MAKING A RURAL WORKFORCE: EXPLORING THE HABITUS OF HEALTH SCIENCES STUDENTS FROM RURAL SOUTH AFRICA Nontsikelelo Olga Mapukata A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy in Public Health Johannesburg, June 2022 Supervisors: Professor Lenore Manderson Professor Steve Reid ii | P a g e DECLARATION I, Nontsikelelo Olga Mapukata, declare that this thesis is my own, unaided work. It is being submitted for the degree of Doctor of Philosophy in Public Health at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at any other university. _____________________________ (Signature of candidate) This 8th day of June, 2022 in Cape Town. iii | P a g e DEDICATION To my family, extended family, my daughter and all my children – thank you for your love, patience, sacrifice, and silent prayers - nindithwele, ndiswele imilomo eliwaka. To friends and PhD warriors – I’m grateful for your support and fellowship. To all my teachers and to all the teachers: lifelong learning is a journey of a thousand steps. Kubo bonke abasaqamela ngengqiniba, imfundo yintsengwanekazi. Never give up on your dreams. iv | P a g e PUBLICATIONS ARISING FROM THIS RESEARCH PROJECT Mapukata, N., 2020. Embodiment of particular ways of being: Habitus as an autobiographical narrative. Ubuntu: Journal of Conflict and Social Transformation 9 (1) 9-24 v | P a g e ABSTRACT In South Africa, finding solutions to ensure sufficient, well-trained professionals to meet health challenges is a national imperative. The apartheid system had marked impact on schools and rural communities, influencing the abilities of students to thrive during their training and to continue to work as health professionals. Globally, a growing body of evidence attests to the benefits of recruiting students of rural origin to respond positively to human resource challenges to meet rural health needs. With a concerted effort to change the demographics of the student body in higher education institutions (HEI) in a post-apartheid era, following the Department of Education’s 1997 mandate for HEI to transform, the number of Black students who enrol to study for higher degrees has increased to reflect the demographics of South Africa’s population. Consequently, there has been an ongoing interest in exploring the habitus of students of rural origin. Drawing on a social constructionist paradigm, using Bourdieu’s framework, I sought to understand the relationship between habitus, capital, and the field, in order to explore the factors that influence the professionalisation of health sciences students. I employed purposive sampling to recruit participants who were registered at the University of Cape Town (UCT) as students in audiology, medicine, occupational therapy, physiotherapy, and speech-language pathology. Drawing on audio- recorded in-depth interviews and journal reflections, I examined the lived experiences of final year health sciences students (n=21) from rural South Africa. Two-thirds of my participants were female, mostly from KwaZulu-Natal Province and the majority speaking isiZulu as their first language. Only four participants lived with both parents during their schooling years. Participants revealed diverse understandings of rurality of their own communities, as heterogenous, complex, dynamic and ambiguous. They offered new descriptors that provided evidence such as “no ATM” (Automated Teller Machine); “no CBD” (Central Business District); “no computers, no library, no internet, no YouTube, no Instagram, no internet café.” The subjective and objective representations of rural spaces reflected the tensions of “living in two worlds at the same time,” as they studied and lived in the metropolitan city in Cape Town. Participants contrasted the anonymity of the city with the closeness of rural settings; in Cape Town, they explained, people do not greet and acknowledge their presence. Through this study, I present theory of practice as a relational multiprofessional framework. Participants had access to social capital generated from multidimensional sources vi | P a g e that included family, community, ancestors and church. The efforts of their families and teachers generated enough cultural capital to secure participants’ place at UCT through a phenomenon of school hopping for 80% of the participants. Despite acquiring an educated habitus, as high achievers in matric, in their first year participants experienced a disrupted habitus. Muted by their rural English, they were misrecognized. Some started to isolate and disengaged and as they experienced failure for the first time, they were prone to mental health challenges. As they progressed in their studies, at times supported by classmates and clinical partners, participants employed social and cultural capital to moderate institutional hierarchies and incidents of racism. Through a generative habitus, supported by academic clinicians and supervisors they experienced transformation in clinical spaces at five levels. Scrubs translated into “professional armour” and became a marker of their professional identity. Participants reported a shift from theory to practice; from standard patient encounters to an appreciation of a holistic and biopsychosocial approach necessary for patient management; a shift from being students to becoming health professionals managing patients under supervision. Lastly, participants experienced a shift in their approach to work, as primary health centres became spaces for multidisciplinary teamwork and facilitated reciprocal learning experiences as participants transformed social attributes into professional attributes. The challenges of being different provided opportunities for their habitus to constrict and expand to different aspects of the field as they generated academic capital. By using a Bourdieusian lens and employing habitus as a theory and a methodological tool, I have generated insights about how students of rural origin negotiate difficult university spaces. Their rural upbringing, resilience and intrinsic motivation allowed participants to generate the kinds of capital that are desirable in health care professionals and accrued benefits for patients. Through this study, it has been possible to challenge the prevailing perception of deprivation that is often associated with rural areas. I highlight the inherent values and strengths of rural communities that have often been overlooked in previous studies. Keywords: Bourdieu, habitus, health care professionals, health sciences students, relational multiprofessional framework, professional armour, rural origin. vii | P a g e ACKNOWLEDGEMENTS This work would not have been possible without the guidance and support of my supervisors – Professor Lenore Manderson and Professor Steve Reid. I am grateful for their wisdom and expertise. They held my hand as I navigated a series of stormy seasons and moments of disquiet. I am grateful for the hours spent in preparation for our weekly meetings, the constructive feedback, the lessons, and all the effort that brought me to the end stage. I extend gratitude to my immediate line manager and the Head of Division of Public Health Medicine - Professor London, the Head of School - Professor Myer; my BP/BHP colleagues; my surrogate family in the Department of Family Medicine; and Ms. Marja Wren-Sargent (FHS librarian). I will be forever grateful for the grant that was extended by UCT Faculty of Health Sciences as it affirmed me as an Emerging Researcher. Thanks to Professor Ian Couper for sharing his vision for rural health and his facilitation of our commitment to the rural health project and to colleagues in the Centre for Rural Health. Gratitude is extended to WIRHE students and now practicing health care professionals in different parts of South Africa who were based at the University of the Witwatersrand, Sefako Makgatho Health Sciences University, and the University of Pretoria - they sowed the seeds for this study. Finally, I owe much to the 2020 final year health sciences students of rural origin at the University of Cape Town. I am grateful for their insightful reflections and for trusting me with their personal life stories. *** Nangamso viii | P a g e TABLE OF CONTENTS DECLARATION...........................................................................................................................II DEDICATION… ........................................................................................................................ III PUBLICATION ARISING FROM THIS RESEARCH PROJECT…….......................……..IV ABSTRACT………………………………………………………………..........................……..V ACKNOWLEDGEMENTS…....................................................................................................VII TABLE OF CONTENTS …………………………………......................................................VIII LIST OF FIGURES…………………………………………………........................................XIII LIST OF TABLES......................................................................................................................XIV NOMENCLATURE ........................................................... ........................................................XV CHAPTER 1: OVERVIEW OF THE STUDY….………………………………………………..1 1.1 Introduction……………………………………………………………………………..1 Background ...................................................................................................................... 1 1.2 Reflexivity ...................................................................................................................... 4 1.4. Defining Habitus........................................................................................................... 6 1.5 Developing a Rural Health Workforce………………………………………………...10 1.6 Problem Statement ........................................................................................................ .13 1.7 Justifying and Contextualising the Study………………………… ............................. .14 1.8 Conceptual Framework……………………………………….………………….…....16 1.8.1 Study Aims and Objectives….…………………………………………………...19 1.8.2 Assumptions……………………………………………….……………………...20 1.9 Structure of the Thesis………………………………………………………………....21 1.10 Summary…………………………………….………………………..……………....22 CHAPTER 2: LITERATURE REVIEW…………………………………………………...…...23 2.1 Rural, Rurality and Access to Health………………………………………………….23 2.1.1 Rurality: A Place and a Space…………………………………………………….23 ix | P a g e 2.1.2 Rurality as a Social Space…….………………………..………………………....24 2.1.3 Rurality and Access to Health Care………………………….…………………...27 2.2 Habitus of Rural Students …………………………….……………………….…......33 2.2.1 Rural Origin in South Africa: A Familial Habitus…………………….………….33 2.2.2 The School: An Educated Habitus……………………………...………………...35 2.2.3 Construction of Cultural Capital…………………………………………………..40 2.2.4 Adapting and Transforming in Higher Education Institutions………………….…43 2.2.5 Transformation and Professional Socialisation……………………………..…….49 2.3 Policy Review………………………………………….…………………………..….51 2.3.1 Document Review………………………………………………...…………...…51 2.3.2 Financial Incentives………………………………………………..……………..54 2.3.2.1 Rural Allowance………………………….……...………………………..56 2.3.2.2 Occupation- Specific Dispensation…..………………….…………….…...57 2.3.2.3 Community Service…………………………………………………….….58 2.3.3 Planning for Rehabilitation Workforce………………................…………….…..59 2.3.4 A Discrete Choice Experiment…….......................……..………………….…….61 2.3.5 Making a Future Workforce………………………….….……................……….62 2.3.6 Rural Pipeline…….…………………..…………...………………………….......63 2.3.7 Targeted Recruitment………....................…………...…………………………..63 2.3.8 Intentional Clinical Exposure…………..............................................…………..66 2.3.9 Longitudinal Integrated Clerkship……………………..………….....…..........…66 2.3.10 Concluding Comments ………………………………………............................69 2.3.11 Summary……..................................……………………….……………………69 CHAPTER 3: METHODOLOGY…………………….…………………………………………..70 3.1 Introduction…………………….…………………………………………………….........70 3.2 Research Methodology .......................................................... ………………………......…70 3.3 Research Design .................................................................... ……………….………….…73 3.4 Study Site……………………….…………………………………………………………77 3.5 Population and Sampling Procedures……………………………………………………...78 3.6 Data Collection…………………………………………………………….……….….…..81 3.7 Ethical Issues………………………………………………………………………………83 x | P a g e 3.8 Data Management and Analysis…………………………………………….…………….88 3.9 Trustworthiness of Data………………………………………………….………….……89 3.10 Summary………………………………………………………………………………….92 CHAPTER 4: RESULTS…………………………………………………..………………………93 4.1 Introduction………………………………………………………………………………..93 4.2 Exploring Rural and Rurality ..............................................................................................93 4.2.1 Theme 1: Demographic Factors…………………………………………….……………93 4.2.2 Theme 2: Social Factors……………………………………………………………....98 4.2.3 Theme 3: Educational Factors ……………………………………………...….….103 4.3 Becoming a Health Sciences Student…………………………………………………...106 4.3.1 An Aspirational Habitus……………………….……………………………………..106 4.3.2 Disorientation………………………………………………………………………...111 4.3.3 Adaptation………………………………………………………………….………...118 CHAPTER 5: RESULTS……………………………………………..………………..………….122 5.1 Introduction………………………………………...…………………………….……….122 5.2 Description of Themes……………………………………………………………………122 5.2.1 Professional Identity……………………………………………...…………………122 5.2.2 Role of Lecturers……………………………………………..……………………..128 5.2.3 Role of Classmates……………………………………………………………….....131 5.2.4 Professional Socialisation………………………………………….…………….....135 5.2.5 Faculty Support…………………………………………..…………………..……..137 5.3 Coping Strategies of Health Sciences Students of Rural Origin…………………….......140 5.3.1 Theme 1: Intrinsic Motivation……………………………….……….……………...141 5.3.2 Theme 2: Resilience………………………………………………………………….142 5.3.3Theme 3: Passion for Rural Health………………………………………………..…143 5.3.3 Theme 4: Vulnerability……………………….……………………………………..144 5.3.4 Theme 5: Rural Background…………………………………………………………145 5.4 On Being Black and of Rural Origin ………………………………………...…...…….149 xi | P a g e CHAPTER 6: BECOMING A HEALTH CARE PROFESSIONAL …………………………154 6.1 Introduction………………………………………………………………………………154 6.2 : Theme 1: Professional Development…………………………………….…………..…154 6.2.1 First Clinical Encounter………………………………………………………….…154 6.2.2 Becoming Health Care Professionals………...............…………………………….156 6.2.3 Teaching and Supervision………………………………………………………….158 6.2.4 Patients’ Contribution to Becoming Health Professionals…………..……………..161 6.2.5 Stated Preference for a Training Facility……………………………………….….164 6.2.6 Successes of the Training Programme………………………………….………......165 6.2.7 Challenges of the Training Programme…………………………………….………168 6.3. Theme 2: Personal Development……………………..………………………………...170 6.3.1 Gender Identity…………………………………………………………………….………..171 6.3.2 The Role of Clinical Partners and Classmates………………………..……………..172 CHAPTER 7: INTEGRATED DISCUSSION…………………………………….…………..175 7.1 A Personal Reflection Beyond the Interviews………………………………….……….175 7.2 Examining the Lived Experiences of Health Sciences Students of Rural Origin…...…..176 7.3 Understanding Rurality and Acquiring Social Capital…………………………..…..... .178 7.4 An Educated Habitus and Acquisition of Cultural Capital………………….…….….…185 7.5 Becoming a Health Sciences Student in an Elite Institution…………………….……....189 7.5.1 Becoming a Health Sciences Student: An Honour and a Burden…………..……192 7.5.2 Becoming a Health Sciences Student: Generating a Relational Habitus…..…….195 7.5.3 Becoming a Health Sciences Student in Gendered Spaces………………………..198 7.6 Becoming a Health Professional…………………………………………………………202 7.7 Becoming Trainee Health Care Professionals……...………………………………..…..206 7.8 On Being Black, Female and of Rural Origin……………………………………………208 CHAPTER 8: CONCLUSIONS AND RECOMMENDATIONS……………………….…...211 8.1 Presentation of Thesis.......................................................................................................211 8.2.1 Habitus Creates Capacity to Accumulate Different Forms of Capital..……..…..213 8.2.2 Cultural Capital Facilitates Adaptations to Disruptions and Tensions…..................215 xii | P a g e 8.2.3 Health Sciences Students Likely to Experience a Disrupted Habitus…….…..….217 8.2.4 Relational Habitus Has Generative Capacity to Transform........................…….....218 8.3 The Process: Constrictions and Expansions of a Habitus…………..……………...……..219 8.4 Contribution of the Study ..................................................................................................222 8.5 Research Limitations……………………………………………………....…………….224 8.6 Opportunities for Further Research……………………………………………………...224 8.7 Making a Rural Workforce……………………………..………………………….…….225 8.8 Recommendations………………………………………………………………….…….226 8.8.1 Rural Education Policy………………………………………………...………………227 8.8.2 Education and Training of a Future Workforce………………………………………...227 REFERENCES………………………………………..…………………………………………..230 APPENDICES……………………….…………………………………………………………….273 Appendix A: Plagiarism Declaration and Turnitin Report .......................................................... 273 Appendix B: Published Article .................................................................................................... 275 Appendix C: Flyer: Opportunity to Tell Your Story… ............................................................... 290 Appendix D: Invitation to Participate in a Research Study… ..................................................... 291 Appendix E: Participant Informed Consent Letter ...................................................................... 294 Appendix F: Participant Informed Consent for Audio Recording… ......................................... 296 Appendix G1: Interview Guide ................................................................................................... 297 Appendix G2: Guided Reflection on Becoming a Health Professional ...................................... 298 Appendix H1; Permission Letter from the Dean… ..................................................................... 300 Appendix H2: Clearance Certificate (Medical) Wits M180308… .............................................. 301 Appendix H3: Permission Letter from the Deputy Registrar (Wits) ........................................... 302 Appendix I: Clearance Certificate (Medical) UCT (REF619/2019) ........................................... 303 Appendix J: Permission Letter: Executive Director of Students (UCT) ...................................... 304 xiii | P a g e LIST OF FIGURES Figure 1: Conceptual framework…………………………………………………………………….17 Figure 2: Harker’s cycle of reproduction…………………………………………………………….34 Figure 3: Map of South Africa………………………………………………………………………70 Figure 3.1: Map of the health districts and subdistricts in the Western Cape Province, SA……...…77 Figure 4.1: Provincial allocation of participants per degree ................................................................ 94 Figure 4.2: Gender profile of study participants .................................................................................. 95 Figure 4.3: School hopping among health sciences students……………………………………….105 Figure 5: Coping strategies of health sciences students……………….…………………………....141 Figure 8.1: A multiprofessional framework…………………………………………..……………212 Figure 8.2: Constrictions and expansions of a habitus……………………………………………..220 LIST OF TABLES Table 2.1 National Quintile Ranking…………………………………………………………….36 Table 2.2 Education and Training of a Future Workforce……………………………………….52 Table 2.3 Policy initiatives to address maldistribution of health workforce in South African…..55 xiv| P a g e xv | P a g e NOMENCLATURE AUD Audiology Therapy Student CHWs Community Health Workers CS Community Service DoE Department of Education DoH Department of Health EC Eastern Cape Province FS Free State Province GP Gauteng Province HCPs Health Care Professionals HCWs Health Care Workers HEI Higher Education Institution HPCSA Health Professions Council of South Africa HRH Human Resources for Health HSS Health Sciences Students KZN KwaZulu-Natal Province LP Limpopo Province MED Medical Student NW North West Province OT Occupational Therapy Student PT Physiotherapy Student SA South Africa SLP Speech-Language Pathology Therapy Student STATS SA Statistics South Africa UCT University of Cape Town WC Western Cape Province WHO World Health Organization Wits University of the Witwatersrand 1 CHAPTER 1: OVERVIEW OF THE STUDY 1. Introduction The novel coronavirus (COVID-2019), which emerged in 2019 and spread to become a global pandemic, exacerbated entrenched health inequalities, and placed enormous burdens on frontline health care workers (Scheeners et al., 2020). In South Africa (SA), as argued by the Academy of Science of South Africa (ASSAf) Standing Committee on Health, COVID has compounded existing health inequalities and is likely to disrupt gains in the management of chronic conditions such as the Human Immmunodeficiency Virus (HIV) and Tuberculosis (TB) (Ataguba et al., 2020a). Despite the swift implementation of a preventative strategy by the government to contain transmission and to mitigate the effects of these measures, national lockdowns as a government- initiated response and subsequent delays in securing a vaccine disrupted economic activity and imposed untold burdens on the health system (Mbunge, 2020). With South Africa operating as a two-tiered health care system, the private health care system is only available to about 17% of the population (Stats SA, 2017). A major challenge in providing health care is filling gaps in human resources, and health needs far exceed available capacity (R. Rensburg, personal communication, July 6, 2021). COVID-19 infections and mortality rates impacted health care workers in their role as frontline service providers along with other people nationwide, threatening what was already a fragile health care system with a shortage of health care workers (Wilson et al., 2009; Couper and Hugo, 2014; van Rensburg 2014; Scheffler and Tulenko, 2016; Ntuli and Maboya, 2017; Shisana et al., 2019) amid a global health crisis (Scheeners et al., 2020). Below, I expound on initiatives to develop a health workforce in the justification of this study. I begin with reflections on how I became interested in these initiatives, and then consider reflexivity in relation to this study. 1.2 Background The stimulus for this research was a series of personal events and experiences. In a small rural town eDutywa in the Eastern Cape Province where I was born and raised, for the first eight years of my life, clinical officers undertook home visits. A few years later, in the 1980s, health care was presented as a facility-based model. In what was a mutually beneficial partnership, the school and 2 the clinic were an integral part of the community. The school was the voice of the clinic as health messages were announced during school assembly. Similarly, social events in the community provided opportunities for health promotion initiatives. These informed my earliest perceptions of health care in my community. During my 18-month internship in the cytology laboratory in a tertiary facility in Cape Town, I came to value the role of language in the provision of health care. Besides fulfilling the requirements of my training programme, from time to time, in specialised clinics (breast, lung and thyroid cancer), I was asked to interpret for patients whose home language was IsiXhosa. I recall struggling to find words to describe the radiation treatment that was prescribed for one patient. A nurse, speaking to another patient who was in the clinic for her review, referred to radiation treatment as ‘ironing’. Her explanation implied that the crinkled tissue would be ironed until it was as smooth as the top layer of the skin. Her tone made clear to the patient the discomfort they would experience when undergoing the treatment, and her explanation was accepted. In that context, I made two observations. First, one can never substitute the value of lived experience in understanding a patient’s expectations and experiences of therapeutic encounters. Secondly, patient education in the patient’s mother tongue mitigates language discordance between health care provider and the patient and is as critical as the treatment itself. I was appointed as a health care provider in Umtata, Eastern Cape after I completed my training. Here, I realised that the resources of the small cytology laboratory could not match the capabilities of a cytology laboratory in Cape Town and the opportunity it would provide me to work as part of a multi-disciplinary team. For many of the patients who accessed primary and secondary health care at the Umtata General Hospital, the closest facility with oncology services was in East London – a 3-hour drive away. Several patients who needed to access oncology services were lost to follow up, as this required a second referral from their rural hometowns. Two patients I spoke to in the outpatient’s department perceived the referral as abandonment, since the treatment facility was far from home and denied them access to family support. Even after they were counselled, they refused further treatment and chose to return home. In 2005, I moved to the Division of Rural Health at the University of the Witwatersrand (Wits). Here I had space to explore some of these factors that influence access to care, particularly for citizens who resided in rural areas of South Africa. Health inequalities were partly due to the maldistribution of health care workers, with many graduates opting for urban rather than rural 3 placements. I worked closely with the Chair of Rural Health, Professor Ian Couper. His main responsibility was to find solutions to human resource challenges in Northwest and Mpumalanga Provinces, the two rural provinces selected by the Faculty of Health Sciences as training sites for Wits students. Among the proposals he tabled for discussion were initiatives that he referred to as “growing your own timber” or “adopting a pipeline approach.” Wits accepted an initiative to adopt a pipeline approach, which informed many of the strategic plans developed to respond to the shortage of health care workers in rural and underserved areas. This initiative included recruiting students of rural origin to study initially at Wits and later at the University of Pretoria and Sefako Makgatho University (SMU) (formerly Medunsa). In addition, all medical students in their 3rd and 4th years were exposed to a range of activities that included, as four-day visits over two years, an introduction to research at community level and participation in health promotion initiatives in rural high schools. In their final year as part of the integrated primary care block, medical students were based in primary health care facilities in Gauteng, Mpumalanga and North West Provinces in six-week rotations. As part of postgraduate training, registrars rotated in the same facilities as final year medical students. Staff training was introduced as a complementary programme for health care workers who were based in the facilities identified as Wits training sites. In an advocacy role, students who were part of the scholarship programme and others in the faculty participated in a rural careers day where they interacted with high school students and, in a peer facilitated approach, briefed the pupils about entry requirements for their own programmes. I participated in many initiatives aimed at responding to human resource challenges in health. These included a scholarship initiative (Mapukata et al., 2017a), a curriculum mediated intervention (Mapukata et al., 2017b), and a social responsibility collaboration between Wits Centre for Rural Health, the Department of Health, and the Department of Basic Education in Northwest Province (Mapukata et al., 2017c). Collectively, these initiatives fed into the pipeline approach that was presented as a solution to prevailing human resources challenges. Yet, despite the implementation of a range of initiatives at Wits and other higher education institutions (HEI), as just described, inequitable access to health care and the maldistribution of the workforce in the rural areas, even in post-apartheid SA, remains a protracted struggle. In the initiative aimed to recruit students of rural origin, I assumed responsibility for a programme whose main thrust was to facilitate the socialisation of these students into higher 4 education at Wits and the two other higher education institutions. For 12 years, in the course of my employment, I observed how students of rural origin engaged with institutional processes. Students faced exceptional difficulties acclimatising to the higher education environment at Wits and the University of Pretoria, where Black student enrolment had been prohibited or highly restricted under apartheid. Levels of discomfort were not as pronounced for the students based at SMU, a university that was reserved for Black students. This was reflected in their throughput rates, positive feedback about their university experience, and their firm commitment to return to their own communities to provide health care. In the first few years, I experienced levels of discomfort similar to those reported by students of rural origin at Wits and the University of Pretoria. My deliberations on the various experiences of these students during our quarterly meetings were the beginnings of this academic enquiry. The groups had a shared identity (rural origin). However, their clinical training took place in a range of contexts that were classified as urban, underserved, and rural as each university had its own training facilities. As I was keen to explore the role of habitus and the contribution of context to identity making – fitting in, adaptation to new ways of doing and performing, and a sense of belonging – two broad questions came to mind. First, what aspects of habitus contributed to the discomfort reported by students of rural origin based in the historically white institutions? Secondly, what aspects of habitus informed the positive experiences of students of rural origin in the historically black institutions? Although the two questions above did not constitute the final research question, they informed the conceptual thinking about the aims and objectives of this study. 1.3 Reflexivity In my essay “Embodiment of particular ways of being: Habitus as an autobiographical narrative” (Appendix B), I explored the forms of capital I had access to as I grew up in a rural village. Rural areas are difficult to define, given their fluidity during the apartheid era. Variable definitions tend to reflect population density or are policy derived, as was the case with the homeland system (Geldenhuys, 1981, p.22). Rural areas are conceptualised as having dense social networks through church, family and community gatherings; rural life is linked to living off the land, a pleasant climate, personal safety, hope for a better future, and perhaps social support from philanthropic organisations. In a case study about the Ndumo community in KwaZulu-Natal, Nell et al. (2015) 5 reported that these factors enhanced psycho-social well-being, generated contentment, and strengthened the ties of social capital for individuals and families in particular communities. In my essay, I drew on personal memory, and using a narrative approach (see Smorti 2011), I described personal experiences that shaped my journey from the rural village of Idutywa in the former homeland of Transkei (Eastern Cape Province) to a higher education institution. In the social structures of which I was a part, I referred to my personal identity as fixed and continuously affirmed (2020, pp. 10-11). The description offered by Bourdieu of habitus as "society written into the body, into the biological individual" (1990a, p.63) reflects the intersectionality of social identities as performed and established practices of culture, and this applied to me as anyone else. My shared identity with my study participants is as of rural origin. This is premised on the description offered by Bourdieu of habitus, as a set of social and cultural practices, values, and dispositions that are characterised by the ways social groups interact with their members (1986, p241). I described my grandmother, who introduced me to storytelling and was the matriarch in communicating and sustaining family values. I observed that child-rearing in our context was a duty that extended beyond the primary care giver to include the community with a shared value- based approach. Even an everyday greeting was more than ritual. It affirmed an understanding that the self is not separate from the world but is part of a network – hence a greeting acknowledges the other and extends respect. In this essay, I refer to patriarchy as a form of social capital that is acquired through the learned dominance of men over women, perpetuated by attitudes, values and the culture of established institutions. I critiqued Bourdieu’s three principles of the labour market as its orientation extended favour to men. Within my family context, daily activities were not aligned to gender roles. As this conflicted with standard community practice, it heightened my awareness of societal gender norms and how they are constructed in my community and more widely in South Africa (2020, pp 14-15). In considering the acquisition of cultural capital described by Bourdieu as knowledge, skills, and behaviours transmitted to an individual within their sociocultural context through teaching (1986, p.241), I examined the role of the school as an integral part of the community. In my essay, I referred to the school as a “space to support community development, it was also a place for behaviour modification and thus a focal point for community activities” (2020, p.15). The school provided objective and structured learning. I referred to work published by Dumais 6 (2002) of the school as a place where we acquire linguistic and cultural competencies. This was possible in a continuum where social learning, as described by Lave and Wenger (1991), is first constructed at a community level through the games that we played and the social activities in which we participated. Both my parents were educators. Even though we were based in a rural setting, there was an appreciation that our participation in school would extend beyond the local primary school. My parents invested in my sisters and me, accruing real knowledge and new ways of doing and performing as kinds of knowledge that could not be offered by our primary school. In the last section of my essay, I wrote specifically of the role of teachers in facilitating a transforming habitus and the benefits I had access to once I completed my studies. Bourdieu and Passeron argue that what is imposed on students through education “contributes towards reproducing the power relations” (1977, p. 31). Agbeyenga (2014) subsequently argued that the capital of the educator is relevant to the extent to which it generates incremental value for the student. What I presented as a reflexive piece defined the role of context and a generative habitus where stones (as play tool sets and mathematical instruments) and books as disposable objects transformed into assets that were instrumental in facilitating the construction of a social, cultural, and symbolic capital and ultimately the attainment of economic capital. By embarking on this doctoral study entitled, “Making a rural workforce: Exploring the habitus of health sciences students from rural South Africa”, I wanted to understand habitus and how it is constituted in students of rural origin. I also wanted to understand its role, if any, in the making of a rural workforce. In the research on which this thesis is based, I explored this with health sciences students at the University of Cape Town (UCT). 1.4. Defining Habitus As already mentioned, this research is framed around habitus as norms, values, attitudes, and behaviours. Habitus is considered a social property of individuals, which guides their thinking and actions, and orients human behaviour (Lingard et al., 2015). The term habitus was initially conceptualised by Aristotle to provide an ethical framework for a moral behaviour and a virtuous character (Sachs, 2002). To that end, the Aristotelian habitus is informed by Greek moral values, and is not something one acquires as a temporary skill. Instead, according to Mozumder (2020), 7 habitus is the quality that is embedded deep into one’s core self and cannot be altered easily. This argument is relevant only insofar as primary habitus is concerned, deriving from acts and behaviours bestowed by family. For example, the act of curtsying and bowing before a figure of authority such as the chief, schoolteacher, hospital matron or a priest is a tradition that should be observed by all. It is therefore the responsibility of parents (families) and teachers (coaches and others) to ensure that anyone who presents before these figures of authority extends that respect. Similar observances are expected across different structures within families, in schools and in churches. Stephens (2013) argues that the level of embeddedness of such habits requires that you must act against it consciously if you wish to lose it. Within families, this is often perceived as an act of defiance, although it may also be as a result of coming into your own when you opt for a different set of values. Of concern, is the militancy with which this type of habitus is enforced, especially to those lower in hierarchies, such as the expectation that children should not look adults in the eye. This reinforces a hierarchy in which adults have authority over children. French sociologist Pierre Bourdieu linked habitus to social context, defining it as “the product of history, capable of producing individual and collective practices.” Further to the stated historical context, it is presented in multiple forms: It is deposited in each organism (individual) in the form of schemes of perception, thought, and action, tend to guarantee the ‘correctness' of practices and their constancy over time, more reliably than all formal rules and explicit norms. (Bourdieu, 1990a, p. 54). Adams (2006) described these phenomena as unconscious formations where one is programmed to act without thinking, but also reveal shared cultural commonalities. Simply put, habitus is by Bourdieu as “that which we do as second nature, the way we are” (1990a, 56). Bourdieu also defined habitus as “a structuring structure, which organises practices and the perception of practices” (1984, p.170), and functional, as “integrating past experiences, functions at every moment as a matrix of perceptions, appreciations, and actions” (1977, p.95). Considering the tensions that arise with reference to a habitus as a structuring structure, Bourdieu justifies the subjectivity and objectivity as a “dialectical relation” (1988, p. 782), culminating in an understanding that habitus is fluid in structure and in function unless it is contextualised. Bourdieu acknowledged that habitus is not only a principle but also a theory of practice and action. These contradictory approaches offered by Bourdieu in his description of habitus are 8 described by Nash (1990) as ‘interesting’, as he also observed that there were limitations (1990, p. 434). In that regard, Nash argues that Bourdieu’s presentation of habitus as a concept should be presented as a theory of socialisation. Wacquant on the other hand offers a more structured description of habitus “as the way in which society becomes deposited in the form of lasting dispositions, or trained capacities and structured propensities to think, feel and act in determinant ways, which then guide them” (2005, p.316). Wacquant observes that earlier forms of identification are framed by a family/parental perspective. In that regard, Abrams and Hogg define one’s personal identity as “people’s concepts of who they are, of what sort of people they are, and how they relate to others” (1999, p.4). The identity is thus drawn from one’s parents, siblings, grandparents, and extended family. As described by Power, habitus is not only the product but also the reproducer of structures, i.e., it generates practices that correspond to the social conditions that produced it (1999, p.49). Demonstrating the interplay between habitus and identity practices, Webb et al. (2002) argue that the embodied dispositions of an ethnic group are not creations of their own doing and may vary between durable or transposable forms across different times and places in their lives. I reported on this durability of transposable dispositions as I referred to an observed culture of reading that was inculcated subconsciously as one of my family values (Mapukata, 2020, p.19). Navarro (2006) in his description of habitus assumes a community perspective, as he refers to socialised norms and forms of thinking. These are not derived from individual processes, and while they are enduring and transferable from one context to another, they are also capable of shifting in relation to specific contexts over a period (Navarro, 2006, p.16). This description of one’s social identity is reported by Jenkins as “ways in which individuals and collectivities are distinguished in their social relations with other individuals and collectivities” (1992, p.4). In that regard, habitus, in Navarro’s description, produces community capital for individuals. Habitus is capable of altering one’s value system and influencing everyday choices and ways of being, unless these are grounded in sound cultural practice (Bourdieu, 1990a). Bourdieu refers to cultural capital as informational capital; Jenkins (1992) refers to cultural capital as legitimate knowledge of one kind or another. Bourdieu (1986) identified three potential sources of cultural capital as the embodied state (language, taste, style, disposition, social grace); objective state (books, cultural goods and works of art); and institutionalised state (credentials, education, qualifications) (pp. 82-84). Social capital is described by Bourdieu and Wacquant (1992) as the 9 “sum of resources, actual or virtual, that accrue to an individual or a group by virtue of possessing a durable network of more or less institutionalised relationships of mutual acquaintance and recognition” (p.19). According to Bhandari and Yasunobu (2009), social capital is considered a multidimensional phenomenon that contributes to economic and social development and can be sourced through institutions that foster cooperation and collective actions for mutual benefit. It can be accessed as structural and cognitive bonds that link to people vertically or horizontally, based on a sense of common identity (“people like us”) – such as family, close friends and people who share our culture or ethnicity. Secondly, they are bridges that stretch beyond a shared sense of identity and can be used to enable collaborations with colleagues and associates. Thirdly, they are linkages to people or groups through which one can establish networks further up or lower down the social ladder (Edgerton and Roberts, 2014). Economic capital is immediately convertible into money and is institutionalised as property rights and other resources such as home-reared animals and housing structures. The field is described by Bourdieu as a social space and may be autonomous or semi- autonomous. It is a place that enables formal and informal interactions and events. The field can exist as a department within a school, a faculty or as a place where cultural capital is generated and is governed by a set of rules. These determine boundaries or a form of power that Bourdieu (1984) referred to as doxa – a combination of both orthodox and heterodox norms and beliefs – the unstated, taken-for-granted assumptions or ‘common sense’ behind the distinctions we make with regards to a specific environment (1984, p.417). Fields are organised around specific forms of capital or combinations of capital, which according to Thompson ‘are both the process within, and product, of a field’ (2008, p.69). Similarly, Navarro (2006) describes the field as a network, structure or set of relationships which may be social, cultural, religious, intellectual, and educational (2006, p.18). In this study, the field is the Faculty of Health Sciences at UCT, made up of a structured system of social relations between the Department of Higher Education and the Department of Health. Actors include lecturers; clinical educators, registrars and consultants; curriculum designers; demonstrators, patients; students; and administrators as agents (see Hunter, 2004). The practice is an outcome of the relationship between an individual's habitus and different forms of capital. ‘The practice’ is thus considered to be ‘the product of a habitus that is itself the product 10 of the embodiment of the immanent regularities and tendencies of the world’ (Bourdieu & Wacquant, 1992, p. 138). Both the actors and agents in the field perform to produce actions that generate cultural capital for registered students. In that regard, UCT provides for both academic capital and scientific capital. Cultural capital can also be a source of inequality. As parents (families) are the first teachers, they determine the forms of capital that their children have access to, and their efforts in turn determine if the child accumulates more or less social capital. The school as a mediator and a generator of social capital can also contribute to inequality as presented in the framework on cycle of reproduction (Harker, 1984). Harker, who critiqued some of Bourdieu’s work and examined the role of habitus in the production of education, similarly defines habitus as the way a culture is embodied in an individual (1984, p.118). Rurality is derived from an individual's primary habitus that is engrained by acts, rituals and performances observed during childhood. This social context affords an individual access to social, cultural, economic and symbolic forms of capital (Bourdieu, 1986, p. 242). According to Power, this primary habitus tends to be more durable than secondary habitus that may be learned later - as one assumes a professional role (1999, p.49). As habitus is not fixed and is not considered a permanent concept (according to Navarro, 2006), examining an individual’s life history is critical in understanding habitus. 1.5 Developing a Rural Health Workforce In response to the problems which I referred in the introduction about rural health services and the rural health workforces globally, the World Health Organization (WHO) developed guidelines for the transformative scaling up of health professionals’ education, to ensure sustainable expansion, and to include reforms in the training so that outcomes are goal-oriented (WHO, 2013). In enforcing the transformative scaling of health profession education, the World Health Organization issued the directive below to universities: Educational institutions must implement reforms that allow them to recruit from the communities they serve, teach to the local disease burden, and educate students to practice within the care delivery models that are likely to best serve the local population health needs (2013, p. 13). 11 This directive was relevant in South Africa. Prior to the implementation of a democratic state in 1994, South Africa had a two-tiered education system such that access to higher education institutions was stratified along racial lines, consistent with the policies of the apartheid regime (de Wet and Wolhuter, 2009). From 1994 the strategic framework of the governing party, the African National Congress (ANC), focused on identifying interventions and levers necessary for higher education to be transformed (DoE, 1997). The mandate to higher education institutions (HEI) was “to redress past inequality and transform the higher education system to serve a new social order to meet pressing national needs and to respond to new realities and opportunities” (DoE, 1997, p.1). The goals of the policy framework included value creation and all stakeholders were required to contribute to the development of knowledge and capacity, cultural enrichment, and the development of a global citizenry (DoE, 1997, p.23). Educational approaches to be followed had to advance the interests and rights of individuals, irrespective of race, religion or creed. With this shift in the policy framework, there was a concerted effort to change the demographics of the student body in HEI, with a recommendation that 50 per cent of all admissions be Black and Coloured students (DoE, 1997). Subsequently, flowing from the DoE policy, during a Department of Health (DoH) National Health Summit, a directive was issued for all medical schools to accept a diverse group of students (Lehmann et al. 2001). This was intended to facilitate learning outcomes congruent with the place and to operate in an environment that enabled democratic citizenship (Moore, 2005), in line with earlier recommendations issued by WHO in 2000 in a report on challenges and opportunities for partnership in health development. The DoE subsequently advised HEI to adopt curricula that focused on reforms to benefit communities (Couper et al., 2007; Kent and de Villiers, 2007). This was in response to the call by the WHO for a shift from health service orientation that was overly biomedical, disease focused, technology driven, and doctor dominated, to promote people-centred health care (WHO, 2007). In 1995, Boelen and Heck, public health specialists at the World Health Organization, argued that medical schools would be judged by their commitment to graduate socially accountable health care professionals able to respond to evolving health challenges. The WHO described social accountability as stated below: The obligation of medical schools to direct education, research and service activities towards addressing the priority health concerns of the community, region or nation that 12 they are mandated to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public (1995, p.3). In line with the aspirations of the global community, a Global Consensus on Social Accountability (GCSA) initiative was established to identify the desirable scope of work required for medical schools to have a greater impact on health system performance and on peoples’ health status. Subsequently, in October 2010, in a meeting held in East London (South Africa), a team of international experts joined delegates from medical educational and accrediting bodies around the world and agreed on a 10-item consensus document that would provide strategic direction for the implementation of social accountability in medical schools (Boelen and Woollard, 2011). Priority areas out of the ten articulated by the GCSA community, of interest to this study, were identified as an understanding of social context, an identification of health challenges and needs, and the creation of relationships between the university and its communities, in order to act efficiently (Boelen and Woollard, 2011). In 2011, Kwizwera and Iputo in their capacity as Professors at Walter Sisulu University, the only medical school considered to have successfully implemented social accountability in South Africa, reported that only a few universities across Africa had kept up with the pedagogical global shift in medical education. Following the establishment of the GCSA forum, in a paper published from a PhD study on the same topic, Green-Thompson and colleagues (2017) conceded to an understanding of social accountability as grounded in academia and central agencies, although they also defined a role for communities. Having considered all global health challenges, Frenk and colleagues (2010) predicted that in an interdependent world, medical education would continue to face major challenges in making a health workforce. In South Africa, push factors such as infrastructure challenges, resources, and skills shortages are described by Mlambo and Adetiba (2017) and Rispel and colleagues (2018) as some of the causes of brain drain of the country’s health professionals, including health sciences educators. Health professionals have migrated in significant numbers to countries with better working conditions, feeding into the pull factors that are associated with globalization. Other factors associated with workplace push factors, particularly of specialist physicians, have been cited by Labonte et al. (2015) as corruption, a high burden of HIV and drug resistant TB, government economic policies, government health sector policies, and concerns about personal and family safety or the children’s future. 13 Earlier, Phillip Tobias (1983) had argued that no matter what scale of policy redress was employed, the rules of engagement had ramifications for people who were Black or Coloured at primary, secondary, and tertiary educational levels, and the ills of the past would have a lasting impact. He maintained that medical education in Southern Africa would have a 30-year training deficit as an outcome of apartheid policies. Despite Tobias’s prediction, the number of Black students admitted in HEI has increased to reflect the demographics of South Africa’s population following the 2001 policy directive that required HEI to prioritise the representation of previously marginalized groups of Black people and women (CHE, 2013). Lehmann (2001), on the other hand, advanced that in a university, students of rural origin are often marginalized by historical discourse and personal circumstances, and sometimes by the context in HEI (see also Janse van Rensburg, 2011; Czerniewicz and Brown, 2014; Pather and Chetty, 2015). In their high schools, mathematics and physics may have been taught by teachers who could compensate for limitations imposed by a rural context such as lacking access to laboratories and libraries. Although these students gain access to a university if they meet the entry requirements, this does not guarantee immediate access to academic capital if their experience of the university context is disorientating. These defining characteristics described by Lehmann (2001) i.e., personal circumstances, historical discourse, and context, are central to understanding the making of a rural workforce. 1.6 Problem Statement In a university setting, Bourdieu saw habitus as a formative influence on how students from different social classes might engage with the education system (1990, p.116). This in turn would predict their subsequent levels of educational and ultimately occupational and socioeconomic attainment. In that regard, a university provides for both academic capital and scientific capital as it is defined as an institutionalised form of cultural capital based on entry requirements that must be met to gain access to a university (Bourdieu, 1988). These include prior educational achievement (in South Africa, matric certificate with exemptions) as well as specially designated competencies that justify access to particular programmes (e.g., a good pass in mathematics and physics as prerequisites to register for degrees offered by faculties of health sciences). 14 In view of the prevailing challenges flagged by Tobias (1983) and Lehmann et al. (2001), even with directed efforts to increase the number of rural students registering for programmes offered by faculties of health sciences and medical schools in South Africa, either through a quota system or through adjusted entry requirements (Tumbo et al., 2009; van Schalkwyk et al., 2014; Ross et al., 2015; Mapukata et al., 2017a), rural students remain under-represented in health sciences (van der Merwe et al., 2016; Mapukata et al., 2017b). This is based on a range of barriers and challenges I alluded to earlier, beyond the control of students, that are reported to contribute to low throughput rates for these students (Wilson et al., 2009; Janse van Rensburg, 2011; Essop 2020). Despite improved access to HEI, as universities continue to mirror societal norms (Mnguni, 2016) as reported by students during the #FeesMustFall student unrest (Langa, 2017), white students are more likely than their African counterparts to succeed and complete (Essop, 2020), as the culture in HEI is considered alienating for Black students (Heleta, 2016). This hampers efforts to increase the number of health care professionals, particularly those willing to work in rural areas (Rose and Janse van Rensburg-Bonthuyzen, 2015; Econex, 2015). Consequently, among researchers, there has been a corresponding interest in exploring the habitus of previously disadvantaged students as one approach to respond to existing human resources challenges in South Africa. In this study, my intention is to explore the habitus of health sciences students of rural origin, with the aim of generating data to inform strategies and approaches to be considered in the making of a rural workforce. 1.7 Justifying and Contextualising the Study Internationally, several interventions have been proposed and implemented to develop a rural workforce by targeting high school students from under-represented, underprivileged, and remote communities (e.g., Lawson et al., 2007; Rabinowitz et al., 2005; Pong and Heng, 2005; Kumar et al., 2015). These include a three-pronged strategy as a framework that was adopted by five countries – Sweden, Norway, Canada, Iceland, and Scotland – to ensure a stable rural and remote workforce. The collaborators agreed on a plan to ensure that the population’s needs were periodically assessed to ensure that the right service model was in place, and that the right recruits were targeted and retained. Activities were conducted to support team cohesion, train current and 15 future professionals for rural and remote health careers and assure the attractiveness of these careers (Abelsen et al., 2020). In Australia, three universities - the University of Newcastle, the University of Western Australia and James Cook University - were tasked with the responsibility of training Indigenous doctors to respond to the needs of Aboriginal people. The Indigenous students were required to host road shows, visit schools and participate in Career Expo, in similar fashion to the initiatives implemented at Wits (Lawson et al., 2007). Locally, interventions to develop a rural workforce have ranged from a broad policy framework instituted by the South African Government (DoE, 1997) to an implementation process, directed by universities (Lehmann et al., 2001) and guided by the Health Professions Council of South Africa (HPCSA Criteria and Guidelines for Accreditors, 2010). As a recommendation towards building a rural workforce, Ross and Couper (2004) suggested a pipeline approach, as I have noted above (see also Tumbo et al., 2009). De Vries and Reid (2003) confirmed that students of rural origin were more likely to return to their communities to practice compared to their urban colleagues. They advanced two sets of recommendations to universities when selecting applicants: prioritising applicants of rural origin and assessing career aspirations particularly for those who indicate that they are likely to choose general practice. The second recommendation is rather tricky to manage, however, as prospective applicants are likely to prioritise general practice if this guarantees their admission to a highly contested medical programme. Transformation, as an institutional process I alluded to as a policy initiative, is central to rural health workforce development (Lehmann et al., 2001; Couper, 2003; Couper et al., 2007; Tumbo et al., 2009). For example, the Wits Initiative for Rural Health Education (WIRHE) at Wits was established in 2003 as a faculty-initiated policy response (Mapukata et al., 2017a), well before debates on the decolonisation of higher education. In response to the shortage of health care workers in rural areas, WIRHE was premised on an understanding that health sciences students of rural origin are most likely to return to and practice in their own communities (De Vreis and Reid, 2003; Wilson et al., 2009). At Wits, WIRHE students registered for professional degrees offered by the Faculty of Health Sciences, with the intention of joining the public sector as health care professionals (HCPs) or health care workers (HCWs). In this study conducted at UCT, health sciences students are enrolled in audiology, medicine, occupational therapy, physiotherapy and the speech-language pathology programmes. Elsewhere, health sciences might include nursing, medical technologists, orthotics and prosthetics, 16 dentistry and other programmes offered by faculties of health sciences at particular institutions. Students of rural origin are defined as having been born and who grew up in rural areas of South Africa, where 32.6% of the population is based (World Bank, 2020). These areas rarely have the same resources as urban areas. At a community level, running water and electricity may be available only intermittently or not at all. Libraries, laboratories, and computers are rare even in contemporary schools. Established as an international learning exchange model, in 1997, the Nelson Mandela/Fidel Castro Medical Collaboration Programme was established with the view to address the shortage of health care workers in rural areas, improve workforce capacity and strengthen the health care system. This partnership is between South Africa’s ruling party – the African National Congress – and the Government of Cuba. To date more than 800 students from rural South Africa have trained in medical universities in Cuba (Donda et al., 2016), returned to South Africa, and following an 18-month placement in a South African medical school, are ready to practice. Two years later, the Umthombo Youth Development Foundation (UYDF) scholarship programme was established in KwaZulu-Natal to benefit students who wished to register for professional degrees in health sciences offered by universities and universities of technology (Ross et al., 2015). WIRHE was modelled on the UYDF, and both WIRHE and UYDF were presented as transformative models for training health sciences students of rural origin. However, despite the successful implementation of these initiatives, the aggregate number of health care professionals has not been sufficient to address the ongoing shortage of health care workers (Econex, 2015; Ross et al., 2015). 1.8 Conceptual Framework In this study, I draw on the social constructivist theory of Pierre Bourdieu (1984) in relation to reproduction in education. The application of Bourdieu’s framework is relevant as it provides an approach to examining the complexities of difference. This framework has been used by others to report on changes in education practice, in policy, and in relation to a changing demographic profile of students in higher education institutions, such as with students of rural origin or working- class students (Reay, 2004; Bathmaker, 2015; Czerniewicz and Brown, 2014; Pather and Chetty, 2015; Gennrich, 2015). The framework allows for a range of factors to be explored to explain how 17 students become (or not) health professionals (Figure 1). These factors include examining habitus, the field (the university) and different stakeholders in the field, and the inter-relationship between power and knowledge in the construction of institutional habitus (1Bourdieu, 1984, p.19). In this study, I examined the relationship between rural origin and rural education in relation to its impact on performance in the field and in practice. Figure 1: Conceptual framework (Bourdieu, 1984) The core elements in Bourdieu’s framework are habitus, the different forms of capital, and the field, described earlier (see 1.4) as an institution or workplace and practice. As the goal of this study is to understand the role of habitus in the professionalisation of students of rural origin, I examine different forms of habitus in context (Adom et al., 2018). In an individual, primary habitus is informed by gender, social class, culture, ethnicity, and family (Meisenhelder, 2000). In South Africa, it is not possible to overlook the historical dimension, including a two-tiered education system. Thus race (and racism) and schooling constitute experiences in the formative years (Larey, 2018) and beyond. Through habitus, individuals accrue social, cultural, symbolic, and economic capital (Bourdieu, 1994, p.179). Habitus provides for the interplay of socialisation, experience, and professional practice (Light and Evans, 2011). In that regard, Bourdieu is of the view that through the mechanics of habitus, in the long-term, the practice of the profession is linked to cultural and economic capital, both of which derive from the activities of a university and from professional and inter- professional networks. Consequently, becoming and being an audiology therapist, medical doctor, occupational therapist, physiotherapist, or speech-language pathology therapist, are derived from the knowledge, skills, attitudes, and behaviours that, as cultural capital, accrue during a person’s time as a student as well as subsequently during their professional practice. 18 In his book, Logic for Practice (1990a), Bourdieu argues that all habitus produces action. In measuring an individual’s commitment to succeed, one must consider that secondary habitus becomes active in relation to a field. For students in a faculty of health sciences, the degree that one is registered for provides the qualities and attributes that faculty and associated professionals wish to reproduce in their students as practitioners (Warde, 2004). It informs their day-to-day interactions with patients, colleagues (including interprofessional partnerships such as doctors vs nurses or doctors vs rehabilitation therapists, where hierarchies are reproduced) and members of the public. On the other hand, the university, although it is essential and is considered a component of the conceptual framework, does not play a substantive role in the same way that the construction of the habits and lasting dispositions are informed by family influences (Harker, 1984, p.118). The cultural capital that is accrued is derived and determined by the context (Warde, 2004). For example, an understanding that stealing is an inappropriate behaviour is an internalised value (and so a habit) that is (ideally) instilled early in life. The university, as it limits itself to teaching on content specific knowledge and skills as related to a particular profession or area of learning, may approach the same topic as plagiarism as a punishable offence or as cheating from a licensing perspective as standards that must be met by health sciences students and registered practitioners. The field on the other hand is most likely to generate symbolic capital in the form of certificates and awards. If one considers habitus as a fluid concept, the same habitus within a group can lead to very different practices and attitudes depending on implicit and explicit influences in the field (Bourdieu, 1990b, p.116). In a university, the culture of an institution greatly influences the type of practitioner one becomes – UCT, for example, has an established track record for producing scholars in the practice of medicine, some of whom are recognised as global leaders. That is not necessarily true for all UCT graduates, and not all graduates practice in ways congruent with the values of the institution. In HEI, power and privilege are inherent to the historical discourse and despite a changed framework that focuses on transformation and equity, institutional culture and epistemological traditions have remained Eurocentric according to Heleta (2016); these are reproduced in existing structures. Costa et al. (2019) consider that one of the drawcards of exploring the lived experiences of health science students is the opportunity this provides to examine everyday relational modes of being. These provide a space to explore the interplay between power and privilege (2019, p.20). 19 Bourdieu’s framework is criticised for downplaying the role of agency which is best explained through critical realism - a philosophical framework that is the brainchild of Roy Bhaskar. In his seminal work, A Realist Theory of Science, Bhaskar (1975) argued that the Western World is real, complex, and structured. Bhaskar’s framework focused on three domains of sociological ontology – ontological realism, epistemological relativism, and judgemental rationality (see also Reid, 2019). His work gained traction in Archer’s writings (1982) as she argued that critical realism as a framework extends value to agency as the driver of reproduction and transformation of social structures. Whilst Archer is concerned with morphogenesis of social structures and reflexivity that is derived from a participant’s capacity and capability, Bourdieu is concerned about reproduction in education and a transforming habitus in the field. As critical realism is a manifestation of the interplay between structure, culture, and agency (Archer, 1982), in this study, I employed Bourdieu’s framework so I can examine the interplay between socialisation, experience, and professional practice for a defined group of students. 1.8.1 Study Aims and Objectives Against this background, I considered the question in this study to be: How does habitus influence the professionalisation of health sciences students of rural origin? Habitus allows for the construction of biographies, and hence I considered a qualitative research design as an appropriate methodology. The research was conducted in the natural environment, with attention to the socio-cultural context of students across a range of programmes in the Faculty of Health Sciences at UCT. The empirical enquiry employed a collective case study design as several phenomena could be studied sequentially to generate a broader appreciation of how habitus influences professionalisation (Crowe et al., 2011) similar to an approach adopted in a doctoral thesis by Hashimoto (2020). Through in-depth interviews and journal reflections, I expected to gain insight into how participants acted in situated contexts (Thomson et al., 2002), the details of which I describe in Chapter 3 of this thesis. The broad aims of the study were to: • Describe the lived experiences of students of rural origin, and • Determine the influences of the learning environment as rural origin students adapt to become health care professionals. 20 I considered the profile of students from rural South Africa, the transition from rural school to university, and explored students’ experiences of training to become health care professionals. Thus, the objectives for this study were: 1. To describe and analyse student experiences of their transition from home to school to university. 2. To determine the role of a university in student continuation and explore the coping strategies of health sciences students while at university. 3. To describe and analyse the experience and professionalisation of the students as they become health care professionals. 4. To describe and analyse different forms of capital and how they produce habitus for students of rural origin. 1.8.2 Assumptions Beyond the interpretation and analysis of qualitative data generated from interviews and journal reflections, in this study, I examine social and cultural attributes of a habitus of students of rural background and the effect of their interactions in everyday experiences on the process of becoming and being health professionals. While developing a testable hypothesis is considered a central construct in quantitative research, in qualitative research (Chigbu, 2019), with a focus on answering the research question using inductive reasoning, a hypothesis generating approach is preferred. Chigbu (2019) describes this as presenting a process that is much more than a tool to restate and clarify the problem under investigation. It is also attributive, that is, meant to describe a scenario, situation, or event; is associative, that is, meant to predict an outcome; and causal, that is, meant to create an understanding of relationships (2019; p.10). Accordingly, assumptions should be made explicit (Nkwake, 2013) and the number of assumptions presented should be sufficient to describe the lived experiences of study participants. I have noted that the chronic shortage of health care workers in the rural areas in South Africa (SA) has resulted in poor health outcomes for citizens in rural communities (Wilson et al., 2009, Veld & Van De Voorde, 2014; Mulaudzi et al., 2016.; Shisana et al., 2019). Health sciences students of rural origin, although they are under-represented and are marginalised by context, are more likely to practice as rural practitioners. However, the defining characteristics of their habitus 21 and its influence on their professionalisation is yet to be established. Accordingly, I offer the following as proposition statements: 1. Social capital creates cumulative value for health sciences students of rural origin. 2. Cultural capital facilitates adaptive capacity in health sciences students of rural origin. 3. Health sciences students are likely to experience a disrupted habitus as they generate power in the field. 4. Habitus of health sciences students of rural origin has generative capacity to facilitate transformation from non-professional to professional spaces. 1.9 Structure of the Thesis In the first two chapters of this thesis, I present my conceptual approach to the study, and provide a review of available literature. In chapter three, I focus on the methodology of the study. Chapters four, five and six are the central results chapters, presenting the findings from in-depth interviews and journal reflections as empirical material interpreted in light of the objective structures of habitus and their generative capabilities. In chapter seven, I discuss these findings and summarise the thesis. Below is the outline of each chapter. As an orientation to this thesis, in chapter one, I discuss the stimulus for this research. I reflect on the historical context and its influence on several national policies in higher education and examine initiatives in HEI that respond to the human resources challenges. As I draw on a Bourdieusian framework, the aims, objectives, and the research design are all intended to facilitate an examination of a habitus of health sciences students of rural origin at the University of Cape Town. In chapter two, I present the literature relevant to this study. I prioritise rural origin of study participants and explore the ambiguity that is associated with the terms rural and rurality, focusing on rural areas as places and spaces that generate habitus for students of rural origin. I discuss Bourdieu’s concept of habitus and consider how others have studied habitus and its influence on access to health. I consider the historical context to health services and note the challenges to building and maintaining a rural workforce. I examine a range of policies and programmes on redress in South Africa and those adopted in countries such as Australia and Canada on initiatives they implemented that focus on rural education, recruitment, and retention of health care workers 22 for rural areas and access to higher education institutions. In analysing this literature, I paid attention to the interplay between socialisation, experience, and professional practice. Using a qualitative methodology to operationalise habitus, in chapter three, I employ a collective case design to generate deep conversations with final year students of rural origin. The study included two phases. In relation to the first objective, informed by in-depth interviews in phase one of the study, in chapter four, I present the findings from a qualitative exploration of rural and rurality by health sciences students as I examine their transition from school to university. In relation to the second objective in chapter five, I describe the role of the university in the continuation of students and students’ coping strategies. In the second phase, participants submitted journal reflections about their experiences in the clinical environment. I examine journal reflections in context in relation to the third objective, and in chapter six, I describe and analyse the participants’ experiences of professionalisation. I provide a detailed description of the approaches I applied in sampling techniques, population identification, data collection methods, data analysis, trustworthiness of data, ethical considerations, and limitations of the study. In analysing the findings, in chapter seven, the study outcomes in chapters four, five and six are linked to the work of others. In chapter eight, I describe and analyse different forms of capital by repopulating the conceptual framework with study-specific variables as these inform future research. For this study, opportunities for future research, and ways to continue to address the challenges to rural health, are also discussed. 1.10 Summary In this chapter, I have described the stimulus for this study as I reflected on the prevailing challenges in providing equitable health care in the rural areas of South African in a context of a global pandemic. I have noted efforts by higher education institutions to provide solutions to prevailing human resources challenges and elaborate on this in the following chapter. I outlined the value in approaching this study as a reflective practitioner and considered reflexivity. I presented a problem statement, aims and objectives of the study and justification for undertaking this research using a Bourdieusian framework. I shared limitations and my assumptions about possible outcomes. In the next chapter, I review the related literature. 23 CHAPTER 2: LITERATURE REVIEW In response to the research question of how habitus influences the professionalisation of health sciences students, I have divided this chapter into three sections. I first explore rural and rurality and assess its impact on health outcomes. I then examine the habitus of students of rural origin and lastly, I review existing policies on recruitment and retention of a health workforce. 2.1 Rural, Rurality and Access to Health In an earlier discussion in Chapter 1, I referred to the stimulus for this study as guided by events and personal experiences and social learning, situated in context as an outcome of extended interactions with others both within and outside of my family structure. Within that social structure, my clan name is a tracer of my genealogy as it relates family history to my place in the ancestry registry (Mapukata, 2020). This is the tracer of the durability of habitus that is embedded in memory as an embodied form of knowledge. Conferring this allegiance defines the relationship of homology as an ingrained link to family and family structures. However, when viewed from a population registry, rural origin as a space I share with my participants is ill-defined. Consensus among policy makers, researchers, and communities is that there is no single definition for rural despite this being a fundamental necessity (Murray et al., 2004; Reid, 2019; Rasheed, 2020; Nelson et al., 2021). Green and Colbert (2013) argued that ruralities is only the plural form of rural. These authors favour the adoption of the plural form as it facilitates a shift from reductionist views about all things rural. I consider this variability below. 2.1.1 Rurality: A Place and a Space The concept of rurality as a place and a space is central to Bourdieu’s work and locating the place of origin of the participants is a critical undertaking in this study. Bourdieu (2000) describes physical space as the place based on the mutual externality of parts as amenities that exist in one’s environment, such as the role one assumes as an individual who is part of a community. In the absence of a uniform definition of rural (Gaede and Vesteeg, 2011), policy makers in South Africa have conceded to discipline-specific working descriptions that apply to all contexts (Reid, 2019; 24 Mngomezulu and Mngomezulu, 2020). Such definitions have tended to reflect population density or are policy derived, often from a service perspective. For example, the Department of Rural Development and Land Reform (DRDLR) in SA limits rural areas to “sparsely populated areas in which people farm or depend on natural resources, including the villages and small towns that are dispersed through these areas. In addition, they include the large settlements in former homelands, created by the apartheid removals, which depend for their survival on migratory labour and remittances” (DRDLR, 2007:1). In a 2012 report, the Human Sciences Research Council (HSRC) described rural areas in the Eastern Cape Province from a deficit perspective as places that did not have ready access to ordinary public services such as water and sanitation. Rural areas were also seen to lack a formalised local authority to direct the provision of such services. A range of indices to describe rural, remote and urban areas including postal codes apply in developed countries such as Canada (Olatunde et al., 2007), United States (Hart et al., 2005), England and Wales (Cloke, 1977), and Australia (Murray et al., 2004). In South Africa, postal codes do not carry much value except for the purpose of mail sorting. Prior to 1994, postal codes were aligned to the geographical classification of provinces where the country was divided into four regions, namely: Northern, Eastern, Central and Southern. This has since been reclassified into nine provinces. In a study that dates back four decades, Beaton and Bourne (1980) used postal codes in monitoring the distribution of doctors across South Africa by tracking their physical addresses. What was significant then and is still relevant, was the maldistribution of doctors as allocation favoured urban metropolitan areas (76,5%) in what the authors described as urban hierarchies. These hierarchies are still in place; for example, Ntuli and Mabuya (2017) established an inter-provincial maldistribution of the workforce in two of the five districts that had features of urban districts in Mpumalanga Province. 2.1.2 Rurality: As Social Space Bourdieu (2000) defines rurality as a social space (or field) based on the mutual exclusion (or distinction) of positions which constitute it, that is, as a structure of juxtaposition of social positions. Rurality is sometimes presented as a range of externalities of parts comprising of demographic, geographic and cultural features, thus requiring a multi-focal lens (Roberts and Greene, 2013; Chigbu, 2013; Hlalele, 2012). In Australia, Veitch (2009) refers to rural, rurality 25 and remoteness as terms that are used interchangeably to include additional elements such as sparse population distribution, isolation, primary industry economic base, and physically constructed or built environments that are most likely to expose residents to unique hazards. This view is shared by Balfour et al. (2008), who also frame rurality from a deficit model and extend Veitch’s (2009) description to include a range of held views about rurality that apply to the South African context: “community, poverty, disease, neglect, backwardness, marginalisation, depopulation, conservatism, racism, resettlement, corruption, entropy, and exclusion” (p.101). In such social spaces, students exist as human beings and social agents, have agency, and may have a role based on privileges to which they have access, or which they lack. According to Haimes (2003), the multitude of places that are occupied by students define their status, class, social position and determine their place within society as individuals and as a community. For example, even a student who has limited cultural and social capital may be promoted to a place of privilege in a university once they assume a new position, for example as the chairperson of the Health Sciences Students Council or when they become a class representative. In instances where they participate in health promotion activities at community level, some members of the community may see them as experts depending on how they communicate a health message or how they respond to the community’s concerns. In that regard, the social space is an invisible set of relationships derived from various social groupings, including class groupings. According to Halfacree (1993), the space is constituted by a set of shared experiences, meanings and symbols but also contains diverse and contradictory elements (p.38) and thus confers a sense of community. To that end, Bourdieu (1996) argues that physical and social space have a lot of things in common, which implies that all the distinct aspects of the physical space are reproduced in the social space (p.96). In the next few paragraphs, I explore the social representation of rurality. This interface between the place and the space is highly valued with regards to rurality as the socio-spatial characteristics, attitudes, and behaviours are best framed by one’s identity as derived from a social construct. In such contexts, several researchers have acknowledged the plurality of views and ambiguity that is associated with rurality as a place where diversity, tradition and cultural practice exist side by side (Hlalele, 2014), and a place that brings together people who have a common ancestry and heritage (Hlalele, 2012; Chigbu, 2013). In addition to this description, Rasheed (2020) referred to observable qualities and complexities about rural places that include evolving cultural, demographic, environmental, geographic, and social variances 26 (p.64). In a first world country like Switzerland, where the focus is on modernity, Lindley et al. (2015) described rurality as a place with poor connectivity, less innovation in subsistence activities such as farming, and a place that has zero public exercise and a poor savings culture. This is in sharp contrast with the experiences of people in rural South Africa where walking is the order of the day due to lack of affordable and reliable transport. Although arguably financial literacy levels are low (Tshabalala, 2019), a savings culture in rural South Africa is structured around stokvels, burial societies and village banks. Stokvels and burial societies are also spaces for social interaction - the meetings are much more than a discussion about bank balances, profit, or loss. This view is supported by Ndofirepi and Masineri who present rurality as constituted by a range of dynamic, complex and heterogenous communities (2020, p.245). Others have extended this understanding to rurality that is derived from socially constructed phenomena (Halfacree, 1993; Woods, 2009). Considered from Creswell’s view of place as a means of “seeing, knowing, and understanding of the world” (2004, p. 11), the place becomes a marker of one’s social class, gender, religious identity and capability. Within a particular community, Budge (2005) identified six habits that confer a sense of place and a sense of belonging to an individual, thus confirming the conception of one’s identity from a social construct. These are “connectedness, development of identity culture, interdependence with the land, spirituality, ideology and politics, and activism and engagement” (Budge, 2005, p.5). In a study by Nell et al. (2015), similar habits contributed to enhanced psychosocial well-being and contentment for the people of Ndumo community in KwaZulu-Natal. The challenges in defining rurality extend also to limitations in research and scholarship. Reflecting on “the two-ness of a rural life and ends of rural scholarship,” Bell (2007) speaks of a disconnect between sociologists, economists, geographers, and anthropologists such that, even in the United States of America, defining rurality is layered (p.403). On the other hand, Edwards and Matarrita-Cascante (2011) acknowledge that there are challenges in operationalising the concept of rurality in empirical research. In a paper published in 2011, Nkambule and colleagues addressed this challenge prompted by the paucity of research that explored discourses underpinning rurality and rural education. The authors presented three frameworks of postgraduate research that were undertaken at Higher Education Institutions in South Africa. These comprised of dissertations and theses that explored rurality as a lived experience focusing on rurality and rural education issues 27 (42%), rurality as context (35%); and social issues related to rurality and rural education (22%). A significant finding was that most of the research was conducted by Black African students. This suggested that postgraduate students were pursuing research in areas related to their own backgrounds and lived experiences. This observation complements my goals as a researcher. In this section, there were no differences in what is reported about descriptive ambiguity and the heterogeneity of rurality, whether communities were based in developed or developing countries. As I have demonstrated that rurality is a fluid concept, a gap in this literature is that views of health sciences students were not solicited in any of the studies. Bennett et al. (2019) are of the view that it is a responsibility of the researcher to clearly define how rurality is operationalised in their work. I cover this in the next section as I review the literature on rurality and its impact on accessing health care. 2.1.3 Rurality and Access to Health Care Following my earlier assertions about rurality as both place and space, the social context becomes a critical variable in understanding and formulating interventions for improved health outcomes of citizens who reside in rural communities and in addressing disparities between urban and rural communities (Harvey, 2010). This is largely attributed to the migration patterns that tend to favour urban areas (George et al. 2019; Jose et al., 2020). As such, rurality has become a proxy for health inequities due to a heterogenous profile of rural communities such that Couper (2003) cautioned against reducing rural communities to just “non-urban” areas (see also Mngomezulu and Mngomezulu 2020). Likewise, Dunbabin and Levitt (2007) observed that diverse demographic profiles were most likely to impact health outcomes. In a series of cases, I examine this interplay between context and health outcomes. In a study that compared health outcomes in urban and rural1 places of residence in Canada and Australia (Lagace et al., 2007), heterogeneity in the geographical classification of rural areas between the two countries resulted in methodological challenges and notable differences in the risk profile and health outcomes. The challenges and 1 In Australia and in Canada places that are classified as rural areas are inclusive of several categories that include and extend beyond rural, remote and very remote areas. Any reference to rural people in this study extends priority to Indigenous people who present with similar profiles to people from rural South Africa (see Veitch, 2009). 28 variations were attributable to differences in the utilization of the WHO recommended medical classification instrument – the International Classification of Diseases and Related Health Problems code, 10th version (ICD -10). Whereas health outcomes were found to be poorer across disease profiles whether citizens were based in rural Australia or rural Canada, cancer mortality risk was lower in rural Canada compared to Australia. Whilst rural men in Australia had a higher risk of incurring diabetes, there were no notable differences between urban and rural citizens in Canada for the same condition. The risk of having motor vehicle accidents (MVAs) was reportedly higher in Australia due to poor roads and long distances, whilst in Canada MVAs were attributable to weather conditions. In addition to the MVAs, Australia had a high incidence of suicides, a point I will come back to later. In contrast, in South Africa, besides weather conditions and poor roads in some areas, MVAs are attributable to attitudes and behaviours (drunk driving, ignoring road signage, unlicensed drivers). With a high trauma incident rate and a corresponding burden of care, there is evidence of South Africans as high consumers of alcohol and binge drinkers according to the 2018 WHO global status report on alcohol and health (WHO, 2019). The global and political mandate to restrict alcohol sales during the first few weeks following the announcement of COVID-19 as a global pandemic reportedly had positive outcomes for a rural district hospital in George in the Western Cape Province (Reuter et al., 2020). Based on a review of hospital records in the Emergency Department, Reuter et al. (2020) reported a significant reduction in trauma cases and related contact crimes (rapes and assaults). This undoubtedly brought relief throughout South Africa’s health system. Based on a reported 5% increase in sexual offences between October–December 2020 (Themba, 2021), particularly in some districts in two rural provinces in KwaZulu-Natal and the Eastern Cape, this relief was short-lived. Along with high alcohol consumption, owing to a high incidence of rape cases, as confirmed in a national study by Machisa et al. (2017) where 46% of sexual offence complainants were children, a rape culture was reported to be thriving in South Africa’s schools (Paterson, 2017). According to a survey conducted by Stats SA (2019), contact crimes are higher amongst less educated compared to people with secondary education. In addition, there is inherent vulnerability to sexual assaults among women and children (Abrahams et al., 2020) who reside in poverty-stricken communities with poor infrastructure and lower levels of education. This supports the reported 5% increase in sexual offences in the latter part of 2020 (Themba, 2021). 29 Consequently, in South Africa, Gender Based Violence (Dlamini, 2021) is considered a twin pandemic to COVID-19 but also a health outcome as a result of other social determinants. With an understanding of the impact of health care access inequity (Gaede and Versteeg, 2011) as an imbalance between need, demand and supply, in a descriptive study in the USA, Butler et al. (2013) developed a social deprivation index (SDI) that was associated with health care access and four health outcomes within a rational area of primary care service. In their study, they employed a range of variables that included poverty, being Black, less than 12 years of schooling, single parent households, and single occupant households, complemented by the Townsend Deprivation Index (1988). They extracted information from the American Census to identify the additional four variables that include households without a car, unemployment in the 18–64 age group, overcrowded households and living in rented households. They reported a positive relationship between SDI, poor access and poor health outcomes, providing a multidimensional measure of deprivation including geographical location. Based on their findings, they observed that health care outcome measures were influenced by changes in SDI variables. The location and the Townsend Deprivation Index were the two common denominators for poor health outcomes. Based on their formula, even with variable definitions of rurality, one would expect a similar outcome for South Africa’s rural areas. In South Africa, Scott et al. (2017) conducted a study in the Western Cape. They employed a social-determinant approach whereby social determinants of health (SDH) were defined as the conditions in the environments where people are born, live, learn, work, play, worship, and age, as broad strokes that apply to any community irrespective of its profile. Tackling the issue of obesity as a public health concern, the authors reported on a range of factors tha