What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research. If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker  asks ‘Hoiterative process in which data, concepts and evidence are connected with one another .According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” :1. He liThe current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods  work we find a tension between scientific explanations that are based on observation and quantification and interpretative research  qualitative research , definition, empirical, research, methodology, studies, fieldwork, interview and observation.In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: American Journal of Sociology, Sociological Theory, American Sociological Review, Contemporary Sociology, Sociological Forum, Sociological Theory, Qualitative Research, Qualitative Sociology and Qualitative Sociology Review) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.As a second phase of our research we searched within nine major sociological journals Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists”  contrasted with *qualitative variables and research” Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read::184. Fro” Alford :4. Like ” Alford :79.Others simply say that qualitative methods are inherently unscientific  and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” . When Becker . Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required  – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often , and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly . Thus, researchers may get closer both when generating the material or when analyzing it.Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables Franzosi :138. Thescientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something  variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables Small . VariablFurther, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands . More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi  has discA second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.


Existing evidence identifies health benefits for children of additional daily physical activity (PA) on a range of cardiovascular and metabolic outcomes. The Daily Mile (TDM) is a popular scheme designed to increase children’s PA within the school day. Emerging evidence indicates that participation in TDM can increase children’s PA, reduce sedentarism and reduce skinfold measures. However, little is known about the potential effects of TDM as a public health intervention, and the benefits and disbenefits that might flow from wider implementation in ‘real world’ settings.n = 22) and focus groups (n = 11) with stakeholders; observations of implementation in 12 classes; and analysis of routine data sources to identify school level factors associated with uptake.We aimed to identify how TDM is being implemented in a naturalistic setting, and what implications this has for its potential impact on population health. We undertook a rapid ethnographic assessment of uptake and implementation in Lewisham, south London. Data included interviews (P = 0.70), mean percentage of children eligible for free school meals , or mean percentage of children from Black and Minority Ethnic populations . Addressing obesity was a key incentive for adoption, although a range of health and educational benefits were also hypothesised to accrue from participation. Mapping TDM to the TIDierR-PHP checklist to describe the intervention in practice identified that considerable adaption happened at the level of borough, school, class and pupil. Population health effects are likely to be influenced by the interaction of intervention and context at each of these levels.Of the 69 primary schools in one borough, 33 (48%) had adopted TDM by September 2018. There were no significant differences between adopters and non-adopters in mean school population size  contains supplementary material, which is available to authorized users. Physical exercise in childhood is important for children’s current health and wellbeing, and for their future health outcomes . Lower rThe Daily Mile (TDM) is one promising intervention for increasing physical activity in children. Originating in Stirling, Scotland, in 2012, the TDM initiative requires school teachers to take schoolchildren out of their classroom to run for 15 min per day, which equates to a distance of approximately one mile. TDM is a scheme promoted by The Daily Mile Foundation, a non-profit organisation funded by INEOS, a multinational petrochemicals company. According to the Foundation website, the aims of TDM are to improve the ‘physical, mental, emotional, and social health and wellbeing’ of children . As of FThere is, then, good evidence that increases in MVPA will improve children’s current and future health , and thaThere has been some scepticism from the public health community on both the likely effects and sustainability of TDM, citing concerns about the minimal impact of an additional 15 min of activity, concerns about it displacing more effective forms of exercise in the school day (such as active play), and the risks of putting children off future participation in sports and exercise if the activity does not meet their needs for meaningful activity . DespiteThe focus of this study is to understand how TDM is being implemented in practice, and to provide a firmer foundation for future evaluations of the public health impact of this and similar interventions. Our aims thus were to: identify factors that impact on whether TDM is adopted in particular settings (e.g. schools and classes); to describe how TDM is being implemented; to identify intended and unintended consequences; and to describe factors that affect whether implementation is maintained. A secondary aim of the study was to identify potential design considerations for future evaluation.Below, we outline the study design, and provide an overview of study participants and our analysis. We use the COREQ checklist  to guideTo understand how TDM operates as a public health intervention in a naturalistic setting, we undertook a study in 2018 (with fieldwork conducted between May and December) of what happened when the scheme was promoted for primary schools (for children aged 5 to 11) across one local authority area, the south London borough (LB) of Lewisham. To understand adoption and implementation of TDM in Lewisham, we undertook a rapid ethnographic assessment . This isLewisham is a diverse borough of south London, UK, with 29.6% of children living in income deprived households . The born = 3), who were interviewed about their experience implementing the project in the borough. Lewisham Public Health also provided data about school characteristics, TDM adoption, percent of pupils from Black and Minority Ethnic (BME) communities and percent of pupils eligible for free school meals. Recruitment was undertaken through invitations sent through a monthly public health newsletter to schools, direct emails to head teachers, as well as recruitment at a local event focused on physical education and sports in schools. Of those schools who indicated an interest we initially selected 6 schools, with varying levels of success in rolling out the intervention. However, one school chose not to participate, with 5 schools in total participating in this study. The schools included a range of school types  with varied levels of TDM implementation (see Table To examine experiences in south London we used a purposive sampling approach to identify and select stakeholders and cases (i.e. schools) from the locality who had varied experiences with TDM adoption and implementation. This included Lewisham public health practitioners (n = 22); focus groups (n = 11) with 41 participants; and participant observation of 49 Daily Miles across 12 classes in the five schools. Interviews and focus groups were recorded and lasted for approximately 30–45 min in length. All participants self-selected to take part and provided their own and, where applicable, parent/guardian consent. Participants from the 5 schools did not know the researcher prior to the commencement of the study.Qualitative data were collected at each school. This included in-depth interviews (n = 3), headteachers (n = 2), assistant head teachers (n = 2), school teachers (n = 5), and pupils (n = 10). Focus groups took place in school settings with teaching staff (assistant head teacher (n = 1), school teachers (n = 2)), parents and carers (n = 3), and pupils (n = 35). Focus groups were made up of participants of the same gender (n = 5), as well as mixed gender (n = 6).Of the 63 participants who participated, in-depth interviews were undertaken with public health practitioners (n = 11) and public health practitioners (n = 2) identified as female. All parents and carers (n = 3) identified as female. There were slightly more male children (n = 25), than female children (n = 20). Children ranged in ages from 7 to 8 (16), 9–10 (17), and 10–11 (n = 12). All teaching staff interviewed were white, whilst 20 children, and 1 parent were BME.Of the qualitative sample, in total 56% of participants were female and 44% male. The majority of teaching staff  what medium-long term plans were in place to sustain the intervention (if any) . Field notes were guided by both the implementation intended outcomes, and topics that emerged from in-depth interviews and focus groups. Field notes were recorded before, during and after the implementation of each TDM across a two-three week period in each of the 12 classes to document what happened in practice.Routine data for schools in Lewisham were collated from existing records, which included secondary data held by Lewisham Council and data they collected as part of the roll out of TDM in the Borough. Existing data on school characteristics of all schools included size of the school (number of pupils); per cent of pupils with free school meal entitlement; and per cent of pupils who identified as from BME populations. The Department of Public Health also recorded date of adoption of TDM.Interview and focus group data were transcribed verbatim. All qualitative data, transcribed interview and focus group data, as well as fieldnotes, were analysed by researchers using thematic content analysis , using NFor analysis of routine data on school uptake we calculated summary statistics in the two school groups (‘daily mile implemented’ and ‘no daily mile in school’). All data were continuous and these were therefore summarised with group means and standard deviations. The distributions of each variable were clearly non-normal . To compare the distributions of these characteristics in adopting and non-adopting schools, we used two-sided Mann-Witney U tests since t tests would not be valid with bimodal and skewed data. We drew density plots to depict the overlap of the distributions of characteristics by school group. The statistical data analysis was conducted using STATA 14.To describe the variation in implementation, we used the template for intervention description and replication for public health and policy interventions (TIDieR-PHP) . This wan = 36) but the differences were not statistically significant (p = 0.70). TDM schools had a slightly greater mean percentage of pupils having free school meals than the non-TDM schools but this was not significant (p = 0.39). The mean percentage of pupils of BME groups were similar in the two school groups (p = 0.41). No differences in characteristics were statistically significant  had adopted TDM by September 2018. Five of these had been taking part since 2016, 17 had started in 2017, and six during 2018. The summary statistics show that the 33 schools that adopted TDM had a lower mean number of pupils with a narrower range of sizes compared to those who did not adopt TDM  varied considerably.Table In practice, TDM was adapted at several levels. The local authority promoted uptake of TDM through organising meetings for school leaders, including visits from the founder of TDM, promotional mailings, and supporting schools by identifying ‘pioneers’ who could share their experiences with other schools. Schools themselves adapted the scheme; classes within schools differed in what they did, and there was variation at pupil level.Locally, within the borough, the scheme was being promoted as ‘The Daily Mile’, as described in the TDM Foundation website. Some schools had adopted different names, such as ‘The Daily Run’ .Although TDM Foundation website highlights the general wellbeing benefits, the LB of Lewisham promoted TDM primarily as a part of their wider strategy around obesity. The opening line of their policy document supporting the scheme was “Lewisham, in common with most of the country, and in particular London, is undergoing an obesity epidemic”. Concern about local levels of obesity were also reported as a key incentive for adopting TDM for heads and teachers in local schools, who linked their enthusiasm to efforts to reduce risks of obesity:the government wants us to address obesity in primary age children, and as a school we were seeing an increase in children … with very worrying weight problems, and they weren’t really being addressed, although the school does have healthy lunch policies, we’re a healthy school, we only allow fruit, we don’t have tuck shops, but it wasn’t enough. So we needed something else. Children also saw these links between weight loss, participation and fitness . For males this was often linked to gaining strength . For other children it was linked to bullying avoidance .A wider range of benefits from engaging in the scheme were also identified by participating teachers and heads. The benefits were most pronounced, they argued, for children who might not get much other physical activity in their day . Parents and carers indicated similarly:I think they all benefit, but I’ll be honest there are some children that do have some weight issues, I’m not going to lie, as I said my son’s not the slimmest, and he’s not the fittest, but I think they all benefit from it, but some more than others A key benefit was improved physical fitness for children, and teachers often adopted ways of monitoring or demonstrating this as an outcome of children’s participation, through (for instance) recording the number of miles children had run  or utilising tools such as “a heartrate monitor … to show how … increased activity and intense activity raises their own heart rates” , or similarly getting students to monitor their own heartrate before and after engaging in TDM. As one teacher explained:[I say to the class] ‘Feel your pulse, right, let’s make our hearts beat faster, that means going … our bodies are working harder, and that’s going to be making us healthier’ These activities were seen to both encourage students to participate actively in the TDM initiative, but also contribute to their physical literacy; a further outcome anticipated from taking part. The link anticipated between TDM participation and health, or health literacy, was confirmed in interviews and focus groups with children .Teachers also identified important non-health benefits. When the intervention took place after lunch it had the reported effect of addressing tensions between students to “run off any problems”, it was positive for peer relationships between children, within their class, as well as peer relationships across year-groups, which we observed as classes across the school would undertake TDM together. It was also cited by teachers to be positive for teacher-student relationships:it’s also quite nice to get to know some of the children … they just talk to you about stuff, and you would never really have that opportunity in any other time (Participant 05 Assistant Head Teacher)In addition teachers indicated it contributed to, at times, better concentration in class, and made contributions to other parts of the curriculum, which they believed enhanced learning outcomes. They reported using TDM as an opportunity to discuss “geography … and of course numbers, [and] maths … I talk to them about, you know, well in a week what sort of average are we doing” , or opportunities to link to wider learning:we’ve learnt shapes of leaves, we’ve done collections for artwork via the Daily Mile, so we might bring bags with us one day and collect things for art, or DT [Design Technology], or make things in the park, so we’ll go the park, we’ll use the resources, photograph them, and then they go on. Yeah, if you’re going to go out and do a mile, every day, you may as well bring as many elements of the children’s learning into it as possible Few interviewees explicitly identified negative potential impacts, other than a shared concern about fitting TDM around “a timetable that’s too full” , which led to some teachers actively choosing not to participate, or prioritising classwork over taking the class outside for a full 15 min period. In often congested areas of inner London, some teachers mentioned pollution as a general risk factor for children’s health locally, but high levels of pollution were not mentioned specifically as putting children’s health at risk when doing outdoor activity. Interviews identified possible stigmatising discourses around overweight and those ‘less sporty’, as indicated above.For some teachers, particularly in schools with high numbers of pupils from lower socio-economic status households, TDM was suggested as a way of countering structural disadvantage, given that their pupils were framed as in higher ‘need’ of health promotion interventions to address poor health status.So everyone’s getting something out of it, however, children that tend to live in say flats, that don’t have garden space, that don’t go out to the park, their weekly news, which is “I went to Saver Centre” week-after-week-after-week, they benefit a great deal In principle, TDM does not require any particular equipment or special surfaces to run on. Most participating schools had playground facilities on which, for some, tracks had been painted, or they used nearby parks. There are now a number of commercial companies offering ‘Daily Mile’ track installation; one school had used a playground upgrade as an opportunity to install a special track. Getting to local parks could involve crossing roads, meaning that a 15 min activity would take around 30 min from class time in practice. Some Lewisham schools were in very congested sites; one had constrained outdoor space that meant doing TDM involved running around a small playground many times. Another had implemented a short ‘circuit’ of activities to replace running for 15 min, because of space constraints.Schools in older buildings - particularly where children had to go down several flights of stairs to get outside, or which had limited outdoor space nearby – had greater challenges in managing the logistics without taking too much time from the school day. Whilst climbing stairs may have an added benefit for children in terms of PA, we found it might be more likely to have an impact on whether or not the intervention takes place at all:proximity to the playground [is an issue] because if you’re on the ground floor it’s a whole lot easier and less time-consuming to nip out, do a quick Daily Mile and then come back, but if you’re on the top floor … coming all the way downstairs, you’re then doing your Daily Mile, then you’re going all the way back upstairs again, and so I think it’s a bit laborious if you’re on the top floor TDM is intended to be inclusive and non-competitive. Although schools and classes implementing the scheme did, in general, include all children in each class, in practice, games and competition were typically introduced to make the activity more appealing to some children. For instance, some teachers described how they would run alongside students and encourage them to run faster, “to spur them on” , which we observed in practice at all schools. Some teachers developed competitive activities to encourage increased participation of children:we came up with a thing where the class started on 10 points, if I pass them they lose a point, and if they pass me they gain 5 points This was observed across several classes, and illustrated in Fig. Children indicated they enjoyed these games:The bit that we enjoy the most is when the teacher chases us around, and we, I mean we like beating her, sometimes she beats us Observations and interviews identified games that had been adapted for TDM which involved competitive elements, where children compete against either their own records, or other children within the class. Teachers created PA-based games for the children to keep them engaged in the mile for 15 min. We observed children taking on different animal characters in one game to chase each other, which the teacher facilitated. These adaptations often involved planning by the teacher, and coordination, and were often used with the younger children to keep them engaged, and as a way to regulate the class during certain problematic weather conditions. As one teacher indicated during the winter:… some days would be too cold, I mean you wouldn’t say it’s too cold for Daily Mile … it was slippery or something, so we would turn it into a penguin march but still Daily Mile In practice, children engage in a mixture of movements during the 15 min period. In our observations we saw children moving between running, walking, skipping, and sprinting across the circuit that was established for TDM activity. This can involve stopping at times as well – some children might choose to sit down for short periods because they ‘are feeling tired’, or alternatively the teacher will actively ask them to stop between the TDM substitution activities - the games – they are facilitating. For those children who do choose to sit down we observed them moving again after a short rest, and they continue engaging in a combination or running, walking and/or sprinting, often with a group of peers.In interviews teachers often reported undertaking The Daily Mile 2–4 times a week. It was less common to implement TDM every day:Well I think it’s that timetabling you know, Year 2 we had SATS, we had all sorts of things going on and although I know it’s beneficial, if I feel that well ‘5-a-Day’ [another PA intervention] is quite sufficient now timewise then that’s fine … we definitely do it at least, you know … three or four times a week In part, as the interviewee describes, this is about fitting it into the curriculum, in this case making space for it in the demands/expectations of student national testing (‘SATs’), is about time demands, and has been found elsewhere to be a major barrier to implementation of health interventions in classrooms . On occaOne of TDM Foundation’s core principles is to ‘keep it simple’ in order to ensure sustainability. However, teachers and other classroom staff typically adopted a range of incentives to keep children interested, including competitive activities (as above) and ‘collecting’ and recording miles in various ways. Although the scheme is designed to be inclusive, and in general, all children in a class did take part, gender differences in how the activity was undertaken were reported and observed. One was the greater tendency for girls to interact with each other while doing the mile:the boys do tend to get into it a bit more than the girls. The girls often you’ll see them all linked arms walking around, having a little chat about it Girls were more often observed moving during TDM holding hands and talking than the boys. However, our field notes also document them running, jogging and sprinting between these conversations.Interventions such as TDM are difficult to evaluate in traditional public health terms with RCT or quasi-experimental designs. Pathways between ‘intervention’ and ‘outcome’ are long and not always linear . This haHowever, given the local commitments to rolling out TDM as part of a broader strategy of obesity, and the focus of the TDM Foundation on particular health outcomes, it is perhaps not surprising that these health benefits were the anticipated outcomes mentioned most frequently. However, our findings also point to other benefits  that were important outcomes of the intervention. This assemblage of wellbeing benefits often facilitated variations in adoption and implementation. Few participants mentioned any potential negative effects, though the erosion of curricula time was a concern that was articulated in all schools. Where this was of particular concern, this, along with spatial constraints and, at times the weather, acted as key barriers that prevented TDM from taking place, and resulting in students not engaging in planned PA.Of particular interest here in terms of outcomes is the focus, at least in this locality, on obesity. This is perhaps the outcome where there is less robust evidence for likely impact, given that TDM may increase PA without demonstrable effects on obesity, at least in the short to medium term, given the limited potential impact of an additional 15 min of PA for children. A systematic review that found ‘moderately’ strong evidence of the effect of obesity programmes in schools drew largely on US data, but with small effect sizes . Recent More generally, an intervention such as TDM can be thought of as an event within multiple interlinked complex systems  such as There was considerable variation across classes in schools that had implemented the scheme. Even where teachers were taking out whole classes most days of the week, individual pupils were not necessarily getting an additional 15 min MVPA, with many not running, or not running unless encouraged in ‘competitive’ ways. The intervention, both in terms of what is being promoted and what is implemented, is also likely to change over time. TDM Foundation are amending their web site and informational material in part as a response to ongoing research findings, and are engaged in resourcing co-ordinators to assist schools with maintaining fidelity to core principles. There is also discussion around mandating the scheme in the light of evidence of its effectiveness for increasing PA in children. This would of course change the intervention: a scheme that schools are required to do might have different effects than one they choose, with a potentially higher likelihood of it displacing other activities.There is increasing recognition of the ways in which context shapes the effects of interventions in complex systems , 40. TheRecent guidance  suggestsThis study was restricted to one borough in London and a relatively small number of schools. However, our sample of schools was relatively diverse, and sufficient to identify considerable variation in implementation. Our aim was to map this variation, and a rapid assessment was sufficient for this, but cannot provide an in-depth understanding of how and why interventions are adopted. More detailed ethnographic work would be needed to understand in detail what happened in schools when they took up the intervention. Our sample of schools and classes was also purposively rather than systematically selected, and drawn from those who volunteered. It is therefore less likely to represent schools uninterested in TDM, or in broader PA initiatives. We are therefore likely to have underreported challenges in implementation. The TIDieR-PHP checklist, although designed for use in describing interventions in evaluation studies, was a useful framework for structuring this study of implementation.The Daily Mile is, in principle, easy to adopt and has potentially positive impacts on children’s current and future health. However, evidence to date of its effects is likely to shed little light on what happens in practice in non-trial settings. This is important, as we have identified a variety of implementation practices in a non-trial setting, which have implications for future population health. This includes both variations in physical movements of the children taking part in each context, as well as variations in implementation, which result from, for example, various spatial (e.g. playground area) and temporal  constraints, as well as the presence or absence of other physical activities implemented within the school. All these adaptations are likely to shape the specific benefits and disbenefits for participants.For complex interventions in public health, there have been calls for the development of more appropriate methods for both describing and evaluating interventions. This study found the TIDieR-PHP framework a useful checklist for describing TDM. In terms of future evaluation, TDM is typical of interventions for improving the health of the public, in that it is often implemented in the context of wider strategies, and in variable ways. Experimental and quasi-experimental methods have well-documented shortcomings for evaluating the causal effects of such complex interventions , 49. FutAdditional file 1:Semi-structured interview and focus group schedules. (ZIP 69 kb)


The shortage of nursing professionals is of growing concern. The causes of this include the demanding physical and mental workload, leading to a dropout of nurses that may start during their education. However, it is unclear to what extent nursing students already perceive a physical and mental workload leading to health problems during their nursing education and placement, and to what extent these health problems cause students to dropout from nursing education. Very few prospective cohort studies have investigated protective and risk factors in relation to dropout and retention among nursing students.Three cohorts of third-year nursing students will be followed for 2.5 years. Students will be enrolled from the Bachelor of Nursing program of the Rotterdam University of Applied Sciences. At baseline, students will receive a self-administered questionnaire. Primary outcome is dropout from nursing education and dropout from the nursing profession. Data on dropout from nursing education will be retrieved from the student administration on a yearly basis. Dropout from the nursing profession will be measured one year after graduation, using the self-reported questionnaire. Secondary outcomes are presenteeism and sick leave (during internship/work). In addition to student characteristics, the questionnaire asks about physical and mental internship/work characteristics, personal and behavioral factors, and experienced physical and mental burden.Main aims of this study are to determine: 1) the prevalence and incidence rates of dropout, 2) the protective and risk factors, and early indicators of dropout, and 3) the interaction between these factors and the indicators.Data analysis of a large, prospective cohort study with regard to determinants of dropout and retention of nursing students and newly graduated nurses is in progress. Findings emerging from this study can be used to develop a predictive model to identify the first indicators of dropout from nursing education and nursing profession, for which targeted interventions can be deployed. In an aging population, a shortage of nurses poses a serious threat to the continuity and quality of health care. This shortage often results from increased demand combined with a declining number of new workforce entrants . In the The shortage of nursing professionals is also a growing concern in the European Union . The EurThe numbers of dropout differ between countries. For example, in the UK in 2015 the average dropout rate for student nurses at universities was ≥20% . In ItalDropout is a complex issue involving a wide range of factors. In Europe, two studies investigated the early exit of nurses and both reported that a considerable proportion of nurses considered giving up nursing , 20. In The intention to leave nursing education or the nursing profession is associated with determinants of study burnout , job satIn the Netherlands, research among 11,000 healthcare employees (including 3057 nurses) revealed that many suffered from physical or mental health complaints due to work-related issues . Nurses It is unclear to what extent (student) nurses already perceive these health problems during their nursing education and/or at the beginning of their career, and to what extent these health problems cause students to dropout from nursing education or their profession. Therefore, the SPRiNG  project was started. SPRiNG is a collaboration between Rotterdam University of Applied Sciences (RUAS), Erasmus University Medical Center, Amsterdam University Medical Center, and the Netherlands Institute for Health Services Research (NIVEL).This article describes the protocol of the SPRiNG cohort study. The aim of this prospective study is to examine dropout and retention of nursing students during their education and/or at the start of their career, and the related protective and risk factors.This is a prospective cohort study including three consecutive cohorts of third-year nursing students from RUAS, followed until one year after graduation.Rotterdam is the second largest city in the Netherlands, with ≥600,000 inhabitants. The RUAS has ≥36,000 students and offers a wide variety of programs in almost all educational sectors. The Bachelor of Nursing is their accredited four-year nursing educational program. According to the Netherlands Association of Universities of Applied Sciences (NAUAS) , the infIn recent years, the majority of nursing students has failed to finish the program within four years. The graduation rate after five years of study among fulltime students dropped from 56.9% in 2007 to 39.8% in 2011. Students with a non-western migrant background had the lowest graduation rate, i.e. 33.3% in 2007 and 19.8% in 2011. Within the RUAS nursing program, dropout rates between 2002 and 2012 increased from 20 to 26.5%.For the present study, three cohorts of third-year nursing students will be followed for three years. They will receive a self-administered questionnaire in the third (t0) and fourth  year of their nursing study t1), and again in their first year as a graduate nurse (t2). The first and the second cohort will be followed for three years and we plan to continue monitoring the third and fourth cohort , dropout among working nurses will be measured using a self-reported questionnaire.Did it happen during your current internship/work that you have gone to internship/work despite the feeling that you really should have taken sick leave because of your state of health?’ [Gezond werken in de zorg) [Presenteeism is defined as ‘Going to work despite judging one’s current state of health as such that sick leave should be taken’ and will be measured by the following question: ‘health?’ . This isde zorg) .Have you ever been on sick leave during this academic year? (‘Yes’/‘No’), ‘How often have you been absent due to sickness?’ (number of times), and ‘How many days of work, all together, have you been on sick leave by estimation?’ (number of days).Absenteeism due to illness will be measured by three questions included in the Netherlands Working Conditions Survey 2014 : ‘Have yA question on absenteeism due to physical health complaints was taken from the Dutch Questionnaire on Experience and Evaluation of Work (VBBA) 1994 . In 1999The Labour Monitor Municipalities (Arbomonitor Gemeenten)  will be Six specific questions will be used to measure absenteeism due to mental health complaints, with response options: ‘Yes’/‘No’.Professional support regarding physical health problems, mental health problems and social problems, will be measured with three items of the Healthy Working in Health Care questionnaire .In the current internship/work period did you look for help regarding the previously mentioned physical complaints?’ Response options are: ‘No’; ‘Yes, a general practitioner/company doctor’; ‘Yes, a physiotherapist’; or ‘Yes, another healthcare professional’.1) Physical: ‘In the current academic year did you visit a healthcare professional for mental help or support?’ Response options are: ‘No’; ‘Yes, a general practitioner’; ‘Yes, a psychologist/psychiatrist’; ‘Yes, a university counsellor’; or ‘Yes, another’.2) Mental: ‘Do you have at this moment due to social problems like financial problems, housing problems etc. a referral to/contact with…?’ Response options are: ‘No’; ‘Yes, a social worker; ‘Yes, a psychologist’; ‘Yes, a debt counsellor’; or ‘Yes, another’.3) Social: ‘The composite questionnaire will include the secondary outcomes (sickness presenteeism and sickness absenteeism), and various general, physical and mental health items. Specific areas include: demographics, internship/work characteristics, personal and behavioural factors, and mental and physical health. Table The digital questionnaire ensures standardized responses to questions and eliminates out-of-range responses. As backup, a paper version of the questionnaire will be available for students. Whenever available, validated constructs will be used. If necessary, questions are rephrased to fit the target group. For example, when the original question is about paid work, it is rephrased as ‘internship/work’, to address a student.Questions on respondent characteristics include: gender , age (years), body height and weight (BMI), educational background , nursing educational pathway , ethnicity (Dutch/western migrant/non-western migrant), Dutch as first language (yes/no), and housing circumstances (living with parents or caregivers/ living on one’s own/ living on one’s own with kids/living on one’s own with partner/living on one’s own with partner and child(ren)). Information on these characteristics will be collected at t0 only.My instructor gives me constructive feedback’; ‘My colleagues give me constructive feedback’; ‘When I got stuck in my learning process I have somebody to discuss this with’, and ‘My instructor has enough time for my guidance’). Responses are on a 4-point Likert scale ranging from ‘totally disagree’ to ‘totally agree’.For these determinants, six subscales of the validated Dutch version of the Job Content Questionnaire (JCQ) will be used , i.e. skFor these determinants, 13 questions related to lifting and bending were taken from the NEXT study . A scaleTwo questions on Visual Display Unit work were taken from the Dutch Questionnaire on the Experience and Evaluation of Work (VBBA) .Three single-item questions on aggression and violence, bullying, and slander were taken from the second version of the Copenhagen Psychosocial Questionnaire (COPSOQ II) . The DutA form of interrole conflict in which the general demands of time devoted to and strain created by the job interfere with performing family-related responsibilities”; and family-work conflict as “A form of interrole conflict in which the general demands of time devoted to and strain created by the family interfere with performing work-related responsibilities.” [Work-family conflict and family-work conflict will be measured using the Netemeyer, Boles scales . These alities.” .“…a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption.” Work engagement will be measured with the 9-item short version of the Utrecht Work Engagement Scale-Short (UWES-S) [Schaufeli & Bakker  defined (UWES-S) .Occupational self-efficacy refers to the confidence a worker has in his/her perceived ability to successfully perform job tasks . This wir = 0.58) and reasonably valid (r = 0.45) questionnaire to measure physical activity. SQUASH will assess the activities during a regular week in the past month with regard to the duration, frequency, and intensity of leisure time activities, household activities, activity at work and school, and commuting activities [The Short QUestionnaire to ASses Health enhancing physical activity (SQUASH), will be used to measure physical activity . SQUASH tivities .To measure non-specific distress we will use the Distress Screener, which comprises three items of the 4DSQ distress subscale. The 4DSQ is a self-report 50-item questionnaire that measures non-specific distress, depression, anxiety and somatization. For the purpose of this study a short questionnaire, and a sensitive instrument able to detect early signs of mental health problems, are needed. The Distress Screener (developed for early identification of non-specific distress) has three items; we will use a cut-off point > 4 to detect moderate distress . The DisNeed for recovery has been conceptualized as the experience of accumulating work-induced fatigue and is an early indicator of risk of depression . The NeeQuestions related to health  from the Dutch Musculoskeletal Questionnaire (DMQ) will be used . The phrMy internship/work corresponds with my expectations of the nursing profession’; ‘My internship/work corresponds with what I learn at the university’; ‘I expect to stay working in the healthcare sector after graduation’; ‘I expect to finish nursing school with a diploma’; ‘I expect to stay working as a nurse after graduation’; ‘I am expecting a study delay’; and ‘I consider to quit my study’. Answers are rated on a 10-point Likert scale ranging from ‘definitely not’ to ‘definitely yes’.Expectations about the nursing program and profession will be measured using seven self-formulated questions: ‘Key aims of this study are to determine: 1) incidence rates of dropout, 2) protective and risk factors, and early indicators of dropout, and 3) interactions between these factors and indicators.Data will be collected using Limesurvey . Data will be exported to a secured SPSS database for management and analyses. To avoid potential conflict of interest, the principle researchers will be blinded from any results that can relate data back to the individual respondents; therefore, this work will be done by independent researchers. Personal data will be extracted from the dataset before analysis takes place. Analyses will be carried out using IBM SPSS Statistics, version 24 or higher .First, for each cohort the differences in demographics  and the primary outcome ‘dropout’ between students included and not included (non-responders) in the cohort will be compared. For students in the cohort, data from the student administration will be used.Second, descriptive statistics of outcomes and determinants will be provided and quantitative variables will be depicted graphically using histograms and normal probability plots.In the study population, point prevalence will be estimated for mental and physical health problems, absenteeism, presenteeism, and sick leave at baseline (t0), after one year (t1), and one year after graduation (t2), in order to characterize the cohort. Incidence in the study population will be calculated for mental and physical health problems, absenteeism, presenteeism, and dropout after one year (t1) and also one year after graduation (t2).p < 0.05. To study the relation between one or more independent variables with the continuous dependent variables , linear regression analyses will be used. Logistic regression analyses will be conducted to study the relation with dependent dichotomous variables .To relate dropout and retention to potential determinants and covariates, regression analyses will be conducted. First we will analyse the univariate relationships between all potential determinants  and outcomes . Then, a multivariate model will be constructed for all determinants with an association of A latent class analysis  will be We expect to have follow-up data (determinants and secondary outcomes) from at least 80% of all students. Primary outcome data (dropout) will be available for all students from the student administration. We will anticipate to the possible missing values (MCAR & MAR). For statistical analysis techniques will be used that are robust for missing values (modelling to collected data) and sensitivity analyses will be performed on multiple imputed data sets .This study will provide information on 1) the prevalence and the incidence rates of dropout, 2) the protective and risk factors, and early indicators of dropout, and 3) the interactions between these factors and indicators. This article describes the protocol and methodology of the study.Few longitudinal studies are available on nursing students and recently graduated nurses. The actual shortage of nurses necessitates the prevention of avoidable dropout. Implementation of effective preventive interventions with regard to physical and mental resilience may help to ensure a sufficient number of nurses, which is an essential condition to guarantee adequate quality of care. Therefore, we need to know which determinants play an important role and which of these determinants are modifiable.A potential limitation of the present study is that respondents originate from RUAS only. To generalize our results to the national population of nursing students and new graduates, we will investigate to what extent the population characteristics of our Rotterdam sample differ from the national population of nursing students and new graduates, as available through NAUAS .The findings of this study can be used to develop a predictive model that identifies early signals for dropout from nursing education and nursing profession, for which potentially targeted interventions can be deployed. Plans within the SPRiNG project include exploring yet unknown reasons for dropout through qualitative research, systematic reviews of effective preventive interventions, and testing of the most feasible interventions in a pilot study. These steps will provide an additional toolbox with targeted interventions that can be implemented in nursing education or nursing practice to prevent dropout.


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.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.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. It is a world in which a Ghanaian-born student at Harvard Medical School might return to Ghana to do a summer of Harvard-sponsored research on the causes of the brain drain affecting the country of her birth, and no cognitive dissonance ensues; a world in which recent events and processes are speeding (or slowing) the emergence and retrenchment of social inequalities almost invisible to some who easily traverse national boundaries, while the same social pathologies are glaringly obvious to others who share, however fleetingly, the same social field. It is a world in which …  while the fruits of science, including treatment, are blocked at customs .The 2014 and deadliest Ebola epidemic to date, visited upon the West African countries of Guinea, Liberia, and Sierra Leone exposed the calamitous state of health systems in the affected countries. Over 11,300 Ebola-infected persons perished, including many healthcare providers , theoretConsider, as a case in point, 52 years old Ghanaian identical twin brothers and physicians Dr. Atsu and Dr. Etse.In 1997, Atsu left Ghana to reunite with his wife in Canada before relocating to the United States (USA) to complete Graduate Medical Education (GME) residency training. He currently holds a faculty position in a medical school in the greater Washington, DC metropolitan area. Conversely, Etse opted to stay and practice in a public hospital in Ghana despite the encouragements of his twin brother to follow him to the USA. He cited his concerns of becoming a “second-class citizen” in a foreign country and his unwillingness to go through the hassles of residency admission in the USA as significant factors in his decision to stay in Ghana. “There is no place like home,” he said repeatedly during our interview . What maWere it not for their twinship and discordant migration decision, the story of these brothers would likely have a feeling of déjà vu. A conservative estimate suggests that as of 2015, roughly 13,000 physicians originating from Sub-Saharan Africa (SSA) had integrated into the licensed physician workforce of the USA  and and28] aAs shown in Fig. Migrant networks theory, which focuses on relational ties between migrants and other actors in the migration channel, is integral to the mesolevel. The macrosystem level of the model explores broader structural factors identified in part by the world systems theory and ranging from historical antecedents to skilled migration  to current national policies/regulations and transnational dynamics   has been there for 50 years, ok? What is preventing people to think about [using] it? Is that any less important than organizing the African Cup of Nations? Think about that. I mean, for 50 years, we don’t have water. And, when they talk about Ghana in the media, they say, ‘Oh Ghana is improving’. If this is the best that we can offer, then what about the rest of Africa?”While acknowledging a relative improvement of physicians’ remuneration in recent years, junior physicians, from Ghana to Ethiopia, deplore the substandard working conditions in government-run hospitals (Cell 5). The challenges arising from the lack of diagnostic equipment, drugs, beds, disinfectants, gloves, and detergents in healthcare facilities are further compounded by the shortage of basic social infrastructure such as water, electricity, and roads (Cell 4). Nigeria, the largest economy in Africa, is crippled by epileptic power supply. In health facilities where the necessary medical equipment is available, often, there is no electricity to run it. Ghana, one of the most stable democracies and fastest growing economies in Africa for several years running has fewer challenges with electricity, but a critical shortage of clean water. A Maryland-based senior emergency physician contemplating retirement in his native Ghana in “the next 8-10 years” reflected:An Addis Ababa-based public health physician explained that, despite an immense need for hospital-based quality care and a limited number of tertiary healthcare facilities in Ethiopia, “hospital utilization rate is only 30%.” On the one hand, this very low utilization rate is due to “geographic inaccessibility” of many health facilities, inadequate road networks and limited public transportation. On the other hand, in rural areas especially, it is a consequence of financial constraint and a reliance on traditional healers as a first port of call for the sick and an affordable alternative to hospital-based care (Cell 11).Investment in social infrastructure is primarily the responsibility of the government. Reflecting on the adverse impact of bad government on health systems and health workers’ wellbeing (Cells 7–9), respondents unanimously decried by the lack of political will by politicians who “feed off the national cake.” The rhetorical question by a US-based Cameroonian respondent echoed this general sentiment: “Why are all our dignitaries in government going abroad to get their care done as opposed to beefing up the country health systems?”The perverse effects of bad governance on the health system are far-reaching. At the mesolevel, the mismanagement and misappropriation of the country’s scarce resources makes the healthcare procurement process highly vulnerable to collusion and corruption. As noted by a Nigerian-trained émigré, “if a contract is being given, the person in the ministry gets a cut, the auditor gets a cut. The contractor inflates the rates. The person who is in-charge of accounts at the ministry and the hospital itself gets a cut. The storekeeper gets a cut.”Furthermore, bad governance compromises the day-to-day management of public health settings. “As politicians decide the staff to be employed,” administrators of government-run hospitals may not necessarily be the most competent, but the most connected. At the micro level, perceptions of endemic corruption and unaccountability of the political elite can inure physician-citizens to such practices, rendering them highly cynical about their government and leading to a dystopian view of one’s own country. Under such a scenario, migration is seen as a necessity and return as a hazard (Cell 9). Another important deterrent to permanent return is the elevated security risks that prevails in many source countries. While I coded it under the social domain (Cell 10), the main drivers of insecurity in Nigeria are political, stemming from religious extremism in northeastern Nigeria, and local resistance to “environmental degradation” from petroleum pollution in the Niger Delta.Under the rubric of empowerment or liberation, research questions that can be answered include: What personal resources and opportunity structures are available to SSA physicians for implementing or halting their migration plans? Once they have settled in the USA, what are their long-term plans vis-à-vis returning or supporting their native countries? How successful are they in carrying out these plans?Table If education is a tool for personal development and liberation, post-graduate medical education empowers migrant doctors to meet their ultimate career goals in the USA. The Bachelor of Medicine, Bachelor of Surgery (MBBS) degree obtained in the home country facilitates their professional integration into US Graduate Medical Education (GME) residency programs and enables their transition from a domestic work environment often characterized by “very rustic” medical facilities to US teaching hospitals endowed with “state-of-the-art technology, investigations, and lab tests.” Although limited, opportunities for post-graduate medical training are available in the SSA countries surveyed. Nigeria and Ghana-based respondents were all fellows of the West African College of Physicians (WACP) or the West African College of Surgeons (WACS), the largest post-graduate medical programs in West Africa (Cell 22). Further, several SSA-based respondents reported staying current with the latest developments in their field of specialization by participating in international seminars and conferences and by collaborating with their US-based colleagues. Hence, the possibility for international consultancy and collaboration and the availability of residency training opportunities in-country has diminished the need for emigration for many West African medical graduates.“I started the Canadian immigration application last year but stopped it because I need a minimum of 60,000.00 Canadian dollars in my account in addition to the cost of planning and funding of my travels and that of my family members before my application could be considered. I was admitted to the University of Boston in 2007 for the MPH but could not afford it. I was again admitted to University of Arizona in 2008 for the MPH but could not afford it. I wanted to use all these as springboards for my emigration plans.”To “make it in the United States,” migrant physicians first need to make it to the United States. This requires obtaining an entry visa. US-based informants obtained their US visas through four main avenues. The preponderant route of entry was skill-based and entailed the support of a US academic institution or a US residency program to obtain either a F-1 visa , a J-1 visa (exchange scholars), or a H-1B visa . The second most popular entry channel was through the “Visitor visa.” With an ulterior motive of pursuing long-term medical practice opportunities in the USA, holders of this short-term visa officially entered the USA as tourists (B-1 visa) or for business purposes such as attendance of scientific conferences (B-2 visa). One respondent who used this visa channel explained that he entered the USA in 1994 as a FIFA World Cup attendee. He eventually adjusted his immigration status and prepared for examinations for admission into GME residency while working as a doorman in a hotel in Washington DC. Five respondents came to the USA as spouses or fiancés of US citizens (K-1/K-3 visas). Two others won the US State Department-sponsored Diversity Lottery visa within a year of graduating from medical school and immigrated to the USA as permanent residents. Not all visa applicants are successful. One Nigerian-based informant who described himself as “totally dissatisfied with the quality of life and professional fulfillment” explained his unsuccessful attempt to get a visa to North America:Reportedly, the private sector of healthcare is expanding rapidly in Nigeria and Ghana, creating more professional opportunities for the medical graduates to practice locally, more competition for skills in the national health labor market, and more choices for patients with the ability to defray the cost of their care. While the growth of a competitive private health sector may represent a positive development for a country’s health system, such development at the expenses of a weak public health system is concerning. A Nigeria-based doctor who works with a Nigerian health NGO and volunteers as a medical faculty in a public university indicated that private practice is “completely unregulated” in Nigeria and too often, the owners of private practices are public employees who take advantage of their positions in the government to embezzle resources needed to build their private clinics. “The beneficiaries of public institutions and government policy seem to have deliberately killed public institutions to allow the private ones to flourish. … It is like robbing Peter to pay Paul,” he lamented.About two decades earlier, the above informant was the national secretary of Nigeria’s National Association of Resident Doctors. Through collective bargaining and strikes, they successfully compelled the then Nigerian military government to increase physicians’ salaries and to allow them to work in private practice after finishing their daily duties in public hospitals. Prior to their successful mobilization, doing locum tenens or holding a private practice was against the law for Nigerian physicians employed in the public sector. Similarly, Ghana-based informants reported that their economic circumstances have improved “markedly” thanks to medical doctors’ “discord and industrial action” conducted over the years by the Ghana Medical Association. However, this has come at a cost as government-led “doctor bashing” has diminished the high regard doctors used to enjoy among the population. “Previously, when doctors went on strike for salaries, the whole nation backed them,” an informant explained. “But now, people get upset. People think that a lot has been done for doctors. But, that’s also because the politicians have made it like that.”While expanding the professional and economic opportunities of émigrés, migration also entails an ongoing process of identity negotiation which involves asserting how they see and define themselves and challenging how others see them. Identity enables the émigrés to claim membership in social groups with shared experiences. Individuals’ identification with a given group confers them with the symbolic capital invested in the group and makes them more amenable to promote/defend the interests of the latter. Judging by several respondents’ statements, many SSA migrant physicians do not want to compromise their national origin: “I am Ghanaian to the core.” “I am a proud Nigerian.” “That one is non-negotiable.” “I do not see myself as an American.” The authors of these soundbites are naturalized US citizens. Yet, they defined themselves almost exclusively in terms of the cultural referents of their native countries.“When I meet colleagues, friends, or just strangers, and we talk; they ask me: Where are you from? What they mean is, ‘You have an accent or, I could detect, I could feel out that you weren’t born and raised in the U.S. You are from somewhere else.’ So as long as people here are asking me where I am from, and are expecting that I answer, “I am from this country, or that country”, then, I will never be able to claim complete identity here.”Other respondents, however, conveyed an attachment to both their native and host countries and could not wholly embrace or reject either. A feeling of belonging to “this country, and that country” appears to be the transcendental feature of their hyphenated social identities. This sense of double consciousness is compounded by a pervasive sense of alienation as captured by the following quote:The Nigerian medical graduate who authored the sentiment above has been living in the USA for over 25 years, becoming a US citizen in 2005, achieving full professorship in pathology and urological research at an elite US university a few years later, and receiving induction into the prominent American Society for Clinical Investigation subsequently. However, despite these stellar accomplishments, fully embracing the American national identity is an aspiration beyond his control. The sense of double consciousness reflected in the accounts of émigrés is associated with an enduring longing for home. Many reported missing their native “food” and “culture”. Despite the relative ease of “picking up the phone and calling”, they miss being around family and friends, and sitting down at sunset and chatting with significant others after the “Maghrib prayer.” To allay their longing for home and the lingering separation anxiety associated with migration, some émigrés return home socially through involvement in hometown associations, diasporic organizations, alumni groups, and humanitarian missions in the home country.“You know, yeah, definitely you have feelings of obligation to help in whatever way you’d be allowed to help, let me state that. Some of this is even financial. …But, the big thing is that, as much as you are trying to give, there is no hand extended to receive. And, I speak not only for myself but for many physicians like me who want to give back one way or another, who are happy to teach in the medical school, do clinic stuff like that. But, the number of obstacles you have to overcome just to do that makes it ridiculous. So, anybody who is doing that, is doing it really after overcoming a lot of hurdles and obstacles. And, of course if you have to go through all that, then the potential impact would be less than it could have been.”The extent to which African-based medical organizations such as the Ghana Medical Association and the Ghana College of Physicians and Surgeons leverage the resources available within the medical diasporas to improve healthcare and promote health in the home countries was not adequately examined. However, the unflattering experiences reported by some émigrés who have attempted to lend support to health organizations in the home countries suggest that the resources of the medical diasporas are not exploited sufficiently by the actors located in the home countries. Commenting on physicians’ obligations vis-à-vis their country, a Ghanaian émigré practicing internal medicine in the Washington, DC metropolitan area reflected:“If the institutions at home will take it as a priority and organize resources that are coming from abroad, it will help. … If the country will say, give incentives to physicians in the diaspora to participate in a project that they create, I bet you that funds will flow directly to it like nothing. But, if people have to take individual initiatives, then you have to have people who are really entrepreneurial like Dr. CC to follow that kind of course. …I have had to deal with the actors in Cameroon directly. And, I found out that most of them are not interested in the big picture. They are mostly interested in ‘what is in there for me?’ And so, that is what my experience has been. …You have a lot of resources that are in this country that we need to use. Like for example, when Bush was President, he had an AIDS for Africa program, where countries would apply to get funds to help HIV orphans and offspring of HIV positive patients. And, we tried to tap into that fund. …The demand had to come from the home country, and the funds had to be sent directly to the home country. So, what we decided to do was to call the person who was in-charge of HIV disease at home and explained that, ‘we know how to write the grant application. We will write the grant application, send it to you. You sign it, send it to them, and they send the money to you.’ They were not interested. So, with all that kind of experience, you begin to ask yourself that, what else can you really do? So, they have to be motivated on their own end.”Echoing a similar sentiment, the Maryland-based past president of the now defunct Cameroon Physicians Association, commented:By all accounts, the resources sent home by the medical diasporas are not properly pooled. Most of these resources are provided on an individual-basis and are primarily directed to family members in the form of remittances. Many émigrés reported sending monies home to significant others sporadically. Most declined to provide any specifics on amount. A Nigerian-trained medical graduate and resident in internal medicine at Howard University Hospital observed with a mixture of humility and pride: “That one is personal, but just know that there’s nobody I know now in Naija that can die because of $1,000.” Respondents who disclosed specific figures reported varying amounts of money ranging from “about $100 a month” to “maybe $5000” a year. The monies are sent home for various reasons including school fees for children and to support émigrés’ aging parents.I feel indebted to the Cameroonian people. From elementary education, to secondary education, to medical school, it was all free for me. So, in some ways the Cameroon Government contributed in making me a physician and I have always felt indebted to them, and I have always expressed it to the authority that be, and I have always worked, as much as I can, in making healthcare more accessible to Cameroonians. To that effect, once I got into residency in the USA, I created a nonprofit organization called GSC. We provide free medications and medical supplies to the Cameroon people. Just last year in 2010 we refurbished two hospitals in Cameroon, one in Bota, Limbe, and another one in Banguem. … I have a medical mission that goes to Cameroon at least twice a year. Last year I went like four times; it depends on the resources that I have, but at least I go twice a year with medications and medical supplies. …I usually go with between 22 to 30 suitcases of medication and medical supplies. I take nebulizer machines, blood pressure machines, EKG machines, urinalysis machines, and then I do my tests on the patients that I examine and then give them the medications. In Yaoundé, where my parents are, every morning from 8 am to 2 pm I see patients. There is a clinic called HS Clinic which also provides quite a lot of free consultation. So, I put part of my medication in HS Clinic. I take some of the medications and equipment to the village which is in Bagangté. And then I have a medical supplies box which is under my dad’s foundation for those who cannot pay for the medications. When they get the prescription script, they just go to the box and get the medication.”“The entrepreneurial doctor cited as an example in the above quote (Dr. CC) has been empowering the health sector of his native Cameroon through the small NGO he created two decades ago. Up to four times a year, he travels to Cameroon with essential medications and medical equipment to address unmet health needs in his village and in the urban neighborhood of Yaoundé, the Cameroon’s capital in which he grew up. His involvement stems from the feeling of moral obligation he has toward his country.Exploring sources of wellbeing may help to provide some answers to the following research questions: How satisfied are migrant (and non-migrant) SSA doctors with their life and career goals? What factors influence these levels of satisfaction?The compensation here, as a physician, is substantially different from Ghana, regardless of how much taxes you pay. Now they are paying physicians well in Ghana; by Ghanaian standards, they are comfortable. But, absolutely, the kind of salary you get here as a physician, anywhere from $200,000 to $600,000 a year depending on what you do, is huge. And it is for doing what you like. So, for me, it is a big draw.”“As suggested by Table As reflected in the quote above, the expectation of a high and steady salary after post-graduate residency is a significant pull factor of migration for many SSA medical graduates plying their skills in the USA. While often, their “energy is used up” for working extensive hours, this expense of “energy converts into money” at the end of the pay period and provides them with a financial security that is hard to achieve in their home countries and in most professions in the USA. Owing to the inclusion of several resident (unlicensed) physicians in my sample, the figures reported by US-based respondents were not as high as suggested above but range from US$120,000 to over US$400,000 for licensed physicians. The lone participant who reported earning US$120,000 annually worked 40 h/week, that is, at least 10 h/week less than most of her peers. At the time, her salary was more than twice the median annual income for US households . Hence, by most standards, she was comfortable. “I am really happy to be a medical doctor, and if I had to start all over again, I would still be a medical doctor,” she stated.“I treated one woman who had a bleeding brain. I called a neurosurgeon. I called a special institution. They came here, flew the patient, did almost eight hours of surgery on the patient and she’s back to work now. She’s back on the floor working! I mean where else can we do stuff like that?”Professional satisfaction is also determined by the enabling environment. At the mesolevel, well-resourced, well-designed, and well-maintained teaching hospitals and non-academic healthcare settings make healthcare practice more attractive and fulfilling for the migrant doctors. At the macrolevel, operating in the world’s single largest health labor market which is the USA provides the migrant doctors with more choices and opportunities for upward mobility. Once they have completed residency, they can pursue licensing and establish themselves in any of the 50 US states and in the District of Columbia. High achievers can to seek further specialization and sub-specialization. Further, the advanced infrastructure of the USA makes life more convenient and emergency response more efficient. One Tennessee-based informant described the convenience of practicing in the USA as follows:“Well, I am staying in my country, because the truth is that I love Ghana, and I love being a first-class citizen in Ghana. And, I believe that no matter what you do, where you go, and who you become forever, you’ll never be a first-class citizen in anybody else’s country but your own. In Ghana, when I open my mouth, wherever I work, wherever I go, this is my home. …I can’t be in the US and the only thing I have is my husband or my children. I mean, there’s a bigger family. And, there’s a bigger circle of friends. And, I mean, I have really good friends who think like I do. We believe that Ghana is our home, and we stay in Ghana, and we work in Ghana. And, then if you need to go for a holiday or travel, you save up some money and then you go. But, by all means we come back to our home, and we will be here.”While no doubt, economic resources are the basis of material wellbeing, socio-cultural and interpersonal factors appear equally important for the wellbeing of many physicians, especially in the home country. A Nigeria-based respondent who acknowledged that “all is not rosy” in Nigeria expressed a deep sense of gratitude for staying home and tending to his late mother and for continuing to “take good care of his wheelchair stuck father”, an obligation he would not be able to take on had he migrated. With a mix of national pride and contentment, an early-career public health physician highlighted the significance of her social support network in Ghana and the intrinsic reward she derives from practicing in her native country:The social determinants of health and health inequities are complex, multidimensional, and dynamics, and “epidemiologically disentangling and isolating [their] multiple influences on a nation’s health” is daunting . Ten yeaMeasuring and understanding social determinants adequately requires an ability to integrate explanatory frames and complementary methods from diverse fields of scholarship . This paCharter on Physician Wellbeing, which outlines guiding principles and key commitments that can help governing bodies and policy makers develop policies aligned with best practices that promote physician wellbeing. At the meso-organizational level, the charter can inspire medical organizations to adopt strategic priorities and interventions that maximize meaning, engagement, and job satisfaction among healthcare team members [The EPV model suggests that physicians migrate to promote their wellbeing. The wellbeing of physicians is essential for effective patient care and improved healthcare system performance. In the USA, the favorite destination of migrating physicians, high rates of depression, burnout, and increased suicide risk are commonly reported among physicians . The eve members . The cha members .Whether physicians leaving Africa to practice say in North America can fully attain wellbeing abroad when their emigrations compromise the health and life outcomes of fellow compatriots in the native countries is debatable. In the face of anti-immigrant sentiments and rising nationalism in many Western nations, the pursuit of wellbeing by way of emigration may become even more problematic as migrating doctors fleeing structural violence at home may encounter fiercer resistance and even outright discrimination abroad , 60. AgaAlthough the findings highlighted in this paper shed some light into some of the dynamics of medical migration and some of the structural and psychosocial processes that can promote health personnel retention, this paper was neither intended to develop a full-fledged analysis of the Africa-to-USA physician brain drain, nor to draw policy implications from its findings. Doing so would have warranted one to address all potential questions the 36 main cells of the EPV matrix may raise. This represents a daunting task for a lone scholar (even one with broad-based knowledge) and is somewhat at odds with the interdisciplinary emphasis of the model. Fully interrogating all domains of capital of the EPV model at all levels of analysis and units of observation necessary entails a collaborative intellectual enterprise among scholars and practitioners from different disciplines but with shared interests in resolving outstanding problems. While resource-intensive and time-consuming, this inclusion of diverse perspectives and modes of inquiry in the analytic process ensures a critical dialogue about ideas and enhances the credibility and practicality of any policy informed by these findings .Questions on the economic factors of health workforce migration and health personnel retention may be most appropriate for a research team led by economists with expertise in migration, development, and health financing. Political determinants of migration and personnel retention can be thoroughly scrutinized by political scientists, public administration scholars, and sociologists of migration. In-depth investigation of cultural determinants of health workforce migration would likely be most complete if led by anthropologists with subject matter expertise in migration, health, and development. Likewise, factors of migration and health personnel retention stemming from the physical and built environment, the purview of civil engineering, can best be addressed by scholars with expertise or working knowledge of civil engineering. Last, the analytical insight of psychologists could be critical for the exploration of personal level dynamics of migration.As one of many frameworks available for interdisciplinary social research, the merit of the EPV model is its bringing to the fore the ubiquity of social power in human interactions. Whether conceived in terms of embodied capability, essence of the influencing process, or dynamic of social structures, power pervades human systems, and effects personal, organizational, and structural change , 65. PowWhere There is no Doctor, states this fact eloquently: “No matter how many pediatricians are sent to Sierra Leone to tell a mother to feed her child, without any means, she will not follow their advice. Poverty is more powerful than knowledge” [Alternatively, there is an important distinction between health and healthcare, and doctors are mere “specialists in the narrow area of healthcare called medicine” . Overstaowledge” .Poverty involves both material needs and capabilities deprivations, and while it is important to address both forms of deprivation, the latter is arguably more detrimental to health and human development than the former . When thIn a globalized, highly dynamic, and interconnected but greatly unequal world, tackling complex social and public health issues requires the use of comprehensive frameworks that capture the complexity of the interlocking environments that structure social problems. This paper sought to describe a transdisciplinary model grounded in ecological and psychopolitical thinking and potentially suitable for the comprehensive analysis of health personnel migration and other social determinants of health. Having been proposed for the first time in 2008 , 30, the