Equitable publishing part 1: Appraising an audience

Estimated reading time: 9 minutes

Coauthored with Thomas Shanahan (@clifford0584), with contributions from Teresa Chan (@TChanMD). Read equitable publishing part 2: Access rules and part 3: Author, sponsor, mentor, replay.

Where should we publish?

You have finally completed your data analysis and came to some interesting conclusions. On discussing these with your study team the conversation turns to publication: “where should we publish?”

You have heard about impact factor, citations and the h-index. You understand that journals with a high impact factor contain highly cited articles. You also understand that more citations will improve your h-index. And that this is likely to be important for promotion and future grant applications (despite what the Declaration on Research Assessment states).

As your mind starts to settle on publishing in a journal with a high impact factor, you wonder if such a journal will reach the right audience. The answer is more complicated than it ought to be.

The right audience

Of the 7.8 billion people living on earth, only around 16% live in a high-income country; and with a few exceptions, most high-income countries are geographically situated in the upper left section of a standard world map. The other 84% largely live in low- and middle-income countries, spread out across the rest of the map.

According to Maslow, irrespective of our income status, we all share a basic need for health. As a result, the universal need for healthcare provision is recognised internationally. The most pressing areas in healthcare provision are summarised by the United Nations Sustainable Development Goals (SDGs) as health targets

United Nations Sustainable Development Goals’ health targets
  1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births
  2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1000 live births.
  3. By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.
  4. By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
  5. Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
  6. By 2020, halve the number of global deaths and injuries from road traffic accidents – we’ve already missed this one 🙁
  7. By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.
  8. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
  9. By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.

It is super likely that you have come across some, or all of these targets, as part of your daily clinical work, CPD, or research portfolio. Example: when was the last time you managed a patient with suspected sepsis (target 3), or acute coronary syndrome (target 4), or a patient with an injury related to a road traffic crash (target 6)? We’re sure you can spot some more.

Can the real audience please stand up?

About 18 million people die annually due to a cardiovascular cause (heart attack, stroke, etc.). It is a pretty important research topic in the West. Indeed, no less than 77% of all publications on cardiovascular research originate from either North America or Europe.

And yet, less than 25% of cardiovascular mortality occurs in high-income countries. Given that low- and middle-income countries shoulder the worst of the mortality burden, it seems fair to say that access to this large, global cardiovascular research collection is at least as likely to be useful to a low- and middle-income audience than a high-income audience.

This argument for access to the global research collection for low- and middle-income audiences can be made for every single SDG target. Consider targets 3 and 6 for example:

  • There are an estimated 11 million sepsis-related deaths worldwide; with around 85% occurring in low- and middle-income countries.
  • There are about 1.35 million road traffic crash-related deaths worldwide; with about 93% of these occurring in low- and middle-income countries.

We could go on. The point is: your prospective audience is really, really big; and by the looks of it, your low- and middle-income audience stands to benefit substantially more than your high-income audience. But how do we access this audience? Let’s have a look.

Oh audience where art thou?

As demonstrated with cardiovascular research, Western-based journals tend to dominate global rankings due to the sheer volume of publications. Nearly 75% of emergency medicine publications are either from North America or Europe. However this does not mean that these journals are preferred everywhere. The table below shows you what a dog’s dinner journal preference is in different regions, both from a scholarly and a usage perspective (note that Europe’s list includes a non-English journal).

Emergency medicine journals ranked for citations attracted between 2012-17 for a selection of publication regions (scholarly impact)
GlobalNorth AmericaEuropeAfrica
ResuscitationAnnals of Emergency MedicineResuscitationWorld Journal of Emergency Surgery
American Journal of Emergency MedicineJournal of Emergency MedicineEmergency Medicine JournalBurns
Annals of Emergency MedicineAcademic Emergency MedicineShockResuscitation
ShockAmerican Journal of Emergency MedicineInternal and Emergency MedicineAfrican Journal of Emergency Medicine
Emergency medicine journals ranked for usage between 2012-17 for a selection of publication regions (disseminative impact)
GlobalNorth AmericaEuropeAfrica
InjuryJournal of Emergency MedicineInjuryWorld Journal of Emergency Surgery
ResuscitationPediatric Emergency CareResuscitationAfrican Journal of Emergency Medicine
American Journal of Emergency MedicineAcademic Emergency MedicineUnfallchirurg (a non-English journal)Injury
Journal of Emergency MedicineAmerican Journal of Emergency MedicineEmergency Medicine JournalBurns
BurnsAnnals of Emergency MedicineBurnsInternational Journal of Emergency Medicine

It makes sense that regional preferences apply, given regional bias to disease burden, healthcare resources and research priorities. This really confuses and complicates finding a journal that will be accessible to both your anticipated and unanticipated audiences.

But it doesn’t have to be confusing: improving access to your research is likely the best way to overcome this barrier. In the simplest terms, if you’re planning to publish open access, this barrier becomes irrelevant, as evidence suggests your audience will find your work as long as it is accessible. So let’s take a look at access for emergency medicine research.

Finding EM

Overall only a third of emergency medicine research (published in emergency medicine journals) is available open access. This is a much lower rate compared to other specialty fields – over 50% of cardiovascular research is available open access for example.

Recent epidemics (Ebola in 2014) and pandemics (SARS-CoV-2) have demonstrated the importance of research reaching the widest audience possible. This was acknowledged by both researchers and publishers who ensured that related research was available quickly and without cost. And rewarded with rapid international research solutions from across the globe. Just imagine what similar access can do for the urgent care-related SDG targets such as sepsis, cardiovascular pathology and injury.

We know, article processing fees that allow for article access without cost to your audience can be expensive to authors. We will be unpacking different access models for research dissemination in the second part of this series.

Think audience access

It is likely that you have a list (in your head) of journals you hold in esteem. It is also likely that you would consider these when you have the opportunity to publish.

You can evaluate the audience and cost of audience access to an article in any journal on your list with the three-step Burundi audience test. If Burundi is too hard, you can also use the Bulgaria test. The test is named respectively for the poorest nations in the world and the European Union (depending on where you live we can also call it the Haiti, Guyana, Kiribati, or North Korea audience test, with some numerical alterations when you get to step 2).

The Burundi (Bulgaria) audience test:

  1. Start with a null hypothesis: there is no audience for my research in Burundi (or Bulgaria). Then immediately reject it as generalisation is nearly always relative.
  2. Once you’ve rejected the null hypothesis, look up the cost in pounds for single article access, and multiply this by 3.4 for Burundi (or 2.3 for Bulgaria).
  3. The result is the hypothetical cost in pounds for single article access if the pound had the same purchasing power as Burundi’s (or Bulgaria’s) local currency (more on purchasing power in part 2).

If this is more than you would be willing to pay for article access, then it is more than what a low- and middle-income audience would pay either. You should consider a more reasonably priced journal, or a different access option (more on access options in part 2).

It is worth mentioning that publishing is often only the first step in dissemination. Bearing in mind the need to reach as wide an audience as possible, as a team, you should also consider sharing your research via FOAMed: social media, podcasts and blogs.

Disclosure from the authors

Regrettably we did not always consider the unanticipated global audience. Nearly all of Stevan’s PhD work on physiology in major injury, and Thomas’s on major trauma triage are only accessible with subscription access (yuck).
But both Stevan and Thomas have published on global health topics too; and nearly always in an open access format. Instinctively this feels like a reasonable balance, doesn’t it? Global health research should afterall ideally be accessible globally.

But what we both misunderstood was, that once we established that global health priorities are universal, all research essentially becomes global health research. Whether you believe it is relevant to a global audience or not is by and large irrelevant. Your unanticipated audience is much, much bigger than you think.

It is possible to track your global research impact through Impactstory (https://profiles.impactstory.org/). You’ll need an ORCID ID to do so.

A final word on citation impact

It is a common misbelief that only articles in high-impact journals matter. Impact factor is a journal-level metric that consists of all the citations of articles published over a set period, divided by a curated selection of articles over the same period.

Not all research published in journals with a high impact factor are highly cited (or cited at all). And the correlation between citations and usage, although positive, is much poorer than you would have thought.

What is very clear is that citations follow the audience. This is especially true for high impact articles. The bigger your audience, the more citations you’re likely to get. The more citations you get, the higher your h-index.

Read equitable publishing part 2: Access rules and part 3: Author, sponsor, mentor, replay. Please let us know about your narratives and experiences in the comments section below.


Stevan @codingbrown

Cite this article as: Stevan Bruijns, "Equitable publishing part 1: Appraising an audience," in St.Emlyn's, July 22, 2021, https://www.stemlynsblog.org/equitable-publishing-part-1-appraising-an-audience/.

1 thought on “Equitable publishing part 1: Appraising an audience”

  1. Dr Shweta Gidwani

    This is an excellent article! Well done Stevan and Thomas. Not only must the research be accessible in journals available to clinicians in LMIC, it must also be, I believe written in a style that is as plain & clear and it filled with academic jargon so that it’s is much more ‘digestible’ for those for whom English is not their first language. There is no Pulitzer Prize for the language in an article, so why make it flowery? !

Thanks so much for following. Viva la #FOAMed

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