Study setting and population

This study was conducted at four major academic centers for clinical care and research with national and international funding in four countries. The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) in Port-au-Prince, Haiti is the largest HIV/AIDS clinic in the region providing care to over 600,000 patients annually. Byramjee Jeejeebhoy Government Medical College (BJGMC) in Pune, India is a major tertiary care facility providing care for over 60,000 inpatients and over 525,000 outpatients annually. Bugando Medical Center (BMC) at the Catholic University of Health and Allied Sciences (CUHAS) in Mwanza, Tanzania is one of four major medical centers in the country and serves a population of 15 million patients. Lastly, Weill Cornell Medicine (WCM) in New York, USA has partnered with each of these sites to collaborate on the conduct of global health research, training, and clinical service for decades. Focus group discussions and in-depth interviews were conducted at off-campus locations in the local language (i.e., Haitian Creole, Hindi, Kiswahili, and English) by experienced local facilitators who were unaffiliated with the participating institution.

Data collection

Female health trainees and faculty from each institution were recruited to participate in a study exploring gender-based challenges to career advancement for women in global health. All study participants completed a confidential quantitative survey to determine the type and prevalence of gender-based challenges experienced in the global health workforce, of which the results have been previously reported [20]. Local study coordinators advertised the study at each institution through flyers, emails to institutional mailing lists, and announcements in classrooms/shared spaces at each site. Interested participants were invited to contact the study coordinators in person or by email or WhatsApp. Participants were also encouraged to invite other potential respondents by snowball sampling [22]. Among a subset of participants who expressed interest in further participation, study coordinators organized focus groups discussions and in-depth interviews. The goal of this qualitative data collection was to understand their experiences of gender-based violence, their perceptions of the underlying drivers, and identify solutions that would address these gender-based challenges. We began with focus group discussions to provide a forum in which women could share experiences and secondarily used in-depth interviews to gather additional data if participants felt uncomfortable sharing in a group setting. Focus group discussions consisted of approximately 5–10 participants, lasted 45–60 minutes, and were stratified by training level (student, post-graduate trainee, or faculty) to encourage sharing of experiences among peers. Individuals who indicated interest participated in additional confidential in-depth interviews following the group discussions, which lasted 30–45 minutes each. Discussions were digitally recorded, transcribed into the local language, and translated into English by professional translation services.

The content of the structured questions used to guide the focus group discussions and in-depth interviews was based on a thematic analysis of data from three large public symposia focused on Women in Global Health Research that occurred between 2015 and 2017. These symposia were organized by study team members from each of the institutions that participated in this study and were attended by over 180 female global health trainees and professionals from seven countries, including LMICs (womenglobalhealth.com). The symposia included panel discussions and small group sessions during which attendees discussed challenges that prevent women from pursuing global health careers. Videos of all talks and panel discussions were recorded, with detailed minutes of the group discussions. In multiple study team meetings, our leadership team (CR, LR, JM, NS, JD, AH), which included women from all four study sites, analyzed data from these symposia. Through group consensus, the team identified three major themes that guided the development of the focus group and interview questions used in this study: gender discrimination, work-life balance, and sexual harassment or assault. Questions were reviewed with the study team in each country to ensure they were appropriate. Qualitative interviewers received training in strategies to avoid and mitigate bias during data collection.

Data analysis

We performed a thematic analysis using interpretive phenomenological analysis to explore participants’ perspectives on their lived experiences as women during their training and work [23–25]. English transcripts were imported into Nvivo Version 10 (QSR International, Doncaster, Australia), which was used to organize study data and codes. Data were initially analyzed and independently coded by two authors, NN and RA, to identify and agree upon emerging themes. In vivo coding was used for themes that emerged during coding. Codes were compared every two weeks during the coding for refinement and clarification by study team members, CR, LR JD, and AH, and differences were resolved via group process. Through repeated examination, an iterative review of the themes, and grouping of codes, we identified prevailing themes that represent women’s perspectives on gender-based challenges experienced during their training and work and associated solutions to these challenges. We continually monitored for data saturation and our analyses indicated data saturation was achieved. Participant quotations illustrating these themes were selected by group process and are presented here.

Theoretical framework

We used the Social Action Theory (SAT) conceptual framework to organize qualitative data related to increasing women in global health leadership, as previously described [20]. This framework incorporates experiences at the contextual, institutional, and individual levels to describe cumulative effects on, as well as to identify strategies for, interventions and outcomes [26,27]. We adapted this model to include participants’ environments, such as local cultural norms, discourse around gender equity, and institutional policies regarding gender discrimination and harassment. Additional adaptations incorporated social interactions such as the availability for peer support and the role of mentors. We used the themes identified from the analysis of our symposia to map our qualitative data thematically to the framework. We additionally adapted components of the framework to include other important influences on social action, such as environment, institution, individual, and social/peer support.

Ethical considerations

Institutional Review Boards at GHESKIO, BJGMC, BMC/CUHAS, the Tanzanian National Institute for Medical Research, and WCM approved this study. Written informed consent was obtained from all participants of the focus group discussions and in-depth interviews. Participants were asked about their experiences during all stages of their training but did not provide identifying information including institutions, locations, or dates of training to protect participant confidentiality. Any identifying information was deleted after data collection was complete. The survey did not differentiate experiences at previous and current institutions. Qualitative data was de-identified during transcription and translation and stored on password protected computers. After analysis, recordings of focus groups and in-depth interviews were destroyed and three years after date of publication all written data will be destroyed. De-identified data from all four sites were compiled after data collection; individual sites were not identified in any analyses to protect participants’ confidentiality.

Cultural power imbalance

Cultural power imbalance refers to engrained ideas, reported from all countries, that women are less capable than men, and that the normative roles of women are to maintain their households and raise children. These core, pervasive beliefs undermined women’s motivation to even a seek leadership role. They described having their inferiority to men impressed upon them since childhood. Even a senior faculty member explained:

“There is a lot of discrimination. [Society] is saying that a man is born to be a leader and a woman is born to be a slave under a man, so that discourages women a lot—that they are created to be under men…A man must be above you…most of the time in anything that you do, as long as a man is there then you will not lead.” (faculty member)

Women at all stages of their careers stated that their career paths had been arduous, requiring them to fight against pervasive cultural norms and continually prove themselves. Participants expressed their struggle to gain respect juxtaposed with the respect perfunctorily offered to men: “When women doctors order men, they do not obey. But if it was a man who had ordered them, they would have obeyed…we women have to shout” (faculty member). Women frequently shared instances in which they or their colleagues were passed over for leadership positions or promotions in favor of men with less experience. Many participants explained that they had been discouraged from male-dominated specialties or penalized for childbearing. When asked about instances of gender discrimination, a surgical trainee stated that:

“Our society perceived [women staying at home] as a normal thing. If you work, it will be like you are doing a supplementary thing. If they see you [at work] they will ask, ‘What have you come to do? You, a woman, are going to operate on somebody?’” (surgical trainee)

Further, these prevailing cultural beliefs led women to feel that “we are devalued by the society, and this belief has been there a long time” and at times led to decisions not to pursue leadership roles in a society that “does not believe women can be given leadership” (faculty member). A trainee observed that even when men and women actually did achieve “similar [leadership] positions… the women are not as respected” (post-graduate trainee). Another trainee described her perception that these biased cultural norms extend to leaders of institutions who commonly think, “women, women, we don’t trust women” (post-graduate trainee).

This experienced cultural power imbalance was further exacerbated for pregnant women. Multiple respondents stated that women who become pregnant are perceived to be less serious about school and work. Both students and post-graduate trainees described women being chastised by their superiors, sometimes in front of others, for becoming pregnant during training. One trainee explained that, after returning from maternity leave, “[The seniors] will ask you more questions just to teach others that they should not [become pregnant] like you” (post-graduate trainee). Another trainee described pervasive gender bias by stating, “by the way they treated women who became pregnant, we can feel it” (post-graduate trainee). Repeatedly observing and experiencing that pregnancy was not compatible with training for a career in medicine discouraged women from considering career advancement or leadership.

Institutional power imbalance

A second major theme that emerged in both focus group discussions and in-depth interviews was the existence of institutional policies and practices that enable gender discrimination and harassment. Women described occasions on which superiors used their institutional power to threaten or block them from advancing in their careers or excluded them from training opportunities altogether. An orthopedic trainee reported that her superiors “failed to give the orthopedics examination” needed to advance her career, hoping that she would “get tired and leave.” They asked her, “Why can’t you go and study pediatrics?” Several women recounted being forced to cover a male colleague’s patients so that he could attend a training seminar, while not being given opportunities to receive training themselves. Again, the pervasive assumption of male superiority and women’s perpetual struggle to get equal treatment sapped motivation to fight these inequities and pursue leadership.

Institutional power imbalance also manifested the cross-cutting theme of balancing maternal and family responsibilities with career advancement. Because trainees are expected to adhere to a rigid training and examination schedule, a maternity leave of several months is currently not possible in many programs. For example, one medical resident was given one week of maternity leave during her residency training and when she asked for additional time was told to “choose school or postpone [her studies] a year.” To avoid this unanticipated year-long delay, she returned to her training program before she had recovered from her delivery and described working through physical pain. A faculty member described getting a breast abscess “because of not feeding the baby on time” when she was not permitted a break during her shift as an intern. Of note, no participant reported having discussed her plans for childbearing with a mentor, or seeking guidance on career-family balance from a mentor, while in her training.

Similarly, participants who had recently returned from maternity leave reported that their careers had been stalled because of their childbearing. A post-graduate trainee stated that “ultimately the accolades go to men because they just did not physically have to bear children and miss out on the opportunities.” Another post graduate trainee described maternity leave hindering a woman’s chance for promotion, stating that, “I hear employers do not like those maternity leaves. If there is [a chance] to choose leaders and you have gone on maternity leave, you cannot be given [the promotion], know that leadership has passed you.”

Men’s power in some institutions further extended to their ability to coerce women into performing sexual acts in order to avoid negative consequences such as unwanted transfers, failing courses, or lack of promotion. One faculty member reported that the head of her institution approached her and threatened to “arrange [to send] her to the village,” an undesirable site to work, if she did not agree to his sexual advances. Another faculty member stated: “Your teacher will disturb you because…when you refuse his advances…you fail his course, so he uses that as an entry point.” A medical student crystallized the challenge of professors’ unchecked authority when she stated, “At this level, your future is in the hands of your teacher, the one harassing you.”

Restricted agency

These cultural gender biases and institutional power imbalances fueled a sense of restricted agency among many participants. Common sentiments in discussions included feelings of futility and resignation in response to prevailing cultural attitudes that normalize gender discrimination, constrain balance between family responsibilities and career opportunities, and tolerate sexual harassment in the workplace. These culminated in the disheartened assumption that since women are unlikely to overcome these challenges, many are not motivated to seek them in the first place. A medical student expressed many women’s resignation to accepting the default of male leadership:

“The words of many people make us fear that they would say ‘This woman isn’t able.’ Because many people have seen that leaders are men…Therefore we remain back, leaving men alone to lead us.”

Participants also described that the combination of unsupportive family policies at work, plus their disproportionate share of family responsibilities compared to their male partners, discouraged them from even trying to pursue leadership positions. One medical student remarked, “[she] cannot do many things at once…therefore women back up from getting into leadership positions.” Others perceived that the emotional weight of balancing work, studies, home, and family limited women’s ability to be fully present for work and career activities. One faculty member described: “You find women’s performance is dropping because they can’t concentrate in studies and work… the child has a fever; the child is not fed.”

Futility was expressed most prominently in instances of sexual harassment or assault in the workplace, which were well-known and frequently described. When asked what women do in response to sexual advances from superiors, participants repeatedly noted the absence of reporting or support systems at their institutions. Without reporting mechanisms, “most women remain silent” (post-graduate trainee) and resort to seeking support and comfort from peers: “There is no special authority where we can report these problems…we remain encouraging each other alone” (faculty member). Another trainee echoed this sentiment, stating that “there is not any system…you just look to your friend to talk about that heartache” (post-graduate trainee).

Further, lack of formal reporting results in lack of consequences for perpetrators and women subsequently lose out on opportunities. One faculty member described that after rebuffing her supervisor’s demand for sex in exchange for his letter approving her request to transfer work location, she “ultimately gave up trying to transfer.” A faculty member described a tragic example of the potential consequences of sexual harassment when students have no recourse and no help:

“[She] loses concentration and psychologically she becomes affected…[it] may cause absenteeism, she doesn’t enter the classroom, she is afraid of meeting that teacher. Therefore, the absenteeism leads her to fail studies and finally leave the college altogether.”

Proposed solutions to address barriers

Women’s practical suggestions for addressing these challenges can be summarized into three key interventions: a robust reporting system, peer support and mentorship, and gender equity and leadership training. Their suggestions are summarized in Table 2 and described in detail below.

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Table 2. Women’s recommendations for interventions to address gender-based barriers.

https://doi.org/10.1371/journal.pgph.0000646.t002

Future directions

Part of the solution to increasing female representation in health leadership requires that all voices be heard equally. However, there remains a paucity of research on male perspectives on gender disparities in health leadership. As men hold a majority of global health leadership roles, it is essential to engage them in conversation towards closing the gender gap in leadership. As such, future research should qualitatively explore male perspectives on gender-based differences in career progression and the role men can play in supporting equality in leadership. Likewise, other qualitative studies would facilitate understanding of gendered obstacles at different levels, including governmental, non-governmental, private, urban and rural health facilities. Furthermore, to assess the impact of interventions being implemented, we will seek participants’ follow-up testimonials and surveys to understand attitudinal shifts, experiences, and challenges as numbers of female leaders in the workplace increase. Lastly, future research on the intersectionality of gender with race, sexual identity and orientation, socioeconomic status, cultural background and other identities will provide a deeper understanding of the roles of these identities on career advancement and equity.