Human-centred mentorship in global health research: are we ready to give what it takes?

Summary box.

• Human-centred mentoring has been suggested as a sustainable strategy to nurture emerging leaders in low-income and middle-income countries for equitable and diverse representation in global health.

• Building on the argument that investigators in these countries need to take responsibility, we take a deeper dive into the challenges of implementing this approach aimed at developing independent leaders.

• The current global health environment where power is concentrated with few individuals hinders any progress towards institutional level changes to promote such practices. Moreover, such an environment also prematurely rewards mentees who may be resistant to this alternative form of mentoring.

• A transformative mentorship relationship which is anchored in trust, respect, meaningful relationships and problem sharing with due responsibilities for both mentors and mentees can help create willingness in mentees to be trained as individuals ready to take on an independent path.

A human-centred mentorship approach to nurture emerging global health leaders has been recommended for diverse and equitable representation.¹ The approach is characterised by ‘valuing empathy and relationship building between the mentor and the mentee built on equitable sharing of power and shedding of privilege within hierarchical structures’.¹ In this paper, we delve into the challenges of implementing such an approach and argue that mentees benefitting from the current status quo can be equally resistant to its adoption.

Given its nature of being an interpersonal endeavour, the human-centred mentorship process is a complex array of responsibilities that requires continuous symbiotic collaboration between mentor and mentee and a deeper holistic focus on the individual with mentee development (personal and professional) being the outcome.^{2 3} Hence, when viewed as a developmental relationship, the ‘reciprocity’ of mentee to the mentor’s investment becomes instrumental for the success of the relationship.⁴ Attributes of the mentee that add to the success of the relationship include open-mindedness towards their mentor, institution and new ideas, flexibility or adapting to change when presented with new situation and ideas, willingness to listen to feedback and perseverance.⁵ In short, to be ‘mentorable’, one needs to be willing to be vulnerable to truly change and learn.⁶

The choice of being vulnerable can be influenced by individual human experiences; personality traits, for example, motivation; and cultural factors including those of academic institutions, for example, the distribution of power.⁷ In this piece, we provide a nuanced perspective of these challenges from working in global health in Pakistan. We believe, though, that it can be applicable to settings where research governance is weak, allowing individuals in power to get away with ineffective and at times detrimental practices.

In Pakistan, there are several challenges to human-centred mentoring where respect is driven through authority discouraging vulnerability, a vital element for empathetic relationships.⁸ Moreover, to demonstrate empathy, that is, being open to other perspectives, requires the ability to simultaneously hold two perspectives: one’s own and that of the others.⁹ The ability may come naturally to some mentors, but it is a skill that has to be nurtured and learnt. Additionally, a lack of understanding of these needs is the reason behind the non-existence of training programmes to address them. Another main challenge which does not receive much attention is the unavailability of skilled mentorable human resource. Lack of skilled research staff is predominantly due to lack of investment in developing local research capacity, leaving us reliant on external funding opportunities.¹⁰ Consequently, the priority is to recruit staff who can communicate in English but not necessarily with rigorous training in research. This creates premature opportunities of progress for individuals who are not ready yet with the prerequisite skills expertise to lead research studies and programmes.¹ Moreover, the hierarchical culture in Pakistan rewards social privilege, creating power asymmetries in access to opportunities manifesting in partiality instead of meritocracy. This same social hierarchy in a way is a disservice to those it promotes as in the vacuum of not challenging power, they also fail to grow and learn.

The high demand due to scarcity of skilled personnel, low to minimal competition for high performance and premature rewarding by powerful mentors makes it harder for these mentees to be open to feedback and to act on it especially when it requires intellectual effort. This hampers the readiness to be vulnerable to learn, a vital element for a mentoring relationship to be formed. The privilege and power of the mentor may facilitate openness to new ideas or feedback, but such individuals may not have the time to nurture and in fact use their influence to reward the mentees beyond their intellectual effort. Consequentially, an ineffective mentorship system has been created where mentees benefit due to their privilege not realising that these benefits have short-term value and creates dependence on the mentor for future opportunities.⁸ When not presented with opportunities that are challenging, mentees fail to develop to their full potential.

Based on our experiences, we realised that taking such an initiative may not always be welcome as it can be seen as threat to existing power hierarchies. However, we do hope that there are investigators who do wish to implement human-centred practices as an alternative approach. We have drafted a set of guidelines for them to help them navigate the challenges (table 1). We believe that a transformative mentorship relationship which is anchored in trust, respect, meaningful relationships, and problem sharing with due responsibilities for both mentors and mentees can help create willingness in mentees to be trained as individuals ready to take on an independent path. The approach may not always work or align with the mentee’s expectations, but it should not be a reason to avoid doing the right thing. Pivoting the approach in honest relationships with team members with due emphasis on value system can also be seen as a form of self-care. However, as discussed for the approach to be effective, the role of mentees is as important. Table 1 also presents a guideline for mentees to better contribute to the mentorship relationship in a way that it is beneficial to them in the long term. We ask for a shift in the perception of the mentee’s role from ‘passive individual’ to an active adult contributor who is well aware of the power dynamics in their institution. And to an invididual who, when has the autonomy to take a decision chooses to be on the right side.

Table 1.

Guidelines for mentors and mentees to promote a culture of human-centredness in global health

Mentors	Mentees
Imparting values and promoting a culture of human-centred mentorship. Mentoring research staff and investigators on human-centred lines is the right thing to do. However, if it is not a usual practice in the institution, it inadvertently makes those who do not practice this look ‘bad’. This may not be completely their fault as they were not exposed to this culture or, more likely, they were never trained to do so. Keep a balance about how much you want to publicise your approach, especially if it gets public recognition from the senior leadership. Not doing so may create divisions. As part of team mentorship, do focus on values as much as technical skills. Regarding the latter, the institutional research policies are a good resource as they usually focus only on the technical aspects. Familiarise yourself with institutional research policies, supplement with your values creating your own ‘team interaction’ guidelines. Share these guidelines with your team. Refer to these often during meetings and interactions with your teams so it becomes part of your team’s culture. Keep the bar high, nothing less than excellence in research and mentorship. That is what should define your work. As the saying goes, ‘it is not failure, but low aim which is a crime’, but do ensure the process is human-centred and you are with your mentees on the bad days.	Choosing a mentor. As a mentee, the natural tendency is to gravitate towards successful (and powerful) mentors. The reality is the drivers for highly competitive Principle Investigators (PIs) may not be conducive to effective mentorship. Find mentors who have the time to invest in your training needs and are available, physically and emotionally. If possible, find an opportunity to work with someone who has a record for demonstrating integrity. Such an inspiration has a unique effect.
Strengthening relationships. Building a relationship with the mentees is the key. This transformative mentorship is anchored in trust, respect, meaningful relationships and problem sharing.3 It allows you to give critical feedback. Invest time in the relationship before you resort to feedback. The appetite for taking feedback has to be built gradually. Your mentees are your ambassadors. It is through them you will be able to give longevity to your value system. Invest accordingly and the best investment is a relationship. Believe in the fact that if done well, the returns on such investments are priceless. There are long-term returns to investment in a human connection.	Familiarisation with the research culture. Familiarise yourself with research protocols and the roles and responsibilities, especially decision making. A cardinal rule to remember is that the PIs remain the final decision makers as they are the ones being entrusted with the funding. Understand that there is no clear research track in global health. The chances that you will get into a faculty role are slim and the ability to support yourself on a grant is even slimmer. Have a learner’s mindset as opposed to a growth mindset. Strive to acquire skills that can be applied to other fields. This will also open up opportunities for you. Once you start growing professionally through mentorship, those who do not have such an opportunity may feel deprived and may give you advice not in your best interest. If something does not make sense, a good approach is to ask questions. It gives the impression that you are trying to learn.
Systems approach. Expect that there will be mentees who will leave the team due to many reasons (including the fact they are well trained and find better opportunities). Hence, do not put all your eggs in one basket. Invest in more than one person. Have operating protocols in place for ease of training of the new staff. There can instances when staff executing the study feel entitled and start taking decisions beyond their role, for example, being in touch with an external PI without knowledge of their PI and at times sharing sensitive information or getting upset at who is invited as a coauthor on a paper from the study or not allowing other team members to present the work. Regular elaboration of team member roles and responsibilities and each one’s contribution can help prevent any issues in the future. If an opportunity is available and mentees want to leave, let them but also provide advice to adjust to the new role. Let them leave on a good note. Grace never fails to influence. Allow the team members opportunities to mentor within the team; facilitate a culture of mentorship. This also ensures relationship building within the team.	Continuous learning, constructive feedback and teamwork is the key. First authorship demands communicating the study along with the intellectual contribution. Contributing significantly to any aspect of the research should be recognised on papers but does not necessarily mean first authorship. If you are being given an opportunity to write your first lead-author paper, expect that it will not be easy. You will receive critical feedback until it is ready to be submitted to an international journal. Depending on your writing skills and your time commitment with other responsibilities, publications may take anywhere between 6 months and 12 months and numerous iterations. It is understandable that you would like to lead as many papers (or all of them!). However, bear in mind that communicating results of a research cannot wait for you to be ready. The PIs usually like to use one study as an opportunity to mentor more than one staff member, especially as opportunities are few. Learn to be okay with peers growing. It builds a stronger science community. Learn to be a giver too. You do not need to wait to be a PI to mentor junior members of the team. Use your strengths to impart skills to others in the team who may not have been as privileged.
Ensuring recognition. Authorship is not always an incentive for team members. For many, institutional prestige matters a lot. Find other opportunities to recognise within the department, for example, presentations, conferences and training workshops. There is always something for everyone. Recognition, for example, authorship, is usually the bone of contention. Be proactive and anticipate issues related to authorship. Discuss at the outset, if possible, with the team and document the decision. Help your team understand International Committee of Medical Journal Editors authorship criteria. Make sure to show your value by following these guidelines, walking one’s talk defines one’s integrity and may be more helpful in instilling ones’ values in the mentee. Discuss it often with concrete examples. The staff who lead implementation or work on operations may develop the feeling that they are doing a lot compared with someone in the office, even the PI. Clarify with the team members about what intellectual contribution means as this is usually a tricky one, given it is not part of the education system. Share examples of all the four aspects: conceptualisation, design, execution and analysis. Science is not complete until communicated, and thus, writing deserves special attention. The write-up of the work done should be clearly planned with mutually agreed timelines and roles. Skilled human resource is rare and an asset. When you choose to invest, other investigators will want to have your high functioning mentee on their team. Keep a balance about how and when you want them to be ‘visible’ in the institution. Too much visibility in the beginning of the career can be a distraction. Visibility can be more effective when done at the right stage of the mentee’s career.	Values over skills. Acknowledge and show gratitude to your mentors even if it is not ‘politically’ in your best interest. It will show your character and will always drive your respect among peers. Not many mentors invest in their mentees especially in toxic cultures. Being privileged has it benefits, and one is entitled to use it to their advantage. However, the downside is that it gives an alternative to waiting and being patient for a longer-term success. Such a strategy may beget more privilege, but an emotional investment by a mentor is what helps you succeed in the long-term. Being humble facilitates such relationship building and an investment from the mentor. Successful careers are not built on one opportunity but several. Humility, patience and perseverance are what gets you more of them. There are times you will feel wronged. It is very tempting to question the mentor, but it is okay to give them the benefit of doubt especially if it is not what they usually do. Mentors are also humans and need to be understood at times. Learn to let go as you are the one who will benefit more from the relationship as long as you are receiving other opportunities. Once you have had the realisation that the success of the relationship lies more with you than with the mentor, the journey becomes much easier. Be active, add value, seek opportunities, show initiative and also loyalty. Mentors invested in your growth should not settle for mediocrity. They will and should push you to get better. Growth requires effort, and effort does not coexist with comfort.
Do take care of yourself. The problem with hierarchical settings is that one is not respected if they demonstrate too much humility. The process of dismantling hierarchy has to be gradual. Maintain a balance. Allow the team to contribute to decision making, but it should be clear that the PI is ultimately responsible, and hence, the final decision lies with him/her. Do not feel shy about taking credit for what you deserve. In a culture where people have to fight for their rights, it is important to remind the team about your contribution too. Generosity of spirit at times can be taken as a weaker stand and can cause serious disruption of team dynamics. The team should know who the captain of the ship is. Learn to accept that some mentees may not be comfortable with your mentorship style. They may feel more at ease (given their privilege) in the current, often mediocre, culture. We cannot change everyone. Implementing these set of values in a hierarchical culture is no less than disruption. Your strategy will be questioned. There will be emotional setbacks. You will be broken, and nothing will break you like betrayal. Rest assured, you can pick yourself up. Self-believe is critical. Do not give up. Some are born to pave a new path. Rest assured, the path of doing what is right is longer but is rewarding.

Informed by our personal successes and failures, we have concluded that a handful of intrinsically driven individuals in a community that values protection of status quo, unfortunately may not be able to bring about a sustainable change. We also realise that taking the path to being independent is longer and harder where achievements have to be earned and are not gifted. This may not be attractive enough in a culture that readily glorifies titles but not quality of work. The pressure to conform is also real and individuals wanting change will always be in a minority with effects on their professional and emotional health.¹¹

We call for global health academia to pause and reflect on existing mentorship practice where the larger emphasis is on academic productivity and publishing¹² and neglecting the big picture thinking.¹³ While the current western model of academia entails elements that are useful, it is largely driven by and for power and privilege.¹⁴ There are mentorship approaches from other cultures that can significantly contribute towards strengthening the current model. An example is the Gurukul system of education in India, dating back to centuries and embedded in core values of fraternity, discipline and humanity.¹⁵ This call presents an opportunity to recognise and benefit from ‘other’ forms of knowledge to redefine mentorship, for example, by Shams Tabrizi, a Persian poet: ‘Don’t confuse power-driven, self-centered people with true mentors. A genuine spiritual master will not direct your attention to himself or herself and will not expect absolute obedience or utter admiration from you, but instead will help you to appreciate and admire your inner self’. We hope such mentoring models can inspire mentees who are willing to take the courage to not conform. That may be a step towards creating a black swan moment rather than waiting for it.

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