Recruitment Strategies To Improve Gender Equity in Clinical and Translational Research Training in Ethiopia

ABSTRACT.

Women from sub-Saharan Africa, including Ethiopia, are underrepresented in biomedical research due in part to limited access to high-quality research training and mentorship. Tuberculosis (TB) is a major public health problem in Ethiopia, with a limited number of female Ethiopian scientists engaged in TB-related research. To improve access to TB-related research training among junior women scientists, our NIH Fogarty International Center-funded D43 program released an all-women request for applications (RFA), which substantially increased the number of women applying for research training and the number of women trained in our program. The impact of the all-women cohort was also bolstered by prominent female representation in mentor teams, program leadership, and program alumnae. Sustained increases in applications from women were seen in subsequent RFAs that included both women and men. Targeted leadership, mentorship, and recruitment efforts were effective in promoting improved gender equity in biomedical research training.

Globally, women^‡ are underrepresented in the fields of science, technology, engineering, and mathematics (STEM). In science, <30% of the world’s researchers are women.¹ Women are highly underrepresented in the biomedical research workforce in Ethiopia. Only 11.5% of the research workforce in Ethiopia are women, one of the lowest rates in the world based on data from the UNESCO Institute of Statistics.¹ Efforts are ongoing by the Ethiopian Ministry of Education to increase the number of women in higher education, and the proportion of women entering Ethiopian undergraduate science programs increased to 49% in 2017, up from 23.7% in 2008.² However, the proportion of PhD graduates and physicians in Ethiopia who are women has remained low; in 2020, only 9.5% of PhD graduates from Addis Ababa University were women,³ and in 2021, only 18% of physicians in Ethiopia were women.⁴

Pursuing and retaining careers as scientific researchers in sub-Saharan Africa (SSA) is challenging regardless of gender. Some of the obstacles to a robust and gender-diverse workforce of trained scientists include limited access to high-quality research training and mentorship, low wages, and limited opportunities for career advancement.^5–7 Gaps in self-efficacy and confidence between men and women are also exacerbated by documented gender discrimination in STEM.^2,8,9 Yet women in SSA working in research are having a dramatic impact with innovative and collaborative approaches to pressing health issues.¹⁰ For more women to engage in science, there have been calls to address barriers to enrollment and retention in the field, in part through international collaboration.^10–12

Tuberculosis (TB) is an enormous global public health problem and a public health emergency in Ethiopia. Ethiopia is 1 of 12 countries worldwide on the WHO “high-burden countries” lists for both TB and TB/HIV.¹³ A major barrier to improved research, treatment, and control of TB in Ethiopia is the scarcity of Ethiopian scientists and health professionals—particularly female scientists—with the relevant research knowledge and expertise to carry out internationally recognized and locally relevant research that can be translated to improve public health practices in Ethiopia and globally, as emphasized in pillar three of the WHO End TB Strategy.¹³

Here we describe how deploying a women-only recruitment approach and other measures to improve access to training among junior women investigators in our NIH Fogarty International Center-funded D43 grant entitled “Ethiopia-Emory Tuberculosis Research Training Program (EETB-RTP)” increased the number of women engaged in clinical and translational TB-related research in Ethiopia.

The EETB-RTP is focused on didactic and mentored clinical and translational research training and enhancing career development for Ethiopian investigators, with the goal of enhancing the TB research infrastructure in Ethiopia. The program represents a partnership between three Ethiopian institutions in Addis Ababa—the Armauer Hansen Research Institute, Addis Ababa University, and the Ethiopian Public Health Institute—with Emory University in Atlanta, GA. The goals of the EETB-RTP are to build human resource capacity and enhance the research infrastructure for TB-related research in Ethiopia through the provision of didactic and mentored research training to researchers in Ethiopia.¹⁴ One of the specific aims of the EETB-RTP is to increase diversity among TB research investigators in Ethiopia with a focus on increasing the number of women researchers, in alignment with the goals of the Ethiopian government to increase the number of women in biomedical sciences.² The EETB-RTP provides 2 years of formal support, which includes didactic research training with distance learning semester-long coursework (biostatistics, data management, epidemiology, scientific and grant writing, and implementation science), in-person and virtual workshops including mentor training and journal club, and mentored research training. All EETB-RTP trainees carry out a clinical and/or translational research project under the guidance of a mentoring team that includes an Ethiopian-based lead mentor and a U.S.-based lead mentor. All trainees receive a stipend to protect their time for research and research training, a laptop computer, access to electronic resources at Emory University (including ejournals, Zoom, etc.), support to present their work at a conference, a modest research supply budget (US$3,500 per year), and an opportunity to apply for a posttraining research grant (US$15,000 for 1 year).

Since program inception in 2013, the EETB-RTP recruitment process has consisted of an open call for applications from junior investigators, including PhD graduate students, postdoctoral trainees (PhDs and physicians), and junior faculty or junior scientists. Applications are reviewed by the program’s Training Advisory Committee, which is composed of Ethiopian and U.S.-based investigators, and are scored using an NIH scoring system.¹⁵ Applicants scoring in the upper half undergo an interview with program leadership. Applicants are selected based on the application score and interview and the availability of funds.

After three application cycles with low numbers of women applicants, the EETB-RTP created a subcommittee on “Women in Research and Mentorship” in 2019, consisting of four women and one man, led by author K. Bobosha, who serves as the Ethiopian-based multiple principal investigator (MPI) of the EETB-RTP. The subcommittee made important recommendations on how to better recruit and support women in TB research. A key recommendation of the subcommittee was to release a request for applications for an all-women cohort of trainees. Such a request for applications from women was subsequently released in late 2019 and circulated by all three Ethiopian partner institutions and previous trainees. As with prior and subsequent calls, an application workshop that provided guidance on submitting a competitive application was held in Addis Ababa in January 2020 for prospective female trainees. A total of 28 women attended the in-person application workshop, and the session was recorded for those not able to attend.

Twenty-four completed applications for the all-women cohort were received in April 2020. This represented a dramatic increase in the number of applications received from women compared previous cycles of request for applications (Table 1). Based on application scores by the Training Advisory Committee and available program resources, six Ethiopian women trainees were selected to join the EETB-RTP as part of the all-women cohort. The impact of the all-women cohort persisted during the next cycle of request for applications from both female and male applicants, with increased numbers of women applicants compared with cycles before the all-women cohort was recruited (Table 1). In the second 5-year cycle of funding, 2019–2024, 11 (52.3%) of 21 Fogarty trainees have been women, which greatly exceeds the number of women trained in the first 5-year cycle of funding (4 [21%] of 19 trainees). There are no significant differences in age, work experience, or educational backgrounds between the six cohorts from 2013 to 2022.

Table 1.

Distribution of applications to the EETB-RTP by gender

RFA Year	Cohort Type	Total of Applications Received, N	Total Female Applications Received, n (%)	Total of Applications Accepted and Enrolled, N*	Total Female Applications Accepted and Enrolled, n (%)
2013	Male and female	21	2 (10)	8	2 (25)
2015	Male and female	27	2 (7)	9	2 (22)
2017†	Male and female	2	0 (0)	2	0 (0)
2019	Male and female	30	5 (17)	9	2 (22)
2020	All-female	24	24 (100)	6	6 (100)
2022	Male and female	24	9 (38)	6	3 (50)
TOTAL	–	128	42 (33)	40	15 (38)

EETB-RTP = Ethiopia-Emory Tuberculosis Research Training Program; RFA = request for applications.

^*Based on available funding.

^† Supported by an NIH administrative supplement and therefore there was no request for applications.

The EETB-RTP has taken additional steps to increase and support women in research. The program has paired female Fogarty trainees with female mentors; of the nine women trainees accepted into the program in 2020 and 2022, seven (78%) have had at least one female lead mentor and four have had ≥2 female mentors. The EETB-RTP has also increased women in its leadership, including transitioning the MPI of the EETB-RTP in Ethiopia in February 2020 to a woman scientist whose translational research interests are focused on TB. Stakeholder meetings and conferences have featured sessions on improving gender representation and support for female trainees. In addition, the Training Advisory Committee that reviews applications for the EETB-RTP and advises on programmatic activities has balanced gender representation.

Releasing a request for applications for an all-women cohort substantially increased the number of women applying for training within the EETB-RTP, from 6 total applicants in three previous cycles to 24 applicants within a single cycle. A subsequent request for applications released in 2022 that included applications from both men and women resulted in applications from nine women (Table 1). Based on interviews conducted as part of an internal needs assessment, the increased number of women applicants in the all-women call may be related to alleviating the confidence gap⁸ among women (A. C. L. Hooper, unpublished data). Several women in the all-women cohort described not considering themselves to be competitive candidates against their male colleagues but believed they would have a higher chance of acceptance in an all-women request for applications. This perceived gender disparity is not reflected in the actual scores received from reviewers from prior cohorts. The development of the all-women cohort appears to have eliminated the self-limiting belief and was impactful in increasing women’s interest in applying to the training program. These same interviews also suggested that the sustained increase in women applicants in subsequent requests for applications was a result of the increased number of current and former female Fogarty trainees sharing the request for applications with other women, prompting more women to apply. These perspectives will be examined further in future program evaluations and forthcoming publications.

To our knowledge, male collaborators, trainees, and mentors were supportive of the implementation of an all-women cohort, as EETB-RTP trainees and leadership have open conversations about the need to improve gender equity at annual program conferences and meetings. During the 5-year funding cycle of the EETB-RTP from 2019 to 2024, three requests for applications were released, two of which accepted applicants of both genders. The all-women request for applications was designed to “catch up,” given the low numbers of women applicants and women trainees from the previous 5-year cycle, and was in line with recommendations from other fields for reducing gender disparities in STEM,⁸ as well as being led by a group of experts chaired by a local female leader.

Alongside short-term recruitment outcomes, the long-term outcomes of this approach have been successful in retaining women in the TB workforce. Of the 12 female trainees who have graduated from the EETB-RTP, all remain in Ethiopia except for one who is completing a postdoc position in the United Kingdom with plans to return to Ethiopia upon completion. Additionally, all 12 have remained in careers that encompass clinical and translational research.

The direct costs per trainee per year amount to $36,272, including the stipend, modest research supply budget, tuition, a laptop computer, publication charges, travel support to in-country conference and one international conference, and program administrative support. These resources are provided to all trainees.

Convening a subcommittee to address gaps in female representation among trainees in a setting with a low proportion of women scientists led to actionable and effective strategies for increasing female representation among early-stage investigators in the EETB-RTP that were appropriate for the local context. Releasing a request for applications from women meaningfully increased the number of female applicants to the EETB-RTP during that application cycle, and the impact seemed to persist in a subsequent cycle of recruitment. Targeted efforts to create a constructive environment for female researchers, including in leadership, mentorship, and recruitment, proved to be effective in promoting gender equity in the EETB-RTP.

Our experience suggests that using a request for applications for an all-women cohort was an effective strategy in improving gender equity in a setting and country where women are highly underrepresented in the biomedical research workforce and may be scalable in other settings to improve female representation in STEM broadly.