Original Article Cephalalgia 2022, Vol. 42(14) 1498–1509 Perceived barriers to career progression ! International Headache Society 2022 in the headache field: A global web-based Article reuse guidelines: sagepub.com/journals-permissions cross-sectional survey DOI: 10.1177/03331024221123081 journals.sagepub.com/home/cep Irene de Boer1 , Anna Ambrosini2, Rashmi B Halker Singh3, Betül Baykan4, Dawn C Buse5, Cristina Tassoreli6,7 , Rigmor H Jensen8, Patricia Pozo-Rosich9,10 and Gisela M Terwindt1; on behalf of the International Headache Society Women’s Leadership Forum Abstract Background: It is well recognized that underrepresented and minoritized groups do not have the same career oppor- tunities. However, there are limited data on the range and specifics of potential barriers that withhold people in headache medicine and science from reaching their full potential. Moreover, people from different geographical regions often perceive different challenges. We aimed to identify world-wide perceived career barriers and possibilities for promoting equality amongst professionals in the headache fields. Methods: A cross-sectional online survey was conducted among professionals in the field of headache globally. The questions of the survey were aimed at assessing perceived career barriers in four domains: professional recognition, opportunities in scientific societies, clinical practice, and salary and compensation. Perceived mentorship was also assessed. Results: In total 580 responders completed the survey (55.3% women). Gender was the most important perceived barrier in almost all domains. Additionally, country of birth emerged as an important barrier to participation in inter- national scientific societies. Career barriers varied across world regions. Conclusion: It is essential that longstanding and ongoing disparities by gender and country of origin for professionals in the headache field are globally acknowledged and addressed in areas of recruitment, retention, opportunities, mentor- and sponsorships, and advancement. Keywords Disparities, career, compensation, women, nationality, mentorship Date received: 2 June 2022; revised: 31 July 2022; accepted: 31 July 2022 1 8 Department of Neurology, Leiden University Medical Center, Leiden, Department of Neurology, Danish Headache Centre, University of The Netherlands Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark 2 9 Headache Unit, IRCCS Neuromed, Pozzilli, Italy Headache Unit, Neurology Department, Vall d’Hebron University 3 Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA Hospital, Barcelona, Spain 4 10 Department of Neurology, Istanbul University, Istanbul Faculty of Headache and Neurological Pain Research Group, Vall d’Hebron Medicine, Istanbul, Turkey Research Institute, Department of Medicine, Universitat Autònoma de 5 Department of Neurology, Albert Einstein College of Medicine, Bronx Barcelona, Barcelona, Spain NY, USA 6 Headache Science & Neurorehabilitation Center, IRCCS Mondino Corresponding author: Foundation, Pavia, Italy Gisela Terwindt, Department of Neurology, Leiden University Medical 7 Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, the Netherlands. Italy Email: g.m.terwindt@lumc.nl de Boer et al. 1499 Introduction These differences can have significant repercussions for careers. Nevertheless, the global medical, scientific, It is increasingly accepted that diversity in the work- and academic communities remain uninformed on the place leads to a competitive edge (1–3), and also leads impact of barriers that prohibit full participation by to tangible benefits including economic vibrancy (1) women and people from underrepresented racial, and innovativeness (2). This seems also true for the ethnic, and national groups. This lack of awareness academic sector (3). A recent study found that research and education results in underrepresentation, under publications authored by ethnically diverse and gender- acknowledgment and failure to fully mobilize the diverse groups receive significantly higher numbers of human potential. citations than papers written by researchers of a single To promote clinical and research opportunities in ethnic group or the same gender (4). Unfortunately, a the headache field based solely on abilities and to closer analysis of publications unveiled important remove possible career barriers providing an unfair dis- inequalities. Not only are there less articles written by advantage, a global assessment of the problem is nec- women as first authors and senior authors in high essary. With this international cross-sectional survey, impact journals compared to men, but these articles we aimed to define current career barriers amongst also had fewer citations (5,6). While the contribution the professional headache workforce, specifically in of women as first authors of original research in high the areas of professional recognition, opportunities in impact medical journals was significantly higher than scientific societies, clinical practice, and salary and 20 years ago, it has plateaued in recent years (6). compensation. Based on the findings obtained regard- Racial disparity is another important issue that is ing perceived barriers, we propose interventions to help evident across multiple subspecialties of medicine (7). strive towards equality. In the USA, only about 12% of the neurology work- force is made up of people from underrepresented racial and ethnic groups (Black or African American, Methods Hispanic or Latino, American Indian or Alaska Native, Native Hawaiian and other Pacific Islanders), Participants while women constitute about 30% of this workforce An anonymous and voluntary web-based survey was (8,9). In academics a similar gap is present (10). While distributed among people with a proven interest in efforts have been made to narrow this gap, disappoint- headache research and clinical care. Members and ingly, over a 35-year period, women physicians in aca- associate members of the International Headache demic medical centers were less likely than men to be Society (IHS), delegates of the 2019 International promoted to the rank of associate or full professor or Headache Conference and members of national head- to be appointed to department chair. Importantly, ache societies affiliated with the IHS were invited to there has been no apparent narrowing of this gap participate. To ensure that all persons working in the over time (10). Persons of color have also been less headache field had the chance to participate, we con- likely than Caucasian individuals to be promoted, tacted the whole membership database of the and women who belong to underrepresented minorities International Headache Society and allowed national may have double barriers (10). Additionally, medical representatives to send out the survey to their professionals in different countries perceive different members. challenges (11). Participation in scientific societies and receiving grant funding are pivotal to the development, growth Survey instrument and administration and success of academic careers. Historically and The survey instrument was developed using previously recently, women have been underrepresented among published surveys (19–21) and the experience of the American Academy of Neurology (AAN) plenary authors (IdB, AA, RBHS, BB, RHJ, PPR, GMT). speakers (12). While the AAN has taken active steps to Consensus was reached with several online rounds address equity, notable gaps remain, especially in spe- and emails. A questionnaire was constructed in cific prestigious plenary sessions (12). Women are also English (see online Supplementary Materials). The less frequently recipients of recognition awards (13,14), survey included multiple choice items with some and women in academia are awarded less grant funding open-ended response options assessing demographics (15), which are key factors in progressing their academ- including age, sex, race/ethnicity (combined), country ic careers (16). These gender gaps in grant funding are of birth, current country resident status, highest level of at least partially attributable to less favorable assess- education achieved, current position and academic ments of women as principal investigators, and not the rank if applicable (see Supplementary Methods). quality of proposed research (17,18). Participants were asked about possible career barriers 1500 Cephalalgia 42(14) and mentorship opportunities. All responses were kept (47.0–60.8% depending on subdomains) or barriers anonymous, and no personal identifying information affecting salary and compensation (39.3%) (Table 1 was collected. The web-based survey was sent in and Figures 1–3). All barriers surveyed; age, country September 2019 and closed in June 2020 with three of birth, ethnicity and gender were reported. In reminders to encourage participation and were domains reflective of professional recognition, gender answered anonymously. was the most frequently reported barrier (13.5–27.8% depending on subdomains) (Table 1 and Figure 1). In Data Analyses most domains concerning opportunities in scientific societies, country of birth was the most frequently Data from the questionnaires were analyzed using SPSS 25.0 (IBM Corporation, Armonk, NY). All sur- reported barrier in international scientific veys were examined for inconsistencies and invalid societies, with 42% indicating that country of birth or responses were treated as missing values. Questions education is a barrier to obtaining positions in interna- with open-ended answer options were scanned to tional scientific societies (Table 1 and Figure 2). For look for patterns or common answers, in the absence positions within national societies, gender was the most of these, these answer options were disregarded. frequent barrier (27.3%), while age was the most fre- Descriptive statistics (frequency counts, percentages) quent perceived barrier that caused participants not to were used to capture demographic data for the study be invited as a speaker or chair (21.9%) (Table 1 and population, as well as perceptions of barriers. Logistic Figure 2). regression was performed to ascertain the effect of gender and workplace location on the likelihood of Perceived barriers stratified by gender participants experiencing career barriers, corrected for In the gender stratified analyses, it became clear that age and race/ethnicity during all analyses. Results were women more frequently experienced gender as a barrier considered significant if p < 0.05. (Table 2). In fact, when age, ethnicity and workplace were corrected for, women were two to three times Results more likely to experience barriers to professional rec- ognition. For instance, women were three times more Participants likely to experience barriers to collaborative research efforts (OR 3.1, 95% confidence interval (95%CI) In total 580 responders completed the survey. All res- 1.9–5.0, p < 0.001) (Table 2). While they did not indi- ponders indicated their gender (male, female or non- cate a different rate of participation in international binary) and the women:men ratio was almost equal to conferences, women were two times more likely to 1, with 320 participants being women (55.3%). One experience barriers to holding a position in both participant identified as non-binary. As all data were analyzed and reported stratifying for gender, this par- national and international scientific societies (respec- ticipant was removed from subsequent analyses to tively OR 2.3, CI 1.5–3.5, p < 0.001 and OR 2.0, 95% ensure anonymity. The highest percentage of respond- CI 1.3–3.0, p ¼ 0.002). Women in clinical practice also ers was from Europe (229, 39.6%), the second most more frequently indicated barriers negatively influenc- represented region was South East Asia (126, 21.8%) ing their interaction with patients (OR 2.8, 95%CI 1.8– followed by the North America (78, 13.5%). Only a 4.6, p < 0.001). The perceived negative effect of gender minority, 23 (4.0%) and 19 (3.3%) were born in on salary and/or grants received, as well as on compen- African and Eastern Mediterranean countries. In sation for work in private practices was almost exclu- total 556 (96.0%) of the responders were healthcare sively reported by women (Table 1 and Figure 3). providers and 480 (82.9%) participated in research Moreover, men sometimes reported a perceived posi- activities. Moreover, 458 (79.1%) of responders partic- tive effect of age on salary and/or grants, this was much ipated in both clinical and research activities. Most res- less often the case for women. ponders were specialists working in academic hospitals. The majority of participants were in a relationship Perceived barriers by geographical workplace (82.7%), and had children (71.8%). Responders’ charac- location teristics are displayed in Supplementary Tables 1 and 2. Unfortunately, there were not sufficient responders working in the African (3.1%) and Eastern Perceived barriers in the headache field Mediterranean (3.1%) regions to be able to evaluate Many participants did encounter barriers affecting specific perceived barriers among individuals from professional recognition (33.7–54.0% depending on these regions. Responders’ characteristics by geograph- subdomains), opportunities in scientific societies ic workplace location are displayed in Supplementary de Boer et al. 1501 Table 1. Perceived career barriers reported by all participants and by gender. Breakdown by gender Women (n ¼ 320) Men (n ¼ 259) Total (n ¼ 579) Work-life balance Influence family care Yes, positively 49 (15.3) 53 (20.5) 102 (17.6) Yes, negatively 45 (14.1) 18 (6.9) 63 (10.9) Both 99 (30.9) 63 (24.3) 162 (28.0) No 127 (39.7) 125 (48.3) 252 (43.5) Professional recognition Collaborative research impacted bya Age 43 (17.2) 10 (5.0) 53 (11.8) Country of birth/education 32 (12.8) 32 (15.9) 64 (14.2) Ethnicity 6 (2.4) 14 (7.0) 20 (4.4) Gender 55 (22.0) 6 (3.0) 61 (13.5) None 145 (58.0) 154 (76.6) 299 (66.3) Research career not taken seriously/and or not welcome as a colleague due tob Age 46 (18.6) 15 (8.2) 61 (14.2) Country of birth /education 28 (11.3) 32 (17.5) 60 (14.0) Ethnicity 6 (2.4) 14 (7.7) 20 (4.7) Gender 81 (32.8) 4 (2.2) 85 (19.8) None 118 (47.8) 124 (67.8) 242 (56.3) In my country not the same opportunities academic career due toc Age 51 (21.7) 21 (11.5) 72 (17.3) Country of birth /education 50 (21.3) 36 (19.8) 86 (20.6) Ethnicity 42 (17.9) 34 (18.7) 76 (18.2) Gender 86 (36.6) 30 (16.5) 116 (27.8) None 91 (38.7) 101 (55.5) 192 (46.0) In my country not the same opportunities to be invited as public speaker due tod Age 63 (26.8) 26 (14.9) 89 (21.7) Country of birth/education 46 (19.6) 33 (18.9) 79 (19.3) Ethnicity 38 (16.2) 27 (15.4) 65 (15.9) Gender 66 (28.1) 23 (13.1) 89 (21.7) None 125 (53.2) 117 (66.9) 242 (59.0) Opportunities Scientific Societies Opportunities relevant positions national scientific societies unequal due toe Age 57 (21.4) 31 (15.0) 88 (18.6) Country of birth/education 54 (20.3) 30 (14.6) 84 (17.8) Ethnicity 43 (16.2) 36 (17.5) 79 (16.7) Gender 95 (35.7) 34 (16.5) 129 (27.3) None 112 (42.1) 122 (59.2) 234 (49.6) Opportunities national scientific society meeting to be speaker/chair unequal due to Age 77 (24.1) 50 (19.3) 127 (21.9) Country of birth/education 51 (15.9) 50 (19.3) 101 (17.4) Ethnicity 33 (10.3) 30 (11.6) 63 (10.9) Gender 85 (26.6) 27 (10.4) 112 (19.3) None 159 (49.7) 148 (57.1) 307 (53.0) Opportunities relevant positions international scientific societies unequal due tof Age 54 (20.8) 23 (11.4) 77 (16.7) Country of birth/education 114 (43.8) 90 (39.6) 194 (42.0) Ethnicity 59 (22.7) 33 (16.3) 92 (19.9) Gender 88 (33.8) 28 (13.9) 116 (25.1) None 85 (32.7) 96 (47.5) 181 (39.2) Opportunities international scientific society meetings opportunity to be speaker/chair unequal due to Age 64 (20.0) 42 (16.2) 106 (18.3) Country of birth/education 124 (38.8) 93 (35.9) 217 (37.5) (continued) 1502 Cephalalgia 42(14) Table 1. Continued. Breakdown by gender Women (n ¼ 320) Men (n ¼ 259) Total (n ¼ 579) Ethnicity 58 (18.1) 41 (15.8) 99 (17.1) Gender 81 (25.3) 26 (10.0) 107 (18.5) None 120 (37.5) 110 (42.5) 230 (39.7) In international scientific meetings not everyone has the same opportunities to participate in conferences due to Age 50 (15.6) 38 (14.7) 88 (15.2) Country of birth /education 105 (32.8) 79 (30.5) 184 (31.8) Ethnicity 50 (15.6) 42 (16.2) 92 (15.9) Gender 67 (20.9) 22 (8.5) 89 (15.4) None 136 (42.5) 122 (47.1) 258 (44.6) At scientific meetings/conferences people do not pay the same attention to speakers because of Age 57 (17.8) 27 (10.4) 84 (14.5) Country of birth /education 95 (29.7) 79 (30.5) 174 (30.1) Ethnicity 60 (18.8) 40 (15.4) 100 (17.3) Gender 73 (22.8) 28 (10.8) 101 (17.4) None 153 (47.8) 139 (53.7) 292 (50.4) Funding Receives salary/grant 260 (81.3) 188 (72.6) 448 (77.4) Salary/grant impacted byg Age – positively 18 (7.3) 33 (19.0) 51 (12.1) Age – negatively 22 (8.9) 11 (6.3) 33 (7.9) Country of birth /education – positively 25 (10.2) 22 (12.6) 47 (11.2) Country of birth / education – negatively 19 (7.7) 8 (4.6) 27 (6.4) Ethnicity – positively 6 (2.4) 5 (2.9) 11 (2.6) Ethnicity – negatively 4 (1.6) 2 (1.1) 6 (1.4) Gender – positively 4 (1.6) 13 (7.5) 17 (4.0) Gender – negatively 49 (19.9) 1 (0.6) 50 (11.9) None 145 (58.9) 110 (63.2) 255 (60.7) Receive compensation from private practices (including fees from companies) 151 (47.2) 131 (50.6) 282 (48.7) Compensation from private practices impacted byh Age – positively 22 (17.7) 20 (19.8) 42 (18.7) Age – negatively 17 (13.7) 10 (9.9) 27 (12.0) Country of birth /education – positively 23 (18.5) 17 (16.8) 40 (17.8) Country of birth / education – negatively 9 (7.3) 11 (10.9) 20 (8.9) Ethnicity – positively 8 (6.5) 3 (3.0) 11 (4.9) Ethnicity – negatively – 5 (5.0) 5 (2.2) Gender – positively 14 (11.3) 15 (14.9) 29 (12.9) Gender – negatively 17 (13.7) 3 (3.0) 20 (8.9) Time to be dedicated – negative 61 (49.2) 38 (37.6) 99 (44.0) Too few request – negative 14 (11.3) 15 (14.9) 29 (12.9) Clinical practice Contact with patients negatively influenced byi Age 55 (18.0) 24 (9.6) 79 (14.8) Country of birth or education 32 (10.5) 20 (8.0) 52 (9.8) Ethnicity 11 (3.6) 14 (5.6) 25 (4.7) Gender 65 (21.3) 11 (4.4) 76 (14.3) None of the above 178 (58.4) 191 (76.1) 369 (69.4) a missing n ¼ 29 (15 men, 14 women). b missing n ¼ 50 (33 men, 17 women). c missing n ¼ 38 (13 men, 25 women). d missing n ¼ 45 (20 men, 25 women). e missing n ¼ 29 (13 men, 16 women). f missing n ¼ 39 (17 men, 22 women). g missing n ¼ 28 (14 men, 14 women). h missing n ¼ 57 (30 men, 27 women). i missing n ¼ 24 (10 men, 14 women). de Boer et al. 1503 (a) (b) Age Age Country Country Women Collaborative Ethnicity Collaborative Ethnicity Men research Gender research Gender None None Age Age Country Country Research career Ethnicity Research career Ethnicity not taken seriously Gender not taken seriously Gender None None Age Age Opportunities Country Opportunities Country academic Ethnicity academic Ethnicity career Gender career Gender None None Age Age Country Invited public Country Invited public Ethnicity speaker Ethnicity speaker Gender Gender None None 0 20 40 60 80 100 0 20 40 60 80 100 Percentage responders Percentage responders Figure 1. Barriers to a career in headache affecting professional recognition. Results from all participants (a) and stratified by gender (b). Country is used to indicate country of birth and/or education. (a) (b) Age Age Country Positions national Country Women Positions national Men Scientific Societies Ethnicity Gender Scientific Societies Ethnicity Gender None None Invitation Age Invitation Age speaker/chair Country speaker/chair Country Ethnicity national Ethnicity national Gender Gender Scientific Societies None Scientific Societies None Age Age Positions Country Positions Country international Ethnicity international Ethnicity Scientific Societies Gender Scientific Societies Gender None None Invitation Age Invitation Age speaker/chair Country speaker/chair Country international Ethnicity Ethnicity international Scientific Societies Gender None Scientific Societies Gender None Age Age Participation Country Participation Country international Ethnicity international Ethnicity meetings Gender meetings Gender None None Payed less Age Payed less Age attention at Country attention at Country Ethnicity Ethnicity international Gender international meetings meetings Gender None None 0 20 40 60 80 100 0 20 40 60 80 100 Percentage responders Percentage responders Figure 2. Barriers to a career in headache affecting opportunities in scientific societies. Results from all participants (a) and stratified by gender (b). Country is used to indicate country of birth and/or education. Table 2. Supplementary Figures 1–3 illustrate perceived North American participants had higher odds of barriers to a career in headache affecting professional reporting issues of colleagues not taking them seriously recognition, opportunities in scientific societies, salary or being welcomed by them compared with their and compensation by geographic workplace, respec- European counterparts (OR 2.1, 95%CI 1.0–4.1, tively. These illustrate a certain degree of variability p ¼ 0.037) (Table 3). The opposite effect was seen in by geographical region in regard to perceived barriers the Western Pacific region where they had lower odds assessed. of perceiving these barriers than their European coun- As Europe was the most common geographical terparts (OR 0.3, 95%CI 0.1–1.0, p ¼ 0.041) (Table 3). work region, we examined the likelihood of non- North Americans and persons from South America European participants reporting perceived barriers had higher odds of reporting barriers preventing par- compared to European participants. There were large ticipation in international scientific societies (OR 2.3, differences in whether and to what extent barriers are 95%CI 1.2–4.4, p < 0.015 and OR 3.1, 95%CI 1.3–7.3, perceived by geographical work location. For instance, p < 0.008) compared to persons from Europe (Table 3). 1504 Cephalalgia 42(14) (a) (b) Age – positively Age – positively Age – negatively Age – negatively Women Country – positively Country – positively Men Country – negatively Country – negatively Salary/grant Salary/grant Ethnicity – positively Ethnicity – positively impacted by impacted by Ethnicity – negatively Ethnicity – negatively Gender – positively Gender – positively Gender – negatively Gender – negatively None None Age – positively Age – positively Age – negatively Age – negatively Country – positively Country – positively Country – negatively Country – negatively Compensation Ethnicity – positively Compensation Ethnicity – positively private practice Ethnicity – negatively private practice Ethnicity – negatively impacted by Gender – positively impacted by Gender – positively Gender – negatively Gender – negatively Time – negative Time – negative Few request – negative Few request – negative 0 20 40 60 80 100 0 20 40 60 80 100 Percentage responders Percentage responders Figure 3. Barriers to a career in headache affecting salary and compensation. Results from all participants (a) and stratified by gender (b). Country is used to indicate country of birth and/or education. Table 2. Likelihood of women reporting perceived barriers opposed to men. Odds ratio 95%CI P-valuea Professional recognition Collaborative research 3.1 1.9–5.0 <0.001 Being taken seriously and/or welcome as a colleague 2.5 1.6–3.9 <0.001 Academic career 2.1 1.3–3.3 0.002 Public speaker 2.1 1.3–3.3 0.003 Scientific societies Position national scientific society 2.3 1.5–3.5 <0.001 Speaker/chair national scientific society meeting 1.7 1.2–2.5 0.005 Position international scientific society 2.0 1.3–3.0 0.002 Speaker/chair international scientific society meeting 1.3 0.9–2.0 0.13 Participation in conferences 1.4 1.0–2.0 0.08 Attention at meetings/conferences 1.4 1.0–2.1 0.08 Clinical practice Negative influence on dealing with patients 2.8 1.8–4.6 <0.001 a Corrected for age, ethnicity and workplace. Number in bold indicate statistically significant results. Academic mentorship be one of the most important barriers to a successful career in the headache field. Importantly, country of The majority of participants was or had past experience birth is also an important perceived barrier for active as a mentee (85.1%) (Supplementary Table 4). For participation in international scientific societies. Lastly, both men and women, most mentors were men. career barriers are perceived differently across world Many positive effects were described, such as fostering regions. These ongoing disparities need to be acknowl- a career (85.2%) and promoting participation in exter- edged and addressed in areas of recruitment, retention, nal professional activities (79.3%) (Supplementary and advancement to improve the yield of the headache Table 4). Remarkably, around one third of participants research field. indicated that their mentors used the mentee’s work to Gender bias (unconscious and conscious) and its advance their own career (31.1%). associated inequity with respect to payment, leadership opportunities, promotion, and retention are universal and permeate nearly all professional and social Discussion domains. While women have closed the sex gap with Our results underline that in the field of headache care respect to medical school admission in some regions, and research, women more often experience career bar- women remain underrepresented in upper faculty ranks riers as opposed to men. Moreover, gender appears to of medical schools (10). Factors contributing to the sex de Boer et al. 1505 Table 3. Likelihood of non-European participants experiencing Table 3. Continued. barriers opposed to participants based in Europe. Odds ratio 95%CI P-valuea a Odds ratio 95%CI P-value Clinical practice Professional recognition Negative influence on dealing with patients Collaborative research South East Asia 0.2 0.1–0.6 0.005 South East Asia 0.4 0.2–1.3 0.13 North America 1.7 0.9–3.2 0.12 North America 1.6 0.8–3.0 0.20 Western Pacific 1.0 0.4–2.7 0.88 Western Pacific 0.6 0.2–1.7 0.36 South America 1.0 0.5–2.3 0.91 South America 0.7 0.3–1.4 0.29 a Corrected for age, ethnicity and gender. Number in bold indicate Being taken seriously and/or welcome as a colleague statistically significant results. As the largest group, Europe was taken as South East Asia 0.5 0.2–1.5 0.23 the reference category. North America 2.1 1.0–4.1 0.037 Western Pacific 0.3 0.1–1.0 0.041 South America 0.7 0.3–1.4 0.29 gap in promotion include a persisting mentality and Academic career climate, lack of sex parity in leadership, lack of South East Asia 0.3 0.1–0.9 0.027 gender equity in compensation, lack of retention of North America 1.6 0.8–3.3 0.16 women (the “leaky pipeline”), and a disproportionate Western Pacific 0.3 0.1–0.9 0.028 burden of family responsibilities and associated diffi- South America 1.0 0.4–2.2 0.93 culties in achieving work–life balance (22). However, Public speaker advising women to better organize their home- South East Asia 0.7 0.3–2.2 0.59 responsibilities will not solve the problem of gender North America 2.7 1.3–5.3 0.005 inequality. Importantly, perceived barriers most likely Western Pacific 1.1 0.4–3.0 0.85 South America 1.1 0.5–2.6 0.77 lead to fewer women entering and staying in science Scientific societies and medicine, despite their valuable contributions. Position national scientific society UNESCO Institute for Statistics fact sheet released South East Asia 0.5 0.2–1.1 0.08 in June 2020 showed that women in research and devel- North America 2.6 1.4–4.9 0.003 opment represent only 23.1% of the total workforce for Western Pacific 0.5 0.2–1.4 0.21 South and West Asia, 25% for East Asia and the South America 2.0 0.9–4.1 0.07 Pacific region, 31.1% for Sub-Saharan Africa, 32.9% Speaker/chair national scientific society meeting for North America and Western Europe and 39.0% for South East Asia 0.4 0.2–0.9 0.024 Central and Eastern Europe (23). These region-specific North America 3.5 1.9–6.4 <0.001 Western Pacific 0.5 0.2–1.3 0.16 differences in the percentage of research scientists who South America 1.9 1.0–3.8 0.06 are women are especially interesting considering that Position international scientific society perceived barriers varied across regions in this study. South East Asia 0.4 0.2–0.9 0.031 While this could be due to local social norms and cul- North America 2.3 1.2–4.4 0.015 tural influences, it might also be in part due to differ- Western Pacific 0.5 0.2–1.2 0.11 ences in response rate per region or potential response South America 3.1 1.3–7.3 0.008 biases. Nonetheless, it is fair to postulate that depend- Speaker/chair international scientific society meeting ing on the region, different barriers to career progres- South East Asia 0.8 0.4–1.8 0.57 sion might be more pressing and might require different North America 3.0 1.6–5.5 <0.001 Western Pacific 1.1 0.5–2.6 0.80 interventions. South America 3.0 1.4–6.3 0.004 This study has some limitations. Firstly, given that Participation in conferences this was a survey study, there is potential for responder South East Asia 1.0 0.5–2.2 0.97 bias. As we wanted to give all individuals working in North America 2.5 1.4–4.4 0.002 the headache field the chance to participate, we con- Western Pacific 1.4 0.6–3.1 0.43 tacted the whole IHS membership database and also South America 3.7 1.8–7.8 <0.001 allowed national representatives to send survey links to Attention at meetings/conferences their members and responders to be anonymous. We South East Asia 0.9 0.4–1.9 0.7 contacted all IHS affiliated national societies (the full North America 2.8 1.5–5.0 0.001 Western Pacific 1.9 0.8–4.5 0.12 list can be accessed from the IHS website https://ihs-h South America 1.9 1.0–3.7 0.07 eadache.org/en/about-ihs/affiliate-member-societies/), but we cannot know for sure which representatives (continued) actually circulated the survey, as this was voluntary. 1506 Cephalalgia 42(14) This meant that we were unable to determine the Climate and culture must be addressed together. response rate. While unfortunate, we considered the Efforts to build a good climate will be unsuccessful if need for all voices to be potentially heard more press- the policies conflict with the values of an organization ing. Nonetheless, a possible language barrier could (24). Thus, addressing and improving organizational have prevented some headache professionals from culture and climate is essential to make underrepresent- responding. Additionally, only 2.4% of respondents ed groups feel welcome, supported, and respected. were Black or African American and 4.0% were Non-surprisingly, many advocates are tired of initia- Hispanic or Latino, which may make the results of tives that focus on the actions of individuals from this study less generalizable to these groups. This underrepresented groups as being the problem, and leads to the discussion regarding underrepresentation making changes to their actions being the solution. of some races and ethnicities in the headache field. These initiatives may presume a masculine heteronor- Moreover, as very few responders were located in mative and Caucasian homogeneous view of the world African and Eastern Mediterranean countries, we also and thus automatically require underrepresented indi- had an underrepresentation of individuals from those viduals to change to fit into the existing dominant regions. Underrepresentation based on ethnicity or system, rather than the system changing to accommo- geographical location led to lack of diversity in the date and nurture the needs of its members. The respon- sample. In addition, race and ethnicity were collected sibility of making a cultural shift cannot be made by together rather than as separate variables, so some the underrepresented individuals themselves as in many specificity may have been lost. We were unable to cases they do not have the power to affect change. include all characteristics that could be the base of Change must occur at the level of the institution, discrimination in our survey; for instance, we did larger systems and broad shifts in cultural norms and attitudes. To achieve real inclusivity, we propose sev- not study the effect of sexual orientation and disabil- eral approaches on individual, local, and (inter-) ity. Finally, it is a self-report survey of perceived bar- national levels (Figure 4). riers to career achievement. There were no outside Providing a safe space for conversations about supporting data used to substantiate respondent inclusivity and diversity must be a goal to improve reports; however, the subjective nature of the data cultures and a responsibility of leadership. Therefore, are useful to report on the perception and beliefs of leaders at all levels should sent clear messages about the respondents. the value of women and individuals from underrepre- While our findings may not be surprising regarding sented races, ethnicity, religions, sexual orientation, perceived barriers by women and people from specific gender identity and countries (25,26). Successful pro- global regions, it is the first time that these barriers are grams aimed at changing culture and climate require being surveyed in the professional field of headache committed resources, for instance sensitivity training of care and research to our knowledge. From our findings hiring staff, and formal recognition that striving we can conclude that there is a continuing need to mon- towards diversity is part of the goal and responsibility itor if enough progress is made for women and people of leaders. There is also an important role the scientific from underrepresented global regions in (academic) societies should play in advocating and modeling headache medicine and healthcare and to improve equality. Explicit statements can change opinions and upon the current gains in equity. clear actions can make an even bigger impact. In addi- Factors contributing to these career barriers are tion, scientific societies should be committed to orga- often multidimensional with potential problems with nizing inclusive conferences, not only in attendees, but individual, interpersonal and societal–institutional also in terms of speakers, panels and organizing com- aspects. Moreover, there are often different nuances mittees (27,28). The presenting faculty at a meeting at different stages of the career path (16). There is a should include individuals from underrepresented need for targeted interventions to counteract social races, ethnicity, religions, sexual orientation, gender stereotypes, transform “masculine” workplace cultures, identity and countries, and be a representation of end discriminatory behaviors, and promote processes the people working in the field and members of the to include women and other underrepresented minori- organization. This should also be the case for society- ties in a transparent format. The critical question is endorsed conferences. Hybrid conferences and scholar- why there is a lack of retention of women and how ships with both in-person and virtual participants can the culture at the working place can be changed to be helpful to increase participation rates throughout promote women to leading positions, hence creating the world, overcoming financial and geographic bar- equal opportunities. riers for participation. Besides voluntary tools for de Boer et al. 1507 Clinician/scientist: Hospitals/centers: • Leaders send a clear message • Provide training in diversity and gender equality • Become allies • Recruit diverse employees • Identify mentors* • Implement policies that • Identify network opportunities foster an inclusive workplace • Identify sponsors* • Ensure pay equity • Provide resources International scientific societies: • Advocate equality • Ensure diversity in committees • Ensure diversity in invited speakers and chairs at congresses • Implement transparent election processes • Promote pay equity for consulting work • Provide network opportunities • Provide opportunities for identifying mentors Figure 4. Approaches to help promote inclusivity and diversity in the headache field. *Both mentors and sponsors can be crucial. Where mentors serve as guides, help solve potential issues and tell mentees that they can do the job, sponsors serve as cheerleaders and speak out about a sponsee publicly and tell others that the sponsee can do the job. organizational change, legislated approaches such as work together). Another useful concept that everyone the use of quotas may also be considered. Quotas are can imply is allyship or sponsorship. In allyship an instrument aimed to accelerate the achievement of members of organization in a position of privilege or diversity by establishing a defined percentage of power seek to operate in solidarity with underrepre- positions, which are allocated to specific groups of indi- sented groups. As an example, it could involve viduals. The concept of quotas often elicits a strong speaking up and supporting women and calling out and adverse response, with claims that quality of discrimination. Some actual instances of sexism work will be affected. While there is limited research experienced by headache healthcare professionals and on the usefulness of quotas, there are indications that effective strategies and actions to take to support they can have positive effects (29). While they are women were already suggested (31). Effective allyship not the only answer, they are a tool that should be requires self-awareness, commitment, respect and considered. hard work (32,33). However, to inspire cultural Another approach to combat career barriers is ade- change a combination of interventions will likely be quate mentorship. Mentoring is associated with objec- necessary (26,34). tive and subjective measures of career success (30). Striving towards an inclusive climate should be a Many participants already indicated that they had continuous process, not a final destination. Setting mentors, however women less frequently acted as men- and measuring predetermined milestones is important, tors compared to men. Finding a mentor should not but any organization should strive to always be diverse solely be the responsibility of underrepresented individ- and inclusive. Now that we know which barriers are uals. There also lies a responsibility for providing ade- being perceived by healthcare professionals, academics quate mentors within centers and scientific societies. and scientists in the headache field, we can start work- Our data show that in one third of cases the mentor ing together towards establishing an ever more inclu- has a mutual interest, (e.g. doing scientific or clinical sive, nurturing and welcoming domain. 1508 Cephalalgia 42(14) Article highlights • Gender is an important barrier to career achievements in the headache field. • Specific perceived career barriers are different across world regions. • Country of birth is a barrier for participation in international scientific societies. • (Inter-)national headache organizations should be aware of these barriers and ensure an equal position for all members independent of gender, ethnicity, geographical location or other personal characteristics. Acknowledgements Dutch Hearth and Brain Foundations, Dioraphte and We kindly thank Carol Taylor for her assistance in distribut- IRRF, she reports consultancy or industry support from ing the survey. Novartis, Lilly and Teva, Allergan (Abbvie), Lundbeck. Declaration of conflicting interests Funding The authors declared the following potential conflicts of The authors disclosed receipt of the following financial sup- interest with respect to the research, authorship, and/or pub- port for the research, authorship, and/or publication of this lication of this article: article: This work was supported by a granted project pro- IdB reports independent support from the International posal by the International Headache Society. Retinal Research Foundation and Dutch Heart Foundation. AA reports consultancy or industry support ORCID iDs from Novartis, Eli-Lilly and Teva. RBHS reports a research Irene de Boer https://orcid.org/0000-0002-7261-762X grant from Amgen. BB has nothing to disclose. DCB has Cristina Tassorelli https://orcid.org/0000-0003-1513-2113 received research funding from the US Food and Drug Patricia Pozo-Rosich https://orcid.org/0000-0003-0796- Administration, the National Headache Foundation and 4702 Amgen. She has also received consulting fees from Amgen, Allergan/Abbvie, Lilly, Lundbeck and Teva. CT has received honoraria as a consultant and speaker for Amgen, Allergan/ References AbbVie, Almirall, Biohaven, Eli Lilly, Lundbeck, Medscape, 1. Levine SS, Apfelbaum EP, Bernard M, et al. Ethnic Novartis and Teva Pharmaceuticals. Her research group has diversity deflates price bubbles. Proc Nat Acad Sci USA received research grants from Allergan/AbbVie, EraNet 2014; 111: 18524–18529. Neuron, Italia Ministry of Health. Her Institution has 2. Østergaard CR, Timmermans B and Kristinsson K. Does received payment for clinical trials from AbbVie, Eli Lilly, a different view create something new? The effect of Lundbeck, Novartis and Teva Pharmaceuticals. 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