Résumé

Objectif

Évaluer les intentions des étudiants en médecine et en soins infirmiers concernant une émigration à l'étranger ou une pratique dans les zones rurales.

Méthodes

Nous avons interrogé 3199 étudiants en première année et en dernière année de médecine ou de soins infirmiers dans les 16 plus grandes institutions gouvernementales au Bangladesh, en Ethiopie, en Inde, au Kenya, au Malawi, au Népal, en Tanzanie et en Zambie. L'enquête contenait des questions pour identifier les facteurs qui pourraient prédire les intentions d'émigration des étudiants. Les résultats primaires étaient les probabilités d'émigration en vue de travailler à l'étranger ou dans les zones rurales du pays où a été livrée la formation, dans les cinq ans suivant la fin de la formation. Nous avons évalué les indicateurs des intentions d'émigration en utilisant des modèles à cotes proportionnelles multivariés.

Résultats

Parmi les répondants, 28% (870/3156) espèrent émigrer à l'étranger, alors que seuls 18% (575/3158) envisagent une carrière en zone rurale. Les étudiants infirmiers désirant pratiquer à l'étranger (rapport des cotes, RC: 1,76; intervalle de confiance à 95%, IC 95%: 1,25–2,48) étaient plus nombreux que les étudiants en médecine. Les souhaits de carrière avant toute installation officielle étaient corrélés avec les intentions actuelles pour les carrières à l'international (RC: 4,49; IC 95%: 3,21–6,29) et dans les zones rurales (RC: 4,84; IC 95%: 3,52–6,66). Le temps passé dans les zones rurales avant installation prédit une préférence pour une carrière rurale (20 contre 0 année: RC: 1,53; IC 95%: 1,19–1,98) et contre le fait de travailler à l'étranger (20 contre 0 année: RC: 0,69; IC 95%: 0,50-0,96).

Conclusion

Une part importante des étudiants interrogés continue à vouloir travailler à l'étranger ou dans les villes après la fin de leur formation. Ces intentions pouvaient être identifiées même avant leur installation. Des normes d'admission tenant compte des années passées dans les zones rurales pourraient favoriser une meilleure rétention des diplômés dans le pays de leur formation et dans les zones rurales.

Resumen

Objetivo

Evaluar las intenciones de los estudiantes de medicina y enfermería de emigrar al extranjero o trabajar en zonas rurales.

Métodos

Se encuestó a 3199 estudiantes de medicina y enfermería de primer y último curso de 16 instituciones gubernamentales de primer nivel en Bangladesh, Etiopía, India, Kenya, Malawi, Nepal, Tanzania y Zambia. La encuesta incluyó preguntas para identificar los factores que podrían predecir las intenciones de emigrar de los estudiantes. Los resultados primarios fueron las probabilidades de emigrar para trabajar en el extranjero o en zonas rurales en el país de formación en los cinco años posteriores a esta. Los indicadores de las intenciones de migración se evaluaron por medio de modelos de probabilidades proporcionales multivariables.

Resultados

Entre los encuestados, el 28 % (870/3156) esperaba emigrar al extranjero, mientras que solo el 18 % (575/3158) preveía una carrera rural. Más estudiantes de enfermería que de medicina deseaban desarrollar su profesión en extranjero (proporción de probabilidad, OR: 1,76; intervalo de confianza del 95 %, IC: 1,25–2,48). Los deseos sobre la carrera profesional antes de la matriculación se correspondían con los deseos actuales de desarrollar una carrera internacional (OR: 4,49; 95 % IC: 3,21–6,29) y rural (OR: 4,84; 95 % IC: 3,52–6,66). El tiempo pasado en zonas rurales antes de la matriculación predijo la preferencia por una carrera rural (20 frente a 0 años: OR: 1,53; 95 % IC: 1,19–1,98) y en contra de trabajar en el extranjero (20 frente a 0 años: OR: 0,69; 95 % IC: 0,50–0,96).

Conclusión

Una proporción significativa de los estudiantes encuestados todavía tiene la intención de trabajar en el extranjero o en ciudades una vez finalizados los estudios. Dichas intenciones pudieron identificarse incluso antes de la matriculación. Las normas de admisión que contabilizan los años pasados en zonas rurales podrían promover una mayor retención de los graduados en el país de formación y en las zonas rurales.

ملخص

الغرض

تقييم نوايا طلاب الطب والتمريض للهجرة إلى الخارج أو العمل في المناطق الريفية.

الطريقة

أجرينا دراسة استقصائية عن 3199 طالب من طلاب الطب والتمريض في السنة الأولى والأخيرة في 16 مؤسسة حكومية رائدة في بنغلاديش وإثيوبيا والهند وكينيا وملاوي ونيبال وجمهورية تنزانيا المتحدة وزامبيا. وتضمنت الدراسة الاستقصائية أسئلة لتحديد العوامل التي يمكنها أن تنبئ بنوايا الطلاب للهجرة. وتمثلت الحصائل الأولية في احتمالات الهجرة بغية العمل في الخارج أو العمل في المناطق الريفية في بلد التدريب في غضون خمس سنوات بعد قضاء التدريب. وقمنا بتقييم عوامل التكهن بنوايا الهجرة باستخدام نماذج الاحتمال النسبية متعددة المتغيرات.

النتائج

توقعت نسبة 28 % (870/3156) من المستجيبين الهجرة إلى الخارج، في حين لم يتوقع العمل في المناطق الريفية سوى 18 % فقط (575/3158). ومقارنة بطلاب الطب، رغب المزيد من طلاب التمريض في العمل خارج بلادهم (نسبة الاحتمال: 1.76؛ فاصل الثقة 95 %، فاصل الثقة: 1.25–2.48). وارتبطت رغبات العمل قبل الالتحاق بالتدريب بالنوايا الراهنة في الحصول على وظائف دولية (نسبة الاحتمال: 4.49؛ فاصل الثقة 95 %: من 3.21 إلى 6.29) وريفية (نسبة الاحتمال: 4.84؛ فاصل الثقة 95 %: من 3.52 إلى 6.66). وتنبأ الوقت الذي تم قضاؤه في المناطق الريفية قبل الالتحاق بالتدريب بتفضيل العمل في المناطق الريفية (20 مقابل 0 سنة: نسبة الاحتمال: 1.53، فاصل الثقة: 95 %، فاصل الثقة: من 1.19 إلى 1.98) وعدم العمل في الخارج (20 مقابل 0 سنة: نسبة الاحتمال: 0.69، فاصل الثقة: 95 %، فاصل الثقة: من 0.50 إلى 0.96).

الاستنتاج

ما زالت نسبة كبيرة من الطلاب الذين تم دراستهم استقصائياً ينوون العمل في الخارج أو في المدن بعد قضاء التدريب. ويمكن تحديد هذه النوايا حتى قبل الالتحاق بالتدريب. ويمكن أن تعزز معايير القبول التي تفسر عدد السنوات التي تم قضاؤها في الريف قدراً أكبر من استبقاء الخريجين في بلد التدريب وفي المناطق الريفية.

.

摘要

目的

评估医疗和护理学生出国或在农村地区就业的意向。

方法

我们调查了孟加拉国、埃塞俄比亚、印度、肯尼亚、马拉维、尼泊尔、坦桑尼亚联合共和国和赞比亚16所主要政府院校3199名一年级和毕业班的医疗和护理学生。调查所包含的一些问题被用来确定能够预测学生迁移意向的因素。主要结果是在五年在岗培训期间迁移到国外工作或在培训国农村地区工作的可能性。我们使用多变量比例优势模型评估迁移意向预测因素。

结果

在应答者中，28%（870/3156）期望出国，仅18%（575/3158）期望在乡村工作。较之医疗学生，更多护理学生期望到国外从业（优势比，OR：1.76；95%置信区间，CI：1.25-2.48）。大学入学之前的职业期望与当前国际（OR：4.49；95% CI：3.21-6.29）和乡村（OR：4.84；95% CI：3.52-6.66）就业意向有关联。入学之前在农村地区呆过的时间预示了想到农村就业（20比对0年：OR：1.53，95% CI：1.19-1.98）以及不希望出国工作（20比对0年：OR：0.69，95% CI：0.50-0.96）的程度。

结论

很大一部分受调查的学生仍打算在培训后出国工作或在城市工作。甚至在入学之前就可以分辨出这种意向。在招生标准中列入农村地区呆过的时间，可以将更多的毕业生留在其接受培训的国家和农村地区。

Резюме

Цель

Оценить стремление студентов, обучающихся на врачей и медсестер, переехать за границу или продолжить практику в сельской местности.

Методы

Мы опросили 3199 студентов первого и последнего курсов, обучающихся на врачей и медсестер в 16 лучших государственных образовательных учреждениях Бангладеш, Эфиопии, Индии, Кении, Малави, Непала, Объединенной Республики Танзании и Замбии. Исследование включало вопросы, помогающие определить факторы, влияющие на желание студентов переехать. Основные результаты определили вероятность переезда за границу или в сельскую местность в стране обучения для работы в течение пятилетнего периода после завершения обучения. Мы оценили факторы, влияющие на стремление переехать, с помощью многоаспектной пропорциональной модели.

Результаты

Среди опрашиваемых лиц 28% (870/3156) планируют переезд за границу и лишь 18% (575/3158) планируют продолжить карьеру в сельской местности. Будущие медсестры чаще, чем будущие врачи, хотят получить работу за границей (коэффициент вероятности: 1,76, 95%; доверительный интервал: 1,25–2,48). Планируемая дальнейшая карьера до поступления в высшее учебное заведение совпадала с текущими стремлениями: для желающих работать за границей (коэффициент вероятности: 4,49, 95%; доверительный интервал: 3,21–6,29) и для желающих работать в сельской местности (коэффициент вероятности: 4,84, 95%; доверительный интервал: 3,52–6,66). Проживание в сельских районах до поступления в высшее учебное заведение часто предопределяло желание работать в сельской местности (20 лет по отношению к 0 лет: коэффициент вероятности: 1,53, 95%; доверительный интервал: 1,19–1,98) по сравнению с желанием работать за границей (20 лет по отношению к 0 лет: коэффициент вероятности: 0,69, 95% доверительный интервал: 0,50–0,96).

Вывод

Значительная часть опрошенных студентов после обучения планируют работать за границей или в городе. Данные цели иногда были определены еще до поступления в высшее учебное заведение. Введение льгот при приеме в учебные заведения может способствовать удержанию выпускников в стране обучения и сельских регионах.

Introduction

Shortages of physicians and nurses jeopardize health system advances in many low- and middle-income countries (LMIC).¹1 Joint Learning Initiative. Human resources for health: overcoming the crisis. Cambridge: Harvard University; 2004.^,22 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. Sub-Saharan Africa has only 2 doctors and 11 nurses or midwives per 10 000 people, compared with approximately 30 physicians and 84 nurses or midwives per 10 000 people in high-income countries.³3 World Bank Data, sub-Saharan Africa [Internet]. Washington: World Bank; 2012. Available from: http://data.worldbank.org/region/SSA [cited 2014 Aug 18].
http://data.worldbank.org/region/SSA... ^,44 World Bank Data, high income [Internet]. Washington: The World Bank; 2012. Available from: http://data.worldbank.org/income-level/HIC [cited 2014 Aug 18].
http://data.worldbank.org/income-level/H... Emigration of health professionals from LMIC to countries with less need of such professionals exacerbates the global workforce imbalance.¹1 Joint Learning Initiative. Human resources for health: overcoming the crisis. Cambridge: Harvard University; 2004.^,22 The world health report 2006: working together for health. Geneva: World Health Organization; 2006.^,55 Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353(17):1810–8. doi: http://dx.doi.org/10.1056/NEJMsa050004 PMID: 16251537
https://doi.org/10.1056/NEJMsa050004... Meanwhile, rural-to-urban migration of those professionals continues to increase provider shortages in rural areas where the need is the greatest.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... ^,77 Lemiere C, Herbst CH, Jahanshahi N, Smith E, Soucat A. Reducing geographic imbalances in health workers in Sub-Saharan Africa [World Bank Working Paper No. 209]. Washington: World Bank; 2011.

To address the human resource problems in LMIC’s health sector, the Global Health workforce alliance was formed in 2006 to identify, implement and advocate solutions to the crisis.⁸8 Global health workforce alliance. Geneva: World Health Organization: 2014. Available from: http://www.who.int/workforcealliance/about/en/ [cited 2014 Jul 8].
http://www.who.int/workforcealliance/abo... Then in 2010, the World Health Organization (WHO) issued a global Code of Practice that intended to curb international migration of health professionals.⁹9 World Health Organization Global Code of Practice on the international recruitment of health personnel. In: Sixty-third World Health Assembly, Geneva, May 2010. Available from: http://www.who.int/hrh/migration/code/practice/en/ [cited 2014 Jan 18].
http://www.who.int/hrh/migration/code/pr... WHO has also published recommendations for attracting, recruiting and retaining health workers in rural areas.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... Since then, partnerships between governments, institutions and funding organizations have emerged to strengthen LMIC health workforces.¹⁰10 Collins FS, Glass RI, Whitescarver J, Wakefield M, Goosby EP. Public health. Developing health workforce capacity in Africa. Science. 2010;330(6009):1324–5. doi: http://dx.doi.org/10.1126/science.1199930 PMID: 21127233
https://doi.org/10.1126/science.1199930... ^–1212 Eichbaum Q, Nyarango P, Bowa K, Odonkor P, Ferrão J, Mashalla Y, et al. “Global networks, alliances and consortia” in global health education-the case for south-to-south partnerships. J Acquir Immune Defic Syndr. 2012;61(3):263–4. doi: http://dx.doi.org/10.1097/QAI.0b013e31826bf957 PMID: 22878420
https://doi.org/10.1097/QAI.0b013e31826b... New medical and nursing schools have been established and existing ones expanded,¹³13 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... while curricular reforms have been instituted to enhance graduate retention.¹³13 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... ^,1414 Buchan J, Couper ID, Tangcharoensathien V, Thepannya K, Jaskiewicz W, Perfilieva G, et al. Early implementation of WHO recommendations for the retention of health workers in remote and rural areas. Bull World Health Organ. 2013;91(11):834–40. doi: http://dx.doi.org/10.2471/BLT.13.119008 PMID: 24347707
https://doi.org/10.2471/BLT.13.119008...

Yet, these investments have been made without systematic analysis of the students’ migration intentions. We know very little regarding the characteristics of students inclined to work in rural areas or remain in the country in which they train.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... Without such information, resource-intensive interventions might promote training of graduates with no plans to practice in areas of need. Scholarship-bonding schemes and compulsory service obligations to work in areas with professional shortages struggle to achieve long-term retention,¹⁵15 Frehywot S, Mullan F, Payne PW, Ross H. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Bull World Health Organ. 2010;88(5):364–70. doi: http://dx.doi.org/10.2471/BLT.09.071605 PMID: 20461136
https://doi.org/10.2471/BLT.09.071605... with most of the health-care professionals leaving shortly after required service terms.¹⁶16 Tankwanchi ABS, Özden C, Vermund SH. Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile. PLoS Med. 2013;10(9):e1001513. doi: http://dx.doi.org/10.1371/journal.pmed.1001513 PMID: 24068894
https://doi.org/10.1371/journal.pmed.100... Greater understanding of factors associated with students’ intentions to work in high-demand regions is needed,⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... ^,1717 Greysen SR, Dovlo D, Olapade-Olaopa EO, Jacobs M, Sewankambo N, Mullan F. Medical education in sub-Saharan Africa: a literature review. Med Educ. 2011;45(10):973–86. doi: http://dx.doi.org/10.1111/j.1365-2923.2011.04039.x PMID: 21916938
https://doi.org/10.1111/j.1365-2923.2011... and this could help direct admissions’ policies towards selecting individuals most likely to serve in these settings long-term.

Previous studies on health worker retention are mainly from high-income countries¹⁸18 Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res. 2008;8(1):19. doi: http://dx.doi.org/10.1186/1472-6963-8-19 PMID: 18215313
https://doi.org/10.1186/1472-6963-8-19... ^–2020 Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88(5):379–85. doi: http://dx.doi.org/10.2471/BLT.09.070607 PMID: 20461133
https://doi.org/10.2471/BLT.09.070607... and are not applicable to LMIC. Compared to graduates in high-income countries, LMIC graduates face greater resource disparities between rural and urban settings, as well as the additional lure of providing support to family through remitted salaries earned abroad. Assessments from LMIC are limited in size and fail to compare class years, degree programmes, institutions and countries.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... To address this research gap, we conducted a multinational assessment of medical and nursing students’ migration intentions in LMIC by surveying first- and final-year students at leading government institutions (Appendix, available from: http://biostat.mc.vanderbilt.edu/StudentMigration).

Methods

Study Design

We considered countries in sub-Saharan Africa and south-east Asia that were classified by WHO as having a critical shortage of health service providers (less than 2.28 physicians, nurses, or midwives per 1000 population).²2 The world health report 2006: working together for health. Geneva: World Health Organization; 2006. To avoid confounding effects of language on migration intentions and because most health professional emigration is to English-speaking nations,²¹21 Adsera A, Pytlikova M. The role of language in shaping international migration [IZA Discussion Paper No. 6333]. Bonn: Institute for the Study of Labor; 2012.^,2222 Clemens MA, Pettersson G. New data on African health professionals abroad. Hum Resour Health. 2008;6(1):1. doi: http://dx.doi.org/10.1186/1478-4491-6-1 PMID: 18186916
https://doi.org/10.1186/1478-4491-6-1... we included only countries where English is the language of instruction. To limit the influence of conflict and political turmoil on the results,²²22 Clemens MA, Pettersson G. New data on African health professionals abroad. Hum Resour Health. 2008;6(1):1. doi: http://dx.doi.org/10.1186/1478-4491-6-1 PMID: 18186916
https://doi.org/10.1186/1478-4491-6-1... we excluded countries with an active United Nations peacekeeping mission or bottom-decile rank in either the Global Peace Index or World Bank Worldwide Governance Indicators.²³23 List of peacekeeping operations: 1948–2012. New York: United Nations; 2012. Available from: http://www.un.org/en/peacekeeping/documents/operationslist.pdf [cited 2013 Sep 24].
http://www.un.org/en/peacekeeping/docume... ^–2525 Worldwide governance indicators [Internet]. Washington: World Bank; 2012. Available from: http://info.worldbank.org/governance/wgi/index.aspx#home [cited 2013 Sep 24].
http://info.worldbank.org/governance/wgi...

To enhance similarity between study institution governance structure and founding principles, we excluded countries without both a government medical and nursing school, or in which either school was established after 1993. This date corresponds to a period of increased attention to health sector reform in developing countries that may have affected guiding missions of health training institutions established thereafter.²⁶26 World Bank. World development report 1993: investing in health. New York: Oxford University Press; 1993.^,2727 Berman P, Bossert T. A decade of health sector reform in developing countries: what have we learned? In: Data for decision making project symposium; 2000 Mar 15, Washington, United States of America. Boston: Harvard School of Public Health; 2000. Three nations meeting selection criteria were excluded due to study resource constraints, leaving eight countries: Bangladesh, Ethiopia, India, Kenya, Malawi, Nepal, the United Republic of Tanzania and Zambia (Appendix). In each country, we selected one government medical school and affiliated government nursing school in the nation’s capital or major commercial city. In countries with multiple qualifying institutions, we used commonly accepted rankings to choose a highly reputed school where institutional approval could also be obtained. Affiliated nursing schools were selected to minimize confounding differences in institutional values, resources and faculty. We focused exclusively on premier government institutions, since they profess a longstanding mission to train future national leaders to address domestic health challenges and employ public funds towards this mission.

The 16 study sites selected are listed in Table 1. Research ethics committee approval was obtained from all sites and from the Vanderbilt University Institutional Review Board.

Procedures

We conducted the study from September 2011 to April 2012. Students eligible for our study were first- or final-year students enrolled in medical (Bachelor of Medicine and Surgery; Medical Doctor) or nursing (Bachelor of Science) degree programmes. At each institution, a self-administered questionnaire was given to all eligible students attending a mandatory class lecture. Written informed consent was obtained before survey administration. Survey items assessed student background characteristics such as socioeconomic status and place of origin, attitudes towards rural and international careers and student career intentions (Appendix). Questions, derived from literature review (Appendix), consisted largely of multiple-choice items and five-point Likert scales. Surveys were in English. To minimize potential bias from variable English proficiency, official language translations were provided as an aide alongside the English questions in five countries (Bangladesh, Ethiopia, Malawi, Nepal and the United Republic of Tanzania) where English is not an official language. Translations were validated using independent back-translation. Field testing was performed in each country and country-specific modifications were made to ensure relevant terminology. The two primary outcomes were self-reported likelihood of choosing to work outside the country or in a rural setting inside the country within five years post-training.

Questionnaire results were entered electronically and data entry audited by randomly selecting 22 electronic questionnaires from each country for comparison with hard copies. Audit sample size was calculated to ensure an estimated data entry error rate less than 5% with 95% confidence interval (CI). Questionnaires with more than 25% of responses missing were excluded from analysis.

Statistical analysis

For each country, we used summary statistics to describe respondent characteristics and multivariable proportional odds models to estimate the independent relationship between 14 selected characteristics (chosen before the analysis) and the likelihood to work internationally or in rural areas. The number of characteristics selected was computed using the smallest country sample size.²⁸28 Harrell FEJ. Regression modeling strategies with applications to linear models, logistic regression, and survival analysis. New York: Springer; 2001. The characteristics were: degree programme, class year, sex, number of languages spoken fluently, native language, years spent in a rural setting, maternal tertiary education, first-degree extended family location, self-reported family economic status, expected number of dependents within five years of graduation, post-graduate study plans, pre-matriculation desire for rural or international careers, and country of childhood. Missing values were accounted for using multiple imputation,²⁹29 Little RJA, Rubin DB. Statistical analysis with missing data. New York: Wiley; 1987. and continuous variables were expanded using restricted cubic splines to avoid assumptions of linearity.²⁸28 Harrell FEJ. Regression modeling strategies with applications to linear models, logistic regression, and survival analysis. New York: Springer; 2001. Country-specific odds ratios (ORs) were combined using the meta-analysis approach of DerSimonian and Laird,³⁰30 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88. doi: http://dx.doi.org/10.1016/0197-2456(86)90046-2 PMID: 3802833
https://doi.org/10.1016/0197-2456(86)900... a random-effects method that adjusts for heterogeneity across institutions. We used R-software version 2.15.1 (http://www.r-project.org ) for data analyses.

Results

At the 16 institutions studied, 3822 students were enrolled in first- or final-year medical or nursing degree classes (Table 1). Of these, 3217 completed the questionnaire, a median class response rate of 87% (range: 66–100%). The primary reason for non-response was student absence during questionnaire administration; six (< 1%) students were present but declined participation. Among collected surveys, 18 (0.6%) were eliminated due to incompleteness and the remaining 3199 were included for analysis. Data entry audits yielded low error rates for all sites (range: 0.02–0.6%).

Ten schools in sub-Saharan Africa comprised 66% (2118/3199) of the study population, while six South Asian schools encompassed 34% (1081/3199) (Table 1). Medical students accounted for 71% (2299/3199) of respondents. Consistent with recent expansions in student enrolment, more first-year students were surveyed than final-year (1369 versus 913). Nearly all students (98%; 3116/3179) were raised in the country of study and most (80%; 2494/3137) reported their families having average or greater wealth (Table 2).

International career intentions

Of all students, 28% (870/3156) reported being very likely to choose work abroad within five years of completing training (Table 3). International careers were anticipated by 24% (542/2254) of all medical students (26% in sub-Saharan Africa, 362/1406; 21% in South Asia, 180/848) and 36% (328/902) of all nursing students (33% in sub-Saharan Africa, 221/680; 48% in South Asia, 107/222). Only 15% (481/3156) of students reported being very unlikely to migrate. Such students were outnumbered by those expecting to leave in seven of eight countries (Appendix).

Multivariable analysis showed that nursing students were more likely than medical students to intend careers abroad (OR: 1.76; 95% CI: 1.25–2.48). Final-year students were less likely to plan international careers than first-year counterparts (OR: 0.83; 95% CI: 0.70–0.99; Table 4). The location of a student’s extended family did not correlate with international migration preferences. However, the longer that students had resided in rural settings, the less likely they were to want to work abroad (20 versus 0 years: OR: 0.69; 95% CI: 0.50–0.96; Table 4). Sex, economic status, number of languages spoken, primary language, the mother’s education and number of expected dependents were not independently associated with international migration intentions (Table 4).

Students who had desired a rural career before matriculating consistently reported having less intention of international migration (OR: 0.85; 95% CI: 0.71–1.01; Table 4), while those who had initially desired careers abroad were far more likely to want to pursue one after graduation (OR: 4.49; 95% CI: 3.21–6.29; Table 4). Final-year students who reported desiring international careers before matriculation remained nearly four times more likely to want to migrate (OR: 3.74; 95% CI: 2.25–6.21; Appendix). The desire for post-graduate specialty education also modestly increased the likelihood of wanting to seek work abroad after training (OR: 1.36; 95% CI: 0.96–1.93; Table 4). Students raised in the country of study desired international careers less than those raised abroad (OR: 0.43; 95% CI: 0.24–0.76; Table 4).

Rural career intentions

Only 18% (575/3158) of all students reported high likelihood of choosing a rural career within five years of training, including 16% (360/2257) of medical and 24% (215/901) of nursing students (Table 3). In sub-Saharan Africa, students who ruled out a rural career (29%, 609/2089) outnumbered those anticipating one (18%, 384/2089). Medical and nursing students’ intentions of rural work did not differ (OR: 0.96; 95% CI: 0.76–1.22; Table 4). Final-year students were less likely to choose rural careers after training than first-years (OR: 0.67; 95% CI: 0.55–0.82; Table 4). Students who spent longer durations in a rural setting were more likely to anticipate selecting a rural practice (20 versus 0 years: OR: 1.53; 95% CI: 1.19–1.98; Table 4). Sex, economic status, number of languages spoken, primary language, the mother’s education, number of expected dependents and the wish for an international career before starting studies were not independent predictors of rural career intentions.

As with international migration intentions, individuals who upon school entry had desired a rural career were now nearly five times more likely to plan one (OR: 4.84; 95%CI: 3.52–6.66; Table 4). Final-year students who had originally sought rural careers remained over three times more likely to choose one (OR: 3.26, 95% CI: 1.94–5.47; Appendix).

Discussion

Our data suggest that in nations with critical shortages of health professionals, nearly a quarter of medical students and over a third of nursing students surveyed felt very likely to leave their country within five years post-training. Meanwhile, less than one fifth of students anticipated a rural career. Much of this intent appears suggested by characteristics evident even before enrolment.

Our findings extend data from LMIC that students who have spent significant time in rural settings are more likely to practice in their country and in rural areas.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... ^,3131 de Vries E, Reid S. Do South African medical students of rural origin return to rural practice? S Afr Med J. 2003;93(10):789–93. PMID: 14652974^–3333 Huntington I, Shrestha S, Reich NG, Hagopian A. Career intentions of medical students in the setting of Nepal’s rapidly expanding private medical education system. Health Policy Plan. 2012;27(5):417–28. doi: http://dx.doi.org/10.1093/heapol/czr052 PMID: 21880690
https://doi.org/10.1093/heapol/czr052... We found new evidence that this likelihood correlated with the duration of residing in rural areas. Conversely, students raised abroad are most likely to emigrate.³⁴34 Kotha SR, Johnson JC, Galea S, Agyei-Baffour P, Nakua E, Asabir K, et al. Lifecourse factors and likelihood of rural practice and emigration: a survey of Ghanaian medical students. Rural Remote Health. 2012;12:1898. PMID: 22967220 As reported elsewhere,³³33 Huntington I, Shrestha S, Reich NG, Hagopian A. Career intentions of medical students in the setting of Nepal’s rapidly expanding private medical education system. Health Policy Plan. 2012;27(5):417–28. doi: http://dx.doi.org/10.1093/heapol/czr052 PMID: 21880690
https://doi.org/10.1093/heapol/czr052... ^,3535 Diwan V, Minj C, Chhari N, De Costa A. Indian medical students in public and private sector medical schools: are motivations and career aspirations different? – studies from Madhya Pradesh, India. BMC Med Educ. 2013;13(1):127. doi: http://dx.doi.org/10.1186/1472-6920-13-127 PMID: 24034988
https://doi.org/10.1186/1472-6920-13-127... sex was not independently associated with migration intentions, suggesting that women are making geographic career decisions independent of perceived family obligations.³⁶36 Kingma M. Nurses on the move: a global overview. Health Serv Res. 2007;42(3 pt 2):1281–98. doi: http://dx.doi.org/10.1111/j.1475-6773.2007.00711.x PMID: 17489915
https://doi.org/10.1111/j.1475-6773.2007... Confirming other studies,³³33 Huntington I, Shrestha S, Reich NG, Hagopian A. Career intentions of medical students in the setting of Nepal’s rapidly expanding private medical education system. Health Policy Plan. 2012;27(5):417–28. doi: http://dx.doi.org/10.1093/heapol/czr052 PMID: 21880690
https://doi.org/10.1093/heapol/czr052... ^,3737 Deressa W, Azazh A. Attitudes of undergraduate medical students of Addis Ababa University towards medical practice and migration, Ethiopia. BMC Med Educ. 2012;12(1):68. doi: http://dx.doi.org/10.1186/1472-6920-12-68 PMID: 22867022
https://doi.org/10.1186/1472-6920-12-68... self-reported economic status did not alone predict desired career location nor did high maternal education.³⁷37 Deressa W, Azazh A. Attitudes of undergraduate medical students of Addis Ababa University towards medical practice and migration, Ethiopia. BMC Med Educ. 2012;12(1):68. doi: http://dx.doi.org/10.1186/1472-6920-12-68 PMID: 22867022
https://doi.org/10.1186/1472-6920-12-68... The association between desire for post-graduate education and intended emigration may be due to the limited supply of specialty training opportunities in many countries studied and indicates the need to strengthen these post-graduate training programmes, while carefully considering which students receive scholarships for additional training.

Although we measured student intentions, our results closely parallel actual rates of migration observed among Asian and African health professionals. Among medical students we surveyed, 26% in sub-Saharan Africa and 21% in South Asia were planning to seek international careers. This resembles school administrative data indicating that 28% of recent sub-Saharan African medical graduates had migrated within five years post-training,¹³13 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... and population estimates suggesting 19–23% of Africa-trained physicians work abroad.²2 The world health report 2006: working together for health. Geneva: World Health Organization; 2006.^,3838 Docquier F, Bhargava A. A new panel data set on physicians’ emigration rates (1991–2004). Louvain-la-Neuve: Unversité catholique de Louvain. Available from: http://perso.uclouvain.be/frederic.docquier/filePDF/ MBD1_Description.pdf
http://perso.uclouvain.be/frederic.docqu... Among South Asian medical graduates – for whom data are limited – 11% work in just four developed countries: Australia, Canada the United Kingdom of Great Britain and Northern Ireland and the United States of America.⁵5 Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353(17):1810–8. doi: http://dx.doi.org/10.1056/NEJMsa050004 PMID: 16251537
https://doi.org/10.1056/NEJMsa050004... Likewise, the 16% of sub-Saharan African medical students planning rural careers in our survey mirrors observed rural practice rates reported by school administrators (16%) and regional population data (13%).¹³13 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... ^,3939 Global health atlas [Internet]. Geneva: World Health Organization; 2007. Available from: http://apps.who.int/globalatlas/ [cited 2013 Sep 24].
http://apps.who.int/globalatlas/... Estimates of nurse migration are more elusive.³⁶36 Kingma M. Nurses on the move: a global overview. Health Serv Res. 2007;42(3 pt 2):1281–98. doi: http://dx.doi.org/10.1111/j.1475-6773.2007.00711.x PMID: 17489915
https://doi.org/10.1111/j.1475-6773.2007... ^,4040 Dovlo D. Migration of nurses from sub-Saharan Africa: a review of issues and challenges. Health Serv Res. 2007;42(3 Pt 2):1373–88. doi: http://dx.doi.org/10.1111/j.1475-6773.2007.00712.x PMID: 17489920
https://doi.org/10.1111/j.1475-6773.2007... Some report 5–11% of all sub-Saharan African nurses (from diploma or degree training programmes) presently practice abroad.²²22 Clemens MA, Pettersson G. New data on African health professionals abroad. Hum Resour Health. 2008;6(1):1. doi: http://dx.doi.org/10.1186/1478-4491-6-1 PMID: 18186916
https://doi.org/10.1186/1478-4491-6-1... The higher rate of intended international migration that we observed in the same region (32%) likely reflects a greater opportunity among bachelor-degree students to move abroad compared to diploma-only graduates. Similarly, the nursing students we surveyed had lower rural practice intentions (24%) than the observed rural practice rates in sub-Saharan Africa (49%) or South Asia (31%).³⁹39 Global health atlas [Internet]. Geneva: World Health Organization; 2007. Available from: http://apps.who.int/globalatlas/ [cited 2013 Sep 24].
http://apps.who.int/globalatlas/... This indicates either a stronger urban preference among bachelor-degree nurses or an increasing trend among students to value urban careers more highly than their predecessors.

This study has several strengths. It is large and comprehensive, with 3199 students surveyed from 32 classes in eight countries (Appendix). Our aggregate class response rate is high (84%). Our study is systematic, employing rigid yet relevant selection criteria to identify study sites. All participating nations face significant health worker shortages and ongoing emigration, but possess stable environments where retention policies are not superseded by larger systemic sociopolitical motivators of migration. We independently analysed 14 student characteristics to identify predictors for a career in the country or in rural areas. Our results have implications for education and health-care policy-makers in LMIC and donor nations.

Our sample cannot be generalized to areas where internal conflict or political turmoil may drive migration regardless of student characteristics, nor can it be extrapolated to non-Anglophone countries. Sub-Saharan African countries have comparable physician emigration rates regardless of national language,²²22 Clemens MA, Pettersson G. New data on African health professionals abroad. Hum Resour Health. 2008;6(1):1. doi: http://dx.doi.org/10.1186/1478-4491-6-1 PMID: 18186916
https://doi.org/10.1186/1478-4491-6-1... indicating that different languages may not impede migrants’ mobility. However, languages do influence the destination that the migrants select,²¹21 Adsera A, Pytlikova M. The role of language in shaping international migration [IZA Discussion Paper No. 6333]. Bonn: Institute for the Study of Labor; 2012. and possibly rural retention rates of graduates.¹³13 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... The effect of languages on students’ migration plans warrants further research.

Our data suggest that students’ career desires before matriculating may persist into the last year of training. Although our study design cannot exclude recall bias, the direction of recall error is unclear and should be further investigated through longitudinal assessment. Similarly, under-reporting of true migration intentions due to perceived values of the school professionals might create a social bias. However, if such bias is present it would strengthen our results, since the true number of students intending to migrate may be higher and those planning to work in rural areas even lower than we report. Social bias was mitigated by survey anonymity and is unlikely to have affected class years differently. Our cross-sectional questionnaire of students’ intentions is not validated for predicting actual migration behaviour. Nonetheless, the similarity of our results to existing migration statistics suggests that students’ intentions may resemble such behaviour.²2 The world health report 2006: working together for health. Geneva: World Health Organization; 2006.^,1313 Mullan F, Frehywot S, Omaswa F, Buch E, Chen C, Greysen SR, et al. Medical schools in sub-Saharan Africa. Lancet. 2011;377(9771):1113–21. doi: http://dx.doi.org/10.1016/S0140-6736(10)61961-7 PMID: 21074256
https://doi.org/10.1016/S0140-6736(10)61... ^,2222 Clemens MA, Pettersson G. New data on African health professionals abroad. Hum Resour Health. 2008;6(1):1. doi: http://dx.doi.org/10.1186/1478-4491-6-1 PMID: 18186916
https://doi.org/10.1186/1478-4491-6-1... ^,3838 Docquier F, Bhargava A. A new panel data set on physicians’ emigration rates (1991–2004). Louvain-la-Neuve: Unversité catholique de Louvain. Available from: http://perso.uclouvain.be/frederic.docquier/filePDF/ MBD1_Description.pdf
http://perso.uclouvain.be/frederic.docqu... ^,3939 Global health atlas [Internet]. Geneva: World Health Organization; 2007. Available from: http://apps.who.int/globalatlas/ [cited 2013 Sep 24].
http://apps.who.int/globalatlas/... Therefore intention could be a feasible measure for migration and does not require long-term follow-up. Formal validation through longitudinal design is warranted.

Further research is needed to understand the migration intentions of students. Our study focused on students at premier public schools, where institutional missions focus on producing practitioners for domestic service and health-care leadership, and where public funds offset educational expenses. Migration ambitions may differ at private or newly-established public institutions with varying school resources, values and admissions standards. Also, longitudinal analysis is needed to discern whether differences in career plans between first- and final-year classes represent an evolution of students’ preferences during the schooling period or a change in class composition resulting from recent enrolment expansions at many institutions studied. Finally, additional migration routes of health professionals in LMIC remain to be studied: from public to private sector and from clinical to administrative sector. This is important research since health professionals’ movements from clinical public-sector work threaten already fragile public-health systems.¹1 Joint Learning Initiative. Human resources for health: overcoming the crisis. Cambridge: Harvard University; 2004.^,22 The world health report 2006: working together for health. Geneva: World Health Organization; 2006.

Increased demand for health professionals in developed countries is projected to attract even more LMIC graduates,⁴¹41 Center for Workforce Studies. The impact of health care reform on the future supply and demand for physicians: updated projections through 2025. Washington: American Association of Medical Colleges; 2010.^–4343 Future nursing workforce projections: starting the discussion. London: Center for Workforce Intelligence; 2013. and is enabled by slow legislative uptake of WHO recommendations on health personnel recruitment.⁴⁴44 Siyam A, Zurn P, Rø OC, Gedik G, Ronquillo K, Joan Co C, et al. Monitoring the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel. Bull World Health Organ. 2013;91(11):816–23. doi: http://dx.doi.org/10.2471/BLT.13.118778 PMID: 24347705
https://doi.org/10.2471/BLT.13.118778... ^,4545 Tankwanchi ABS, Vermund SH, Perkins DD. Has the WHO Global Code of Practice on the international recruitment of health personnel been effective? Lancet Glob Health. 2014;2(7):e390–1. doi: http://dx.doi.org/10.1016/S2214-109X(14)70240-2 PMID: 25103389
https://doi.org/10.1016/S2214-109X(14)70... Given the human resource needs in LMIC, migration between countries and from rural to urban settings deserves attention from policymakers both in countries with health worker shortages and partnering nations that provide technical and financial resources.⁴⁶46 Padilha A, Kasonde J, Mukti G, Crisp N, Takemi K, Buch E. Human resources for universal health coverage: leadership needed. Bull World Health Organ. 2013;91(11):800–800A. doi: http://dx.doi.org/10.2471/BLT.13.118661 PMID: 24347699
https://doi.org/10.2471/BLT.13.118661... Multiple approaches have been recommended by WHO, such as education strategies, regulatory interventions, financial incentives and personal and professional support (Table 5). They must be combined for an effective outcome.⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... Simply increasing student volume without considering student selection ignores the labour-market dynamics after training,⁴⁷47 Sousa A, Scheffler RM, Nyoni J, Boerma T. A comprehensive health labour market framework for universal health coverage. Bull World Health Organ. 2013;91(11):892–4. doi: http://dx.doi.org/10.2471/BLT.13.118927 PMID: 24347720
https://doi.org/10.2471/BLT.13.118927... and may also threaten education quality. Holding graduates in the country or in rural areas with compulsory service schemes does not seem to work in the long term,¹⁵15 Frehywot S, Mullan F, Payne PW, Ross H. Compulsory service programmes for recruiting health workers in remote and rural areas: do they work? Bull World Health Organ. 2010;88(5):364–70. doi: http://dx.doi.org/10.2471/BLT.09.071605 PMID: 20461136
https://doi.org/10.2471/BLT.09.071605... since students who migrate leave promptly after such obligations end.¹⁶16 Tankwanchi ABS, Özden C, Vermund SH. Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile. PLoS Med. 2013;10(9):e1001513. doi: http://dx.doi.org/10.1371/journal.pmed.1001513 PMID: 24068894
https://doi.org/10.1371/journal.pmed.100... Additional curricular reforms incorporating rural coursework may be inadequate to attract students to rural areas,⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... ^,1919 Grobler L, Marais BJ, Mabunda SA, Marindi PN, Reuter H, Volmink J. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev. 2009;1(1):CD005314. PMID: 19160251^,2020 Dolea C, Stormont L, Braichet JM. Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bull World Health Organ. 2010;88(5):379–85. doi: http://dx.doi.org/10.2471/BLT.09.070607 PMID: 20461133
https://doi.org/10.2471/BLT.09.070607... as our data suggest short rural exposures have minimal impact compared with selection of students raised in these areas.

With nearly 64% of people in sub-Saharan Africa and 69% in South Asia residing in rural areas,³3 World Bank Data, sub-Saharan Africa [Internet]. Washington: World Bank; 2012. Available from: http://data.worldbank.org/region/SSA [cited 2014 Aug 18].
http://data.worldbank.org/region/SSA... it is imperative to boost the long-term attractiveness of rural careers among students or change admissions’ criteria to select students more likely to prefer rural work in the first place. Targeted admissions of rural applicants has been a key component of comprehensive education reforms in developed countries, where schools instituting such policies have increased rural retention from 3–9% to 53–64% of graduates.⁴⁸48 Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Acad Med. 2008;83(3):235–43. doi: http://dx.doi.org/10.1097/ACM.0b013e318163789b PMID: 18316867
https://doi.org/10.1097/ACM.0b013e318163... However, despite 2010 WHO recommendations supporting such reforms,⁶6 Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf?ua=1 [cited 2014 Jul 10].
http://whqlibdoc.who.int/publications/20... all 16 sites we studied admit students based on academic merit, with insufficient consideration of students’ geographic origin. Our data suggest that altering admissions policies in LMIC to favour rural-origin applicants or those desiring to stay in the country will help governments to succeed in retaining health-care professionals where they are most needed, and to avoid spending public and donor resources on training physicians and nurses most likely to leave.

Acknowledgements:

The authors acknowledge the Vanderbilt University School of Medicine Medical Scholars Program for funding support, and for data acquisition: RD Adhikari, N Alam, A Asaminew, A Banerjee, L Basu, E Belay, M Bhusal, E Bomani, H El-Busaid, F Chaula, J Chemere, E Erai, B Gillis, D Hailemariam, W John, K K’Orimba, E Malaba, S Manandhar, R Mlay, M Mtsinje, M Mulatu, E Muthumbi, T Pokharel, H Saidi, J Samwel, S Semotine, N Sedi, H Sharma, NP Singh, T Tesfaye, E Watli and T Zeray.

Competing interests:

References

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