Exploring the migration decisions of health workers and trainees from Africa: a meta-ethnographic synthesis

Social disparities in sleep health of African populations: A systematic review and meta-analysis of observational studies

OBJECTIVES

To document the relationship between socioeconomic status (SES) and sleep health in African populations.

METHODS

Observational cross-sectional or cohort studies examining the association between SES indicators and sleep outcomes in participants from African countries were included. The search was performed in the MEDLINE, Embase, and Web of Science Core Collection electronic databases in June 2021. Selection, confounding, attrition/exclusion, detection, and selective reporting bias were assessed using the OHAT Risk of Bias Tool. Random effects meta-analysis was used for summarizing the effect estimates.

RESULTS

Forty-three reports were selected, having sampled 153,372 Africans from 26 countries. Education was the most frequent SES indicator and composite measures of sleep quality or disturbances was the most common sleep outcome. Low educational attainment was significantly associated with lower odds of short sleep (odds ratio [OR]=0.65, 95% confidence intervals [0.50, 0.84], p = .001) and higher odds of insomnia (OR=1.53, [1.18, 1.99], p = .001) or poor sleep quality (OR=1.60, [1.17, 2.18], p = .003). Low levels of income/assets were related to higher odds of insomnia (OR=1.38, [1.02, 1.86], p = .04) and low occupational/employment status was linked to lower odds of short sleep duration (OR=0.49, [0.30, 0.79], p = .004).

CONCLUSIONS

Socioeconomic disadvantage was a significant predictor of insomnia and poor sleep quality, while it was associated with longer sleep duration. Significant heterogeneity in terms of exposure and outcomes, scarcity of longitudinal designs, lack of objective outcome measurement, and low representation of rural samples and participants from low-income countries limit the quality of evidence.

Exodus of Lebanese doctors in times of crisis: a qualitative study

Introduction

Since 2019, Lebanon is experiencing an unprecedented exodus of doctors, seriously threatening the national health system, which is expected to continue without quick and effective solutions. Therefore, this study aimed to understand the factors that push Lebanese doctors to migrate and the factors that retain others in the country. Additionally, this study aims to propose solutions to preserve an adequate supply of medical care amidst the crisis.

Methods

Qualitative semi-structured interviews and focus group discussions were conducted using pre-developed guides. Purposive and snowball sampling was adopted to recruit physicians who emigrated and physicians staying in Lebanon. Transcripts of interviews and focus groups were coded using Dedoose software and analyzed through a combination of inductive and deductive approaches.

Results

Emigration was found to be the result of numerous interconnected factors. The main drivers for emigration were declining income, career problems, reduced quality of care, unhealthy work environment, and the deteriorated political and socio-economic contexts leading to instability and insecurity. As for the retention factors, they included affective attachment and sense of belonging to the professional environment and the country, followed by recognition and valorization at work. Several recommendations were developed to maintain quality of care delivery, including reforms of the health system, development of focused human resource retention strategies based on resource mapping evidence, negotiations with recruiting institutions to endorse the code ethics ending unethical practices draining countries' human resources, provision of financial incentives to doctors, and the recognition and valorization of physicians. Other rapid interventions were suggested, such as short-term medical missions to mitigate shortages in certain specialties, telemedicine, adaptation of recruitment processes to compensate for resources shortages in certain specialties, and adoption of task-shifting approaches to alleviate the workload on overburdened specialists.

Discussion

The findings of this study shed the light on the different factors influencing migration while framing them in the Lebanese context. These findings and recommendations should inform stakeholders and policy makers about the interventions needed to restore the quality of care. The feasibility and sustainability of most formulated recommendations depend on several factors, with political and socio-economic security and stability being the most crucial ones.

Why move abroad? Factors influencing migration intentions of final year students of health-related disciplines in Nigeria

BACKGROUND

Limited human resource for health may impede the attainment of health-related sustainable development goals in low-income countries. This study aims to identify migration factors among final-year students of health-related disciplines at a Nigerian university, reflecting trends in Nigeria and sub-Saharan African countries.

METHODS

A cross-sectional study was conducted using a semi-structured, self-administered questionnaire to collect data from 402 final-year students of Medicine/Dentistry, Nursing, Pharmacy and Occupational therapy Physiotherapy at Obafemi Awolowo University, Ile Ife. Univariate, bivariate and multivariate data analysis were conducted and a p-value < 0.05 was taken as statistically significant.

RESULTS

The mean age of the respondents was 24.3 ± 2.3 years. Most (326; 81.1%) respondents had intentions to migrate and majority (216; 53.7%) of respondents had an unfavourable attitude towards practising in Nigeria. Students of Nursing constitute the highest proportion (68; 91.9%) of those willing to migrate (p = 0.009). The common preferred destinations for those who intend to migrate were the United Kingdom (84; 25.8%), Canada (81; 24.8%), and the United States of America (68; 20.9%). Respondents who had favourable attitude towards practicing abroad (AO.R: 2.9; 95% C.I 1.6-5.2; p = 0.001) were three times more likely to have migration intentions compared with those who had an unfavourable attitude towards practicing abroad, while the odds for those who had favourable attitude towards practicing in Nigeria (AO.R: 0.4; 95% C.I 0.2-0.7; p = 0.002) was two times less than those who had an unfavourable attitude towards practice in Nigeria. Respondents who desire specialist training (AO.R: 3.0; 95% C.I 1.7-5.4; p < 0.001) were three times more likely to have intention to migrate abroad when compared to those who were undecided or had no desire to pursue specialist training.

CONCLUSION

Most respondents had the intention to migrate abroad after graduation and this could be attributed to the desire for specialist training and their attitude towards practising in Nigeria. Interventions aimed at improving specialist training in Nigeria and incentivizing health care practice may reduce migration trends among Nigeria's health professionals in training.

How do foundation year and internship experience shape doctors' career intentions and decisions? A meta-ethnography

PURPOSE

Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors' opinions about how they want to continue their career. We aimed to understand how medical doctors' internship experiences influence their career intention/decision.

METHODS

We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000-2020 and included papers exploring how foundation years or internship experiences shape doctors' career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is 'more me'?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories.

CONCLUSIONS

Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors' career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.

Prevalence and pattern of migration intention of doctors undergoing training programmes in public tertiary hospitals in Ekiti State, Nigeria

BACKGROUND

Emigration of Nigerian doctors, including those undergoing training, to the developed countries in Europe and Americas has reached an alarming rate.

OBJECTIVE

This study aimed at assessing the prevalence, pattern, and determinants of migration intention among doctors undergoing residency and internship training programmes in the public tertiary hospitals in Ekiti state, Nigeria.

METHODS

This was a cross-sectional study using a quantitative data collected from 182 doctors undergoing residency and internship training at the two tertiary hospitals. An adapted semi-structured questionnaire was used to collect information on migration intention among the eligible respondents. Univariate, bivariate and multivariate data analyses were done. The level of significance was determined at p-value < 0.05.

RESULTS

Majority (53.9%) of doctors undergoing training were between 30-39 years, and the mean age was 33.2 ± 5.7 years, male respondents were 68.1%, and 53.8% of the respondents were married. The proportion of doctors undergoing training who had the intention to migrate abroad to practice was 74.2%. A higher proportion of the internship trainees, 79.5%, intended to migrate abroad to practice while the proportion among the resident doctors, was 70.6%. Among the respondents who intended to migrate abroad to practice, 85(63%) intend to migrate abroad within the next 2 years, while the preferred countries of destination were the United Kingdom 65(48.2%), Canada 29 (21.5%), Australia 20 (14.8%) and the United States 18(13.3%). Seventy percent of respondents who intend to migrate abroad had started working on implementation of their intention to migrate abroad. The majority of the junior resident doctors, 56(72.7%), intend to migrate abroad compared with the senior resident doctors, 21(27.3%), (χ² = 14.039; p < 0.001). The determinants of migration intention are the stage of residency training and level of job satisfaction.

CONCLUSION

There is a high prevalence of migration intention among the doctors undergoing training in the public tertiary hospitals in Ekiti State, Nigeria, with the majority already working on their plans to migrate abroad. Doctors undergoing training who are satisfied with their job and those who are in the senior stage of residency training programme are less inclined to migrate abroad.

RECOMMENDATIONS

The hospital management in the tertiary hospitals should develop retention strategies for human resources for health, especially doctors undergoing training in their establishment, to avert the possible problems of dearth of specialists in the tertiary health facilities. Also, necessary support should be provided for the residency training programme in the tertiary health institutions to make transition from junior to senior residency stage less strenuous.

J, Bosongo S, Dossou JP, Waweru E, Apers L, Zannou M, Criel B. The expanding movement of primary care physicians operating at the first line of healthcare delivery systems in sub-Saharan Africa: A scoping review

INTRODUCTION

In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare.

METHODS

We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders.

FINDINGS

We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa.

CONCLUSIONS

This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs.

Factors affecting job choice among physician anesthesia providers in Uganda: a survey of income composition, discrete choice experiment, and implications for the decision to work rurally

BACKGROUND

One of the biggest barriers to accessing safe surgical and anesthetic care is lack of trained providers. Uganda has one of the largest deficits in anesthesia providers in the world, and though they are increasing in number, they remain concentrated in the capital city. Salary is an oft-cited barrier to rural job choice, yet the size and sources of anesthesia provider incomes are unclear, and so the potential income loss from taking a rural job is unknown. Additionally, while salary augmentation is a common policy proposal to increase rural job uptake, the relative importance of non-monetary job factors in job choice is also unknown.

METHODS

A survey on income sources and magnitude, and a Discrete Choice Experiment examining the relative importance of monetary and non-monetary factors in job choice, was administered to 37 and 47 physician anesthesiologists in Uganda, between May-June 2019.

RESULTS

No providers worked only at government jobs. Providers earned most of their total income from a non-government job (50% of income, 23% of working hours), but worked more hours at their government job (36% of income, and 44% of working hours). Providers felt the most important job attributes were the quality of the facility and scope of practice they could provide, and the presence of a colleague (33% and 32% overall relative importance). These were more important than salary and living conditions (14% and 12% importance).

CONCLUSIONS

No providers accepted the salary from a government job alone, which was always augmented by other work. However, few providers worked only nongovernment jobs. Non-monetary incentives are powerful influencers of job preference, and may be leveraged as policy options to attract providers. Salary continues to be an important driver of job choice, and jobs with fewer income generating opportunities (e.g. private work in rural areas) are likely to need salary augmentation to attract providers.

Migration of Medical Professionals: The Case of Psychiatric Trainees in Spain

The social and economic situation in Europe seems to play a role in the migratory flow of doctors and other health professionals within the continent. However, little is known about the particular reality of workforce migration in Spain. The objective of this study was to explore the factors that motivate migration among junior doctors training in psychiatry in Spain. A semistructured questionnaire of 61 items was circulated to psychiatric trainees in Spain to explore the extent and the factors that influence the decisions regarding workforce migration. A total of 95 psychiatric trainees participated in the survey. More than two-thirds (n = 71, 74.7%) had "ever" considered migrating to another country, and more than one-fourth (n = 21, 29.5%) had already taken "practical steps" to go abroad. The main reasons to consider leaving the country were financial (n = 82, 86%) and the opportunity to progress professionally (n = 82, 84%). However, nearly half of the trainees (n = 47, 49%) were satisfied with their current income. While the majority of the psychiatric trainees in this survey had considered migrating abroad, these potential future migrations could lead to a loss of human capital with an important sociosanitary impact.

Retention and Migration of Rwandan Anesthesiologists: A Qualitative Study

BACKGROUND

Health care professional migration continues to challenge countries where the lack of surgical and anesthesia specialists results in being unable to address the global burden of surgical disease in their populations. Medical migration is particularly damaging to health care systems that are just beginning to scale up capacity building of human resources for health. Anesthesiologists are scarce in low-resource settings. Defining reasons why anesthesiologists leave their country of training through in-depth interviews may provide guidance to policy makers and academic organizations on how to retain valuable health professionals.

METHODS

There were 24 anesthesiologists eligible to participate in this qualitative interview study, 15 of whom are currently practicing in Rwanda and 9 had left the country. From the eligible group, interviews were conducted with 13 currently practicing in Rwanda and 2 who had left to practice elsewhere. In-depth interviews of approximately 60 minutes were used to define themes influencing retention and migration among anesthesiologists in Rwanda. Interviews were conducted using a semistructured guide and continued until theoretical sufficiency was reached. Thematic analysis was done by 4 members of the research team using open coding to inductively identify themes.

RESULTS

Interpretation of results used the framework categorizing themes into push, pull, stick, and stay to describe factors that influence migration, or the potential for migration, of anesthesiologists in Rwanda. While adequate salary is essential to retention of anesthesiologists in Rwanda, other factors such as lack of equipment and medication for safe anesthesia, isolation, and demoralization are strong push factors. Conversely, a rich academic life and optimism for the future encourage anesthesiologists to stay.

CONCLUSIONS

Our study suggests that better clinical resources and equipment, a more supportive community of practice, and advocacy by mentors and academic partners could encourage more staff anesthesiologists to stay and work in Rwanda.

Coping with water insecurity at the household level: A synthesis of qualitative evidence

Water insecurity is a key public health and developmental challenge for many communities across the world. Using a meta-ethnographic synthesis, this study examines how households cope with water insecurity, as well as the socio-economic consequences and determinants of water insecurity coping strategies. A systematized keyword search was conducted in various electronic databases (PubMed, CINAHL EBSCOHost, Embase Ovid, Science Direct, Medline, Global Health, SCOPUS, Google and Google scholar). Out of 1352 potential articles, 21 studies were selected for review. Households employed nine key coping strategies. These strategies include water storage, construction of alternative water source, water sharing and borrowing from social networks, buying water from private vendors, water management and reuse, illegal connections to public water networks, water harvesting, fetching water from distant sources, and water treatment to improve the quality. Some of these coping strategies had far-reaching health and economic consequences, including the risk of water contamination, adverse psychosocial health, and impacts on household savings. We found that poor households, due to their over-reliance on short term labour-intensive and time-consuming coping strategies, are further economically disadvantaged by water insecurity. From a policy perspective, we recommend that investments in effective and efficient water supply infrastructure are needed to help alleviate the day-to-day hassles of water users. While policymakers are looking for long term solutions to these problems, some of the coping strategies identified in this synthesis, such as water conservation, water reuse, and purification of water before consumption, could be encouraged as supplementary strategies to meet households' immediate water needs.

Home is home-Botswana's return migrant health workers

The shortage of skilled healthcare workers in Sub-Saharan Africa is aggravated by their emigration to high resource countries. There is evidence that a small number of healthcare workers return to their home countries. It is important to understand the factors that influence decisions to return in order to develop appropriate strategies to attract more back. This study sought to investigate the perspectives of healthcare workers who returned to Botswana after working in the diaspora. We conducted semi-structured interviews of 8 healthcare workers. Using the thematic analysis method we developed a thematic index to code the data. The main reasons for returning were family ties and missing home whilst the key reasons for emigration were concerns about the quality of health care, lack of professional progression opportunities and feeling under-valued. Difficulties reintegrating into the Botswana health care system are a potential push factors for those who return. Policies that aim to attract back healthcare workers should address professional progression, reintegration and improvement of the healthcare system.

Integrating human rights approaches into public health practices and policies to address health needs amongst Rohingya refugees in Bangladesh: a systematic review and meta-ethnographic analysis

Background

The Rohingya people of Myanmar are one of the most persecuted communities in the world and are forced to flee their home to escape conflict and persecution. Bangladesh receives the majority of the Rohingya refugees. On arrival they experience a number of human rights issues and the extent to which human rights approaches are used to inform public health programs is not well documented. The aim of this systematic review was to document human rights- human rights-related health issues and to develop a conceptual human rights framework to inform current policy practice and programming in relation to the needs of Rohingya refugees in Bangladesh.

Methods

This systematic review was conducted using the 2015 Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Eight computerized databases were searched: Academic Search complete, Embase, CINAHL, JStor, Pubmed, Scopus, SocIndex, and Proquest Central along with grey literature and Google Scholar. Of a total of 752 articles retrieved from the eight databases and 17 studies from grey literature, 31 studies met our inclusion criteria.

Results

Using meta-ethnographic synthesis, we developed a model that helps understand the linkages of various human rights and human rights-related health issues of Rohingya refugees. The model highlights how insufficient structural factors, poor living conditions, restricted mobility, and lack of working rights for extended periods of time collectively contribute to poor health outcomes of Rohingya refugees.

Conclusion

This review provides a human-rights approach to frame actions both at program and policy level in a sustained way to address the health needs of Rohingya refugees in Bangladesh. Such policy actions will focus on finding long term solutions for integrating the Rohingya population while addressing their immediate rights issue.

Trial registration

This systematic review has not been registered.

Oppression, liberation, wellbeing, and ecology: organizing metaphors for understanding health workforce migration and other social determinants of health

Background

The Commission on Social Determinants of Health (CSDH) identifies the maldistribution of power, money, and resources as main drivers of health inequities. The CSDH further observes that tackling these drivers effectively requires interventions to focus at local, national, and global levels. Consistent with the CSDH’s observation, this paper describes the eco-psychopolitical validity (EPV) paradigm, a multilevel and transdisciplinary model for research and action, thus far insufficiently tapped, but with the potential to systematize the exploration of the social determinants of health.

Results

Using the physician migration from Sub-Saharan Africa (SSA) to the United States as illustration, this paper articulates how the EPV model can be applied to the systematic analysis of a complex social problem with health inequity implications. To help explore potential determinants of physician migration, a comprehensive coding matrix is developed; with the organizing metaphors of the EPV model–namely oppression, liberation, and wellbeing–serving as analytical categories. Through the lens of the EPV model, migrating physicians are revealed as both ecological subjects enmeshed in a vast web of transnational processes linking source and destination countries, and potential change agents pursuing liberation and wellbeing. While migration may expand the opportunities of émigré physicians, it is argued that, the pursuit of wellbeing by way of migration cannot fully materialize abroad without some efforts to return home, physically or socially.

Conclusion

Clarifying the relationship between various social determinants of health and health inequities at different levels of analysis is a more complex but essential endeavor to knowledge generation than using a one-dimensional frame. With its roots in interdisciplinary thinking and its emphasis on both individual and contextual factors, the EPV paradigm holds promise as a model for examining the social determinants of health.

The meaning of "capacity building" for the nurse workforce in sub-Saharan Africa: An integrative review

BACKGROUND

"Capacity building" is an international development strategy which receives billions of dollars of investment annually and is utilized by major development agencies globally. However, there is a lack of consensus around what "capacity building", or even "capacity" itself, means. Nurses are the frequent target of capacity building programming in sub-Saharan Africa as they provide the majority of healthcare in that region.

OBJECTIVES

This study explored how "capacity" was conceptualized and operationalized by capacity building practitioners working in sub-Saharan Africa to develop its nursing workforce, and to assess Grindle and Hilderbrand's (1995) "Dimensions of Capacity" model was for fit with "capacity's" definition in the field.

DESIGN

An integrative review of the literature using systematic search criteria.

DATA SOURCES SEARCHED INCLUDED

PubMed, the Cumulative Index for Nursing and Allied Health Literature Plus, the Excerpt Medica Database, and Web of Science.

REVIEW METHODS

This review utilized conventional content analysis to assess how capacity building practitioners working in sub-Saharan Africa utilize the term "capacity" in the nursing context. Content analysis was conducted separately for how capacity building practitioners described "capacity" versus how their programs operationalized it. Identified themes were then assessed for fit with Grindle and Hilderbrand's (1995) "Dimensions of Capacity" model.

RESULTS

Analysis showed primary themes for conceptualization of capacity building of nurses by practitioners included: human resources for health, particularly pre- and post- nursing licensure training, and human (nursing) resource retention. Other themes included: management, health expenditure, and physical resources. There are several commonly used metrics for human resources for health, and a few for health expenditures, but none for management or physical resources. Overlapping themes of operationalization include: number of healthcare workers, post-licensure training, and physical resources. The Grindle and Hilderbrand (1995) model was a strong fit with how capacity is defined by practitioners working on nursing workforce issues in sub-Saharan Africa.

CONCLUSIONS

This review indicates there is significant informal consensus on the definition of "capacity" and that the Grindle and Hilderbrand (1995) framework is a good representation of that consensus. This framework could be utilized by capacity building practitioners and researchers as those groups plan, execute, and evaluate nursing capacity building programming.

Experiences of Nigerian Internationally Educated Nurses Transitioning to United States Health Care Settings

Introduction: Successful transition to practice of internationally educated nurses (IENs) can critically affect quality of care. The aim of this study was to characterize the facilitators and barriers to transition of Nigerian IENs (NIENs) to the United States health care setting. Method: Using a descriptive phenomenology approach, 6 NIENs were interviewed about their transitional experiences in the United States. Thematic methods were used for data analysis. Results: The three major themes identified from the participants’ stories were “fear/anger and disappointment” (FAD), “road/journey to success/overcoming challenges” (RJO), and “moving forward” (MF). The FAD theme predominated, including experiences of racism, bullying, and inequality. The RJO theme included resilience, and the MF theme encompassed personal growth. Discussion: NIENs face personal and organizational barriers to adaptation, especially fear, anger and disappointment. Future research should seek to develop a model for optimal adaptation that focuses on improving both personal and organizational facilitators and decreasing barriers.

The views of migrant health workers living in Austria and Belgium on return migration to sub-Saharan Africa

BACKGROUND

The negative consequences of the brain drain of sub-Saharan African health workers for source countries are well documented and include understaffed facilities, decreased standards of care and higher workloads. However, studies suggest that, if migrated health workers eventually return to their home countries, this may lead to beneficial effects following the transfer of their acquired skills and knowledge (brain gain). The present study aims to explore the factors influencing the intentions for return migration of sub-Saharan African health workers who emigrated to Austria and Belgium, and gain further insight into the potential of circular migration.

METHODS

Semi-structured interviews with 27 sub-Saharan African health workers in Belgium and Austria were conducted.

RESULTS

As mentioned by the respondents, the main barriers for returning were family, structural crises in the source country, and insecurity. These barriers overrule the perceived drivers, which were nearly all pull factors and emotion driven. Despite the fact that only a minority plans to return permanently, many wish to return regularly to work in the healthcare sector or to contribute to the development of their source country.

CONCLUSION

As long as safety and structural stability cannot be guaranteed in source countries, the number of return migrants is likely to remain low. National governments and regional organizations could play a role in facilitating the engagement of migrant health workers in the development of the healthcare system in source countries.

Meta-synthesis of qualitative research: the challenges and opportunities

Synthesis of qualitative studies is an emerging area that has been gaining more interest as an important source of evidence for improving health care policy and practice. In the last decade there have been numerous attempts to develop methods of aggregating and synthesizing qualitative data. Although numerous empirical qualitative studies have been published about different aspects of health care research, to date, the aggregation and syntheses of these data has not been commonly reported, particularly in pharmacy practice related research. This paper describes different methods of conducting meta-synthesis and provides an overview of selected common methods. The paper also emphasizes the challenges and opportunities associated with conducting meta-synthesis and highlights the importance of meta-synthesis in informing practice, policy and research.

Protecting health workers from infectious disease transmission: an exploration of a Canadian-South African partnership of partnerships

BACKGROUND

Health workers are at high risk of acquiring infectious diseases at work, especially in low and middle-income countries (LMIC) with critical health human resource deficiencies and limited implementation of occupational health and infection control measures. Amidst increasing interest in international partnerships to address such issues, how best to develop such collaborations is being actively debated. In 2006, a partnership developed between occupational health and infection control experts in Canada and institutions in South Africa (including an institute with a national mandate to conduct research and provide guidance to protect health workers from infectious diseases and promote improved working conditions). This article describes the collaboration, analyzes the determinants of success and shares lessons learned.

METHODS

Synthesizing participant-observer experience from over 9 years of collaboration and 10 studies already published from this work, we applied a realist review analysis to describe the various achievements at global, national, provincial and hospital levels. Expectations of the various parties on developing new insights, providing training, and addressing service needs were examined through a micro-meso-macro lens, focusing on how each main partner organization contributed to and benefitted from working together.

RESULTS

A state-of-the-art occupational health and safety surveillance program was established in South Africa following successful technology transfer from a similar undertaking in Canada and training was conducted that synergistically benefitted Northern as well as Southern trainees. Integrated policies combining infection control and occupational health to prevent and control infectious disease transmission among health workers were also launched. Having a national (South-South) network reinforced by the international (North-south) partnership was pivotal in mitigating the challenges that emerged.

CONCLUSIONS

High-income country partnerships with experience in health system strengthening - particularly in much needed areas such as occupational health and infection control - can effectively work through strong collaborators in the Global South to build capacity. Partnerships are particularly well positioned to sustainably reinforce efforts at national and sub-national LMIC levels when they adopt a "communities of practice" model, characterized by multi-directional learning. The principles of effective collaboration learned in this "partnership of partnerships" to improve working conditions for health workers can be applied to other areas where health system strengthening is needed.

Stakeholders' Perceptions on Shortage of Healthcare Workers in Primary Healthcare in Botswana: Focus Group Discussions

Background

An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana.

Method

Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data.

Results

There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service.

Conclusions

Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. They should be competently managed and adequately remunerated and the living conditions and rural infrastructure should also be improved.

Factors influencing the career choice and retention of community mental health workers in Ghana

BACKGROUND

Whilst there have been several studies exploring retention in health workers, little is known about health workers engaged in the provision of mental health services and the factors that affect their recruitment and retention.

AIMS

The objective of this research was to examine the views of stakeholders about the factors which influence career choices and retention of community mental health workers (CMHWs) in Ghana.

METHODS

We administered three separate, self-administered, semi-structured questionnaires to 11 psychiatrists, 29 health policy directors and 164 CMHWs across Ghana, including 71 (43.3%) community psychiatric nurses (CPNs), 19 (11.6%) clinical psychiatric officers (CPOs) and 74 (45.1%) community mental health officers (CMHOs).

RESULTS

Overall, 34 (20.7%) of all CMHWs chose to work in mental health because of the job prospects in mental healthcare. Overall, 12 (16.2%) CMHOs, 1 (5.3%) CPO and 20 (28.2%) CPNs reported they had considered leaving the mental health profession because of the stigma, with 4 (36.4%) psychiatrists and 12 (41.4%) health policy coordinators also reporting that they knew some CMHWs who had considered leaving the mental health profession because of stigma. Similarly, 16 (21.6%) CMHOs, 4 (22.1%) CPOs and 38 (53.5%) CPNs said they had considered leaving the mental health profession because of concerns about risk. Furthermore, 6 (54.5%) psychiatrists and 3 (10.3%) health policy directors said they knew some CMHWs who had considered leaving the mental health profession because of concerns about risk. Overall, 61 (37.2%) of CMHWs reported that they have considered leaving the mental health profession for other reasons other than stigma and risk including the following: the lack of support, respect and recognition from healthcare managers, lack of opportunities for professional development and poor conditions of service including low salaries, lack of office and personal accommodation and lack of risk allowance and transportation as well as poor inter-professional relationships.

CONCLUSIONS

Several factors affect the recruitment and retention of CMHWs in Ghana, including the prospects of easy employment, stigma, risk, lack of opportunities for career progression and low salaries.

Portrayal of the human resource crisis and accountability in healthcare: a qualitative analysis of ugandan newspapers

BACKGROUND

Uganda is one of the 57 countries with a critical shortage of health workers. The aim of this study was to determine how the human resources and health service crisis was covered in Ugandan newspapers and, in particular, how the newspapers attributed accountability for problems in the health services.

METHODS

We collected all articles related to health workers and health services for the calendar year 2012 in the two largest national newspapers in Uganda (collection on daily basis) and in one local newspaper (collection on weekly basis). These articles were analysed qualitatively regarding the main themes covered and attribution of accountability.

RESULTS

The two more urban national newspapers published 229 articles on human resources and health services in Uganda (on average over two articles per week), whereas the local more rural newspaper published only a single article on this issue in the 12 month period. The majority of articles described problems in the health service without discussing accountability. The question of accountability is raised in only 46% of articles (106 articles). The responsibility of the government was discussed in 50 articles (21%), and negligence, corruption and misbehaviour by individual health workers was reported in 56 articles (25%). In the articles about corruption (n=35), 60% (21 articles) mention corruption by health workers and 40% (14 articles) mention corruption by government officials. Six articles defended the situation of health workers in Uganda.

CONCLUSIONS

The coverage of accountability in the Ugandan newspapers surveyed is insufficient to generate informed debate on what political actions need to be taken to improve the crisis in health care and services. There exists not only an "inverse care law" but also an "inverse information law": those sections of society with the greatest health needs and problems in accessing quality health care receive the least information about health services.

'You can't stay away from your family': a qualitative study of the ongoing ties and future plans of South African health workers in the United Kingdom

Background

Migration of African-trained health workers to countries with higher health care worker densities adds to the severe shortage of health personnel in many African countries. Policy initiatives to reduce migration levels are informed by many studies exploring the reasons for the original decision to migrate. In contrast, there is little evidence to inform policies designed to facilitate health workers returning home or providing other forms of support to the health system of their home country.

Objective

This study explores the links that South African-trained health workers who now live and work in the United Kingdom maintain with their country of training and what their future migration plans may be.

Design

Semi-structured interviews were conducted with South African trained health workers who are now living in the United Kingdom. Data extracts from the interviews relating to current links with South Africa and future migration plans were studied.

Results

All 16 participants reported strong ongoing ties with South Africa, particularly through active communication with family and friends, both face-to-face and remotely. Being South African was a significant part of their personal identity, and many made frequent visits to South Africa. These visits sometimes incorporated professional activities such as medical work, teaching, and charitable or business ventures in South Africa. The presence and location of family and spouse were of principal importance in helping South African-trained health care workers decide whether to return permanently to work in South Africa. Professional aspirations and sense of duty were also important motivators to both returning and to being involved in initiatives remotely from the United Kingdom.

Conclusions

The main barrier to returning home was usually the development of stronger family ties in the United Kingdom than in South Africa. The issues that prompted the original migration decision, such as security and education, also remained important reasons to remain in the United Kingdom as long as they were perceived as unresolved at home. However, the strong residual feeling of identity and regular ongoing communication meant that most participants expressed a sense of duty to their home country, even if they were unlikely to return to live there full-time. This is a resource for training and short-term support that could be utilised to the benefit of African health care systems.

"Why should I have come here?"--A qualitative investigation of migration reasons and experiences of health workers from sub-Saharan Africa in Austria

BACKGROUND

There are many health professionals from abroad working in the European Union and in Austria. The situation of sub-Saharan health workers in particular has now been studied for the first time. The objective was to explore their reasons for migration to Austria, as well as their personal experiences concerning the living and working situation in Austria.

METHODS

We conducted semi-structured, qualitative interviews with African health workers. They were approached via professional networks and a snowball system. The interviews were transcribed and analysed using atlas.ti.

RESULTS

For most of our participants, the decision to migrate was not professional but situation dependent. Austria was not their first choice as a destination country. Several study participants left their countries to improve their overall working situation. The main motivation for migrating to Austria was partnership with an Austrian citizen. Other immigrants were refugees. Most of the immigrants found the accreditation process to work as a health professional to be difficult and hindering. This resulted in some participants not being able to work in their profession, while others were successful in their profession or in related fields. There have been experiences of discrimination, but also positive support.

CONCLUSIONS

Austria is not an explicit target country for health workers from sub-Saharan Africa. Most of the study participants experienced bad work and study conditions in their home countries, but they are in Austria mostly because of personal connections. The competencies of those who are here are not fully utilised. The major reason is Austria's current resident and work permit regulations concerning African citizens. In addition, the accreditation process and the German language appear to be barriers.

A meta-ethnography of the acculturation and socialization experiences of migrant care workers

AIM

To report a meta-ethnography of qualitative research studies exploring the acculturation and socialization experiences of migrant care workers.

BACKGROUND

Migrant care workers are increasingly participating in health and social care in developed countries. There is a need to understand this increasingly socioculturally diversified workforce.

DATA SOURCES

A comprehensive search through 12 databases and a manual search of journals related to transculture for studies on socialization and acculturation experiences (published 1993-2013) was completed. The inclusion criteria were peer-reviewed studies on the acculturation or socialization experiences of migrant care workers published in English in any country, using a qualitative or mixed-methods approach.

DESIGN AND REVIEW METHODS

This meta-ethnography employed the seven-phase Noblit and Hare method with reciprocal translation, refutational synthesis and lines-of-argument to synthesize qualitative studies.

RESULTS

Three main themes were identified: (a) schema for the migration dream: optimism; (b) the reality of the migration dream: so close, yet so far; and (c) resilience: from chaos to order. A general framework of motivated psychosocial and behavioural adaptation was proposed. This meta-ethnography also revealed the vulnerabilities of migrant nurses in the process of acculturation and socialization.

CONCLUSIONS

The general framework of behavioural and psychosocial adaptation revealed factors that impede and facilitate behavioural and psychosocial changes. Strategies to enrich external and internal resources should be targeted at encouraging multiculturalism and at improving the psychosocial resources of migrant care workers. It is suggested that research investigating the prominence of nursing vulnerabilities be conducted.