Most of the world’s population lives in low- and middle-income countries (LMICs), but the research conducted there is underrepresented in major medical journals, and researchers face a variety of barriers to publishing their study findings. Recent efforts by medical journals and nonprofit groups seek to narrow the gap between publications from high-income countries (HICs) and LMICs and open the door to research that is more representative of global demographics and health care resources.
An analysis of studies published in five high-impact peer-reviewed journals — British Medical Journal, The Lancet, New England Journal of Medicine, Annals of Internal Medicine, and Journal of the American Medical Association — showed that in 2017 just 11.9% were from authors in LMICs. That figure showed a small increase from the same survey conducted in 2000, when 6.5% of articles came from authors in LMICs.1
In the meantime, nonprofit organizations are providing free or discounted access to high-impact medical journals and offering prepublication writing and editing support, while journals are increasing the diversity of their editors and discouraging so-called parachute research that extracts data from LMICs without providing credit to local researchers. The American Society of Hematology (ASH) is also helping to spotlight the research happening in LMICs and has launched the open-access journal Blood Global Hematology, which has no fee to submit articles and uses a sliding scale based on country income for publication fees.2
“There’s a very vibrant discourse happening in certain pockets of the publishing community,” said Ella T. August, PhD, clinical associate professor of global public health at the University of Michigan and editor-in-chief of the Pre-Publication Support Service (PREPSS), which helps researchers in LMICs get their work published in peer-reviewed journals. “But we have a long way to go overall.”
ASH Clinical News spoke with researchers in LMICs, journal editors, and organizations that assist those researchers with prepublication support and access to journals about the challenges and new initiatives to increase the publication of studies from LMICs.
Barriers Start Early
Researchers from LMICs can face several barriers to publishing research in high-impact journals, including publications fees, difficulty translating their research into another language, inadequate training on proper research methods, and cultural bias.
Felix Bongomin, MD, a lecturer at Gulu University Medical School in Uganda, said problems start at the beginning of the process with the development of a research question. Dr. Bongomin said he has worked with many colleagues who haven’t had the training in research methods to know which questions are appropriate for a study and how to develop ideas into a research protocol. “Someone has an idea, but the idea can’t be translated into a research question and objectives,” he said.
That lack of training can include academic writing skills, such as how to draft the background and justification for the project, developing a comprehensive literature search strategy, and even knowing how to use automatic reference software to make the citation process manageable when putting together a manuscript. “It looks so obvious to someone who has been doing it with the right people, but for the majority of people in LMICs, it becomes a real challenge,” said Dr. Bongomin, who learned these foundational research skills while training in the U.K. and U.S.
Today, Dr. Bongomin mentors other investigators in Uganda as part of a grant project with the Center for International Reproductive Health Training to build research capacity for reproductive health. Though Dr. Bongomin trained as a medical microbiologist and an internal medicine physician, he said the foundational skills are transferrable across clinical areas.
Time is also a barrier to submitting research for many. In LMICs, it is difficult to be a full-time researcher. Most researchers are also teaching, supervising students, and even working an outside job to make extra money, explained Madeleine Mukeshimana, PhD, a nursing educator and professor at the University of Rwanda.
Studies done by local researchers in Rwanda and other LMICs are often descriptive studies, case studies, or observational studies that may not be of interest to high-impact journals, Dr. Mukeshimana said. The language barriers can also create problems because it is harder for researchers to achieve the level of academic writing necessary for acceptance in a high-impact journal when they are not writing in their first language, she said.
Additionally, Dr. Mukeshimana said she has seen bias from journals in accepting work from LMICs. “Researchers from LMICs often face bias in the peer review process. For example, work from a high-income institution may be favored or perceived as much more credible,” she said.
Though Dr. Mukeshimana is a full professor at the University of Rwanda, if she wants to publish in a high-impact journal, she said she has a better chance of success if she partners with a researcher from an HIC so the work is considered “credible and given value.”
Dr. Bongomin, though, disagrees that bias is a factor. “I don’t believe it is a bias that if this study is coming from Africa, then it is low quality. I believe it is the rigor of the study,” he said. “When a study is rigorously conducted and well written, there’s no doubt that it can make it to the highest journal in the land.”
Several descriptive studies suggest a bias toward publishing articles that originate from HICs and highly regarded institutions. Additionally, a systematic review of randomized controlled trials (RCTs) that looked at whether geographic bias was at play in the assessment of research quality found that two of three RCTs indicated there was some form of bias affecting the peer review process.3
Partnerships, Journal Access
International partnerships can be one way to open doors for researchers in LMICs. Collaborations between researchers from HICs and those in LMICs bring funding, mentorship, and capacity building, Dr. Bongomin said. Funding can provide equipment and new technology that stays in the local country after a project has ended, but it can also help individual researchers learn to write grants, study protocols, and research papers, he said. When the researchers from the HICs leave, there is now local expertise that can be spread to others.
The collaboration also has benefits for the researchers from HICs who may have the research skills but not the local knowledge. “How we maneuver to solve local problems may also help them to solve their problems on the other side of the world,” Dr. Bongomin said. “At the end of the day, it’s about solving global problems.”
Dr. Mukeshimana has also had positive experiences with international partnerships, which can help with grant writing and getting published. However, she noted that making those connections can be difficult, especially for researchers who aren’t able to travel to conferences where that networking often occurs.
Research4Life, an organization that provides free or low-cost online access to scientific journals for institutions in LMICs through a health science collection called Hinari, works in partnership with five UN agencies including the World Health Organization and the World Intellectual Property Organization (WIPO), universities, the International Association of Scientific, Technical & Medical Publishers (STM), and more than 200 international publisher partners.
Gracian Chimwaza, PhD, director of the Information Training & Outreach Centre for Africa and a past chair of the Research4Life Executive Council, said that providing journal access allows researchers to stay current on scientific advances and assists in the development of their own research proposals and protocols. “Opening up this access is crucial for researchers,” he said.
A recent analysis by WIPO on the impact of Hinari found that it increased scientific output by up to 75% in LMICs. Academic paper output rose by 80% to 100% in the Caribbean, Central Asia, Europe, and Latin America, while clinical trial activity rose by up to 35% in East Asia, the Pacific, the Middle East, and North Africa.4
Research4Life is expanding its efforts beyond content donation to try to make other areas of knowledge exchange more equitable, including encouraging conferences to be held in areas in or near the global South, ensuring that committee roles are advertised globally, and calling on editorial boards to include representation by researchers from LMICs, said Sarah Phibbs, STM’s director of Research4Life publisher partnerships.
Some journals have already started to address diversity within their own ranks, said Dr. August. PLOS Global Public Health, a journal that launched in 2022, has two editors-in-chief who come from LMICs. They have also invited a diverse set of section and academic editors to be part of the journal.5 “These are the gatekeepers, but also they’re really in a position to help authors improve their work and get in the door for peer review,” Dr. August said.
BMJ Global Health and Lancet Global Health have made similar shifts toward diversity, including allowing for large author teams. Rather than cutting off the number of authors at six, for instance, they allow for all who meet the standard authorship criteria to be included, which is especially important for researchers from LMICs looking to secure future grant funding or advance their careers, she said.
Some journals will also allow for co-first and co-last authors, allowing more people to share in the power positions on a paper. “At the University of Michigan, for example, there’s no difference in the credit I receive for salary raises and promotion potential for being co-first versus first,” Dr. August said. “It’s a win-win to have more people getting credit.”
Beyond the Bubble
Giving more reach and visibility for the work of researchers in LMICs has benefits for everyone, researchers said. The COVID-19 pandemic and mpox outbreaks around the world are just some recent examples that disease knows no borders.
“North-south collaboration helps to solve many of these emerging global public health issues. At one point, diseases may appear to be geographically restricted to one place, but at some point, they will have global dissemination,” Dr. Bongomin said.
Not all research can be done in well-known universities in the U.S., said Jorge Cortes, MD, editor-in-chief of the new ASH journal, Blood Global Hematology, and director of the Georgia Cancer Center at Augusta University. While such work is of high quality, it is done in a “bubble” and doesn’t apply to most of the world because of the resources and characteristics of the population around the world. “What you can do in a rich country frequently applies to a much smaller part of the population globally,” he said.
HICs can also learn a lot from LMICs in terms of resource utilization and running more practical clinical trials, Dr. Cortes said.
References
- Woods WA, Watson M, Ranaweera S, et al. Under-representation of low and middle income countries (LMIC) in the research literature: ethical issues arising from a survey of five leading medical journals: have the trends changed? Glob Public Health. 2023;18(1):2229890.
- Publication fees. Blood Global Hematology. Accessed November 25, 2024. https://ashpublications.org/bloodglobal/pages/publication_fees.
- Skopec M, Issa H, Reed J, et al. The role of geographic bias in knowledge diffusion: a systematic review and narrative synthesis. Res Integr Peer Rev. 2020;5:2.
- Cuntz A, Mueller-Langer F, Muscarnera A, et al. Access to science and innovation in the developing world. Economic Research Working Paper No. 78/2024. Accessed November 25, 2024. https://www.wipo.int/edocs/pubdocs/en/wipo-pub-econstat-wp-78-en-access-to-science-and-innovation-in-the-developing-world.pdf.
- Robinson J, Kyobutungi C, Nyakoojo Z, et al. Editors as allies: our two-year experience at PLOS Global Public Health. PLOS Glob Public Health. 2023;3(11):e0002644.
ASH Launches Global Hematology Journal
The American Society of Hematology (ASH), in partnership with Elsevier, has launched a new open-access, peer-reviewed journal aimed at providing a global perspective on hematology research and a platform for researchers from LMICs.
The journal, called Blood Global Hematology, is part of ASH’s Blood journals portfolio. The journal is currently accepting manuscripts, with the first issue scheduled to publish in early 2025. Initially, the journal will be published quarterly.
The idea, which was developed by members the ASH Publications Committee, was to fill a gap not covered by existing journals to publish hematology research happening in LMICs. “[The committee] felt that providing a space where we learn more from what’s being done there — the type of research, the way they use resources, the characteristics of their population, regional guidelines — would be very valuable,” said Jorge Cortes, MD, editor-in-chief of the new journal and director of the Georgia Cancer Center at Augusta University.
Blood Global Hematology accepts original research, as well as population science, local and regional guidelines, health policy pieces, and resource utilization. “[Researchers in LMICs] may not be studying the newest drug, for example, but they are developing new approaches to handle specific needs that their population has, or they may be adapting some of the existing regimens because of either cost or the characteristics of the population or the availability of drugs,” Dr. Cortes said. “They become very creative, and they do very good research.”
Acknowledging that fees can limit many investigators’ access to research and prevent them from publishing their own, the journal is open access, and researchers will not be charged a fee when submitting research. There are article processing charges (APC) payable by authors or their institutions to cover costs associated with publication, but these are discounted based on the corresponding author’s country. For example, a full-length regular article has an APC of $3,000, but that fee is $600 for authors in LMICs and $0 for authors in low-income countries. The discounted rates are based on income categorizations from the World Bank.
Dr. Cortes said the journal is also seeking to break down barriers for researchers in LMICs by having broad global representation among its editors. The associate editors will represent different parts of the world, including Eastern Europe and Central Asia, Latin America and the Caribbean, the Middle East and North Africa, South and Southeast Asia, and sub-Saharan Africa. Additionally, most of the editorial board will comprise investigators from LMICs. “They better understand these issues,” Dr. Cortes said.
Another common barrier for LMIC researchers getting published is that English is not their first language. Dr. Cortes said Blood Global Hematology is planning to offer some editorial support, including using artificial intelligence tools, so authors can concentrate on the science, not the language or grammar. Eventually, they also hope to offer support for statistical analysis.
The publication is open to anyone who is working in global health, including researchers in HICs doing research in other parts of the world, but Dr. Cortes said he expects that most of the authors will be investigators from LMICs.
As the journal begins publishing, the team will be working with hematology societies around the world to get the word out, including giving presentations about the journal at the upcoming Highlights of ASH meetings in Japan, Morocco, and Uruguay. “ASH has a very active international program, so we’re taking advantage of that and the relationships that exist with a lot of these organizations to make them aware of the journal and using Blood Global Hematology to expand these international efforts,” Dr. Cortes said.
For more information about Blood Global Hematology, including details about submission guidelines and fees, visit ashpublications.org/bloodglobal.