Table 2 Characteristics of included studies

Carson et al. [32]

Iceland, Ireland, Norway, Scotland, Sweden, Greenland

1046 rural health professionals (doctors, nurses, allied health professionals)

Cross-sectional

Selection of rural background or rurally-schooled students; rural health professional training (rural pipeline)

Intention to stay with same rural organisation for at least the next 2 years (or until retirement if intending to retire within 2 years)

There was a significant relationship (χ² = 3.98, p < 0.05) between having a rural background and intending to stay with the same rurally located organisation. Spending the majority of school education in a rural area was also significantly associated with intention to stay (χ² = 8.7, p < 0.01). Health professionals working in outer rural areas who had undertaken some of their health professional training in a rural area were more likely to intend to stay than those who had no rural training (χ² = 4.22, p < 0.05)

Chauhan et al. [55]

Canada

642 rural physicians

Cross sectional

Any length of rural training during medical school

Intention to leave rural practice within the next 2 years

There was no significant association between having had at least one rural experience of any length during medical school (versus no rural rotations at all) and intention to leave rural practice within 2 years

Cogbill and Bintz [39]

USA

19 rural General Surgeons who worked for Gundersen Health System since it commenced in 1978

Case report

A rural general surgery network designed as a sustainable model for delivery of general surgery services within a large rural region of the midwestern USA (Minnesota, Wisconsin, Iowa)

Mean number of months that currently employed General Surgeons have been practising in Gundersen Health System network

The study showed that of the 19 rural General Surgeons ever employed in the network 21% (n = 4) have retired, 53% (n = 9) continue to practice in the network, and only 26% (n = 5) left the network before retirement. The nine currently employed General Surgeons have been practising in the network for a mean of 88.0 months (SD 83.6; range 24 to 288 months). Six have practiced in one location for more than 20 years

Fleming and Mathews [48]

Canada

391 physicians who were initially licensed to practice in Newfoundland-Labrador (NL) between 1993–2004

Cohort

Trained locally at Memorial University (MMG) versus trained elsewhere in Canada (CMG) versus provisionally licensed international medical graduates (IMGs (Prov)) versus fully licensed international medical graduates (IMGs (Full))

Hazard of remaining in NL

Overall, CMGs, IMGs (Prov) and IMGs (Full) were 1.99 (95% confidence interval [CI] 1.28–3.10), 2.11 (95% CI 1.50–3.00) and 1.86 (95% CI 1.19–2.90) times more likely to leave NL, respectively, than locally trained MMGs. Physician group was the only significant covariate in the Cox regression analysis

Gardiner et al. [40]

Australia

361 rural General Practitioners (GPs) in South Australia

Cohort

Group and individual coaching by qualified psychologists and 6 weeks of email coaching over a 3-year period

Retention rate in rural general practice at two time points, 3 years apart

Despite having a much higher intention to leave rural general practice before coaching, only 6% left after coaching. In other words, 94% of participants stayed compared with 80% of the general rural GP population [χ² = 4.89, p = 0.027]

Gaski and Abelsen [41]

Norway

388 Graduating medical students

Cohort

Medical internships early sign up versus raffle in the study area versus a comparison area with similar workforce issues

% former interns in the area staying in (rural) county as at April 2014 (Finnmark versus another rural county)

The proportion of interns who signed up early who still worked as physicians in the study area (29%) was twice as high as among the regular interns (15%) and interns in the comparison area (14%). None of the 59 physicians who had been early signup interns worked in any of the 15 remote municipalities in the study area

Gorsche and Woloschuk [42]

Canada

29 rural doctors working in an established rural practice in Alberta with written support from their regional medical director, who enrolled in the skills enrichment program March 2001–March 2005 and their 29 matched controls

Cohort

Skills enrichment program comprising training for acquisition of or maintenance of existing skills of at least 2 weeks’ duration but less than 1 year, with preceptor funding and locum support available and funded up to $80,000 per annum (pro rata)

Rural practice retention 5 years after the program

After 5 years, all 29/29 (100%) physicians in the enrichment group remained in rural practice compared with 22/29 (71%) of physicians who did not participate in the enrichment program: (Relative Risk 1.31; 95% CI 1.06–1.62). Two enrichment participants who left the province and their controls were excluded from analyses

Jamar et al. [56]

Australia

74 University of Adelaide Rural Clinical School domestic medical students 2003–2010

Cohort

Rural Clinical School education exposure comprising completing the whole of fifth (penultimate) year of clinical studies at a rural location

% of graduates who spent no time, 3 to 18 m and 2+ years in a rural area since graduation

Of the 72 survey responses analysed, 44% (n = 32) spent no time in a rural location, 28% (n = 20) spent 3 to 18 months in a rural area and another 28% (n = 20) spent two or more years in a rural area since graduation

Jamieson et al. [53]

Canada

480 University of British Columbia Family Medicine residency graduation cohorts from 1990 to 2007

Cohort

Rurally distributed postgraduate training sites versus training in metropolitan teaching centers

Retention in current community for more than 1 year

Amongst those who had been in their current community for more than 1 year, those who had postgraduate training in smaller rurally distributed sites were 36 times more likely to be working in a rural or regional practice than those trained in metropolitan sites (95% CI 12.2–108.5)

Johnson et al. [31]

Australia

397 dental graduates of University of Sydney 2009–2013

Cohort

Rural Clinical Placement Program comprising an opt in 1-month clinical placement in rural NSW in final year of dental school; previous rural life experience

Working in a rural location in both 2015 and 2017 versus not working in a rural location in both 2015 and 2017

Having had some form of rural experience prior to the rural clinical placement (PR 3.75 95% CI 2.75–5.11) and pre‐placement rural intentions (PR 3.54 95% CI 2.25–5.57) were significant independent predictors of an increased likelihood of working in a rural location in both 2015 and 2017

Kahn et al. [49]

USA

47 IMG physicians participating in Conrad program 1995–2003 who were assigned to a rural community for return-of-service

Cohort

Conrad program which allows thirty J-1 visa waivers each year in Washington state with participants having a ROS obligation of 3 years for primary care physicians and 5 years for specialists

Retention rate in rural areas after completing rural J-1 visa waiver ROS obligation

Of the 47 physicians who undertook their periods of service in a rural area, only 12 (26%) stayed in a rural area following completion of the ROS obligation

Kwan et al. [38]

Australia

729 medical graduates of University of Queensland (2002–2011)

Cohort

Rural clinical exposure for one (RCS-1) or two (RCS-2) years; bonded scholarship; rural background vs metropolitan background

Long term rural practice (LTRP) defined as ≥ 50% of the graduates’ primary place of practice since graduation being rural

Independent predictors of LTRP were Rural Background (OR 2.10 [95% CI 1.37 ± 3.20]), RCS-1 (OR 2.85 [95% CI 1.77 ± 4.58]), RCS-2 (OR 5.38 [95% CI 3.15 ± 9.20]) and having a bonded scholarship (OR 2.11 [95% CI 1.19 ± .76])

Li et al. [57]

Australia

1117 rural GPs who participated in the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2009

Cross-sectional and discrete choice experiment

Locum relief guarantee, retention payments, rural skills loading, family isolation/secondary school costs or retention grants for existing rural doctors

Probability of attracting rural General Practitioners to (hypothetically) choose to stay in rural practice

Increasing the level of locum relief guarantee, GP retention payments and rural skills loading from zero to the middle and high levels was associated with increased rural GP retention. In order from highest to lowest effect on retention were: guaranteed locum coverage for 6 weeks every 12 months (β = 1.51); 50% increase in retention payments (β = 1.36); guaranteed locum coverage for 4 weeks every 12 months (β = 0.85); rural skills loading payment increase by 20% (β = 0.82); 25% increase in retention payments (β = 0.54); and a rural skills loading payment increase by 10% (β = 0.33). One-quarter of rural GPs were not influenced by the rural incentive packages

Mathews et al. [50]

Canada

60 physicians who were trained at Memorial University Newfoundland and held ROS (Return-of-Service) agreements (1997 to 2009) and started practice in Newfoundland and Labrador (NL) 2000–2005 compared with all 67 other NL physicians who started practice in NL between 2000 and 2005

Cohort

Opt-in ROS agreements offered to medical students and junior doctors which included two types of bursaries: Family Medicine Bursary and Special Funded Residency Position (offering postgraduate training positions which are usually accepted by physicians who were unable to secure a position through the usual application process)

Retention of physicians in the Canadian province of NL at the end of the follow-up period (December 31, 2010)

Whether or not Memorial University Newfoundland-trained (MUN-trained) physicians received a ROS bursary was a significant predictor of leaving NL. ROS physicians were 3.2 (95% CI 1.4–7.1) times less likely to leave NL than non-ROS physicians. Amongst the 60 ROS and 67 non-ROS MUN-trained physicians, 10 (16.9%) ROS versus 28 (41.8%) non-ROS physicians left NL province by 2010 (p = 0.004)

McGrail and Humphreys [36]

Australia

3782 responses from GPs who responded to Medicine in Australia: Balancing Employment and Life (MABEL) survey at least twice between 2008 and 2012 (inclusive)

Cohort

Training location (Australian trained vs non- Australian trained); restrictions on access to provider numbers related to geographic location for International Medical Graduates (IMGs)

Annual location retention rates in regional, rural and remote areas and odds ratios for leaving a rural area

There was no significant difference in the risk of leaving rural practice for IMGs compared to Australian non-restricted graduates. This was true for IMGs whether or not they had restrictions on access to provider numbers limiting where they could practice

McGrail et al. [58]

Australia

610 Medicine in Australia: Balancing Employment and Life (MABEL) survey respondents (2008–2014 inclusive) who had completed GP training and were transitioning to independent practice

Cohort

Vocational training location (rural or metro); rural/metro origin; rural bonding (being contracted to work for part of their early career in a rural location)

Proportions of GPs working in rural and metropolitan locations during each of the first 4 years following completion of GP vocational training; proportions of rurally-trained GPs working in the same or a different rural community from that in which they completed their vocational training

The rural training pathway, regardless of childhood location, was extremely strongly associated with subsequent rural practice (ORs ranged from 29 to 92 in the first 4 years following completing GP training). The odds of rural practice for the rural training cohorts of GPs decreased with time. Rural bonding (OR 3.5–5.1) and rural origin (ORs 2.0–4.1) were also positively and significantly associated with rural practice in each of the first 4 years following completing GP training

Murray et al. [28]

USA

60 nursing staff employed by Bassett Medical Center in rural upstate New York, USA

Cohort

A Partnership for Nursing Opportunities opt-in Program which involved Bassett Medical Center collaborating with two different local colleges to better design postgraduate degree pathways that were attractive to nurse employees. The intervention included: fully paid tuition with return-of-service; flexible scheduling arrangements supporting full and part-time paid work; local teaching; academic advisor

Vacancy rates and annual turnover rates of nurses from the rurally located Bassett Medical Center

Licensed Practice Nurses turnover decreased from 16.8% in 2005 to 6.8% in 2009. There was no trend in reduced annual turnover evident for Registered Nurses, but Registered Nurse vacancy rates fell from 16.5% in 2005 to 4.3% in 2009

Nilsen et al. [29]

Norway

159 nursing students doing a bachelor’s degree course in Finnmark University and who graduated in 2002, 2004 and 2005

Cohort

Bachelor of Nursing program which offered off-campus training in rural areas near the students’ place of residence and using more flexible and team-based learning methods as an alternative to the usual on-campus training at a regional centre

Retention rate in Finnmark county (living and working) for at least 4 years after completing the study program

Off-campus training was associated with a considerably higher retention rate n = 37/40 (92.5%) in Finnmark county for graduates compared to on-campus training n = 83/119 (70%). The majority of the nurses who trained off-campus worked in rural or remote communities where nurse shortages were more pronounced

Norbye and Skaalvik [30]

Norway

233 Registered Nurses training at the Arctic University of Norway by a decentralised nursing education model

Cohort

Decentralized nursing education allowing part-time postgraduate study at proximate study centres to accommodate students’ family and work responsibilities

Nurse retention rates in rural areas after graduation from postgraduate studies

The majority [n = 190/233 (81.6%)] of nurses completing postgraduate education using the decentralised nursing education model continued to work in rural areas

Opoku et al. [51]

USA

240 physicians with an initial rural Nebraska county practice location and enrolled in J-1 visa or Nebraska Loan Repayment Program 1996–2012 inclusive

Cohort

J-1 visa program (waiver of the requirement for IMGs on J-1 visas to return to their home country in exchange for service in a health professional shortage area) and state loan repayment programs (loaning physicians up to $40,000 per annum for up to 3 years in exchange for service)

Hazard of leaving rural Nebraska (hazard ratio), average length of stay (years)

The average length of stay in rural Nebraska for J-1 visa waiver and state loan repayment physicians were 4.1 and 8.1 years, respectively (SD = 0.27 and 0.47, respectively) and for physicians who had completed the minimum obligatory period were 5.6 and 9.7 years (SD = 0.27 and 0.43, respectively)

The likelihood of departure from rural Nebraska was higher for beneficiaries of the J-1 visa waiver program (HR = 3.76, 95% CI 2.02–6.98) compared to those receiving state loans

Patterson et al. [59]

USA

Family Medicine “1–2” Rural Training Track (RTT) residency programs that responded to survey providing information about 253 enrolled residents who graduated 2008–2014 inclusive

Cohort

“1–2” RTT Family Medicine residency program which includes up to 1 year of urban training and 2 years of rural training

% of RTT graduates who were practising in a rural location at 1 year, 2 years, and 3 years after finishing residency

Just under one-third (32.8%) of RTT graduates practiced in rural areas in their 1st year post graduation. The percentage practising in a rural location increased thereafter such that the percentage was above 35% in most of the 7 years post-graduation

Pepper et al. [61]

USA

693 physicians practising in the State of Wyoming and responding to a survey

Cross-sectional

Variation in malpractice insurance costs between different USA states

Intention to change practice in Wyoming in next 10 years: relocate within Wyoming, move out of Wyoming, stop patient care

The high cost of malpractice insurance in Wyoming was associated with planning to move out of state instead of moving within the state (OR 22, 95% CI 1.7–287.9). Of those planning to leave Wyoming, just under one half (44%) gave malpractice insurance costs as a reason

Playford et al. [60]

Australia

915 University of Western Australia graduates 2004–2010

Cohort

Training medical students at a Rural Clinical School; selecting 25% of students into medicine based on having a rural background; recipients of a Bonded Medical Place at medical school (a place in medical school in exchange for return of service in a district of workforce shortage) or a Medical Rural Bonded Scholarship (recipients of a bursary during medical school in exchange for return of service in a rural area following graduation)

Mean cumulative duration (in years) in rural practice, ratio of means

Rural origin Rural Clinical School participants had a cumulative duration of rural practice over 5 times higher than the urban origin/urban training reference group (Ratio of means 5.4, 95% CI 4.3–6.8). Urban origin and Rural Clinical School (Ratio of means 2.2, 95% CI 1.8–2.7) and rural origin and no Rural Clinical School (Ratio of means 2.9, 95% CI 2.2–3.8). Bonded graduates had longer mean cumulative duration of rural practice than non-bonded graduates (p < 0.0001)

Rabinowitz et al.

[43]

USA

92 Jefferson Medical College graduates 1978–1986 inclusive who initially practised Family Medicine in a rural area

Cohort

Physician Shortage Area Program (PSAP) of Jefferson Medical College which is medical school rural program with features including: selection based on rural background, commitment to rural practice, faculty mentoring and career guidance, 6 week clinical placement in a small town in 3rd year, encouragement to take up rural preceptorship in 4th year and expectation of completing family medicine residency training

Numbers of PSAP and non-PSAP graduates who originally entered rural family medicine and were still practicing family medicine in the same rural area (including in five adjacent counties) in 2011

Of the 37 PSAP graduates who originally entered rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011. A significantly smaller proportion of the 52 non-PSAP graduates (n = 24, 46.2%) were practising in the same rural area (p = 0.02)

Renner et al. [33]

USA

66 health professionals who were participants in one of three Colorado loan repayment programs 1992–2007 and had fulfilled terms of service

Cohort

The Colorado loan repayment programs had varying rates of repayment of recipients’ educational debts (maximum of $35,000 per annum), duration of return of service commitments (0, 1 and 2 years) and eligibility based on health profession. Analysis was for participants in any of the 3 programs, with no comparison of outcomes of the different programs

Retention rate in a rural community, retention rate in the same rural community after completing their return of service commitment, percentage retained in the same rural community for 0–1, 2–4 and 5 or more years

Of the loan repayment recipients who had completed their service commitment at the time of the survey, 27 (64%) of the rural participants were still practising in a rural community compared to 23 (96%) of the urban participants who were still practicing in an urban community. Rural retention rates were not associated with past attendance at rural high schools or by intention to practice in a rural community regardless of loan repayment. Of the 36 loan repayment recipients who were still at their original site after completing their terms of service or having their loan paid off, 21 were rural participants. Of these who stayed, 10 (47.6%) had stayed 0–1 additional years, 8 (38.1%) had stayed 2–4 years, and 3 (14.3%) had stayed for 5 years or longer

Robinson and Slaney [44]

Australia

57 GP registrars trained in the rurally located Bogong Regional Training Network 2004–2009, Victoria

Cohort

Decentralised model of GP training in rural Victoria

Retention rate in rural general practice following training in Bogong region; retention rate in Bogong region following training in Bogong region

More than 42% of the GPs who had completed their GP vocational training remained in rural general practice and 32% remained in the Bogong region

Rodney et al. [45]

USA

80 Obstetrics and Gynaecology Family Medicine fellows 1992–2010 inclusive

Cohort

1-year post-residency obstetrics fellowship undertaken in a rural location

Service in a rural community for at least 2 years

Rural service of at least 2 years occurred among 47/74 (64%) of the graduates

Ross [46]

USA

62 graduates of a rural Family Medicine residency program in Oregon (Cascades East Family Medicine Residency Program) 1994–2009 inclusive

Cohort

Rural residency in Oregon undertaken in a community of population size 42,000

Length of stay in first practice location, length of stay in current (2009) practice location

Graduates spent a mean 3.5 years at their first practice location and 3.7 years at their current practice location. Only 40% (n = 25/62) of graduates had relocated their practices at least once since graduation. Half of all program graduates remained currently working in rural communities (defined as having a population size of less than 25,000 and located more than 25 miles from major centres)

Russell et al. [37]

Australia

2783 rural GPs working in New South Wales 2003–2012, (excludes locums, GPs in border towns or offshore and GP Registrars)

Cohort

Holding rights to admit patients to the local hospital as a Visiting Medical Officer, having restrictions on access to a provider number (conditional registration)

Hazard of leaving a rural community for more than 3 months

Rural NSW GPs with conditional registration were more likely to leave (HR 1.49, 95% CI 1.24–1.79) a rural community than those with no such restriction. Having no public hospital admitting rights (HR 1.49, 95% CI 1.30–1.71) was associated with a higher risk of leaving rural NSW communities

Straume et al. [52]

Norway

76 postgraduate trainee physicians in Family Medicine or Public Health 1995–2008 inclusive

Cohort

A 5-year postgraduate training model offered to interns in either a Family Medicine or Public Health training group which included professional support provided through group tutorials for 2–3 years, in-service training opportunities provided in rural areas and completion of compulsory courses

Retention rates in Finnmark 5 years after completion of compulsory group tutorage component of the postgraduate training

Amongst the 15 Public Health doctors who had completed the group tutorage more than 5 years ago, 10 (66.7%) were still working in the county. Overall 28/40 (70%) of the Public Health graduates were still working in Finnmark in 2009. Amongst the 37 Family Medicine doctors who had completed the group tutorage more than 5 years ago, 24 (64.9%) were still working in the county. Overall 53/72 (73.6%) of the Public Health graduates were still working in Finnmark in 2009

Wearne et al. [47]

Australia

24 General Practice Registrars enrolled in the Remote Vocational Training Scheme (RVTS) 1999–2005 inclusive

Cohort

RVTS program which trains doctors in general practice in remote communities using distance education and supervision

Retention rates of RVTS graduates still working in rural areas

The majority [n = 17/21 (81%)] of RVTS graduates continue to work in rural areas (defined as Rural, Remote and Metropolitan Areas 3–7) 2–8 years after completing the program

Woolley et al. [54]

Australia

529 James Cook University (JCU) Queensland graduates 2005–2011 inclusive

Cohort

JCU Rural Clinical School (Darwin), rural generalist (residency) training, outer regional or remote location for internship

Prevalence odds ratios (POR) for practising in a remote location for 1 year or more from Postgraduate Years (PGY) 4–10

Forty-seven (8.9%) of the 529 JCU medical graduates in the first seven cohorts had practised for at least 1 year in a remote location between PGY 4 and 10. The likelihood of JCU medical graduates practising in a ‘remote’ location from PGY 4 to 10 was associated with undertaking rural generalist training (p < 0.001; POR = 17.0), attending the Darwin clinical school in years 5–6 (p = 0.005; POR = 4.7) and undertaking an internship based in an outer-regional or remote community (p = 0.006; POR = 3.5)

Yong et al. [35]

Australia

Australian GPs responding to the Medicine in Australia, Balancing Employment and Life (MABEL) survey 2008–2014 inclusive and providing data for 4,822 exits from rural locations that were eligible for receiving General Practice Rural Incentives Program (GPRIP) incentive payments

Cohort

Changes to the GPRIP policy made some locations newly eligible for rural retention incentives and increased retention incentives for other rural locations already eligible

GP exits (turnover) from always eligible locations versus newly eligible locations under GPRIP

For both newly eligible and always eligible rural locations, GPRIP appeared to have no statistically significant effects on GP relocation exits (turnover)

Zhou [34]

USA

Physicians licensed in North Carolina and working in rural areas. Sample size for the rural retention simulation study was unclear. The overall study sample was 29,908 unique physicians working in North Carolina contributing 165,688 person-year observations

Cohort and simulation

Loan forgiveness programs, increased physician reimbursement rate, change in the composition of health care providers: changes to mid-level practitioner supply, increase supply of RNs, Medicaid and Medicare expansion in rural areas

Retention in rural areas of North Carolina (excludes becoming inactive, moving out of North Carolina)

Simulated loan forgiveness programs (representing an almost doubling of income for rural physicians) was associated with a small (up to 3%) decrease in the probability of them moving away from the same rural area after 1 or 2 years of service, while a 5% increase in rural county physician salary decreased the probability of moving away from the same rural area after 2 years by 7%. There was a decreasing marginal return on the probability of moving away from the same rural area with salary increases of 10 and 20%. A 5% increase in mid-level practitioners in rural counties increased the probability of rural physicians moving away after 2 years by 8%, while a 5% increase in RNs in rural counties decreased the likelihood of physicians leaving rural areas by 3%. Medicaid and Medicare expansion in rural areas were associated with increased physician movement away from their rural county of service after 2 years by 10% and 11% respectively