Underrepresentation of Low- and Middle-Income Nations in Ophthalmology Journals: A Critical Analysis on Diversity, Equity, and Global Representation

Abstract

Purpose: Low- to middle-income nations contain more than 80% of the world's population; however, only 4% of articles in ophthalmology journals belong to these countries. We aim to analyze the global diversity of the editorial boards of ophthalmology journals.

Methods: Cross-sectional study, including all journals in the Ophthalmology section of the SCImago Journal & Country Rank (SJR). Journals were classified according to the country of origin, SJR interquartile range (Q1–Q4), impact factor, and open-access policy. Global diversity among journals was determined by the country of affiliation of editors-in-chief and editorial board members. Nations were classified by income according to the World Bank's 2022 system. The association between editorial diversity and the journal's metrics and country of origin was analyzed using the χ² test and the Mann–Whitney U test.

Results: A total of 116 journals were included and 83.6% belonged to high-income nations. Only 18 (13.3%) editors-in-chief and 582 (13.5%) board members were affiliated with middle-income nations. The most prevalent middle-income countries in editorial boards were Brazil (n = 184, 4.26%), India (n = 150, 3.47%), Turkey (n = 42, 0.97%), and Iran (n = 36, 0.83%). Only 40 (1.07%) editorial board members of Q1 journals were affiliated with non-high-income nations, most belonging to India (n = 28, 70%). Journals from middle-income nations had a statistically significant lower prevalence in the first- and second-quartile ranking (P < 0.001) and a higher proportion of open-access policies (P = 0.019).

Conclusions: A clear underrepresentation of low- to middle-income nations was observed in ophthalmology journals. Promoting editorial diversity and minimizing the possibility of editorial bias could lead to greater exposure to real-world data from resource-constrained settings.

Translational Relevance: The documented underrepresentation of low- to middle-income nations in ophthalmology journals highlights the importance of promoting diversity and inclusion.

Introduction

Low- and middle-income countries contain more than 80% of the world's population with the largest economic burden of diseases.¹ Unfortunately, most of the information available from scientific publications is derived from studies conducted in high-income countries and is often impractical to the real-world scenarios of low- and middle-income nations.^2–8 The 10/90 report of the Global Forum for Health Research stated that less than 10% of the world’s research resources are allocated to 90% of health problems.⁹ Health issues in developing countries differ from those in developed nations not only in epidemiology and presentation but also in diagnostic and therapeutic approaches, rendering information applicable to these scenarios very scarce.¹⁰ 

Disparities in scientific production between low- to middle-income nations and high-income nations in the field of medicine can be attributed to multiple factors such as financial restraints and language barriers.^10,11 However, editorial bias might play an important role in the unbalance of scientific contribution. Previous studies have demonstrated an underrepresentation of low- and middle-income countries in the editorial board of leading medical journals, as well as in many leading subspecialty journals, including traumatology,³ critical care/anesthesia,⁴ pediatrics,⁵ medical education,⁶ pharmacy,⁷ and psychiatry.⁸ The presence of this phenomenon in ophthalmology journals remains unclear. 

We aim to assess the global diversity of the editorial boards of ophthalmology journals as an effort to identify potential research biases. 

Methods

We conducted a cross-sectional study describing the general characteristics and metrics of ophthalmology journals as of October 2022. The country of affiliation of editors-in-chief and editorial board members was included as well as the gender and research impact of editors-in-chief. All variables were obtained by three independent observers and further revised by a fourth observer. 

Journal Information

All journals found in the Ophthalmology section of the SCImago Journal & Country Rank (SJR) portal were included. The portal contains journal rank indicators developed from the Scopus database. Journals without a valid website and/or without a list of editorial board members were excluded from the analysis. Journals with websites in non-English languages without an automatic English language conversion/equivalent provided by the website or Google were also excluded. The SJR webpage provides classification of journals by interquartile range from first to fourth (Q1–Q4) according to the SJR indicator, which expresses the average number of weighted citations received in 2022 by the documents published in the journal in the 3 previous years. The average citation per document in 2 years, referred to as cites/docs, and the availability of open-access policies from each journal were also retrieved from the SJR website. 

The Journal Citation Reports, a publication of Clarivate Analytics that provides basic bibliographic information about academic journals, was used to search for each journal's impact factor. 

Editorial Data

Editors-in-chief and editorial board members were considered for the analysis. Administrative staff such as managing, copy, illustration, video, and technical editors were not included. For each editor-in-chief, gender (man versus woman) was identified through profiles (biography and/or photograph within the past 10 years) on institutional affiliation websites. If profiles were unavailable, gender was defined using an application programming interface (https://gender-api.com), which generates a percentage value indicating the certainty of the gender determined by the first name. A cutoff of 90% certainty was used, and any individual whose gender could not be determined with certainty equal to or greater than 90% had their gender verified via an exhaustive Google search. If the gender could not be determined after the abovementioned steps, the editorial member was denoted to have an unknown gender. 

The Web of Science website was accessed to retrieve the country of affiliation of the editors-in-chief and the editorial board members. The country of affiliation was further classified based on the gross national income (GNI) per capita in 2022 using the World Bank's 2022 classification criteria. Nations with a GNI per capita of $1135 or less were classified as low-income, lower- to middle-income economies were those with a GNI per capita between $1136 and $4465, upper-middle-income nations had a GNI per capita between $4466 and $13,845, and high-income economies presented a GNI per capita of $13,846 or more.¹² 

The research impact of editors-in-chief was assessed using the H-index provided by the Web of Science database and calculated based on the list of publications ranked in descending order by the times cited, in which the value of h is equal to the number of papers (N) in the list that have N or more citations.¹³ 

Income and Region

The country of origin of each journal was abstracted from the journal's website and categorized according to the World Bank's 2022 classification of countries by income, as mentioned above (low, lower-middle, upper-middle, and high-income nations), and by geographical region (East Asia and Pacific, Europe and Central Asia, Latin America and the Caribbean, Middle East and North Africa, North America, South Asia, and Sub-Saharan Africa).¹² The country of affiliation of each editor-in-chief and editorial board member was also recorded and classified accordingly. 

Ethics Approval

This is an observational study. The Research Ethics Committee of our institution has confirmed that no ethical approval is required. 

Statistical Analysis

For continuous variables, normality was tested using the Kolmogorov–Smirnov test. Normally distributed variables were presented as mean and SD and compared using the independent samples t-test. Nonparametrically distributed variables were reported using median with range and compared using the Mann–Whitney U test. For categorical variables, proportions were reported, and the χ² test was used to compare frequencies. A P value of 0.05 was considered for statistical significance. Data were analyzed using SPSS V.25 (SPSS, Inc., Chicago, IL, USA). 

Results

A total of 128 ophthalmology journals were found on the SCImago webpage. Twelve were excluded from the study due to language impediments (2), lack of an existing webpage (5), and lack of information on editorial board members (5). Therefore, 116 journals were included in the analysis. 

Journals

Overall, the median impact factor among journals was 2.66 (0.70–21), and the median cites/doc in 2 years was 1.57 (0–18.4). Impact factors were unavailable for 58 (50%) journals, including 4 from Q1, 8 from Q2, 25 from Q3, and 21 from Q4. A total of 44 (37.9%) journals had an open-access policy. The majority of the journals belonged to the United States (n = 40, 34.5%) and the United Kingdom (n = 26, 22.4%), followed by Switzerland and India, with 5 journals each (4.3%). 

Additionally, most of the journals belonged to high-income nations (n = 97, 83.6%), and only 10 (8.6%) and 9 (7.8%) belonged to upper-middle- and lower-middle-income nations, respectively. Europe and Central Asia represented the majority of the journals according to the region (n = 51, 44%), followed by North America (n = 40, 34.5%) and East Asia and Pacific (n = 13, 11.2%). All journals ranked as Q1 belonged to high-income nations. The highest percentage of journals from middle-income nations was observed in the Q4 group (42.8%). Information according to the journal's quartile is presented in Table 1. 

Table 1.

 

Interquartile Comparisons Among Journals, Editors-in-Chief, and Editorial Board Members

 

Editorial Board

A total of 4317 editorial board members were found. The median number of members among editorial boards was 30 (7–183). The majority, 3735 (86.5%), were affiliated with high-income nations, 351 (8.13%) with upper-middle-income nations, 230 (n = 5.3%) with lower-middle-income nations, and only 1 (0.02%) with a low-income nation, which was Ethiopia. Only 40 (1.07%) members of the editorial board of Q1 journals were affiliated with non-high-income nations; among these, 28 (70%) belonged to institutions in India. 

Of the 582 (13.5%) members not affiliated with high-income nations, 184 (31.6%) belonged to Brazil and 150 (25.7%) to India, followed by 42 (7.2%) to Turkey and 36 (6.18%) to Iran. Notoriously, among these largely represented nations, 142 (77.2%) of members from Brazil, 82 (54.6%) from India, 16 (39%) from Turkey, and 30 (83.3%) from Iran were members of journals belonging to the same country. 

Only 10.30% of members from middle- and low-income nations belonged to the editorial boards of journals ranked as Q1. The largest proportion of middle-income members according to quartile was reported in Q4 journals (24.49%), whereas the lowest was seen in Q1 (4.18%). Information according to the journal quartile is presented in Table 1. 

Editors-in-Chief

A total of 135 editors-in-chief were found. Ninety (66.7%) were male and 45 (33.3%) were female. The highest proportion of females was seen in Q3 journals (87.1%). The median H-index reported for all editors-in-chief was 27 (1–132). The H-index of one editor-in-chief from a high-income journal was not available. Most editors (n = 50, 37%) belonged to institutions in the United States, followed by 19 (14.1%) in the United Kingdom, 9 (6.7%) in Germany, and 5 (3.7%) in Japan. Likewise, 117 (86.7%) belonged to high-income nations, whereas only 10 (7.4%) and 8 (5.9%) to upper-middle and lower-middle countries, respectively. Most editors affiliated with middle-income nations (94.4%) belonged to journals from middle-income nations and only one to a high-income journal. 

North America was the main region represented by editors-in-chief (n = 53, 39.5%), followed by Europe and Central Asia (n = 49, 36.3%) and East Asia and Pacific (n = 17, 12.6%). Information according to classification by quartile is demonstrated in Table 1. 

Group Comparisons

Journals belonging to middle-income nations presented a statistically significant lower prevalence in Q1 and Q2 journals (P < 0.001) and a higher proportion of open-access policies (P = 0.019), whereas journals from high-income nations presented a significantly lower proportion of editors-in-chief (P < 0.001) and editorial board members (P < 0.001) belonging to middle-income nations. Comparisons between high- and middle-income journals are displayed in Table 2. 

Table 2.

 

Differences in Composition Between High-Income and Middle-Income Journals

 

Discussion

Editorial board members function as the gatekeepers of scientific journals and alongside editors-in-chief play an essential role in the advancement of science. Their influence dictates what information will be publicly available, which will further shape clinical guidelines and health policy. 

Unfortunately, research conducted in low- to middle-income nations is poorly represented in the published literature, as only 6.5% of the publications found in the British Medical Journal (BMJ), the Journal of the American Medical Association, the New England Journal of Medicine, The Lancet, and Annals of Medicine contain authors from countries where 90% of the population live.¹¹ Likewise, among these journals, only the BMJ (19.2%) and The Lancet (12.5%) contain editorial board members from low- or middle-income countries.¹⁴ 

Previous reports have found a composition of editorial board members from middle-income nations of 0.85% in the 11 leading psychiatry journals,⁸ 7.2% in the top 3 medical education journals,⁶ 8.6% in the 4 leading spine journals,³ and 8% in the top 11 pediatric journals.⁵ In contrast, our report included all ophthalmology journals, hence revealing a slightly higher proportion of 13.3% editors-in-chief and 13.5% editorial board members. However, when adjusting for the highest-ranked ophthalmology journals, the representation of low- to middle-income countries decreased to 2.1% and 1.53% in the top 10 and top 5 journals, respectively. 

Several research barriers preclude the development and publication of scientific papers from resource-constrained settings such as lack of funding, poor facilities, limited technical support, and data recollection systems.¹⁵ Additional unseen limitations faced by young professionals include the lack of formal training in scientific research due to competing clinical commitments, restrained resources, and different donor-driven agendas for research.¹⁵ Moreover, the publication of research papers from developing nations is also hampered by the rising prevalence of publication fees in more attainable journals. As demonstrated by our report, open-access policies were more prevalent in journals with a lower impact factor and a relatively greater representation of developing nations. Finally, editorial bias has gained special attention in the past years as an additional obstacle for scientific publication from lower-income nations since various medical journals have identified a low proportion of editorial board members from developing nations.^{1,11,14,16,17} 

To our knowledge, this is the first study to report the composition and diversity of editorial board members in ophthalmology journals. However, previous reports have analyzed the geographical distribution of publications in ophthalmology journals. The United States and Japan were the largest producers of articles from the top five ophthalmology journals published between 2002 and 2006, with 69% of the articles belonging to the United States, Japan, the United Kingdom, Germany, and Australia. There were no data on low- to middle-income nations reported.¹⁸ A report that collected publications from 2009 to 2013 in the 20 top-ranked ophthalmology journals found that the United States, Europe, and the United Kingdom accounted for 60.2% of the articles.¹⁹ The only developing countries mentioned were India, accounting for 2.1% of total publications, followed by Turkey and Brazil, responsible for 1.1% each.¹⁹ Finally, a study including articles from the same 20 journals published between 2000 and 2020 reported similar results as the previous studies, with the United States responsible for 35.2% of total articles, followed by the United Kingdom (8.9%) and Japan (7.2%). Likewise, the only developing countries appearing were India (2.4%) and Turkey (1.5%).² Interestingly, Brazil, India, and Turkey were the developing countries with the largest representation in editorial boards found in our report. This suggests the presence of editorial bias and emphasizes the need for equitable editorial representation. Importantly, most of the members affiliated with Brazil, India, and Turkey functioned as board members of journals from the same nation, denoting an underlying lack of diversity within journals. 

Disparities in the composition of the editorial boards of medical journals hinder exposure of research from developing countries as the editors may be unfamiliar with the economic burden, drug shortage, and lack of diagnostic tests and surgical devices faced by most of the population. Proper diffusion of data from resource-constrained settings in medical journals is of utmost importance to adjust clinical recommendations tailored to these scenarios. 

Limitations in our study include the unavailability to obtain the impact factor from 58 journals due to recently funded journals or insufficient journal data to calculate. Moreover, our results demonstrate underrepresentation but can only suggest the presence of editorial bias. Further studies are needed to assess editorial bias by comparing the affiliation of scientific publications of each journal to the global composition of the editorial board. 

Conclusions

A clear dearth of representation of low- to middle-income nations was observed among the editorial boards of ophthalmology journals. Additionally, the majority of members affiliated with developing nations belonged to the editorial boards of journals from the same country, revealing a lack of diversity as well. Ensuring global representation and editorial diversity could decrease the possibility of editorial bias and lead to greater exposure to real-world data from resource-constrained settings. 

Acknowledgments

Disclosure: E.M. Ramos-Dávila, None; I.A. Domínguez-Varela, None; R.E. Ruiz-Lozano, None; L.G. Villagómez-Valdez, None; D.I. Lopez-Zúñiga, None; M.V. Lopez-Cabrera, None; J.E. Valdez-García, None