Rabinowitz, Diamond, Markham e Wortman (200826. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication. Acad Med 2008 Mar; 83(3):235-43.) Academic Medicine
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Systematic review |
10 studies selected (1972-2002). Six universities promoted an increase in settlement in rural areas (53 to 64%). Highlight: Univ. Minnesota and Univ. Thomas Jefferson with settlement of 87% and 79%, respectively, with a mean stay of 7 years. |
1-Selection of undergraduate students taking into account the place of origin and career intention; 2-Curricula with great rural insertion - extended internship, minimum six months or mandatory full time, in the last two years of medical training. |
Wilson, et al. (200927. Wilson, NW, Couper ID, De Vries E, Reid S, Fish T, Marais BJ. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote áreas. Rural Remote Health 2009; 9(1060):1-21.) Rural and Remote Health
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Narrative review |
110 studies were selected (1995-2008). Results of five strategies to encourage settlement in rural and remote areas. No study with convincing evidence. Strong evidence only for the selection of students (rural origin as an isolated criterion with stronger evidence - OR 2.5 to 3.5; career intention when starting graduation and female gender, the latter with a negative impact) and linked residency program (stronger evidence). Rural training/internships with conditions for qualified clinical practice (moderate evidence). |
1-Selection of students of rural origin; 2-Curricula with long-term clinical practice in rural communities, with good infrastructure and experienced preceptorship; 3-Qualified tutoring in specialties related to PHC. |
Barrett, Martin, Lipsky e Lutfiyya (201128. Barrett F, Martin MLS, Lipsky S, Lutfiyya MN. The impact of rural training experiences on medical students: a critical review. Acad Med 2011 Feb; 86(2):258-63.) Academic Medicine
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Narrative review |
72 studies were selected (1966-2009). Association between the quality of rural training and the choice of a PHC specialty (89% of studies); three times more chances of future work in rural areas, when compared to the national average (31% of studies). Few studies, with inconclusive results, on the settlement in these areas (6% of the studies). |
1-Graduation programs included in rural areas. |
Crampton, McLachlan e Illing (201337. Crampton PES, McLachlan JC, Illing JC. A systematic literature review of undergraduate clinical placements in underserved áreas. Med Educ 2013;47:969-78.) Medical Education
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Systematic review |
54 articles selected, mostly from Canada and Australia - rural context (1991-2011). Schools located in unassisted areas promoted an increase in the number of professionals settled in rural areas, greater (but not exclusively) of doctors with rural origin. Studies have not been conclusive regarding long-term permanence or about the impacts on small towns. There were improvements in training (clinical knowledge, confidence, interpersonal skills) and equivalence in clinical competences between rural and traditional schools; in some studies, rural schools have better scores in clinical and relational skills. |
1- Extended training (duration of around two years) in PHC carried out in rural and unassisted urban areas; 2-Body of preceptors with qualification and experience in PHC, FCM and Rural Medicine. |
Viscomi, Larkins e Gupta (201329. Viscomi MH, Larkins S, Gupta TS. Recruitment and retention of general practitioners in rural Canada and Australia: a review of the literature. Can J Rural Med 2013;18(1):13-23.) Canadian Journal of Rural Medicine
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Narrative review |
86 studies selected (2002-2012) - mostly from Canada and Australia Studies with family doctors working in rural and/or remote areas have shown that the most important educational factors (studies with higher quality scores) were: preparation programs for high school (HS) students from rural areas; selection of students (rural origin, older, male, partner of rural origin); community-based curricula; longer-term training; campuses in rural areas; qualified clinical experiences under FCM preceptorship. Some studies have shown that the quality of rural experiences can attract students of urban origin. |
1-Programs for the preparation of students since HS and selection of students of rural origin and / or who attended HS and/or who have lived for at least 6 years in these areas; 2-Positive experiences in elective FCM disciplines developed in rural regions, with exposure to appropriate rural elective content, teachers acting as good reference and students reaching an understanding on the needs of rural communities. |
Farmer, Kenny, McKinstry e Huysmans (201530. Farmer J, Kenny A, McKinstry C, Huysmans RD. A scoping review of the association between rural medical education and rural practice location. Hum Resour Health 2015;13(27):1-15. doi: 10.1186/s12960-015-0017-3. https://doi.org/10.1186/s12960-015-0017-...
) Human Resources for Health
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Integrative review |
37 studies were selected (2000-2012). Evidence that rural exposure during medical graduation (basic cycle and internship) increased the probability of working in rural areas, with averages above national ones (26 to 67%). The duration of activities in rural areas was identified as an important factor, but few studies (3) showed a ratio between an increase in the time of rural experiences and an increase in settlement rates. |
1-Rural origin is considered the strongest isolated predictor for rural practice; 2-Graduation in rural areas and with a longer time of clinical experience in these areas. |
Myhre, Bajaj e Jackson (201531. Myhre DL, Bajaj S, Jackson W. Determinants of an urban origin student choosing rural practice: a scoping review. Rural Remote Health 2015;15(3483):1-10.) Rural and Remote Health
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Integrative Review |
17 studies were selected (1970 to 2014). Most determining factors for students of urban origin were financial, followed by educational ones. The financial incentive associated with recruitment (80% of students accumulate high debt), with many choosing small towns close to large centers due to job opportunities. Education also has a great influence, especially the quality of the preparatory school for selection, increasing the students’ interest, the characteristics of medical education and the qualification profile of teachers/preceptors. |
1-Quality of the preparatory school for the selection of students; 2-Profile and experience of teachers / preceptors; 3-Relationship between the student and the preceptor; 4-Duration of contact with users and the community; 5-Local infrastructure; 6- Valuation and institutional stimulation for students of urban origin with an interest in these areas. |
Goodfellow et al. (201632. Goodfellow A, Ulloa JG, Dowling PT, Talamantes E, Chheda S, Curtis B et al. Predictors of primary care physician practice location in underserved urban or rural areas in the United States: a systematic literature review. Acad Med 2016;91(9):1313-21. doi: 10.1097/ACM.0000000000001203. https://doi.org/10.1097/ACM.000000000000...
) Academic Medicine
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Systematic review and meta-analysis |
72 studies were selected (2007 to 2015). The predictors of settlement in unassisted rural and urban areas found in the studies were the personal aspects (19 studies): having grown up in the rural area (7 studies, 1.7 times more likely to settle), ethnic (14 studies) and participation in International Medicine programs (12 studies with little evidence). Also, community and PHC-oriented curricula, in disadvantaged urban areas (8 studies) and in rural areas (12 studies), with a settlement average of 53% to 67%, with a strong association between the place of graduation and work, and 51% of doctors working in the same state where they graduated. A study showed a 10-fold higher chance of settlement among students in these programs. Participating in financial incentive programs with debt reduction associated with compulsory work (about 2 years) is a strong predictor for the short term. |
1-Type of school selection, favoring the admission of students who grew up or attended HS in unassisted areas, either rural or urban; 2- Location of schools in rural areas (satellite campuses) or underprivileged urban areas; 3- Community-based curriculum and focused on PHC, which allows students to get closer to these communities. |
Reeve et al. (201633. Reeve C, Torres W, Ross SJ, Mohammadi L, Halili Junior SB, Cristobal F et al. The impact of socially-accountable health professional education: a systematic review of the literature. Med Teach 2016;39(1):67-73. doi: 10.1080/0142159X.2016.1231914. https://doi.org/10.1080/0142159X.2016.12...
) Medical Teacher |
Systematic review |
22 studies were selected. Schools with social accountability (SAHPE) promoted positive impacts on the training quality (10 studies), on the workforce through greater settlement (6 studies) and on the health of the local community (5 studies). Training (5 studies) - equivalence of the clinical training quality in four studies, greater effectiveness in relation to the needs of the population compared to schools in the large cities. Community health: one study with improved access, two studies with positive changes in the population’s behavior and one study with a reduction in infant mortality. Workforce (6 studies) with greater retention and improvement in the quality of professionals. |
1-Selection processes valuing students from rural areas, students from disadvantaged and excluded minorities; 2-Strategies to avoid dropout of these students; 3-Formal strategies for integration with the local community and the service and health network; 4-Education based on qualified practices of prolonged immersion in these communities; 5-Development of educational projects defined by the needs of the community. |
Guilbault e Vinson (201736. Guilbault RWR, Vinson JA. Clinical medical education in rural and underserved areas and eventual practice outcomes: a systematic review and meta-analysis. Educ Health 2017;30:146-55.) Education for Health
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Systematic review and meta-analysis |
Students from schools located in unassisted areas are 3 times more likely (RR = 2.94) to work in these areas, compared to students from other locations. Students from schools located in unassisted areas are 4 times more likely (RR = 4.35) to work in PHC, compared to students from other locations. |
1-Large number of students belonging to excluded minorities; 2-Curricula with problematization methodologies and activities in rural areas since the basic cycle of the course, with increasing complexity; 3-Preceptors with experience in FCM/PHC; 4-Satellite campuses in rural areas, with rotating training from 12 weeks to 32 weeks, in the 3rd and 4th years of the medical course. |