Research from low-income and middle-income countries will benefit global health and the physiotherapy profession, but it requires support

Disparities in research publications are common in the physiotherapy and rehabilitation fields [[1]]. A small proportion of published research arises from low-income and middle-income countries (LMICs), [[1],[2] home to 85% of the world's population. Systems-level, institutional-level, and individual-level factors contribute to these disparities. With urgent and unified actions, global health and the standard of physiotherapy research in LMICs can be improved and strengthened. In this editorial, we will discuss the challenges encountered by researchers from LMICs in conducting and publishing high-quality research and propose potential strategies to address these challenges.

Background

LMICs are defined as countries with a cumulative annual gross national income per capita of US$ 13,205 or less (Table 1) [[3]]. Many LMICs have a higher prevalence of injuries and long-term conditions requiring rehabilitation services compared to high-income countries [[4],[5]. Despite the greater disability burden in LMICs, the quality and quantity of research conducted in these countries is underwhelming. For example, despite being ranked as the number one cause of disability, low back pain lacks primary data from many LMICs. [[2],[6].

Table 1Categorisation of low-, middle- and high-income countries based on the World Bank.

* Gross national income of high-income countries ranges from US$ 13,260 for Seychelles to US$ 116,540 for Bermuda (UK) reflecting a wide range of countries included within this category.

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LMICs have different research priorities than high-income countries. Compared to high-income countries, LMICs often have underdeveloped and resource-limited health systems and different disease burdens, with research only starting to catch up. Because of between-country/culture differences in illness beliefs and coping strategies, research from high-income countries, [7]] where most evidence is generated, may not apply in LMICs. In other words, interventions developed using resources and clinical populations in high-income countries may not be culturally appropriate or feasible in LMICs. For example, education, a commonly recommended intervention for chronic health conditions, needs to consider patient's socioeconomic and cultural factors [[8]]. This warrants significant cultural adaptation and testing of healthcare interventions when used in different health settings/systems. Given that there is limited local research on many clinical conditions, clinicians in LMICs are left to rely on research from high-income countries for patient care. Although the need for high-quality research to address local research gaps has been frequently highlighted, research publications from the LMICs remain limited [[9]].

Barriers related to conducting high-quality research in LMICs

While LMICs may share some common barriers to conducting and publishing research with high-income countries, some challenges are unique to LMIC contexts [[10]]. Many LMICs do not prioritise research, which results in a lack of research funding, no research culture, limited awareness of research, and no research workforce [[10]]. LMICs rarely include research funding in their national budget. Awareness about research is lacking at all levels and therefore health professionals, academic staff, and the general public have little to no understanding of research. School and university curricula also lack a research focus.Academic institutions do not offer adequate research support to their staff and students, who lack research training, ongoing mentorship, research resources and infrastructure (including but not limited to access to online databases), reliable internet access, secured computers, and statistical software. Unfair expectations are imposed on academic staff to generate research productivity without dedicated research hours and administrative support (e.g., research assistants). For example, publishing two or more original research papers is commonly expected in three years for academic promotion. In a survey of researchers from 27 African countries, lack of dedicated research-related roles was the most common barrier identified, reported by 48% of the respondents [[10]].

Barriers/threats to publishing research from LMICs

Barriers to publishing research are linked with the barriers to conducting research described above. One widely known barrier is language. Writing academic papers can be daunting, especially when writing in a non-native language. Researchers in LMICs who do not speak English as their first language find it especially challenging to write journal articles in English. They also lack local support to improve their writing skills.

The second barrier is related to, as alluded to earlier, the differences in research priorities in LMICs and high-income countries. Many international journals lack geographic diversity in their editorial boards. As a result, the manuscript handling editors (and reviewers) lack adequate understanding of the local research contexts and the need for studies in LMICs when looking from their own lenses of research priorities in high-income countries. Finding reviewers who understand local research contexts is also challenging, further complicating the editorial decision.

Third, researchers in LMICs are frequently the targets of predatory publishers. As a consequence, researchers from LMICs publish their work in ‘predatory’ journals [[11]]. The researchers see predatory journals as “low-hanging fruit”, despite costs associated with publication, because the publishing requirements are easier to meet while the publication process is often swift, in contrast to (international) peer-reviewed reputable journals. Lastly, some editors/reviewers of international peer-reviewed journals deem research from LMICs to have local relevance and impact only, and therefore flag them as more appropriate for local journals. The major problem with this is that most local journals are not indexed and are therefore often undiscoverable through traditional databases (e.g., PubMed). Publishing in these non-indexed local journals contribute to duplicate research and therefore research waste [[1],[12]. For example, 75% of research on clinical pain in Nepal was published in local journals with duplicate and redundant research.^[1]

 The international research community should facilitate research from LMICs so that this research can make both local and international impacts.