Nonacademic Attributes Predict Medical and Nursing Student Intentions to Emigrate or to Work Rurally: An Eight-Country Survey in Asia and Africa

David M. Silvestri Vanderbilt University Institute for Global Health, Nashville, Tennessee.

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Meridith Blevins Vanderbilt University Institute for Global Health, Nashville, Tennessee.
Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.

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Kenneth A. Wallston Vanderbilt University Institute for Global Health, Nashville, Tennessee.
Vanderbilt University School of Nursing, Nashville, Tennessee.

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Arfan R. Afzal International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
Department of Mathematics and Statistics, University of Calgary, Calgary, Alberta, Canada.

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Nazmul Alam Department of Mathematics and Statistics, University of Calgary, Calgary, Alberta, Canada.

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Ben Andrews Vanderbilt University Institute for Global Health, Nashville, Tennessee.
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia.

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Miliard Derbew Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.

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Simran Kaur Department of Physiology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, Delhi, India.
Department of Physiology, All India Institute of Medical Sciences, Ansari Nagar, Delhi, India.

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Mwapatsa Mipando University of Malawi College of Medicine, Blantyre, Malawi.

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Charles A. Mkony Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.

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Philip M. Mwachaka Department of Human Anatomy, University of Nairobi, Nairobi, Kenya.

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Nirju Ranjit Department of Anatomy, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.

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Sten H. Vermund Vanderbilt University Institute for Global Health, Nashville, Tennessee.
Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

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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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Author Notes

* Address correspondence to David M. Silvestri, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. E-mail: david.m.silvestri@gmail.com

Financial support: This study was financially supported by the Vanderbilt University School of Medicine Medical Scholars Program.

Authors' addresses: David M. Silvestri, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, E-mail: david.m.silvestri@gmail.com. Meridith Blevins and Ben Andrews, Vanderbilt University Institute for Global Health, Nashville, TN, E-mails: meridith.blevins@vanderbilt.edu and lauandrews@yahoo.com. Kenneth A. Wallston, Vanderbilt University School of Nursing, Nashville, TN, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, and Harvard Affiliated Emergency Medicine Residency, Boston, MA, E-mail: ken.wallston@vanderbilt.edu. Arfan R. Afzal, Department of Mathematics and Statistics, University of Calgary, Calgary, Alberta, Canada, E-mail: nafzal@isrt.ac.bd. Nazmul Alam, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh, E-mail: nazmul@icddrb.org. Miliard Derbew, Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia, E-mail: milliardderbew@gmail.com. Simran Kaur, Department of Physiology, All India Institute of Medical Sciences, Ansari Nagar, Delhi, India, E-mail: simranmamc@gmail.com. Mwapatsa Mipando, University of Malawi College of Medicine, Blantyre, Malawi, E-mail: mipando@medcol.mw. Charles A. Mkony, Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, E-mail: charles_mkony@yahoo.com. Philip M. Mwachaka, Department of Human Anatomy, University of Nairobi, Nairobi, Kenya, E-mail: pmaseghe@gmail.com. Nirju Ranjit, Department of Anatomy, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal, E-mail: nirju_r@yahoo.com. Sten H. Vermund, Yale School of Public Health, New Haven, CT, E-mail: sten.vermund@yale.edu.

Reprint requests: Sten H. Vermund, Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN 32703, E-mail: sten.vermund@vanderbilt.edu, Tel: 1-615-322-9374.

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