|ORIGINAL RESEARCH PAPER
|Year : 2013 | Volume
| Issue : 2 | Page : 89-97
Kenyan women medical doctors and their motivations to pursue international research training
Joseph Daniels1, Ruth Nduati2, Carey Farquhar3
1 Department of Global Health, University of Washington, Seattle, WA, USA
2 Department of Global Health, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Nairobi, Nairobi, Kenya
3 Department of Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, USA
|Date of Web Publication||29-Oct-2013|
UCLA Program in Global Health, 9911 West Pico Blvd., Suite 955?Los Angeles, CA 90035 2703, USA
Source of Support: None, Conflict of Interest: None
Context: There is a need to understand the factors that influence African women medical doctors to pursue international health research training because they remain under-represented in research fields but increasingly represented in medicine. Methods: We conducted a program study with Kenyan women (N = 12) who participated in a US funded AIDS International Training and Research Program implemented by the University of Washington. Interviews were conducted to understand their clinical research career motivations and training pathways into global health research. The transcripts were analyzed for themes using predefined code areas. Results: The findings outline entry into research, professional and career balance motivations, and two stages of a career path into research. Discussion: Kenyan women medical clinical researchers shared similar motivations as US women but differed as well. Kenyan medical doctors pursued health research within a context of limited resources, but the ability to balance work and family while contributing to public health through research and leadership was highly valued. International training programs can effectively engage women in research training by developing women's health research areas, supportive family policies, and aligning program design with local training to develop career pathways for women.
Keywords: East Africa, international clinical research training, women medical doctors, US
|How to cite this article:|
Daniels J, Nduati R, Farquhar C. Kenyan women medical doctors and their motivations to pursue international research training. Educ Health 2013;26:89-97
| Context|| |
In the field of global health, there has been significant focus on clinical research capacity building in low-resource settings to address health issues such as HIV/AIDS, malaria, and tuberculosis. ,,,, International training has been one tool used to develop local research leadership. ,,,,, However, there is limited understanding of factors that have influenced participation of African women medical doctors in international training programs and then how this training shaped their clinical research leadership locally. This is important to understand because the representation of African women in research careers has been low historically, yet there has been an increase in the numbers of women globally in medical training programs. ,,,,,, Thus, we conducted a program study of the University of Washington AIDS International Training and Research Program (AITRP) because it had a high representation of Kenyan women. We wanted to understand women's motivations to pursue this international research training program and then build a health-oriented research career in their home country.
We use research on US women medical doctors' career pathways to provide context because there is limited research about women clinical researchers in African countries, and AITRP uses a US curriculum. In the US, women medical students and doctors continue to experience gender bias within institutional environments, and there are limited opportunities for mentorship needed to pursue an academic career that includes clinical research. , In addition, studies have shown that women pursue balanced contributions to their career and family, which is challenged when institutional policies are not in alignment with these goals. , In response to these challenges, institutional training programs have been designed to increase women's self-efficacy in research careers. Also, there has been focus on developing women's health research areas in medical schools in order to retain them as leaders in academic medicine. , The outcomes of these programs for women show that career-family balance, leadership and role-models are important factors in retaining women in clinical research. These three factors provide a context to explore Kenyan women medical doctors' career decision-making to pursue this international research training program.
In this article, we describe AITRP and the qualitative methods used in this study. Then, we present two distinct motivations for a clinical research career that informed women's decision-making to pursue international training. Next, we describe two common steps in the pathway toward a clinical research career for women in Kenya. We conclude with a discussion comparing these Kenyan women with US women in clinical research in the areas of career-family balance, leadership and role-models. Finally, we outline three implications for effective international training program engagement with women medical doctors in African settings.
The University of Washington AITRP Case
AITRP was funded by the Fogarty International Center (FIC) in 1988 as a response to the human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) epidemic.  The University of Washington program specialized in the prevention of mother-to-child transmission of HIV/AIDS, and it was one of the first training programs to be funded by FIC in 1988. These training programs were competitively renewed, 5-year grant cycles. Each program was implemented by faculty in US higher education institutions and designed to meet the needs of HIV research capacity-building at higher education institutions in low-resource settings.
The University of Washington AITRP trained participants from six countries: Kenya, Mozambique, Uganda, Peru, Thailand, and India. The program included short-term and long-term training in the areas of epidemiology, biostatistics, biomedical research, and socio-behavioral research. Short-term training consisted of 3- or 4-month specialized skill development such as laboratory skills. Long-term training usually led to degree completion such as Masters in Public Health (MPH), Masters of Science (MSc), and Doctorate of Philosophy (PhD) degrees. Training occurred in the US with research projects conducted in these six countries.
This article focuses on trainees from Kenya due to the high representation of women from Kenya in the program. Over the 25 years the program was implemented, there were 153 short- and long-term trainings offered to future Kenyan researchers. Within these cadres, women medical doctors completed 30% of these trainings, and 56% of all trainings offered included women in medicine, social science, epidemiology, and biomedical research.
This case study focuses on women medical doctors who completed degrees only, because research degrees allow medical doctors to pursue grants that can lead to independent research programs. In [Table 1], women medical doctors who completed degrees through the program are shown.
Over the 25 years, there were 19 degrees awarded to women medical doctors. There were 18 MPH degrees and 1 PhD degree, with all the degrees in epidemiology. Comparatively, men medical doctors completed 16 degrees. There were a total of 43 degrees awarded across all the grant cycles to both men and women medical doctors and those with training in related HIV/AIDS research fields such as biological sciences. Therefore, women medical doctors represent 44% of all degrees awarded over the time since this program was implemented. All the women in this program did practice medicine prior to completing training and continued with a combination of HIV/AIDS prevention research, clinical practice, and teaching. This study sought to select a representative sample of women medical doctors in this degree group in order to better understand their motivations for a local HIV/AIDS research career.
| Methods|| |
This was a qualitative evaluation of the University of Washington AIDS International Training and Research Program utilizing a semi-structured interview protocol. The study was conducted between 2008 and 2010. In this article, we present data from 12 of 19 Kenyan medical doctors who completed a degree through AITRP.
The participants represent the grant cycles except for the final cycle because these women were still completing their degrees at the time of this evaluation. In order to maintain participant anonymity since each cycle had few women, we are not identifying the numbers of women we interviewed in each of the cycles. The general profile of all the women who completed this training program included specialized medical training in obstetrics and gynecology or pediatrics. All but one woman returned to Kenya to pursue a combination of clinical research, medical practice, teaching, and programmatic-related work that addresses HIV/AIDS in Kenya. At the time of this study, the women were at different stages in their careers. Three women had independent research projects ongoing and the remaining women were early in their career.
Participant interviews were conducted in English. During the interviews, participants were asked about their educational and professional histories, their motivations for a research career, and how these motivations informed their future training and career decision-making. We were particularly interested in interview discussions that captured four areas, which we used as major codes for the analysis: Medical career steps, leadership, research, and mentoring. The interviews were transcribed, and then we analyzed the data using the four areas as major codes. The major codes were refined during the analysis with sub-codes, which were used to analyze the transcripts in a second review. , After each of the transcripts were coded, we compared findings across individuals and participant groups based on the grant cycle in which they completed their degree. Although each grant cycle reflected a generally similar training program design, there were some changes from cycle to cycle that may have influenced participant motivations and experience in their research career. Therefore, the comparison of participants across grant cycles was important to confirm findings. The findings presented here are shared across all the participants.
There are some important notes about the data represented in this paper. First, the participants are identified as medical doctors to maintain anonymity. At times, brackets are used in the quotes to clarify the context of the conversation, and identifying information was removed in the quotes. All participants gave their oral consent to participate in this program study.
| Results|| |
We found that women gained entry into international research through social networks of women in hospitals and their clinical expertise. Also, they shared two common motivations to pursue international clinical research training: (1) professional and (2) balancing career with family. The study also revealed that women experienced some common stages in their pathway from training to a clinical research career that they navigated in order to return home and transfer their knowledge to medical students and doctors. We provide a brief "lessons learned" after each finding presented.
Finding 1: Entry into Research and their Motivations
Women medical doctors interviewed did not initially intend to enter research fields because of the limited national opportunities for research in Kenya. This was a shared experience among the participants as one doctor explained:
Our university courses don't focus a lot on research. Even at medical school there isn't much research, but students do research projects on community health projects during their fourth year. But they are very preliminary, precursory…We don't have a strong focus on research and the different elements of research.
Participants were exposed to small research projects during their medical training, but these were not a primary focus of their degree nor was research demonstrated as a benefit to clinical practice in their medical training. Another doctor explained that after medical school, "I never really thought I'd do research. It came incidentally." Due to a combination of limited resources for research and limited research exposure in medical training, all the participants stated that they did not intend to enter research. But, women began their research career through international research projects occurring in the hospitals where they were practicing medicine.
Clinical expertise for research
All the women in this study were recruited into international research opportunities because of their expertise in one of two clinical areas: Pediatrics or obstetrics and gynecology. As these three doctors explain:
Researchers were looking for doctors to do [a research project], and it was difficult to get an OB/GYN who wasn't already in private practice. Because I was interested in research, [they] sent someone to talk with me about the projects…I told them I wasn't sure if I wanted to do research or clinical work. They said that the only way to find out if you want to do research is to do some research…I agreed to handle the research for the three weeks [to cover someone who was out of country]. So, I came and worked in the clinic for the project, and then [my research training and career] sort of took off and that's how I got involved.
So, we had a gynecologist [from the US] who was doing his research work here in Nairobi, and he also gave a presentation in the department [where I was working]. And, I was interested in laparoscopic work, and so we started working together. Then, [that's how] I got involved in his [US researcher] research work…
[I] started working in the hospital as a specialist [after my post-graduate training as an OB/GYN]. Then in 2004, I started talking with Dr. X [former AITRP fellow] about my career who told me they needed someone to fill in for a short time [on a research project]. Somehow that became another way [career path]. It just sort of came up…It was supposed to be just for three months, and I said it was ok since it was something I had not done before. [Once I started the project], I worked in the clinics, saw patients, and implemented study procedures…from that point on, I worked in research [as well as maintaining clinical duties].
Participants discussed that they found out about international research opportunities through US and other Kenyan doctors and investigators involved in research. The quotes represented here are from three doctors who completed AITRP at different time periods. The first two doctors discussed their connection to research through US investigators. However, as those who completed the training program returned to Kenya to lead their own research, more women linked to research through them as the third doctor above. Further, most participants stated that they were initially unsure about doing research. However, after completing a short research project, women developed interest and realized the feasibility of research. Eventually, this research experience led to training through AIRTP. There were two major motivations among the women in this study that intersected and informed their decision-making to take on these small research projects. These motivations were "professional" and "family and career balance."
In the interview data, there were two professional motivations shared among the medical doctors that drew them to this international research training program: Women's health research and medical career development. Neither reason was more important than the other, but these concerns were inter-linked for the doctors who pursued the training program. Two doctors captured the perceived role of research among the women medical doctors in this study:
While I was [at university], the HIV epidemic in Kenya…was coming up as a topic and everyone was talking about it and not much was being addressed. So, I wanted to learn about it. I actually did my thesis on HIV perinatal transmission, and that's how I got involved in that field of research.
HIV/AIDS is a local problem and social problem…There is not a lot of people [in Kenya] willing to dedicate time [research time] to address this issue. We support future researchers…so that you're not doing it yourself but you can multiply yourself. And, also, to make a difference in the patients is important but to make a difference in public health is important for the long-term.especially in our area of mother-child transmission.
As the quote from the second doctor explains, participants felt that there were few Kenyan medical doctors interested in HIV/AIDS research. Also, since all the women had specializations in pediatrics or obstetrics - gynecology, all participants stated that mother-to-child transmission of HIV and pediatrics HIV/AIDS was a significant concern and motivating factor to pursue research as a solution. The first quote reflects the view among participants that there was a national need to address HIV/AIDS. This doctor got involved in HIV research early in her medical training, which led her to pursue mother - child HIV transmission research in her career through international training. The second quote captures the perspective among participants that there was a need for medical doctors to work together to address HIV/AIDS, and public health research was one approach to address this issue at a community level. Specifically, each participant discussed their individual experiences with women and children living with HIV/AIDS prior to their research training, and the doctors learned that these patients reflected a broader public health and women's health issue of the epidemic in Kenya. Participants believed that increasing the numbers of doctors trained in research would improve public health, especially for women and children.
In addition to the women's health implications that HIV/AIDS presented, medical careers were challenged by limited institutional capacity, low morale in the workplace, and limited intellectual engagement in their clinical careers. In this study, all doctors described how these challenges with limited capacity and intellectual engagement were important in their decision-making to pursue research:
When I was doing my internship at Kenyatta.I was not really happy with the work I was doing.It was not dysfunctional but had a low morale. So, I bumped into the consultant who told me I should go and meet [internationally trained local researcher].I came and talked with her.she was doing a small project.and she told me to come and see what they were doing and see if [I was] interested in doing [the project].
It's good to serve people, but there is not much future career development [in clinical practice]. [If you are posted in a district hospital], you get out of touch with what's going on in the [medical] field.
Across the participants, the doctors were interested in developing their careers in medicine and public health. However, the challenge was the sites where these doctors were practicing medicine. As explained by doctor one, low morale negatively influenced her work, and doctor two described being disconnected from the medical field for intellectual engagement. In the latter case, the doctor was posted in a rural setting far from Nairobi; yet, it was there that she got connected to research. Participants described a common sense of professional isolation and to motivation among the medical doctors that research seemed to address. Women perceived that adding research to their clinical duties would increase their engagement in the medical profession and support the health of communities. As one participant stated, there were three reasons why she was interested in research: "The first reason is that I prefer preventative medicine because you may clean cobwebs by treating individual patients, but the spider is still spinning [more patients coming in with the same condition like untreated HIV/AIDS disease]. The second reason is that I don't like wards much because of the patient load and depressing environment. The third reason is the ability to balance my family and career." In addition to professional motivations like preventative medicine and low morale in clinical practice, women doctors discussed the added benefit research contributed to their personal lives.
Family and career balance motivations
Most of the participants had children, and this led them to discuss a personal connection to research. Women discussed having "corridor conversations" with other women medical doctors, and for one-half of the participants, these conversations led them to learn about international research opportunities because they shared medical expertise in either pediatrics and obstetrics and gynecology. In these corridor conversations, women stated they discussed balancing family and clinical work that research seemed to address. Across the participants, women stated that they chose research for professional reasons, but they appreciated that there was an added benefit: Balancing family and career. This was equally motivating among women in the study who were planning to have children. As one participant described a common factor among the women in the study:
In a clinical setting, when a hospital is admitting, you could admit 100 patients that night. You're admitting one after the other. The ward is full. And then the next day you're doing the investigations, and so it is very demanding to do the clinical work.For me, I try to encourage women to join research.
Women researchers encouraged other women to consider research to address clinical care challenges with the added benefit of time with their families. Not only did the high clinical workload expose women to patients with common health conditions like HIV/AIDS that they learned that research could address, but also the high clinical workload influenced their decisions to become researchers in order to balance family and work.
Many participants explained that research allowed them to bring work home rather than putting in regular long hours away from their family that could lead to professional burnout. Research offered them the opportunity to see clinical care from a public health perspective. Women were invested in their careers. As one participant explained, "You want to concentrate on your family 100%, and you want your career to move on." Research represented a shift in how women saw their roles as doctors in Kenya that motivated them to pursue a research career to address the HIV/AIDS epidemic in the country.
Entry into research for these women was through social networks of other women medical doctors. Thus, recruitment and support may benefit by integrating these social networks more formally into programs like AITRP. Women's health was one factor that motivated participants to pursue research, and it seems that participants perceived that research would complement clinical responsibilities and family involvement. A balance of clinical, research, and family responsibilities was perceived as important to their retention in medicine. Thus, after women decided to pursue HIV/AIDS research, they experienced two common stages in their pathway toward a research career.
Finding 2: Pathways to a Clinical Research Career
As described earlier, the pathway to a clinical research career among these women began with short-term research project exposure to international research. All women described this exposure as an "eye-opening" moment to the applications of clinical research to HIV/AIDS. This stands as a key first stage in their clinical research career. After the women completed their training, they transferred their international knowledge locally as another key stage in their career. These two stages are designated as Stage I, Feasibility, and Stage II, Knowledge Transfer.
Stage I: Feasibility
When the women medical doctors entered the international HIV/AIDS research field, they participated in a short-term research project. Due to the limited research capacity locally, this project led each to a personal "eye-opening moment" about research. Doctors learned about international research methodologies, techniques, and procedures including the implications for research in public health. Through this eye-opening experience, women found that research was feasible because they were able to work with more up-to-date resources to do research and that they could learn to conduct the analysis of data themselves. One doctor explained that she got involved with international research because the research was "state-of-the-art, up-to-date, and current, which made research appealing." A doctor explained the benefits of laboratory resources that increased research motivations among the women in this study:
I learned to collect samples and learned about STDs and how research is done.I had the facilities unlike at public hospitals. I could do a wet mount in a lab and see if the yeast was invasive.Although it was syndrome management.I worked with the patient and researcher.[I did this for about a year, then worked on another study] where I set up a cohort and learned about the problems of setting up [cohorts].
In this international research setting, the doctor was exposed to sample collection and laboratory testing for sexually transmitted diseases (STDs) while working with the patient and researcher. The laboratory experience allowed the doctor to learn hands-on research skills with up-to-date laboratory resources, which were not available in public hospital facilities. Women described learning research techniques such as the wet mount in this example, and they learned how to run study cohorts for epidemiological studies. In addition to experiencing more advanced resources for international research practice, doctors stated that they wanted to learn to interpret data that was being discussed among the researchers. Also, they learned how international research and training was locally relevant, and how to develop research projects from previous investigations.
The women doctors explained in this study that they found out early on in their international research experience that there were gaps in their knowledge, and that training is about learning to refine your research question. Doctors explained:
I realized I needed to have more skills because those skills I learned for analyzing data was something I could only do so much. A lot of times I would have to consult with [US researcher] to find out how to analyze particular types of statistical data, and then I realized that I needed to get that training myself in order to be able to do it.
My thesis was on how breastfeeding affects mother's health while living with HIV. Specifically, we were interested in finding out how breastfeeding affected the health of the mother. We found out that that those who breastfeed had higher mortality than those who did not breastfeed…[but] my project for my thesis was too big and [I] had not finished collecting data. I came back [to Kenya] to finish collect data and wrote several papers on the research.
During the short-term research projects or work on research projects, they learned the basics of research, such as data collection and analysis, but soon realized that advanced training in epidemiology and biostatics was needed to sustain their contribution to research. Also, women developed confidence as a researcher during these short-term projects. Women wanted to continue to develop in their clinical research careers, which led them to participate in the Fogarty training program. As shown earlier, many of the women pursued a Masters in Public Health degree with the goal of returning home to build a research career. Most women used their master's thesis research to develop new research ideas and write publications that would support their career development, like the second doctor above who focused on breastfeeding among HIV-positive women in Kenya. As a result, among the participants of this study, all the women contributed to knowledge transfer in two distinct areas.
Stage II: Knowledge transfer
During this stage when the participants returned home, they discussed how they transferred their research knowledge through teaching and mentoring as well as developing an independent research program. Former fellows of the training program integrated their research training into their work with other medical doctors, researchers, and medical students in Kenya. Women described their role in teaching and mentoring as well as their activities to develop independent research programs in Kenya.
Teaching and mentoring
All the participants described roles and responsibilities in teaching and mentoring future medical researchers; and three women were contributing to curriculum development in Kenyan higher education institutions because participants discussed the importance of mentoring in their careers. All of the participants identified an individual who completed AITRP as a mentor for their research training and career. Three participants in this study served as mentors for most of the remaining women in this study. Further, these women had established research careers and also maintained institutional responsibilities. One of these participants stated that she is "teaching the concepts of evidence-based medicine and hypothesis testing" to show postgraduate and medical students how to "crack" a patient and take histories in order to develop a plan of management. She went on to say, "research training has given me a new perspective that teaching is not just a black board process but it goes into patient consulting in order to [for students] to learn how to diagnose." This participant was transferring her research training into her medical teaching to build critical thinking skills among medical students. As discussed earlier, women in this study completed small research projects in their medical training in Kenya but research was not emphasized nor integrated into the clinical practice, which the participants believed limited critical thinking in the medical curriculum. This doctor explained she was emphasizing the skills she gained in the program like approaches to evidence-based medicine and hypothesis testing, and incorporating these into the medical curriculum and teaching. These are typical examples of women in this study that demonstrate the impact of the training program locally, with former fellows incorporating mentoring and critical thinking skills into their work.
Among the three more senior doctors who had established a research program, they also found they were applying their international research training experiences that included mentoring approaches they experienced with US faculty. One participant reflected on the perception of US mentoring approaches among the women in this study:
I believe in the kind of mentoring I received during my MPH where you work with a faculty member and each of you know your responsibilities. These are the responsibilities as a student and these are the responsibilities as a mentor…I think that if I say I am taking on a student to mentor, then I work very closely with them until they complete their program and so they can learn useful skills to apply in future work. If we are to going to meet, then we plan ahead of time…As I look back at my professors, they did a lot of work…you must dedicate your time…
Participants discussed their mentoring commitments to students and their expectations for students such as basic mentoring meeting planning. Many participants discussed how this mentoring approach is not common in Kenya, and they were bringing this approach to Kenyan research. Also, many participants described mentoring students, residents, and local researchers. As one participant stated, she mentors two different types of people in research, those committed to a research career who may eventually pursue international research training and those based at the university who must complete research as a required part of their postgraduate medical training:
I have two levels of mentorship. In our organization, I work with researchers. Maybe they are new medical doctors or they are scientists. We work with them and develop them and bring them through the whole process of research. The others ones, the university based ones, they already have a system, and they come to me looking for a mentor. So, I work with them through the system and develop their proposal. Help them review their results and write up the results.
This participant stated that her international training provided her with the skills to mentor others in research from proposal development to data analysis and writing. In this way, she and other doctors in this study were transferring their research knowledge locally through teaching and mentoring. These mentoring relationships were mainly described as informal activities, but participants described an increased focus on formal mentoring within medical departments to support up-and-coming researchers and those interested in additional research training.
Developing research independence
In addition to teaching and mentoring, all the women in this study explained their plans to contribute to HIV/AIDS research capacity. They did this through participating in ongoing research and prevention programs as well as building early career grant funding so they can run their own research programs. One doctor explained her involvement with current projects, but her long-term goal was the development of independent funding. The ability to develop a research program after completing the training is the next important step in a research career. Most participants stated that their goal was to become an independent researcher, but this goal did have challenges without funding. One participant describes her process of pursuing early career grant support for research:
In 2005, I wrote a project for NIH [National Institutes of Health] via FIC [Fogarty International Center] for students who did their degree in the US, a transition grant…I applied for it but didn't get it, but they liked the idea and they gave their comments. So, I thought I would write it for 2006, and so I did, and I got the results last year, and it was funded…Sometimes it took people 3-5 years to fund a research project [after they were hired by an institution]. During that time, they have not much occupying them. So it can be demotivating since you don't have anything to do. There are local or government grants that you can apply for but they are very small and it is a challenge to something useful or meaningful with them…The MPH training was very good, and enabled me to apply for grants so I could have my own funding. I was happy to start immediately with my own projects.
All the women medical doctors in this study were able to continue with research immediately after they completed their training. They recognized that doctors with similar training had challenges moving their research forward after training due to the limited local resources for research. In this study, women were able to stay connected to research through the international collaborations that were linked to the training program through US investigators, or they applied for their own grants to start their own research program. As explained by the participant, the ability to get one's own funding is pivotal to staying motivated in research. She stated that many potential researchers wait for 3-5 years to get onto a research project or get their own funding, and this wait time demotivates those interested in a research career. Although there are small national grants available locally, the women in this study pursued the larger international grants because larger research studies would have greater impact nationally in Kenya. The opportunity to develop a local research career that had greater impact was important to the women in this study.
The key lesson here is that women needed to find that research was a feasible career, because there is limited funding and any career models for research in Kenya. Not only resources made research feasible, but also their medical training provided women with a foundation to contribute to research through a small project that empowered them to pursue training. Early self-efficacy in research was important to these women in their pursuit of training. During training, mentors and mentoring were significant responsibilities for developing research thinking and supporting early research careers.
| Discussion|| |
Kenyan women medical doctors interviewed in this study shared professional experiences with US women medical doctors pursuing an academic research career. First, it has been demonstrated in the US that institutional policies and expectations often limit women's ability and desire to balance career and family contributions. , In this study, women did not discuss institutional policies that limit women's ability to balance family and career, however, they recognized that the high clinical work load and long hours prevented family contributions. Similar to US women, Kenyan women's decision-making to pursue international research training was based on professional motivations. Yet, different from US women, Kenyan women decided to pursue international research training because there was the added incentive to balance family and career and contribute to public health issues to address HIV/AIDS.
Research feasibility through role-models
After their international training, women medical doctors served as role-models and leaders for other women interested in clinical research, which has been shown to be effective in developing and retaining women in clinical research careers. ,, The women served as role models by showing a career path that balances family with their careers in medicine and clinical research that contributes to health beyond a single patient in a population. The pathway toward clinical research leadership among these women included common stages. After exposure to international research through small projects or work, women stated that they found it was feasible to get trained in clinical research and maintain a research career in Kenya. This is a unique stage in sub-Saharan Africa because there are limited resources for research, which make the idea of a research career unfeasible without this international research exposure. ,,,,,, In this study, women benefited by the program by gaining exposure and then training in international research to contribute to local capacity-building.
Women building a research environment
When women returned home after their international training, they linked their research careers to local knowledge through mentoring, teaching, and developing research independence. Knowledge transfer was an important responsibility among the women in this study because they believed it ensured the development of future generations of HIV/AIDS researchers and improved clinical practice of future medical doctors in Kenya. Also, the development of clinical research career pathways among these participants was dependent on knowledge transfer within supportive institutional environments. Kenyan women medical doctors' decision-making and motivations to pursue international research training stemmed from a local research environment compromised of supportive role-models and early international research experiences that demonstrated research feasibility. Yet, more research is needed in order to elaborate on the function of limited resources and socio-cultural dimensions of gender and ethnicity in geographic spaces within countries where these influence education across the life-span toward a clinical research career. , These functions and educational dimensions may serve as a complementary framework to Bakken et al., as a way to support global health workforce goals. ,
Research-clinical practice balance
There is a concern that such programs may move needed medical doctors out of practice into research. It has been demonstrated among this group that women maintained both clinical research and practice responsibilities. As shown earlier, the ability to use research to inform clinical practice was an added advantage for women in this study. Further, in Kenya, the medical school is implementing a program to incorporate research opportunities for doctors practicing in more rural areas as an added incentive for retention.  Although women stated that research was not a primary focus in the medical curriculum, this new program is designed to build research into the Kenyan medical system. Thus, the increased value in evidence-based medicine in Kenya may create career pathways that balance research with clinical practice as an incentive to eliminate medical brain drain.
This study had three limitations. First, we interviewed women who had completed their training and not any women who were just entering research training. As a result, women were asked to reflect on their past motivations for a clinical research career. We adjusted for this limitation by comparing women based on the grant cycle they completed their degree in order to see if there were any differences in motivations. Second, this study had a small sample size, but we were able to interview participants who were representative of the grant cycles. Further, we interviewed 12 of 19 women who received degrees through this program and were conducting research in Kenya. Third, this is a case study of one AIDS International Training and Research Program, and the findings cannot be generalized to all women in the Kenya nor other countries. But, the study shows that there are shared experiences and motivations for research between women in this training program and US women, which can be elaborated with additional case studies of African women medical doctors in clinical research.
The experiences of this group of Kenyan women clinical researchers translates into three implications for international training program design to increase the number of women in research in low-resource settings and address global health issues. First, women's health research may motivate and retain women medical doctors in a research career, and effective international training programs seeking gender equity may have to work to develop these research areas, ideally with female researchers on the US side who serve as international mentors and role models. Second, international training programs should take a lead on implementing program policies to support contributions women may make to both their research careers and family. These policies should focus on how training commitments are balanced with family commitments within a global context, which includes the time away from home for training. Third, there is a need to formalize these clinical research career pathways within African institutions as a guide for other women, requiring more alignment between international and local training. Attention to these three concepts will allow training programs to effectively engage women in clinical research to build health research capacity in low-resource settings in sub-Saharan Africa and other parts of the world.
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