Exploration of the preconceptions of living in a rural community by general practitioner registrar partners

The difficulty in recruitment and shortage of general practitioners (GPs) working in rural and remote areas of Australia have been a concern for the government since the 1990s. Research has largely focused on identifying the established GPs’ perspective concerning issues around rural practice and living and has often been retrospective,1-3 rather than investigating the perspective of GP registrars during their training period. Research has identified that the spouses’/partners’ (hereafter referred to as partners) experiences and perceptions of a rural community are important factors in influencing the GP registrar's decision to work in rural and remote areas.4, 5 Barriers to the recruitment of rural GPs associated with their partners and families include: partner's employment opportunities;6-8 children's education;4, 5, 8 housing;5 lifestyle and cultural differences;4 and community characteristics.4 One of the Australian government's strategies to address rural medical workforce shortages is the requirement of all GP registrars to undertake a rural placement for a minimum of six months during their training. The partners’ perspective of these placements in a rural community has not been investigated. The aim of this study was to explore the preconceptions of rural community from the partner perspective of GP registrars. Recruitment was carried out through initial mail-out and follow-up phone calls to all eligible partners from each of the three South Australia (SA) Regional Training Providers (RTPs). These included the Adelaide to Outback GP Training Program, Greater Green Triangle GP Education and Training and Sturt Fleurieu GP Education and Training. Following a registration of interest, contact was then made with the partner directly. A total of 12 of the possible 42 partners of GP registrars due to undertake their rural placement in 2008 participated in the study. All participants received an honorarium for their time. Focus groups were used to investigate the perceptions of participants. Two focus groups, with five to seven participants in each, were undertaken between December 2007 and January 2008. Consent was obtained from all participants. A modified version of the Nominal Group Technique9 was used in the focus groups where ranking of themes by participants did not occur. A Nominal Group Technique allows for more equal contribution from all participants,9 and is especially suitable for groups of people who do not know each other or from diverse backgrounds. Seven questions were responded to and discussed by the group with two questions beginning with silent generation of responses onto paper, followed by a group discussion of written responses. The focus groups were recorded and transcribed verbatim. Thematic analysis was used to explore the transcripts and was managed using qualitative research software (NVivo, version 7.0, QSR International Pty Ltd, Melbourne, Victoria, Australia). Data were collated to generate initial codes, then sorted and grouped to form overarching themes and sub-themes reflecting recurrent patterns in the data.10 The themes and sub-themes were then reviewed in relation to the extracts found in each of the codes and revised, where appropriate, to more accurately reflect the dataset.10 Ongoing analysis was continued to further identify the relationship between codes themes and sub-themes.10 The final coding scheme consisted of 20 codes, organised in a three-level coding hierarchy (Table 1). Themes identified were verified by two investigators (SP and CL), and differences resolved through discussion and subsequent adjustment of analysis. Approval was gained from the University of Adelaide Human Research Ethics Committee. The majority of participants in this study were male (83.3%). This reflected the available cohort of GP registrars at the time of the study, almost two-thirds of whom were female. Of the participants, 41.7% were aged 25 to 34 years and 66.6% were born overseas, with a greater percentage in the second focus group (80%), than in the first (57%). Almost all participants were tertiary educated (91.7%), 83.3% were in professional employment and 50.0% had dependent children. The analysis revealed positive and negative aspects to rural communities by partners of GP registrars about to undertake rural placements (Table 1). This theme was comprised of four sub-themes: the community size, distance and culture; education; the lifestyle; and the physical environment (Table 1). In terms of the culture of rural communities, partners regarded experiencing a new community, culture and friends as beneficial. Rural communities were seen as smaller and closer communities with access to recreational and leisure activities. Additionally, rural areas were also considered safe environments. Partners also considered that they can save money in rural areas. This related to general spending, as well as schooling and accommodation, which were seen as less expensive in rural areas. The physical environment of rural communities was perceived as positive. Partners considered a rural community to be a good environment for family and raising children. The negative aspects of rural communities contained four sub-themes relating to amenities, community size, distance and culture, education and work (Table 1). Amenities and work formed the largest component of discussion for participants for both groups. A lack of accommodation options in rural communities was a concern for participants. Partners emphasised the lack of facilities and entertainment as a barrier to rural living, particularly restaurants and entertainment. The cost of living in terms of transport and groceries was also considered a negative aspect. Participants expressed concern that their cultural needs would not be met and that lifestyle/cultural differences would be a barrier to rural living. Loneliness and boredom and the separation and distance from partner and family were raised as a concern for those not relocating, while separation from family and friends was also a concern for participants who would be relocating with their GP registrar partner. A significant sub-theme related to work, both of the partner and the GP registrar. The GP registrars’ workload when working within a rural community was perceived as an issue by the participants. For the partner, the decision to live in a rural community was influenced by the lack of employment opportunities, which for some also extended to adult children. Education and culture were aspects of rural communities that were perceived as both positive and negative (Table 1). Primary schooling was considered of high quality no matter where you went, whereas secondary schooling was perceived as a real concern. Participants indicated that everyone knows who you are as a GP registrar and partner living in a rural area. GPs are a unique person/group in rural communities, and this was perceived by participants as both positive and negative. The research literature has focused on established GPs’ perceptions of working and living in rural communities.1-3 Limited studies have investigated the perceptions of their partners. This study sought to investigate the perceptions of partners of GP registrars before participating in a rural placement. Although this study was conducted before GP registrars participated in a rural placement, participants held strong perceptions regarding SA rural communities. Participant responses reflected limited knowledge regarding rural communities and rural life, with blanket statements being made. Participants’ concerns regarding communities’ lack of facilities and entertainment, lifestyle and cultural differences, and lack of employment opportunities for partners support previous findings.4, 6-8 Participants’ employment was a concern, limiting their capacity to relocate to a rural community for their GP registrars’ short-term placement. This is of particular concern for Generation X and Y, when both the GP registrar and partner are in an important stage of career development, especially for a short-term placement. Such placements also impact on children's education and raised issues for participants in choosing to move as a family, or not moving and separating family members. This might need to be a consideration for future change in government policy. Some issues discussed by partners might be addressed by the relevant RTP and rural community, such as a lack of knowledge/exposure to rural communities through provision of information. Yet, other matters are certainly outside the role of the RTPs, such as community size and geographic distance from a large urban centre. This study has a number of limitations. Only a small sample of partners was included and limited to the partners of GP registrars in SA; therefore, perceptions can relate to SA only. The small number of participants means that saturation is unlikely to have been met. There were a larger number of male participants in this study, and findings might not reflect a balanced perspective of sexes. This reflects the current cohort of GP registrars and is likely to continue as a pattern of recruitment across different RTPs. Findings of this study are therefore of national relevance and concern for the future. Overall, this study has provided a deeper understanding of preconceptions of rural living from the partner perspective of GP registrars. Findings are similar to previous research,4-8 yet this study identifies the unique concerns of partners regarding short-term rural placement. A useful follow-up study would be an exploration of whether these preconceptions were confirmed following the rural placement. The authors would like to thank the Rural Doctors Workforce Agency, South Australia for providing funding for this research. Thank you to the following organisations and people for their support and contributions to this study: Peter Clements and Kathryn Taylor from Sturt Fleurieu GP Education and Training; Brian Trotter from Greater Green Triangle GP Education and Training; Jane Griffin, Lyn Buchanan and Jess Yee from Adelaide to Outback GP Training Program; and to all the partners who contributed to the focus groups. SP, 40%; CL, 40%; LB, 10%; LP, 10%.