Gender balance and suitable positive actions to promote gender equality among healthcare professionals in neuro-oncology: The EANO positive action initiative

Abstract Background The proportion of women among healthcare and biomedical research professionals in neuro-oncology is growing. With changes in cultural expectations and work-life balance considerations, more men aspire to nonfull-time jobs, yet, leadership positions remain dominated by men. Methods The European Association of Neuro-Oncology (EANO) disparity committee carried out a digital survey to explore gender balance and actions suitable to promote gender equality. The survey was distributed among EANO members in 2021, with responses analyzed descriptively. Results In total, 262 participants completed the survey (141 women, 53.8%; median age 43). Respondents were neurosurgeons (68, 26.0%); neurologists (67, 25.6%), medical oncologists (43, 16.4%), or other healthcare or research professionals; 208 participants (79.4%) worked full-time. Positive action to enforce the role of women in neuro-oncology was deemed necessary by 180 participants (68.7%), but only 28 participants (10.7%) agreed that women only should be promoted until gender balance is reached. A majority of respondents (162, 61.8%) felt that women with an equivalent CV should be prioritized over men to reach gender balance. If in the future the balance favored women at higher positions, 112 respondents (42.7%) agreed to apply positive action for men. The top indicators considered relevant to measure gender balance were: salary for similar positions (183/228, 80.3%), paid overtime (176/228, 77.2%), number of permanent positions (164/228, 71.9%), protected time for research (161/227, 70.9%), and training opportunities (157/227, 69.2%). Conclusions Specific indicators may help to measure and promote gender balance and should be considered for implementation among healthcare professionals in neuro-oncology.

Both men and women are exposed to conditions at work that may affect their physical or psychological health.Additionally, both genders face the challenge of finding a balance between work and private life.There is a trend toward a more global sex-neutral workforce contributing to the economy. 2o promote equal opportunities for men and women, gender-based positive action measures could be introduced.These could focus on removing existing inequalities that affect women's opportunities.For a measure to be acceptable as positive action for women in employment and education, it should be based on clear and unambiguous criteria and should address specific career inequalities and help women to conduct their professional life on a more equal footing with men. 3 Compared with other domains of professional life, gender disparities are probably less dominant in medicine.This includes neuro-oncology, where females constitute a large proportion of the workforce already.While the number of women among healthcare professionals is still growing and more men aspire to nonfull-time jobs, the leadership positions remain mainly dominated by males. 4- 6In this survey, we aimed to evaluate indicators that might potentially be useful to measure gender balance in neurooncology and to inquire which actions could be suitable to promote gender equality among healthcare professionals in the field of neuro-oncology.

Design and Participants
A digital survey using SurveyMonkey was developed by the members of the Disparity Committee of EANO and sent out from 2 September, 2021 until 31 December 2021 to the membership of EANO using the email list of the organization.To increase the response rate, a reminder was sent out 2 weeks later, and presidents of national neuro-oncology organizations throughout Europe were contacted with the request to distribute the survey among their respective membership.
The survey was available in English only and consisted of 3 parts, related to: (i) sociodemographic characteristics, comprising 13 questions; (ii) examples of positive actions that could be suitable to promote gender equality, comprising 19 questions; and (iii) indicators that might potentially be useful to measure gender balance, comprising 13 questions.The complete survey can be found in Supplemental File 1. Participation was anonymous.

Statistical Analyses
Survey answers were exported directly from SurveyMonkey to SPSS software (IBM version 25.0) for analysis.Descriptive statistics were used to report the sociodemographic characteristics of the respondents as well as the responses to the categorical items in the survey.For comparisons between men and women, χ 2 tests were used.A P-value < 0.05 was considered statistically significant.

Respondents
A total of 302 colleagues opened the survey of which 262 colleagues (87%) answered at least one question related to positive action.Only these 262 respondents were taken into account in the statistical analyses.
Out of the 262 respondents, 141 respondents (53.8%) identified themselves as females.Three participants (1%) did not wish to disclose their gender and another 3 individuals did not answer.The median age was 43 years (range: 25-73), and 95% of the respondents were residents of European countries.1).
There were no differences in sociodemographic characteristics between men and women, except for the living situation.Women lived more often alone (17.7% vs 5.2%) and less often with a partner and children (40.4% vs 61.7%) than men, and a lower proportion of women spent >5 h per week outside of office hours on research activities than men (37.6% vs 60.0%).

Positive Actions to Promote Gender Equality
The results with respect to positive actions to promote gender equality for women are presented in Table 2.The majority of respondents (180/262, 68.7%) indicated that it was relevant (ie, scored as "quite a bit" or "very much" on a 4-point Likert scale ranging from "not at all" to "very much") to initiate positive action to enforce the role of women in neuro-oncology.There was no statistically significant difference between women and men in this response.If a gender disbalance was identified, respondents thought this should be preferably addressed immediately (121/262, 46.2%).Only a small proportion of respondents (28/262, 10.7%) agreed that women only should be considered for certain roles until the gender balance has been reached.If deemed appropriate, this would concern the roles of department chairs in 41.6% (109/262), assistant or associate professors in 37.4% (98/262), or senior physicians in 30.5% (80/262).The majority of respondents (172/262, 65.6%) did not agree with the statement that women with an inferior CV compared with male competitors should be given a position to reach gender balance.In the case of an equivalent CV, only 10.3% (27/262) of respondents indicated that they did not agree that the position should be given to women; instead 162/262 (61.8%) of respondents indicated that this action would be appropriate to reach gender balance.Moreover, most respondents did not agree (176/262,

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Neuro-Oncology Practice 67.2%) with the statement that women should be put under pressure to accept a position with a high level of responsibility to reach gender balance.Most respondents (112/262, 42.7%) did not agree that higher positions with responsibilities should be fulfilled only by people who work full-time.Respondents were not in agreement on whether there is a risk of limiting career opportunities for women when developing gender equality rules, with 29.8% (78/262) not agreeing compared to 11.5% (30/262) and 8.0% (21/262) agreeing "quite a bit" to "very much, " respectively.Similarly, if the future balance favored women in higher positions, only 42.7% (112/262) of respondents agreed to apply positive action for men, with more women agreeing "quite a bit" or "very much" (51.1% of women vs 20.2% for men, P = .014).
When asked which topics would be appropriate for positive action (Figure 1, Table S1), respondents rated career breaks for pregnancy, maternity, paternity, or adoption leave (135/260, 51.9%), caring responsibilities (44.6%, 116/260), ethnicity/race (42.9%, 111/259), and disability (39.5%, 102/258) as most relevant.Ethnicity/race and social class were rated significantly more often as relevant (both P = .017)by women than by men.Religion/ belief and sexual orientation were rated as least relevant, by 10.4% (27/260) and 15.4% (40/260) of respondents respectively.In the free comments, several respondents indicated that people should be hired based on their competency, skills, qualifications, and merit, regardless of sex or ethnicity.

Possible Indicators to Measure Gender Balance
The top five indicators that were deemed relevant (scored as "quite a bit" or "very much") to measure gender balance in neuro-oncology were salary for a similar position ) were deemed least relevant.In general, a higher percentage of women rated the possible indicators as relevant compared to men, but the top five indicators were similar (Figure 2).Lastly, 164 of 232 respondents (71%) agreed that the same criteria to measure gender balance should be applied to men in the situation where women outnumber men in higher positions (Table 3).

Discussion
The present study is part of the efforts of EANO to understand the role of gender imbalances and their impact on the development of a balanced, qualified workforce serving patients, caregivers, and research in neurooncology across Europe.Given the membership of EANO of 659 individuals in 2021, the response by 262 individuals indicates that this topic is considered to be of interest.The majority of responders came from clinical neuro-oncology, reflecting the membership of EANO.Since the survey was also distributed across national neuro-oncology groups, we have no information on how many respondents were actually EANO members.
The work profile characteristics of respondents indicate that neurosurgeons are more often men (23/43: 53%), whereas respondents were more often women in other disciplines (neurology: 40/65: 62%; radiation oncology: 20/33: 61%, medical oncology: 23/43: 53%).Women live more often alone and allocate less time to research activities outside of working hours than men (Table 1).There was generally a positive view on action to support the career opportunities of women in neuro-oncology (Table 2).However, a majority of responders would not support that women with an inferior CV would be given priority for positions until a gender balance has been achieved.Interestingly, once women might have taken over the majority of higher positions, there was still no majority to apply positive action for men, at least in the current situation where the survey was conducted.
Most of the parameters proposed in the survey to assess whether the gender balance has been achieved were considered useful by the respondents (Table 3), but for some statements, including the same salary for a similar position or the same compensation for paid overtime, one might argue that these should be implemented as indicators of balance immediately, if not already equal between genders.To obtain permanent positions and secure protected time for research may require more time and training and education opportunities for women notably in some countries where the academic workforce is still very dominated

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Neuro-Oncology Practice by men at present, but these figures should already be monitored.
Limitations to positive discrimination include the need to consider biological differences, such as physical strength, but these should not be overrated. 2Pregnancy and parental leave will continue to shape career paths, likely in a profession-and country-specific manner.Personal choices of lifestyle and career choices have also to be considered.Both men and women engaged in neurooncology are regularly confronted with severely ill and understandably demanding patients and may be exposed to sources of irradiation and potentially toxic agents when administering tumor pharmacotherapy.As seen in this survey, more than 20% of respondents declared spending more than 10 hours on research activities outside of office hours, demonstrating their personal engagement.Looking at the results directly, most respondents did not feel that full-time employment was required to assume leadership roles.
Surveys such as the present one have inherent limitations.The sample size was rather small, given the likely heterogeneity of age, profession, country, and setting of work positions.We did not learn about the attitudes of the large number of colleagues who were invited but decided not to respond.Further, surveys collect opinions and experiences which are necessarily subjective, and not data.Importantly, the survey did not address an association between gender and quality of care.It has been claimed that the rates of morbidity and mortality are lower with female than with male physicians in certain domains of medicine [7][8][9] but such analyses need to be interpreted with caution, and it remains open whether considerations apply to contemporary neuro-oncology.
The current recommendation of some institutions, such as the EU Clinical Trials Expert Group (https:// ec.europa.eu/transparency/expert-groups-register/screen/home?lang=en), to use curriculum vitae without personal data, including omission of birth date, gender, nationality, would limit positive discriminatory actions.Lastly, positive discrimination and follow-up of key indexes, even if encouraged by professional societies, can currently probably only be performed at the institutional level.
In light of this, EANO can contribute significantly by prioritizing the promotion of training and mentoring for motivated females.Concentrating efforts in this area would be a reasonable task to undertake.Gender balance serves as a powerful source of inspiration and motivation for future generations of healthcare professionals.It helps create an environment where individuals are evaluated based on their skills, qualifications, and expertise rather than predetermined gender roles.The disparity committee of EANO takes a proactive stance in fostering gender balance, equity, and inclusivity within various programs such as mentoring and webinar series.This vision strengthens the field and creates opportunities for individuals to excel based on their abilities, ultimately benefiting, and advancing the field of neuro-oncology as a whole.

Figure 1 .Figure 2 .
Figure 1.Overview of the percentage of women and men rating the examples of positive actions as relevant (scored as "Quite a bit" or "Very much").

Table 1 .
Sociodemographic Characteristics For All Respondents, and Males and Females Separately.

Table 2 .
Positive Actions to Promote Gender Equality for WomenDo you agree with positive action to enforce the role of women in neuro-oncology?
Do you agree that women only should be considered for certain roles until the optimal gender balance has been reached?

Table 2 .
ContinuedDo you agree that women should be put under pressure to accept a position with a high level of responsibility if gender balance needs to be reached?If in the future the balance would favor women at higher positions, would you agree to apply positive action for men? †

Table 3 .
Possible Indicators to Measure the Gender Balance in Neuro-OncologyIn your opinion, should the following aspects be used to measure gender balance (ie, measured separately for women and men, and subsequently be compared)?

Table 3 .
ContinuedNumber of times participating in scientific meetings/ conferences supported by the institution?† Lastly, would you accept the same criteria to maintain gender balance for men when women will outnumber men in higher positions?