On being a rural origin Health Care Professional: Lives, learnings and practice Submitted to: COLLEGE OF EDUCATION UNIVERSITY OF KWAZULU-NATAL, DURBAN SOUTH AFRICA Submitted in fulfilment of the academic requirements for the degree: Doctor of Philosophy in Faculty of Education University of KwaZulu-Natal. This research dissertation is presented in the publication format By Andrew John Ross SUPERVISOR Dr G. Pillay Date of Registration with Higher Degrees Committee: 19 October 2012 Dates and Registration Number with Research Ethics Committee: 16/11/2012 - HSS 1205 / 012D Date of Current Version of Dissertation: 30 May 2016 i ABSTRACT Rural origin health care professionals (HCPs) have been identified as those who are most likely to work in rural areas after graduation. However, there are significant challenges of access, selection and throughput for South African rural students wanting to train as HCPs. Many studies have focused on strategies for staffing rural healthcare facilities. However a life history approach has not previously been used to study the educational experiences of rural origin HCPs in South Africa, and there is a paucity of data about the lived personal and professional educational experiences of rural origin HCPs and their experiences of returning to work in rural areas after graduation. A deeper understanding of these issues using a life history approach may help in supporting rural origin students and contribute to improved staffing levels at rural healthcare institutions. Social identity theory and a generative understanding of rurality provided the theoretical framing for this study. A life history approach complemented by arts-based methods generated stories through which to gain an understanding of the complex, multidimensional, multi-layered lives of HCPs who grew up in rural areas, their personal lives in relation to others, and the context in which they grew up (time, person and place). Their developing identity is seen in their performances through the choices they make in response to everyday situations. Their learning experiences are complex and reveal that as active and critical thinkers they adopted a range of strategies to succeed at institutions of higher learning, and found platforms and communities to develop as those with knowledge and agency to change/challenge dominant and stereotypical ways of being. They demonstrate their willingness and ability to work in rural contexts, leading transformation in the healthcare setting. The findings of this study point to a new understanding of rurality – that of home and a sense of belonging where the possibility for better healthcare services exists. A junctional hub is presented as a theoretical ‘model’ to frame lived experiences and to understand rural origin HCPs’ personal and professional identity and work in a complex, interconnected, negotiated space where different forces are negotiated. This provides a platform to open up the opportunity for other ways of being, knowing and practising. (362 words) ii DECLARATION I, Andrew John Ross, declare that The research reported in this dissertation, except where otherwise indicated, is my original research. This research dissertation has not been submitted for any degree or examination at any other university. This research dissertation does not contain other persons’ data, pictures, graphs or other information, unless specifically acknowledged as being sourced from other persons. This research dissertation does not contain other persons’ writing, unless specifically acknowledged as being sourced from other researchers. Where other written sources have been quoted, then: a) their words have been rewritten but the general information attributed to them has been referenced; b) where their exact words have been used, their writing has been placed inside quotation marks, and referenced. Where I have reproduced a journal publication of which I am an author, I have indicated in detail which part of the publication was actually written by me alone and not by other authors, editors or others. This research dissertation does not contain text, graphics or tables copied and pasted from the Internet, unless specifically acknowledged, and the source being detailed in the research dissertation and in the References section. Signature and Name of Student: A.J. Ross ____________________ Signature and Name of Supervisor: G. Pillay (Daisy) ___________________ College of Education, University of KwaZulu-Natal, South Africa May 30, 2016 iii ACKNOWLEDGEMENTS I would like to acknowledge the support and encouragement of my family – Glenys, Michael and Jonty – without which it would not have been possible for me to complete this research dissertation. I would also like to acknowledge the role that my parents Sam and Morag Ross played in reading and rereading my articles, stories and other written material, and providing encouraging and insightful feedback. I also extend my thanks to Daisy Pillay my supervisor for her ongoing support, insight and encouragement, and to Betty Govinden for critically reading and providing insightful comments which were extremely helpful. My father died in January 2015 and this research dissertation is dedicated to his memory and all that I am because of his influence in my life. I am grateful to those rural origin healthcare professionals who have returned to work in rural areas, who have been willing to share their stories with me. I believe that these stories must be told. They are stories of hope, of possibility, of changing the script, of daring to dream and then having the courage to work towards the fulfilment of those dreams. I salute you all. iv PUBLICATIONS AND PRESENTATIONS Publications 1. Ross A, MacGregor G, Campbell L. Review of the Umthombo Youth Development Foundation scholarship scheme, 1999–2013. African Journal of Primary Health Care and Family Medicine. 2015; 7(1), Art. #739, 6 pages. http:// dx.doi.org/10.4102/phcfm. v7i1.739 2. Ross A, Pillay G. Portrait of a rural health graduate: exploring alternative learning spaces. Medical Education 2015; 49: 499- 508. DOI: 10.1111/medu.12676 3. Ross A.J. Building on Tinto’s model of engagement and persistence – experiences from Umthombo Youth Development Foundation scholarship scheme. African Journal of Health Professions Education. 2014; 6(2): 119-123 4. Ross AJ Working in rural area – the experiences of Umthombo Youth Development Foundation graduates. African Journal of Primary Health Care and Family Medicine. 2014; 6(1): 1-7. doi: 10.4102/phcfm.v6i1.673 5. Ross AJ, MacGregor RG. Scholarship success: Umthombo Youth Development Foundation. South African Medical Journal. 2012; 102(5): 288 6. Ross, A. From rural scholar to health care professional. South African Family Practice. 2015, 1(1), 1-6. doi:10.1080/20786190.2015.1071537 Accepted for publication by the South African Journal of Higher Education Pillay G, Ross A. Troubling selection: Towards a broader understanding of selection Presentations based on research findings 1. Educational journey of rural origin health care professionals working in rural areas. 16th National Family Physicians conference May 2013 2. Educational journeys of rural origin health care professionals working in rural areas. 17th National Family Physicians conference June 2014 3. Doing research – workshop on how to do a literature review. Primafamed conference June 2014 4. Learning spaces of rural origin health care professionals at institutions of higher learning. SAERA conference, Durban 13 August 2014 5. Learning spaces of rural origin health care professionals at institutions of higher learning. College of Health Sciences research day, 11 September 2014 6. Learning spaces of rural origin health care professionals at institutions of higher learning. WONCA Africa conference, Ghana, 7 May 2015 v 7. Troubling selection: Towards a broader selection policy. Family Practice conference, Durban, 31 July – 2 August 2015 8. Troubling selection: Towards a broader selection policy. Story telling conference, Oxford, England 3- 5 September 2015 9. Troubling selection: Towards a broader selection policy. Teaching and learning conference, University of KwaZulu Natal, 22 September 2015 vi ACRONYMS AND ABBREVIATIONS FOM Friends of Mosvold FOMA Friends of Mosvold Alumni HCP Healthcare professional HCW Healthcare worker HPCSA Health Professions Council of South Africa KZN KwaZulu-Natal NGO Non-governmental organisation SA South Africa UKZN University of KwaZulu-Natal UYDF Umthombo Youth Development Foundation WHO World Health Organization vii TABLE OF CONTENTS ABSTRACT ............................................................................................................................................. ii DECLARATION .................................................................................................................................... iii ACKNOWLEDGEMENTS................................................................................................................... iv PUBLICATIONS AND PRESENTATIONS ........................................................................................ v ACRONYMS AND ABBREVIATIONS ............................................................................................... vii TABLE OF CONTENTS ....................................................................................................................... viii FIGURES ................................................................................................................................................