Provision of Care to the Underserved Populations by National Health Service Corps Alumni Dentists
Cecil G. Sheps Center for Health Services Research, University of North Carolina, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA. Journal of Public Health Dentistry
(Impact Factor: 1.65).
02/2002; 62(2):102-8. DOI: 10.1111/j.1752-7325.2002.tb03429.x
This study examined factors associated with dentists continuing to provide care to the underserved populations beyond their National Health Service Corps (NHSC) obligation period.
Self-administered questionnaires were mailed in 1998 to 404 dentists who had completed their service obligation between 1980 and 1997. The outcome variable was dentist self-report of continuing to work with the underserved population past NHSC obligation.
Among 249 respondents (62% response rate), 46 percent of alumni dentists continued to work with an underserved population. Multivariate analyses found that being an African American (odds ratio [OR] = 3.2), higher final salary during the NHSC assignment (OR = 1.2), and higher altruistic motivation to work with the underserved populations prior to entering NHSC (OR = 1.1) were significantly associated with continued service to the underserved populations.
A small number of factors were associated with alumni NHSC dentists' decisions to continue to provide care for the underserved populations. Targeting African-American students and students interested in caring for the underserved may improve the long-term commitment of dentists to provide care for the underserved populations. Attention will also need to be given to increased salary as a potential intervention to increase the numbers of dentists who continue to serve the underserved populations.
Available from: PubMed Central
- "One of the fifteen studies did not report an enrolment period or lag time . Enrolment periods in the remaining 14 studies were four [76,77], five , nine , ten , fifteen , eighteen [63,80], nineteen , twenty , twenty-three , twenty-four , twenty-five , and twenty-six  years. There was no lag between enrolment and observation in five studies [45,56,67,71,74]; lag times in the other studies were 1 [58,63,76,80], 6 , 8 , 11 , and 29  years; two studies assessed retention results after three different lag times (3, 7 and 9 years  and 9, 13, and 15 years ). "
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ABSTRACT: In many geographic regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off.
We carried out systematic literature searches of PubMed, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, and the National Health Services Economic Evaluation Database for studies evaluating outcomes of financial-incentive programs published up to February 2009. To identify articles for review, we combined three search themes (health workers or students, underserved areas, and financial incentives). In the initial search, we identified 10,495 unique articles, 10,302 of which were excluded based on their titles or abstracts. We conducted full-text reviews of the remaining 193 articles and of 26 additional articles identified in reference lists or by colleagues. Forty-three articles were included in the final review. We extracted from these articles information on the financial-incentive programs (name, location, period of operation, objectives, target groups, definition of underserved area, financial incentives and obligation) and information on the individual studies (authors, publication dates, types of study outcomes, study design, sample criteria and sample size, data sources, outcome measures and study findings, conclusions, and methodological limitations). We reviewed program results (descriptions of recruitment, retention, and participant satisfaction), program effects (effectiveness in influencing health workers to provide care, to remain, and to be satisfied with work and personal life in underserved areas), and program impacts (effectiveness in influencing health systems and health outcomes).
Of the 43 reviewed studies 34 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60-80%). Seven studies compared retention in the same (underserved) area between program participants and non-participants. Six studies found that participants were less likely than non-participants to remain in the same area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Thirteen studies compared provision of care or retention in any underserved area between participants and non-participants. Eleven studies found that participants were more likely to (continue to) practice in any underserved area (nine studies reported the difference to be statistically significant, while two studies did not provide the results of a significance test); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with their work and personal lives in underserved areas.
Financial-incentive programs for return of service are one of the few health policy interventions intended to improve the distribution of human resources for health on which substantial evidence exists. However, the majority of studies are from the US, and only one study reports findings from a developing country, limiting generalizability. The existing studies show that financial-incentive programs have placed substantial numbers of health workers in underserved areas and that program participants are more likely than non-participants to work in underserved areas in the long run, even though they are less likely to remain at the site of original placement. As none of the existing studies can fully rule out that the observed differences between participants and non-participants are due to selection effects, the evidence to date does not allow the inference that the programs have caused increases in the supply of health workers to underserved areas.
Available from: sph.unc.edu
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