This pilot study sought to understand the reasons why female doctors want to enroll in postgraduate residency programs and the factors that support, influence or hinder their enrollment. The study used a resilience framework applied at the individual, social and institutional levels. It is widely recognized that every individual has the capacity to adapt and overcome risks and adversities (Ungar 2005). Therefore, we can define resilience as the capacity of individuals to endure stress and devastation, continue to perform in the midst of adversities and even radically change to prevent future risk exposure and continue their development process (Cornbluth 2014; Reyes 2013). Resilience is not static and develops over a period of time. It comes from supportive relationships, religious and cultural beliefs and traditions, that help people cope with the inevitable knocks in life (Wykle, Faan and Gueldner 2011). Various factors contribute to the development of resilience. They include, but are not limited to: close relationships with family and friends, confidence in one’s own strengths and abilities, problem-solving skills, seeking help, coping with stress in healthy ways, and finding positive meaning in life despite difficult conditions and traumatic events (Meichenbaum 2007). Thus, for this study we sought to answer some initial questions categorizing resilience in human, social and institutional realms. These questions were:
• Human resilience: What is the life experience of female doctors who want to enroll in postgraduate residency programs and of those who are already enrolled?
• Social resilience: How do family factors, cultural norms and other social factors influence female doctors’ enrollment in postgraduate residency programs?
• Institutional resilience: How is female enrollment in postgraduate residency programs affected by geographical distance and the type of female-friendly facilities in hospitals?
I. Methodology: We began to answer these questions by interviewing nine female medical doctors (enrolled and not enrolled in postgraduate residency programs) working in two maternity hospitals in Kabul. A second part of this study plan was to conduct a survey questionnaire with 34 additional participants; however, this report focuses only on the qualitative data collection, and reports on the findings related to risks. The second par includes a report on the assets. A transcript of each interview was prepared and analyzed for major categories or themes, and then compared with each other. A Local Advisory Committee (LAC) comprised of a representative from the research department of the Ministry of Public Health (MoPH), a research focal point from each hospital, and a WHO technical officer for Reproductive Health, assisted in identifying and selecting the study participants. The support of female LAC members was a key factor for the success of this pilot study.
The mixed-methods approach can help us to apprehend diversities and issues around the enrollment of female doctors in postgraduate residency programs in a short time. For the qualitative component, a selection of a diverse sample (female graduates, current students and prospective students), helped us understand the problems and motivating factors that affect their enrollment. In addition, sequential sampling (first qualitative followed by quantitative) was instrumental in identifying the key issues to be included in a future questionnaire. Discussion of the application of this questionnaire is not part of this pilot report, which only focuses on the qualitative phase of the study, and the findings related to risks. Moreover, the formation of a Local Advisory Committee was critical in identifying and accessing potential study participants. Furthermore, the extensive interaction among the researchers with diverse experience and backgrounds, in two RES-Research workshops and guidance provided by its facilitators supported us to better understand resilience research methodology and its application to different fields in education.
II. Context of adversity and desirable outcomes for female students in higher education and the field of medicine Cultural norms, family values, religious concerns, physical access, individual/gender preferences and security concerns all affect the enrollment of female students in specialized medical education programs. Subsequently, these factors influence their deployment in health facilities. However, growing access opportunities resulted in steady progress in educating and deploying female health care providers in large cities such as Kabul, Nengarhar, Herat, Mazar and Kunduz over the last decade (George W. Bush Institute 2013; Baharustani 2012). A thorough assessment conducted by Human Resources for Health in 2011 indicates that 45,042 health personnel are employed by the public health system in Afghanistan (MoPH 2011). Sixty percent are civil servants and 40 percent work with NGOs under contractual arrangements with the MoPH (MoPH 2011). There are 7.26 health care providers (medical doctors, nurses and midwives, both male and female) per 10,000 population in the country, which is still within the critical shortage zone according to the WHO’s benchmark of 23 health care professionals per 10,000 population. Despite the considerable increase in the training of nurses and midwives scheduled for the next 5 years, the ratio of these health care providers to 10,000 population will only increase from 7.26 to 9.12 (MoPH 2011). Cultural diversity, family values, and religious concerns seriously affect the enrollment of female students in specialized medical education programs. The shortage of female nurses, female doctors particularly in provinces, male and female physical therapists and psychosocial counsellors, medical technologists, and bio-medicalengineers, is more critical and requires immediate corrective measures. There are 16.7 public health workers per 10,000 population in rural areas (including unqualified support staff), compared with 36 per 10,000 population in urban areas. Most qualified private health workers reside in urban areas and serve only 22.6 percent of the population. The southern part of the country suffers from a serious shortage of qualified health care providers followed by the western and north-eastern regions. The mal-distribution of health care providers leaves the peripheral health facilities and remote areas understaffed. The main reasons for the maldistribution are poor working, living and social conditions, security concerns, lack of educational facilities for children and lack of transportation (MoPH 2011).
The potential economic and social benefits of increasing the number of highly educated individuals within a population, and particularly females, are known and understood worldwide (Bloom, Canning and Chan 2006). Female workers make up only 28 percent of total public health care providers. All midwives and 36 percent of support staff are female, while only around 20 percent of higher-educated health care providers (e.g. doctors, dentists and pharmacists) are female (MoPH 2011).
III. Findings and analysis: The study participants had graduated from medical university between 1989 and 2011 (most had graduated since 2002). The majority of the participants were still trying to enroll in a postgraduate residency program; others were already enrolled in the program, and few had completed the program. This section presents their life experiences reflecting the assets and obstacles to female enrollment and graduation from a postgraduate residency program. Human, social and institutional resilience in female doctors in postgraduate residency programs Interviewed participants shared with us their aspirations and social demands for women in postgraduate medical programs. This pointed to human, social and institutional resilience factors, shared succinctly below for both doctors aspiring to enter a residency program and those already enrolled. Experiences of women aspiring to enroll in a postgraduate residency program We identified many motivating factors of participants who want to be enrolled in a medical residency program. These include the opportunity to acquire new knowledge and skills, better job opportunities, popularity, elevated self-esteem, increased income in private practice and enhanced capacity to serve the people. However, participants who want to enrol in postgraduate residency programs have major concerns such as complicated bureaucratic procedures for enrollment, the difficult entry test, the unavailability of standard teaching materials for preparation, cumbersome preparation required for the entry test, a lack of job opportunities, insufficient time to study, and many issues related to family which create barriers to enrollment in a postgraduate residency program. Married female doctors are most affected as they are also housewives and responsible for house chores. Unmarried female doctors and new graduates have better chances of being enrolled in a residency program. Experiences of women already enrolled in a postgraduate residency program Community demand for female doctors (especially gynecologists and obstetricians) along with a personal desire to continue their professional development, encourages female doctors’ enrollment in residency programs. Some of the female doctors doing residency, who participated in the study, are optimistic that acquiring more knowledge and experience will lead to good job opportunities, a better life and respect in society, in the future. Women who are enrolled in a postgraduate residency program seem to have been raised by highly educated families with positive attitudes towards girls’ education, good economic status, and the women’s husbands are in the same profession. The interview data suggests that these factors help female doctors’ enrollment in the residency program, especially the community demand for highly qualified female doctors, liberal families, and the adherence to cultural and traditional norms. However, these supportive assets do not come without costs at the individual, family, cultural and other social levels. In addition, geographic proximity and the female friendliness of facilities constrain both access and completion of postgraduate residency programs. Obstacles in fostering human, social and institutional resilience of postgraduate female doctors In spite of the high motivation of female doctors to continue their postgraduate studies in Afghanistan, as well as the social demand for a high level of women professionals in the medical fields, presently there are various factors that hinder their resilience. These are discussed next within each type of resilience process: human, social and institutional. Human Resilience The life experiences of female doctors who are already enrolled in postgraduate residency programs indicate difficulties with working in hospitals, and particularly performing night duty. Female doctors have serious concerns about low salary, lack of proper facilities for their child patients in hospitals, inadequate family support, and uncertainty about job opportunities in urban areas after graduation. Married female doctors face even more problems, including the double burden associated with working and taking care of their children, husband and in-laws in joint families. Social Resilience Family factors, which influence female doctors’ enrollment in postgraduate residency programs, vary from family to family. Women residing in rural areas are more disadvantaged than women in urban areas, and married women are less likely to enroll compared to single women. Family commitments, including being a mother and a wife, negatively affect the enrollment of female doctors in residency programs. In addition, criticisms by extended family members for not devoting enough time to their children, husband and in-laws, denial of permission for night duty in conservative families, and lack of child care support are among the other factors that reduce female doctors’ enrollment. Cultural norms, such as negative attitudes towards women who work outside of house, criticism from extended families, religious misbeliefs, low literacy rates within the family and surrounding community, discrimination against women, relatives’ attitudes towards female doctors’ night duty and restrictions on travels outside of the country, all negatively influence female doctors’ enrollment. Social factors that hinder female doctors’ enrollment vary from place to place. These include beliefs that a woman’s only role is as a mother and a housewife, negative attitudes towards female education (particularly away from home, either in other cities and outside the country), living in extended families, and the excessive role of the husband, mother-in-law, father-in-law and other relatives in decision-making. These factors are more dominant in rural areas as compared to urban areas.
Institutional Resilience Geographical distance influences access to higher education for both males and females. However, its impact on girls’ and women’s education is much higher compared to that of boys and men. Their support to their family is reduced because of their time spent away from the home, during which time they cannot take care of their children and breastfeed. This eventually leads to fewer enrollments of women in residency programs. In addition, lack of transportation or inability to pay transport costs, insecurity, prescience of irresponsible and impolite people on the way to the hospital, and living in rural areas, also minimizes female doctors’ enrollment in postgraduate medical programs. The lack of female-friendly facilities in hospitals limits both access and completion of residency programs. These include kindergartens, hostels, libraries, access to internet, positive attitudes overall towards women, qualified female trainers, good interpersonal skills of trainers, separate female services such as office space and washrooms, facilities that ensure privacy, transport, shift work, manageable standard workloads, and proper accommodation for night duty. Study participants also noted that the provision of job opportunities for husbands when residency programs are in faraway hospitals improves women’s enrollment in postgraduate residency programs. IV. Tentative recommendations for policy and practice The study findings indicate that various factors at the individual, family, community, society and institutional level influence the enrollment of female doctors in postgraduate residency programs. A holistic approach to supporting the increased participation of women in these programs should respond to the obstacles and foster the assets identified. Higher education and health sector development policies should consider how:
• Individual preferences and commitment, family support, and good socioeconomic status have a positive impact on the enrollment of female doctors in residency programs. However, their limited decision-making power and the involvement of extended family members in all family decisions reduces the probability of further education for female doctors.
• Negative attitudes towards girl’s education in society, misbeliefs regarding the role of women, concerns about work outside the house (particularly in a different city or country) hinder the enrollment of female doctors in postgraduate residency programs. However, massive community demand for the deployment of female doctors encourages girls to pursue careers in the medical field. Long-term investment in women’s education, and the engagement of community and religious leaders to support the education of girls and women, will help make a gradual shift towards the equality of girls/women and boys/men in the family and society.
• The following measures will encourage female doctors to pursue postgraduate residency programs: affirmative action for girls education, simpler residency enrollment procedures, opportunities for entry test preparation, more job opportunities for women, establishment/ strengthening of female-friendly facilities in hospitals, provision of additional incentives for female doctors, provision of transport, proper accommodation, shift work, and deployment of female trainers.
V. Conclusions and future research needs To continue to identify the action required for an increased participation of women in postgraduate residency programs, it is important to expand the limited scope of this pilot study. We recommend using focus groups that include medical doctors working in various provinces, alongside in-depth interviews with those who are responsible for managing the current residency programs in the Ministry of Public Health and higher education. The former will help us to further explore additional problems and opportunities faced by female medical doctors in the provinces. The latter will provide a different angle to our understanding of the important factors that could improve the enrollment of female doctors in postgraduate residency programs. Moreover, engaging a broader range of stakeholders will be helpful in order to study different sides of the problems and opportunities.
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