Dataset Information

Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment.

ABSTRACT:

Background

Inadequate and unequal distribution of health workers are significant barriers to provision of health services in Malawi, and challenges retaining health workers in rural areas have limited scale-up initiatives. This study therefore aims to estimate cost-effectiveness of monetary and non-monetary strategies in attracting and retaining nurse midwife technicians (NMTs) to rural areas of Malawi.

Methods

The study uses a discrete choice experiment (DCE) methodology to investigate importance of job characteristics, probability of uptake, and intervention costs. Interviews and focus groups were conducted with NMTs and students to identify recruitment and retention motivating factors. Through policymaker consultations, qualitative findings were used to identify job attributes for the DCE questionnaire, administered to 472 respondents. A conditional logit regression model was developed to produce probability of choosing a job with different attributes and an uptake rate was calculated to estimate the percentage of health workers that would prefer jobs with specific intervention packages. Attributes were costed per health worker year.

Results

Qualitative results highlighted housing, facility quality, management, and workload as important factors in job selection. Respondents were 2.04 times as likely to choose a rural job if superior housing was provided compared to no housing (CI 1.71-2.44, p<0.01), and 1.70 times as likely to choose a rural job with advanced facility quality (CI 1.47-1.96, p<0.01). At base level 43.9% of respondents would choose a rural job. This increased to 61.5% if superior housing was provided, and 72.5% if all facility-level improvements were provided, compared to an urban job without these improvements. Facility-level interventions had the lowest cost per health worker year.

Conclusions

Our results indicate housing and facility-level improvements have the greatest impact on rural job choice, while also creating longer-term improvements to health workers' living and working environments. These results provide practical evidence for policymakers to support development of workforce recruitment and retention strategies.

SUBMITTER: Berman L

PROVIDER: S-EPMC8216531 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundWorkforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia.MethodsThe study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job "choice sets," was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked.ResultsAlthough health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11-1.75), employment incentives influenced health workers' decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12-6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake.ConclusionsNon-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Project description:BackgroundNurse practitioners play a critical role in improving the access to care and in meeting the needs for health care. However, prior to the COVID-19 pandemic, the average turnover rate of nurse practitioners was 10 % with associated total direct cost that ranged from $85,832 to $114,919 for each episode of turnover in the United States. Little is known about the job preference of nurse practitioners and the cost savings to an organization that provides jobs with characteristics attractive to nurse practitioners.ObjectiveThe aim of this study was to identify the preferred job characteristics that are associated with nurse practitioners' job choices; and to determine the extent to which nurse practitioners would need to be compensated for practicing without these characteristics.DesignA two-stage design using a mixed method approach.Setting(s)The state of Georgia in the United States.Participants2757 nurse practitioners who were actively licensed were invited to participate. Of the 412 participants, 372 actively employed in Georgia were included in the analysis.MethodsA 2-stage discrete choice experiment was designed. Stage-1 was a qualitative design using a focus group to identify nurse practitioners' preferred job characteristics. Stage-2 was a quantitative design using survey distribution and analysis. A mixed logit model was used for ranking nurse practitioners' preferred job characteristics and the extent to which they would need to be compensated.ResultsOn average nurse practitioners were 47.4 years of age; the majority were female (90 %), white (75.3 %), and educated at the master's level (88.7 %). Participants did not value teams that were not very cohesive (β = -1.50); administration that was not very responsive and supportive (β = -1.04); being supervised by a physician (β = -0.58); not having their own panel of patients (β = -0.42); and not billing under their own National Provider Identifier (β = -0.18). Participants would need an increase in annual income of USD$21,780 for practicing in a not very cohesive team; USD$15,280 for practicing with a not very responsive administration; and USD$21,450 for being supervised by a physician.ConclusionsA cohesive, responsive, and supportive working environment and being able to practice independently are important characteristics for nurse practitioners when choosing a job. Healthcare managers should provide a workplace culture that reflects these preferred job characteristics to attract and retain nurse practitioners. Policymakers should consider reforming the scope of practice legislation to promote the independent practice of nurse practitioners.

Project description:BackgroundDiscrete choice experiments (DCEs) are attribute-driven experimental techniques used to elicit stakeholders' preferences to support the design and implementation of policy interventions. The validity of a DCE, therefore, depends on the appropriate specification of the attributes and their levels. There have been recent calls for greater rigor in implementing and reporting on the processes of developing attributes and attribute-levels for discrete choice experiments (DCEs). This paper responds to such calls by carefully reporting a systematic process of developing micro health insurance attributes and attribute-levels for the design of a DCE in rural Malawi.MethodsConceptual attributes and attribute-levels were initially derived from a literature review which informed the design of qualitative data collection tools to identify context specific attributes and attribute-levels. Qualitative data was collected in August-September 2012 from 12 focus group discussions with community residents and 8 in-depth interviews with health workers. All participants were selected according to stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three researchers to identify context-specific attributes and attribute-levels. Expert opinion was used to scale down the attributes and levels. A pilot study confirmed the appropriateness of the selected attributes and levels for a DCE.ResultsFirst, a consensus, emerging from an individual level analysis of the qualitative transcripts, identified 10 candidate attributes. Levels were assigned to all attributes based on data from transcripts and knowledge of the Malawian context, derived from literature. Second, through further discussions with experts, four attributes were discarded based on multiple criteria. The 6 remaining attributes were: premium level, unit of enrollment, management structure, health service benefit package, transportation coverage and copayment levels. A final step of revision and piloting confirmed that the retained attributes satisfied the credibility criteria of DCE attributes.ConclusionThis detailed description makes our attribute development process transparent, and provides the reader with a basis to assess the rigor of this stage of constructing the DCE. This paper contributes empirical evidence to the limited methodological literature on attributes and levels development for DCE, thereby providing further empirical guidance on the matter, specifically within rural communities of low- and middle-income countries.