From similar starting point to divergent academic trajectories: Evidence from rural order-oriented medical students in China

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INTRODUCTION: The training program for Rural Order-Oriented Medical Students (ROMS) in China is an important policy instrument designed to address the shortage of healthcare professionals in primary-level institutions. It plays a critical role in promoting educational equity and optimizing the allocation of health resources. However, challenges remain regarding the quality of training. Previous studies have primarily focused on the overall characteristics of ROMS, overlooking a subgroup whose entry-level academic ability are comparable to those of students who are not order-oriented (hereafter referred to as Non-Rural Order-Oriented Medical Students, non-ROMS). This oversight may obscure the underlying mechanisms that affect training quality. METHODS: This cross-sectional study compared 250 ROMS and 985 non-ROMS in western China. Guided by the Input-Environment-Outcome (IEO), we analyzed inputs (demographics, socioeconomic status, and cultural backgrounds), environment (cognitive, emotional and behavioral engagement), and outcomes (academic performance) to examine divergent academic trajectories between the two groups, despite their comparable academic ability at enrollment. RESULTS AND DISCUSSION: ROMS were more likely to come from socioeconomically and culturally disadvantaged backgrounds, with higher proportions of female and ethnic minority students. Although emotional engagement did not differ significantly between groups, ROMS displayed lower cognitive and behavioral engagement, setting less ambitious goals, using self-regulated learning strategies less often, and spending less time on extracurricular study. Consequently, ROMS achieved significantly lower academic performance. Even when ROMS demonstrate comparable entry-level academic ability, as reflected by National College Entrance Examination (NCEE) scores, gaps in engagement and academic performance persist. We argue that expanding access alone is insufficient; substantive equity requires targeted, process-level interventions to ensure that policy-driven recruitment translates into high-quality, sustainable rural healthcare workforce development.

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