• 1.

    Collins FS, Glass RI, Whitescarver J, Wakefield M, Goosby EP, 2010. Public health: developing health workforce capacity in Africa. Science 330: 13241325.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 3.

    Kruk ME, Myers M, Varpilah ST, Dahn BT, 2015. What is a resilient health system? Lessons from Ebola. Lancet 385: 19101912.

  • 4.

    World Health Organization (WHO), 2006. The World Health Report 2006: Working Together for Health. Geneva, Switzerland: WHO.

  • 5.

    Joint Learning Initiative, 2004. Human Resources for Health: Overcoming the Crisis. Cambridge, MA: Harvard University.

  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 22.

    World Health Organization (WHO), 2010. Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention. Geneva, Switzerland: WHO.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 25.

    De Vries E, Reid S, 2003. Do South African rural origin medical students return to rural practice? S Afr Med J 93: 789793.

  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 28.

    Institute for Economics and Peace, 2011. Global Peace Index: 2011 Methodology, Results, and Findings. Sydney, New South Wales: Institute for Economics and Peace.

    • Search Google Scholar
    • Export Citation
  • 29.

    World Bank, 2012. Worldwide Governance Indicators. The World Bank Group. Available at: http://www.govindicators.org. Accessed September 23, 2013.

    • Search Google Scholar
    • Export Citation
  • 30.

    World Bank, 1993. World Development Report 1993: Investing in Health. Washington, DC: The World Bank Group.

  • 31.

    Harrell FE, 2001. Regression Modeling Strategies With Applications to Linear Models, Logistic Regression, and Survival Analysis. New York, NY: Springer.

    • Search Google Scholar
    • Export Citation
  • 32.

    Little RJA, Rubin DB, 1987. Statistical Analysis with Missing Data. New York, NY: Wiley.

  • 33.

    DerSimonian R, Laird N, 1986. Meta-analysis in clinical trials. Control Clin Trials 7: 177188.

  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 45.

    Clemens M, Pettersson G, 2008. New data on African health professionals abroad. Hum Resour Health 6: 1.

  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 49.

    Albanese MA, Snow MH, Skochelak SE, Huggett KN, Farrell PM, 2003. Assessing personal qualities in medical school admissions. Acad Med 78: 313321.

  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
  • 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.

    • Search Google Scholar
    • Export Citation
 
 
 

 

 
 
 

 

 

 

 

 

 

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

View More View Less
  • 1 Vanderbilt University Institute for Global Health, Nashville, Tennessee.
  • | 2 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
  • | 3 Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
  • | 4 Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
  • | 5 Vanderbilt University School of Nursing, Nashville, Tennessee.
  • | 6 International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
  • | 7 Department of Mathematics and Statistics, University of Calgary, Calgary, Alberta, Canada.
  • | 8 Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia.
  • | 9 Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.
  • | 10 Department of Physiology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, Delhi, India.
  • | 11 Department of Physiology, All India Institute of Medical Sciences, Ansari Nagar, Delhi, India.
  • | 12 University of Malawi College of Medicine, Blantyre, Malawi.
  • | 13 Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
  • | 14 Department of Human Anatomy, University of Nairobi, Nairobi, Kenya.
  • | 15 Department of Anatomy, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.

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.

    • Supplemental Materials (PDF 449 KB)

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.

Save