Introduction: The chronic shortage of dentists in rural communities may affect the quality of care provided to these communities. The aim of this study was to explore the knowledge and perspectives of Quebec's future dentists regarding rural dental practice and their career intentions.
Methods: We conducted a qualitative study at 2 major dental faculties using the interpretive description method. Purposeful maximum variation sampling and snowball techniques were used to recruit 4th-year dental students and specialty residents as study participants. Face-to-face, semi-structured, 60–90-minute interviews were conducted and audio-recorded. Qualitative data were analyzed using a thematic approach including interview debriefing, transcript coding, data display and interpretation.
Results: Of the 17 interviews, 10 were with women and 7 with men; the age range of participants was 22–39 years. Five major themes emerged from the interviews: awareness of access to oral health care in rural areas, image of rurality, image of rural dental practice, perceived barriers to and perceived enablers of rural dental practice. Students said that undergraduate dental education, financial rewards, professionalism, professional support and social media may positively affect their perspective on rural dental practice.
Conclusions: There is a need to implement and support strategies known to increase dental students' knowledge of rural practice and their motivation to choose rural practice. Dental educators have an essential role to play in shaping professional character and encouraging apprenticeship to meet these goals.
The chronic shortage of dentists and allied oral health care professionals in rural, remote and Aboriginal communities is a persistent challenge for health care systems, as it may affect the quality of care provided to these communities.1-7 It is widely reported and recognized that residents of rural and remote areas have less access to dental care services because of geographic isolation.8 Because inadequate access to oral health care can negatively affect oral health status, several countries have implemented sustainable intervention programs and policies to service these disadvantaged populations.9-15 Some of these programs have focused on the integration of research, service and education and have been associated with effective workforce recruitment and retention.14,16,17 Lessons learned from these experiences suggest that moving toward an effective health system necessitates identifying barriers and facilitators, sharing knowledge, delivering information and creating strategies to attract and retain more health care professionals in rural and remote communities.3,17-19
A review of the literature indicates that several factors impede the recruitment and retention of oral health care providers in rural and remote areas.20 These include sociodemographic characteristics, environmental barriers, income and lack of professional and familial support.2,3,16,20-23 Although previous research in this field has provided valuable information on this subject, to our knowledge relatively few studies have sought to understand how oral health care practitioners and allied workforce personnel perceive working in rural and remote areas.3 The views of dental students are pivotal in understanding the challenges that the future generation may encounter as they choose the location of their dental practice.11,24
Therefore, the purpose of this qualitative exploration was to understand the perspectives and knowledge of final-year Quebec dental students and specialty residents with regard to rural and remote dental practice.
We used a qualitative approach and "interpretive description" to gain a deep insight into the perceptions of dental students toward rural dental practice.25,26
In 1997, Sally Thorne introduced the interpretive description approach as an alternative to traditional qualitative methods. This applied qualitative approach emphasizes the generation of knowledge that is grounded in practice and will lead to informed action. Without sacrificing the reliability and truthfulness of qualitative research, this method identifies themes and patterns by broadening the interpretive lens within a practice-linked health care discipline.26,27
Study Setting, Sampling and Participants
This study was conducted at 2 major dental faculties in Montreal, Canada. Study participants were recruited from among Université of Montréal and McGill University 4th-year undergraduate students and postgraduate residents via direct communication and email. Purposive or selective sampling with maximum variation was used to select the study participants.25,29 Contrary to random sampling, the goal of purposive sampling is to select a sample that enables the qualitative researcher to answer the research questions, but with no intention of generalizing the results to the whole population.25 Heterogeneous sampling (maximum variation) allowed us to capture a wide range of perspectives of dental students from different backgrounds regarding rural practice experience, place of residency training and university curriculum. Moreover, the recruited participants were invited to identify other students who might participate in the study (snowball technique).29 Recruitment continued even after saturation was reached to ensure that bringing in a new participant would not raise any additional finding from the interviews.30
Ethical approval for this study was obtained from the institutional review board of the Université de Montréal. Informed written consent was obtained from each student, specifying that their participation was completely voluntary and would not in any way affect their academic standing. Ethical guidelines were respected to ensure the confidentiality and anonymity of the students.
Semi-structured, face-to-face, in-depth interviews were conducted between April and July 2013 at locations convenient for the participants.31 A postgraduate student (NS), who wastrained in qualitative research and interviewing techniques,was responsible for conducting the interviews. To avoid potential bias caused by issues of trust, neither the lead researcher (EE) nor any other person from academia was involved in the interview process.Interviews were audio-recorded, and each lasted 60–90 minutes.
A bilingual interview guide with open-ended questions was designed based on the theoretical knowledge gained from the literature review.26
Each interview started with general questions regarding level of knowledge about rural dental practice, followed by more specific questions about the participant's perspectives, attitudes and expectations. Further questions were based on the interviewee's responses and consisted mainly of seeking clarification and probing for details.25 At the end of each interview, students were invited to answer questions regarding their age, marital status and perceived socioeconomic status.
In qualitative data analysis,common themes are identified and the raw data are transformed into research findings.32,33Our data analyses included transcription, debriefing, codification, data display, thematic analysis and interpretation. Data collection and analysis were performed concurrently.33
Primary data analysis was started after the first interview to confirm the relevance of central questions and to shape further data gathering.25 Data saturation was reached after the 12th interview; however, data collection continued up to 15th interview to ensure the saturation level.25
Interviews were transcribed verbatim from the recordings. Each transcript was read carefully with continual debriefing and reflection on the meaning, using the results of the literature review as a basis. Raw data were coded manually then analyzed using ATLAS-ti version 7 (ATLAS-ti Scientific Software Development GmbH, Berlin, Germany) to facilitate the analysis.34
Transcripts were summarized and sorted in the form of analytic matrices35 under preliminary themes to identify commonalities and differences among participants.26
Transcription of interviews and coding were conducted primarily by NS. The lead researcher (EE) then cross-examined the raw data. Labeling and sorting of the data into themes and subthemes was done collectively to achieve overall agreement on the emerging interpretations and results.
Ultimately, preliminary themes and interpretations were reviewed during team meetings and major themes were elaborated.
Sociodemographic characteristics of the study participants are shown in Table 1. Seventeen interviews were carried out with 10 women and 7 men, aged 22–39 years. Thirteen participants were 4th-year undergraduate dental students, and 4 were residents in orthodontic and prosthodontic disciplines. Most participants described their socioeconomic status as average, but emphasized their high level of debt resulting from the cost of their education.
|Characteristic||No. of participants|
|Age group (years)|
|Self-reported socioeconomic status|
|Rural upbringing or experience|
|Last-year postgraduate residents||4|
|Université of Montréal||14|
Five major themes emerged from the qualitative analyses: awareness of access to oral health care in rural areas; image of rurality; image of rural dental practice; perceived barriers to rural dental practice; and perceived enablers of rural dental practice.
Awareness of Access to Oral Health Care in Rural Areas
Most students were aware of disparities between rural and urban regions with regard to availability of dental personnel and access to dental services. However, they were less clear about the causes of these disparities and health care policies that could improve the situation. Students were exposed to underprivileged populations via outreach programs, community dentistry and courses in dental public health, but these academic activities did not focus on rural communities.
"Well, maybe we have some courses in the university like public health, and it's kind of interesting, but rural dentistry was not a topic that has been talked about in class."
A few students mentioned that representatives of dental recruitment agencies and dental companies were the main sources of information about rural dental practice. These agencies hold a meeting each year for senior dental students at the University of Montreal to inform them of dental practice vacancies. "I met… who has a recruitment agency, and she is my only source of information about metropolitan or rural sections."
A few students, especially those with a rural background and/or with work experience in rural and remote regions, had more knowledge about rural access to care. "There is not enough infrastructure, especially in the health care system."
Image of Rurality
Participants had various images of rurality. Most recognized that rural areas are different from urban areas: they associated rural regions with a slower pace of life and a family-oriented environment. A few students appreciated the supportive social interactions among rural community members and, thus, believed that dentists would have a sense of belonging to the community.
"I think they are isolated communities. But at the same time, you can have a slower life style and you can raise a family there perhaps. It's a more relaxing type of atmosphere and simpler life that people might enjoy."
"Rural is a family-oriented kind of environment… as if the whole community is looking out for you and your family."
However, there was consensus that these regions are not attractive to younger dentists. A few participants were concerned about the privacy of their lives in a small town. "[You tell your rural patients that dental treatment] will cost $5000 and it's expensive for them. Then in the weekend, when you want to do the cruise on your private boat, they will judge you for having a beautiful luxurious life."
Image of Rural Dental Practice
Participants perceived rural dental practice as having a high level of autonomy associated with great responsibility and multitasking. "There's a real ownership and autonomy about the way you practice. The flip side is also you have the total responsibility. You are the only dentist there."
Most of the students were positive about rural working hours, the type of clientele and the lack of competition between dentists. A few mentioned that the lack of specialists in rural areas would increase the workload of general dentists and the nature of the treatments they offer. "You have to work more, because you cannot refer patients easily… There are not a lot of specialists, so the general dentists should be able to offer different treatments."
Furthermore, they mentioned the critical importance of a dentist's reputation in small rural communities. "In a small town your reputation is everything.... You're getting feedback from your patients."
Perceived Barriers to Rural Dental Practice
Three subthemes emerged under this theme: proximity maintenance and separation distress; fear of the unknown; and lack of infrastructure, resources and professional support.
Proximity maintenance and separation distress: The desire to remain close to people to whom they are emotionally attached and fear of isolation were psychological concepts that emerged from the discussions."One of the factors that make professionals not go to rural areas is the isolation, you don't have Internet, you are already far from family, city, and people. So, you feel even more isolated."
Most students with an urban background were concerned about giving uptheir metropolitan lifestyle for a rural way of life."Leaving friends, cultural and social activities as a result of moving to a far rural region is hard for someone who comes from Montreal." "For the person who was born, raised, and studied in cities, going to work in rural regions is very difficult."
Fear of the unknown: Participants without a rural background and/or rural experience expressed fear resulting from their lack of knowledge and uncertainty about the nature of rurality and rural dental health care services. In addition, lack of confidence in treating rural patients emerged in their comments."When someone has never been in a small town, they often see small towns for what they lack! As opposed to seeing what small towns have to offer. So, it's scary. It's fear of the unknown."
Lack of infrastructure, resources and professional support were considered to be disadvantages of working in rural areas for most dental students."The lack of infrastructure and resources is the main barrier,which can possibly affect the quality of your work in a rural area."
Perceived Enablers of Rural Dental Practice
Four subthemes emerged from this theme: highlighting the advantages of rural dental practice; monetary and non-monetary incentives; creating job opportunities for partner/spouse; and dental education.
Highlighting the advantages of rural dental practice: Participants mentioned the importance of marketing to provide dental students with more information about positive aspects of rural dentistry and working in rural and remote regions. They suggested putting effort into social networking as a good interface for knowledge dissemination among young dentists.
"We should mention the benefits of working in rural [areas] because people don't know the advantages."
"There can be a trip in which we might invite future graduates. They can look up and try to go and visit the place by themselves."
"Giving the information out there and make it as attractive as possible.... They have to be somehow convinced that their urban chic lifestyle can be satisfied there and that's a challenge. The key is marketing!"
Monetary and non-monetary incentives: Participants suggested debt forgiveness and tax bonuses as effective initiatives, addressing the debt phobia of the majority of dental students."I think incentivizing is a great way to go... you could send a dentist to Siberia with debt forgiveness."
They explained that the government could intervene to support health care professionals financially and psychologically."Definitely the government should make some steps to encourage dentists to go to rural areas and stay there."
However, a few participants believed that the government had already offered enough incentives and,being part of an autonomous industry, dentists resist government measures. One of the participants mentioned the critical role of government in dental insurance challenges for rural communities."We need government subventions for dental insurance in rural populations."
Creating job opportunities for partner/spouse: Most of the female participants perceived partner's career as an important factor in their decision-making and retention. However, they knew creating job opportunities requires collaborative efforts between government employment bodies and rural communities."It's not just attracting one person, it's attracting a couple! And if the other one can work there or not."
Dental education: Participants suggested that dental schools could contribute to improving rural dental practice by adopting rural-oriented admission strategies and dental curricula and exposing dental students to rural regions."It would be a good idea to put rural dentistry course in the university curriculum."
Our findings show thats eparation anxiety, lack of professional confidence and the absence of previous experience working or living in geographically isolated communities constitute major barriers to establishing a rural dental practice. However, dental students believe that training and education in rural and remote areas would provide an opportunity to become engaged in such communities and learn about rural dental practice. It is interesting to note that, although our students' profiles were different in terms of year of education (undergraduate students versus specialty residents), they shared the same perspectives with regard to choice of practice location.
These findings support the initiatives of various dental schools to provide community-based dental education programs to increase access to oral health care for rural and remote populations.36,37 Evidence from successful programs in the United States, Australia and other countries shows that these programs are effective in terms of raising students' awareness, increasing their knowledge and promoting a positive attitude toward future rural practice.11,14,38
Furthermore, such rural-focused programs and training might help students understand the significance of their contribution to the oral health of underserved populations22,39,40 and increase their sense of professionalism and social responsibility.40
The results of our study indicate that students with rural upbringing and experience might be more interested in a rural career and more sensitive to the needs and demands of rural communities.12,15,41-46 According to McFarland and colleagues,13,46 these students are 6 times more likely to return to work in rural communities after graduation. These findings support the policies of certain dental faculties in regard to the selection of students from rural and remote areas.13,46 They also highlight the need to invest in strategies that modify or ensure the human desire to maintain bonds to family, partner, peers, places and neighborhoods. According to the attachment theory introduced by Bowlby and Ainsworth,47relationships and bonds between people provide a sense of security to individuals, and separation may cause anxiety and distress.47 Thus, strategies such as psychosocial education, rural infrastructure development and entrepreneurship, creation of various job opportunities for partners and families, as well as monetary incentives, could be beneficial in addressing rural deprivation.
Our findings also show that monetary incentives, including scholarships, loan forgiveness and tax bonuses, could be motivators because of the increasing debt load of Canadian dental school graduates.3,23,48-53 However, it is important to note that, although these financial incentives might increase recruitment of dental personnel, they might not have an effect on their retention in rural and remote areas.22,54 This highlights the need to focus on non-monetary incentives, such as access to professional support and job satisfaction. There is overwhelming evidence that job satisfaction can overcome all other barriers and help retain health care professionals in rural and remote regions.3,20
This study raises awareness of the role of academia and policymakers inproviding appropriate education and infrastructure for rural dental practice and other health-related disciplines. Different models of education and curricula should be developed to promote social dentistry and prepare students for working in rural and remote areas. Development of a rural residency dental program with adequate governmental financial support could be a target strategy.
However, these results should be interpreted with caution because of the limitations of our approach. Our study reflects a particular group of dental students: French- and English-speaking students in Montreal. As a consequence, our findings might not be generalizable to dental students from other societal, geographic and academic contexts. In addition, our study reports the perspectives of a relatively small number of participants, even though the size of the sample is adequate based on interpretive description methodology.
According to the literature, in interpretive description, a minimum number of 8 interviews could be considered adequate to uncover insights related to the study objectives and to attain saturation 26,30. However, this limited number does not allow generalization of the results.55 In fact, in qualitative research, the credibility of findings is ensured by triangulation of interpretations.56,57 Further research in other settings is necessary to determine whether the themes identified in this study are relevant to other dental students from different faculties and countries.
The findings of this study indicate that there is a need to implement and support strategies that are known to increase the knowledge and motivation of dental students to choose rural locations. Dental educators have an essential role in shaping professional character and encouraging apprenticeship to meet these goals.
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