The number of articles published by first authors from a high-income country was 87% while in 87.3% of cases, the corresponding author’s affiliation was an institution located in a high-income country. The journal BMC Medical Education had the highest percentage of first and corresponding authors from middle and low-income countries.
A study published in 2020 had shown that 80% of published articles included in the study were published by authors based in North America, Western, and Northern Europe.4 The authors concluded that teams from North America and Europe dominate publications in HPE. They mentioned that the relatively stagnating and homogeneous origins of the published research should be a matter of particular concern in HPE. We agree. Countries other than high-income have most of the world’s population and most of the medical and health professions education institutions. Populations and their healthcare needs are constantly evolving, and insights gained from middle and low-income settings may be particularly applicable to certain Western contexts especially those in resource-constrained settings.10 Climate change is a global phenomenon with serious negative consequences and significant implications for HPE globally.11 This highlights the importance of including global voices in HPE in journal publications.
There have been significant advances in HPE outside the setting of high-income countries. The Foundation for the Advancement of International Medical Education and Research (FAIMER) fellowship programs have strengthened knowledge and skills in educational leadership, education methods, and project management and evaluation.12 There is interest in HPE globally and data from 2018 showed there were 150 programs worldwide with several being offered in developing nations.13 Developing nations are increasing their budget for research and development and their scientific impact was growing at twice the rate for developed nations pre-COVID.14 The COVID-19 pandemic had a significant impact globally, especially in developing economies.15
The possibility of bias in judgments of the suitability of an article for publication has been mentioned. A study mentions that in one of the four abstracts studied, the respondents were influenced by the country of source of the researcher in their rating of the abstracts.16 There have also been anecdotal concerns about whether the ability to pay the APC influences acceptance decisions. The open-access journal BMC Medical Education had the highest number of articles published from outside high-income countries. The publisher has a policy of offering discounts and waivers for authors from lower-middle- and low-income countries. There has been speculation that the primary customer base for traditional subscription-based journals is in high-income countries, and this can influence the article selection process. Open-access journals have a different business model and depend on APC paid by researchers and may be less influenced by the nature of the readership base.
The authors of a previous article mentioned that encouraging diversity in HPE publications supports knowledge translation across different contexts.4 Looking at this data there seems to have been little progress in increasing the percentage of publications from outside high-income countries. We carefully examined the aims and scope of the journal at the journal websites and all mention being an international journal. There may be challenges in meeting this objective if most of the world’s population and countries have a very limited representation in the journal. Collaborative research has been mentioned as one of the strategies to expand research into under-represented areas and countries.17 Modifying the manuscript handling process at journals may influence manuscript acceptance rates from outside the high-income world. Diversification of editorial boards and peer reviewers has been recommended though progress has been slow.18 We examined the editorial boards of these journals, and the journal BMC Medical Education had the maximum number and the greatest diversity of editorial board members. Is there a possible link between the editorial board diversity and increased acceptance of research from UMICs, LMICs, and LICs? A study examining communication journals showed that diverse editorial boards are more likely to publish more diverse research articles based on the country of the first author and the country where the data was collected.19 Having a more international group of editors and possibly reviewers may result in a more balanced consideration of challenges faced by researchers in resource-constrained settings. Journals can consider displaying on their website the number of manuscripts they receive according to the income status of the country and the final acceptance rates according to this parameter.
Careful peer review of aims and objectives displayed on journal websites to determine how international they really are and whether more tempered statements are required can provide more objective information to potential authors.4 Privileging HPE research published in journals based in North America and Europe in an era of web-based and social media-based platforms is a debatable issue.20 We may also have contributed to this notion of privilege through our choice of top-ranked medical education journals for analysis in this study. International under-representation in traditional modes of knowledge dissemination is a serious issue.4 The percentage of authors from middle-income and low-income countries has not improved over time. A study published in 2004 examined articles published during a year in five leading medical journals (BMJ, Lancet, NEJM, Annals of Internal Medicine, and JAMA).21 The average contribution to the literature from the rest of the world (excluding the UK, USA, Australia, Canada, and New Zealand) was 6.5%. The rest of the world includes several high-income countries. Over 68% of articles published from the rest of the world included authorship from developed nations in Europe and North America. An analysis of all articles published in 24 medical education journals between 2000 and 2020 revealed that only 11.4% of articles were written by global south authors.22 Most global countries are under-represented in high-impact journals.
The strength of the study is that the authors examined publications in six high-impact medical education journals according to the income status of the country of affiliation of the first author and the corresponding author. The study also had limitations. The data was extracted manually. Some first and corresponding authors had multiple affiliations to institutions. If these affiliations were in countries belonging to different income levels, then the publication was duplicated. Only six journals were selected for analysis due to logistic reasons. Only a limited period of three years was studied. We did not study the gender distribution of the authors though the literature suggests female authors are under-represented. This could have introduced bias.