Collaborative research partnerships with disadvantaged communities: challenges and potential solutions

Does diversity beget diversity? A scientometric analysis of over 150,000 studies and 49,000 authors published in high-impact medical journals between 2007 and 2022

Background

Health research that significantly impacts global clinical practice and policy is often published in high-impact factor (IF) medical journals. These outlets play a pivotal role in the worldwide dissemination of novel medical knowledge. However, researchers identifying as women and those affiliated with institutions in low- and middle-income countries (LMIC) have been largely underrepresented in high-IF journals across multiple fields of medicine. To evaluate disparities in gender and geographical representation among authors who have published in any of five top general medical journals, we conducted scientometric analyses using a large-scale dataset extracted from the New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), The Lancet, and Nature Medicine.

Methods

Author metadata from all articles published in the selected journals between 2007 and 2022 were collected using the DimensionsAI platform. The Genderize.io API was then utilized to infer each author's likely gender based on their extracted first name. The World Bank country classification was used to map countries associated with researcher affiliations to the LMIC or the high-income country (HIC) category. We characterized the overall gender and country income category representation across the medical journals. In addition, we computed article-level diversity metrics and contrasted their distributions across the journals.

Findings

We studied 151,536 authors across 49,764 articles published in five top medical journals, over a long period spanning 15 years. On average, approximately one-third (33.1%) of the authors of a given paper were inferred to be women; this result was consistent across the journals we studied. Further, 86.6% of the teams were exclusively composed of HIC authors; in contrast, only 3.9% were exclusively composed of LMIC authors. The probability of serving as the first or last author was significantly higher if the author was inferred to be a man (18.1% vs 16.8%, P < .01) or was affiliated with an institution in a HIC (16.9% vs 15.5%, P < .01). Our primary finding reveals that having a diverse team promotes further diversity, within the same dimension (i.e., gender or geography) and across dimensions. Notably, papers with at least one woman among the authors were more likely to also involve at least two LMIC authors (11.7% versus 10.4% in baseline, P < .001; based on inferred gender); conversely, papers with at least one LMIC author were more likely to also involve at least two women (49.4% versus 37.6%, P < .001; based on inferred gender).

Conclusion

We provide a scientometric framework to assess authorship diversity. Our research suggests that the inclusiveness of high-impact medical journals is limited in terms of both gender and geography. We advocate for medical journals to adopt policies and practices that promote greater diversity and collaborative research. In addition, our findings offer a first step towards understanding the composition of teams conducting medical research globally and an opportunity for individual authors to reflect on their own collaborative research practices and possibilities to cultivate more diverse partnerships in their work.

Revisitando definições e naturezas da intersetorialidade: um ensaio teórico

Resumo Este ensaio teórico aborda definições e características centrais das ações intersetoriais para a saúde. Tem como objetivo, portanto, refletir sobre o conhecimento produzido a respeito das concepções e da natureza das ações intersetoriais para a saúde. Para a construção das análises, realizou-se uma revisão integrativa a partir de publicações referentes ao período de 2000 a 2019 identificadas nas bases de dados Lilacs, SciELO, Web of Science e Science Direct. O corpus contemplou 12 artigos, sendo analisados os aspectos relacionados com a finalidade, o propósito ou o método da ação intersetorial, sendo possível traçar similaridades e contrastes entre as definições. Diante da opacidade na construção de definições, coube situar que existe uma construção sócio-histórica dos conceitos, mas as definições provisórias expressam certo borramento ou apagamento que se encontram em disputa no interior do campo da saúde e que podem direcionar a distintos pontos de vista e constituir barreiras para incluir a implementação das ações intersetoriais relacionadas à promoção da saúde nas práticas cotidianas. De tais reflexões derivaram um conjunto de proposições acerca das naturezas das ações intersetoriais para a saúde, com vistas a contribuir para o debate sobre a temática.

Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review

Background

Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs).

Methods

We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability.

Results

When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed.

Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.

Conclusions

Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.

Experiences from a pilot study on how to conduct a qualitative multi-country research project regarding use of antibiotics in Southeast Europe

Background

In 2014, a qualitative multi-country research project was launched to study the reasons behind the high use of antibiotics in regions of Southeast Europe by using previously untrained national interviewers (who were engaged in other antibiotic microbial resistance-related investigations) to conduct qualitative interviews with local patients, physicians and pharmacists. Little knowledge exists about how to implement qualitative multi-country research collaborations involving previously untrained local data collectors. The aim of this paper was therefore to contribute to the knowledge regarding how to conduct these types of research projects by evaluating a pilot study of the project.

Methods

Local data collectors conducted the study according to a developed protocol and evaluated the study with the responsible researcher-team from University of Copenhagen. The pilot study focused on ‘local ownership’, ‘research quality’ and ‘feasibility’ with regard to successful implementation and evaluation. The evaluation was achieved by interpreting ‘Skype’ and ‘face to face’ meetings and email correspondence by applying ‘critical common sense’.

Results

Local data collectors achieved a sense of joint ownership. Overall, the protocol worked well. Several minor challenges pertaining to research quality and feasibility were identified, in particular obtaining narratives when conducting interviews and recruiting patients for the study. Furthermore, local data collectors found it difficult to allocate sufficient time to the project. Solutions were discussed and added to the protocol.

Conclusions

Despite the challenges, it was possible to achieve an acceptable scientific level of research when conducting qualitative multi-country research collaboration under the given circumstances. Specific recommendations to achieve this are provided by the authors.

Community Participation in Health Systems Research: A Systematic Review Assessing the State of Research, the Nature of Interventions Involved and the Features of Engagement with Communities

BACKGROUND

Community participation is a major principle of people centered health systems, with considerable research highlighting its intrinsic value and strategic importance. Existing reviews largely focus on the effectiveness of community participation with less attention to how community participation is supported in health systems intervention research.

OBJECTIVE

To explore the extent, nature and quality of community participation in health systems intervention research in low- and middle-income countries.

METHODOLOGY

We searched for peer-reviewed, English language literature published between January 2000 and May 2012 through four electronic databases. Search terms combined the concepts of community, capability/participation, health systems research and low- and middle-income countries. The initial search yielded 3,092 articles, of which 260 articles with more than nominal community participation were identified and included. We further excluded 104 articles due to lower levels of community participation across the research cycle and poor description of the process of community participation. Out of the remaining 160 articles with rich community participation, we further examined 64 articles focused on service delivery and governance within health systems research.

RESULTS

Most articles were led by authors in high income countries and many did not consistently list critical aspects of study quality. Articles were most likely to describe community participation in health promotion interventions (78%, 202/260), even though they were less participatory than other health systems areas. Community involvement in governance and supply chain management was less common (12%, 30/260 and 9%, 24/260 respectively), but more participatory. Articles cut across all health conditions and varied by scale and duration, with those that were implemented at national scale or over more than five years being mainstreamed by government. Most articles detailed improvements in service availability, accessibility and acceptability, with fewer efforts focused on quality, and few designs able to measure impact on health outcomes. With regards to participation, most articles supported community's in implementing interventions (95%, n = 247/260), in contrast to involving communities in identifying and defining problems (18%, n = 46/260). Many articles did not discuss who in communities participated, with just over a half of the articles disaggregating any information by sex. Articles were largely under theorized, and only five mentioned power or control. Majority of the articles (57/64) described community participation processes as being collaborative with fewer describing either community mobilization or community empowerment. Intrinsic individual motivations, community-level trust, strong external linkages, and supportive institutional processes facilitated community participation, while lack of training, interest and information, along with weak financial sustainability were challenges. Supportive contextual factors included decentralization reforms and engagement with social movements.

CONCLUSION

Despite positive examples, community participation in health systems interventions was variable, with few being truly community directed. Future research should more thoroughly engage with community participation theory, recognize the power relations inherent in community participation, and be more realistic as to how much communities can participate and cognizant of who decides that.

Considerations for preparing a randomized population health intervention trial: lessons from a South African-Canadian partnership to improve the health of health workers

Background

Community-based cluster-randomized controlled trials (RCTs) are increasingly being conducted to address pressing global health concerns. Preparations for clinical trials are well-described, as are the steps for multi-component health service trials. However, guidance is lacking for addressing the ethical and logistic challenges in (cluster) RCTs of population health interventions in low- and middle-income countries.

Objective

We aimed to identify the factors that population health researchers must explicitly consider when planning RCTs within North–South partnerships.

Design

We reviewed our experiences and identified key ethical and logistic issues encountered during the pre-trial phase of a recently implemented RCT. This trial aimed to improve tuberculosis (TB) and Human Immunodeficiency Virus (HIV) prevention and care for health workers by enhancing workplace assessment capability, addressing concerns about confidentiality and stigma, and providing onsite counseling, testing, and treatment. An iterative framework was used to synthesize this analysis with lessons taken from other studies.

Results

The checklist of critical factors was grouped into eight categories: 1) Building trust and shared ownership; 2) Conducting feasibility studies throughout the process; 3) Building capacity; 4) Creating an appropriate information system; 5) Conducting pilot studies; 6) Securing stakeholder support, with a view to scale-up; 7) Continuously refining methodological rigor; and 8) Explicitly addressing all ethical issues both at the start and continuously as they arise.

Conclusion

Researchers should allow for the significant investment of time and resources required for successful implementation of population health RCTs within North–South collaborations, recognize the iterative nature of the process, and be prepared to revise protocols as challenges emerge.

Supporting southern-led research: implications for North-South research partnerships

BACKGROUND

Global health research partnerships are commonly led by Northern investigators who come from resource-rich research environments, while Southern partners participate with a paucity of research skills and resources. This power asymmetry within North-South research partnerships may further exacerbate the unequal distribution of benefits from the research process.

METHODS

This study is designed to present the benefits and challenges of engaging in the research process from the perspective of The AIDS Support Organization (TASO), an HIV/AIDS care and treatment organization that has been involved in global health research partnerships. It uses a validated research tool entitled "Is Research Working for You?" to facilitate qualitative interviews surrounding the experienced benefits and challenges in engaging in the research partnerships as described by TASO staff.

RESULTS

Three key themes emerged from the content and thematic analysis: 1) the reported benefits of research (e.g., evidence-based management, advocacy, etc.), 2) the challenges the research committee members face in becoming more involved in the research process (e.g., lack of data analysis skill, lack of inclusion in the research process, etc.), and 3) the institutional ambition at TASO to develop a Southern-led research agenda.

CONCLUSIONS

This is one of the few studies to document the development of a Southern-led research agenda in addition to the challenges of engaging in the research process. Mechanisms for moderating power dynamics within North-South partnerships can provide opportunities for improved research capacity and quality.

Patient-expert partnerships in research: how to stimulate inclusion of patient perspectives

OBJECTIVE To gain more insight into exclusion mechanisms and inclusion strategies in patient-expert partnerships. BACKGROUND Patient participation in health research, on the level of 'partnerships with experts' is a growing phenomenon. However, little research is conducted whether exclusion mechanisms take place and to what extent patients' perspectives are included in the final outcomes of these partnerships. Case study  A dialogue meeting attended by experts, patients and patient representatives to develop a joint research agenda. Different inclusion strategies were applied during the dialogue meeting to avoid possible exclusion. METHOD Data were collected by the means of audio and video recordings, observations, document analysis and evaluative interviews. The data are clustered using a framework that divides exclusion mechanisms in three categories: circumstances, behaviour and verbal communication. The data are analysed focusing on the experiences of participants, observation of occurrence of exclusion and difference between input and outcome of the dialogue meeting. RESULTS The circumstances of the dialogue and the behaviour of the participants were experienced as mainly inclusive. Some exclusion was observed particularly with respect to verbal communication. The input of the patients was less visible in the outcome of the dialogue meeting compared to the input of the experts. CONCLUSION This case study reveals that exclusion of patients' perspective occurred during a dialogue meeting with experts, despite the fact that inclusion strategies were used and patients experienced the dialogue meeting as inclusive. To realize a more effective patient-expert partnership, more attention should be paid to the application of some additional inclusion strategies.

Fieldwork challenges: lessons learned from a north-south public health research partnership

The value of collaborative international research in addressing global public health challenges is increasingly recognized. However, little has been written about lessons learned regarding fieldwork to help guide future collaborative efforts. Through a research partnership between two Northern universities, one Southern university, and a Southern faith-based organization, we evaluated a school-based HIV prevention intervention with South African adolescents. In this article, we highlight the seven key fieldwork-related challenges experienced and identify the lessons learned. The underlying theme is that of reconciling a structured and reasoned "desk" planning process with the more fluid and unpredictable reality of conducting fieldwork. This concern is particularly significant in resource-deprived environments and/or contexts that are less familiar to Northern partners. Fieldwork is unpredictable, but obstacles can be minimized through meaningful participation in both planning and field research. Sharing practical lessons from the field can prove a useful resource for both researchers and practitioners.

The role of leadership and management in six southern public health partnerships: a study of member involvement and satisfaction

Research has led to greater understanding of what is needed to create and sustain well-functioning public health partnerships. However, a partnership's ability to foster an environment that encourages broad member involvement in discussions, decision making, and activities has received scant empirical attention. This study examined the relationship between partnership members' perceptions of how well leadership and management facilitated their involvement, and their satisfaction with their role and influence within the partnership. Data came from 60 individuals who participated in two waves of a quantitative process evaluation of six southern interorganizational partnerships, formed as part of a national pilot project to increase cervical and breast cancer screening rates. Results suggested that environments fostering broad partner involvement were associated with measures of member satisfaction, controlling for other partnership characteristics. Findings indicated that facilitation of member involvement deserves increased consideration from researchers and practitioners as an indicator of the quality of partnership functioning.

The role of advocacy and interpretation services in the delivery of quality healthcare to diverse minority communities in London, United Kingdom

Inequalities in access to appropriate and acceptable healthcare contributes to a pattern of poorer health status, reduced life expectancy and greater dissatisfaction with healthcare amongst people from Black and minority ethnic communities (BME). Language acts as a further barrier to access. The development of bilingual advocacy fuses two key functions--interpretation and advocacy--to ensure that people from BME communities are able to have their healthcare needs met appropriately. This paper explores the development of bilingual advocacy in East London, which has a highly diverse population speaking over 100 different languages. It considers the development of the bilingual advocacy services by an NHS University Hospital Trust, the local experience of these services and the factors that have influenced their development. We employed the Delphi method amongst the four authors to examine the advocate-, service- or client-related challenges that face advocacy services; and the threats of these challenges to Trust-based advocacy and their implications to the service, client and advocate. Advocate-related challenges included status, esteem and remuneration of bilingual advocates in relation to other health professionals, as well as skills development, career progression, gender, capacity building and potential research contributions. Service-related challenges included work load, case mix, administration, commissioning processes/arrangements; entrepreneurial aspects of advocacy services; and mechanisms/potentials for cost recovery. Client-related challenges included continuity of advocacy; language requirements and advocacy needs of clients; and ways in which mobile populations influence planning and delivery of advocacy services for inner city hospitals. The paper concludes with identifying the implications for future development of bilingual advocacy services and the implications for their workforce.

One size fits all partnerships? What explains community partnership leadership skills?

The authors evaluated W. K. Kellogg-funded Community Partnerships (CPs) between academic, health service, and community partners in South Africa. Stakeholders (N = 668 respondents) completed questionnaires to explore the operational, functional and organisational factors that contribute to members' perceptions of the skills of their CPs' leadership. Ten factors accounted for 53% of leadership skills across five participating CPs and six stakeholder groups. Each CP displayed its unique footprint of factors that accounted for its leadership levels. Similarly, each stakeholder group had its unique signature of factors that were associated with its leadership. Two factors (communication mechanisms and operational understanding) accounted for more than 25% of leadership skills; management capabilities and participation benefits accounted for 4% and 3%; and effectiveness, benefits to difficulties ratio of being a member, engagement in education, flow of information and sense of ownership accounted for 2% to 3% each. Attention to these and other factors is warranted.

Perspectives on a Community-Based Course for Public Health Students

In recent years, there has been an increase in collaborations between universities and local community agencies. During the 2005-2006 academic year, the Department of Behavioral and Community Health Sciences at the University of Pittsburgh Graduate School of Public Health began a community—university partnership with Hosanna House Inc., a local community service center. The initial phase of this partnership included holding a departmental community development course at the community service center. Information from student journals, course evaluations, and key informant interviews were used to describe the attitudes and perspectives of the students, course instructor, and key informants toward this experience. Overall, this experience positively affected the personal and professional development of the students and was well received by faculty and staff within the academic department and community service center. The authors anticipate that this information will promote and serve as a reference for similar community—university partnerships at other schools of public health.

Engagement and action for health: the contribution of leaders' collaborative skills to partnership success

A multi-site evaluation (survey) of five Kellogg-funded Community Partnerships (CPs) in South Africa was undertaken to explore the relationship between leadership skills and a range of 30 operational, functional and organisational factors deemed critical to successful CPs. The CPs were collaborative academic-health service-community efforts aimed at health professions education reforms. The level of agreement to eleven dichotomous ('Yes/No') leadership skills items was used to compute two measures of members' appreciation of their CPs' leadership. The associations between these measures and 30 CPs factors were explored, and the partnership factors that leadership skills explained were assessed after controlling. Respondents who perceived the leadership of their CPs favourably had more positive ratings across 30 other partnership factors than those who rated leadership skills less favourably, and were more likely to report a positive cost/ benefit ratio. In addition, respondents who viewed their CPs' leadership positively also rated the operational understanding, the communication mechanisms, as well as the rules and procedures of the CPs more favourably. Leadership skills explained between 20% and 7% of the variance of 10 partnership factors. The influence of leaders' skills in effective health-focussed partnerships is much broader than previously conceptualised.

Promoting public health: benefits and challenges of a Europeanwide research consortium on student health

AIMS

The purpose of this paper is to highlight some of the benefits and challenges when undertaking research across several countries comprising diverse ethnic, lingual and historically different communities.

METHODS

Literature review and experiences of the researchers who participated in the Students' Health Inquiry, as regards the benefits and the challenges that can emerge when conducting collaborative research. The Delphi technique was employed to reach consensus on and prioritise the emerging challenges and suggested solutions.

RESULTS

Challenges of research consortia include the preparatory work before the study, the ownership of the data and dissemination of results, as well as methodological, financial, operational, and structural challenges. These are described, each challenge is further broken down in its subcomponents, examples are given, and potential solutions are suggested.

CONCLUSIONS

If challenges can be prevented or solved, the benefits of research consortia include greater generalisability of findings, and more comprehensive understanding of the issues than would be possible with a single-site study. There is also an increased probability to bring about policy changes and programmatic adjustments. Cross-national research consortia can contribute to reduction in the inequality of resources and research opportunities in the collaborating countries. Research consortia deserve the attention of funding agencies. They are capable of bringing about synergies that result from working collaboratively together of large multi-disciplinary team of investigators who share their strengths, disciplines and expertise in order to bear on the same research issue in multiple countries and diverse populations.