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$ 13205 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 1.

Categorization of low-, middle- and high-income countries based on the world bank.

Income bracket	2021 gross national income per capita (USD)	Countries (n)	Example countries	Pooled population
Low	≤ $1,085	28	Afghanistan, Ethiopia, Malawi, Liberia, Somalia, Sudan, Syria, Uganda, Yemen	.7 billion
Lower-middle	$1,086 to $4,255	54	Bangladesh, Bolivia, Egypt, Haiti, India, Indonesia, Kenya, Nepal, Philippines, Tajikistan, Vietnam	3.3 billion
Upper-middle	$4,256 to $13,205	54	Albania, Botswana, Brazil, China, Colombia, Jamaica, Jordan, Kazakhstan, Libya, Malaysia, Mexico, South Africa	2.5 billion
High	>$13,205*	80	Aruba, Australia, Belgium, Canada, Chile, France, Israel, Japan, Latvia, Malta, Poland, Qatar, Singapore, UK, USA	1.2 billion

*Gross national income of high-income countries ranges from US$ 13260 for Seychelles to US$ 116,540 for Bermuda (UK) reflecting a wide range of countries included within this category.

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 prioritize 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.

A call to action

Urgent actions can help address key barriers to conducting and publishing research in LMICs. The potential solutions to each of the barrier are presented in Table 2.

Table 2.

Barriers to research in low-income and middle-income countries (LMICs) and proposed solutions.

Type of barrier	Barriers	Proposed solutions
Barriers to conducting research	Lack of research priority	Government and academic institutions should prioritize research and develop a research priority agenda for common health conditions. Funding should be allocated toward addressing these research priorities.
	Research awareness and education	Research should be introduced early in school and during undergraduate education. The importance of research should be shared with the public. Academic institutions and clinical settings (e.g. hospitals) should emphasize the importance of both conducting and using research for improving healthcare.
	Research funding	Government and universities should allocate a defined proportion of their budgets for research. Research scholarships should be awarded for postgraduate degree and postdoctoral fellowships.
	Lack of institutional support	Universities should support researchers. Full-time and part-time research roles should be created so that researchers can commit their time and focus on conducting high-quality research. Academic staff should be allocated research hours to allow dedicated research time. Institutions should also favorably appraise high-quality research over any research.
	Lack of research workforce	As above, both government and universities should support full-time and part-time research roles to develop research workforce and high-quality research skills.
	Lack of research training	Government and universities should promote high-quality research training. They should also promote local and international research mentoring as well as collaborations across fields.
Barriers to publishing research	High editorial bar for international journals	Journals could offer special editorial support to authors from LMICs. International collaborations or mentorship could help with the publication process. Appointing editors and reviewers who understand local research priorities and contexts and who are better able to make informed judgment about the need for the research and its potential impact.
	Language barrier	Proofreading of the final manuscripts by native English-speaking collaborators and journal editorial board members could address language barriers related to publishing in an international journal. AuthorAID (https://www.authoraid.info/en/) connects researchers from LMICs to the international community. Mentors and mentees can connect through the AuthorAID program.
	Predatory publishing	Frequent webinars around publishing in the right journals should be offered. Government, funding bodies (if present), and institutions should emphasize publishing in credible journals. Authors should think critically about the credibility of the journals they submit to, drawing on resources like Think, Check, and Submit (http://thinkchecksubmit.org).

What can researchers from LMICs do?

Early career researchers may initiate collaborations with experienced local and international researchers with shared interests. Experienced researchers may extend mentorship opportunities to junior researchers both locally and internationally, facilitate inclusion on a journal editorial board, and volunteer to review papers.

What can international journals do?

International physiotherapy journals are in a strong position to support and promote physiotherapy research in LMICs, especially through the leadership of the International Society of Physiotherapy Journal Editors.

First, journals should consider equity, diversity, and inclusion within the editorial board – not only in terms of gender and race but also diversity based on national economies. Editors who understand local research contexts are better able to make informed editorial decisions. Where possible within the scope of the journal, editorial decisions should be made considering research priorities from the originating country and the impact of the research there. This will assist with providing strong research foundations for LMICs.

Second, editors should also prioritize recruitment of reviewers with research experience in LMICs, preferably from the same countries where the research was conducted. Editors may also request specific feedback regarding whether the study methods are appropriate for the local context.

Third, journals may provide additional support to authors from LMICs. This may include providing additional assistance in editing, proofreading, or responding to peer reviewers. Journal websites may provide specific guidance to authors with limited publishing experience, such as links to resources for conducting and writing research. Journals may also offer current and prospective authors Massive Open Online Courses (MOOC) on research and academic writing, with the content targeted at authors from LMICs. Alternatively, paid workshops might be offered with a waiver for participants from LMICs.

A final strategy to consider is that publishers/journals may guide authors who need mentorship to a list of volunteer mentors. The journal manuscript submission platform could include a button to click if the author is looking for a mentor or is willing to mentor. The extent of mentorship could vary from proofreading the current paper, to analyzing data, to assisting in writing a paper, to mentoring the development of a research question. The latter can especially be valuable for many, as journal editors frequently encounter research with poorly developed research questions and flawed research methods. With these problems, even the most supportive editors cannot help as it is too late to help. One initiative to support early career researchers is available through AuthorAID (https://www.authoraid.info/en/). Authors may choose to be listed as a mentor or a mentee and provide or receive mentorship at various stages of research including planning, analysis, writing, editing, and proofreading. Strategies to promote high-quality research in LMICs are summarized in Figure 1.

Figure 1.

Strategies to promote high-quality research in low- and middle-income countries.

‘Bright spot’

Despite several significant challenges, research with wide-scale implications has started to arise from LMICs which addresses local health research priorities [8,13–15]. Some prominent journals in physiotherapy, pain, science, and medicine have already started to identify the importance of equity, diversity, and inclusion in health research which is likely to make a meaningful impact in promoting research from LMICs [16–20]. Selected publishers also waive publication fees for authors from LMICs to assist in open-access publishing.

Conclusion

Local research in LMICs is necessary to advance science and improve patient care in these settings. However, researchers in LMICs face several unique challenges to conduct and publish their research internationally. The International Society of Physiotherapy Journal Editors and member journals support research from the LMICs to improve the health and lives of the 85% of the world’s population that lives in LMICs.

Biographies

Saurab Sharma is a Postdoctoral Research Fellow at the University of New South Wales and Neuroscience Research Australia, Sydney, Australia. Dr Sharma has authored over 75 peer-reviewed publications. He is interested in improving health equity and health care for culturally diverse individuals and those living in low- and middle-income countries (LMICs) primarily in the area of pain. Before completing a PhD in New Zealand in 2020, he gained a decade of teaching, research and clinical experience in the area of musculoskeletal physiotherapy and pain in Nepal. He is a currently an Associate Editor for Journal of Orthopedic & Sports Physical Therapy and Physiotherapy. Dr Sharma is currently leading Consortium for Low Back Pain in LMICs which aims to develop and address priority research areas via collaborations with stakeholders from >35 LMICs.

Arianne P. Verhagen is the Chair of International Society of Physiotherapy Journal Editors. She (has) participate(d) in several editorial boards as associate editor: Journal of Physiotherapy (until 2021), Journal of Orthopedic & Sports Physical Therapy (until December 2023), Musculoskeletal Science & Practice, and the Cochrane Diagnostic Test Accuracy Review Methods Group (until 2019). She has published over 330 peer-reviewed papers. Her main topic of research is musculoskeletal disorders in primary care (intervention as well as diagnostic studies) and systematic review methodology for a broad variety of systematic reviews.

Mark Elkins is the Editor-in-Chief of the Journal of Physiotherapy. He is a Clinical Associate Professor in the Faculty of Medicine & Health at the University of Sydney, a research mentor in the Sydney Local Health District, and a co-director of the Physiotherapy Evidence Database (PEDro).

Jean-Michel Brismée is the Editor-in-Chief of the Journal of Manual and Manipulative Therapy. Dr Brismée is Professor in the Doctor of Philosophy and Doctor of Science in Rehabilitation Sciences Programs at Texas Tech University Health Sciences Center. Dr Brismée teaches at TTUHSC in the areas of neuromusculoskeletal care and is involved in clinical research in Orthopaedics, Manual Therapy and Movement Sciences.

George D. Fulk is the Editor-in-Chief of Journal of Neurologic Physical Therapy. Dr. Fulk is the director of the Division of Physical Therapy in the School of Medicine at Emory University. His research interests are in the area of walking recovery and the impact of sleep on recovery after stroke.

Jakub Taradaj is a physiotherapist and specialist in wound healing/lymphedema therapy. He is an Editor in Chief of Physiotherapy Review. He is a Head of Department of Physical Therapy at Academy School of Physical Education in Katowice, Poland and was visiting professor/guest researcher in College of Rehabilitation Sciences at University of Manitoba in Winnipeg, Canada. He was a Vice – President of Polish Society of Lymphology. Prof. Taradaj is a therapist and clinical consultant in Medical Center TOMMED Katowice, Poland. He is a member and trustee of European Pressure Ulcer Advisory Panel.

Lois Steen is the Editor-in-Chief of Fysioterapi (Swedish Physiotherapy Journal). Lois is a science journalist with a Bachelor of Medical Science in Physiotherapy.

Alan Jette is the Editor-in-Chief of PTJ: Physical Therapy & Rehabilitation Journal.

Ann Moore is the Editor-in-Chief of Musculoskeletal Science & Practice. Dr Moore is a Professor Emerita of Physiotherapy at the University of Brighton. She is a Fellow of the Chartered Society of Physiotherapy and a Fellow of the Musculoskeletal Association of Chartered Physiotherapists and is a specialist in Musculoskeletal Physiotherapy. Ann’s teaching and research interests have focused largely on Non-Specific Low Back Pain and her approaches have included clinical trials, Laboratory based studies, qualitative research and more latterly Art and Health approaches. Ann is particularly interested in the patient experience, increasing public awareness of the impact of Low back Pain on individuals and developing new approaches to patient care, patient education, self-management and standardised data collection and Patient Recorded Outcome Measures. In recognition of her services and contributions to Physiotherapy Ann has received several awards including: Commander of the Order of the British Empire, An International Service Award from the World Confederation of Physical Therapy, Honorary Fellowships from the Chartered Society of Physiotherapy and the Musculoskeletal Association of Chartered Physiotherapists. She also received an Honorary Doctor of Science Degree from Bedford University for Services to the Allied Health Professions and Osteopathy.

Aimée Stewart PhD is an Associate Professor in the Department of Physiotherapy, School of Therapeutic Sciences, University of the Witwatersrand and is in a retirement post. She served as the Africa representative on the International Scientific Congress Committee of the World Confederation of Physical Therapy (WCPT) and chair of this committee for the 2015 congress in Singapore. She has over 130 publications in peer-reviewed journals and has presented her work at many conferences. She has supervised over 40 masters’ students to completion and over 20 PhD’s to completion. She was the winner of the South African Department of Science and Technology “Distinguished Women in Science” award in the Social Sciences and Humanities category in 2011. She was awarded an exceptional service medal by the Faculty of Health Sciences in 2007, 2012 and a service award from the Africa region of WCPT for her work in Africa in 2012. She was awarded a University of the Witwatersrand gold medal in 2022 for her services to the university and wider community.

Barbara J. Hoogenboom is the Editor-in-Chief of the International Journal of Sports Physical Therapy. Dr. Hoogenboom is a Professor and Associate Chair in the Physical Therapy Program at Grand Valley State University, Grand Rapids, Michigan. She has contributed to the literature by original research/case reports/commentaries, home study courses, textbook chapters, and as co-editor of a textbook. She has performed research and presented widely on topics related to the female athlete triad/RED-S, sports nutrition, the female athlete across the age span, core strengthening, aquatic therapy, functional performance and testing, surface electromyography, and 2-D and 3-D motion analysis.

Anne Söderlund, is a Professor in Physiotherapy with Behavioral Medicine profile at School of Health, Care and Welfare, Mälardalen University, Västerås, Sweden. She is also affiliated professor at Arcada University of Applied Sciences in Helsinki, Finland. Professor Söderlund is an Editor-in-Chief for the European Journal of Physiotherapy. She is a leader of a multidisciplinary group, BeMe-Health, of 20 researchers. Her research area is on the prevention, treatment, and evaluation of health problems from a behavioral medicine perspective in physiotherapy. Her research is focused on the individual's behavior and ability to function in everyday life at different ages. Professor Söderlund has 118 published scientific articles, several editorials, and book chapters and has received research funding as PI for about 1,4 million EUR. She has supervised 12 graduate Ph.D. students. She has international cooperation with researchers from many countries and is a European Pain Federation Academy Board member.

Michele Harms is Editor-in-Chief of Physiotherapy. She is a Fellow of the Royal Statistical Society, a member of the Committee on Publication Ethics and a Member of the International Society of Physiotherapy Journal Editors. Her research interests encompass: Biomechanics, musculoskeletal medicine, measurement and outcome measures, statistical analysis and data handling. Her work has been published in leading journals including Rheumatology, BioMed Central, Clinical Biomechanics, European Journal of Physical Medicine and Rehabilitation, Journal of Medical Engineering and Technology, International Journal of Cardiology and Physiotherapy.

Rafael Z. Pinto is the current Secretary of International Society of Physiotherapy Journal Editors and an Editor-in-Chief of Brazilian Journal of Physical Therapy. Dr Pinto is Lecturer in Physical Therapy at the Universidade Federal de Minas Gerais (UFMG), Brazil.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

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