Achieving health equity in global health through workforce diversity

This International Women’s Day we honor the achievements of women leaders working to advance the health and well-being of people all over the world. Their path to success was certainly not easy. It was fraught with numerous challenges; challenges that are not only experienced by those of us working in global health but by women across all industries.

We are considered either too soft and feminine or too bossy and pushy to be seen as competent leaders. Our work culture lacks family-oriented, work-life balance policies which enable us to contribute to our field in significant ways. We lack female mentors to encourage us to grow and push us to overcome any obstacles we encounter in our career. We work for organizations where the people who make the big decisions on what policies and programmatic areas to focus on are men. The struggles we face trying to advance in our careers are reflected in the lack of gender equality in the global health workforce. While women make up 70% of the global health workforce, only 25% of leadership positions in global health are held by women.

We have known for a long time that when women are given equal opportunities for leadership at all levels of decision-making in economic, political, and public life, everyone in society does better. Female leaders in health “promote access to contraceptives, empowerment programs for girls, women’s rights to family planning and maternity care, safe abortions, and protecting environmental assaults on children’s health.” In addition, women leaders at all levels of governance have shown to be the primary driver toward financing public goods such as health, education, hospitals, clean water, and sanitation. Women’s participation and leadership in economic, political, and public life is so critical to advancing societies that it is even written into one of the sustainable development goals. When women have a voice at all levels of decision-making, we are closer to eliminating the inequities that lead to disparities in health.

More global health organizations are recognizing the need for women leaders and organizations such as Women in Global Health are working toward achieving gender equality in global health leadership. Last year the World Health Organization’s newest Director-General, Dr Tedros Adhanom, appointed eight women to senior leadership, effectively outnumbering the men. In doing so, he took one big leap toward achieving gender equity at the WHO – a goal that was first set in 1997 and that took two decades to realize.

Gender equality is not the only type of diversity we need to strive toward in our global health leadership however. Diversity in global health leadership must also focus on inclusion of people from different ages, race and ethnicity, sexual orientation, social class, geography, religion, and other characteristics of personal identity.  As a woman and a first-generation Filipino-American working in global health in the United States, I often find myself at global health and public health conferences and meetings wondering why there are very few leaders that encompass the diversity that I represent on stage (and occasionally even in the audience). The people who make the decisions with the biggest impact in global health must reflect the diversity of the people we serve.  

Learning from, understanding, and seeing the world through another person’s point of view is at the heart of working in global health and a driving reason for why I chose to work in this field. In order to truly reflect the diversity of this field though, the definition of diversity itself needs to go far and beyond the characteristics of one’s personal identity. To fully be inclusive, we must also be open to learning from, understanding, and seeing the world through the perspectives of individuals in the global health workforce with diverse backgrounds, life experiences, and competencies. Our field could benefit from the ideas of diverse individuals in solving some of the world’s most pressing global health problems. These ideas cannot always come out of our own echo chambers. 

Achieving diversity in the global health workforce is everyone’s job. It requires each one of us to recognize and overcome the personal biases (whether they are subconscious or not) which prevent us from hiring and working with more diverse talent. For those of us responsible for making decisions, we must work to create policies at all levels which not only promote but require inclusion. It’s only then that we can achieve true diversity in our workforce and our leadership. It’s only then that we can progress further in achieving health equity.

Stay tuned for part two of my series on Achieving health equity in global health through workforce diversity in which I will discuss different ideas for how we can achieve diversity in the global health workforce.


IHSC career development webinar recording “En Route from the Ebola Tent to Congress” now available

The APHA International Health Student Committee hosted a webinar called “En Route from the Ebola Tent to Congress” on September 27, 2017 with Deborah Wilson, RN and MPH candidate at Johns Hopkins Bloomberg School of Public Health. Debbie led an interactive webinar walking attendees through a day in the life of an Ebola Treatment Center, including a bit about the political fallout upon returning to the USA, and how her experiences shifted her from direct patient care to public health policy.

If you have any questions, please email:

Health Literacy: Is Educational Attainment Enough?

This is a guest blog post by Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. It is the second blog  in a three-part series the IH Blog will feature this summer, Global Health Literacy: Conceptual Basis, Measurement and Implications.

Part II: Health Literacy: Is Educational Attainment Enough?

For over a decade I worked in primary care practices providing health education to patients with a broad range of educational and professional backgrounds, from persons who had dropped out of high school to those with dual doctoral degrees. I recall that when I first started I assumed that persons with higher levels of educational attainment would more readily understand and incorporate health education into their daily lives. I soon realized that I was entirely wrong. While persons who had higher levels of education were somewhat more likely to comprehend health information, a large proportion of these persons were unable to adequately understand and act on the health information presented to them. I remember sitting with a patient who had a doctoral degree who explained to me how his depression medication worked best when taken only on Sundays. Conversely, one patient who had not completed high school explained to me the intricacies of high blood pressure management with such clarity that it would have rivaled any veteran educator’s attempts at explaining it. All of these experiences fostered my interest in this concept of health literacy. What was health literacy? How could we adequately measure and improve it? What caused poor health literacy? Was it poor communication, a lack of numeracy skills, cultural barriers or other factors? The complexity of these questions fascinated me and I have pondered them over the last several years in my research.

In recapping my exploration let’s start by discussing how health literacy was initially distinguished from educational attainment. Much evidence has demonstrated that social factors occurring outside of the clinical encounter, namely education and income, profoundly influence health outcomes. Health disparities based on population (e.g. age, race, class, disability) or geographic residence (e.g. neighborhood, urban, country) are significant and have been the subject of much investigation. While a myriad of indicators have been explored in relation to such disparities, many investigations report that educational attainment is the most influential predictor of health. This relationship has been substantiated in a wide range of settings and time periods as well as by the application of varying methodological approaches and indicators of health. Educational attainment improves health through mechanisms on the individual level (e.g., health literacy and skill development); community level (e.g., location of residence characteristics); and macro level (e.g., policies, legislation, infrastructure).

The term health literacy (HL) was introduced and differentiated from educational attainment or literacy beginning in the 1970’s. During this time it was found that while one’s HL level was related to educational attainment (years of schooling) or reading ability/literacy, there was not a perfect linear correlation between educational attainment/literacy and HL. Research showed that individuals who functioned successfully at home or work often lacked adequate literacy to function within the context of a health care system. While varying opinions on the definition of HL have existed over time and are the subject of ongoing debate, generally speaking, being health literate meant that one could read, understand, and act on health information that was provided to them. HL encompassed proficiency in more than just reading ability but also writing, speaking, and listening as well as computational abilities (numeracy). A health literate individual was able to understand health information and use that health information appropriately. For example, a health literate elderly adult who received instructions from a primary physician on how to take medication for blood pressure would both understand the instructions and then take the medication as instructed by the physician. Thus, those with low HL were unable to adequately function within the healthcare environment increasing their risk for poor outcomes.

Some recent initiatives have sought to document stories related to health literacy. To this end, the U.S. federal government hosted an initiative called ‘Stories from the field’ as a part of a program to reduce the burden of low HL. In one story a doctor in Wisconsin struggled with his patients’ lack of comprehension of his instructions during medical encounters. He pondered whether it was poor communication on his part or whether there were other causes. After research and reflection he identified low HL as a prominent underlying cause and founded a small statewide literacy organization aimed at improving low HL called Wisconsin Literacy.

In order to address what has been called a “Health Literacy Epidemic,” both governmental and non-governmental initiatives have been developed to improve HL and in turn, reduce it’s public health burden. A transdisciplinary approach has been encouraged and specific guidelines have been established to foster improved communication. The U.S. Department of Health and Human Services (HHS) developed a National Action Plan to Improve Health Literacy. Broad goals and strategies of this plan are to improve HL in every sector and organization that provides health information and services. With the aim of fostering effective communication the federal government created The Plain which is an internet clearinghouse of information pertaining to the use of clear and understandable language. This initiative defines plain language as “… communication your audience can understand the first time they read or hear it. Language that is plain to one set of readers may not be plain to others.” The Plain Language Action and Information Network (PLAIN), a group of federal employees from many different agencies and specialties who support the use of clear communication in government writing, work to manage the initiative’s website. The Partnership for Clear Communication was established to spread awareness and address the issue of low HL. It established the “Ask me 3” program which informs healthcare consumers of 3 questions that should be asked during a medical encounter: (1)“What is my main problem?” (2) “What do I need to do?” (3) “Why is it important for me to do this?”  The Health Literacy Tool Shed, is a database created and administered by Boston University and the National Library of Medicine to foster collaboration and resource-sharing related to health literacy. The online search engine includes 129 tools related to the assessment of health literacy which range in terms of their purpose and design. They are either general in scope or focus on a certain domain(s) within the construct of health literacy (e.g. numeracy). Many of these tools aim to assess HL related to a specific medical condition (e.g. arthritis or cancer), categorization of health (e.g. oral health) or population (e.g. Dutch, Japanese).  Some tools were developed for rapid assessment.

For the global examination of HL the Institute of Medicine Roundtable on Health Literacy was convened to bring together leaders in the global health field to discuss activities and progress around the world related to HL. The United Nations as well as over a dozen countries were present at this meeting. The roundtable discussed different country’s unique approach to addressing low HL. For example, in Australia HL initiatives are part of the national Commission on Safety and Quality in Health Care. Canada connects HL with health promotion activities and the public health sector governs HL initiatives. A consensus from the meeting was that educational systems do not provide their students with the skills to adequately use health information and access health services. Furthermore, participants agreed that there was a lack of capacity for health care services to meet the needs of persons with low HL. This was accompanied by a lack of data on the nature and scope of the problem of low HL as well as the effectiveness of interventions targeting HL. This issue was particularly pronounced in LICs and LMICs, in which very little research had examined HL in any form.

Given the lack of evaluation of HL in LICs and LMICs there is an urgent need to develop a measure HL that can be feasibly employed. Establishing a measure that can assess the burden of low HL as well assess it’s relation to health outcomes is important so that effective interventions can be developed and deployed. Please stay tuned for Part III: The Evaluation and Measurement of Health Literacy in which I discuss my research group’s work in creating and establishing a measure of HL for use in LICs and LMICs.


Dr. Heather F. de Vries McClintockis currently Assistant Professor of Public Health at the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and improve health literacy and the quality of care provision for persons in Sub-Saharan Africa.

Innovative Malaria Research in Southeast Asia: a UCI GHREAT Initiative (Video Review)

by Niniola Soleye

The University of California, Irvine (UC Irvine) recently released the first video in their four-part series showcasing the success of their Global Health Research, Education and Translation (GHREAT) Initiative. The initiative is headed by IH section member Dr. Brandon Brown. The goal of the video series is to demonstrate how GHREAT projects are enhancing health and saving lives all over the world. This first video was shot in Thailand and focuses on malaria research in Southeast Asia.

Myanmar has the largest number of malaria cases in Asia. Due to the poor economic conditions in the country, people immigrate to neighboring countries, including Thailand, to look for employment opportunities. Additionally, there has been an increase in drug-resistant malaria and an influx of counterfeit drugs. That, coupled with poverty and people not having funds to travel to the hospital or buy medicine, has resulted in malaria becoming a major public health problem in the region.

UC Irvine faculty, staff, and students partnered with the ministry of health, hospital workers, local health workers, and academic researchers in China, Myanmar, and Thailand to study malaria control in the border regions, and develop solutions for containing the malaria outbreak.

The video shows the UC Irvine team observing local health workers as they perform diagnostic blood-tests for malaria in Thai villages. Their observations led them to focus their efforts for this project on developing an innovative, non-invasive diagnostic test using saliva instead of blood.

Untreated, malaria can lead to death two to three weeks after infection, so early diagnosis and treatment are key. Blood testing requires workers to send samples away daily, delaying the start of treatment. Using saliva would allow for a fast, portable, low-cost diagnostic tool, all critical factors in a developing country setting.

One scene that stood out showed a young child getting tested for malaria. She was crying because she didn’t want to get her finger pricked, and also because she was afraid of the health worker. In situations like that, the new test would be quite beneficial.

Overall, the video does a good job of emphasizing how direct, firsthand experiences and observations are important when trying to innovate and solve problems in global health. I would have liked to hear more about the technique behind the saliva test, their border control efforts, how they plan to deal with the counterfeit drug problem, and how they’ll address drug-resistant malaria but the video doesn’t go into detail on those topics.

Click here to watch the video.

Mahila Mandals: Case Studies from Mumbai, India

The following post was written by Sarah Simpson, MPH-Epidemiology Candidate at the University of Medicine and Dentistry New Jersey. Sarah is an IH section member who has contributed to the blog previously. The following post is about her winter internship in Mumbai, India.

ssimpson_mumbaiHome to more than 18 million people, India’s most populous city, Mumbai, continues to be an attraction for millions looking for a better life for themselves and their families. Migrants from different parts of India, religions and cultures end up in the crowded slum communities around Mumbai. This past winter I had the opportunity to learn about urban health issues in these slum communities along with 20 other students from around the US and the world for three weeks at the Tata Institute of Social Sciences (TISS) in Mumbai.

My project group and I sped around town in rickshaws, trudged through sludge, and dust to study urban health issues in the slum areas of Shivaji Nagar. Located in the M Ward and home to some of the largest slums in India, about 600,000 people live in this area, which is located near the Deonar dumping ground, a man-made mountain of debris and trash. The health of the urban poor is complicated by many issues ranging from waterborne illnesses to infectious and communicable diseases, and when compounded by inadequate nutrition and overcrowded and poorly constructed living conditions makes for a dire situation for millions of people.

During our first day, we were introduced to the “Mahila Mandals” or women’s groups there are instrumental to addressing these public health issues. Parts of Shivaji Nagar are plotted slum areas recognized by the government; however they have minimal access to facilities and services provided by the Brihanmumbai Municipal Corporation (BMC). Imagine sharing 28 bathroom stalls (14 for men, 14 for women) with 1,000 other people and as you can imagine they quickly become unsanitary. The breakdown of government services has lead to the organization of community based organizations such as Mahila Mandals.

Instead of using a needs-based or problems-focused approach which would highlight only the worst aspects of a community, we decided to highlight the community’s assets by writing a case study using SWOT (Strengths, Weakness, Opportunities and Threats) Analysis to help us investigate how to best utilize these important community assets. We interviewed 6 Mahila Mandal groups consisting of some registered and unregistered groups and varying in size and number of members. We concluded that not only do the Mahila Mandals work to solve issues with sanitation, but they also promote immunization of children, maternal and child health education and resolve domestic violence issues. However, their impact is limited mostly due to funding and support from the local community.

At the end of our study, we recommended that the government provide more funding and implement community-based participatory research programs which would allow the communities to identify, support, and mobilize existing resources to create a shared vision of change and encourage greater creativity in solving community issues. Two community organizations like these groups and community engagement are important for continued public health and social change. Further research is needed on how to best utilize these valuable community assets.

Our internship presentation can be found at:


  1. Mili, D. Migration and Healthcare Access to Healthcare Services by Migrants Settled in Shivaji Nagar Slum of Mumbai, India. TheHealth 2011; 2(3): 82-85
  2. P A Sharpe, M L Greaney, P R Lee, S W Royce. Assets-oriented community assessment. Public Health Rep. 2000 Mar-Jun; 115(2-3): 205–211.