Growing up in North Africa, I was fortunate enough to see women of various professional backgrounds in my community. Now as a female physician to-be, I notice acts of sexism in the medical setting. A small example would be the number of times I heard patients say they prefer a male physician over a female one. They confuse the male gender with higher skill.
I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.
I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.
Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.
I disagreed with him.
I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.
This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.
No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.
I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.
I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.
Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.
As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.
Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.
Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.
The elephant in the room
My curiosity was sparked. What does the recent evidence say about imbalances between men and women who are physicians and nurses in Africa?
In this article, I will share with you 5 facts about gender disparity among African healthcare workers. Continue reading to find out more.
Africa has the lowest proportion of female doctors and nurses across the globe. A 2019 WHO analysis of 91 countries revealed that only 28% of physicians in Africa are women. (1)
Many reasons explain this workforce disparity. Unfortunately, a lot of women in Africa are denied access to education. Millions of girls remain out of school because of gender norms, early forced marriage, pregnancy and violence in school.
52 million African girls are out of primary and secondary school in Sub-Saharan Africa (2). According to UNESCO, none of these countries has achieved gender equality in education (3).
Covid-19 school closures and lockdowns made the situation worse. In 2020, a survey of 130 teachers from 14 countries that are mostly African was conducted. Teachers reported a higher drop-out rate for girls (59%) and an inability to keep up with distance learning. Besides, they had concerns about early pregnancy ( 41%) and marriage ( 45%). (4)
Promoting a culture of equality in education should be a top governmental priority everywhere in Africa.
Major gender disparity is evident in workplace violence. Research has proven higher violence against female healthcare workers in various African countries like Egypt, Ethiopia, Nigeria. Many female doctors and nurses experience daily physical and sexual assault, verbal abuse and threatening behaviours.
In 2017, researchers investigated workplace violence against nurses in Ghana. They found that 79.2% of the women experienced physical violence versus 20.8% of men. Female nurses in Ghana experience violence almost 4 times more than men. (5)
The absence of a policy on violence is reported in various countries, like Gambia and Ethiopia (Yenealem et al., 2019), as well as a lack of a proper reporting system. (6) (7)
Research from Ethiopia and Egypt revealed that even when the victims report the violent events, there is a lack of administrative action against the perpetrators (8) (9). Only 31% of abuse victims declared that action was taken to investigate the causes of the violent incident against female nurses in Ghana. (5)
Even more shocking is that a study found the perpetrators of sexual violence in Ghana to be male doctors in 50% of cases. (5)
A workplace free from gender-based violence is a fundamental human right. All African countries should have clear policies to protect healthcare workers and bring justice to the victims.
According to UIS data, around 30% of the world's researchers are women. In most African countries, participation of female researchers is less than 25% (10)
This affects the diversity of scientific perspectives on gender dimensions of health and society's capacity to advocate for maternal and reproductive health research priorities. According to UNESCO, this disparity is also evident in responsibility and leadership positions (11). WHO says that In great studies, women are rarely the research directors or lead investigators. (12)
Women have more barriers accessing support to professional development and leadership roles due to the mostly patriarchist African societies.
I believe that initiatives to enhance health research and services in Africa must include training, employment, and promotion of women in medical science.
Creating a network of female scientists will help decrease the research gender bias that naturally occurs when one gender dominates the scientific community.
The WHO estimates the gender pay gap to be around 28% in the health workforce globally
In sub-Saharan Africa, gender gaps are wide in many countries. Actually, there is a low representation of women in the private health sector (13). Men tend to get better pay and opportunities in the private sector.
Surprisingly, there is very little recent data about the public sector pay gap in Africa. In 2007, women in the health sector were getting paid 28,1% less than men per hour. (14)
I believe that enhancing the gender pay gap reporting laws is crucial to eliminating discrimination. They could be turned into an instrument for action rather than merely measurement.
On top of that, equal pay laws are absent in many countries. Even when present in the law, men and women sometimes do not receive equal pay for the same job. A Lancet study that analysed the annual income for health workers in Burkina Faso in 2005, found that female midwives have a lower income than their male coworkers. (15)
The problem doesn't concern female health care workers only.
Gender inequalities are observed in African women's access to health care as well. Only 42.91% of women have access to healthcare in East Africa. This finding was revealed in research that analysed data from 2008 to 2017 of 12 East African countries, including nearly 150,000 participants.
Women who were educated, married to an educated husband, had a planned pregnancy and decent income, had more access to health care. (16) This goes to show how deep of an impact exclusion from education makes.
On top of this, there is high inequality in access to maternal healthcare. In 29 Sub Saharan African countries, opportunities for access to healthcare for women of all ages was studied. It was revealed that the lowest coverage of all health care services is for maternity care packages. (17)
Even though there has been significant improvement in maternal health care in Africa in the last 2 decades, 57% of all maternal deaths still occur in Africa.
In perspective, 1 in 39 women in Africa risk dying from a pregnancy problem vs 1 in 4700 in developed countries (18). The risk of maternal death is increased by more than 120 times.
Sadly, millions of Africans who have lost their mothers, wives, and sisters feel like their fate was decided by where they were born.
Being aware of existing gender disparities and ensuring accountability are the first steps toward changing mindsets to actively seek ways to improve the current situation.
It is truly disheartening to witness people getting treated unequally based on their gender. Considering my African background, it is normal for me to advocate for equality for my fellow female healthcare workers.
However, you don't have to be African or a woman to advocate for African women's rights.
I believe that it is the duty of all to advocate for the oppressed everywhere in the world. Gender inequality among health care workers leads to the loss of female talent, perspective, ideas and knowledge, weakening thus global health.
We can not expect to enhance the quality of health service in Africa or any other place of the world if women are excluded from the decision-making process of health policies and research.
Positive change could be accomplished in simple ways. Promotion of equality culture, research, and addressing disparities by policymakers will undoubtedly impact the current situation immensely.
5- Boafo IM, Hancock P, Gringart E. Sources, incidence and effects of non-physical workplace violence against nurses in Ghana. Nurs Open. 2016;3(2):99-109. Published 2016 Jan 10. doi:10.1002/nop2.43
6- Sisawo EJ, Ouédraogo SYYA, Huang SL. Workplace violence against nurses in the Gambia: mixed methods design. BMC Health Serv Res. 2017;17(1):311. Published 2017 Apr 28. doi:10.1186/s12913-017-2258-4
7- Yenealem DG, Woldegebriel MK, Olana AT, Mekonnen TH. Violence at work: determinants & prevalence among health care workers, northwest Ethiopia: an institutional based cross sectional study. Ann Occup Environ Med. 2019;31:8. Published 2019 Apr 3. doi:10.1186/s40557-019-0288-6
8- Tiruneh BT, Bifftu BB, Tumebo AA, Kelkay MM, Anlay DZ, Dachew BA. Prevalence of workplace violence in Northwest Ethiopia: a multivariate analysis. BMC Nurs. 2016;15:42. Published 2016 Jul 8. doi:10.1186/s12912-016-0162-6
9- Abou-ElWafa HS, El-Gilany AH, Abd-El-Raouf SE, Abd-Elmouty SM, El-Sayed Rel-S. Workplace violence against emergency versus non-emergency nurses in Mansoura university hospitals, Egypt. J Interpers Violence. 2015;30(5):857-872. doi:10.1177/0886260514536278
11. UNESCO Institute for Statistics, 2015
13- Monnet, Marguerite. 2015. Gender and Health : Barriers and Opportunities for Women's Participation in the Private Health Sector in Africa. Health, Nutrition, and Population (HNP) discussion paper;. World Bank, Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/22965 License: CC BY 3.0 IGO.
15. McCoy D, Bennett S, Witter S, et al. Salaries and incomes of health workers in sub-Saharan Africa. Lancet. 2008;371(9613):675-681. doi:10.1016/S0140-6736(08)60306-2
16. Minyihun A, Tessema ZT. Determinants of Access to Health Care Among Women in East African Countries: A Multilevel Analysis of Recent Demographic and Health Surveys from 2008 to 2017. Risk Manag Healthc Policy. 2020;13:1803-1813. Published 2020 Sep 30. doi:10.2147/RMHP.S263132
17. Pons-Duran C, Lucas A, Narayan A, Dabalen A, Menéndez C. Inequalities in sub-Saharan African women's and girls' health opportunities and outcomes: evidence from the Demographic and Health Surveys. J Glob Health. 2019;9(1):010410. doi:10.7189/jogh.09.010410
West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion
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Dear Digital Diary,
I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.
This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.
Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.
Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.
The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.
Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.
No more elephants in this room