Impact of selection strategies on representation of underserved populations and intention to practise: International findings

Context: Socially accountable medical schools aim to reduce health inequalities by training workforces responsive to the priority health needs of underserved communities. One key strategy involves recruiting students from underserved and unequally represented communities on the basis that they may be more likely to return and address local health priorities. This study describes the impacts of different selection strategies of medical schools that aspire to social accountability on the presence of students from underserved communities in their medical education programmes and on student practice intentions. Methods: A cross-sectional questionnaire was administered to students starting medical education in five institutions with a social accountability mandate in five different countries. The questionnaire assessed students' background characteristics, rurality of background, and practice intentions (location, discipline of practice and population to be served). The results were compared with the characteristics of students entering medical education in schools with standard selection procedures, and with publicly available socio-economic data. Results: The selection processes of all five schools included strategies that extended beyond the assessment of academic achievement. Four distinct strategies were identified: the quota system; selection based on personal attributes; community involvement, and school marketing strategies. Questionnaire data from 944 students showed that students at the five schools were more likely to be of non-urban origin, of lower socio-economic status and to come from underserved groups. A total of 407 of 810 (50.2%) students indicated an intention to practise in a non-urban area after graduation and the likelihood of this increased with increasing rurality of primary schooling (p = 0.000). Those of rural origin were statistically less likely to express an intention to work abroad (p = 0.003). Conclusions: Selection strategies to ensure that members of underserved communities can pursue medical careers can be effective in achieving a fair and equitable representation of underserved communities within the student body. Such strategies may contribute to a diverse medical student body with strong intentions to work with underserved populations.