Tobacco and cannabis use are strongly interrelated, but current national and international cessation programs typically focus on one substance, and address the other substance either only marginally or not at all. This study aimed to identify the demand for, and describe the development and content of, the first integrative group cessation program for co-smokers of cigarettes and cannabis.First, a preliminary study using expert interviews, user focus groups with (ex-)smokers, and an online survey was conducted to investigate the demand for, and potential content of, an integrative smoking cessation program (ISCP) for tobacco and cannabis co-smokers. This study revealed that both experts and co-smokers considered an ISCP to be useful but expected only modest levels of readiness for participation.Based on the findings of the preliminary study, an interdisciplinary expert team developed a course concept and a recruitment strategy. The developed group cessation program is based on current treatment techniques  and structured into six course sessions.The program was evaluated regarding its acceptability among participants and course instructors.Both the participants and course instructors evaluated the course positively. Participants and instructors especially appreciated the group discussions and the modules that were aimed at developing personal strategies that could be applied during simultaneous cessation of tobacco and cannabis, such as dealing with craving, withdrawal, and high-risk situations.There is a clear demand for a double cessation program for co-users of cigarettes and cannabis, and the first group cessation program tailored for these users has been developed and evaluated for acceptability. In the near future, the feasibility of the program will be evaluated.ISRCTN15248397Current Controlled Trials  Tobacco and cannabis are interrelated in a unique, multi-dimensional manner, with some connecting mechanisms that are distinct from the co-use of drugs in general . Two of Investigations examining the initiation of use, the transition to regular use, and the cessation of tobacco and cannabis use exemplify this interrelation. Tobacco use can act as a gateway to cannabis use , but theRegarding the cessation of tobacco use, longitudinal observational studies have demonstrated that tobacco smokers who also consumed cannabis made fewer attempts to quit using tobacco  and wereDespite this evidence, current cessation programs typically focus on one substance while only addressing the other substance either marginally or not at all. To our knowledge, no integrative smoking cessation program (ISCP) targeting co-smokers of cigarettes and cannabis in a group setting has been designed.However, results of concurrent treatments of tobacco and alcohol dependence ,19 and tThe separate treatment histories surrounding tobacco and cannabis may be explained by the different legal statuses of the two substances that are often the subject of political discourse and election campaigns. In Switzerland for example, tobacco is categorised as a licit substance, while cannabis is an illicit drug. The divisions of the Swiss government that deal with these substances are both organisationally and financially separated from each other and, currently, so is the funding for prevention programs and research projects. Another explanation for the lack of combined treatment for tobacco and cannabis use may be the historical development of treatment and prevention systems in many industrialised countries. Treatment of cannabis dependence and co-occurring mental health problems is provided by the psychiatric systems of many countries. In contrast, tobacco cessation is possible without the involvement of psychiatrists and is part of the more general public health systems ,25 that In recent reviews, researchers have stressed the need to develop and evaluate combined interventions for tobacco and cannabis users ,26,27. AThe aim of the current study was to develop an ISCP. This process was accomplished in three steps, which will be explicated in this report. First, a preliminary study clarified whether there was a demand for an ISCP. Second, after having identified the demand, explicit information regarding co-smokers’ attitudes towards tobacco and cannabis and the association between both substances was collected for use when developing an ISCP. Moreover, co-smokers’ relevant experiences regarding quitting one or both substances simultaneously were collected. Third, based on the information gained during the second step, an ISCP was developed tailored to co-smokers of cigarettes and cannabis. This program incorporates the established therapeutic principles and strategies of former tobacco and cannabis cessation programs and takes into account reasonable concepts and ideas from the ongoing discussion about the mechanisms underlying the co-use of tobacco and cannabis and potential dependency problems.p ≥ .05) were removed successively from the multivariate model. The resulting model was verified by separately adding the excluded variables to the model to account for suppressor effects. Only significant predictors (p < .05) were retained in the final model. In these analyses, only the respondents currently smoking cigarettes and using cannabis were included. All quantitative analyses were conducted using PASW Statistics Version 18 and 20 .The perception of and the need for an ISCP were explored with semi-structured qualitative interviews with addiction experts, qualitative age-specific user focus groups, and a quantitative online survey designed for current and former co-smokers. Qualitative data were analysed according to the coding procedures of Grounded Theory . QuantitTwelve addiction experts participated in the semi-structured interviews about the relationship between tobacco and cannabis use and the demand for and possible design of an ISCP. These addiction experts worked in research or were practicing psychotherapy, medicine, prevention, or epidemiology. The majority were known local experts in tobacco and/or cannabis use. The experts were reimbursed with 180 Swiss Francs (corresponding to about 167 US dollars in February 2010 when the interviews were conducted). Most of the experts emphasised a substantial relationship between tobacco and cannabis use that can cause problems, especially in the context of cessation attempts. For example, some experts observed that individuals who consumed both tobacco and cannabis increased their use of one substance when attempting to quit the other, which could lead to elevated risk of relapse. Quitting both substances simultaneously might prevent this balancing effect. Thus, the experts perceived a clear demand for an ISCP. Despite this demand, the experts assumed that few co-smokers would be ready to stop their tobacco and cannabis use simultaneously because smokers often perceived quitting tobacco use as a “loss” and probably would not be ready to additionally “give up” cannabis use.Regarding the design of an ISCP, the experts favoured a group setting and suggested incorporating methods from cannabis treatment manuals into an established tobacco cessation program. The experts believed that integrating an additional substance into a tobacco cessation program would enhance its complexity . Thus, an ISCP should offer comprehensive medical, psychiatric, and psychotherapeutic support for participants, on-demand additional single treatment sessions, and specific training for the course instructors that would aid in addressing the complexities and potential problems of double cessation.The experts differed in their opinions about the appropriate age range of the participants. However, some experts suggested that co-smokers aged 25 years and above should be targeted because the experts expected a higher level of readiness to participate in an ISCP among this age group compared with younger co-smokers. This reasoning was based on the common assumption that cannabis use during adolescence is transient and thus less problematic and on the fact that family planning usually becomes more relevant at the age of 25 years. Two experts suggested separating groups by gender.The focus group discussions were conducted to gain in-depth information concerning users’ problems, experiences, and methods of coping with the issues that occurred during cessation attempts. Recruitment was organised via counselling facilities, and participants received financial reimbursement for participation. To be included in the focus group discussions, candidate participants had to self-report 1) past or current tobacco dependence, 2) past or current use of cannabis at least several times per week, and 3) at least one attempt to quit cigarette smoking, cannabis use, or both with formal treatment. As an incentive, focus group participants received 100 Swiss Francs in cash (corresponding to about 95 US dollars in April 2010 when the focus groups were conducted).Similar to the experts, the 14 participants of the focus group discussions (10 adolescents aged 16 to 22 years and four adults aged 27 to 39 years) perceived a strong relationship between tobacco and cannabis use. Many of the participants reported experiences with the aforementioned balancing effect. However, the adolescents in particular demonstrated low willingness to quit cannabis and discussed their negative outcome expectancies concerning tobacco and cannabis cessation attempts . The participants assumed that the general willingness of co-smokers to quit both substances would be low. However, due to the relationship between tobacco and cannabis use, they considered an ISCP to be useful.Regarding the ISCP design, participants emphasised the importance of appropriate knowledge transfer concerning the interrelationship of the substances. The participants deemed the differences between potential participants with regard to their motivations to quit, aims, consumption patterns, and life situations to be relevant. Therefore, they suggested that all course participants should form a common goal. Furthermore, focus group participants indicated that there was a strong need for the development of appropriate relaxation and stress reduction methods.Taking into account the information provided by the expert interviews and user focus groups, the online survey included questions concerning smoking behaviour, quitting experiences, and attitudes towards tobacco, cannabis, and an ISCP. Moreover, the online survey investigated the demand for an ISCP, co-smokers’ willingness to participate in such a program, and their readiness to quit both substances simultaneously. Former co-smokers were asked to indicate whether they would have been willing to participate in an ISCP and whether they would have been ready to quit tobacco and cannabis simultaneously. Recruitment was achieved through advertisements in internet forums on smoking, cannabis use, and health and via two social media platforms. Lotteries for a city trip, a tablet computer, and book vouchers were used to encourage participation.n = 109) or in the past (n = 138). Current co-use was defined as daily tobacco use and the use of cannabis during the past seven days before the survey. The survey was completed by 79.4% (196/247). Data from drop-outs were excluded in an item-wise manner. There were no significant differences between the drop-outs and the completers regarding age , sex (χ2(1) = 0.368, p = .636), educational level , or smoking frequency .The online survey began with 247 respondents who met the inclusion criteria of smoking both tobacco and cannabis either regularly at the time of the survey , and 44.9% (111/247) were female. More than half of the respondents had previously attempted to stop smoking tobacco  and/or cannabis  at least once. Of those who had attempted to quit tobacco, 19 respondents (33.3%) increased their cannabis use after their tobacco cessation. More than half (51.6%) of those who had attempted to quit cannabis reported an increase in tobacco use.The respondents were between the ages of 14 and 88 years  thought that smoking tobacco and cannabis were interrelated . Furthermore, 67.6% (140/207) of the respondents affirmed the need for an ISCP .CI] = 0.20–0.37) stated that they felt ready to quit both substances simultaneously , and 41.4%  felt ready to participate in an ISCP .However, of those who were currently smoking tobacco and using cannabis only 27.6% . Furthermore, using cannabis at least once a week predicted a lower likelihood of feeling ready to quit compared with using cannabis less frequently . Finally, partial or full agreement with the statement “Cannabis is harmful to my health” increased the likelihood of readiness to quit the substances simultaneously .Three predictors significantly predicted readiness to quit tobacco and cannabis simultaneously in a logistic regression analysis. Age was positively associated with readiness for simultaneous cessation  of the respondents considered an ISCP useful for individuals between 20 and 25 years and more than half of the respondents found it useful for those between 15 and 20 years (101/179) and for those between 25 and 30 years . In general, 69.9% (137/196) of the respondents preferred age-separated but only 14.3% (28/196) preferred sex-separated groups. The majority of the respondents  also suggested making the groups accessible only to smokers of both substances.Given that both experts and co-smokers considered a therapeutic program for co-smokers as important and sensible, the development process was continued.The intervention development proceeded as follows: first, literature was reviewed concerning effective interventions for tobacco and those for cannabis. Based on these findings and the results of the preliminary study, an interdisciplinary expert team composed of three psychologists, one social education worker, and three psychiatrists developed the group intervention. The team members had experience (and expertise) in research, therapeutic practice , and/or the development of intervention programs for the treatment of substance abuse. The program development was an incremental and iterative process that provided the team members with multiple opportunities for feedback. The experts met eight times during the seven months before the beginning of the course. During and after the first implementation phase, the experts held two further meetings to adapt the manual for the second implementation phase.Additionally, a thorough recruitment strategy was designed to reach as many co-smokers as possible and motivate them to participate in the ISCP. The recruitment process was conceptualised as an integral part of the ISCP and acted as an intervention in and of itself. Therefore, this recruitment strategy will be described in detail in the following chapter about the ISCP.After the first implementation phase, the intervention was slightly refined based on the feedback of the course facilitators, some of whom were also part of the expert team. Given that there were only minor changes , in the following chapter not both versions are described but only the adapted, second version.The recruitment strategy was planned extensively given that both the experts and focus group participants anticipated in the preliminary study that co-smokers would only show modest willingness to quit their tobacco and cannabis use simultaneously and to participate in an ICSP. To reach as many co-smokers as possible, information about the new course was spread via different channels.http://www.i-cut.ch) consisting of two parts was designed. The first part provided information about the course  and the possibility to register for an information evening. The second part aimed to enhance co-smokers’ motivation to quit simultaneously and participate in the ISCP, primarily by providing information, offering a self-assessment with normative feedback, and using techniques adapted from motivational interviewing [First, a website  centres in the canton of Zurich and bordering cantons helped spread flyers and leaflets that referred to the website for more information. Additionally, two social media platforms and an advertisement in the online edition of a popular free newspaper were used for online recruitment, also referring to the program website for more information.The final step involved planning an information evening. Interested co-smokers could attend it without any obligation to participate in the course. The information evening provided the opportunity to ask questions that were answered by the course instructors, who introduced themselves and the course program and presented some background information. As central issues, they emphasised the association between tobacco and cannabis use and the potential physical harm of cannabis use, which was underestimated by co-smokers in the preliminary study. Additionally, instructors mentioned that co-smokers could participate together with co-smoking friends and partners to start the behavioural change together and support one another.Consistent with the findings from the preliminary study, the expert team considered an outpatient group-setting with 8 to 12 co-users of tobacco (who smoked at least one cigarette per day) and cannabis (who smoked at least once a week) per group as appropriate. The group-setting was preferred due to several general advantages of group therapy, such as cost-effectiveness (fewer treatment personnel are needed) and interpersonal processes  . AdditioTwo local addiction treatment centres in the Swiss cities of Zurich and Winterthur offered the courses. Each course was guided by two course instructors, at least one of whom had to be a psychiatrist to guarantee the offer of prescription pharmacotherapy to reduce acute withdrawal symptoms or eventual exacerbations of severe psychiatric symptoms. The second instructor had to have experience in treating tobacco or cannabis smokers and could be from a different profession. The members of the expert team either guided the course sessions themselves or trained additional instructors to do so. All instructors received a therapist manual containing instructions for guiding the sessions and the information that was provided to the participants in their workbook (see below).The experts interviewed during the preliminary study recommended using an established tobacco cessation program as the basis for the ISCP and combining it with cannabis-specific elements. We therefore utilised parts of the group tobacco cessation course used by the UK’s leading charity for gay men’s health (GMFA), which was evaluated by Harding and colleagues  and withSubsidiary elements of the course sessions were a smoking diary and workbook which were introduced and distributed to the participants during the first session. The workbook contained background information, an overview of the course structure and content, and work sheets to reflect on personal reasons for cessation and develop and write down personal strategies. The smoking diary was a small notebook that could easily be carried to constantly monitor consumption and thoughts, feelings, and actions associated with the use of one or both of the substances. The notebook should promote vigilance and self-examination. Furthermore, participants measured their expired carbon monoxide at every session to receive an immediate objective feedback on their therapy progress and for later program evaluation. They could enter their individual values in their notebooks and thereby monitor the changes in the values.The main goal of the intervention was dual abstinence of tobacco and cannabis. The instructors promoted moderation of tobacco and/or cannabis use, for example, reducing smoking frequency or changing to a less harmful method of administration  only when participants failed to quit several times during the course. This was done to avoid course dropout. Regarding the cessation sequence of tobacco and cannabis, the expert team supported a simultaneous cessation with one fixed quit date (Quit Day), when the participants were required to stop their tobacco and cannabis use, which is in line with Agrawal’s suggestions . Before The course was primarily based on principles of motivational interviewing , self-coAlthough most of these principles and techniques were applied throughout the whole duration of the course, the emphasis on the application of each principle differed according to the Transtheoretical Model of Behavior Change . ConsequAdditionally, participants were encouraged to use medications that are typically used as first-line medications to increase long-term tobacco abstinence . As someThe intervention sessions that followed the information evening occurred in a group course setting. A meaningful part of every session was the group discussion. In these discussions, the participants could share experiences and problems, and support was provided both among the participants and from the instructors to the participants . Confidentiality was ensured, and instructors placed great value on providing an open, non-judgemental atmosphere. Additionally, the instructors promoted the formation of small quit teams, i.e., subgroups of two or three participants who supported each other, especially between the course sessions, such as during episodes of strong craving. Engagement in a Quit Team was optional and the formation and organization of the Quit Teams was not guided by the course instructors.We investigated the acceptability of the intervention among the participants and course instructors. Further analyses of smoking-related outcomes and utilisation will be conducted with the follow-up data in the near future.Course participants were recruited with the above-mentioned methods. To be included in the intervention, participants had to use cannabis at least weekly, smoke tobacco (in addition to any tobacco used in joints) daily, be at least 18 years old, and be German literate. Participants were not reimbursed, but participation was free, which may have been attractive because, in Switzerland, tobacco cessation programmes usually require payment from the participants themselves.Recruitment of course instructors began within the expert team that developed the intervention. As mentioned above, some experts also acted as course instructors. The experts also trained co-workers from their institutions to guide the courses.At the end of treatment, participants completed questionnaires that they received either at the end of the last session or by mail if they missed the last session. The questionnaire contained a set of items that measured the participants’ opinions toward the intervention in general and toward several components of the intervention. The instruction for the general items began as follows: “How would you evaluate the course regarding”. The instruction for the course component items began as follows: “How helpful were the following components for you?” All items were rated on a scale from 0 to 5, and higher values indicated more positive evaluations.The course instructors received an analogous evaluation form after they had conducted the last course and indicated to what extent the course components were helpful to the participants.In addition to descriptive statistics, the ratings for the general items were compared between participants of the first (five course sessions) and second implementation phases (six course sessions) using Mann–Whitney U tests. This comparison was not applied to the specific course components because their contents did not differ between the two phases.This intervention study was performed in compliance with the Declaration of Helsinki and was reviewed by the Ethics Committee of the Canton of Zurich, which did not declare any objections (KEK-StV-Nr.23/11). Participants signed an informed consent form prior to the first group therapy session.M = 34.0 (SD = 8.1) years, and most (84.7%) were Swiss. Regarding educational attainment, 33.9% had a university degree, 51.5% had completed secondary education (the majority of these participants had finished an apprenticeship), 5.1% had finished primary school, 3.4% had no degree, 3.4% had a degree not listed, and 1.7% did not answer this question.Over nine months, a total of 77 co-smokers participated in seven groups with six to 13 participants each. Of these participants, 59 (76.6%) answered at least one item of the course evaluation. Of these 59, 31 participated during the first and 28 during the second implementation phase. The majority of the respondents (71.2%) were male, their mean age was N = 8, 3 females) completed the evaluation form.In addition to the participants, all course instructors  and course instructors . Regarding its comprehensibility, participants and course instructors evaluated the course very positively . The ratings of the courses’ atmosphere were comparatively high . Participants rated the opportunity to openly discuss illegal issues particularly high , and the course instructors also provided high ratings on this measure . As displayed in Table Overall, the course was rated positively by the participants , which was usually accompanied by an extensive group discussion involving exchanges of experiences between the participants. With the exception of “handling of social risk situations”, participants and course instructors provided high ratings of all the modules that aimed at developing concrete, personal strategies for handling problems that can occur during smoking cessation. Course instructors also considered the carbon monoxide measurement as helpful for the participants. Of all the course components, the Quit Teams which were an optional element received the lowest ratings from both the course instructors  and the 38 participants who indicated that they have been a member of such a Quit Team .Table This study describes the development and content of the first integrative group cessation program for co-smokers of tobacco and cannabis. The program was developed after a preliminary study revealed that both experts and co-smokers of cigarettes and cannabis demanded combined interventions to address simultaneous tobacco and cannabis cessation. This result is consistent with previous theoretical discussions ,26,27.During the preliminary study, experts stressed the multi-dimensional relationship between tobacco and cannabis use that is particularly evident during cessation attempts. Many consumers reported experiencing the balancing effect mentioned by the experts . However, among the queried co-smokers, there was only a modest level of readiness to quit tobacco and cannabis simultaneously and of readiness to participate in an ISCP that addressed both substances at the same time. Many co-smokers were not aware of the relationship between tobacco and cannabis use or the harmful physical health consequences of smoking cannabis. This lack of awareness might explain the modest level of readiness to quit simultaneously. To overcome this lack of awareness and knowledge, the interdisciplinary expert team developed a participant recruitment strategy that was an integral part of the ISCP.The recruitment for the courses was a success because 77 participants were recruited, and seven courses were accomplished within a relatively short time frame of nine months. This success may be attributable to two factors. First, course participation was free of charge because the ISCP was still in development. In Switzerland, participants are usually required to pay for their own participation in tobacco cessation programs. Thus, participation rates may change when the program cannot be offered free of cost. Second, after the press release and a report that appeared in a common free commuter newspaper at the beginning of the first implementation phase, participation rates for the information evening and the course itself were especially high. Because this strategy cannot be applied regularly, it is necessary to switch to appropriate alternatives in the future. In Switzerland, these alternatives could include regular advertisements in the two most common commuter newspapers, which reach a large part of the population.According to their evaluations of the course, both the participants and the course instructors found the ISCP highly acceptable. Because the items measuring the general acceptance of the course were rated more positively by the participants of the second implementation phase, a course length of six, rather than five, sessions may be more appropriate. The finding that participants especially appreciated the group discussions indicates that group settings are appropriate for targeting co-smokers of tobacco and cannabis. Furthermore, participants and course instructors valued those course modules that aimed at developing strategies which can be applied when quitting tobacco and cannabis use. Additionally, the course instructors considered the carbon monoxide measurements to be helpful. Thus, these measurements should remain part of the intervention when the scientific evaluation is completed and biochemical validation is not needed any longer.The Quit Teams were the least appreciated course element and only two thirds of the participants engaged in a Quit Team. Possibly the participants felt no need of this optional buddy support system because the group setting provided sufficient social support. Thus, exclusion of the element of Quit Teams could be considered for a future version of the program. This conclusion is supported by two studies which show that buddy systems provide an additional benefit in an individual smoking cessation setting  but not The ISCP developed in this study combines two substances in one cessation program and connects professionals from general health provider services and psychiatric services. Consequently, the professionals from these services will learn and potentially benefit from their complementary knowledge and experiences. However, beyond this intervention, policy makers should be sensitive to the issue of tobacco and cannabis co-use. Furthermore, the treatment of co-use should be implemented in the health care system and should be covered by existing basic health insurance. The public health approach of Screening, Brief Intervention, and Referral to Treatment (SBIRT) could be applied to the co-use of tobacco and cannabis. Thus, screening for tobacco use in primary care settings could be extended to include screening for co-smoking. Depending on the severity of co-smoking and the willingness to quit, practitioners could then provide information and advice and refer co-smokers to targeted interventions such as the one presented here. Proactive strategies like this may be capable of reaching a broad range of co-smokers and prevent the intake problems that the ISCP might face when it will be conducted without the media interest that surrounded its first implementation. Historical precedents, such as ignoring cannabis in tobacco cessation programs and vice-versa and the use of cigarettes as reinforcers in psychiatry ,25, willHowever, the co-use of tobacco and cannabis should not only be addressed in treatment but also in prevention. According to the findings of our preliminary study, there is a lack of knowledge about the relationship between tobacco and cannabis among co-smokers. It is likely that smokers who only use tobacco or cannabis are not aware of this issue, and it is possible that increased awareness would help to prevent the initiation of the use of the second substance among these smokers. Thus, information about the problems associated with co-smoking should be spread, especially among adolescents and young adults.One limitation of this study is that the online survey of former and active co-smokers was conducted using a convenience sample with a wide age range, those data are based on self-reports and retrospective cessation attempt reports. Furthermore, it is difficult to disentangle the reasons for the differences in the general evaluations of the course between the first and the second implementation phases. Course length may be one reason, but other factors, such as the number of participants in the courses and the identities of the course instructors, also varied between implementation phases.ISRCTN15248397).Currently, we are conducting a thorough feasibility study on the ISCP and expect to have the results of the follow-up data in the autumn of 2013. More details on this feasibility study are provided in the study’s entry at Current Controlled Trials (The proposed intervention for co-smokers of tobacco and cannabis is important because it is the first group cessation program targeting these two interrelated substances simultaneously. The developed ISCP integrates the opinions of both users and experts, established therapeutic principles, and the strategies of former tobacco and cannabis cessation programs. This intervention also takes into account reasonable concepts and ideas that have emerged from on-going discussions about the underlying mechanisms and relationships between cannabis and tobacco use, such as the common route of administration . To prevIn the near future, the presented ISCP will be evaluated for feasibility and initial efficacy.The authors declare that they have no competing interests.JB analysed the quantitative data from the preliminary study, contributed to program development, and wrote the first draft of the manuscript. IH performed the data collection for the preliminary study, analysed and interpreted the qualitative data, and revised the manuscript. OB, MS, AH, and AK contributed to program development and revised the manuscript. MPS designed the study, supervised the data collection and analyses, contributed to program development, and revised the manuscript. All authors have approved the final version of the manuscript.


Nepal is a small developing country in South Asia situated between China and India. The last fifteen years have seen a tremendous growth in the number of medical schools in the country. At the beginning of August 2011 there were eighteen medical schools and all except four were in the private sector [Among government-run schools, the National Academy of Medical Sciences (NAMS) is a postgraduate training institution attached to Bir Hospital, the oldest hospital in Nepal. The Institute of Medicine (IOM) was the first medical school to be started in the late 1970s. IOM admits students from other countries who are paying privately to the undergraduate medical (MBBS) course. The other two schools, BP Koirala Institute of Health Sciences (BPKIHS) and Patan Academy of Health Sciences (PAHS) admit students paying partial and full tuition to the MBBS course. Colleges in Nepal also admit students from India, Sri Lanka, and from developed nations who pay higher tuition fees than Nepalese students. PAHS does not admit foreign students to the MBBS course.In Nepal, there are scholarship students, Nepalese self-financing students, and self-financing students from South Asia and from other regions. Scholarship students have to serve in rural areas for two years after graduation. At PAHS all students (scholarship and self-financing) will be expected to serve in rural areas for a period of time according to a sliding scale (depending on the method of financing) after graduation. The author is conducting a study on student perceptions about working in rural Nepal after graduation from KIST Medical College. Preliminary results indicate certain self-financing students may be highly motivated to emigrate to developed nations, mainly the United States and Australia, after graduation. This is also the author's personal observation after teaching in self-financing schools in Nepal for about twelve years. Tuition fees for self-financing students are high, ranging from US$32,000-40,000 for Nepalese students, US$50,000-53,000 for Indian students, and US$60 000 for students from other countries [The faculties in Nepalese medical schools mainly come from Nepal and India, with a few faculty members coming from other countries. Many faculties are not familiar with the sociocultural milieu of Nepal and with healthcare delivery in rural areas. The duration of the MBBS course is four and half years followed by a year of rotating internship which foreign students can do in their home countries. At PAHS, the MBBS course is of six years duration (with internship) and there is a premedical phase of 6 months where students review science subjects and English and are introduced to rural and underserved community experiences. The medical schools are affiliated with and follow the curriculum of two Nepalese universities, Tribhuvan University, a government university, and Kathmandu University, a private university. BPKIHS and PAHS are autonomous institutions. The curricula in most schools are broadly similar. During the first two years, students learn the basic science subjects of anatomy, physiology, biochemistry, pathology, microbiology, and pharmacology along with community medicine and early clinical exposure. The curriculum of all universities have the ostensible purpose of creating doctors for rural Nepal, though only a small percentage eventually work in rural areas. At PAHS the curriculum has been designed to admit and train a high percentage of students from rural Nepal and to model rural service and social responsibility throughout the medical course.Medical education and medical schools especially in South Asia have long espoused the principle that one 'size' or 'style' of medical education fits all. With the rapid advancements occurring in medical knowledge, it may be time to recognize that no medical student can learn all 'necessary' facts and skills. The knowledge and skills to be taught and learnt may be determined by students' career plans after graduation and where he or she plans to work. In Nepal and in many other countries, self-financing students are supported by their families or educational loans and their primary motive may be to recover the high investment as quickly as possible after graduation. The government does not provide scholarship to these students and many students may not consider having a 'social' and 'community' obligation after graduation. Working and settling in developed nations or in specialty and super-specialty hospitals in urban areas in the home country is their priority. However, there may be indirect investments by the country/community in terms of faculty dedication, faculty professional development, and other inputs devoted to the education of these students. Ideally all medical students should feel an obligation towards their country and serving the underserved population regardless of whether the school pays their tuition fees or not. Private medical colleges also have students who have to work in rural areas after graduation. In many cases, these two groups of students i.e., students who are required to work in rural areas and those who are not required, have a different outlook and way of life. Scholarship students can become 'corrupted' by the ostentatious lifestyle of a few self-financing students, look down on rural service, and develop the desire to make money quickly. A self-financing seat costs about 3 million Nepalese rupees and the overall expenses at the end of the course may be around 3.5 to 4 million. Because of this, many self-financing students have to be from a strong financial background. In Nepal, government student loans are absent, and banks may require collateral and good financial status to approve loans. However, it is also possible that students from urban areas come to know and appreciate the needs of their less fortunate countrymen by working and studying alongside students from rural backgrounds.The training does not prepare scholarship students for their service in rural Nepal. Though students spent time in communities, the training is not adequate to enable them to work independently in rural areas, handle administrative responsibilities, interact with rural communities, and live in rural Nepal. PAHS has carefully designed its curriculum to prepare students for practice in rural Nepal and it would be interesting to follow the progress of this 'different' medical school and its students. Many self-financing students have their goals set firmly on examinations like the United States Medical Licensing Examination and postgraduate entrance examinations and/or establishing an urban practice. Teachers suffer from an inadequate knowledge of conditions in rural Nepal and of the government healthcare system. Many have not spent adequate time in rural areas. A similar situation may exist in medical schools in other south Asian countries and other developing nations. Privatization of medical education and admission of scholarship students to these schools has created a student body with diverse educational needs and outlooks. Foreign students further add to the diversity. Will this diverse group of students require curricula and teaching methods tailored to their specific needs? One approach could be of a core curriculum for all students and of electives which students can pursue according to their interests. This concept has not yet gained acceptance in Nepal. Another approach could be to design a medical school like PAHS with a common curriculum of social responsibility for all its students but with electives that students can pursue according to their interests and career choices. In this scenario it may be time to review and reconsider the old basic principle of medical schools in Nepal and other countries that states, 'One size of medical education fits all students'.


With the rapid advance of genetics, the application of genetic testing has become increasingly popular. Test results have had a tremendous impact on individuals who receive the test and his or her family. The ethical, legal, and social implications (ELSI) of genetic testing cannot be overlooked. The Internet is a potential tool for public engagement.This study aimed at establishing ethical guidelines for genetic testing in Taiwan through a participatory citizen consensus approach via the Internet.The research method used was a citizen consensus conference modified by an Internet application and the Delphi technique. The citizen consensus conference is one of the public participation mechanisms. The draft ethical guidelines for genetic testing were written by an expert panel of 10. The Delphi technique was applied to a citizen panel recruited via the Internet until a consensus was reached. Our research population was restricted to people who had Internet access.Included in the citizen panel were 100 individuals. A total of 3 individuals dropped out of the process. The citizen panel was exposed to the issues through Internet learning and sharing. In all, 3 rounds of anonymous questionnaires were administered before a consensus was reached in terms of importance and feasibility. The result was ethical guidelines composed of 4 categories and 25 items. The 4 categories encompassed decision making (6 items), management of tissue samples (5 items), release of results (8 items), and information flow (6 items). On a scale of 1 to 10, the average (SD) importance score for the decision-making category was 9.41 (SD 0.58); for the management of tissue samples category, the average score was 9.62 (SD 0.49); for the release of results category, the average score was 9.34 (SD= 0.59); and for the information flow category, the average score was 9.6 (SD = 0.43). Exploratory analyses indicated that participants with higher education tended to attribute more importance to these guidelines.The resulting recommended ethical guidelines had 4 categories and 25 items. We hope through the implementation of these guidelines that mutual trust can be established between health care profession and the general public with respect to genetic tests. A genetic test is defined as the analysis of human DNA, RNA, chromosomes, proteins, and certain metabolites in order to detect heritable disease-related genotypes, mutations, phenotypes, or karyotypes for clinical purposes . Every yEvery genetic test should be offered in such a way that individuals and families are free to refuse or accept according to their wishes and moral beliefs. All testing should be preceded by adequate information about the purpose and possible outcomes of the test and potential choices that might arise. Children should only be tested when it is for the purpose of better medical care .Nonetheless, the ethical, legal, and social implications (ELSI) of genetic testing cannot be overlooked. The test results often have a tremendous impact on the lives of the individuals who receive the test and his or her family. As such, the 1998 World Health Organization’s Proposed International Guidelines on Ethical Issues in Medical Genetics and Provisions of Genetic Services recommended that:            More importantly, genetic testing is not only an issue of individual choice, but also of social choice. Health care professionals should conduct such testing in compliance with social norms so as to avoid the potential chaos that genetic testing is capable of creating.Various ethical, legal, and social issues have been raised in the past regarding genetic testing. For instance, in 2008 the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion on ethical issues in genetic testing that included informed consent, prenatal genetic testing, genetic data and the family, genetic data and insurers and employers, genetics and assisted reproductive technology, in addition to other topics. The more contentious issues included confidentiality, privacy, the right of minors, the balance between the rights of individuals and their families, and potential discrimination by employers or insurers -8.Due to the clear need of guidance in translating genetic discoveries into clinical care, guidelines in this regard have been developed throughout the world . There hMost professional ethical guidelines have been written entirely within the profession. The use of expert focus groups is one of the commonly applied methods for developing ethical guidelines . HoweverEngaging citizens in policy making has attracted much attention in recent years. Public participation, public engagement, or public involvement refer to interactions between the public and decision-making bodies, and the guiding principles for these activities are transparency and openness, which ensure that decisions are made based on the best available evidence .For instance, member countries of the Organization for Economic Cooperation and Development (OECD) also strengthen their relations with citizens in order to improve the quality of policy . As statThere are 3 classes of public engagement based on the flow of information between participants and sponsors: public communication, public consultation, and public participation . In publThe research method we applied was the citizen consensus conference modified by Internet application and Delphi technique.Originating in Denmark, the citizen consensus conference is a method of public opinion extraction that gives ordinary citizens opportunities to make their voices heard in technology policy debates . This kiAccording to a typology developed by Rowe , there aThis research was divided into 3 phases, each of which is described in more detail below. In the first phase, we used the Internet to recruit citizens to join the research. We recruited and randomly sampled volunteers and obtained written consent from the final list of participants. The next phase was to invite the citizen panel to participate in Internet learning, sharing, and discussion. Written background material was distributed to the participants via email. Participants could engage in exchanges and discussions through the group email list where our expert panel also participated via group emailing. Meanwhile, we drafted ethical guidelines for genetic testing and invited an expert panel of 10 to review content validity. The third phase was to apply the Delphi technique to the citizen panel until a consensus was reached in terms of importance and feasibility of items contained in the guidelines.By posting Internet announcements to recruit the lay panel, our research population sample was restricted to people who had Internet access. The announcement was posted for 1 month in popular local Internet portals such as Yam and Kijiji, as well as on websites of some universities and community colleges. The inclusion criteria were age greater than 20 years and an interest in the ethics of genetic testing. In total, 119 persons volunteered. Of the 119 in the preliminary sample, 47 had health care professional backgrounds, and 72 did not. After random sampling in a ratio of 4 to 6, the final panel included 40 people who had a health care background and 60 who did not.The research questionnaire used in the Delphi processes was based on ethical guidelines drafted by the steering committee, which was composed of the principal investigator (PI) and the coinvestigators. The committee invited 10 experts  to review the questionnaire. Each item’s content validity index (CVI) of .8 in terms of importance was preserved. Our first draft had 4 categories and 28 items; after the expert panel’s review, 4 categories and 21 items were retained in the questionnaire. Each item was scored on a scale of 1 to 10 in terms of importance and feasibility, with higher scores indicating higher levels of importance and feasibility.The technique we applied is, in effect, a Delphi technique modified by the application of the Internet. The Delphi technique is one of the nominal group techniques that use questionnaires to build consensus. Conventionally, questionnaire surveys can only be completed by pen and paper, but these can now be conducted through the Internet. Administration of Web questionnaires has been reported in the literature to have the same reliability  as maileIn terms of data analyses, we applied CVI to determine expert content validity. Internal consistency calculations were used in the Delphi stage to determine whether a consensus had been reached. All other analyses were descriptive and exploratory in nature. The PI of this study was deemed responsible for the storage and confidentiality of the database.In total, 3 persons dropped out of the lay panel during the process. From In the Delphi stage, 3 rounds of anonymous questionnaires were conducted prior to consensus in terms of importance and feasibility, which achieved an internal consistency of Cronbach alpha .93. In the final stage, the ethical guidelines included 4 categories and 25 items. The 4 categories were: decision making, management of tissue samples, release of results, and information flow. The importance scores of each item ranged from 9.34 to 9.62 on average for these 4 categories .The decision-making category included 6 items that dealt primarily with autonomy and informed written consent. The management of tissue sample categories included 5 items that encompassed the scope of use, storage security, timing of destruction, and research problems. The release of the results category included 8 items and dealt with privacy issues, such as whether and how family members should be informed of test results. The information flow category included 6 items, primarily centered on confidentiality issues that emphasized how test results should be kept confidential from insurance companies, third persons, and employers. All categories and items within each category are presented in P = .047), release of results (P = .02), and information flow (P = .02), whereas in the management of tissue samples category, the average scores of educational groups in descending order were: doctoral students, people with a master degree, graduate students, and college students (P = .02). The results implied that participants with higher education tended to attribute more importance to these guidelines.Whether personal characteristics affected the responses of the lay panel was further explored. In terms of importance scoring, only the variable of education had a significant influence on all 4 categories according to ANOVA. Post hoc Scheffe’s analyses indicated that the average scores of graduate students were significantly higher than those of college students in the categories of decision making  the results of genetic testing subject perfectly healthy individuals to discrimination due to potential future illnesses, (2) the uncertainties of genomic application including genetic testing and genetic treatment are still ominous, (3) there are consequences not only for the individuals who test, but also for family members .Most scholars agree that, although it is imperative to respect autonomy and privacy in conducting genetic testing, health care professionals must also inform the examinee that it is his or her moral obligation to inform family members regarding hereditary risks -8. DurinBecause a breach of confidentiality in genetic information might affect family relations, employment, insurance, paternity law suits, and so on, and might further lead to stigmatization and discrimination, high standards of security must be established to ensure confidentiality ,7. As a Another interesting phenomenon worth noting is that feasibility score averages tended to be lower than those of importance scores for the same item . That isFurthermore, the lowest feasibility score was for item 4.6, which stated that employers be prohibited from subjecting their employees to genetic testing. This item clearly shows a lack of confidence in employers and reflects a worry that employers are unstoppable and will eventually control their employees through genetic testing in some way.Another finding worth noting is that our lay panel inserted a contractual requirement for the health care industry. Item 4.2 states that the examiner should sign a contract with the examinee before testing to assure confidentiality. Under most health care circumstances, patients or recipients of care are requested to sign consent forms. Although the responsibilities of the physicians and caregivers are also specified in the consent forms, most people felt that their consent was sought merely to protect the health care professionals rather than themselves. In short, the requirement for informed consent was not deemed reciprocal by the general public. Therefore, it is natural for laypersons to think that they are entitled to written contracts from examiners to ensure that examiners fulfill their obligations, underlining the importance of the citizen consensus conference in giving voice to the general public.Many countries have applied the techniques of the citizen consensus conference to explore public issues including Argentina, Australia, Austria, Japan, Netherlands, New Zealand, Canada, Denmark, France, German, Israel, Norway, Korea, Switzerland, the United Kingdom, and the United States as well as others . CitizenOur research group adopted the same techniques to help with the revision of the code of ethics for nurses in Taiwan in 2005 and 2006 . AlthougCitizen consensus conferences need to have ample participation from the lay panel. As a result, for the modified Delphi technique to work for a citizen consensus conference, a good response rate to the questionnaires is very important. Internet technology has been reported to have the potential to decrease the time and cost in conducting a health care survey and increase response rates . AlthougThe composition of our citizen panel tended to be young urban students. This phenomenon was caused by our reliance on the Internet in this study because such students are more technology savvy and broadband services are more ubiquitous near city centers. Although this phenomenon limits the generalizability of our research results, the fact that the younger well-educated generation will ultimately provide the opinion leaders of the future suggests that our draft guidelines will likely be relevant for some time to come.Another drawback is that we had a high percentage of health care professionals in the lay panel who were knowledgeable about genetic testing. Therefore, the composition of the lay panel was not representative of society. This difficulty arose due to the high percentage of respondents having medical backgrounds. It is reasonable to assume that those with medical backgrounds would be more interested in this issue than those without. Regardless, the common sense of health care professionals is important for forging societal consensus.On the other hand, these limits to generalizability could have been caused by our advertising and recruiting strategy. Due to the limitation of funding, we relied solely on free Internet portals. If our recruitment announcements could have been placed in major commercial portals, such as Yahoo and Google, we might have been able to gather a more varied population of volunteers as potential participants.Despite the growing interest in public participation, the real effectiveness of participation remains difficult to ascertain. The main difficulty comes from how to define effectiveness and how to make it operational . In the No doubt, the sample size of this study is inadequate to draw definitive conclusions about the sensitive issue at hand. This study was merely an attempt to forge some consensus in genetic testing through Internet public participation. Whether a larger number of participants would add strength to this policy making exercise remains to be seen. From the experience gained by conducting this study, we found that a sample size of 100 participants was fairly difficult to manage. For a citizen consensus conference to operate efficiently and effectively, researchers need to communicate with the participants constantly throughout the process. As the group gets larger, even with the help of information and communication technology, it becomes harder and harder to keep tract of the participants and make sure they keep their commitments. Other mechanisms need to be added if a broader participation is desired. There is no way in a democracy that citizen consensus conferences can replace all other policy-making mechanisms, such as referendums.The ethical, legal, and social impact of genetic testing cannot be overlooked. Test results not only have a tremendous impact on the life of the individuals who receive the test, but also impact his or her family. This research helped to establish ethical guidelines for genetic testing using public participation via the Internet. The recommended ethical guidelines had 4 categories and 25 items; the 4 categories encompassed decision making, management of tissue samples, release of results, and information flow. We hope, through the implementation of these guidelines, mutual trust can be established between the health care professionals and the general public with respect to the application of genetic tests.


Medical emigration from developing to developed countries is a well established phenomenon of substantial importance. Though Libya is classified as an upper-middle income country, it has been affected by this trend. This study was undertaken to identify some of the possible reasons behind the emigration of Libyan doctors and factors that might motivate them to return.Seventy-four completed questionnaires were analysed. Median age of the respondents was 43 years (33-60) and median duration of stay outside Libya was 15 years (6-29). Most of the participants were resident in Europe (66%). The desire to further their education and research was the main reason given by 88% of the respondents for leaving Libya, while 50% of them gave that as the main reason for staying abroad. One-third of the respondents (31%) cited economic factors as the main reason for not returning. None of the respondents ruled out returning to Libya, and about half of them stated that they definitely or probably will return to Libya. 58% ranked reform of the Libyan health system as the most important reason that could induce them to return to Libya.The study shows that reforming the health care system in Libya might induce some of the physicians who moved abroad mainly for educational and economic reasons to return to Libya to practice medicine. The last few years have witnessed rising interest in analysing various issues related to migration of physicians from developing countries. Recent publications have tried to shed light on the number of migrating physicians ,2, the r2 and a population of 5.3 million. One-third of the population is under the age of 15 years, and the majority of the population lives in the coastal cities, the most prominent of which are Tripoli  and Benghazi (second largest city). Libya had been an Italian colony from 1911 until the end of the Second World War, when it became a British protectorate. In 1951 Libya gained its independence and was established as a kingdom. In 1969 Colonel Muammar Qadhafi took over and he has been leading the country since then.Libya is a North African Arab country. It has a surface area of 1,775,500 kmThe discovery of oil in the 1960s completely transformed the socioeconomic status of the country. As living standards rose in the 1970s, the number of medical schools and health service facilities increased. However, in the 1980s Libya's relations with the United States and European countries deteriorated, and its political isolation culminated in United Nation sanctions in the 1990s. This had negative repercussions on the country's infrastructure. However, in recent years Libya has been rapidly re-emerging from international isolation.The Libyan public health sector is the main provider of health services, which are provided free at the point of delivery. Twenty-seven specialised hospitals and 36 general hospitals in different parts of the country provide secondary and tertiary care. There are 39 polyclinics, 23 communicable disease centres and 1165 primary health care units and centres . PrivateThe first Libyan medical school was established in Benghazi in 1970, followed by the one in Tripoli in 1973. Between 1987 and 2001 the number of medical students increased dramatically as seven new medical schools were established in different parts of the country. The medical education system is based on the traditional British curriculum and uses English as the language of instruction.Like many other Arab and African countries, Libya has been affected by the drain of its doctors. Clemens and Pettersson reported a total of 585 Libyan physicians when they used the destination-country census data of 2000 to estimate the number of African-born doctors who had immigrated to the United Kingdom (UK), the United States of America (USA), Australia, Canada, France, Spain, and Belgium by . Mullan,This study is an attempt to identify some of the reasons behind the emigration of Libyan doctors and the factors that might induce them to return. By highlighting the problem, our results might assist in planning and execution of further studies of this important subject in more depth.A simple questionnaire consisting of three parts was designed [Additional File Part I contains background questions about age, sex, year of departure from Libya, place of primary medical qualification, current country of residence, and type of current job. It also asks about how settled the respondent feels both professionally and socially in his or her current country of residence.Part II asks about the reasons for initially leaving Libya and the reasons for later deciding to settle abroad. The respondents were given four options: educational (to pursue further education and research), economic (to seek a better income and living standard), personal , and other (the respondents could explain in their own words). Respondents were allowed to select more than one answer, but in such cases they were asked to prioritise their choices as 1, 2, 3, and 4, one being the most important and four being the least important.per se and physician employment conditions. The other options were significant improvement in the prospects for research in Libya, social reasons, other reasons (the respondents could explain in their own words), and not returning under any circumstances. The respondents were allowed to choose more than one answer, in which case they were asked to prioritise their choices as 1, 2, 3, and 4, as described above. The respondents were finally asked about the type of employment they would take up if they were to return to Libya: public hospital, academic institution, private sector, non-medical job, or other.Part III asks about the likelihood of returning to Libya to practice medicine. Five options were provided: definitely, probably, possibly, unlikely and never. The respondents were also asked about what would induce them to return to practice medicine in Libya. They were given five options. The first, significant reform of the Libyan health care system, was meant and has been used by Libyan doctors and health officials in a global sense that covers both health care deliveries Our target consisted of doctors who were Libyan citizens and practicing abroad. We recruited participants from the Libyan Journal of Medicine database  and the Libyan Doctors Society (a society of Libyan doctors abroad). We also asked potential participants to forward us the e-mails of any expatriate Libyan doctors they knew. In this way we obtained 225 e-mail addresses of Libyan doctors practicing outside Libya, and we targeted them all. The purpose of the study was explained, and confidentiality and anonymity were pledged. The responses of the first ten respondents were reviewed carefully and a note was sent to clarify that the question concerning the country of qualification meant the country in which the first medical degree was obtained. A reminder was sent after two weeks to those who had not responded. In total, 78 questionnaires were returned, giving a response rate of 35%. Respondents who had been abroad for five years or less were excluded, which left 74 questionnaires for analysis. We excluded these respondents because many Libyan graduates are funded by the Libyan government during their post-graduate training abroad, which lasts a few years. Hence, they cannot be considered to have settled abroad during that period of sponsorship. The responses of the remaining respondents were entered in Microsoft Excel for descriptive analysis.Only one of the respondents was a female. Median age of the respondents was 43 years (33-60 years) and median duration of stay outside Libya was 15 years (6-29 years). Most of them were resident in Europe (66%), 20% were in North America, and 14% were in Arab Gulf countries. Whether the respondent had been resident in other countries since leaving Libya was not investigated.Almost all respondents  obtained their first medical degree in Libyan universities; only two physicians obtained it elsewhere. Most respondents were working primarily as clinicians providing services , of whom 28 respondents (38%) were also active in clinical research. The profession of the remaining seven respondents (10%) was medical research not involving direct patient care.Most of the respondents felt professionally well settled  or reasonably settled . However, they seemed to fare less well in terms of social integration, with only 16 (22%) stating that they were socially well integrated, and 34 (46%) and 21 (28%) saying that they were reasonably or partially integrated, respectively.The most important reason given for having gone abroad initially was the desire to further education and research , while 9 respondents 12%) gave first rank to seeking a better income and living standard. However, the reasons given for deciding to say abroad showed a different pattern  were the most commonly given reasons for having settled abroad . By contrast, economic and social factors were the reasons given most frequently by those who settled in Arab countries  or in North America . Of those in Europe, 38.8% said they were not integrated or only partly integrated, compared to 20% of those in Arab countries and also 20% of those in North America.Doctors who have settled abroad for professional and educational reasons were more active in biomedical research  compared to those staying for economic or social reasons .None of the participants ruled out the possibility of returning to Libya. About half of the respondents (54%) stated that they definitely or probably will return to Libya, and 46% described the likelihood of their return as possible or unlikely. The average length of stay abroad was shorter for those who were most likely to return compared to those who were less likely to return .Most respondents  ranked reform of the Libyan health system as the most important reason that could motivate them to return to Libya Table .Most respondents said that if they were return to work in Libya, they would most likely work in a public hospital  or an academic institution . Only 11 respondents (15%) ranked work in the private sector as their first choice.Our study shows that the most important reasons given by Libyan physicians for emigration are the pursuit of further education or research opportunities and the search for better income and lifestyles. These factors have been reported by others as reasons for emigration from poor to rich countries -13. HoweOur results point to the attraction of career opportunities in destination countries with well established health infrastructures and academic institutions and advanced technology. The importance of these opportunities might even trump the factors of salary or lifestyle amenities already available in an upper-middle income country such as Libya.per se  or the conditions of employment  are more important in this respect requires further investigation. Gaining an understanding of what would motivate repatriation is as important as what causes migration, and such understanding would be useful in planning reforms.There is general agreement among Libyan health care officials and Libyan doctors inside and outside Libya that the Libyan health care system requires considerable reform. Significantly, the results also indicate that such reform could be the strongest motivation for expatriate doctors to return home. Whether reform of health care delivery Effective reform of the Libyan health care system is possible because the country enjoys a healthy economy, with an estimated per capita income of more than $7000 . HoweverRecruiting participants in the survey was made difficult by the absence of a database for expatriate Libyan doctors. We sought to recruit participants in a non-biased way from the database of the Libyan Journal of Medicine and members of the Libyan Doctors Society (a society for expatriate doctors). It might be argued that this led to recruitment only of doctors who are more "visible." But by asking the participants to help recruit others through their personal means we sought to reach others who were not "visible" through the society and the journal, and also to increase sample size.Despite our efforts to maximise sample size, we were able to contact only about one-third of the reported expatriate Libyan physicians, and the response rate was disappointingly low. This limits the possibility of making generalisations and comparing different groups in the study, such as those residing in different countries. Our results should be viewed as preliminary data that give broad indications of the reasons for migration and the potential motivations for returning to Libya. Our results can be useful when planning studies of this type, both in terms of capitalising on its positive aspects and by avoiding its limitations. We support the suggestion made by Stilwell that data collection should be improved by establishing and maintaining a database on migration . Such a The relatively low response rate in this study might reflect a lack of interest among Libyan expatriate doctors in this issue. It might also reflect a belief among them that science journals would have no interest in this issue as it relates to a small country such as Libya, as stated by one respondent. Therefore, raising awareness of medical professionals about the significance of the migration issue is crucial for facilitating future studies and reducing the impact of this limitation.e.g. paediatrics, are staffed mostly by females whereas others, such as surgery, are staffed mostly by males. It is possible that those in female-dominated specialties are less likely to be sent abroad for post-graduate studies and specialisation.We were somewhat surprised that only one of the 74 respondents was a woman, because in Libya women occupy a much larger share of this profession. We could not find officials figures, but the ratio of females to males is probably closer to at least 1:2. The 1:64 ratio we observed is difficult to account for, but we suspect that two social reasons could be involved. First, female doctors are probably less likely to travel abroad for postgraduate training, particularly if they are not married or their spouses do not approve. Second, female doctors in postgraduate training outside Libya are probably less likely to settle abroad than their male counterparts if they are unmarried or if their spouses do not agree. Moreover, some specialties, The ethical issues that arise when implementing a questionnaire-based study include potential risks that participation might entail. In our study, all measures were taken to respect the participants' privacy, and they were and are assured of anonymity. Moreover, the participants are highly trained professionals who are familiar with these issues and can make an independent decision as to whether they want to participate in a study of this nature. Last but not least, criticisms of the performance of the Libyan health system have been discussed openly in conferences in Libya and employment conditions criticised.Another limitation of this study is that it included only Libyan doctors working abroad. Including the views of Libyan doctors who returned and those who never left the country would be more comprehensive. Moreover, gathering the views of health officials, possibly by conducting semi-structured individual interviews and focus groups, would add another dimension to this type of work. It would also be interesting to explore the intentions of the newly qualified Libyan doctors and medical students to see whether a culture of medical migration is developing in Libya as has occurred in some other countries ,6. HowevThe study was not designed to look at the effects of the migration of Libyan doctors. However, a report from the World Health Organization about the health system profile in Libya in 2007 states that the density of physicians in Libya decreased from 13.7 per 10,000 of the population in 1995 to 12.5 in 2006 . By contTaking in consideration all the limitations of this study, it is reasonable to conclude that reform of Libya's health system, including improvement of the conditions of practice and acceleration of investments in research and academic infrastructure, might motivate some of the physicians who moved abroad mainly for professional and economic reasons to return to their home country to practice medicine. The policymakers should take this point into consideration if they wish to manage this worrying phenomenon and avoid its consequences. Further studies looking at other issues related to the migration phenomenon, such as the negative impact on the country and whether an emigration culture is emerging, are needed to get more insight into the drain of doctors from Libya.The authors declare that they have no competing interests.HB conceived and designed the study, participated in data collection, analysis and interpretation, and drafted the manuscript. AB helped in designing the study, analysis and interpretation of data, and critical review of intellectual content. OB participated in design of the study, analysis and interpretation of data, and critical review of intellectual content. All authors read and approved the final manuscript.The study questionnaire. The questionnaire used to collect data from the study participants.Click here for file