationwide wave of Covid-19 infection. All data from the valid responses were entered and coded.

Statistical methods

Dependent variable

In this study, the dependent variable is the turnover intention of rural doctors. To measure this, a survey question was administered asking whether a rural doctor intended to continue working at his/her current post after the contract service period expires. Responses were initially recorded on a 5-point Likert scale, where “5” indicated the highest likelihood of continuing and “1” indicated the lowest likelihood. For the purpose of facilitating logistic regression analysis and enhancing the interpretability of the results, the original 5-point Likert scale responses were converted into a binary variable [36]. Specifically, responses of “1” and “2” (the lowest likelihood of continuing the post) were recoded as “1” (indicating high turnover intention), while responses of “3”, “4”, and “5” were recoded as “0” (indicating neutral or low turnover intention).

Independent variables

Demographic characteristics

The demographic characteristics analyzed in this study include gender, marital status, whether the individual is an only child in the family, and parents’ occupation.

Continuing professional development (CPD)

CPD activities were assessed through two specific measures: engaging in graduate degree programs and undergoing non-degree training in higher-level medical institutions for durations exceeding three months. In China, rural doctors have the opportunity to apply for and enroll in graduate degree programs as part-time students. The duration of CPD non-degree training programs is not standardized and varies among regions, often following a quarterly structure lasting approximately three months.

Work environment and organizational supports

This section includes questions such as whether the job position is a permanent one, their professional titles, work location, commuting distance, having complimentary on-site lodging, and proximity to their parents’ family. As a general policy, rural hospitals or health centers in remote areas often provide doctors with complimentary on-site lodging.

Statistical analysis

Frequency tables were used to describe data. A Chi-square test was used to test the relationship between each independent variable and TI. Furthermore, adjusted odds ratios, along with their corresponding 95% confidence intervals (CI) derived from a binary logit model, were used to analyze the factors associated with turnover intention.

A multivariate binary logistic regression model was used to examine the relationship between TI and various sociodemographic factors among rural doctors. We assessed collinearity among the explanatory variables using Variance Inflation Factors (VIF). We adhered to the commonly accepted threshold, considering a VIF value of 5 as the cutoff for potential multicollinearity concerns. The analysis was performed using STATA (version 15) with a significance level of 0.05.

Ethical statement

The study was carried out in accordance with the Declaration of Helsinki and was approved by the Medical Ethics Committee of the authors’ institute (Ref. LLSC-2023,164). Participants were fully informed of the research purpose, assured that their information would only be used for research purposes, and made aware of their right to withdraw from the study at any time. Informed consent was obtained from all respondents prior to their participation in the survey questionnaire. Participants were informed about the voluntary nature of their participation and reassured regarding the confidentiality and anonymity of their responses.

Results

A total of 1,500 questionnaires were distributed to the TAME alumni network through WeChat (the most popular multi-media social communication app in China). Out of these, 1,369 valid responses were received, resulting in an effective return rate of 91%, approximately one quarter of the study population, 4,199 total TAME graduates in Jiangxi Province during 2010–2022.

Demographic and professional characteristics

As shown in Table 1, among the respondents, 620 (45.3%) were female and 930 (67.9%) were married. Additionally, 362 (26.4%) were identified as the only child in their families. Most respondents reported that their parents were currently engaged in farm work (Proportion of fathers: 1232, 90.0%; Proportion of mothers: 1214, 88.7%).

In terms of professional characteristics, 1197 (87.4%) of the respondents held permanent positions, while 568 (41.5%) held administrative positions or professional titles. More than half (735, 53.7%) worked far from the central city, and approximately 895 (65.4%) have longer commuting distances. Furthermore, 541 (39.5%) of the respondents reported living in proximity to their parents’ family, and 137 (10.0%) lived in employer-provided complimentary on-site lodging. The study also found that 937 (68.4%) respondents were pursuing continuing education in a graduate degree program, and 1156 (84.4%) had received continuing education or training lasting over three months in a higher-level institution.

Turnover intention

As illustrated in Table 2, among the 1,369 respondents, 392 individuals (28.6%) indicated experiencing turnover intention (TI). The group with TI had a higher proportion of females (259, 66.07%), individuals who were the only child in the family (172, 43.88%), and married individuals (329, 83.93%) compared with the group without TI. In the group with TI, the percentages of parents currently engaged in farm work (310, 79.1%) were lower by about 15% points compared to the group without TI (922, 94.4%). Similar pattern is observed among the mothers (the group with TI: 298, 76.0%; the group without TI: 916, 93.8%).

In terms of professional characteristics, the group with TI were less likely to have permanent positions (304, 77.55%), work near a central city (99, 25.26%), hold an administrative position or professional title (83, 21.17%), have short commuting distances (64, 16.33%), or live in proximity to their parents’ family (85, 21.68%). Additionally, the group with TI was less likely to have complimentary on-site lodging (the group with TI having on-site lodging: 10, 2.55%; the group without TI but having on-site lodging: 127, 13.00%).

Table 2 also shows that a higher proportion of doctors in the group with TI had pursued continuing education in a graduate degree program (the group with TI who achieved certificate education: 328, 83.67%; the group without TI who achieved certificate education: 609, 62.33%) or received continuing education in a higher-level institution of totally more than three months (the group with TI who achieved higher-level institution education: 382, 97.45%; the group without TI who achieved higher-level institution education: 774, 79.22%). The Chi-square test results indicate that all categorizations were statistically significant (p < 0.005).

Associations between the turnover intention and associated factors

As reported in Table 3, multivariate binary logistic regression analysis identified several factors associated with TI among alumni doctors of the TAME program. Male doctors were less likely to report TI than females (aOR = 0.427, 95% CI: 0.318 to 0.575, p-value < 0.001). Doctors who were the only child in their family are more likely to report TI (aOR = 1.888, 95% CI: 1.380 to 2.583, p-value < 0.001), as did those who were married (aOR = 2.311, 95% CI: 1.617 to 3.306, p-value < 0.001). Rural doctors whose fathers were farmers were less likely to report TI (aOR = 0.401, 95% CI: 0.249 to 0.676, p-value < 0.001), and a similar effect was seen for mothers who worked on farms (aOR = 0.390, 95% CI: 0.247 to 0.617, p-value < 0.001).

In terms of professional characteristics, rural doctors with permanent positions (aOR = 0.470, 95% CI: 0.314 to 0.704, p-value < 0.001), those who worked in locations near central cities (aOR = 0.387, 95% CI: 0.283 to 0.527, p-value < 0.001), those who held administrative positions or professional titles (aOR = 0.446, 95% CI: 0.322 to 0.617, p-value < 0.001), and those who had short commuting distances (aOR = 0.375, 95% CI: 0.264 to 0.532, p-value = 0.001) and those who had proximity to their parents’ family (aOR = 0.573, 95% CI: 0.413 to 0.796, p-value = 0.002), and those had complimentary on-site lodging (aOR = 0.303, 95% CI: 0.145–0.634, p-value = 0.001), were less likely to report turnover intention (See Table 3). Conversely, rural doctors who had pursued continuing education in a graduate degree program (aOR = 1.818, 95% CI: 1.272 to 2.597, p-value < 0.001), or had training in a higher-level institution totally for more than three months (OR = 6.810, 95% CI: 3.333 to 13.909, p-value < 0.001), are much more likely to report turnover intention.

In addition, the average VIF across all variables is 1.10, with the highest VIF being 1.23. These values are well below the commonly accepted threshold of 5.

Discussion

This study conducted a cross-sectional survey of rural doctors who were trained in a Targeted Admission Medical Education program and have worked for 5–10 years in rural areas of Jiangxi Province, China. This study examined CPD activities and other factors associated with turnover intention among these rural doctors. The estimated results are discussed below.

Prevalence of TI

Nearly one-third of alumni doctors of the TAME program in this study reported TI. This finding is generally consistent with the rates reported in the literature. Specifically, a systematic review by He and colleagues [28] found an overall TI rate of 30.4% among primary healthcare workers in China, with higher levels of TI among those with higher levels of medical education. As such, the nearly one-third among alumni doctors of the TAME program may be slightly lower than those of primary care workers in urban regions or those in developed regions of China, considering the formal college medical education received by alumni doctors of the TAME program.

Demographic characteristics associated with TI

This study found that certain demographic characteristics, such as being female, married, or the single child of the family, were associated with higher turnover intention (TI) among alumni doctors of the TAME program [37, 38]. The study suggests that these factors may contribute to the challenges that alumni doctors of the TAME program face in their work environment and personal lives, leading them to consider leaving their current job positions [38].

Female alumni doctors of the TAME program encounter a unique set of challenges that warrant further examination. Working in rural or remote locations poses distinct obstacles for these female doctors, including limited access to essential resources, professional isolation, and inadequate support systems [37, 38]. The geographical isolation and sparse healthcare infrastructure in rural areas can magnify these challenges, making it harder for female doctors to access CPD, networking and mentorship opportunities [28, 38]. It may be harder for them to balance professional responsibilities with family commitment. Moreover, research has highlighted that female doctors experience heightened levels of anxiety, especially in times of crisis such as the Covid-19 pandemic [39]. The increased anxiety levels observed among female rural doctors may also lead to higher level of TI.

Married alumni doctors of the TAME program may also face challenges in balancing their professional responsibilities with family commitments [38]. They may feel pressure to provide for their families financially and emotionally. These findings are consistent with previous research on rural doctors in India, who have reported that “good schooling for their children” is among important factors for continuing to work in rural and remote areas [40].

Similarly, alumni doctors of the TAME program who are the sole child in their families may experience a heightened sense of responsibility to provide financial and emotional support to their aging parents. If they encounter challenges in meeting these familial obligations within their current job roles, they may contemplate exploring alternative career paths. Additionally, students encounter difficulty in honoring their post-graduation rural employment commitments when the location of their workplace is farther from their hometown, thus increasing likelihood of turnover intention [35].

The study has revealed that if the father of an alumni doctors of the TAME program is still working at farm, his/her probability of reporting turnover intention is reduced by almost 60%, indicating the influence of rural family origins on career decisions. This finding is consistent with recommendations of effective practice by WHO, which suggest that rural origin background may provide strong adaption, social connection and network supports that are favorable for retention [11]. Additionally, alumni doctors of the TAME program with parents currently still working on a farm may be influenced by their family to be self-content and have less interest in pursuing positions in competitive urban environments. This is consistent with previous research that has shown that rural background and family ties can play a significant role in shaping the career choices and retention of alumni doctors of the TAME program [41, 42].

Work environment

The findings of this study indicate that a supportive work environment is associated with lower TI among alumni doctors of the TAME program, which is consistent with existing literature on the topic. Associated factors, such as job security (such as permanent positions) [43], career development (administrative/technical titles) [43], work-life balance (work location near cities, convenient commuting, or workplace being close to parents’ house) [44,45,46], play positive roles in reducing turnover intention.

Indeed, job satisfaction and work-life balance are among the top crucial factors in terms of retaining healthcare personnel generally [47].Further, this study found that, alumni doctors of the TAME program living in complimentary on-site lodging reported reduced levels of TI. In remote work settings, doctors frequently confront a static and isolated lifestyle, impeding the cultivation of a sustainable work-life balance [37, 38]. The provision of complimentary on-site lodging policy is implemented to guarantee that rural doctors have appropriate living conditions when operating far from their familial residences. However, studies conducted in Tanzania and Uganda suggest that solely offering free lodging may not be adequate to enhance the appeal of rural doctor positions [48, 49].

Continuing professional development (CPD)

The study found that alumni doctors of the TAME program who participated in continuous professional development (CPD) had a significantly higher level of TI, particularly among those who pursued a graduate degree program. The likelihood of reporting TI was found to be almost seven times as likely among this group. This factor was found to have the most prominent role among all factors analyzed in the study. Healthcare personnel with advanced degrees or qualifications are more inclined to be drawn to hospitals that possess superior accreditation [21]. Highly competent rural doctors are inclined to pursue advanced CPD through higher graduate degree programs as a means to transition from their current rural-based positions to urban placements. According to the market signaling theory and human capital theory, CPD activities and achievements are regarded as strong signals of professional skills and productivity [50]. Employee’s human capital value, or external marketability can be enhanced through CPD, especially obtaining rigorous academic degrees. Their abilities to leave current position have been improved when they become more competitive in the open job market [51]. For example, employees who participate in a tuition-reimbursement program may have low turnover while still studying in school, but the turnover increases after they earn their graduate degree [52].

Further, voluntary participating CPD in many cases may signal internal motivation [50] or turnover intents. For example, a nurse may engage in additional CPD as a means to seek future employment [53]. Indeed, most of the TAME students wish to work in higher level hospitals [34].

On another hand, the observation that some alumni doctors of the TAME program may exhibit poor motivation to study during their academic years due to the guarantee of a job after graduation raises concerns regarding their professional development. The lack of adequate management measures to stimulate these students’ motivation upon entering the workforce poses a significant challenge. This situation may impede the acquisition and mastery of essential medical knowledge, potentially compromising the quality of healthcare services delivered to rural communities in the future. It is imperative for educational institutions and healthcare organizations to address these issues proactively to ensure the continued growth and competence of medical professionals serving in rural areas [33]. Future research is required to investigate this observation.

Limitations

The study’s strengths lie in the utilization of survey data collected from a unique rural doctor population that is often difficult to access conveniently. A substantial sample size with high reliability was effectively obtained. Meanwhile, this study has several limitations. Firstly, while the cases in Jiangxi Province has been a representative example for the majority regions in the central and eastern China, they may not be generalizable to some provinces in the northwest regions in China which have unique geographical and populational challenges. Secondly, the study relied on self-reported data from the doctors, which may be subject to bias. Thirdly, the study was not able to investigate other potentially confounding variables that could influence TI or CPD motivations, such as psychological traits, personal competencies, health status, or individual value systems. Considering the large sample size of the study, the risk of type-I errors might have been reduced. Finally, the cross-sectional design of the study limits the ability to establish causality between turnover intention and the identified factors. Further research will utilize a more diverse sample from multiple provinces, as well as a longitudinal design, to better understand the causality relationship. Additionally, variables like “short commute” and “proximity to parents’ family” could be quantified to improve the precision of the measurement.

Conclusion

In this study, we found that nearly one-third of TAME-trained doctors in rural placements in central China reported high likelihood of turnover intention. Among the factors that were associated with the high turnover intention include, doctors’ CPD participation, especially those pursuing a graduate degree program, is significantly linked to a higher likelihood of TI. In order to retain these competent rural doctors who have undergone CPD pursuing higher degrees, it is imperative to implement efficiency wages that align with their professional skills, as reflected in the healthcare labor market value. These wages should be competitive enough to not only attract them but also incentivize them to continue serving in rural areas. In addition, a rural healthcare system with more career growth opportunities for rural doctors can better enhance the likelihood of retaining these valuable professionals in the long term.

Table 1 Demographic and professional characteristics of the respondents (N = 1369)
Full size table
Table 2 Demographic and professional characteristics by turnover intention
Full size table
Table 3 Associations between turnover intention and relevant factors (N = 1369)
Full size table

Data availability

The author confirms that all data generated or analysed during this study are included in this published article. Furthermore, the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

PCP:

Primary Care Physicians

TI:

Turnover Intention

TAME:

Targeted Admission Medical Education

CPD:

Continuing Professional Development

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Acknowledgements

We sincerely thank all the rural doctors who participated in this research survey and were able to take us our questionnaires and interviews seriously despite their busy schedules. We would also like to thank the researchers at the Macau University of Science and Technology for their many discussions and guidance in order to successfully complete the thesis.

Funding

This study was funded by Key Research Base Program for Humanities in Higher Education of Education Department of Jiangxi Province (Grant No.: JD23057). JZ is financially supported by the Macau University of Science and Technology Foundation (Grant No.: FRG-24-040-MSB). The funders had no role in the design of the study, the collection, analysis, interpretation of the data, and in writing the manuscript.

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Authors and Affiliations

  1. First School of Clinical Medicine, Gannan Medical University, Ganzhou, 341000, China

    Jingya Wang

  2. School of Business, Macao University of Science and Technology, Macao S.A.R, 999078, China

    Jingya Wang, Hongmin Zhang & Jinghua Zhang

  3. Faculty of Social Sciences, University of Macau, Macao S.A.R, 999078, China

    Yijun Chen

Authors
  1. Jingya Wang
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  2. Yijun Chen
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  3. Hongmin Zhang
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  4. Jinghua Zhang
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Contributions

JZ and JW designed and supervised the project. JW performed data collection, and pre-processing management. YC, JW and JZ performed data analysis. JZ, JW, YC and HZ reviewed the literature and wrote the manuscript. JZ, JW and YC revised the manuscript. All authors read and approved the final manuscript. JZ should be considered as the corresponding author.

Corresponding author

Correspondence to Jinghua Zhang.

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Ethics approval and consent to participate

This study’s collection and usage of data was approved by the First Affiliated Hospital of Gannan Medical University Human Ethics Advisory Committee (Ref. LLSC-2023,164).

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Not applicable.

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The authors declare no competing interests.

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Wang, J., Chen, Y., Zhang, H. et al. Turnover intention and continuing professional development of rural doctors from targeted admission medical education program in China: a cross-sectional study in the post-COVID-19 era. BMC Prim. Care 25, 389 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12875-024-02637-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12875-024-02637-5

Keywords

BMC Primary Care

ISSN: 2731-4553

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