The motivations and aspirations of Indian physiotherapists who migrate overseas to study and work: a grounded theory study

Objective To explore why Indian physiotherapists seek to migrate overseas for study and work. Design Qualitative research using Constructivist Grounded Theory (CGT) methodology. Setting Individual interviews and focus groups were conducted in the UK and India, at university, clinic or hotel locations convenient to the participants. Participants Nineteen physiotherapists from across India. Thirteen had studied or worked in the UK, Australia or Kuwait, and six had no overseas experience. Findings The participants desired a ‘better life’ due to factors perceived as less favourable in India: pay levels, professional respect and professional development. These elements were inter-dependent and their importance varied between participants and according to gender. Indian societal values ampliﬁed the importance of pay for male physiotherapists, whereas females prioritised professional development. Migrant physiotherapists aspired to professional autonomy through the development of knowledge, skills and experience. Respect was important, but there were different perspectives on its achievement and the relevance of titles. For those studying overseas, work was sought to recoup the cost of that study, and, importantly to consolidate learning and experience of autonomous physiotherapy practice. They all planned to return to India and wished to transfer their knowledge and skills back into practice in India. Conclusion Pay, respect and professional development are all motivators for Indian physiotherapists to study and work overseas. An ability to practise physiotherapy autonomously is a key factor underpinning the achievement of each of these elements and thus the ultimate aspiration to have a ‘better life’.


Introduction
Thousands of Indian Physiotherapists have sought to travel overseas to work or study, yet no research explores why Indian physiotherapists migrate. Between 2002 and 2015, approximately 2,500 Indian physiotherapists registered to practise in the United Kingdom (UK); which was 26% of overseas physiotherapy registrants [1]. Australia reports that between 2007-2010, 10% of new overseas physiotherapy [2,8,9] and possessing a degree from the host country is more advantagious than a degree from a foreign education institution [10]. Motivators for applying to study overseas include employment and residency opportunities and the quality of the student experience [11]. Students also travel internationally for specialist education that is insufficiently provided in their home country; this education may assist their home country through the transfer of technical and cultural knowledge [7,12].
Global migration has been analysed through 'push' and 'pull' factors that influence an individual's decision to travel. The factors that 'push' emigration of professionals whilst contextually specific for individual migrants, have commonalities for the country of origin. Empirical studies identify the main 'push' factors as less favourable management and governance issues, pay, working conditions and personal safety [7,[13][14][15].
'Pull' factors can include work-force shortages in the destination country provoking active recruitment [16]. For migrant doctors, key 'pull' factors revolve around opportunities for professional development; access to higher education, working with experts, better professional infrastructure and employment opportunities. Migrant nurses also identified access to training opportunities and career progression but gave greater emphasis to socially focused drivers around income, quality of life and education for children [13,[17][18][19]. Wage differential between developing and developed countries is variably reported. Some studies suggest that financial incentives are strong [7,20], others demonstrate little difference between wages when adjusted for purchasing power parity [21]. The consensus is that financial considerations are important [22,23].
Only two studies have considered the migration of physiotherapists. An 'e-survey' explored the perspectives of 34 international allied health professionals (AHP), where 11 were physiotherapists working in the UK [24]. Travel, money and career opportunities were the main incentives. The source countries were Australia, South Africa, New Zealand and Ireland, the respondents most commonly entering the UK on working holiday visas; hence their perspectives may not be representative of health professionals from countries with emergent economies and healthcare systems. A national survey of 340 Hungarian physiotherapists indicated that low pay, lack of professional recognition and limited career advancement opportunities were key factors causing consideration of overseas migration or leaving the profession [25]. Another study explored the impact of health worker migration on the Philippines including data from 18 physical/occupational therapists showing job satisfaction was crucial in migration decisions [7]. There is no literature specifically exploring physiotherapy migration from India, but health worker migration generally is an issue for concern requiring policy response [15]. India has significant healthcare workforce needs, and it is estimated that an additional 6.4 million AHPs are needed [26,27]. India cannot afford to lose its physiotherapists and, to inform policy, it is important to understand the perspectives on migration of Indian physiotherapists. This study was conducted to answer the research question of why Indian physiotherapists choose to be globally mobile?

Study design
This qualitative study was conducted from an interpretivist perspective that contends meaningful reality, rather than being objectively verifiable, is constructed in and out of interaction between humans and their world [28]. Constructivist grounded theory (CGT) methodology using interviews was employed [29]. Charmaz [29] describes CGT as relying on co-construction between researcher and participant and the interpretative actions of the researcher to construct categories of social meaning. This approach allowed the researcher to generate interpretive understandings from the participants' standpoint. This paper reports one category of this study.

Settings
Interviews were conducted in multiple locations including a university, a clinic and hotel venues across India; a university setting in the UK and one interview occurred at an overseas conference. The locations were selected for logistical convenience of meeting with participants and in environments conducive to security, comfort and privacy during the interview.

Sampling and participants
At the outset of the study the broad participant inclusion criterion was to recruit physiotherapists who had trained and worked in India and thus had knowledge of the phenomonen of interest: they had experience, or were considering, migration to study and/or work [28]. For interview cycle 1 (see Table 3) purposive sampling recruited participants holding a range of perspectives: those studying in the UK; those who had not travelled overseas and were studying a masters in India and others who had travelled and returned. Subsequent theoretical sampling for interview cycles 2 and 3 was led by issues emergent from previous interviews and developing categories, participants were selected who could elucidate and contribute to the issues and the construction of the categories.
Professional networks and recommendations were used to identify the twenty one potential volunteers. All those contacted, who came from 10 of India's 29 states, agreed to participate but for logistical reasons two people were not interviewed. Nineteen Indian physiotherapists, 12 females and 7 males, were interviewed once, either individually or in focus groups according to their level of experience. Participants' overseas study experience was in the UK, and 1 participant had also studied in Australia. Overseas work expe-

Data collection and analysis
Interviews lasted between 55 and 80 minutes and were conducted in English; all formal physiotherapy education in India occurs in English and all participants were fluent in English. Three focus groups were conducted with the postgraduate student participants. The participants of each group knew each other previously, and this familiarity enhanced peer support and the discussion's flow. Six individual interviews were conducted with the more experienced participants. All interviews were conducted by the researcher. The initial interviews were loosely-structured; open questions were used to promote a conversational tenor enabling participants to articulate issues and areas that were important to them. Follow-up questions were used to extend discussion and clarify understandings. Subsequent interviews became more focused to follow emergent theoretical leads interpreted from earlier interviews [29]. Table 3 summarises the focus of each interview. Memos were made immediately after each interview reflecting upon communication nuances within the interview, possible areas for exploration in future interviews and links to the iterative data analysis. Partly for logistical reasons and the scope of the study there was only one researcher present, this was methodologically congruent [29] and it was felt that it enhanced the development of rapport and trust between the researcher and participants. The interviews were digitally recorded and transcribed verbatim by English speaking professional transcribers in India. The transcripts were checked for accuracy by the researcher.
Data analysis was managed using QSR-NVIVO v10 software and was concurrent with data collection. In keeping with CGT methodology [29] an initial analysis of each interview transcript was conducted before the next, key issues that arose were introduced in the next interview each interview providing the direction for the next, remaining open to new issues emerging (see Table 3). Open coding was undertaken involving a line by line analysis and labelling, and grouping of the codes into developing subcategories and subsequently into categories. Throughout the data collection and analysis memos were written that captured the meaning of each code and category and their relationships. Constant comparisons of these data segments facilitated the construction of categories. Data saturation was achieved when no new issues and concepts arose in interviews.

Ethics
Ethical approval for the study was gained from a UK university ethics committee and data protection legislation was followed. Institutional approval was gained in India for the focus group that occurred there. No funding was received to support the study.
To ensure informed consent, potential participants were provided with information regarding the study and why they had been invited to contribute. All were able to contact the researcher with questions prior to agreeing to the interview. Prior to the start of each interview all information was clarified and any queries addressed. It was particularly important to minimise power differentials between the researcher and focus groups 1 and 2 who were still in education. Signed consent was gained with the understanding participation was confidential, entirely voluntary and withdrawal from the study was possible at any stage without consequence. Participant anonymity was achieved by focus group participants selecting their own Bollywood pseudonyms and the allocation of pseudonyms for the individual interviews.

Rigour and reflexivity
Charmaz [29] identifies 'credibility', 'resonance', 'originality' and 'usefulness' as key criteria for ensuring the quality of CGT studies. The 'credibility' of the analysis was ensured by repeatedly returning to the recorded interviews to ensure that the developing categories were grounded in the data. This part-time doctoral research occurred over a 3 years permitting time for analysis between data collection points, this is important for CGT iterative data generation and analysis processes. Memos were kept that captured the underpinning rationale for code and category development and key decisions during the analysis process. The memos formed an audit trail through which the analysis development could be tracked and through which self-reflection of underpinning influences and perspectives were considered.
All emergent analyses were shared with two qualitative research experts in within the doctoral research team. This enabled the researcher to check out her interpretations with colleagues. Bazeley [30] advises this is not to verify that the analysis is objectively 'true', but to consider the plausibility of the interpretation and potentially to add dimensions and prompt fresh ideas.
The 'resonance' of the findings were established through a validation interview with an informed participant who was able to relate to the 'story' of Indian physiotherapy migrant experience. The study findings are 'original' as no other published study explores the global mobility of Indian physiotherapists and offer a 'useful' insight into what may impact physiotherapists' migration decisions and usefully inform policy in India and receiving countries.
The methodological approach to the study acknowledges that interpretation is fundamentally influenced by who we are as individuals. The researcher acknowledges and makes public his/her positioning by providing the reflexive account below: The researcher is a white British female physiotherapist with extensive experience of education of UK and international students, has travelled extensively in India visiting public and private sector hospitals and physiotherapy colleges; and so was able to use these understandings of the field. This experience and shared profession influenced the framing of the opening questions and follow-up conversations, and assisted in gaining the perspectives of the experts who were grounded in the phenomenon. On the other hand, not being an Indian physiotherapist enabled the researcher to probe and explore issues from a naive and curious perspective. This outsider position encouraged the participants to explain their motivations and influences to help those unfamiliar with Indian physiotherapy to fully understand the context. This facilitated a comprehensive articulation of the issues without assumptions being made. Most participants identified their delight that someone outside India was interested in Indian physiotherapy.

Findings
Two key categories 'The Journey' and 'Wanting a Better Life' were constructed, underpinning a core category and substantive theory. Within the 2 key categories were 3 subcategories, Fig. 1 shows the relationships between them. The 'Wanting a Better Life' category and its sub-categories: 'Professional Development', 'Pay' and 'Respect' are discussed in this paper. Examples of quotes that support the category narrative are presented in Table 4.

Wanting a Better Life category
'Wanting a Better Life' captures the motivations and long term aspirations of the migrant physiotherapists. There was complexity in what a better life might incorporate: the importance of autonomous practice and professional satisfaction; the challenge of changing the cultural context in which practice occurs and the detrimental effect of low pay, particularly for males, on their self-worth and position within society and associated respect. Participants frequently used the term "better" associated with prospects, practice, earnings and quality of life across professional and personal dimensions.
By travelling overseas, they felt empowered to achieve a 'better life'. They sought opportunities for professional development through education, different work environments and experiencing different cultures. These, they perceived, would lead to increased respect and better remuneration. The participants still in the UK all intended to return home when they had met their objectives for overseas travel, with planned timescales ranging from 1 to 10 years.
Perceived differences reinforced the motivations for migration. These differences underpinned the drive to achieve a better life and were related to education, professional autonomy, earning potential, and levels of professional respect.

Professional Development subcategory
The participants all aspired to be better physiotherapists and to treat patients effectively. Those who travelled overseas to study or work identified a striving to fulfil their personal and professional development needs. Professional development motivated all the participants who travelled; they sought different knowledge and experience to that available in India.
The key areas identified as being different overseas were theoretical and practical knowledge and skill, educational pedagogy, and autonomy of physiotherapy practice. Many of the participants sought to practise autonomously and were frustrated by the hierarchical, medically prescribed ways of working they experienced in India. They considered that overseas master's level study was different to that in India. It would enable them to develop new skills, to gain new knowledge and new ways of thinking through development of reflective, critical evaluation and research skills. These would enable them to evaluate established modes of treatment critically. The acquisition of these practical and cognitive skills was dependent on them gaining overseas practice experience and education to understand the contextual origin of the knowledge in different social and cultural environments.
Several participants referred to the development of confidence, through improved knowledge of research evidence and an ability to justify their practice, as an important objective for their overseas professional development. This was particularly important for the female physiotherapists who also sought improved communication skills.
Some participants referred to professional development in relation to how their new expertise would enhance their careers, "putting them ahead of others" in challenging and competitive working environments; they were driven to acquire professional recognition, respect and enhanced financial remuneration. The international master's degree was identified as an asset that would symbolise their international knowledge base and, coupled with increased confidence, would help gain the 'respect' of doctors.

Pay subcategory
Low pay in India was identified as a major source of dissatisfaction amongst participants and consequently, a key motivator for going overseas was to seek increased pay. Indian physiotherapists' pay was reported to be substantially lower than other similarly qualified professionals, especially the hospital manager, a career path that was seen as an alternative to physiotherapy. These observations led to a feeling of not being valued or respected as an individual or as a profession.
However, low pay in isolation was not sufficient to instigate travel, and participants identified that pay was a factor that inter-related with others in seeking a better life: professional and practice development and respect. The frequent mention of pay and its connectivity to other factors amplified its importance. However, migrants placed variable emphases on the significance of pay in their decision to travel. Some identified that increased pay had no influence, it being more about professional development that was not accessible in India. For others, the significance of low pay was more multidimensional and reflected a sense of self-worth and respect, as much as a basic need to provide for family and dependents.
Females placed greater emphasis on the development of clinical expertise and personal development to improve their standard of clinical practice, and less on financial remuneration. For males the emphasis was on the longer term and more externally focused rewards associated with a successful career. Clinical skills and knowledge development were a stepping stone towards successful career development and ultimately increased earning potential.
Pay levels were seen as particularly pertinent to an individual's position in the hierarchy of Indian culture. Participants reported that their financial worth would impact upon whom they were eligible to marry. They identified that Indian society expected males to be able to support their family and there was no expectation that females would continue to work once they have children. Hence the level of pay determined much more than a male's spending power, it extended to his worth as a husband and so influenced his marriage opportunities.
When evaluating the potential return on investment in travelling overseas to study, participants took a long term perspective. Many Indian physiotherapists fund their overseas studies through loans from banks or relatives, and the participants were unanimous that they must repay the loan before they would consider return. Returning overseas masters graduates did not appear to be paid more that Indian masters graduates, but were perceived to be preferentially employed in some cases, and it was important that a returning physiotherapist should earn more than prior to their travel. They considered the skills and reputation associated with their overseas exposure could enable them to develop a private practice resulting in greater long term financial remuneration.

Respect subcategory
A key factor in the decision to travel for several participants was a perceived lack of respect for physiotherapy in India, which was related to low pay. It was considered that there was a greater respect for physiotherapy as a profession overseas, where the physiotherapists' knowledge and skill set were valued by doctors and by the public. Participants linked this difference in respect with the autonomous position that physiotherapy holds in many countries overseas. They acknowledged that many people in India, especially doctors, considered physiotherapy inferior to medicine as a profession. They reported that the physiotherapy profession in India aspired to achieve the same level of 'automatic' respect as doctors. The failure to command this respect was a source of great frustration to individuals and the profession as a whole. A key element, upon which the claim for parity of respect was based, was the comparable length of time to gain qualification between medicine (5.5 years) and physiotherapy. The entry level bachelors' physiotherapy degree is 4.5 years and the postgraduate masters' level study in some states is increasing from 2 to 3 years.
Some participants referred to the use of the 'Dr.' prefix as a way of gaining the respect of patients and gaining status in society. However, the use of the title had created conflict with the medical profession in the media and in the courts. It seemed a contentious issue with some identifying that it was an "ingrained right" and a useful tool to gain patients' respect, others considered it a self-made conflict with the medics that was not helpful in the current professional climate in India.
Despite the desire for automatic respect by virtue of their profession, the participants were clear that respect must be earned at an individual level. Variability in the quality of physiotherapy practice in India was acknowledged, with poor practice perceived to be holding the profession back and impacting upon all.
A part of the motivation for studying overseas was to develop the knowledge and skills needed to develop their reputation and thereby gain respect. Participants also wished for a healthcare environment where physiotherapy enjoyed greater respect, was practised autonomously and did not have a physician dominated hierarchical structure. These aspirations were fueled by physiotherapists in India hearing how their migrant peers were working as autonomous practitioners and felt respected as individuals and that physiotherapy overseas was respected as a profession.
The search for a better life through migration to another country where the "complete package" of good professional practice, pay and respect was available, was a shared quest. Some participants articulated that if the environment in one country was not conducive to practising in a way that they felt comfortable, they would move to a country where it did feel right.
Professional development, pay and respect were clearly linked (Fig. 2) and it was considered that until respect for physiotherapy in India increased the pay would remain low. Participants identified that increased knowledge and consistent quality of professional practice were key to achieving respect. Through journeying overseas the participants sought to develop themselves professionally, and the remuneration often associated with increased respect worked together to achieve the overall aspiration of a better life than they left in India.

Discussion
The study findings regarding the motivations for travel are resonant with global mobility literature. These findings align with existing knowledge around global mobility of students who travel overseas for education that is insufficiently provided at home [12] and that an overseas degree is seen as a pre cursor to employment in the destination country [10]. Aspiring to a better life is not unique to physiotherapists in India, and it is well documented as a motivation for overseas migration generally and for nurses specifically [12,17,21,31,32].
In Khadria's [17] study, Indian doctors (over 85% were male) were motivated primarily by professional development and for female nurses pay was more important. Paradoxically this study finds that for physiotherapists pay is more important for the males and professional development more important for the females. In line with Kingma [23], and Ross et al's [22] conclusions, pay was not the most significant factor in selecting the destination country, the importance of professional development opportunities and increased respect were emphasised.
To enhance their status and gain respect in society, the IAP promote the use of the 'Dr' prefix, supported by the suffix 'PT', to differentiate between medical doctors [33]. The issue and legality of this has been debated in the Indian media and contested in the courts. Different state councils have taken opposing views, some support and some prohibit its usage by physiotherapists [34,35]. Ahuja et al. [33] suggest that physiotherapy in India should take a longer term view, rather than a short term gain of respect. They consider that physiotherapists calling themselves doctor unnecessarily creates a conflict with medical peers, rather than working in partnership with them.
The desire for professional development and professional knowledge are attributes that align with an individual's professionalisation [36], and is considered essential in establishing an autonomous profession that can command the rewards (pay and respect) associated with professional status [37]. The literature considers that the social status and respect conferred upon an individual are key features of a profession [38,39] and it is suggested that in the west, a professional hierarchy has replaced class as a matrix of society [40].
India has a well-developed education system, with degree, masters and PhD physiotherapy education opportunities available within India; raising the question of why the status of physiotherapy is considered low, or the wide perception that professional development opportunities available in India are insufficient. There is a need to comprehend the context of physiotherapy education and practice in India to understand this phenomenon, indicating that further research is needed to support successful return migration.
In this study the CGT methodology traded the scale and breadth of coverage of questionnaire based studies for a depth and richness of data. The narrative data allowed an in-depth understanding to be developed. The approach taken acknowledges that the white UK researcher interpreted the Indian participants' narratives from an outsider's perspective. The study was undertaken within a UK context and could therefore be seen as limiting, but the narrative was a global one: Indian physiotherapists' mobility is global. Over the timeframe of the study, there were world-wide changes that influenced Indian physiotherapy migration and the choice of destination. The UK changed its visa system, the Australian physiotherapy overseas registration process changed, the IAP national election ended with a disputed result, subsequently splitting into two associations. There was rejection of Indian government legislature that effectively denied Indian physiotherapy coherent autonomy and formal recognition of their existence, and global economics influenced the rupee exchange rate. What did not appear to change significantly was Indian physiotherapy itself, how it was practised and the desire for overseas migration.
This research is important as it describes, from physiotherapy migrants' perspectives, why they choose to study and work overseas. This understanding should be used to inform policy in India to address physiotherapy recognition, autonomy, education and pay, with the aim of retaining and facilitating the return of its physiotherapy workforce. Other research that calls for policy changes focuses upon doctors and nurses migration [7,15] and this study shows that physiotherapist motivations do not align with doctors or nurses and therefore it is inappropriate to extrapolate from these other health workforces.
The findings are also important to receiving countries, especially the UK, and should be used to inform migration policy so both workforce and migrant needs can be met. Receiving educators and employers can use the findings to more clearly understand the migrants with whom they work so mutual needs and goals can be met. The findings also provide a lens through which Indian physiotherapists can reflect upon their personal career development and decisions.

Conclusion
Indian physiotherapists travel overseas to achieve a 'better life' in terms of professional development, better pay and increased personal and professional respect. The relative importance of the elements of pay and respect varies between individuals. What united all the participants who travelled was the quest for professional development and to gain different knowledge and experience not available in India. Pay and respect were clearly linked and it was perceived that until respect for physiotherapy in India increased, pay would remain low. Participants identified that increased knowledge and consistent quality of professional practice was key to achieving respect. Through journeying overseas they sought to develop themselves professionally, to earn respect and the associated remuneration together with the overall aspiration of 'gaining a better life'.

Key messages New knowledge
• Indian physiotherapists migrate to study and work overseas to achieve a better life but they aspire to return to India. • Professional development, better pay and increased personal and professional respect are all inter-related key elements to achieve a better life. • Gender differences influence the relative importance of these elements and are underpinned by Indian societal expectations.

What it adds to the literature
• To date no other published study has explored physiotherapy global migration from India or any other developing country to more developed country. • Provides evidence that positions Indian physiotherapy overseas migration motivating factors and aspirations alongside those of doctors, nurses and other migrating professions. • Provides new knowledge which may inform policy in India targeting retaining its health care workforce and in receiving countries' policies regarding migration and supporting Indian physiotherapy migrant needs.

Acknowledgements
This paper reports on research undertaken in partial fulfilment of the requirements of Sheffield Hallam University for the degree of Doctor of Professional Studies. Thank you to the Indian physiotherapists who gave their time to participate in the interviews and without whom this research would not have been possible. Thank you to Dr. Christine Ferris who co-supervised the doctorate.
Ethical approval: Ethical approval for the study was gained from Faculty of Health and Wellbeing Research Ethics Committee, Sheffield Hallam University in the UK. Where recruitment of a focus group occurred in Delhi, the consent of the Principle of the host institution was gained. Participants were volunteers, were fully informed about the study and gave written consent prior to the interviews.