Research Equity in Otolaryngology–Head and Neck Surgery

Head and neck pathologies disproportionately affect low- and middle-income countries (LMICs). For example, hearing loss is the fourth-leading cause of morbidity worldwide, ¹ with 80% of the 400 million individuals affected by moderate or severe hearing loss residing in LMICs. ² For children in LMICs, an estimated 75% of hearing loss is preventable, as compared with 48% in high-income countries (HICs). ³ Additionally, LMICs will bear 80% of head and neck cancer deaths and up to US$394 billion in associated economic losses by the year 2030. ⁴

Given the disproportionate burden of disease, LMIC-led research should be promoted, as local stakeholders possess relevant perspectives to prioritize and foster appropriate research, investigate pertinent questions, and formulate sustainable health policies.^5,6 Such an investment allows innovations and lessons such as contact tracing amid pandemics and community health worker–led outreach to be shared worldwide.^7-9 However, there exists an imbalance in the existing research output between HIC and LMIC researchers. For example, LMIC authorship represented only 35% of articles published in the Lancet Global Health between 2013 and 2017. ¹⁰

Inequalities in research output from LMICs may stem from multiple causes, ranging from limited funding, lack of research infrastructure, language barriers, limited research training, and competing clinical demands.^6,11,12 The preference for English in international journals may prevent nonnative speakers from more broadly disseminating their research. ¹³ The skill needed to thoroughly research a clinical question, the costs of accessing literature for background research, as well as the open access publishing fees may be additional barriers. ¹⁴ Further deterring LMIC research, manuscripts authored by local researchers may not be afforded the same consideration by reviewers for top-tier international journals. A study found that LMIC-based randomized clinical trials were published in lower–impact factor journals than HIC-based trials despite a high proportion of potential clinical benefit—even after adjusting for whether trials reported positive or negative results of an intervention. ¹⁵ Double- or triple-blind review could help overcome some of these issues. ¹⁶

Authorship can serve as a marker for the downstream impact of these barriers. High rates of foreign authorship have been reported in research specific to LMICs. For example, Dimitris et al reported that low-income country authors constituted 36.8% and 29.1% of first and senior authors, respectively, in publications related to their countries of affiliation. ¹⁷ Pertaining to surgical research, Pauyo et al reported that 24% of articles about low-income countries were authored exclusively by high-income foreign nationals. ¹¹ This extends to conference presentations, with significantly lower rates of abstract and oral presentations by LMIC authors. ¹² While authorship trends still need to be characterized in the field of otolaryngology–head and neck surgery (OHNS), we propose that research collaborations focused on care delivery in LMICs take proactive measures to promote equity by using the framework outlined here.

Proposed Components of a Research Equity Framework

To achieve a vision of research equity, country- and region-specific research priorities must be determined in collaboration with local OHNS researchers. Country- or region-specific research should not be undertaken by foreign researchers without participation by local providers throughout the research process. Resources, including funding and technical support, should support local investigators. ¹⁸ Furthermore, local OHNS providers must be commensurately recognized through equity in authorship, opportunities to disseminate findings, and additional means of professional growth. ¹⁹

This model for international research collaborations has been championed by several efforts, most notably by the nonprofit Partners in Health/Rwanda (PIH/R). The PIH/R research department implemented guidelines to ensure equitable representation of Rwandan authors. ²⁰ It achieved >50% Rwandan representation in first and senior authorships and have critically invested in building Rwandan clinical research capacity. To advance research equity in global OHNS collaborations, we urge the OHNS community to incorporate a similar approach into international research partnerships.

The Global Otolaryngology–Head and Neck Surgery Initiative (Global OHNS Initiative) is an international effort consisting of >170 members from 45 countries that aims to advance global OHNS care through collaborative research, ²¹ and it has emphasized research equity as a core tenet by adapting the PIH/R guidelines. ²² Initiative members were invited to review and comment on the guidelines, and feedback was incorporated to ensure that they reflect the diverse perspectives and priorities of initiative members.

The finalized Global OHNS Initiative “Research Equity Guidelines” ( Table 1 ) are designed to ensure that all Global OHNS Initiative research prioritizes researchers from the region of focus. It is our hope that OHNS researchers adopt these principles and modify them to their contexts, because only with a shared conscious focus on equity will OHNS research and, by extension, OHNS care best serve patients around the world, especially those with the most need.

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Table 1.

Global Otolaryngology–Head and Neck Surgery Initiative Research Equity Guidelines.

1. Global research projects will aim to include a diverse team of students, trainees, and researchers of various languages, countries, experience, and expertise. Region-specific research will include regional representation from the initiation of the project and will prioritize having local representatives as first or co–first authors to highlight and develop local expertise. Global projects will include diverse, global representation. 2. All authors will meet early in the project to draft role descriptions (including provisional first and senior authors), ensuring that each role is defined and agreed upon. These roles will guide the order of authorship. Authorship discussions will occur early in the research process and be reviewed periodically throughout the research. 3. Authors should be involved early in project development and have meaningful roles in subsequent academic outputs such as manuscripts, abstracts, and articles. 4. All authors listed will satisfy the International Committee of Medical Journal Editors authorship criteria. 5. The first, corresponding, and/or senior authors of a publication have primary responsibility for all aspects of the work, including project development, circulation for review, and submission. They will oversee all other authors’ standards for authorship and will present concise written descriptions of contributions to the work, which must be approved by all authors. This record must be submitted to the Global OHNS Initiative project manager to be shared with the initiative both at the initiation of the project and again prior to publication. 6. Each research project must be overseen by a senior researcher who can attest to the veracity of the work. 7. Manuscripts should be submitted for review by Global OHNS Initiative members to provide input before final approval. 8. First authors should have priority to present the research (eg, at conferences).