1921
Volume 96, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645

Abstract

Abstract

We sought to identify independent, nonacademic predictors of medical and nursing student intent to migrate abroad or from rural to urban areas after graduation in low- and middle-income countries (LMIC). This was a cross-sectional survey of 3,199 first- and final-year medical and nursing students at 16 training institutions in eight LMIC. Questionnaires assessed demographics, career intentions, and preferences regarding selected career, location, and work-related attributes. Using principal component analysis, student preferences were reduced into four discrete categories of priorities: 1) work environment resources, 2) location livability, 3) altruistic job values, and 4) individualistic job values. Students' preferences were scored in each category. Using students' characteristics and priority scores, multivariable proportional odds models were used to derive independent predictors of intentions to emigrate for work outside the country, or to work in a rural area in their native country. Students prioritizing individualistic values more often planned international careers (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.16–1.78), whereas those prioritizing altruistic values preferred rural careers (aOR = 1.82, 95% CI = 1.50–2.21). Trainees prioritizing high-resource environments preferentially planned careers abroad (aOR = 1.38, 95% CI = 1.12–1.69) and were unlikely to seek rural work (aOR = 0.60, 95% CI = 0.49–0.73). Independent of their priorities, students with prolonged prior rural residence were unlikely to plan emigration (aOR = 0.67, 95% CI = 0.50–0.90) and were more likely to plan a rural career (aOR = 1.53, 95% CI = 1.16–2.03). We conclude that use of nonacademic attributes in medical and nursing admissions processes would likely increase retention in high-need rural areas and reduce emigration “brain drain” in LMIC.

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References

  1. Collins FS, Glass RI, Whitescarver J, Wakefield M, Goosby EP, , 2010. Public health: developing health workforce capacity in Africa. Science 330: 13241325.[Crossref] [Google Scholar]
  2. Samb B, Desai N, Nishtar S, Medis S, Bekedam H, Wright A, Hsu J, Martiniuk A, Celletti F, Patel K, Adshead F, McKee M, Evans T, Alwan A, Etienne C, , 2010. Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. Lancet 376: 17851797.[Crossref] [Google Scholar]
  3. Kruk ME, Myers M, Varpilah ST, Dahn BT, , 2015. What is a resilient health system? Lessons from Ebola. Lancet 385: 19101912.[Crossref] [Google Scholar]
  4. World Health Organization (WHO), 2006. The World Health Report 2006: Working Together for Health. Geneva, Switzerland: WHO. [Google Scholar]
  5. Joint Learning Initiative, 2004. Human Resources for Health: Overcoming the Crisis. Cambridge, MA: Harvard University. [Google Scholar]
  6. World Health Organization (WHO), 2014. Global Health Workforce Statistics, 2014 Update. Geneva, Switzerland: WHO. Available at: http://www.who.int/hrh/statistics/hwfstats/. Accessed October 20, 2015. [Google Scholar]
  7. WHO, 2014. Global Health Estimates 2014 Summary Tables: Deaths by Cause, Age and Sex by WHO region, 2000–2012. Geneva, Switzerland: WHO. Available at: http://www.who.int/healthinfo/global_burden_disease/en/. Accessed October 20, 2015. [Google Scholar]
  8. Tankwanchi ABS, Vermund SH, Perkins DD, , 2014. Has the WHO Global Code of Practice on the International Recruitment of Health Personnel been effective? Lancet Glob Health 2: e390e391.[Crossref] [Google Scholar]
  9. Tankwanchi ABS, Vermund SH, Perkins DD, , 2015. Monitoring sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: temporal and geographic patterns in the United States. PLoS One 10: e0124734.[Crossref] [Google Scholar]
  10. Mullan F, Frehywot S, Omaswa F, Sewankambo N, Talib Z, Chen C, Kiarie J, Kiguli-Malwadde E, , 2012. The Medical Education Partnership Initiative: PEPFAR's effort to boost health worker education to strengthen health systems. Health Aff (Millwood) 31: 15611572.[Crossref] [Google Scholar]
  11. Middleton L, Howard AA, Dohrn J, Von Zinkernagel D, Parham Hopson D, Aranda-Naranjo B, Hall C, Malata A, Bvumbwe T, Chabela A, Molise N, El-Sadr WM, , 2014. The Nursing Education Partnership Initiative (NEPI): innovations in nursing and midwifery education. Acad Med 89 (Suppl): S24S28.[Crossref] [Google Scholar]
  12. Eichbaum Q, Nyarango P, Bowa K, Odonkor P, Ferrão J, Mashalla Y, Vainio O, Vermund SH, , 2012. “Global networks, alliances and consortia” in global health education-the case for south-to-south partnerships. J Acquir Immune Defic Syndr 61: 263264.[Crossref] [Google Scholar]
  13. Talib ZM, Kiguli-Malwadde E, Wohltjen H, Derbew M, Mulla Y, Olaleye D, Sewankambo N, , 2015. Transforming health professions' education through in-country collaboration: examining the consortia among African medical schools catalyzed by the Medical Education Partnership Initiative. Hum Resour Health 13: 1.[Crossref] [Google Scholar]
  14. Olapade-Olaopa EO, Baird S, Kiguli-Malwadde E, Kolars JC, , 2014. Growing partnerships: leveraging the power of collaboration through the Medical Education Partnership Initiative. Acad Med 89 (Suppl): S19S23.[Crossref] [Google Scholar]
  15. Eichbaum Q, Bowa K, Pires P, Vanio O, Nyarango P, , 2014. Challenges and opportunities for new medical schools in Africa: the Consortium of New Southern African Medical Schools (CONSAMS). Acad Med 89 (Suppl): S108S109.[Crossref] [Google Scholar]
  16. Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, Wassermann T, Abubakr DEE, Awases M, Boelen C, Diomande MJ-MI, Dovlo D, Ferro J, Haileamlak A, Iputo J, Jacobs M, Koumaré AK, Mipando M, Monekosso GL, Olapade-Olaopa EO, Rugarabamu P, Sewankambo NK, Ross H, Ayas H, Chale SB, Cyprien S, Cohen J, Haile-Mariam T, Hamburger E, Jolley L, Kolars JC, Kombe G, Neusy A-J, , 2011. Medical schools in sub-Saharan Africa. Lancet 377: 11131121.[Crossref] [Google Scholar]
  17. Mokone GG, Kebaetse M, Wright J, Kebaetse MB, Makgabana-Dintwa O, Kebaabetswe P, Badlangana L, Mogodi M, Bryant K, Nkomazana O, , 2014. Establishing a new medical school: Botswana's experience. Acad Med 89 (Suppl): S83S87.[Crossref] [Google Scholar]
  18. Tankwanchi ABS, Ozden C, Vermund SH, , 2013. Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile. PLoS Med 10: e1001513.[Crossref] [Google Scholar]
  19. Silvestri DM, Blevins M, Afzal AR, Andrews B, Derbew M, Kaur S, Mipando M, Mkony CA, Mwachaka PM, Ranjit N, Vermund S, , 2014. Medical and nursing students' intentions to work abroad or in rural areas: a cross-sectional survey in Asia and Africa. Bull World Health Organ 92: 750759.[Crossref] [Google Scholar]
  20. Mills EJ, Kanters S, Hagopian A, Mtambo A, Bourgeault IL, Luboga S, , 2011. The financial cost of doctors emigrating from sub-Saharan Africa: human capital analysis. BMJ 7031: 113. [Google Scholar]
  21. Lehmann U, Dieleman M, Martineau T, , 2008. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 8: 19.[Crossref] [Google Scholar]
  22. World Health Organization (WHO), 2010. Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention. Geneva, Switzerland: WHO. [Google Scholar]
  23. Grobler L, Marais BJ, Mabunda S, , 2015. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 6: CD005314. [Google Scholar]
  24. Dolea C, Stormont L, Braichet J-M, , 2010. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ 88: 379385.[Crossref] [Google Scholar]
  25. De Vries E, Reid S, , 2003. Do South African rural origin medical students return to rural practice? S Afr Med J 93: 789793. [Google Scholar]
  26. Zimmerman M, Shakya R, Pokhrel BM, , 2012. Medical students' characteristics as predictors of career practice location: retrospective cohort study tracking graduates of Nepal's first medical college. BMJ 345: e4826.[Crossref] [Google Scholar]
  27. United Nations (UN), 2012. List of Peacekeeping Operations: 1948–2012. UN. Available at: http://www.un.org/en/peacekeeping/documents/operationslist.pdf. Accessed September 24, 2013. [Google Scholar]
  28. Institute for Economics and Peace, 2011. Global Peace Index: 2011 Methodology, Results, and Findings. Sydney, New South Wales: Institute for Economics and Peace. [Google Scholar]
  29. World Bank, 2012. Worldwide Governance Indicators. The World Bank Group. Available at: http://www.govindicators.org. Accessed September 23, 2013. [Google Scholar]
  30. World Bank, 1993. World Development Report 1993: Investing in Health. Washington, DC: The World Bank Group. [Google Scholar]
  31. Harrell FE, , 2001. Regression Modeling Strategies With Applications to Linear Models, Logistic Regression, and Survival Analysis. New York, NY: Springer. [Google Scholar]
  32. Little RJA, Rubin DB, , 1987. Statistical Analysis with Missing Data. New York, NY: Wiley. [Google Scholar]
  33. DerSimonian R, Laird N, , 1986. Meta-analysis in clinical trials. Control Clin Trials 7: 177188.[Crossref] [Google Scholar]
  34. Koenig HG, Büssing A, , 2010. The Duke University Religion Index (DUREL): a five-item measure for use in epidemological studies. Religions (Basel) 1: 7885.[Crossref] [Google Scholar]
  35. Eley D, Young L, Przybeck TR, , 2009. Exploring temperament and character traits in medical students; a new approach to increase the rural workforce. Med Teach 31: e79e84.[Crossref] [Google Scholar]
  36. Royston PJ, Mathieson K, Leafman J, Ojan-Sheehan O, , 2012. Medical student characteristics predictive of intent for rural practice. Rural Remote Health 12: 2107. [Google Scholar]
  37. Rabinowitz HK, Diamond JJ, Markham FW, Santana AJ, , 2012. The relationship between matriculating medical students' planned specialties and eventual rural practice outcomes. Acad Med 87: 10861090.[Crossref] [Google Scholar]
  38. Huntington I, Shrestha S, Reich NG, Hagopian A, , 2012. Career intentions of medical students in the setting of Nepal's rapidly expanding private medical education system. Health Policy Plan 27: 417428.[Crossref] [Google Scholar]
  39. Kotha SR, Johnson JC, Galea S, Agyei-Baffour P, Nakua E, Asabir K, Kwansah J, Gyakobo M, Dzodzomenyo M, Kruk ME, , 2012. Lifecourse factors and likelihood of rural practice and emigration: a survey of Ghanaian medical students. Rural Remote Health 12: 1898. [Google Scholar]
  40. Johnson JC, Nakua E, Dzodzomenyo M, Agyei-Baffour P, Gyakobo M, Asabir K, Kwansah J, Kotha SR, Snow RC, Kruk ME, , 2011. For money or service? A cross-sectional survey of preference for financial versus non-financial rural practice characteristics among Ghanaian medical students. BMC Health Serv Res 11: 300.[Crossref] [Google Scholar]
  41. Blaauw D, Erasmus E, Pagaiya N, Tangcharoensathein V, Mullei K, Mudhune S, Goodman C, English M, Lagarde M, , 2010. Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Bull World Health Organ 88: 350356.[Crossref] [Google Scholar]
  42. Serneels P, Montalvo JG, Pettersson G, Lievens T, Butera JD, Kidanu A, , 2010. Who wants to work in a rural health post? The role of intrinsic motivation, rural background and faith-based institutions in Ethiopia and Rwanda. Bull World Health Organ 88: 342349.[Crossref] [Google Scholar]
  43. Kruk ME, Johnson JC, Gyakobo M, Agyei-Baffour P, Asabir K, Kotha SR, Kwansah J, Nakua E, Snow RC, Dzodzomenyo M, , 2010. Rural practice preferences among medical students in Ghana: a discrete choice experiment. Bull World Health Organ 88: 333341.[Crossref] [Google Scholar]
  44. Leon BK, Riise Kolstad J, , 2010. Wrong schools or wrong students? The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania. Hum Resour Health 8: 3.[Crossref] [Google Scholar]
  45. Clemens M, Pettersson G, , 2008. New data on African health professionals abroad. Hum Resour Health 6: 1.[Crossref] [Google Scholar]
  46. Larkins S, Michielsen K, Iputo J, Elsanousi S, Mammen M, Graves L, Willems S, Cristobal FL, Samson R, Ellaway R, Ross S, Johnston K, Derese A, Neusy AJ, , 2015. Impact of selection strategies on representation of underserved populations and intention to practise: international findings. Med Educ 49: 6072.[Crossref] [Google Scholar]
  47. Sen Gupta T, Murray R, Hays R, Woolley T, , 2013. James Cook University MBBS graduate intentions and intern destinations: a comparative study with other Queensland and Australian medical schools. Rural Remote Health 13: 2313. [Google Scholar]
  48. Bailey N, Mandeville KL, Rhodes T, Mipando M, Muula AS, , 2012. Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study. BMC Med Educ 12: 87.[Crossref] [Google Scholar]
  49. Albanese MA, Snow MH, Skochelak SE, Huggett KN, Farrell PM, , 2003. Assessing personal qualities in medical school admissions. Acad Med 78: 313321.[Crossref] [Google Scholar]
  50. Parry J, Mathers J, Stevens A, Parsons A, Lilford R, Spurgeon P, Thomas H, , 2006. Admissions processes for five year medical courses at English schools review. BMJ 332: 10051009.[Crossref] [Google Scholar]
  51. Stagg P, Rosenthal DR, , 2012. Why community members want to participate in the selection of students into medical school. Rural Remote Health 12: 1954. [Google Scholar]
  52. Lumsden MA, Bore M, Millar K, Jack R, Powis D, , 2005. Assessment of personal qualities in relation to admission to medical school. Med Educ 39: 258265.[Crossref] [Google Scholar]
  53. Frehywot S, Mullan F, Payne PW, Ross H, , 2010. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Bull World Health Organ 88: 364370.[Crossref] [Google Scholar]
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Supplemental Appendix, Table, and Figure

  • Received : 16 Sep 2016
  • Accepted : 21 Jan 2017

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