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Female global health leadership: data-driven approaches to close the gender gap

2019; Elsevier BV; Volume: 393; Issue: 10171 Linguagem: Inglês

10.1016/s0140-6736(19)30203-x

1474-547X

Jyoti S. Mathad, Lindsey K. Reif, Grace Seo, Kathleen F. Walsh, Margaret L. McNairy, Myung Hee Lee, Adolfine Hokororo, Aarti Kinikar, C. Thomas Riché, Marie Deschamps, Sandy Nerette, Smita Nimkar, Neema Kayange, Hyasinta Jaka, Glory Joseph, Domenica Morona, Thandiwe Yvonne Peter, Nishi Suryavanshi, Daniel W. Fitzgerald, Jennifer A. Downs,

Global Health and Surgery

Women hold a minority of health leadership positions globally. Yet, 75–80% of trainees, health workers, and faculty interested in global health are women.1Downs JA Reif LK Hokororo A Fitzgerald DW Increasing women in leadership in global health.Acad Med. 2014; 89: 1103-1107Crossref PubMed Scopus (72) Google Scholar, 2HRH Global Resource CenterResource spotlight: gender and health workforce statistics.https://www.hrhresourcecenter.org/gender_statsDate accessed: February 22, 2018Google Scholar This disparity in global health leadership negatively affects health outcomes for women and children worldwide.3Beaman L Duflo E Pande R Topalova P Female leadership raises aspirations and educational attainment for girls: a policy experiment in India.Science. 2012; 335: 582-586Crossref PubMed Scopus (401) Google Scholar We aimed to investigate the gender-based challenges of female health trainees and professionals, and identify data-driven interventions. For this study, we recruited women from Weill Cornell Medicine (WCM) in New York (NY, USA) and three international centres affiliated with WCM: the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections in Haiti, Weill Bugando School of Medicine at the Catholic University of Health and Allied Sciences in Tanzania, and Byramjee Jeejeebhoy Government Medical College in India. Participants were recruited by use of emails via insitutional mailing lists, flyers posted in the inistutions, and announcements in classrooms or shared spaces at each site. Participants were encouraged to invite other potential respondents to apply. Individuals were eligible for participation if they were female and working or had worked in low-income or middle-income countries (LMICs) in health-related careers. On the basis of previous formative research (appendix),1Downs JA Reif LK Hokororo A Fitzgerald DW Increasing women in leadership in global health.Acad Med. 2014; 89: 1103-1107Crossref PubMed Scopus (72) Google Scholar we developed a survey and held in-depth interviews and focus groups to collect data on three gender-based challenges in the workplace: work–life balance, gender discrimination, and sexual harassment or assault.1Downs JA Reif LK Hokororo A Fitzgerald DW Increasing women in leadership in global health.Acad Med. 2014; 89: 1103-1107Crossref PubMed Scopus (72) Google Scholar Local study coordinators at each site administered the survey online by email link or in-person on electronic tablets or paper. Interviews and focus groups at each institution were done off-site by an experienced facilitator unaffiliated with the institution. Participants reviewed definitions of discrimination, sexual harassment, and assault, including culturally appropriate examples. We solicited data from all stages of participants' training (including at previous institutions) and avoided identifying information to protect confidentiality (full details of methods are in the appendix). Institutional review boards at all study sites approved this study and study activities were done in local languages. To account for different sample sizes by site, we used a mixed model with site as a random effect to estimate the grand mean across the means of each site for each challenge and associated 95% CIs. We analysed qualitative data using a thematic survey with interpretive phenomenological analysis.4Smith JA Flower P Larkin M Interpretative phenomenological analysis: theory, method and research. SAGE Publications, London2009Google Scholar We adapted the social action theory (SAT) conceptual framework to organise data into interventions at the environmental, institutional, and individual level (appendix). Between Feb 24, 2017, and Jan 15, 2018, of 653 women recruited, 346 (53%) completed the survery, of whom 85 (25%) participated in qualitative discussions (70 in focus groups, 19 in interviews). 291 (84%) women reported at least one challenge, of whom 228 (78%) reported work–life balance (grand mean 72%, 95% CI 44–90), 154 (53%) reported gender discrimination (grand mean 46%, 37–56), and 160 (55%) reported sexual harassment or assault (grand mean 38%, 25–53; figure; appendix). Of those who reported work–life balance to be a challenge, a grand mean of 47% (95% CI 21–75) stated that global health work resulted in insufficient time with their families and 37% (95% CI 16–64) reported it negatively affected their childbearing decisions (figure). Gender discrimination included experiences of being made to feel inferior (37%, 95% CI 26–49) and discouragement from promotions or leadership positions on the basis of gender (20%, 95% CI 16–26; figure). Unwelcome sexual advances were reported by 120 (29%, 95% CI 17–45) participants and 32 (7%, 95% CI 3–15) felt coerced to engage in unwanted sexual behaviour. Only 35 (22%) of 160 participants who experienced sexual harassment or assault reported it to anyone. Reasons for not reporting incidents among the remaining 125 participants included assuming the experience was normal (20 [16%]) or would not be resolved (36 [29%]), lack of a reporting system (31 [25%]), fear of negative repercussions (12 [10%]) or jeopardising their academic standing (nine [7%]), and fear of not being believed (five [4%]). Overall, the major themes elicited from qualitative discussions included fear, futility, and resignation (appendix). Women expressed resigned acceptance about handling work and all household responsibilities. Multiple respondents declined leadership opportunities, such as promotions and committee chair positions, because of family obligations. Many reported the lack of a safe and unbiased system for seeking help following harassment or assault. This study highlights the high prevalence of gender-specific challenges to career advancement among female global health trainees and professionals. Work–life balance was the most common barrier. However, the most alarming finding was the high prevalence of gender discrimination, sexual harassment, and assault, which we found were systemic barriers participants faced at all stages of their global health careers in all countries included. We also identified potential interventions to begin addressing these barriers. Participants in the focus groups identified interventions that we grouped by SAT categories, including the following: environmental, ongoing public promotion of gender equality in the workplace; institutional, formal policies on gender discrimination and harassment with clear reporting methods and independent committees to review and address complaints; and individual, gender-specific leadership training to empower women and peer mentorship support groups to provide a safe forum to discuss and address barriers. Studies5Dennehy T Dasgupta N Female peer mentors early in college increase women's positive academic experiences and retention in engineering.Proc Natl Acad Sci USA. 2017; 114: 5964-5969Crossref PubMed Scopus (211) Google Scholar, 6Kwedi Nolna SK Essama Mekongo PE Leke RGF Mentoring for early-career women in health research: the HIGHER Women Consortium approach.Glob Health Epidemiol Genom. 2017; 2: e3Crossref PubMed Scopus (5) Google Scholar suggest that these interventions can have an immediate effect. A recent study from the USA showed that same-gender peer mentoring at key career transition times resulted in sustained improvement in women's success and retention.5Dennehy T Dasgupta N Female peer mentors early in college increase women's positive academic experiences and retention in engineering.Proc Natl Acad Sci USA. 2017; 114: 5964-5969Crossref PubMed Scopus (211) Google Scholar Formalised female mentor–mentee relationships are also effective in promoting women in global health research, including in LMICs.6Kwedi Nolna SK Essama Mekongo PE Leke RGF Mentoring for early-career women in health research: the HIGHER Women Consortium approach.Glob Health Epidemiol Genom. 2017; 2: e3Crossref PubMed Scopus (5) Google Scholar Other solutions include flexible working arrangements (eg, working remotely) to allow women to schedule work around family responsibilities for an improved work–life balance. Research enabling funds have been used at prominent universities, including Harvard (Cambridge, MA, USA) and Cornell (Ithaca, NY, USA), to support junior faculty members during periods when their work–life balance is challenged—eg, hiring a research assistant to continue their work during maternity leave or while caring for a sick family member.1Downs JA Reif LK Hokororo A Fitzgerald DW Increasing women in leadership in global health.Acad Med. 2014; 89: 1103-1107Crossref PubMed Scopus (72) Google Scholar, 7Glimcher LH Lieberman J Harvard's women four years later.Nat Immunol. 2009; 10: 559-561Crossref PubMed Scopus (4) Google Scholar Many participants in our study viewed gender discrimination as a normal part of their culture. Accordingly, few examples exist of successful models to decrease discrimination, especially in LMICs. Educational training modules and individualised feedback are effective first steps in reprogramming ideas about natural roles for men and women.8Devine PG Forscher PS Cox WTL Kaatz A Sheridan J Carnes M A gender bias habit-breaking intervention led to increased hiring of female faculty in STEMM departments.J Exp Soc Psychol. 2017; 73: 211-215Crossref PubMed Scopus (118) Google Scholar The pattern of learned acceptance of sexual harassment and assault also seems universal. All academic institutions must develop a clear reporting algorithm for sexual misconduct. Employees must understand the definitions of sexual harassment and assault, and repercussions for offenders. The US National Science Foundation is researching the utility of workshops to train academic leaders in addressing sexual misconduct.9Russell C Confronting sexual harassment in science.Sci Am. Oct 27, 2017; https://www.scientificamerican.com/article/confronting-sexual-harassment-in-science/Date accessed: January 10, 2018Google Scholar Similar models in LMICs are urgently needed. Our study has some limitations. We included three common challenges, which is not an exhaustive list of the challenges faced by women in global health careers. Our study population did not include PhD candidates, although other studies report similar issues among these trainees.10Clancy KB Nelson RG Rutherford JN Hinde K Survey of academic field experiences (SAFE): trainees report harassment and assault.PLoS One. 2014; 9: e102172Crossref PubMed Scopus (243) Google Scholar Finally, we did not analyse the data by site to protect confidentiality, which might obscure cultural nuances around these challenges. Gender balance helps institutions to reflect the populations they serve and improves health outcomes.3Beaman L Duflo E Pande R Topalova P Female leadership raises aspirations and educational attainment for girls: a policy experiment in India.Science. 2012; 335: 582-586Crossref PubMed Scopus (401) Google Scholar New interventions must be substantiated with evidence-based research, including in LMICs, to account for variables such as country and stage of training. We must commit to providing a safe environment for everyone or risk losing a generation of female health workers who play a crucial part in improving health globally. For more on the #LancetWomen initiative see https://www.thelancet.com/lancet-women For more on the #LancetWomen initiative see https://www.thelancet.com/lancet-women We declare no competing interests. JSM, LKR, and GS contributed equally. This study was supported by the US National Institutes of Health, National Institute of Allergy and Infectious Diseases, and the Fogarty International Center (K23AI129854 to JSM, K23AI110238 to JAD, K24 AI098627 to DWF, D43TW009606 to DWF, and D43TW009574 to AK), and Weill Cornell Medicine's (WCM) Office of the Dean and Center for Global Health. Use of the REDCap database was supported by the US National Center for Advancing Translational Sciences through the WCM CTSC grant (UL1 TR000457-06). We thank the Director of The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections Centers, the Dean of Byramjee Jeejeebhoy Government Medical College, the Director General of Bugando Medical Center, the Vice Chancellor of Catholic University of Health and Allied Sciences (CUHAS), the Dean of the Weill Bugando School of Medicine at CUHAS, and the Dean of WCM for their insightful and progressive leadership. We thank Warren Johnson for his support and review of the manuscript. Download .pdf (.43 MB) Help with pdf files Supplementary appendix