title: Lifecourse factors and likelihood of rural practice and emigration: a survey of Ghanaian medical students.
abstract: BACKGROUND
  Health worker shortages and maldistribution have important implications for the capacity of health systems. Ghana has one of the highest physician emigration rates in the world, and over 75% of those who remain work in Ghana's two largest cities. The aim of this study was to investigate the contribution of experiential factors across Ghanaian medical students' lifespans on intent to practice in a rural area and intent to emigrate.
  
  
  METHODS
  All fourth year medical students in Ghana were surveyed on demographics, rural and international experience, and future career plans. Key outcomes of interest were students' stated likelihood of practicing in a deprived rural area or emigrating after graduation. Lifecourse predictors of interest were parental socioeconomic status, gender, relationship status, rural and international living experience, and school of study. Bivariate and multivariate logistic regression were used to estimate associations between predictors and outcomes of interest.
  
  
  RESULTS
  Of 310 eligible students, 307 (99%) participated in the survey. Of these, 228 were Ghanaian and the focus of this analysis. It was found that 131 (57.5%) were willing to work in a deprived area in Ghana and 148 (64.9%) had considered emigrating after graduation. In the multivariate regression models, willingness to work in a deprived area was predicted by male gender (OR: 2.31, 95%CI: 1.23-4.35), having lived in a rural area but never lived abroad (OR: 2.77, 95%CI: 1.08-7.13), and low parental professional and educational status (OR: 2.33, 95%CI: 1.23-4.43). Consideration of emigration was predicted by having lived abroad but never in a rural area (OR: 3.39, 95%CI: 1.15-9.97). A sub-set of 80 individuals (35%) reported that they were willing to work in a deprived area in Ghana but also considering emigration. These subjects were more likely to be male.
  
  
  CONCLUSIONS
  Students with parents of a lower socioeconomic class, those with rural experience, and those without international experience are more likely to stay in Ghana and are also more likely to work in a deprived area after graduation. Selective admissions policies based on lifecourse factors combined with exposure to rural practice in medical school may have a role in increasing the number of rural physicians.
authors.affiliation: University of Michigan Center for Global Health, Ann Arbor, Michigan, USA. sranikotha@gmail.com
authors.forename: Sudha Rani
authors.initials: SR
authors.lastname: Kotha
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Johnson
authors.forename: Sandro
authors.initials: S
authors.lastname: Galea
authors.forename: Peter
authors.initials: P
authors.lastname: Agyei-Baffour
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Nakua
authors.forename: Kwesi
authors.initials: K
authors.lastname: Asabir
authors.forename: Janet
authors.initials: J
authors.lastname: Kwansah
authors.forename: Mawuli
authors.initials: M
authors.lastname: Gyakobo
authors.forename: Mawuli
authors.initials: M
authors.lastname: Dzodzomenyo
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Kruk
mesh_terms: D002321:Career Choice; D002983:Clinical Competence / Q000706:statistics & numerical data*; D004641:Emigration and Immigration / Q000706:statistics & numerical data*; D005191:Family Characteristics; D005260:Female; D005550:Foreign Medical Graduates / Q000523:psychology / Q000706:statistics & numerical data; D005869:Ghana; D006801:Humans; D016015:Logistic Models; D008297:Male; D017533:Marital Status; D008507:Medically Underserved Area; D015999:Multivariate Analysis; D010558:Personnel Loyalty; D010560:Personnel Selection / Q000379:methods / Q000592:standards; D010820:Physicians / Q000706:statistics & numerical data / Q000600:supply & distribution; D011204:Poverty Areas; D011365:Professional Practice Location; D012111:Residence Characteristics / Q000706:statistics & numerical data; D019035:Rural Health Services; D013337:Students, Medical / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D019037:Urban Health Services; D000078329:Workforce