To Test or Not To Test?

To test or not to test? Shouldn't the answer (almost) always be yes? Then why, in a country as medically advanced as Ireland, are people still being type-caste for HIV testing?

During the Education, Sports and Music- Social Vaccines Against AIDS event at Limerick University on November 28^th, 2012 in honour of World AIDS Day, experts and distinguished guests discussed issues around HIV prevention and testing in Ireland and abroad. The event, organised by Irish Aid in collaboration with the Irish Forum for Global Health and The University of Limerick, hosted a diverse array of individuals such as HIV/AIDS activist Father Michael Kelly, Minister of State for Trade and Development, Joe Costello, and Munster Rugby Player Marcus Horan.

Ann Mason, from the Red Ribbon Project in Limerick, spoke of the current HIV/AIDS situation in Ireland. In 2011, 320 people were diagnosed with HIV, with men who have sex with men making up the highest proportion of newly diagnosed cases. According to the Health Protection Surveillance Centre’s (HPSC) HIV Quarterly Report[1], in the first three quarters of 2012 there have been 248 new HIV diagnoses. Ms. Mason noted that individuals in groups commonly perceived to be at higher risk are not the only people who are HIV-positive and made reference to newly divorced/separated people that are no longer in monogamous relationships. However, these populations are usually not targeted for HIV/AIDS messages and testing and are difficult to reach.

The problem of perception- what do we think an HIV at risk individual looks like - was raised by Infectious Disease Specialist Dr. Busi Mooka. As stated by Dr. Mooka, “HIV becomes a medical problem only when you present, before then, it is a social problem”. She acknowledged that we do not know the true burden of HIV in Ireland, because the statistics only indicate who has been tested, and our testing of often subject to perception.

Often people are tested based on their risk stratification, which as Dr. Mooka states, is subject to social constructs. Men who have sex with men, sex workers and people who inject drugs are commonly seen as “at-risk” groups and are encouraged to have an HIV test. But what about the rest of the population? If we stratify populations as, “Too rich, too posh, too white…”, or assume that “HIV is not me, not my mother, not my sister or brother”, as stated by Dr. Mooka, then we are missing a lot of people who could benefit from an early diagnosis. Dr. Mooka proposed a de-stigmitisation of HIV risk groups and to test everyone, so that all can be aware of their status.  

This seems like a daunting task. In Ireland, though, we may be able to raise awareness and decrease social stratification by using the “social vaccines” model. This model, which uses music, sports and education to prevent HIV, has had noted success in many low and middle-income countries (LMIC) with high HIV prevalence.  Father Michael Kelly spoke of how education in LMIC’s has been used to combat the spread of HIV, and stated that because of education we “[have] confidence that this disease is being tackled and overcome”.

However, in Ireland, like in so many other countries, we must not only educate on the risks of HIV, but also use this to reduce sterotypes because as stated by Father Michael Kelly, “one of the worst curses in this area is discrimination and stigma against people living with HIV/AIDS”. Using music, sports and education in Ireland, with a focus on destigmatisation and the importance of testing, may reduce preconceived notions and stereotyping of HIV at risk individuals.

Ireland should look to other countries for lessons on how to screen for HIV. As Professor Sarah Moore, Associate Vice President of Academia at the University of Limerick stated, “No nation or community is entirely exempt [from HIV], but most of the lessons come from Africa…and we have much to learn from their experiences”.   Health practitioners should more actively encourage testing for at minimum all sexually active people, and not only target key populations at higher risk. This will mean identifying more people living with HIV earlier, and since people living with HIV can have a normal life expectancy with proper care and diagnosis, isn’t this a good thing?

Brynne Gilmore
Key Correspondent
Email: gilmorb@tcd.ie

Author Affiliations: School of Nursing & Human Sciences, Dublin City University

Option 1- Scientific / Empirical Research Findings Presented as - Oral Presentation

Aims:

To explore hospital factors that account for the variation in rates of non-EU qualified nurses in general hospitals in Ireland. Working hypotheses were that: large, teaching, urban hospitals would have higher levels of non-EU qualified nurses, given their higher turnover rates; hospitals with more negative work environments would have higher levels of non-EU qualified nurses as they would have relied more heavily on active overseas recruitment.

Methods:

Secondary analysis of data gathered during the FP7 RN4CAST project, was carried out. Data were collected in 30 acute general hospitals in Ireland in 2009/10, focusing on 112 medical and surgical wards. Nurses (n=1,406) completed a survey about their working environment and their own characteristics. An organisational profile was completed for all hospitals.

Results:

Organisational data on nurses with non-EU qualifications were only provided for 12 of the 30 hospitals and showed that up to half of the nurses employed in some large teaching hospitals have non-EU qualifications. However no characteristics such as size, voluntary/HSE status, geographical region were clearly associated with higher levels of non-EU qualified nurses. Also, hospital level nurse-reported factors such as high burnout level and a negative practice environment were not associated with higher hospital levels of non-EU qualified nurses.

The data gathered in 2009/10 do not tell the story of the trends across time of overseas trained nurses who were actively recruited and subsequently left the hospital before data collection. Therefore it is plausible to suggest that hospitals with better work environments have retained non-EU qualified nurses to a greater extent. Retaining nurses who were actively recruited to Ireland is even more important in the current health service context. There was limited organisational-level data available for many hospitals, though this was supplemented by nurse-reported survey data on place of qualification for this analysis.

Authors: Ibrahim N., Bidwell P.


Author Affiliations:Centre for Global Health, Trinity College Dublin

Option 1- Scientific / Empirical Research Findings Presented as - Poster

Aims:

The aim of this research was to investigate about the migration of the Sudanese doctors to work in Ireland: what are the factors that contribute to their decisions to leave Sudan and come to work in Ireland, their perception about working in Ireland and What is their future plan; whether if they are returning back to Sudan to work as doctors.

Methods:

Cross-sectional quantitative research using on-line survey: SurveyMonkey.com. A sample of 120 Sudanese doctors completed the survey. Emails had been collected from doctors using Sudanese Society in Ireland and snowballing approach to recruit more doctors by sending more emails from colleagues wishing to participate in the study, which create a pool of about 345 emails.

Results:

• 
  Response rate 43.7 %


• 
  The main challenge which faces Sudanese doctors in Sudan is lack of training


• 
  Most of the participants in this research were from specific regions in Sudan and acquired their medical 
degree mainly from two out of 30 medical colleges in Sudan


• 
  Career development and training opportunities appeared to be the main incentives for working in Ireland. 
However their feeling of discrimination from their colleagues and patients, and having unequal training 
opportunities was significant


• 
  Most of them are planning to go and work mainly in Khartoum.

Discussion/conclusions/ implications:

• 
  Ireland: More understanding of the work environment of the Irish hospitals and the reasons behind Sudanese doctors as an example of foreign doctors feeling of discrimination is needed as the overseas doctors are an essential part in Irish health services.


• 
  Sudan: Addressing the issues of doctors training is very important to retain Sudanese doctors in Sudan. More research is needed about the migration of doctors from all the medical colleges what the differences in their migration pattern if any.


• 
  More research and collaboration between Sudan and Ireland is needed for finding different ways to change Sudanese negative brain drain to positive brain exchange. The government of Sudan need to reduce the pushing factors for Sudanese doctors to retain their human resources to meet Sudan’s health care needs. 

Authors:Brugha R.¹, Bidwell P.², Dicker P.¹, Humphries N.¹, Thomas S.², Normand C.²

Author Affiliations:1Royal College of Surgeons in Ireland, 2Trinity College Dublin

Option 1- Scientific / Empirical Research Findings Presented as - Oral Presentation

Aims:

The Doctor Migration Project aims to provide a better understanding of the scale of Ireland’s reliance on non-EU doctors. It will report on their experiences of working in Ireland and future plans.

Methods:

The Irish Medical Council (IMC) supplied the research team with a spread-sheet containing the numbers and non- personal information on doctors on its Register, 2000-2010. Data included medical school where qualified, but not nationality. A Biostatistician (PD) created a database, searchable by a unique identifier, and calculated entrants and exits from the register.

Results:

The proportion of non-Irish medical graduates rose from 13.4% of all registered doctors in 2000 to 33.4% by 2010. The largest increase was in non-EU graduates, rising from 972 (7.4%) in 2000 to 4,740 (25.3%) of registered doctors in 2010. The biggest source country in 2000 was Pakistan, followed by India, Egypt and Sudan. By 2010, South African trained doctors had overtaken Pakistan, followed by India, Nigeria and Sudan. The number of doctors trained in the EU but outside Ireland doubled from 780 (2000) to 1,521 (2010), mainly due to an increase from Eastern European countries.

Discussion/conclusions/ implications:

Following the 2011 overseas doctor recruitment drive, Ireland may have moved from second to first among OECD countries in the proportion of its doctors trained overseas. In 2008, its proportion of foreign trained nurses was double the country ranked second. Registration data may over-estimate the numbers actively working as health workers in Ireland. However, they (i) illustrate Ireland’s rapidly increasing and potentially unsustainable reliance on foreign-trained health workers to staff its health services; and (ii) are the only currently available measure for reporting on Ireland’s commitment to implementing the Global Code on the International Recruitment of Health Personnel, which Ireland must do at the World Health Assembly, May 2012.

Author Affiliations:Royal College of Surgeons in Ireland

Option 2- lessons from the field; project and programme evaluations; and syntheses or analyses Presented as - Oral Presentation

Background:

Over half of the doctors from 11 of the poorest Caribbean and African countries are practicing in OECD (high income) countries. 75% of doctors and 79% of nurses practicing in the Gulf Cooperation Council countries of the Middle East are expatriates. In 2008, Ireland – at 47% - had twice the proportion of registered foreign trained nurses to the OECD country ranked second, and by 2011 may also rank first for foreign-trained doctors.

Global Code development:

The Global Code was drafted and negotiated by WHO, 2007-10, supported by the Global Policy Advisory Council (on which the author served). The World Health Assembly adopted the Code in 2010. It is a voluntary instrument that articulates global ethical norms – principles and practices – around the international recruitment and migration of health workers. While non-binding, it includes strong reporting and compliance mechanisms

Issues facing Ireland:

Its requirements on WHO member countries, which have short and medium term implications for Ireland, include: ethical international recruitment; health workforce development and health systems sustainability; fair treatment of migrant health personnel; international cooperation and support to developing countries; and data gathering and Information exchange.

Ireland, because of its disproportionate reliance on passively and actively recruited non-EU trained nurses and doctors, has ethical responsibilities both to its foreign health workers and their countries. In the long-run, it will be Ireland’s success or not in developing and retaining its domestic health workforce that will determine its compliance.

Next steps:

Ireland’s imminent Global Code compliance responsibilities are manageable, with the support of Irish Global Health researchers working in partnership with the Department of Health, Irish Medical Council, Irish Nursing Board and the HSE. These are to monitor and report – to the WHO Secretariat in 2012 and World Health Assembly in 2013 – trends in registered doctors and nurses by country of qualification.

Authors:Bidwell P., Thomas S.


Author Affiliations: Health Policy & Management, Trinity College Dublin

Option 1- Scientific / Empirical Research Findings Presented as - Oral Poster

Aims:

The consequences of doctor migration on health systems has become of increasing concern worldwide. Policy makers have largely tended to perceive doctor migration as a problem and therefore have tried to control it. Yet the more important issues are of managing migration to mitigate the negative impact to the source country, while also boosting supply in the recipient country. The aim of this study is to explore the different phenomena and circumstances under which temporary and permanent doctor migration to Ireland occurs.

Methods:

South African doctors working in Ireland form a natural case study whereby it is possible to explore the dynamics of temporary movement and contrast this with permanent migration. Quantitative and qualitative methods were used including survey and interviews.

Results:

129 temporary migrants completed a postal questionnaire (RR 29.9%). 55 permanent migrants completed the postal questionnaire (RR 29.6%) and a total of 28 in-depth interviews were done. Preliminary analysis shows that of the temporary migrants 27.2% had visited Ireland 1-2 times and 29.6% had visited 3 or more times. The main incentive for temporary migrants choosing Ireland was salary. The in-depth interviews further revealed that temporary migrants enjoy the ‘overseas experience’ and they all cited ease of registration in Ireland. Length of time spent in the destination country is also important, with temporary migrants preferring to spend short periods (approximately 3 weeks away).

Discussion/conclusions/ implications:

The primary motivation for moving differs for temporary and permanent migrants. Temporary migrants are more motivated by economic gain and are less affected by push factors from within their own country. Permanent migrants are more motivated by personal safety and are more affected by push factors from within their own country. The outputs of this research will strengthen the knowledge base of medical migration and will allow for evidence based policies to be developed on ethical recruitment and workforce planning.

Author Affiliations: 1Department of Epidemiology & Public Health, University College Cork, Ireland, 2Public Health Department, Mountains of the Moon University, Uganda

Option 2- Lessons from the field; project and programme evaluations; and syntheses or analyses

Presented as – Oral Poster

Issues:

Collaboration between academic Public Health departments in higher educational institutions in the North and South will facilitate: (i) health worker career development (ii) capacity strengthening in teaching and learning for higher education & (iii) capacity strengthening in research. The outcome of such collaboration(s) will strengthen public health practice from a global perspective.

Description:

The Mountains of the Moon University (MMU), established in 2002, is located in the Western Ugandan town of Fort Portal. MMU has initiated an innovative Bachelor of Science degree in Public Health to address the shortage of Public Health professionals in Uganda, and to assist in strengthening the health system for Uganda and other regional countries. The vision and purpose of the MMU programme mirrors that of the BSc in Public Health & Health Promotion which commenced in University College Cork (UCC) in 2004. Staff from the UCC Department of Epidemiology and Public Health and the MMU Department of Public Health, have been working in collaboration since late 2008 with the overall aim of developing a skilled and knowledgeable public health workforce in Ireland, Uganda and potentially other African countries.

Lessons learned:

• 
  Significant capacity building potential for both parties but lack of sustainable funding limiting progress


• 
  Requirement to develop administrative structures to facilitate the collaborative processes


• 
  Restriction on joint activities also linked to the limited numbers of, and time, which interested staff can dedicate to the collaboration

Next steps:

Teaching and learning:

• 
  Source assistance from appropriately experienced colleagues in UCC to work with MMU on distance learning methodology, technology, innovation


• 
  Source funding for student exchange in 2012


• 
  Investigate opportunities for lecturer exchange in the short to medium term research


• 
  Implement first collaborative research project


• 
  Source research funding options for immediate project proposal