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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
 
 
FACTORS INFLUENCING ACCEPTANCE OF RURAL POSTING BY 
HEALTH WORKERS TO KRACHI WEST DISTRICT, VOLTA REGION, 
GHANA 
 
BY 
HILARIUS ASIWOME KOSI ABIWU 
(10602638) 
 
A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH, 
UNIVERSITY OF GHANA, IN PARTIAL FULFILLMENT FOR THE 
AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE 
 
 
JULY, 2019
 
 
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DECLARATION 
I, Hilarius Asiwome Kosi Abiwu, declare that except for the other people’s 
investigations which have been duly acknowledged, this work is the result of my own 
original research and that this dissertation, either in whole or in part has not been 
presented elsewhere for another degree. 
 
 
………………………………….                                …………………………………. 
Hilarius Asiwome Kosi Abiwu                                                           Date 
               (Student) 
 
 
 
 
………………………………….                                …………………………………. 
             Dr Justice Nonvignon                                                         Date 
                    (Supervisor) 
 
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DEDICATION 
This dissertation is dedicated to my family, my wife Mrs. Gloria Dede Abiwu and my 
daughters Augustina Mawunya Ama Abiwu and Theresah Ewoewonyo Abra Abiwu 
who have had to bear the pain of my long periods of absence from home and other 
responsibilities during the course of this work. I appreciate your patience, love, and 
support. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
I wish to acknowledge the contributions of the many people who supported me during 
this research work. I am eternally grateful to my supervisor Dr. Justice Nonvignon for 
his patience and enormous input and guidance which ensured that this project came 
out successful. 
I also wish to acknowledge the contributions of Dr. Eli Aba for his invaluable 
feedback and suggestions and for reading through the write up on a number of 
occasions. My appreciation also goes to my hard-working research assistants Mr. 
John Bless Akortiakumah, Mr. Nicholas Azumah, Mr. Joseph Amuzu, and Mr. Divine 
Setrodzie. To my MPH classmates, management and staff of Krachi West District 
Health Directorate and Hospital, and other friends I say thank you for your support 
and encouragement throughout this course of study. 
Above all my most profound appreciation goes to the almighty God for making this 
dream a reality without whose support this would never have been achieved. 
 
 
 
 
 
 
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ABSTRACT 
Introduction: Access to quality healthcare depends on the availability of qualified 
and adequate healthcare workers; unfortunately, most health workers prefer to work in 
urban and peri-urban communities to the detriment of those living in rural 
communities including Krachi West District. Identifying factors influencing 
acceptance of rural posting and formulating policies based on these factors will 
improve rural posting acceptance. This study, therefore, investigated factors 
influencing acceptance of rural posting to Krachi West District. 
Methods: This was a cross-sectional analytical study which adopted both qualitative 
and quantitative approaches to data collection. Self-administered structured 
questionnaires were administered to all health workers at post. Descriptive statistics 
were performed and statistical significance of various factors and acceptance of rural 
posting was tested using Chi-square and Fisher’s exact tests. Logistic regression was 
used to determine the association between the various factors and acceptance of rural 
posting to Krachi West. Five Focus Group Discussions were held, digitally recorded 
and transcribed verbatim. The qualitative data were analysed using framework 
analysis.  
Results: Though several factors working together determine the willingness of a 
health worker to accept rural posting to Krachi, the only factor showing statistically 
significant association with acceptance of rural posting is the attitude of the staff 
towards working in a rural area (Adjusted OR 9.25; p-value < 0.001). Additionally, 
health workers received news of posting to Krachi with negative emotions such as 
sadness, frustration, and feeling of punishment but the process of visiting the district 
to verify their fears often led to the acceptance of the posting.  
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Conclusion: A health workers’ attitude to working in a rural area is the only 
statistically significant factor associated with acceptance of rural posting to Krachi 
West District. Posting to the district is associated with negative emotions but exposure 
to the district led to acceptance of the posting. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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TABLE OF CONTENTS 
DEDICATION ............................................................................................................... ii 
ACKNOWLEDGEMENT ........................................................................................... iii 
ABSTRACT .................................................................................................................. iv 
TABLE OF CONTENTS .............................................................................................. vi 
LIST OF TABLES ........................................................................................................ xi 
LIST OF FIGURES ..................................................................................................... xii 
LIST OF ABBREVIATIONS .................................................................................... xiii 
CHAPTER ONE ............................................................................................................ 1 
INTRODUCTION ......................................................................................................... 1 
1.0 Introduction ..........................................................................................................1 
1.1 Background ..........................................................................................................1 
1.2 Problem statement ................................................................................................3 
1.3 Study objectives ..............................................................................................5 
1.3.1 General objective. .................................................................................... 5 
1.3.2 Specific objectives. .................................................................................. 5 
1.4 Research questions ..........................................................................................5 
1.5 Significance of the study .................................................................................6 
1.6 Conceptual Framework for factors influencing acceptance of rural posting by 
healthcare staff ...........................................................................................................6 
1.7 Summary ............................................................................................................10 
CHAPTER TWO ......................................................................................................... 11 
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LITERATURE REVIEW ............................................................................................ 11 
2.0 Introduction ........................................................................................................11 
2.1 Important role of the health workforce in healthcare delivery ...........................11 
2.2 Maldistribution of health workforce ..................................................................13 
2.3 Theories of motivation .......................................................................................14 
2.3.1 Need motivational theories. ......................................................................... 15 
2.3.2 Equity theory. .............................................................................................. 19 
2.3.3 Expectancy theory. ...................................................................................... 19 
2.3.4 Job design. ................................................................................................... 21 
2.4 Factors influencing acceptance or otherwise of rural posting ............................22 
2.5 Health system interventions to address the maldistribution of health workers 
along rural-urban divide. ..........................................................................................24 
2.5.1 Education. .................................................................................................... 25 
2.5.2 Financial incentives. .................................................................................... 25 
2.5.3 Regulatory interventions. ............................................................................. 26 
2.5.4 Professional and personal support. .............................................................. 28 
2.5.5 Putting it all together ................................................................................... 28 
2.6 Summary ............................................................................................................29 
CHAPTER THREE ..................................................................................................... 31 
METHODS .................................................................................................................. 31 
3.0 Introduction ........................................................................................................31 
3.1 Study design .......................................................................................................31 
3.2 Study location .....................................................................................................31 
3.3 Variables.............................................................................................................33 
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3.4 Study population ................................................................................................37 
3.5 Data collection methods .....................................................................................37 
3.5.1 Administration of questionnaires................................................................. 37 
3.5.2 Focus group discussions (FDG). ................................................................. 38 
3.6 Selection of Participants .....................................................................................38 
3.6.1 Quantitative study. ....................................................................................... 38 
3.6.2 Qualitative study. ......................................................................................... 38 
3.7 Data collection techniques and tools/instruments ..............................................39 
3.7.1 Questionnaires. ............................................................................................ 39 
3.7.2 Focus Group Discussions (FDG) Guide. ..................................................... 39 
3.8 Quality Control ...................................................................................................39 
3.8.1 Training of interviewers. ............................................................................. 40 
3.9 Data Processing and Analysis ............................................................................40 
3.9.1 Qualitative data processing. ......................................................................... 40 
3.9.2 Qualitative data analysis .............................................................................. 41 
3.9.3 Quantitative data processing ........................................................................ 41 
3.9.4 Quantitative data analysis. ........................................................................... 41 
3.10 Ethical consideration/issues .............................................................................42 
3.10.1 Ethical clearance. ....................................................................................... 42 
3.10.2 Informed Consent. ..................................................................................... 42 
3.10.3 Confidentiality. .......................................................................................... 43 
3.10.4 Risks and discomfort. ................................................................................ 43 
3.10.5 Benefits ...................................................................................................... 43 
3.11 Pretesting and review of instruments/tools ......................................................44 
3.12 Limitations of the study....................................................................................44 
3.13 Generalizability of the research findings .........................................................44 
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3.14 Summary ..........................................................................................................44 
CHAPTER FOUR ........................................................................................................ 46 
RESULTS .................................................................................................................... 46 
4.0 Introduction ........................................................................................................46 
4.1 Proportions of health workers who accepted posting to Krachi Willingly (by 
socio-demographic characteristics) ..........................................................................46 
4.2 Individual-level factors and acceptance of rural posting ...................................48 
4.4 Organisational factors and acceptance of rural posting .....................................49 
4.5 Contextual/socio-cultural factors and acceptance of rural posting ....................51 
4.6 Simple and multiple logistic regression of factors associated with acceptance of 
posting ......................................................................................................................53 
4.7 Experiences of persons who accepted posting to Krachi West District .............55 
4.7.1 How people felt when they were posted to Krachi West District. .............. 55 
4.7.2 Events leading to acceptance of posting to Krachi West District. ............... 56 
4.8 Summary ............................................................................................................57 
CHAPTER FIVE ......................................................................................................... 59 
DISCUSSION .............................................................................................................. 59 
5.0 Introduction ........................................................................................................59 
5.1 The proportion of health workers who willingly accepted the rural posting. ....59 
5.2 Individual/personal level factors and acceptance of rural posting .....................61 
5.3 Institutional/organisational factors and acceptance of rural posting ..................64 
5.4 Contextual/socio-socio-cultural factors and acceptance of rural posting ...........67 
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5.5 Experiences of those who accepted the rural posting ........................................69 
5.6 Summary ............................................................................................................70 
CHAPTER SIX ............................................................................................................ 73 
CONCLUSIONS AND RECOMMENDATIONS ...................................................... 73 
6.0 Conclusion ..........................................................................................................73 
6.1 Recommendations ..............................................................................................74 
REFERENCES ............................................................................................................ 75 
APPENDIX A .............................................................................................................. 80 
QUESTIONNAIRE ..................................................................................................... 80 
APPENDIX B .............................................................................................................. 87 
Focus group discussion guide ...................................................................................... 87 
APPENDIX C .............................................................................................................. 90 
Consent form for Focus group discussion guide.......................................................... 90 
APPENDIX D .............................................................................................................. 93 
Consent form for self-administered questionnaire ....................................................... 93 
APPENDIX F............................................................................................................... 96 
Human Resource GAP Analysis .................................................................................. 96 
APPENDIX F............................................................................................................... 99 
Ethical Approval letter ................................................................................................. 99 
 
  
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LIST OF TABLES 
Table 1: Factors Influencing Acceptance of Rural Posting ........................................... 9 
Table 2: Health System Interventions to Improve Acceptance of Rural Posting ........ 29 
Table 3: Five-year Trend of Healthcare Staffing Situation in Krachi West District ... 33 
Table 4: Study Variables .............................................................................................. 34 
Table 5: Willing Acceptance of Rural Posting by Socio-demographic Characteristics
...................................................................................................................................... 48 
Table 6: Willing Acceptance of Rural Posting by Individual-level Factors ................ 49 
Table 7: Willing Acceptance of Rural Posting by Organisational/institutional Factors
...................................................................................................................................... 50 
Table 8: Willing Acceptance of Rural Posting by Contextual/Socio-cultural Factors 52 
Table 9: Bivariate and Multiple Logistic Regression of Factors Associated with 
Acceptance of Rural Posting to Krachi West District ................................................. 54 
 
 
 
 
 
 
 
 
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LIST OF FIGURES 
Figure 1. Conceptual framework of factors influencing acceptance of rural posting. ... 7 
Figure 2. Maslow's hierarchy of needs. ....................................................................... 18 
Figure 3. A histogram showing percent distribution of healthcare staff in Krachi West 
District by professional category ................................................................................. 47 
 
 
 
 
 
 
 
 
 
 
 
 
 
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LIST OF ABBREVIATIONS 
CHN   Community Health Nurse 
CHO   Community health Officer 
CHPS   Community-based Health Planning and Services 
DCE   District Chief Executive 
DHD   District Health Directorate 
DHMT  District Health Management Team 
FGD   Focus Group Discussion 
GHS   Ghana Health Service 
IDI   In-Depth Interview 
KWDH  Krachi West District Hospital 
MDG   Millennium Development Goals 
MOH   Ministry of Health 
SDG   Sustainable Development Goals 
TBA   Traditional Birth Attendant 
WHO   World Health Organisation 
GSS                            Ghana Statistical Service 
 
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CHAPTER ONE 
INTRODUCTION 
1.0 Introduction 
This chapter presents a brief introduction to the study on the factors influencing 
acceptance of rural posting. It provides a background to the study, presents the 
problem statement and study objectives, the significance of the study as well as the 
conceptual framework for conducting the study.  
1.1 Background 
Human resources are an important asset to organisations in terms of the realisation of 
their strategic goals (Baker, Hassan, Hanson, Manzi3, Marchant, Peterson and 
Hylander, 2017). High quality and adequate human resources in their right mix 
provide a competitive advantage for most organisations, and the health service is no 
exception.(Sen, Choudhary, 2014) stated that the basis of a competitive organisation 
is a satisfied, highly motivated and loyal employees. Indeed, the health sector is one 
sector that relies heavily on human resources despite the advancement in technology.  
Access to quality healthcare depends largely on the availability of qualified and 
adequate healthcare workers (Baker et al., 2017). Unfortunately for most people living 
in rural communities, access to quality healthcare remains a mirage. This is largely 
because most healthcare workers prefer to work in Urban and peri-urban communities 
to the detriment of those living in rural communities.  
Half the population of the world live in rural and remote areas and are served by less 
than a quarter of the world’s doctors, and about a third of the world’s population of 
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nurses (WHO, 2010). The situation is similar in both developed and developing 
countries but worse in developing countries (Hoyler, Finlayson, McClain, Meara, & 
Hagander, 2014). For example, the United Kingdom (UK) is plagued with inequity in 
the distribution of healthcare staff (Chapman, Congdon, Shaw, & Carter, 2005), in 
like manner, countries like United States of America, Canada, Australia and Japan 
also have issues in respect of equitable distribution of healthcare workers (Mobaraki, 
Hassani, Kashkalani, & Khalilnejad, 2013). 
 The situation is worse in developing and middle-income countries because resources 
are scarce and incentives are unavailable to attract these staff to the rural areas. 
According to Buchan et al. (2013), the uneven placement of health workers on the 
basis of rural and urban areas is a major policy concern for all countries, Ghana 
inclusive. 
 In Ghana, more than 65% of the population live in the rural areas and managed by 
about 15% of the country’s doctors who work in the districts (Africa Health 
Workforce Observatory, 2011). According to Ghana’s Ministry of Health, for the year 
2016, the best Doctor-patient ratio of 1:3518 was attained in Greater Accra that hosts 
the country’s capital while the worst ratio of 1:24,985 was attained by Upper East 
Region (MOH, 2017). This is because of difficulty in distributing healthcare workers 
equitably. The skewed distribution of healthcare staff positively towards urban areas 
is observed at all levels from national, regional and district levels. 
A similar picture observed with the urban-rural divide in terms of inequitable 
distribution of healthcare staff is observed also between the developed and developing 
country. It is estimated that about 3% of the world’s health workers take care of the 
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needs of WHO Africa region which has about 24% of the global disease burden. In 
contrast, the WHO region of the Americas with only 10% of the global disease burden 
rather has more than a third (37%) of the world’s health workers (Grobler et al., 
2009). 
1.2 Problem statement 
Krachi West District is a rural peninsula located in the Northern most part of the 
Volta Region with a population of about sixty thousand (60,000) people according to 
projections from the 2010 population census conducted by the statistical service: thus, 
travelling to Krachi for most parts involves crossing one water body or the other.  
The distance and location of the district coupled with a lack of basic amenities and 
difficult access have made the place unattractive to most health workers who consider 
postings to the district as punishment. This has led to an acute shortage of critical 
health care staff of all cadres in the district for a long period of time. In 2009, the 
Krachi West District Hospital had only one retired medical doctor whose contract 
with the Ministry of Health had expired after a number of renewals and so was being 
paid from internally generated funds of the hospital. The hospital had no substantive 
health services administrator, no Nurse Manager and no Pharmacist who constitute 
the core management team of the hospital by policy. Thus, the entire management 
team of the hospital was made up of temporal staff reflecting the acute shortage of the 
needed manpower to manage the hospital. The staffing situation in respect of nurses 
was worse than that of the management team. The nominal roll of the 120-bed 
capacity District hospital at the time indicated that they had very few nurses 
numbering twenty-two (22) including six (6) midwives; hence at some difficult times, 
ward assistants worked as nurses without any supervision. The hospital had only one 
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laboratory technician, and no health information officer or biostatistician(Krachi West 
District Hospital, 2010). After the year 2010 when a pharmacist accepted posting to 
the facility, three other pharmacists posted in successive years either refused the 
posting or changed their mind upon reporting to the facility and realising the 
conditions in the district. 
In 2016 two graduate general nurses were posted to Krachi and none of them 
reported. In 2017, eight registered general midwives were posted to the district; out of 
this only four of them reported representing just fifty percent (50%) of those posted 
rd
(Krachi West District 2017 3  Quarter Review Report).  
The inadequate number of qualified staff has resulted in a high work load for the few 
workers who are available. The increased workload coupled with the lack of 
appropriate incentive schemes has led to a state of demotivation for the staff. A 
number of health indicators for the district like stillbirth rate, neonatal mortality and 
under-five mortality remain unimpressive. The inadequate numbers of critical staff 
also resulted in a situation where the district has to employ temporal and casual staff 
and pay them from internally generated funds putting a huge financial burden on the 
district’s already bad finances. This research, therefore, seeks to investigate the 
factors influencing the acceptance of rural posting to Krachi West District. 
Most works that have been done have largely focussed on students in final year and 
interns with the aim to see what will make them accept rural postings (Daniels-Felix, 
Conradie, & Voss, 2015; Nallala, Swain, Das, Kasam, & Pati, 2015; Shannon & 
Jackson, 2011). However, there is paucity of data on work done on staffs who have 
actually accepted rural posting and seeking to understand what factors made them 
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accept their postings. Thus, for those who reported and have stayed in Krachi, it is 
important to investigate what made them accept the posting, how they felt when they 
were posted, what went through their mind when they received the news of their 
being posted to Krachi, what eventually made them decide to accept the posting and 
finally whether they accepted willingly or under compulsion. Answers to these 
questions may provide a useful basis for designing programmes that focus on what 
actually works and that could encourage more people to come and work in Krachi.  
1.3 Study objectives 
1.3.1 General objective. 
The general objective of this study was to determine the factors that affect acceptance 
of rural posting by health workers.  
1.3.2 Specific objectives. 
The specific objectives of this study were: 
1. To determine the proportion of health workers posted to Krachi West District who 
accepted the posting willingly 
2. To determine factors influencing acceptance of rural posting. 
3. To explore the experiences of persons who accepted posting to Krachi West 
District 
1.4 Research questions 
The study sought answers to the following research questions:  
1. What proportion of health workers accepted posting to Krachi West District 
willingly? 
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2. What individual/personal, institutional/organisational and contextual/socio-
cultural factors influence the decision of healthcare staff to accept rural posting? 
3. What were the experiences of those who accepted posting to Krachi West District 
when they were posted and what were the factors/events that tipped their decision 
in favour of accepting the posting? 
1.5 Significance of the study 
The information gathered from this work could be useful to policymakers as they 
design programmes to bridge the rural-urban gap in healthcare staff distribution. It 
could also provide useful information to the District Assembly as they work to attract 
and retain more critical healthcare staff to the district. The management of the Krachi 
West District can also use the findings from this study to improve on the attraction 
and retention of posted healthcare staff to the district by focussing on the factors that 
influence staff to accept posting to Krachi. Hospitals and health directorates in similar 
positions could draw on the lessons from Krachi West in addition to their peculiar 
circumstances to improve on the attraction and retention of staff to their district. 
Additionally, the findings will add up to data on the subject and make room for 
further studies 
1.6 Conceptual Framework for factors influencing acceptance of rural 
posting by healthcare staff 
The WHO (2010) identified six factors that relate to decisions to stay or live in rural 
areas as well as relocate or accept rural posting which are personal origin and values, 
family and community aspects, working and living conditions, career-related factors, 
financial aspects, and bonding or mandatory service. This forms the key factors 
influencing the decision of staff to accept rural posting. However, the response of the 
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health system to these factors work in concert to make these factors deciders in the 
acceptance of rural posting. The interplay of these two broad factors has been further 
categorised by Ramani, Rao, Ryan, Vujicic, & Berman (2013) into Individual factors, 
Organisational or Institutional factors, and Contextual or Socio-cultural factors. This 
forms the basis of the conceptual framework for this study as shown in Figure 1. 
 
Figure 1. Conceptual framework of factors influencing acceptance of rural posting. 
 Adapted from “For more than love or money: attitudes of student and in-service 
health workers towards rural service in India” by Sudha Ramani, Krishna D Rao, 
Mandy Ryan, Marko Vujicic and Peter Berman 2013, Human Resources for Health 
2013, 11:58 doi:10.1186/1478-4491-11-58, © 2013 Ramani et al.  
 
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The conceptual framework identifies three broad categories of factors influencing 
acceptance of rural posting. These are individual, institutional/organisational and 
contextual/socio-cultural factors. Each of these broad groups of factors affects and 
influences each other and ultimately influences the acceptance of rural posting. 
Details of the factors under these three broad categories of factors are shown in Table 
1. A combination of all three factors (individual, institutional and socio-cultural) more 
strongly favours acceptance of rural posting than any one of them taken in isolation. 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
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Table 1: Factors Influencing Acceptance of Rural Posting  
Individual Organizational Contextual 
 Age  Financial attributes  Living facilities (housing, 
 Gender  Salary electricity, water, access to 
 Marital status  Facilities market, hygiene) 
 Need for  Clinic infrastructure (drugs,  Proximity to family (near 
respect/self- equipment, laboratories, hometown) 
esteem ambulance)  Children’s development 
(recognition  Physical work environment (availability of good 
of work, (cleanliness, availability of water, schooling, extra activities, 
sense of electricity, toilets, good furniture, future opportunities) 
fulfillment, good construction, private cabins)  Family’s well-being and 
the prestige  Support staff (helping hands for comfort (spouse job 
of the job) working) availability, spouse career 
 Personal  Mentoring staff (for advising and growth, support to parents) 
attitude guiding)  Safety (physical security, 
towards rural  Workload (fixed working hours, legal protection against 
work shift systems, adequate number of political interference) 
 Familiarity patients)  Connectivity (transport 
with a rural  Organizational policies and management availability, no sense of 
context  Transfer policies and promotions isolation) 
 (transparent policy, time of service  Social life (entertainment 
in rural areas clearly stated, no facilities, social circle) 
political interference in transfers)  Community type (comfort 
 Job security (permanency of job, and connect with the 
pensions) community, no language 
 Regulatory policies to regulate barriers) 
absenteeism, punctuality of staff) 
 Policies on leave (ability to take 
leave when required, especially 
emergency) 
 Management (administration, 
bureaucracy) 
 Career growth opportunities 
 Learning opportunities on the job 
 Training opportunities 
 Research opportunities 
 Postgraduate opportunities 
 
Note. Adapted from “Differences in preferences for rural job postings between 
nursing students and practicing nurses: evidence from a discrete choice experiment in 
Lao People’s Democratic Republic”. (Rockers et al., 2013)  Human Resources for 
Health 2013 11:22.  
 
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1.7 Summary 
The issue of maldistribution of health workers along rural-urban divide is a major 
policy issue confronting health system managers. The situation is prevalent in both 
developed and developing countries but worse in the developing countries including 
Ghana because of the lack of resources and the absence of strong health systems and 
institutions.  
Krachi West District is one of the rural hard to reach districts in the Northern part of 
the Volta region. The district has inadequate numbers of staff due to health workers’ 
refusal to accept posting to the district. The inadequate numbers have led to increased 
workload and demotivation of the few staff with its attendant negative impact on 
healthcare indicators. It has also led to the district relying on temporal staff who are 
paid from internally generated funds thus putting a strain on the scarce financial 
resources of the district. 
This study, therefore, sought to investigate the proportion of health workers willingly 
accepting rural posting to the district, determine the factors influencing acceptance of 
rural posting to the district and also explore the experiences of those posted. It is 
hoped that the findings will lead to policy decisions that will improve acceptance of 
rural posting to the Krachi West District. 
 
 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0 Introduction  
This chapter presents a review of the literature on the important role of the health 
workforce in delivering quality healthcare and improving on health outcomes, the 
problem of maldistribution of health workers along rural-urban divide, the underlying 
theories of motivation explaining why this is the case, and also the general factors 
identified as influencing the acceptance of rural posting. The review ended by looking 
at efforts that have been made in several areas in an attempt to address this problem of 
healthcare staff maldistribution along rural-urban divide.  
2.1 Important role of the health workforce in healthcare delivery 
Quality healthcare is a product of a mix of inputs including health workforce, 
medicines and technology, governance, quality data and information, appropriate 
financing among many others (WHO, 2010). The most crucial of these inputs remains 
the health workforce as they determine the success or failure of any of the other inputs 
of the health system. The availability of adequate, well-trained healthcare staff is a 
crucial requirement for the delivery of quality healthcare, and especially so in the 
operation of an effective primary healthcare system (Lawan, Amole, & Khayi, 2017).   
World Health Organisation, (2010) has stated that ‘A strong human infrastructure is 
fundamental to closing today’s gap between health promise and health reality, and 
anticipating the health challenges of the 21st century’. 
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This human infrastructure must not only be available but must be adequate, and in the 
right mix in terms of cadre and calibre to ensure effective functioning and growth of 
the health system (Gupta & Dal Poz, 2009). The value of human resources in the 
effective functioning of any organisation especially in the service industry is not in 
doubt. 
The positive impact of adequate numbers of health workers on health outcomes such 
as mortality, coverage of immunisation or skilled birth attendants has been amply 
demonstrated in several studies (Castillo-Laborde, 2011; Anand and Bärnighausen, 
2004) found that in addition to other factors, the density of healthcare staff is 
important in accounting for the variation in health indicators such as maternal 
mortality, infant mortality and under-five mortality across countries. They explained 
that this effect is more pronounced in reducing maternal mortality than child mortality 
probably because higher levels of skills may be required to address the disease 
conditions that cause the death of children compared with mothers. Others have also 
demonstrated that the density of health workers especially physicians is negatively 
correlated with disability adjusted years: an increase of one unit in density of health 
workers per 1000 population will decrease on average the total burden of disease 
between 1% and 3%. Therefore increasing the health workforce density will lead to an 
appreciable reduction in the burden of disease, in particular, communicable diseases 
(Castillo-Laborde, 2011).   
There is no controversy that the availability of adequate numbers of healthcare 
professionals often translates to better health outcomes of the population. However in 
most parts of the world especially the developing countries, there is a mismatch 
between the demand and supply of health workers (Lehmann, Dieleman, & 
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Martineau, 2008). The problem of shortage of healthcare workers is in part due to 
inadequate production or training of the health workforce and also due to the 
maldistribution of available numbers (WHO 2010). 
2.2 Maldistribution of health workforce  
 According to Mobaraki et al., (2013), the problem of maldistribution of healthcare 
workers continue to be a major policy issue for health system managers. In most parts 
of the world, the distribution of healthcare professionals along rural and urban 
communities remains largely skewed in favour of urban communities. Available data 
show that most health workers prefer to work in urban and peri-urban communities as 
compared with rural and remote areas (Goel et al., 2016; Buchan et al., 2013; 
Mobaraki et al., 2013).  
According to the WHO (2010), half the population of the world lives in rural and 
remote areas yet they have access to just about 25% of the World’s doctors and less 
than 33% of the world’s nurses. In Ghana, according to the 2010 census conducted by 
the Ghana statistical services (GSS), more than 65% of the population live in the rural 
areas and managed by about 15% of the country’s doctors who work in the Districts 
(Africa Health Workforce Observatory, 2011). In the 2016 Holistic assessment of the 
health sector by the Ministry of Health, released in 2017, the best doctor-patient ratio 
of 1:3518 was attained in Greater Accra that hosts the country’s capital while the 
worst ratio of 1: 24,985 was attained by Upper East Region. The three worst regions 
in terms of the doctor-population ratio were Western Region with 1: 20,275, Volta 
region where Krachi West District is located recording a ratio of 1: 19,434 and Upper 
East Region as noted above. The situation is slightly different when it comes to nurse-
population ratio. The best nurse-population ratio was obtained by Upper East of 1:500 
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while the worst was recorded by the Northern region of 1: 1,033. This is largely due 
to the policy of retaining all nurses to work in the regions where they are trained. The 
Upper East region being one of the least populated regions in the country benefitted 
largely from this policy as the numbers trained by the nursing training colleges were 
retained to work in the region. 
2.3 Theories of motivation  
Inequities in the distribution of health workers remain a major policy issue for most 
health managers globally (Purohit & Martineau, 2016; Lehmann, Dieleman, & 
Martineau, 2008). At the heart of the uneven distribution of healthcare workers along 
rural-urban divide is the issue of human motivations and needs which if understood 
and addressed can lead to improved numbers in the rural areas (Prytherch et al., 
2013). Motivation is defined as ‘the psychological processes that cause the arousal, 
direction, and persistence of voluntary actions that are goal oriented’ (Mitchell, 1982). 
Robbins (1993) on the other hand defines motivation as the ‘willingness to exert high 
levels of effort toward organisational goals, conditioned by the effort’s ability to 
satisfy some individual need’. The definition proffered by Mitchell, (1982), indicates 
that there are processes in the psyche of individuals that cause them to do what they 
do and not to do. Thus, if these processes can be uncovered in terms of how they drive 
actions, it can inform policy decisions in a manner that can positively influence the 
acceptance of rural posting. Additionally, it can be deduced from the definition 
offered by Robbins (1993) that individuals have needs that drive them to take 
decisions aimed at meeting those needs. Thus, understanding what these needs are, 
can lead to efforts being made through policy to either meet these needs directly by 
managers or provide opportunities for those needs to be met by the staff themselves. 
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Ramlall (2004) indicates that though most theorists differ in terms of the specific 
needs that individuals seek to meet or where the energy to do what is required is 
derived from, one thing they agree on is that motivation requires a desire to act, and 
also have an objective. This write-up will focus on four motivational theories out of 
the many theories out there. The four theories are chosen based on Kreitner & Kinicki 
(1998) position that there are about five ways of explaining behaviour: needs, 
reinforcement, cognition, job characteristics, and feelings/emotions. These five ways 
which form the basis of modern theories of human motivation are adequately covered 
by the chosen four theories which are the Need theory, equity theory, expectancy 
theory, and job design model. 
2.3.1 Need motivational theories. 
Need motivational theories postulate that there are internal factors that energize 
behaviour and these internal factors can be influenced by external environmental 
factors. These internal factors or needs in humans change over time and place. The 
key theories here include Maslow’s hierarchy of needs theory and McClelland’s need 
theory.   
Maslow (1943) postulated that individuals have needs in five levels/hierarchy namely, 
physiological, safety, social, ego and self-actualizing. Maslow’s hierarchy of needs is 
often represented in the form of a pyramid with a bottom which is the broadest 
representing most of the fundamental needs of individuals while the top which is the 
narrowest represents the need for self-actualization and transcendence. He believed 
that in order for motivation to occur at any level, the needs of the preceding level 
must be satisfied first within the individual.  
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The first step in internal motivation is the physiological need, which needs include 
homeostasis, food, water, sleep, shelter, sex, etc. These needs represent the most basic 
needs of all human’s and if they are not met an individual is unlikely to desire the 
other needs at the higher levels in the model. An individual who is able to meet his 
physiological needs will next think of meeting his safety needs 
The need for safety assumes dominance in an individual’s life once his or her 
physiological needs have been met. These needs include personal, emotional and 
financial security, health and wellbeing as well as safety needs against accidents and 
their adverse impacts. These needs manifest in the form of job security, operation of 
savings accounts, taking insurance policies, need for well-outlined grievance 
procedures for protection from an unbalanced authority, disability accommodation 
among many others. According to Maslow, once these needs are also met, then social 
needs emerge. 
The need for belongingness is the next level of need to be met after safety needs. 
These needs will come in the form of friendship, intimacy and family belongingness. 
It is his view that all humans need to feel a sense of belonging and acceptance among 
varying social groupings such as professional groups, co-workers, online communities 
among others. In the absence of these, an individual may become prone to emotional 
disorders such as depression, anxiety, and loneliness.  Meeting these needs will lead 
to individuals now desiring the need for self-esteem.  
The needs for esteem or need for one’s ego, according to Maslow follows after 
meeting social needs where individuals suddenly become concerned about receiving 
respect, status, importance, and recognition from others. These needs if met offer the 
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individual a sense of value or contribution. The lack of this may lead to an inferiority 
complex and could manifest in the individual actively depending on approval from 
others or feel the need to seek for fame or glory. This can worsen the individual’s 
self-esteem unless the individual internally accept who he/she is and is proud of it.  
Self-actualization occupies the peak of the needs of individuals according to Maslow. 
At this stage, the individual feels the need to fulfil his full potential and this will often 
manifest after an individual not only meet the needs of the lower levels of the pyramid 
but also master them. This may take the form of being the best in parenting or mate 
acquisition, utilizing one’s abilities, or simply seeking happiness. A later revision of 
his theory led to the introduction of a higher stage called transcendence, where the 
needs of the individual focus on things whose benefits go beyond oneself such as 
spirituality and or altruism. 
As amply demonstrated in Maslow’s hierarchy of needs, the satisfaction or the 
meeting of one need only leads to the desire for another need considered to be higher 
in the hierarchy as shown in Figure 2. This means that policymakers need to realise 
that one intervention is not enough to attract and retain staff to work in rural areas, as 
the needs of the health worker will continue changing. Meaning, interventions must 
be regularly reviewed and updated to remain relevant. Maslow (1943) posits that on 
average, most humans are partially satisfied and partially unsatisfied in all of one’s 
needs/wants. It means that managers and policymakers should recognize this and 
design programmes or make policies that create the environment for health workers to 
achieve their fullest potential. Indeed, the creation of the environment for workers to 
realise their full potential fits into the organisational or institutional factors that 
influence the acceptance of rural postings such as availability of mentors, and 
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opportunities for postgraduate/ further training. Failure to provide a conducive 
environment for self-actualization theoretically can lead to poor performance, 
demotivation and high turnover rate of staff (Ramlall, 2004). 
 
Figure 2. Maslow's hierarchy of needs. Motivation and Personality, by Abraham H. 
Maslow, 1954. Copyright © 1954 by Harper & Row, Publishers, Inc.  
  
McClelland (1961) on the other hand theorised focusing on three needs: power, 
achievement, and affiliation.  In his view, there are people who have a strong desire to 
succeed and often strive for personal achievement and not necessarily the rewards of 
such success. He defines the need for power as the need to make others behave in a 
way that they would not have under normal circumstances. On the need for affiliation, 
he says it’s the desire for close interpersonal and friendly relationships. The need for 
achievement on the other hand he indicates is the drive to excel or to achieve in 
relation to set standards. Kreitner & Kinicki (1998) emphasizes the importance of the 
need for achievement in motivation when he stated that motivation and performance 
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vary according to the strength of one’s need for achievement. This theory explains 
some of the personal factors influencing acceptance of rural postings such as the 
desire for self-esteem or respect. 
2.3.2 Equity theory. 
The equity theory holds the view that people develop beliefs about what constitutes a 
fair and equitable contribution to their jobs, that people tend to compare what they 
receive to be the result of their engagement with employers and that if they perceive 
that what they get for their efforts is not fair, relative to what others get, then they will 
be motivated to take actions they deem appropriate (Robbins, 1993). Thus while the 
need theory says that people have needs and therefore strive to have those needs, the 
equity theory on the other hand says that meeting one’s need alone is not enough and 
that even when one’s need is met as expected but the individual believes what he got 
was not fair relative to what others obtained, he may not be satisfied and that will 
motivate him to take other actions he or she deems appropriate. This thinking 
underscores the proposition to make moving to rural or remote areas worth the effort. 
People or health workers must feel satisfied that for the sacrifices they make by 
accepting posting to these areas, what they get in return is worth it relative to what 
their colleagues in urban areas get. 
2.3.3 Expectancy theory.  
Expectancy theory states that motivation is a combined function of the individual’s 
perception that effort will lead to performance and of the perceived desirability of 
outcomes that may result from the performance (Steers & Lyman, 1983). In practical 
terms, people act based on expectations of some favourable outcomes and how 
valuable those outcomes are. The higher the value of the outcome that is expected the 
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greater the motivation to act (Chen & Fang, 2008). Two theories are relevant in 
expectancy theory; these are Vroom’s Original Theory and Porter and Lawler’s 
extension. 
Vroom’s theory states that ‘choices made by a person among alternative courses of 
action are lawfully related to psychological events occurring contemporaneously with 
the behaviours’ (Vroom, 1964, p.15). In simple terms, the way people behave is a 
result of choices they make consciously from among a list of alternatives, based on 
their beliefs and attitudes (Pinder, 1984). According to Vroom, there are three mental 
processes that direct behaviour: Valence, Instrumentality, and Expectancy. Valence 
for him refers to the emotional orientations or the value people place on expected 
outcomes. A positive valence means a desired outcome or a valued outcome. This has 
clear implications for policy decisions to attract and retain health workers to rural 
areas. The rewards for accepting rural posting must be seen as useful to motivate a 
staff to decide to accept the rural posting. These rewards may be financial or non-
financial.  Instrumentality by Vroom means the thought that if one performs well a 
valuable outcome will be obtained. Thus, the individual must believe that his positive 
efforts will yield a desirable result. This has a lot to do with reasons why most health 
workers will ask for clear cut written policies in respect to what will be the benefits of 
working in rural settings. Under organisational factors, one of the factors identified is 
the need for clear policies on promotions, transfers, etc. (Ramani et al., 2013). Finally, 
expectancy according to Vroom (1964) explains that expectancy defines the strength 
of one’s belief on the fact that higher or increased effort will lead to better 
performance. Thus people must think that the efforts will not be in vain.  
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Porter and Lawler extended Vroom’s expectancy theory where they sought to identify 
the source of peoples valence/expectations and also provide a link between their effort 
and performance and or satisfaction (Ramlall, 2004).  To them, ‘effort is viewed as a 
function of the perceived value of reward and the perceived effort–reward 
probability’. Thus the relationship between effort and performance is moderated by 
the employee’s ability, traits, and role perceptions. The greater the ability the greater 
the performance at a given effort (Ramlall, 2004).    
2.3.4 Job design. 
The last but not the least of the motivational theories underpinning the factors driving 
acceptance or otherwise of rural postings is the Job design model. This model or 
theory believes that the job to be done itself is key to employee motivation – thus a 
very challenging job is motivating while a boring or monotonous task demotivates 
(Ramlall, 2004). This explains the finding by Hoodless & Bourke, (2009) that 
enrolled nurses with a greater scope of work obtained greater work motivation than 
those with a narrower scope.  
In job design, there are two ways of adding variety and challenge that is job 
enrichment and job rotation. These two are explained by the Motivation-Hygiene 
theory and the job characteristics model. 
The above four theories of motivation explain the basis of the factors that influence 
the acceptance of rural postings. These factors which have been categorised as 
Individual, organisational and contextual/ Socio-cultural will be examined in a little 
more detail  
 
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2.4 Factors influencing acceptance or otherwise of rural posting 
There are a number of factors reported in the literature as influencing acceptance of 
rural posting ( Goel et al., 2016; Daniels-Felix et al., 2015; Nallala et al., 2015; 
Ramani et al., 2013; WHO 2010). World Health Organisation (2010) identified and 
grouped these factors into six broad categories namely personal origin and values, 
family and community aspects, working and living conditions, career-related factors, 
financial aspects, and bonding or mandatory service. These factors influence to 
varying degrees the intention of a health worker to accept posting to a rural area. The 
attitude and response of the health system to these factors work ultimately to 
determine whether a health worker will accept rural posting or not. Based on the 
factors identified by WHO and also the health system response to these factors, 
Ramani et al., (2013) further categorised the factors influencing acceptance of rural 
posting into individual-level factors, organisational- or institutional-level factors and 
contextual or socio-cultural factors. They argue that the decision-making process of 
accepting a rural posting is a complex phenomenon and requires a mix of 
interventions based on all these categories of factors in order to increase the chances 
of health workers accepting the rural posting.  
Individual-level characteristics have been reported by several writers as important in a 
health worker deciding to work in a rural area (Kizito, Baingana, Mugagga, Akera, & 
Sewankambo, 2017; Darkwa, Newman, Kawkab, & Chowdhury, 2016; Ramani et al., 
2013; Rockers et al., 2012). These factors include having lived in a rural area before, 
marital status, history of working in a rural area, the need for personal recognition or 
achievement, etc. Qualitative research was done by Mcmillan & Barrie, (2012) which 
found that students who have lived in a rural area before had three times stronger 
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commitment towards rural employment compared with their compatriots who are 
born and bred in the city. Similarly work done in nine countries across Africa and 
Asia found that students from low to middle-income countries who have spent 
significant time in rural areas are more likely to practice in rural areas; the longer the 
duration of rural experience or stay, the more likely they are to be committed to rural 
employment (Silvestri et al., 2014). In work done by Kizito et al., (2017) on 
undergraduate students’ decision to work in underserved areas in Uganda, they found 
that before community-based education, 44% of respondents expressed willingness to 
work in rural areas but after community-based education, the percentage rose to 
48.4%. A similar study that was done in Ghana by Amalba et al., (2016) also found 
that 60.9% and 67.8% of the students from towns and cities respectively said they 
were influenced by community-based education to be willing to work in rural areas. 
Apart from rural experience, most health workers who work in rural areas also are 
reported to do so because of their desire to be of help to the poor and humanity 
(Serneels et al., 2010). In a qualitative research by Prytherch et al. (2013) in three 
countries, most of the rural staff described being drawn to their job by a sense of 
vocation and also held the strong view that health work was honourable and a health 
worker would have to leave a positive legacy 
In addition to individual-level characteristics, there have been reported health system 
factors that determine whether a health worker will decide to work in a rural area or 
not (Rajbangshi, Nambiar, Choudhury, & Rao, 2017). These health system factors are 
sometimes called the pull factors and include issues such as the availability of 
financial incentives, good management practices by facility managers, opportunities 
for continuous professional development and progression, availability of mentorship 
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opportunities among many others (Rockers et al., 2013; Johnson et al., 2011). Johnson 
et al., (2011) found that for all health trainees in Uganda, job posting was strongly 
influenced by salary, facility quality, and manager support relative to other attributes. 
This emphasises the important role of the health system factors also in ensuring health 
workers decide to work in rural areas. 
Additionally, some researchers have also pointed out the importance of socio-cultural 
factors in the acceptance of rural posting. For some health workers, issues such as 
educational facilities for children, maintenance of more than one household if they 
have  to live away from their families, and the availability of decent accommodation 
in these areas are some of the considerations in deciding to accept to work in rural 
areas (Rajbangshi et al., 2017). An effective policy towards improving acceptance of 
rural posting must, therefore, take all of these factors into consideration. 
On the basis of what is known a number of health system interventions have been 
designed and implemented with varying results. These are examined in further detail 
below.  
2.5 Health system interventions to address the maldistribution of health workers 
along rural-urban divide. 
The WHO identifies four broad categories of interventions which in combination can 
be used to improve the attraction and retention of workers in remote and rural areas. 
These are Personal and professional support, financial incentives, regulation and last 
but not the least education (WHO, 2010). These four health system interventions will 
be briefly discussed in turns. 
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2.5.1 Education. 
One of the first places to look in designing interventions for improving the number of 
health workers in rural areas is education. Education forms the core of processes 
aimed at producing competent health workers. The methods and curricula used in 
training health workers can potentially influence their future practice location (WHO, 
2010). Thus, it is important to make conscious efforts to select the ‘right’ students in 
terms of those who are more likely to practice in remote and rural areas and also train 
them in such locations. Students who have a rural background (That is have lived in 
rural and remote environment before), trained in schools cited in rural areas, made to 
offer clinical rotations in rural areas, and trained with a curricula that reflect rural 
health issues are known to be more likely to work in remote or rural areas (Rockers et 
al., 2012). 
2.5.2 Financial incentives. 
One other intervention that is known to influence positively acceptance of rural 
posting is the availability of financial incentives, mainly salaries and allowances 
(Belaid, Dagenais, Moha, & Ridde, 2017; WHO, 2010). Financial incentives used in 
this context refers to all the extra benefits paid or provided to health workers to entice 
them to accept to work in remote and rural areas. These include monetary bonuses, in-
kind provisions like free accommodation and or vehicle, and other benefits that 
mitigate the opportunity costs associated with staying and working in deprived areas.  
The WHO recommends the use of a combination of fiscally sustainable financial 
incentives which must be sufficient enough to outweigh the opportunity cost of 
working in rural areas to attract and retain health workers in rural areas. This 
notwithstanding, available evidence from the literature suggests mixed results with 
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this intervention. For example in Niger, improved financial incentives increased the 
number of health workers opting for rural service including doctors, however the 
increase in numbers stagnated two years after the introduction of the intervention 
(Belaid et al., 2017; WHO, 2010). In Australia, it is reported that an incentive system 
aimed at improving staffing in rural areas succeeded in achieving as much as 65% 
retention rates of physicians after nearly half a decade of its introduction (Mason, 
2013). 
2.5.3 Regulatory interventions.  
Regulatory interventions refer largely to government control which finds expression 
through legal, legislative, administrative and or policy tools. Some of the regulatory 
interventions recommended by WHO include an enhanced scope of practice, training 
different types of health workers, the introduction of compulsory rural service and 
subsidized education in return for rural service (WHO, 2010).  In view of the shortage 
of the appropriate mix and calibre of health professionals in remote and rural areas, 
the few there often have to perform tasks far outside what they have been trained to 
do. In this case, regulations or decrees can be made to give legitimacy to the enhanced 
scope of service with the hope of increasing access to health care.  It has been 
suggested that this enhanced scope of practice can improve on job satisfaction of 
practitioners (Hoodless & Bourke, 2009), however, the extent to which this 
intervention can lead to increased retention and attraction is uncertain. Hoodless & 
Bourke, (2009) reported that in Australia, enrolled nurses who are allowed to 
prescribe reported higher levels of job satisfaction than their colleagues who are not 
allowed to prescribe. 
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One other regulatory practice is the use of a policy of compulsory rural service. This 
has been used by various countries. Frehywot, Mullan, Payne, & Ross (2010), reports 
as much as 70 countries have either used or are still using compulsory schemes to 
improve the availability of rural health workforce. The extent of success of these 
schemes in the long term is unclear because there is little data on the evaluation of 
these schemes to determine their medium to long term success but WHO, (2010), 
reported that after three decades of implementing compulsory rural service schemes in 
Thailand, about 50% of doctors in rural district hospitals are new graduates presumed 
to be completing their rural service.  
An additional regulatory intervention suggested by WHO is the introduction of 
different types of health workers with appropriate training and regulation for rural 
practice with the aim to increase the rural health workforce. In sub-Saharan Africa, it 
is documented that 25 out of 37 countries investigated were using non-physician 
clinicians. The advantage with this practice include but not limited to low training 
costs, reduced training duration and success in rural training (Frehywot et al., 2010), 
with significant potential for roles in the scale-up of health workforce. 
The last but not least regulatory intervention is the practice of introducing education 
subsidies and tying it to compulsory rural placements. This involves the provision of 
educational subsidies such as scholarships and bursaries with enforceable agreements 
of return of service in rural or remote areas to increase recruitment of health workers 
in these places (WHO, 2010). A systematic review conducted (Bärnighausen & 
Bloom, 2009), reported the retention rate from as low as 12% to as high as 90% and 
evaluated schemes from the USA, Canada, Japan, and a few other countries. However 
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WHO reports some serious methodological flaws in some of the articles included in 
this review and so cautioned over-reliance on the results (WHO, 2010).  
2.5.4 Professional and personal support. 
It is known that working in remote and rural areas often makes people feel isolated 
and neglected both professionally and personally (WHO, 2010). It is no wonder that a 
number of studies have reported the need for support as one of the requirements for 
accepting rural posting (Buchan et al., 2013; Mbaruku, Larson, Kimweri, & Kruk, 
2014; Ramani et al., 2013; WHO, 2010): on a personal level this includes issues such 
as good infrastructure, opportunities for social interaction, schooling for children, and 
employment for spouses among many others. Professionally, opportunities to advance 
careers and to communicate and consult with peers through networks, telehealth or 
other approaches are equally important for most health workers willing to work in 
deprived areas. However, it is worth noting that these interventions by themselves are 
not adequate and ought to be complemented with other interventions in order for them 
to yield the desired results (WHO, 2010). 
2.5.5 Putting it all together 
It is evident from the above review of available literature on health system 
interventions aimed at attracting and retaining health workers in rural and remote 
areas that no one intervention is sufficient in achieving success. Again, there is very 
little high-level evidence on the impact of these interventions on the availability of 
health workers in rural areas as most of the studies available are largely observational 
in design. However, in the absence of any large control trials involving the subject 
area, the available evidence from these studies will continue to provide guidance in 
the design of interventions for improving the numbers of health workers in remote 
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and rural areas. The summary of these health system interventions discussed is 
presented in Table 2. 
Table 2: Health System Interventions to Improve Acceptance of Rural Posting  
Category of intervention Examples 
 
 A1   Students from rural backgrounds 
 A2    Health professional schools outside of major 
A. Education cities 
A3    Clinical rotations in rural areas during studies 
A4    Curricula that reflect rural health issues 
A5    Continuous professional development for rural 
health workers 
 
 B1    Enhanced scope of practice  
 B2     Different types of health workers 
B. Regulatory B3    Compulsory service 
B4     Subsidized service 
 
C. Financial incentives C1    Appropriate financial incentives 
 
 D1    Better living conditions 
 D2    Safe supportive working environments 
D. Professional and personal D3    Outreach support 
support D4    Career development programmes 
D5    Professional networks 
D6    Public recognition measures 
Note. From “Increasing access to health workers in remote and rural areas through 
improved retention” by (WHO, 2010) 
 
2.6 Summary 
In summary, human resources remain one of the most important components of the 
health system building blocks. The inequity in the distribution of health workers to the 
disadvantage of rural areas is one of the key threats to the delivery of quality 
healthcare and the implementation of effective primary healthcare. There are varying 
factors influencing the uneven placement of healthcare staff ranging from individual-
level factors, health system factors as well as socio-cultural factors. At the core of 
these factors are the theories of human motivation which determine what health 
workers will do or not do.  A thorough understanding of these factors can form the 
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basis of effective policy formulation towards addressing the problem. The literature is 
replete with work that has been done to understand these factors believed to influence 
the acceptance of rural posting. However, most of the investigators have focussed 
their attention on health trainees often in their final years of training or internship 
seeking to find out what will make them accept to work in rural areas. Very few 
studies have focussed on health workers who have already accepted rural posting 
seeking to understand the factors that influenced their decision to accept to work in 
rural areas. The view is that since these workers have already accepted posting, 
focussing on them will reveal the real factors influencing acceptance of rural postings, 
and strengthening these factors will go a long way to improve on the acceptance of 
rural postings. 
 
 
 
 
 
 
 
 
 
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CHAPTER THREE 
METHODS 
3.0 Introduction  
This chapter presents the method section of the study and covers study design, study 
location, variables used in the study including their definition and how they were 
measured. It also covers the study population, methods of data collection, selection of 
participants, data collection techniques and tools/instruments, quality control in the 
study, data processing and analysis. It ends by looking at issues of ethical 
considerations, pretesting and review of study instruments/tools, limitations of the 
study and the generalizability of the research findings. 
3.1 Study design 
The study design is cross-sectional adopting both qualitative and quantitative 
approaches in data collection and analysis (mixed design).  
3.2 Study location 
Krachi  West District is one of the twenty-five (25) administrative districts in the Volta 
Region with its capital being Kete-Krachi. The District has a total population of about 
sixty-thousand (60,000) people. The district is located at the North-western part of the 
region; it is bordered to the East by Nkwanta South and Krachi East Districts, to the 
West by Sene District in Brong Ahafo Region, to the North by Krachi Nchumuru 
District and to the south by the Volta Lake. The District covers a land surface area of 
three thousand one hundred and thirty square kilometres (3,130sq.km) about one-third 
of the land surface covered by water bodies. The district is divided into four sub-
districts namely Denteh, Osramanae, and Ehiamankyene the Island sub-districts. It 
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comprises of twelve (12) health facilities (Eleven CHPS compounds) including the 
district hospital which serves as the major referral point to all the facilities within the 
district and to adjoining districts such as Krachi Nchumuru, Krachi East, Kpandai 
District in the North and Sene East Districts that do not have a District hospital. About 
forty-five percent (45.1%) of the communities are scattered along the banks of the 
lake and is only accessible by a boat. Fifty-four point nine per cent (54.9%) other 
communities are remotely located inland and are accessible by motorbikes and four-
wheel drive vehicles only. All these roads and paths are sometimes cut off during the 
rainy season. There are no tarred roads in the district except the district capital 
township road which itself is in a very deplorable state. This makes travelling within 
the district and accessing the district hospital difficult in emergencies. For most 
community members, they can only get a car to Kete-Krachi on Market days which is 
twice a week. 
The occupation of the inhabitants is mainly farming and fishing on a small scale basis. 
The district is considered one of the most deprived districts in the Volta region. The 
location of the district among water bodies means that travelling to the district will 
involve crossing a water body at one point or the other except if one is coming 
through the Northern Region. 
The Krachi West District was chosen for this study because it is considered one of the 
rural districts in the Volta Region. Postings to Krachi West District have been seen by 
most health workers as punishment or disincentive because of the difficulty in 
accessing the district and the distance from the urban areas of the region. This has led 
to inadequate numbers of critical healthcare staff as is reflected in the health worker- 
population ratios shown in table 3. 
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Table 3: Five-year Trend of Healthcare Staffing Situation in Krachi West District  
Indicator       Year   
 
2014 2015 2016 2017 
 District population                                 54,546 55,911 55,951 57,260 
No. of doctors 2 3 3 4 
Population to doctor ratio 1:27,273 1:18,637 1:18,650 1:19067 
Number of nurses 89 107 122 140 
Number of community health 10 10 10 13 
officers 
Population ratio to community 1:5455 1:5591 1:5595 1:5726 
health officers 
No of midwives 17 19 19 25 
Population to midwife ratio 1:3209 1:2943 1:2945 1:2290 
Note. Adapted from the annual reports of the Krachi West District Health Directorate 
for 2014 – 2017 
 
3.3 Variables 
The outcome variable for this study is the acceptance of rural posting by health 
worker whiles the independent variables are the individual, institutional and socio-
cultural factors that influenced the decision of staff to accept rural posting to Krachi 
West District. Details of these variables are shown in table 4.  
 These variables were selected following a comprehensive review of literature on staff 
motivation, attraction, and retention in the health sector.  
 
 
 
 
 
 
 
 
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Table 4: Study Variables  
Variables Description Measurement 
Dependent   
Acceptance of rural posting   For this study, this variable is Staff are asked whether they 
defined as staff accepting to accepted posting to Krachi 
work in Krachi willingly or Willingly or unwillingly 
unwillingly  
   
Independent Variable 
   
Personal factors 
Age Age at last birthday As stated by respondent 
Sex  Either male or female As stated by respondent 
Marital status Whether married, divorced or As stated by respondent 
single 
Need for self-respect/Self- Health worker satisfaction Extent of health worker 
esteem  derived from recognition for agreement or disagreement 
work done, sense of 
fulfilment, prestige of the job 
Familiarity with rural context Having lived or worked in a Extent of health worker 
rural community before agreement or disagreement 
Personal attitudes towards The attitude of the health Extent of health worker 
rural work worker to working in a rural agreement or disagreement 
setting 
   
   
Institutional/   
Organisational factors 
 Financial incentives  
Periodic Salary increase  Extent of health worker 
agreement or disagreement 
Rural allowance  Extent of health worker 
agreement or disagreement 
Rent allowance or free  Extent of health worker 
accommodation agreement or disagreement 
  Extent of health worker 
agreement or disagreement 
   
 Facilities  
Equipment Availability of resources and Extent of health worker 
medical equipment for agreement or disagreement 
service delivery 
 
 
 
   
 
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Variables Description Measurement 
   
Physical work environment Cleanliness of the work Extent of health worker 
environment, availability of agreement or disagreement 
potable water, electricity, 
toilets good furniture etc. 
 
Support staff Availability of helping hands Extent of health worker 
for work agreement or disagreement 
 
Mentoring (staff) Availability of mentors to Extent of health worker 
help in professional and agreement or disagreement 
personal development of staff  
 
Workload Health worker expectation of Extent of health worker 
the extent of workload agreement or disagreement 
   
   
   
 Organisational policies and  
management 
 
Transfer policy and Availability of a transparent Extent of health worker 
promotions  policy in terms of time in agreement or disagreement 
rural area clearly stated, no 
political interference in 
transfers  
 
Job security The level of permanency of Extent of health worker 
job, availability of pension agreement or disagreement 
schemes 
 
Policies on leave  Clearly outlined policy on Extent of health worker 
leave, ability to take leave agreement or disagreement 
when required especially in 
emergency conditions 
 
Management  Staff perception of quality of Extent of health worker 
management of the facilities agreement or disagreement 
in terms of administration, 
bureaucracy etc. 
   
   
 Career growth opportunities  
 
Learning opportunities on Availability of opportunities Extent of health worker 
the job to learn on the job  agreement or disagreement 
 
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Variables Description Measurement 
Training opportunities Availability of opportunities Extent of health worker 
to participate in training agreement or disagreement 
programmes in and out of the 
district 
 
Research opportunities  Availability of opportunities Extent of health worker 
to do research agreement or disagreement 
 
Postgraduate opportunities Availability of opportunities Extent of health worker 
and sponsorship for agreement or disagreement 
postgraduate studies and ease 
of release for postgraduate 
studies when required 
   
   
   
   
   
Contextual/ Socio-cultural   
factors 
 
Living facilities Availability of good housing, Extent of health worker 
electricity, water, access to agreement or disagreement 
market, hygiene etc 
 
Proximity to family Closeness or otherwise of the Extent of health worker 
district to hometown or agreement or disagreement 
where family lives 
 
Children’s development Availability of good schools, Extent of health worker 
extra-curricular activities, agreement or disagreement 
future opportunities 
 
Family’s well-being and Availability of job for Extent of health worker 
comfort spouse, spouse career growth agreement or disagreement 
opportunities, support to 
parents etc 
 
Safety/peace of mind  Staff perception of level of Extent of health worker 
physical security, legal agreement or disagreement 
protection against political 
interference 
 
Connectivity Transport availability with no Extent of health worker 
 sense of isolation agreement or disagreement 
  
 
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Variables Description Measurement 
Social life Availability of entertainment Extent of health worker 
facilities, social circle etc agreement or disagreement 
 
Community type Perceived level of attitude of Extent of health worker 
community members to agreement or disagreement 
health workers, comfort and 
level of connection to 
community with no 
communication barriers  
 
3.4 Study population 
The study population consisted of all health workers in the Krachi West District. This 
included Doctors, General Nurses, Enrolled nurses, Midwives, Ward Assistants, 
Community Health nurses, Dispensing technicians, Disease control officers, nutrition 
officers, et cetera.  
3.5 Data collection methods 
Data collection for this study was done by conducting Focus Group Discussions and 
the administration of structured questionnaires.  
3.5.1 Administration of questionnaires. 
A census was conducted. Two hundred and twenty-three (223) self-administered 
questionnaires were distributed to all staff at post in the district through their unit 
heads. The unit heads were trained or given orientation on the questionnaire to enable 
them coach staff working in their units to complete them and also assist them if they 
encounter any difficulties during the completion of the questionnaire. The completed 
questionnaires were collated by various unit heads and collected by the researcher and 
research assistants. Data entry was done into excel and exported to STATA 15 for 
analysis. 
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3.5.2 Focus group discussions (FDG). 
The researcher aimed to conduct a minimum of four and a maximum of eight Focus 
Group Discussions but five were held during this study. Additional FDGs were not 
conducted because saturation of the issues was reached. The groups involved in the 
FDGs were nurses, midwives, and prescribers (Physician Assistants). Three FDGs 
were conducted among the nurses, one among midwives and one among prescribers 
(Physician Assistants). The nursing group was stratified into Community Health 
Nurses, Enrolled Nurses and Registered General Nurses. Each of the groups was 
made up of 6-8 participants totalling 37 participants. The seating arrangement during 
the discussions was such that the participants were seated in a semi-circular fashion 
while the researcher and recorders were in the middle. For each question that was 
posed, each participant or discussant was allowed to make an input or contribute 
before another question was posed. On the average, each FDG took between 1-2 
hours.  
3.6 Selection of Participants 
3.6.1 Quantitative study. 
The study included all health workers at post in the Krachi West District during the 
period of the research. Each unit/facility head was given a number of questionnaires 
commensurate with the number of staff in each unit (Hospital) or facility as the case 
was. 
3.6.2 Qualitative study.  
The qualitative study included nurses, midwives, and prescribers (physician 
assistants). Purposive sampling was used in selecting participants for the FGDs. The 
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nursing group was stratified into Enrolled nurses, Community Health Nurses, and 
Registered General Nurses. The midwives and prescribers were not stratified. Each of 
the groups included males and females 
3.7 Data collection techniques and tools/instruments 
3.7.1 Questionnaires. 
A self-administered structured questionnaire was used in the quantitative data 
collection. The questionnaire had four sections: socio-demographic characteristics, 
individual level factors, institutional/organisational level factors and contextual/socio-
cultural factors. The sections on individual, institutional and contextual factors had 
several questions coded on a five-point Likert scale. There were five questions under 
individual-level factors, thirteen questions under the organisational factors, and ten 
questions under contextual/socio-cultural factors. 
3.7.2 Focus Group Discussions (FDG) Guide.  
FDG guide was the main tool used for the qualitative data collection in this study. The 
guide was designed in English and covered areas such as ground rules, experiences, 
and feeling of participants when they were posted to Krachi and what events or 
factors made them accept the posting finally. 
3.8 Quality Control  
The questionnaires and interview guides were designed in English and were pre-tested 
in two facilities in the Krachi Nchumuru district which is a neighbouring district 
carved out of the Krachi West District in 2012. The difficulties and defects found 
following the pre-testing were used to revise the questionnaire and the guides. The 
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final questionnaire was evaluated for validity as well as internal consistency. 
Cronbach’s alpha was used in checking for internal consistency. 
 Unit heads and three research assistants with a background in research were recruited 
and trained to assist in the effective collection of the data. The training touched on 
issues of confidentiality, professionalism and effective questioning among others. 
Written protocols and reference guides were provided these officers to use when the 
need arises during the data collection period. They were supervised to ensure that the 
data was collected as required.  
The collected data was saved in Google Drive (cloud storage) with adequate 
passwords and biometric fingerprint locks to ensure data security and prevent data 
loss. 
3.8.1 Training of interviewers. 
The principal investigator organised a training session for all interviewers and 
accompanied the interviewers to the field for the pretesting of the data collection 
tools. The observations and lessons learned during the pretesting were used to retrain 
the interviewers.  
3.9 Data Processing and Analysis 
3.9.1 Qualitative data processing. 
FDGs conducted were digitally recorded with prior consent of or permission from the 
participants.  The notes that were taken during the data collection were translated into 
data documents within twenty-four hours of their collection.  The transcriptions were 
done to ensure the identity of the respondents were not disclosed, numbers rather than 
names were used for the identity of the participants. 
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3.9.2 Qualitative data analysis 
The data analysis was done within the conceptual framework used for this study. A 
framework analysis here allowed the concepts developed to be included in the 
analysis. Additionally, emerging themes informed the refining of the conceptual 
framework at the same time. The full process of framework analysis was followed 
which includes, familiarisation, identification of a thematic framework, indexing, 
charting, mapping, and interpretation. These processes were followed in a to and fro 
manner until all the useful themes and patterns were obtained from the data for 
interpretation. This ensured that the final work output was grounded firmly in the 
data. Efforts were made to get an independent analyst to check the coding, 
relationships, categories and the matrix against the transcribed information from the 
data collected. This was for quality assurance purposes. 
3.9.3 Quantitative data processing 
The questionnaires administered were received and the various items checked to be 
sure each was answered by the respondents. The questionnaires were also checked to 
be sure they were correctly answered and where problems were identified the 
respondent was requested to address them. The questionnaires were numbered serially 
1 to 223 as they were received from the respondents. The responses on the 
questionnaire were coded and data entered into excel and exported to STATA 15 for 
analysis. Positive responses were coded 0 and negative responses were coded 1. 
3.9.4 Quantitative data analysis. 
The quantitative data were analysed in a different manner. First of all, there was a 
descriptive analysis of the socio-demographic data of the study population. There was 
also the use of chi-square, and cross-tabulations for the analysis of the data under each 
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of the variables under individual, institutional and contextual factors. This analysis 
tested whether there was any statistically significant association between the factors 
under the three broad categories above and acceptance of rural posting. Factors which 
were found to be significant statistically at the bivariate level using chi-square and 
Fisher’s exact tests were then used in a simple and multiple logistic regression model 
to determine the direction of their significance at the bivariate level and also 
determine if there was any statistically significant association between them and 
acceptance of rural posting after controlling for other relevant factors. The analysis 
and the interpretation of the data were carried out at 0.05 significance levels.  
3.10 Ethical consideration/issues 
3.10.1 Ethical clearance. 
Ethical clearance was sought from the Ghana Health Service Ethical Review 
Committee (Ethical review certificate number GHS-ERC: 151/12/17) to ensure that 
the study conformed to the full requirement of research using human subjects. It was 
only after the ethical clearance was obtained that the study was conducted  
3.10.2 Informed Consent.  
Informed consent was obtained both from institutional levels as well as the levels of 
the individual participants. Written consent was obtained from the Volta Regional 
Director of Health Services, the Krachi West District Director of Health Services and 
also the Medical Superintendent of the Krachi West District Hospital. Informed 
consent was also obtained from participants before they completed the questionnaire. 
In conducting the FGDs the participants were required to give written consent before 
participating in the discussions and interviews. They were made aware that at any 
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point during the process they can withdraw their consent if they deem it appropriate to 
do so without any form of coercion or compulsion from the research team. 
3.10.3 Confidentiality.   
The research team took steps to ensure confidentiality in respect of all study 
participants. Codes instead of names were used for the study participants. Their 
responses especially those digitally recorded were done using a technology that 
muffles the voices to ensure the participants could not be identified by their voices. 
All information about the study participants and their responses were strictly kept 
confidential, both for the quantitative and qualitative data collection. 
Participants were counselled similarly to keep responses of other colleagues simply 
within the confines of the discussions and advised not to disclose to third parties not 
present at the discussions or interviews 
3.10.4 Risks and discomfort. 
The research team did not encounter any discomfort or risk for study participants or 
others that were connected remotely to this study. That notwithstanding, participants 
were well informed that they can withdraw their consent and not continue to 
participate in the study without any consequences whatsoever. 
3.10.5 Benefits 
Generally, there was no personal compensation for the study participants, however, 
the District Health Directorate will benefit from the findings of the study in terms of 
what they could do and not do if they are to attract staff into the district. 
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3.11 Pretesting and review of instruments/tools 
The data collection tools made up of the questionnaire and FGD guides were pretested 
in Krachi Nchumuru district. This is a neighbouring district carved out of the Krachi 
West District in the year 2012. The deficiency detected during the pretesting was used 
to refine the tools. 
3.12 Limitations of the study 
This study was done interviewing staff who are working in a rural area. Interviewing 
them on the reasons for accepting posting may mean asking them to recall what 
happened at the time of their posting (recall bias). This has the tendency of affecting 
the quality of the information as a number may have forgotten exactly the issues that 
tipped their decisions in favour of accepting the rural posting. 
3.13 Generalizability of the research findings 
This study was conducted in one rural district and so the findings may not have 
generalizability in other rural places as the context may be different.  
3.14 Summary 
This was a cross-sectional analytical study which adopted both qualitative and 
quantitative approaches to data collection. The quantitative part of the study was done 
using self-administered structured questionnaires. The questionnaires were given to 
all health workers at post in the district. The questionnaire covered socio-demographic 
characteristics, individual, organisational and sociocultural factors influencing 
acceptance of rural posting. Descriptive statistics were performed and statistical 
significance of various factors and acceptance of rural posting was tested using Chi-
square and Fisher’s exact tests. Logistic regression was used to determine association 
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between the various factors and acceptance of rural posting to Krachi West. The 
qualitative part of the study involved conducting Focus Group Discussions. Five 
Focus Group Discussions were held, digitally recorded and transcribed verbatim. The 
qualitative data were analysed using framework analysis. Ethical clearance was also 
sought to ensure that the study conformed to all standards required for conducting 
human experiments. 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER FOUR 
RESULTS 
4.0 Introduction  
This chapter reports the quantitative and qualitative results of the study. The 
quantitative results are categorised into the proportion of health workers accepting 
rural posting to Krachi West District willingly, individual-level factors and 
acceptance of rural posting, institutional/organisational factors and acceptance of rural 
posting, and contextual factors and acceptance of rural posting. The qualitative result 
is presented under the experiences of persons who accepted posting to Krachi West 
District. 
4.1 Proportions of health workers who accepted posting to Krachi Willingly (by 
socio-demographic characteristics) 
As shown in Table 5, the proportion of health workers who accepted posting to 
Krachi West District willingly is 69.5% with 30.5% reporting accepting the posting 
unwillingly. Sixty-four point seven percent (64.7%) of those who willingly accepted 
posting to Krachi West District were males and the rest were females. About half 
(51.8%) of those who willingly accepted rural posting were married. In like manner 
47.5% of those who willingly accepted posting to Krachi West district had children. 
Seventy-four point eight percent (74.8%) of those who accepted posting to Krachi 
willingly were clinical staff made up of nurses, midwives, doctors, laboratory staff 
and pharmacy staff with the rest 25.2% being non-clinical staff (accounting staff, 
administrative staff, technical officers and others like labourers). Ask whether their 
residence was in the same town where they worked, 92.0 % reported living in the 
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same town as the facilities where they work; similarly, 92.1% of those who willingly 
accepted the posting reported living in the same town where their health facilities are 
located. 
In terms of the distribution of the study participants by socio-demographic 
characteristics, 57.5% of the health workers who participated in this study were nurses 
or midwives as shown in Figure 3, with all the other health workers altogether making 
up 42.5%. Almost two-thirds of the study participants were males. About half (52.0%) 
of health workers in the district are married and also 47.5% of them reported having 
children. Asked whether their residence is in the same town where they work, 92.5% 
reported living in the same town or village as the facilities in which they worked. 
These are shown in Table 5.  
50
40
30
20
10
0
Professional categories of health staff 
 
Figure 3. Percentage distribution of healthcare staff in Krachi West District by 
professional category  
 
The test of association between socio-demographic characteristics and acceptance of 
rural posting indicated that socio-demographic factors show no statistically significant 
association with acceptance of rural posting. These results are also shown in Table 5. 
 
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Table 5: Willing Acceptance of Rural Posting by Socio-demographic Characteristics  
  Acceptance of posting   
Variable Total Willingly Not Willingly Chi-square p-value 
N=200 N =139 (69.5) N=61 (30.5) value 
Sex      
     Male  122 (61.0) 90 (64.7) 32 (52.5) 2.6913 0.101 
     Female 78 (39.0) 49 (35.3) 29 (47.5)   
Professional      
categories 
     Clinical staff 155 (77.5) 104 (74.8) 51 (83.6) 1.877 0.171 
     Non-clinical staff 45 (22.5) 35 (25.2) 10 (16.4)   
Marital status      
     Married 104 (52.0) 72 (51.8) 32 (52.5) 0.0074 0.931 
     Single 96 (48.0) 67 (48.2) 29 (47.5)   
 
Religion     
ϯ
     Christian 185 (92.5) 127 (91.4) 58 (95.1) 0.8434  0.561 
     Others 15 (7.5) 12 (8.6) 3 (4.9)   
 
Children     
ϯ
  Children 95 (47.5)  71 (51.1) 24 (39.3) 2.9325  0.196 
  No children 104 (52.0) 67 (48.2) 37 (60.7)   
     Missing 1 (0.5) 1 (0.7) 0 (0.0)   
Residence       
     Within area 184 (92.0) 128 (92.1) 56 (91.8) 0.0046 0.946 
     Not within 16 (8.0) 11 (7.9) 5 (8.2)   
*= statistical significance       ϯ= Fisher’s exact value 
4.2 Individual-level factors and acceptance of rural posting  
In Table 6 the tests of association between individual-level characteristics and 
willingness to accept posting are shown. All but one variable showed significant 
associations from chi square or fisher’s exact tests. The influence of individuals such 
as regional officers, district officers, facility officers, family members and others 
(colleagues, religious leaders) did not have any significant association with whether or 
not a respondent was willing to accept the posting. On the other hand, factors such as 
living or working in a rural area in the past, having a sense of being appreciated by the 
community or patients in the rural area, having no difficulty in being posted to a rural 
area and having the perception that being single is the best time to work in a hard-to-
reach area were all significantly associated with willingness to accept posting. 
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Table 6: Willing Acceptance of Rural Posting by Individual-level Factors  
  Acceptance of posting   
Variable  Total Willing Not willing Chi-square p-value 
N (%) N =139 (69.5) N =61 (30.5) value 
Rural background      
     Disagree 110 (55.0) 65 (46.8) 45 (73.8) 12.4946 <0.001* 
     Agree  90 (45.0) 74 (53.2) 16 (26.2)   
Attitude to rural post      
     Disagree  92 (46.0) 41 (29.5) 51 (83.6) 49.9713 <0.001* 
     Agree  108 (54.0) 98 (70.5) 10 (16.4)   
Need for recognition      
     Disagree  108 (54.0) 65 (46.8) 43 (70.5) 9.6101 0.002* 
     Agree 92 (46.0) 74 (53.2) 18 (29.5)   
Marital status and      
acceptance 
     Disagree  132 (65.5) 80 (57.5) 51 (83.6) 12.7338 <0.001* 
     Agree  69 (34.5) 59 (42.5) 10 (16.4)   
Rural network      
     Disagree  140 (70.0) 86 (61.9) 54 (88.5) 14.3424 <0.001* 
     Agree 60 (30.0) 53 (38.1) 7 (11.5) 12  
 
Influential people     
ϯ
     Regional Officers 69 (34.5) 41 (29.5) 28 (45.9) 8.3164  0.084 
     District officers 12 (6.0) 9 (6.5) 3 (4.9)   
     Facility Officers 20 (10.0) 17 (12.2) 3 (4.9)   
     Family members 36 (18.0) 23 (16.6) 13 (21.3)   
     Others 63 (31.5) 49 (35.2) 14 (23.0)   
*= statistical significance. ϯ= Fisher’s exact value Rural background= lived in a rural area before so it wasn’t difficult to accept 
posting Krachi West District. Attitude to rural post= have no difficulty in being posted to a hard-to-reach area to work. Need for 
recognition= will be appreciated by patients and the community in Krachi. Marital status and acceptance= was single and felt it 
was the best time to work in a hard-to-reach area. Rural network= accepted posting to Krachi West District because of past work 
experience in a rural area.  Influential people= was influenced by certain people in making decision to accept posting. 
 
4.4 Organisational factors and acceptance of rural posting  
Thirteen questions were asked to measure the association between organisational or 
institutional factors and willingness to accept the posting. Two items in this set of 
questions were found to have a statistically significant association: the availability of 
good mentorship from senior colleagues and opportunities to learn and gather a lot of 
experience as shown in Table 7. 
 
 
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Table 7: Willing Acceptance of Rural Posting by Organisational/institutional Factors  
  Acceptance of posting   
Variable  Total Willing Not willing Chi-square p-value 
N =200 N =139 (69.5) N =61 (30.5) 
Financial incentives      
     Disagree  160 (80.0) 109 (78.4) 51 (83.6) 0.7135 0.398 
     Agree  40 (20.0) 30 (21.6) 10 (16.4)   
Cost of living      
     Disagree  101 (50.5) 71 (51.1) 30 (49.2) 0.0611 0.805 
     Agree 99 (49.5) 68 (48.9) 31 (50.8)   
Infrastructure      
     Disagree  163 (81.5) 110 (79.1) 53 (86.9) 1.6882 0.194 
    Agree  37 (18.5) 29 (20.9) 8 (13.1)   
Good mentorship      
     Disagree  143 (71.5) 92 (66.2) 51 ( 83.6) 6.313 0.012* 
     Agree 57 ( 28.5) 47 (33.8) 10 (16.4)   
Good management      
     Disagree  133 (66.5) 91 (65.5) 42 (68.9) 0.2180 0.641 
     Agree 67 (33.5) 48 (34.5) 19 (31.1)   
 
Low workload     
ϯ
     Disagree 187 (93.5) 128 (92.1) 59 (96.7) 1.4986  0.221 
     Agree 13 (6.5) 11 (7.9) 2 (3.3)   
Promised school       
     Disagree 105 (52.5) 78 (56.1) 27 (44.3) 2.3884 0.122 
     Agree 95 (47.5) 61 (43.9) 34 (55.7)   
Early promotion      
     Disagree 122 (61.0) 88 (63.3) 34 (55.7) 1.0216 0.312 
     Agree 78 (39.0) 51 (36.7) 27 (44.3)   
 
Only option      
ϯ
     Disagree 183 (91.5) 125 (89.9) 58 (95.1) 1.4479  0.282 
     Agree 17 (8.5) 14 (10.1) 3 (4.9)   
Integrity of      
management 
     Disagree 142 (71.0) 99 (71.2) 43 (70.5) 0.0110 0.916 
     Agree 58 (29.0) 40 (28.8) 18 (29.5)   
 
Opportunity to     
learn 
ϯ
     Disagree 54 (27.0) 30 (21.6) 24 (39.3) 7.0907  0.022* 
     Agree 145 (72.5) 108 (77.7) 37 (60.7)   
     Missing  1 (0.7) 0 (0) 1 (0.5)   
Positive influence      
from colleagues 
     Disagree 141 (70.5) 97 (69.8) 44 (72.1) 0.1123 0.738 
     Agree 59 (29.5) 42 (30.2) 17 (27.9)   
Sponsor studies      
     Disagree 140 (70.0) 97 (69.8) 43 (70.5) 0.0101 0.920 
     Agree 60 (30.0) 42 (30.2) 18 (29.5)   
*= statistical significance. ϯ= Fisher’s exact value    Financial incentives= accepted posting because of financial incentives like 
allowances. Cost of living= low cost of living in the Krachi West District and  make savings on accommodation, food, and other 
living conditions.    Infrastructure= heard or knew about good infrastructure in Krachi West District.    Good mentorship= get 
good mentorship from senior colleagues and officers.    Good management= heard of good management practices in the district.    
Low workload= accepted because the workload is not too much.  Promised school= was promised will be allowed to go to school 
on time.    Early promotion = will be promoted when the time is due.    Only option= there is no job where they have an  interest 
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in working.    Integrity of management= could trust the management on the promises made.    Opportunity to learn = there are 
opportunities to learn and gather a lot of experience    Positive influence from colleagues= colleagues spoke favourable of the 
place.    Sponsor studies= will be sponsored for postgraduate studies or further studies. 
4.5 Contextual/socio-cultural factors and acceptance of rural posting  
Measuring the association between contextual/ socio-cultural factors and willingness 
to accept posting, the nearness of the area to a respondent’s hometown was 
statistically significant. Also, the perception of the area as peaceful and quiet also 
showed significant associations. The availability of social or recreational amenities 
among other contextual and socio-cultural factors failed to show significant 
relationships. The details are as outlined in Table 8. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table 8: Willing Acceptance of Rural Posting by Contextual/Socio-cultural Factors  
  Acceptance of posting   
Variable  Total Willing Not willing Chi-square p-value 
N =200 N =139 (69.5) N =61 (30.5) 
Free accommodation      
     Disagree  125 (62.2) 92 (66.2) 33 (54.1) 2.6434 0.104 
     Agree  75 (37.5) 47 (33.8) 28 (45.9)   
Close to hometown      
     Disagree  167 (83.5) 111 (79.9) 56 (91.8) 4.3921 0.039* 
     Agree 33 (16.5) 28 (20.1) 5 (8.2)   
Freedom from family      
     Disagree  154 (77.0) 105 (75.5) 49 (80.3) 0.5489 0.459 
    Agree  46 (23.0) 34 (24.5) 12 (19.7)   
Availability of schools      
     Disagree  116 (58.0) 80 (57.5) 36 (59.0) 0.0372 0.847 
     Agree 84 (42.0) 59 (42.5) 25 (41.0)   
Spouse is near      
     Disagree  181 (90.5) 123 (88.5) 58 (95.1) 2.1433 0.143 
     Agree 19 (9.5) 16 (11.5) 3 (4.9)   
Peaceful environment      
     Disagree 143 (71.5) 90 (64.8) 53 (86.9) 10.1954 0.001* 
     Agree 57 (28.5) 49 (35.2) 8 (13.1)   
Social amenities      
     Disagree 137 (68.5) 92 (66.2) 45 (73.8) 1.1299 0.288 
     Agree 63 (31.5) 47 (33.8) 16 (26.2)   
Quiet environment      
     Disagree 133 (66.5) 86 (61.9) 47 (77.0) 7.3812 0.016* 
     Agree 66 (33.0) 53 (38.1) 13 (21.3)   
     Missing  1 (0.5) 0 (0) 1 (1.6)   
Recreational amenities      
     Disagree 85 (42.5) 63 (45.3) 22 (36.1) 1.4870 0.223 
     Agree 115 (57.5) 76 (54.7) 39 (63.9)   
Language barrier      
     Disagree 126 (63.0) 85 (61.1) 41 (67.2) 0.6684 0.414 
     Agree 74 (37.0) 54 (38.9) 20 (32.8)   
*= statistical significance       ϯ= Fisher’s exact value    Free accommodation= knowledge of free accommodation by hospital was 
an influence in accepting posting.    Close to hometown= accepted posting because it was close to hometown and family.    
Freedom from family= accepted posting because it was far from hometown and prevent relatives from bothering them.    
Availability of schools= availability of good schools and recreational facilities were an influence in accepting posting.    Spouse 
is near= spouse is working in the same district.    Peaceful environment= accepted posting because area is a peaceful place.    
Social amenities = accepted posting because of availability of social amenities like telephone network, electricity, water and 
television coverage.    Quiet environment= accepted posting because environment is quiet.    Recreational amenities= is bothered 
about lack of recreational or entertainment facilities.    Language barrier= accepted posting because there is no language barrier. 
 
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4.6 Simple and multiple logistic regression of factors associated with acceptance 
of posting  
Table 9 below shows the results of simple (bivariate) and multiple logistic regression 
analysis of factors associated with acceptance of rural posting. In this analysis, 
variables that were found to have a statistically significant association with rural 
posting at the bivariate level using chi-square/fishers’ exact tests were included in a 
simple logistic regression and then other factors adjusted for in a multiple logistic 
regression analysis. In the adjusted analysis all the factors failed to show any 
statistically significant association with acceptance of rural posting, except attitude to 
rural posting. Those who had a good attitude towards rural posting (they had no 
problem with being posted to a rural area) were 9.5 times at odds of accepting posting 
compared to those who did not (Adjusted Odds ratio 9.5, p-value <0.001).   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table 9: Bivariate and Multiple Logistic Regression of Factors Associated with 
Acceptance of Rural Posting to Krachi West District  
Predictor Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-value 
Rural background     
     Disagree 1 0.001* 1 0.988 
     Agree 3.20 (1.65 – 6.20)  0.99 (0.41 – 2.40)  
Attitude to rural post     
     Disagree 1 <0.001* 1 <0.001* 
     Agree  12.19 (5.65 – 26.32)  9.52 (3.95 – 22.91)  
Need for recognition     
     Disagree  1 0.002* 1 0.585 
     Agree  2.72 (1.43 – 5.17)  1.27 (0.53 – 3.04)  
Marital status and     
acceptance 
     Disagree  1 0.001* 1 0.530 
     Agree  3.76 (1.76 – 8.02)  1.35 (0.53 – 3.46)  
Rural network     
     Disagree  1 <0.001* 1 0.562 
     Agree  4.75 (2.01 – 11.22)  1.39 (0.46 – 4.18)  
Good mentorship     
     Disagree  1 0.014* 1 0.341 
     Agree  2.61 (1.21 – 5.59)  1.61 (0.60 – 4.32)  
Opportunity to learn     
     Disagree  1  0.011* 1 0.698 
     Agree  2.34 (1.21 – 4.90)  1.19 (0.49 – 2.93)  
Close to hometown     
     Disagree 1 0.043* 1 0.838 
     Agree 2.83 (1.03 – 7.71)  1.14 (0.31 – 4.24)  
Peaceful environment     
     Disagree 1 0.002* 1 0.233 
     Agree 3.61 (1.59 – 8.20)  1.95 (0.65 – 5.82)  
Quiet environment     
     Disagree 1 0.026* 1 0.714 
     Agree 2.23 (1.10 – 4.50)  0.84 (0.34 – 2.11)  
*= statistical significance      OR= odds ratio    Rural background= lived in a rural area before so it wasn’t difficult to accept 
posting Krachi West District    Attitude to rural post= have no difficulty in being posted to a hard-to-reach area to work.    Need 
for recognition= will be appreciated by patients and the community in Krachi.    Marital status and acceptance= was single and 
felt it was the best time to work in a hard-to-reach area    Rural network= accepted posting to Krachi West District because of 
past work experience in a rural area.    Good mentorship= get good mentorship from senior colleagues and officers.    
Opportunity to learn = there are opportunities to learn and gather a lot of experience.    Close to hometown= accepted posting 
because it was close to hometown and family.    Peaceful environment= accepted posting because area is a peaceful place.    
Quiet environment= accepted posting because environment is quiet. 
 
 
 
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4.7 Experiences of persons who accepted posting to Krachi West District 
4.7.1 How people felt when they were posted to Krachi West District. 
The study generally unearthed how respondents felt when they were posted to the 
Krachi West District. The news of being posted to the Krachi West district generally 
evoked negative emotions of sadness, regret, feeling of punishment and frustration. 
Some respondents indicated they cried when they received the posting, others said 
they refused to eat for a number of days because of the posting, while others also said 
they felt depressed by the news of being posted to the Krachi West district. 
These findings appear to ran through the various categories of staff who took part in 
the focus group discussions as shown in the following quotes from a number of the 
discussants  
“When I was first told that I have been posted to Krachi West I cried. Because the 
stories that were coming, …… Krachi, you have to cross a lake before getting 
there and the place is very far and so for good two days I refused food, I didn’t 
want to come here. I seriously didn’t want to come.” (Enrolled nurse1) 
 
“On the day we were given the posting, they said I should go to Krachi West. I was 
not happy about it because I don’t even know the area they were talking about and 
they said you have to cross…… cross the lake before getting to the other end and 
take car to Krachi, I was scared because I have never lived close to a river and I 
cannot swim so in case something happens on the lake?” (Community Health 
Nurse 1) 
“Hmmmmmm I cried! (Loudly exclaimed to demonstrate her emphasis on crying) 
I cried because, first, I didn’t know Krachi. I have to cross the Volta Lake before 
coming to Krachi so I cried and pleaded with the DDNS (Deputy Director of 
Nursing Services) at the Regional Health Directorate, Sister Cudjoe to change the 
posting for me but she said no! Go and help my people and after one year when 
your juniors complete school I will post them to replace you and I will let you 
leave Krachi. So, that was what happened and I came to Krachi”. (midwife1) 
 
“I cried for more than one hour when I heard I was posted to Krachi. I was just 
crying and moreover, my colleagues were laughing at me. The way and manner my 
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colleagues were laughing at me alone made me even sadder and got me crying 
more”. (midwife 4) 
 
4.7.2 Events leading to acceptance of posting to Krachi West District.  
The study found varying experiences by respondents during the process of their 
posting to the Krachi West District. As indicated earlier, most of the respondents had 
experienced negative emotions upon hearing the news of their posting. Most of them 
faced with the difficult decision of accepting the posting decided to investigate the 
area in a number of ways. Some chose to visit the district to see things for themselves, 
others spoke to senior colleagues who were already in the district and others also took 
to the internet to find out more about the place, These are reflected in the following 
quotes  
“So I googled the whole Krachi West District to see how like or just have a feel of 
how the place will be, I did and you wouldn’t even know what it is so I wanted to 
come here myself to see how the place is so I did. I came and unfortunately, our 
bus broke down on the way and we had to wait a couple of hours before getting 
another” (Enrolled nurse 1) 
 
“So that day we were about fourteen nurses that were posted to Krachi West 
District so we have agreed that we should come and see the place, how the place is 
before we know what to do next because that time most of our friends said they 
want to change the posting and all that stuff” (Community Health Nurse 1) 
 
“Now we were supposed to come and submit the posting letter to the district so I 
came with one other colleague, female, we couldn’t reach Krachi that same day. 
My area you can stop a car and go anywhere at all, but it was there I got to know 
that Krachi you cannot just get up on your own and travel like that on your own 
time. There are specific rules and regulations you are supposed to follow. 
Travelling in or out, you can’t get up and travel anytime because you will be 
frustrated”. (Community Health Nurse 3) 
 
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The process of finding out about the place appears to have identified factors that 
ultimately helped in making a final decision to accept the posting. Some indicated that 
when they saw the level of deprivation in the area they thought it will be an 
opportunity to make an impact and so decided to accept the posting. Yet others also 
met colleagues in the district who convinced them that the situation is not as bad as 
they heard and that the cost of living is much lower and they could make savings 
working in the area as the community members could give them varying gifts. 
“……what I heard, it really touched my heart so I wanted to come here and see 
things for myself. ……and, when I came the way I saw the people living here……, 
I heard stories like some people don’t get three square meals a day, some don’t 
have clothes to wear, some live-in mud houses, I haven’t seen some before. I have 
lived in Accra all my life……. And I thought this was going to be an adventure for 
me so I said let me just come and see how the life will be here and see how I will 
cope in case I find myself in any situation as they find themselves, so I decided to 
come and I came”. (Enrolled nurse 1) 
 
4.8 Summary 
The result of this study shows that 69.5% of health workers in the Krachi West 
District accepted the rural posting willingly while 30.5% of them reported accepting 
the posting unwillingly. The socio-demographic characteristics of the respondents did 
not show any statistically significant association with acceptance of rural posting. 
All the individual level factors investigated were significantly associated with 
acceptance of rural posting statistically at the bivariate level. At the multivariate level, 
only the attitude of the health worker towards acceptance of rural posting was found 
to have a statistically significant association with acceptance of rural posting to 
Krachi West District.  
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At the organisational level, none of the factors investigated showed any statistically 
significant association with acceptance of rural posting at the multivariate level 
though the availability of good mentorship and opportunity to learn were significant at 
the bivariate level of analysis. 
At the contextual level, none of the factors investigated showed any statistically 
significant association with acceptance of rural posting at the multivariate level of 
analysis. However, at the bivariate level, the need to be close to one’s hometown, and 
the need for a peaceful and quiet environment were significantly associated with 
acceptance of rural posting to Krachi West District. 
Overall when all factors were considered at the multivariate level of analysis, only the 
attitude of the health worker towards working in a rural area showed statistically 
significant association with rural posting {Unadjusted OR: 12.19 (5.65 – 26.32), p-
value < 0.001; Adjusted OR 9.25 9.52 (3.95 – 22.91), p-value 0.001} 
The qualitative study showed that health workers generally received the news of 
posting to Krachi West District with negative emotions such as sadness, frustration, 
disappointment and a feeling of punishment. Most of the health workers eventually 
decided to accept the posting after visiting the district to verify their concerns. 
 
 
 
 
 
 
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CHAPTER FIVE 
DISCUSSION 
5.0 Introduction  
This chapter discusses the results of the study. The results show that apart from the 
attitude of a healthcare worker towards working in a rural area, there is no statistically 
significant association between the factors investigated and acceptance of rural 
posting. In the following discussion, the result is situated within the existing literature 
and efforts made to explain the findings within the context of what is known of the 
subject and the context of the research. The discussion looked at the proportions of 
health staff willingly accepting rural posting, the individual factors, institutional 
factors, contextual or socio-cultural factors and also the experiences of the 
participants when they were posted to the area and what events made them decide to 
accept the posting. 
5.1 The proportion of health workers who willingly accepted the rural posting.  
The majority of the respondents (69.5%) accepted posting to Krachi West District 
willingly. A search of the literature did not reveal studies that report directly on the 
proportion of health workers posted to rural areas who accept the posting. In work 
done by Kizito et al., (2017) on undergraduate students’ decision to work in 
underserved areas in Uganda however, they found that before community based 
education, 44% of respondents expressed willingness to work in rural areas but after 
community-based education, the percentage rose to 48.4%. A similar study that was 
done in Ghana by Amalba et al., (2016) also found that 60.9% and 67.8% of the 
students from towns and cities respectively said they were influenced by community-
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based education to be  willing to work in rural areas. The result of this study, 
therefore, is filling a gap in the literature as far as the proportion of health workers 
accepting rural posting is concerned and opens the way for research on the acceptance 
rates of rural posting. 
In terms of professional category, more than two-thirds (74.8%) of health workers 
who willingly accepted posting to the Krachi West District were clinical staff. A 
search of the literature on work done in this area reveal that most researchers often 
focus on clinical staff such as nurses, midwives, laboratory staff, pharmacy staff with 
very little focus on non-clinical staff ( Amalba, Abantanga, Scherpbier, & Van Mook, 
2018; Johnson et al., 2011; Kizito et al., 2017; Kwamie, Asiamah, Schaaf, & 
Agyepong, 2017; Rajbangshi et al., 2017; Amalba et al., 2016; Willcox et al., 2015). 
The few research that looked at some non-clinical health workers considered 
categories like community health workers (Lawan et al., 2017), rather than staff such 
as accountants, administrators etc. as was examined in this study. The WHO 
definition of health worker, however, covers all these categories of workers. This 
study, therefore, serves to fill a vacuum in the literature in terms of non-clinical health 
workers accepting posting to rural areas.  
A look at the socio-demographic characteristic of the respondents reveals that there is 
no association between socio-demographic characteristics and acceptance of rural 
posting. An extensive review of literature by Lehmann, Dieleman, & Martineau 
(2008), concluded that associations between demographic factors and acceptance of 
rural posting in terms of age, educational level, and gender is inconclusive. However, 
they found that the available literature does not show any association between marital 
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status and acceptance of rural posting and this agrees with the findings from this 
study.  
5.2 Individual/personal level factors and acceptance of rural posting  
One of the factors reported from literature that could influence the acceptance of rural 
posting is characteristics of the individual such as having stayed in a rural area before, 
the need for personal recognition and appreciation for work done, marital status and 
history of working in a rural area (Darkwa, Newman, Kawkab, & Chowdhury, 2015; 
Lehmann et al., 2008). Our study investigated five individual-level characteristics, 
which are: staff with a rural background, the general attitude towards rural posting, 
the need for recognition or appreciation of one’s work, marital status, and having 
worked in a rural area before.  
These characteristics investigated at the individual level were all significantly 
associated with acceptance of rural posting statistically at the bivariate level using 
Chi2 and fishers exact test. At the multivariate level however only, the attitude of the 
health worker shows a statistically significant association with acceptance of rural 
posting. The study thus revealed that, of all the individual level factors investigated, 
the only factor that is the strongest predictor of acceptance of rural posting is the 
attitude of the health worker towards rural work. This means, health workers who do 
not really mind where they are posted or whether they are sent to work in a rural area 
or not are the most likely persons to accept rural posting willingly. At the bivariate 
level, this was found to be highly significant (Chi2 49.9713, p-value <0.001). This 
characteristic or variable remained statistically significant at the multivariate level 
when other factors were controlled for (Unadjusted OR: 12.19, p-value <0.001, 
Adjusted OR 9.52, p-value <0.001). A search of the literature did not find this 
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particular factor (attitude) measured in respect of work on acceptance of rural postings 
though all the other individual-level factors were examined. This therefore becomes 
one of the contributions of this study to the knowledge of the subject area. 
The other individual-level factors investigated included a history of rural background. 
Having lived in a rural area before was significantly associated with acceptance of 
rural posting at the bivariate level (Unadjusted OR 3.2, p-value <0.001). However, 
when other factors were controlled for, it was found not to be statistically significant 
(Adjusted OR 0.99, p-value 0.988).  Contrary to this finding, work done in Uganda to 
determine the influence of community-based education on undergraduate health 
professions student’s decision to work in rural areas found at the multivariate level 
that geographic area where the student spent his or her childhood was a significant 
predictor of intention to work in a rural area when the data was collected before the 
students were educated in a rural/community school. However after completion of the 
school when the same data was collected, the rural background was no longer found 
to be a significant predictor of intention to work in a rural area (Kizito et al., 2017). 
The loss of statistically significant association does not only agree with our finding at 
the multivariate level but also highlights the dynamic nature of the decision-making 
process for most health workers.  
The literature is however replete with data showing some connection between rural 
background and acceptance of rural posting (Lehmann et al., 2008). For example, 
work done by Mcmillan & Barrie (2012), found that students of rural origin had three 
times stronger commitment to rural employment than students of city origins. It’s 
important to state however that this was purely a descriptive study and the 
significance could have been lost if analytics were applied as happened in our study. 
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In their work on medical and nursing students intentions to work abroad and in rural 
areas in nine countries across Africa and Asia, Silvestri et al. (2014), found that 
students from low to middle-income countries who have spent significant time in rural 
settings are more likely to practice in rural areas. Additionally, they found that this 
likelihood of working in a rural area correlated with the duration of residing in a rural 
area. It is possible that a positive attitude which we found to be the only significant 
factor at the multivariate level could have been influenced by such factors such as 
rural background even though rural background by itself was not statistically 
significant.  
The approach to or the design of this study could account for the difference in the 
findings in respect to the statistical significance of rural background in acceptance of 
rural posting. Other studies were projecting from respondents who have not yet 
accepted posting while this study actually interviewed those who accepted to work in 
rural areas and therefore mirrors the reality much more than most other studies. This 
design could be replicated in other areas and with larger sample sizes to see whether 
the results will be the same as was found in Krachi West District. 
 When asked whether respondents accepted posting to the rural area because they felt 
their work will be much more appreciated in these areas, more than two-thirds of the 
respondents agreed. This was tested at the bivariate level and was found to be 
statistically significant (Unadjusted OR 2.72. p-value 0.002). This strong association 
was lost once other factors were controlled for in the multiple logistic regression 
model (Adjusted OR 1.27, p-value 0.585). Serneels et al. (2010) reported that the 
desire to help the poor and be appreciated for it was one of the significant reasons 
health workers chose to work in the rural area in Ethiopia and Uganda. In qualitative 
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research by Prytherch et al. (2013) in three countries, most of the rural staff described 
being drawn to their job by a sense of vocation and also held the strong view that 
health work was honourable and a health worker would have to leave a positive 
legacy. However, this was a qualitative study and the significance of this could have 
been lost if an inferential statistical analysis was conducted as was observed in the 
model used for this study. This could explain the difference in the findings between 
the literature and this study. 
One other thing which we sought to find out under individual-level characteristics was 
whether an experience of working in a rural area was significantly associated with 
acceptance of rural posting. Respondents who had a rural work experience were found 
to be 43% more likely to accept rural posting but this was not significant when other 
factors were controlled for (Adjusted OR 1.07, p-value 0.346).  
5.3 Institutional/organisational factors and acceptance of rural posting 
There are factors at the organisational level or within health institutions that have 
been identified in the literature as having some effect on the acceptance of rural 
posting (Rockers et al., 2012). We interrogated thirteen of these which are availability 
of financial incentives, relatively lower cost of living, availability of good mentorship 
opportunities, good management practices, workload, opportunities for further 
studies, possibility of early promotion, lack of other opportunities for employment, 
integrity of management team, the availability of learning opportunity, opportunities 
for sponsorship for further studies, and the influence of colleagues on acceptance of 
rural posting. Of all the thirteen items investigated, only the availability of good 
mentorship opportunities showed statistically significant association with acceptance 
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of rural posting but even this association was lost at the multivariate level when other 
factors were controlled for.  
An extensive review of the literature by Lehmann et al., (2008) indicated that the 
importance of some of these institutional factors such as financial incentives on 
acceptance of rural posting and working in rural areas is inconclusive. A WHO (2004) 
work indicated that only 24% of respondents quoted better remuneration or financial 
incentives for the decision not to work in a rural or deprived area. This reflects to 
some extent our findings in this study where no statistically significant association 
was found between financial incentives and acceptance of rural posting. 
Contrary to our findings, the literature is replete with research works that have 
emphasized the importance of organisation or institutional factors in acceptance of 
rural posting. (Rajbangshi, Nambiar, Choudhury, & Rao, 2017; Rockers et al., 2013; 
Snow et al., 2011; Kruk et al., 2010).  
 Lehmann et al. (2008), reports that the general working environment including 
organisation arrangements, management support, availability of working tools, etc are 
believed to be key factors in health worker decisions in respect of staying or working 
in a rural area. These same conditions and factors have been cited by health workers 
for requesting transfers out of rural areas such as poor working environment, lack of 
recognition and reward system for extra effort and sacrifice, professional stagnation 
etc. (Lawan et al., 2017). All cadres of health workers involved in a study on rural 
recruitment and retention cited poor management practices with resultant lack of 
essential medicines, equipment ambulances etc. as a major source of concern when it 
comes to making the decision to work in a rural area (Rajbangshi et al., 2017). 
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In a three-country qualitative enquiry by Prytherch et al. (2013), it is reported that 
participants across the three countries suggested financial incentives in the form of 
salary increase, rural allowance, and greater possibilities to attend seminars, payment 
of overtime etc. as necessary for making work in the rural area attractive. Greater 
opportunities for attending workshops and seminars were linked to financial 
incentives because a lot of time, attendance at these seminars is tied to payment of per 
diems. 
Our results show that apart from the availability of good mentorship opportunities and 
the opportunity to learn and gain experience, all the other organisational level factors 
was not found to be significantly associated with rural posting. Even these two factors 
were only significant at the bivariate level but lost their statistical significance at the 
multivariate level. (Good mentorship: Unadjusted OR 2.61, p-value 0.014, Adjusted 
OR 1.61, p-value 0.341, Opportunity to learn: Unadjusted OR 0.011, p-value 0.11, 
Adjusted OR 1.19, p-value 0.698). Lehmann et al., (2008) in their extensive review of 
the literature indicated that the link between access to continuing professional 
education, professional advancement, and acceptance to work in a rural area is 
unclear; whereas work from high income countries did not find close correlations 
between opportunities of career advancement and turnover/working in a rural area, 
evidence from a six-country study in Africa including Ghana shows a relatively 
stronger link.  
The lack of statistically significant association between these institutional factors and 
acceptance of rural posting can be explained by the fact that, most of the health 
workers in the district did not actually know much about what was prevailing in the 
district at the time of posting and therefore did not use these as basis for acceptance of 
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rural posting. Again, in the Volta Region where the study was conducted, there is no 
written policy of early promotion for working in rural areas and therefore, this could 
not have been a reason why the staff accepted posting to this area. The Ghana Health 
Service also doesn’t have any reliable policy on the provision of financial incentives 
for persons working in the rural or hard to reach communities as stated in the Krachi 
west District 2017 annual report, and this the health workers would have been aware 
of and therefore did not consider financial incentives as reason for accepting the rural 
posting.  
5.4 Contextual/socio-socio-cultural factors and acceptance of rural posting 
Socio-cultural/contextual factors have also been identified in the literature as one of 
the many factors that influence the acceptance of rural posting (WHO, 2010; 
Lehmann et al., 2008). We investigated some of these factors to see if they were 
associated with acceptance of rural posting in the case of health workers posted to the 
Krachi West District. Some of the factors we looked at included the availability of 
free staff accommodation, closeness of the workplace to one’s hometown and family, 
availability of good schools for children, freedom to be far from family, nearness to 
spouse, peaceful environment in the town, the need for a quiet environment away 
from the noise of the city, availability of recreational activities and social amenities 
like water, electricity, telephone networks etc and the lack of language barrier. 
 Among these ten factors investigated in this study, only three of them were found at 
the bivariate level to be statistically significant in predicting acceptance of rural 
posting. These three are 1. The need to be close to one’s hometown (Unadjusted OR 
2.83, p-value 0.043).  2. The need for a peaceful environment (Unadjusted OR 3.61, 
p-value 0.002), and, 3. The need for a quiet environment (Unadjusted OR 2.23, p-
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value 0.026). However, when other factors were adjusted for at the multivariate level, 
none of the contextual factors were found to be statistically significant. In a discrete 
choice experiment by Rockers et al., (2013) looking at differences in preferences for 
rural job postings between practicing nurses and student nurses, they found that things 
such as accommodation, transportation to and from work, need for promotion, etc 
were a concern to both students and practicing nurses except that it was more for the 
nursing students.  
The literature, however, identifies a number of these contextual factors as essential in 
attracting and retaining health workers to rural areas (Edson Araujo and Akiko 
Maeda, 2013.) Rajbangshi et al. (2017) report that work done on health workers 
across cadres in North East India that, family and community factors such as lack of 
educational facilities for children, and maintenance of more than one household was a 
major concern for those willing to work in rural areas. They also reported acts of 
vandalism and insecurity as major concerns when it comes to their choice of working 
in the rural area. Another study by Kruk et al., (2010), among medical students, also 
found that provision of free accommodation is a key determinant of the intention to 
practice in the rural area. 
 Snow et al., (2011) in their qualitative study on key factors leading to reduced 
recruitment and retention of health professionals in remote areas of Ghana found 
doctors highlighting the need for good accommodation and other social amenities to 
encourage young doctors to work in rural areas 
What is evident from the literature is that practicing health workers appear to put a 
relatively lower premium on these amenities than do students. This could be the case 
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also in our study as we surveyed practicing health workers who are provided free 
accommodation for at least three years (Krachi West District 2017 Annual report). 
5.5 Experiences of those who accepted the rural posting   
This study shows that the posting to Krachi West District is associated with a negative 
emotion such as sadness, regret, a feeling of punishment, frustration and grief for 
most of the respondents that took part in the research. Virtually all the respondents 
reported a general bad feeling when the news of posting to Krachi West was received. 
They attributed largely this to the negative publicity or image of the area from friends, 
tutors in school and others including staff of the Ghana Health Service. This has a 
way of negatively impacting on the decision to accept rural posting, as the initial 
processes and experiences are a key factor in the accepting of rural posting as noted 
by Purohit & Martineau, (2016). This perhaps explains the reason why WHO (2010) 
recommended the posting of staff to their native regions or areas to improve attraction 
and retention. The idea is that these staff would have known much about the areas 
they are being posted to and therefore minimise the negative emotions associated with 
the hearsay about the rural areas they are being posted to. Indeed, it came out during 
the focus group discussion that a number of the initial negative emotions disappeared 
when staff who were posted decided to make a trip to Krachi West and found to their 
dismay, that some of the negative stories they heard were not true. 
This again perhaps explains why exposure to rural areas in training could potentially 
increase the likelihood of health workers opting to work in rural areas as copiously 
reported in the literature (Ossai et al., 2016; Amalba et al., 2016; Silvestri et al., 2014; 
Lehmann et al., 2008) 
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Thus, the initial negative emotions experienced by the respondents could in part be 
removed by an opportunity to visit and experience at first hand, work in the rural area 
or at least see how the rural area looks like. This experience may not only dispel the 
bad image associated with posting to these areas but could also expose the staff to the 
difficulties that human beings in these areas face in accessing health care as some of 
the respondents reported during the focus group discussion. For example, as noted in 
the results in chapter four, one physician assistant indicated that experiencing a child 
dying in a health centre on the morning he visited the facility to see how the place was 
like was the change factor in his decision to stay and save lives. It is important to state 
however that this experience could have a dual effect, while it can make others decide 
to work in the rural area; the extent of deprivation can also scare some people from 
accepting to work in these areas. In our study, however, it turned out that the finding 
that the place they were posted to was not as bad as it was portrayed was one of the 
major reasons for finally deciding not to change the posting. 
5.6 Summary 
 In summary, the majority of respondents (69.5%) of health workers accepted posting 
to Krachi West District willingly. A search in the literature did not reveal any study 
that reported directly on the proportion of health workers accepting rural posting. The 
result of this study in this respect, therefore, serves to fill a vacuum in the literature as 
far as acceptance of rural posting is concerned.  
This study also reveals that socio-demographic characteristics of health workers do 
not have any statistically significant association with acceptance of rural posting. An 
extensive review of literature by Lehmann, Dieleman, & Martineau (2008), concluded 
that associations between demographic factors and acceptance of rural posting in 
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terms of age, educational level, and gender is inconclusive. However, they found that 
the available literature does not show any association between marital status and 
acceptance of rural posting and this agrees with the findings from this study.  
Individual-level factors, organisational level factors and contextual factors were not 
found to be statistically significant in this study except the attitude of the health 
worker towards rural work. The literature, however, shows that these factors do 
influence the willingness of health workers to accept rural posting. This difference 
could be explained by the fact that a number of these studies were qualitative and 
descriptive studies. Therefore, these factors could have equally lost significance if 
subjected to rigorous statistical analysis or modelling as happened in this study when 
significance was only demonstrated at the bivariate level of analysis. Additionally, 
compared with most of the studies found in the literature where trainee health workers 
were interviewed and their views sought on what will make them accept rural posting, 
the design or approach of this study was to interview those who are actually working 
in the rural area and determine the factors that made them accept rural posting. The 
result from this approach is thought to be more reliable as projections from persons 
who are yet to accept posting to rural areas could change when the time of posting 
actually comes. This approach to investigating this topic is novel and could, therefore, 
be responsible for the findings from this study being different from what is generally 
reported in the literature. 
The news of postings to Krachi West often evoked negative emotions of anger, 
sadness, frustration, and feeling of punishment. This could largely be attributed to 
negative publicity received about Krachi West District. The fact that most of the staff 
finally accepted the posting after visiting the district to allay their fears proves that 
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familiarity with the rural area could make acceptance easier. This perhaps is the basis 
for WHO recommending recruitment, training, and deployment of staff to their native 
areas or regions to improve acceptance of rural posting. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER SIX 
CONCLUSIONS AND RECOMMENDATIONS 
6.0 Conclusion 
This study sought to determine the proportion of health workers who willingly 
accepted rural posting as well as factors influencing acceptance of rural posting by 
health workers to Krachi West District and also to explore the experiences of persons 
posted to Krachi West and the factors that influenced their decision to accept the 
posting. From this study, the following conclusions were drawn.  
Firstly, the majority (69.5%) of health workers posted to the Krachi West District 
accepted the posting willingly. Additionally, the majority of those who accepted the 
posting willingly were males and an overwhelming majority of those with rural 
background accepted the posting willingly. 
Secondly, attitude of the health worker to working in a rural area predicts whether a 
health worker will accept rural posting (to Krachi West District).  
Thirdly, the Krachi West District has a very negative image especially among health 
workers who have never visited the area before. This is in respect of the perceived and 
or real level of deprivation of the area and the difficulty in accessing the district. This 
has accounted largely for the refusal of many health workers to accept posting to the 
district as most of them reported experiencing negative emotions upon hearing the 
news of their being posted to the district.  
Finally, most health workers who visited the district immediately following the 
postings changed their perception about the area and decided to accept the posting.  
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6.1 Recommendations  
In line with the findings from this study, the following recommendations are made.  
1. The (Krachi West) District Assembly/Assemblies working in collaboration with 
the District Health Directorates needs to undertake a deliberate rebranding 
exercise. This they can do by among other things enhancing social and other 
infrastructure that would improve the lives of personnel, thereby attracting them to 
their districts. This rebranding exercise should involve people from across sectors 
including health workers, traditional authorities, and also the staff of the various 
health training institutions. 
2. The Ministry of Health needs to make efforts to formulate and implement a 
written policy on rural placement that has in it a bouquet of interventions covering 
individual level, organisational and socio-cultural factors aimed at positively 
influencing the attitude of the health worker towards acceptance of rural posting. 
3. Health training institutions should make it mandatory for students to have a rural 
experience (rural internships) as a way of shaping their attitude towards rural 
posting as is currently done by the University of Development Studies in a 
number of its programmes.  
 
 
 
 
 
 
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APPENDIX A 
QUESTIONNAIRE 
Dr Hilarius Asiwome Kosi Abiwu is a student of the University of Ghana, School 
Public Health. As part of the requirements for the award of Masters in Public Health, 
he is expected to do a project under the supervision of the school. He is in this regard 
seeking to investigate the factors influencing the acceptance of rural posting using 
Krachi West District as a case study. You are invited as a health worker who has 
accepted rural posting to participate in this study voluntarily. All responses to the 
questionnaire will be anonymous and confidential. 
 
PART I 
Demographic Characteristics of Respondents 
 
Please tick  one box 
 
Que QUESTION  
No RESP
ONSE 
1            Sex  
1. Male                                                                                                                    
 
 
2. Female                                                                                                               
 
 
2 Professional Category  
1. Doctor                                                                                                                
 
 
2. Nurse                                                                                                                  
 
 
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3. Midwife                                                                                                              
 
 
4. Accountant/Finance officer                                                                                
 
 
5. Radiologist/Radiographer/X-ray staff                                                                
 
 
6. Laboratory staff (technician, biomedical scientist, lab assistant)                    
 
 
7. Technical officer (Nutrition, disease control, etc)                                         
 
 
8. Pharmacy staff (pharmacist, technician, MCA)                                                 
 
 
9. Administrative staff (Administrator, HR, Admin assistant, secretary etc)        
 
                                                                                                                                                        
10. Others specify 
……………………………………………………………………………
…… 
 
3   
What is your age as at your most recent birthday?      
………………………………………………. 
 
4 Highest level of education   
 
1. No formal education                                                                                                   
 
 
2. Primary                                                                                                                          
 
 
3. Vocation school                                                                                                           
 
 
4. Secondary or technical school                                                                                   
 
 
5. Tertiary/ post-secondary                                                                                            
 
5 Marital Status   
 
1. Married                                                                                                                          
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 
 
2. Single                                                                                                                             
 
 
6 Religious affiliation  
1. Christian                                                                                                                         
 
 
2. Muslim                                                                                                                           
  
 
3. Traditionalist                                                                                                                 
 
 
4. Others, specify                                                                                                              
 
7 Do you have children?   
 
1. Yes                                                                                                                                  
 
 
2. No                                                                                                                                   
 
8 Number of Children  
 
If yes to 7 above how many children do you have? Please state 
…………………………………. 
 
9 Ages of children  
  
What are their ages? 
  
10 Location of residence in relation to place of work  
 
Is your workplace or facility in the same town or village where you live?  
 
1. Yes                                                                                                                               
 
 
2. No                                                                                                                                
 
11 Distance from Work  
 
If No to question 10 above, how long?  
State the average distance you need to travel to get to 
work....................................... 
  
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WORK EXPERIENCE AND ACCEPTANCE OF RURAL POSTING  
 
12   
For how many years have you worked as a health worker (please state in 
years)………… 
 
13   
This question seeks to understand whether you willingly accepted to work in 
Kete-Krachi or you did so under compulsion. Kindly provide an honest answer 
or response as this represents the crux of the research by ticking the appropriate 
response. 
 
Did you WILLINGLY accept the posting to work in Krachi West District? 
 
1. Yes                                                                                                                                  
 
  
2. No                                                                                                                                   
 
 
14   
Which people had the most influence on you in terms of making you accept the 
posting to work in Krachi? Please choose only one  
 
1. Regional officers                                                                                                          
 
 
2. District officers                                                                                                             
 
 
3. Facility officers                                                                                                             
 
 
4. Family members                                                                                                          
 
 
5. Colleagues/classmates                                                                                               
 
 
6. Religious leaders (my pastor, Imam, etc)                                                    
 
 
7. Others 
specify………………………………………………………………… 
 
   
 
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PART III 
Individual Factors 
The following sets of questions seek your honest views on some personal factors that 
influence acceptance of rural posting. You are kindly requested to answer the 
questions on a scale of 1 -5 where  
1             Indicates strongly agree 
2             Indicate agree 
3             Is neutral 
4             Indicate disagree 
5               Indicate strongly disagree     
Please tick as appropriate 
 
  
1 2 3 4 5 
 
15 
I have lived in a rural area before so it wasn’t difficult for me to 
     
accept posting to Krachi West District 
16 I personally don’t have any difficulty being posted to a hard to 
reach area to work, reason I accepted the posting to Krachi 
     
West District 
 
17 I believe that in a rural area like Krachi West my work will be 
more appreciated by my patients and the community than 
working in a big town where I wouldn’t be recognised and this 
     
was one of the reasons I accepted posting to Krachi West 
District. 
 
18 When I was posted I was single and so felt that was the best 
time to work in a hard to reach area. This was one of the 
     
reasons I didn’t have any difficulty accepting posting to Krachi. 
 
19 I accepted posting to Krachi West District because I have 
worked in a rural area before.      
 
       
 
 
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1. PART IV 
Organisational or institutional factors 
The following sets of questions seek your honest views on some institutional factors 
that influence acceptance of rural posting. You are kindly requested to answer the 
questions on a scale of 1 -5 where  
1    Indicates strongly agree                                                   2         Indicate agree 
3    Is neutral                                                                        4.        Indicate disagree 
5    Indicate strongly disagree     
Please tick as appropriate  
 Strongly agree     1 2 3 4 5 strongly 
     
disagree 
  1 2 3 4 5 
20 Knowledge of provision of financial incentives like allowances was 
     
one of the reasons I accepted posting to Krachi West District 
21 I accepted to work in Krachi West because I felt I would make 
savings in terms of accommodation, cost of food and other living      
conditions   
22 One reason I accepted to work in Krachi West is because I heard or 
     
knew there was good infrastructure and facilities 
23 One reason I accepted to work in Krachi West was because I felt I 
could get mentorship from some senior colleagues and officers I      
have heard about 
24 I accepted to work in Krachi West District because I heard of their 
good management practices or because I heard the management      
does well 
25 I accepted to work in Krachi because the workload is not much       
26 I accepted to work in Krachi because I was promised I will be 
     
allowed to go to school on time  
27 One reason I accepted to work in Krachi West was because I 
     
believed I will be promoted when due  
28 I accepted to work in Krachi West District because there is no job 
     
where I would have wished to work 
29 I accepted to work in Krachi West because I could trust the 
     
management on the promises made to me  
30 I accepted to work in Krachi West District because it offers me 
     
more opportunities to learn and gather a lot of experience 
31 I accepted to work in Krachi because some colleagues of mine 
     
spoke favourably of the place 
32 One reason I accepted to work in Krachi was because I believed I 
     
will be sponsored for postgraduate studies or further studies 
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PART V 
Contextual/ socio-cultural factors 
The following sets of questions seek your honest views on some Contextual factors 
that influence acceptance of rural posting. You are kindly requested to answer the 
questions on a scale of 1 -5 where  
1        Indicates strongly agree 
2        Indicate agree 
3        Is neutral 
4        Indicate disagree 
5       Indicate strongly disagree 
Kindly tick as appropriate    
 Strongly agree  1 2 3 4       5       Strongly 
disagree      
 
  1 2 3 4 5 
33 My knowledge of provision of free accommodation by the hospital 
     
was one of the reasons I accepted posting to Krachi 
34 I accepted to come and work in Krachi because it was close to my 
     
hometown and family 
35 I accepted to come and work in Krachi because it was far from my 
hometown and that will prevent relatives and other family members      
from worrying me unduly (with their needs)  
36 Even though I accepted to come to Krachi, availability of good 
     
schools, and even recreational facilities are things that I think about  
37 I accepted posting to Krachi because my spouse is working in the 
     
same district or nearby district 
38 One of the reasons I accepted to work in Krachi because is because it’s 
     
a peaceful place  
39 One reason I accepted to work in Krachi is because I know there are 
social amenities like telephone network, electricity, water and      
television coverage. 
40 I accepted to come and work because I wanted a very quiet 
     
environment away from the usual noisy and busy schedules of city life 
41 One of the things that bother me while working here is the lack of 
     
recreational or entertainment facilities, making the place very boring   
42 One of the reasons I accepted to work in Krachi is because there is no 
language barrier for me as I can speak some of the languages spoken      
by the people 
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APPENDIX B 
Focus group discussion guide 
Introduction 
You are welcome to this very important discussion. I wish to first of all express my 
appreciation to you all for accepting to be part of this important discussion. One of the 
difficult issues the District is grappling with is how to attract and retain staff to the 
district. You here have braced the odds to be here. We think that it will be important 
to find out from you how you felt when you were first posted, the things that went 
through your mind and what eventually made you to decide you will come to Krachi. 
We are hoping that these findings will in making policies to improve the attraction of 
staff to the District. This project is part of my work towards the award of a Master’s 
degree in Public health at the University of Ghana where I am currently a student. 
This focus group discussion should take about thirty minutes. And should feel 
uncomfortable at any stage you can decide to opt out without any consequences at all. 
Please feel free to air your views candidly 
Category of participants: Example midwives 
Participant consent: Participants will sign an informed consent form 
 
Discussion guide: 
Welcome: I wish to thank you once again for taking time to be part of this discussion. 
You were included because we thought your views matter a great deal in this survey. 
Ground rules 
i. The first and most important rule is that we should respect each other’s views 
even if we disagree with them 
ii. Only one person speaks at a time, this is to ensure that we hear everyone out 
clearly 
iii. Remember that there is not a correct answer and there is not a wrong answer. 
What we are interested in is your views, thoughts, feelings etc. in respect of 
this issue of rural posting when you were first posted 
iv. There is no particular order in which we want people to speak, if at any time 
you have something to say just lift up your hand and you will be called to 
speak 
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v. Because everyone has specific reasons for accepting posting to Krachi west 
your answer need not be what another person is saying except of course if 
your reasons are the same 
vi. Please does anyone have any questions? 
 
Setting the tone  
First of all we will all introduce ourselves.  Please tell us your name  
Introductory question 
Kindly take a few minutes to think about your whole experience when you were first 
told or you found out that you have been posted to Krachi West District. How was it 
like? And eventually what made you decide to come or accept the posting? When 
ready, anyone could share with us how the experience was like hearing that news.  
 
Guiding Questions  
 Did choose Krachi West District yourself or you were posted without your 
input? 
 How did you feel when you were told or you found out you have been posted 
to Krachi?  
 What went through your mind following the posting?  
 Did you consider asking for change of posting? 
 Did you actually actualize your thoughts by going to ask for change of 
postings? 
 What were the reasons for which you would have wanted to change the 
postings ? What reasons did you have against coming to work in Krachi 
 What eventually made you decide to come to Krachi ? 
o Officers of the regional health directorate 
o Officers of the Krachi West District 
o Advice from family, friends or colleagues  
o Religious leaders 
o Family members 
o others 
 Would you have acted differently if you were being posted today?  
 What in your view will make it easier for other staff to accept posting to rural 
areas like Krachi West 
 
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Final question: 
Of all the reasons discussed today, which of them made you decide to accept the 
posting to Krachi?  
 
Conclusion 
 We wish to thank you for your time and inputs  
 We hope it was interesting enough 
 We appreciate and value your input into this important r=exercise 
 In case there is something you are unhappy with kindly contact the 
administrator or myself after we have closed for it to be addressed  
 I wish to re-assure you that this whole interaction will be anonymous 
 If  anyone still has our questionnaires he or she can hand them over to us 
before leaving please 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX C 
Consent form for Focus group discussion guide 
Introduction  
This study is seeking to explore the factors that influenced acceptance of rural posting 
by healthcare workers to Krachi West District. You are being invited to participate in 
this study. However we wish to ensure that you are well informed about what it 
involves and also seek your written consent. In this regard you are provided a consent 
form which you need to read and if you agree to the details, sign the form to confirm 
your written informed consent to participate in this study. Kindly feel free to ask me 
for any clarifications if you need one. 
Purpose 
The aim of this study is to find out the factors that influenced the decision of 
healthcare staff to accept posting to Krachi West District with the view to informing 
policy on recruitment. The data to be collected include views on the factors that 
influenced your decision to accept posting to Krachi as well as demographic 
characteristics such as age, sex etc. 
Your role 
Your role in this study should you agree to participate will be to be interviewed as 
part of a small group of health workers in the district. The interviews will take not 
more than two hours.  
 
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The right to withdraw 
As a participant you have the right to withdraw from the study at any time even after 
you have signed the informed consent form without any consequences to you 
whatsoever. Participation is completely voluntary but your views as a participant will 
be greatly appreciated. 
Confidentiality 
A firm commitment is made in this document to keep every information provided 
confidential except otherwise with your prior approval. Your name shall not be on any 
of the questionnaires or documents or even mentioned in the study unless you 
approve. The interview will be recorded but will be kept securely till the study is over, 
thereafter it will be destroyed. 
Benefits 
There are no personal financial benefits or compensation to you for participating in 
this study, however your input will be contributing to shaping policy to attract and 
retain health workers to serve the people of Krachi West and other similar rural areas. 
Risk or Discomfort 
It is not anticipated that participating in this study will cause you any discomfort or 
expose you to any risks. However if at any time you feel threatened or identify a risk, 
or experience any form of discomfort in respect of participating in the study, you are 
free to stop participating. 
 
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Contact person for Questions  
The following persons can be contacted at any time for questions, clarifications, etc in 
respect of the study. 
………………………………………..  
ERC Administrator 
Mr Destiny Avedetsi (Administrator, Krachi West District Health Directorate): 
0208101090 
Mr Samuel Omega (Administrator, Krachi West District Hospital): 0246791917 
Dr Hilarius Asiwome Kosi Abiwu (Principal investigator or researcher): 
0242934269 
A copy of this form will be left with you for future reference 
Informed consent to participate in this study 
I have read or have read to me the information above and have understood the 
processes, benefits, risks and purpose of this study. I have signed below to participate 
in this study voluntarily. 
…………………………………………………………………………………… 
Date    Signature of study participant 
…………………………………………………………………………………….. 
Date    Signature of facilitator or data collector 
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APPENDIX D 
Consent form for self-administered questionnaire 
Introduction  
This study is seeking to explore the factors that influenced acceptance of rural posting 
by healthcare workers to Krachi West District. You are being invited to participate in 
this study. However, we wish to ensure that you are well informed about what it 
involves and also seek your written consent. In this regard you are provided a consent 
form which you need to read and if you agree to the details, sign the form to confirm 
your written informed consent to participate in this study. Kindly feel free to ask me 
for any clarifications if you need one. 
Purpose 
The aim of this study is to find out the factors that influenced the decision of 
healthcare staff to accept posting to Krachi West District with the view to informing 
policy on recruitment. The data to be collected include views on the factors that 
influenced your decision to accept posting to Krachi as well as demographic 
characteristics such as age, sex etc. 
Your role 
Your role in this study should you agree to participate will be to be to answer the 
questions in this questionnaire as a health worker in Krachi West District. All health 
workers are targeted to participate in the study. The questionnaire will take less than 
10 minutes to answer.  
 
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The right to withdraw 
As a participant you have the right to withdraw from the study at any time even after 
you have signed the informed consent form without any consequences to you 
whatsoever. Participation is completely voluntary but your views as a participant will 
be greatly appreciated. 
Confidentiality 
A firm commitment is made in this document to keep every information provided 
confidential except otherwise with your prior approval. Your name shall not be on any 
of the questionnaires or documents or even mentioned in the study unless you 
approve.  
Benefits 
There are no personal financial benefits or compensation to you for participating in 
this study; however your input will be contributing to shaping policy to attract and 
retain health workers to serve the people of Krachi West and other similar rural areas. 
Risk or Discomfort 
It is not anticipated that participating in this study will cause you any discomfort or 
expose you to any risks. However if at any time you feel threatened or identify a risk, 
or experience any form of discomfort in respect of participating in the study, you are 
free to stop participating. 
 
 
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Contact person for Questions  
The following persons can be contacted at anytime for questions, clarifications, etc in 
respect of the study. 
………………………………………..  
ERC Administrator 
Mr Destiny Avedetsi (Administrator, Krachi West District Health Directorate): 
0208101090 
Mr Samuel Omega (Administrator, Krachi West District Hospital): 0246791917 
Dr Hilarius Asiwome Kosi Abiwu (Principal investigator or researcher): 
0242934269 
A copy of this form will be left with you for future reference 
Informed consent to participate in this study 
I have read or have read to me the information above and have understood the 
processes, benefits, risks and purpose of this study. I have signed below to participate 
in this study voluntarily. 
…………………………………………………………………………………… 
Date    Signature of study participant 
…………………………………………………………………………………….. 
Date    Signature of facilitator or data collector 
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APPENDIX F 
Human Resource GAP Analysis 
Table 10: Krachi West District Hospital Human Resource GAP Analysis 
   KRACHI WEST DISTRICT HOSPITAL - HR GAP ANALYSIS 
 Serial Number Number HR 
number Category of staff required at post gap 
1 Accountant 3 2 -1 
2 Finance Officer 4 0 -4 
3 Accounts Officer  11 0 -11 
4 Internal Auditor 1 1 0 
5 Finance Officer (Audit) 1 0 -1 
6 Biomedical Scientist 6 1 -5 
7 Technical Officer (Laboratory) 15 0 -15 
8 Laboratory Assistant  10 3 -7 
9 Biostatistics/Medical Records Assistant  15 1 -14 
10 Biostatistics Officer 2 1 -1 
11 Clinical Engineering Technologist 3 0 -3 
12 Clinical Engineering Manager 1 0 -1 
13 Dental Surgeon 2 0 -2 
14 Dental Surgery Assistant 2 0 -2 
15 Dental Technician 2 0 -2 
16 Medical Officer 10 5 -5 
17 Obstetrician & Gynaecologist 3 0 -3 
18 Ophthalmologist 1 0 -1 
19 Paediatrician 3 0 -3 
20 General Surgeon 2 1 -1 
21 Family Medicine Physician 2 0 -2 
22 Midwife 41 17 -23 
23 Community Health Nurse 10 2 -8 
24 Enrolled Nurse 60 34 -26 
25 Registered General Nurse 91 38 -53 
26 Ophthalmic Nurse 3 0 -3 
27 Public Health Nurse 6 0 -6 
28 Pharmacist 5 1 -4 
29 Pharmacy Technician 13 1 -12 
30 Dispensing Assistant  6 1 -5 
31 Certified Registered Anaesthetist  5 1 -4 
32 Physician Assistant (COHO)  3 0 -3 
33 Physician Assistant (Medical) 4 2 -2 
34 Physician Assistant (Herbal) 1 0 -1 
35 Mental Health Nurse 4 0 -4 
36 X-ray Technician 4 0 -4 
37 Radiographer 4 1 -3 
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Serial Number Number HR 
number Category of staff required at post gap 
         38 Technical Assistant (X-Ray) 2 0 -2 
Artisans (Mechanic, Electricals, 
39 Plumbing) 14 3 -11 
40 Health Service Administrator 1 1 0 
41 Human Resource Manager 2 1 -1 
42 IT Manager  2 0 -2 
43 IT Officer/Technician 3 0 -3 
44 Procurement Officer 2 0 -2 
45 Procurement Manager 1 2 1 
46 Supply Manager 1 0 -1 
47 Supply Officer 2 0 -2 
48 Blood Bleeder/Phlebotomist 3 0 -3 
49 Clinical Pharmacist  2 0 -2 
50 Blood Donor Organizer 3 0 -3 
51 Critical Care Nurse 7 0 -7 
52 Emergency Nurse 16 0 -16 
53 ENT Nurse 3 0 -3 
54 Peri-Operative Nurse 11 0 -11 
55 Clinical Psychologist 2 0 -2 
56 Executive Officer 3 0 -3 
57 Dietician 3 0 -3 
58 Optician 2 3 1 
59 Optometrist 2 0 -2 
60 Physiotherapist 1 0 -1 
61 Physiotherapy Assistant 2 0 -2 
62 Prosector 1 0 -1 
63 Technical Officer (Disease Control) 3 0 -3 
64 Catering Officer 2 0 -2 
65 Driver 3 2 -1 
66 Hospital Orderly 17 17 0 
67 Labourer 7 1 -6 
68 Launderer 5 2 -3 
69 Mortuary Attendant 2 0 -2 
70 Nutrition Officer 1 0 -1 
71 Technical Officer (Nutrition)  2 1 -1 
72 Private Secretary 2 1 -1 
73 Security Guard 11 3 -8 
74 Staff Cook 4 0 -4 
75 Telephonist 2 0 -2 
76 Transport Officer 2 0 -2 
77 Field Technician 2 0 -2 
78 Administrative Manager 2 0 -2 
         79 Health Research Officer 1 0 -1 
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Serial Number Number HR 
number Category of staff required at post gap 
80 Technical Officer (Health Promotion) 1 0 -1 
81 Technical Officer (Health Information) 3 0 -3 
  TOTAL 522 150  -372 
Note. Adapted from the annual reports of the Krachi West District Health Directorate 
2018 
 
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APPENDIX F 
Ethical Approval letter 
 
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