Achieving Universal Health Coverage, which is the aim of countries’ health system, requires making healthcare accessible for all of its citizens. Access to health is a right for all people regardless of their religion, ethnicity, and living place. This issue is declared in several documents, the Constitution of World Health Organization (WHO), and Article 29 of the Constitution of Islamic Republic of Iran. WHO in “Health for All” policy emphasizes on achievement of all people to the highest attainable level of health.

Despite all of these assertions, in many countries habitants of rural and underserved areas have some barriers in accessing healthcare. For example in China, rural women do not utilize healthcare facilities equitably with urban women [1,2]. This is the same for Ghanaian women [3,4]. This is not just related to developing countries. In the US, rural population is more likely to be dissatisfied with the healthcare provided compared with urban population [5]. Also, rural population of New York State has worse health behavior and do not have a regular medical care provider [6]. By proportion, rural settings of Canada have fewer healthcare providers than urban locations [7]. This is called inverse care law that states those who need more health care, have less access that could be seen in different contexts [8-10].

General practitioners (GPs) are one of the main providers of healthcare. In fact they are the gateway of health system in many countries [11,12]. In this regard, Iranian Family Physician Plan and rationing system heavily depends on GPs [12,13]. Thus, they should be accessible in every place for all citizens which can guide them in the health system.

But, in rural and underserved areas lack of GPs hinder accessing peoples to healthcare. In fact GPs are not motivated to work in rural and underserved areas. In a study which is done in China, only one third of medical students have positive attitude toward working in rural and underserved areas [14]. As well, less than 18% of Japanese medical students are positively motivated for rural practice and more than 25% declared they will avoid rural practice [15]. Also in School of Medicine of University of Miami Miller, more than 36% of medical students which volunteered at a rural health fair have not planned to practice as a primary care provider [16].

It seems that medical education is a key factor in motivating GPs for working in rural and underserved areas [17]. Medical education policies including student selection, curriculum, education place, and etc. could have significant impact on their motivation. Regarding to pivotal role of education in retention, medical education in Iran should be analyzed and accordingly strategies set for their retention in rural areas.

Accordingly education is one of the most important issues that could affect GPs retention in rural and underserved areas. Regarding to importance of the issue, the present research aimed at exploring challenges in medical education that makes GPs disinterested for working in rural and underserved areas. This issue is very important and the results of this research could help policy makers and educational planners for addressing GPs retention in rural areas with intervention in their education process.

Qualitative design was applied for the purpose of the study and data were collected via interviews. Prior to starting qualitative study, reviewing the literature was done and accordingly topic guide for interviews was extracted for interviews. Topic guide mainly focused on challenges of medical education and educational strategies for GPs retention in rural and underserved areas. Questions of topic guide were about challenges and strategies in student selection, education place, curriculum, instructors and faculty members, and necessary skill for rural practice. Although, during interviews and according to participants responses some modification in topic guide were made. Based on topic guide and its modifications, deep and semi-structured interviews were conducted from March 2015 to June 2015 with different types of participants.

Participants were divided in three main categories including faculty members and academic key informants, executive key informant, and GPs who retained at least five years in rural and underserved areas as well as GPs who avoid continuing rural practice. Participants were selected using purposive and snowball sampling with maximum variation approach. We tried to cover all areas and we select sample from all over the country at micro and macro level of the Iran’s health system.

Interviews were performed until reaching to data saturation. Finally, 6 academic informants (PA1-PA6), 8 executive key informants at micro and macro level of Ministry of Health and Medical Education (PE1-PE8), and 8 GPs who retained (PPR1-PPR8) as well as 6 GPs who avoid practicing in rural settings (PPA1-PPA6) were selected for interview. Although, most of participants in three categories (24 from 28 participants) had studied medicine and were well informed about medical education and thus the results would be reliable.

From all 28 interviews, 21 were performed face-to-face. Since GPs mainly works in remote areas and hardship in face-to-face interview, seven GPs were interviewed via telephone. The interview time varied from 24 minutes to 60 minutes and the average time was 39 minutes. This average for face-to-face interviews was 42 minutes and 35 minutes for telephone ones. Except one interview (in the case of telephone interview which the participant did not allow recording), all others were recorded and transcribed verbatim and in one case interviewer noted during interview. Coding was checked by two experts in qualitative research and it was confirmed. Data were analyzed using content analysis approach. In this way, texts were coded and issues and subthemes were extracted. The main themes were created via interpretation of codes and issues.

Several ethical issues were considered in interviews with participants. All participants approved a written or recorded informed consent before beginning the interview. They were informed about recording or noting of interviews. Also they were consented to attend in the study and free to express their opinions about the subject. Interviewees were ensured the confidentiality of recorded and noted interviews and their names and positions. As well, the study protocol complies with the ethical guidelines of the 1975 Declaration of Helsinki and approved by ethics committee of Tehran University of Medical Sciences (code: IR.TUMS.REC.1395.2648).

After analyzing and data interpretation, we found four main themes including student selection, medical students’ perception about their field of study, education setting and approach, curriculum of medical education. Each of these main themes encompasses several subthemes and accordingly each subtheme encompasses several issues. The thematic framework of the findings is presented in Table 1. According to Table 1, challenges of medical education for retention in rural and underserved areas of Iran are as follow:

GPs are the key healthcare provider in rural and underserved areas of Iran and their retention is a crucial issue which is rarely addressed in research projects. Education is a factor that could affect GPs retention in rural areas and accordingly this qualitative research was done to find educational challenges that limit GPs rural intention to work. According to the results four main challenges were identified in GPs’ education including student selection, medical students’ perception about their field of study, education setting and approach, and curriculum of medical education.

It was found that dominance of non-native, women, urban, and welfare-experienced students are challenges in student selection that make graduates less intended for working in rural and underserved areas. Student selection criteria as a strategy for GPs retention in rural and underserved areas was highly debated in literature that could forecast retention. Several studies found that women are less positive about rural practice [14,18]. Rural origin also could be a good predictor for rural practice of GPs [19-21]. Parental education level [22], occupation of father [21] and cultural background [23], as socioeconomic factors, are significant factors on GPs retention. Relations between personality and retention in rural settings also confirmed [18,23]. Even GPs’ spouse could determine rural practice [24] that could be addressed. On the contrary, Dossajee et al. [25] found that rural background, marital status, religion, and gender of Kenya medical students did not affect urban or rural practice. Also, Amiresmaili et al. [26] found there is no definite relation between demographic factors and retention in rural family physician plan. Thus student selection as a factor that affects retention in rural settings should be considered and its challenges should be minimized; although, somehow is addressed in entrance quotas for medical students in Iran. Maybe this issue needs more well designed studies for Iranian GPs to evaluate the effect of demographic factors on GPs retention.

Another challenge was related to students’ perception about their future working condition. Most of students look for specialized courses in medicine and they would not stay GP. They do not consider rural practice after graduation in many cases. In fact Students’ perception about their personal career development is a factor that affects retention in rural area [14,27]. Personal and professional expectations also proved as a factor affecting on retention [23]. On the other hand GPs are not exposed to rural settings and they do not think about rural practice in future [19]. Even short-stay in rural settings could be effective for retention [28]. Whereas, good and positive rural training experiences increase GPs’ interest for rural practice and retention [29]. Accordingly it seems necessary that some modification in education is needed to guide students’ perception toward rural practice after graduation.

Curriculum of medical education in Iran is a factor that does not properly make GPs ready for rural practice. Stearns and Stearns [30] consider curriculum as a factor that build an image for future working. In fact, rural practice needs some skills that are not addressed properly in Iran. At first, medical curriculum in Iran is hospital-oriented; whereas, rural-oriented education increases intention of working in a rural area [14,31]. Though, the students are not getting familiar with skills needed for rural practice. Students’ experiences during education is a factor that highly affects retention in rural areas especially during first years of education [32]. Hence, courses about familiarity of medical students with Family Physician Program, and facing with rural patients during education are needed for guarantee their retention in rural settings.

Lack of GPs knowledge about management and leadership is another challenge in medical curriculum. In fact, in rural settings GPs are the head of health team [12] and they are coordinator, community leader for health, administrator, health policy analyzer, and fund holding [33]. On the other hand, GPs role in rural and remote areas is more focusing on health rather than curing patients [33]. GPs coordinate health activities and they need to have a good command of management, health and epidemiology subjects. Nevertheless, these issues are not addressed properly in medical curriculum in Iran.

The last challenges that were found in this research were challenges related to education setting and approach. Instructors and education location as well as education approach could have a significant impact on educated GPs’ retention. Training background is a factor that affects retention in rural areas [23]. Hospital oriented education of GPs in Iran, does not make GPs ready for rural practice. Education approach shapes the expectations of GPs and if it is turned to rural-oriented education, we could expect more retention [14]. Community based education could improve quality as well as retention of GPs [34]. In fact, it fills the gap between public health and clinical medicine which is a challenge for rural GPs of Iran.

Instructors also are critical for making students interested in rural practice. Instructors who did not work in rural settings are not a good pattern for GPs who are expected to work in rural settings. Supervisors and instructor roles is very important factor on GPs. Studies have revealed that instructors can have either positive [35] or negative [36] impact on staff morale. Another factor is education place that most of medical students in Iran are educated in big cities. Educations in remote areas and small towns or rural settings have a positive impact on choosing rural settings by GPs [19,31,37-39]. Even changing education setting for a semester from big cities to smaller towns could have a significant effect on rural and remote areas retention [40]. Though, reform in education setting and moving to education in small towns could be a good policy for making GPs more interested about practice in rural and underserved areas.

The results of this study gives a good oversight about education challenges that makes GPs less interested for working in rural and underserved areas based on experts and GPs experience and viewpoints. The results could guide educational planners and policy makers to reform GPs’ education toward making them interested for rural practice. The present qualitative started a way toward educational factors that could affect GPs retention in rural areas of Islamic Republic of Iran; but more researches are needed to survey the effect of each factor on retention.