Publication bias is the consequence of a lack of diversity, equity, and inclusion

Promoting Health Equity, Diversity, and Inclusion in Medical and Scientific Writing and Publishing of Research: A Statement from the Inaugural Diversity, Equity, and Inclusion (DEI) Advocacy Team of the Journal of General Internal Medicine

The Journal of General Internal Medicine (JGIM) has a long-standing history of publishing manuscripts focused on health equity and is committed to diversity, equity, and inclusion (DEI) in scientific writing and publishing. This is extremely important in the current climate where false narratives and attacks on DEI and health equity are rampant. To demonstrate their commitment to DEI and health equity, the JGIM Editors-in-Chief created an inaugural DEI Advocacy Team. Composed of four academic scholars with vast knowledge and expertise in health equity and DEI, the JGIM DEI Advocacy Team is posed to create the infrastructure for improving DEI in scientific writing and publishing within JGIM. The team strives to advocate for diversity among the editorial board and staff; foster an inclusive environment where all contributions are valued; and facilitate increased and equitable opportunities for publishing of scholarly work by underrepresented groups in medicine. To operationalize their goals, the JGIM DEI Advocacy Team created the 5TDEI Conceptual Framework (team, tools, tracking, transparency, training). This perspective provides a statement from the inaugural JGIM DEI Advocacy Team on how we envision promoting health equity, diversity, and inclusion in medical and scientific writing and publishing of research in JGIM.

Barriers, facilitators, needs, and preferences in seeking information regarding cervical cancer prevention programs among Turkish, Moroccan, and Syrian immigrant women: a scoping review

BACKGROUND

Cervical cancer (CC) is the fourth most frequently diagnosed cancer in women worldwide. Immigrant women are often disproportionately affected by CC but show low participation in CC screening and human papillomavirus (HPV) vaccination.

METHODS

We conducted a scoping review on immigrant women's information needs regarding CC screening participation and HPV vaccination uptake. A total of 584 articles were found on Embase.com, PsychINFO, and CINAHL, of which 87 articles were included.

RESULTS

This review revealed that immigrant women indicate a need for more personalized information regarding CC screening and HPV vaccination. We identified barriers to obtaining, processing, and understanding the information, which included overall practical, emotional, cultural and religious aspects (e.g., shame, taboo, lack of trust, fatalism, and cultural norms and values regarding sexual activity). Facilitators, such as translation services, receiving information from people with similar cultural and/or religious backgrounds, encouraging other women or family, and using home visits as an outreach strategy, were also identified.

CONCLUSIONS

Our review provides a comprehensive overview of the information needs and preferences of immigrant women, which could be used to tailor interventions, considering the contextual nuances in which these women are situated. The needs and preferences of immigrant women should be taken into account during the development of new information materials or other interventions. This would help immigrant women make informed decisions regarding participation in CC screening and HPV vaccination.

Considerations of equity, diversity and inclusion in peer reviews conducted for Medical Education

What equity, diversity and inclusion issues are commented upon by Med Educ's reviewers? This commentary offers an analysis and recommendations for authors, reviewers and editors alike.

Gender representation trends in cardiothoracic surgery journal editorial boards

OBJECTIVE

We aimed to characterize chronologic trends of gender composition of the editorial boards of major cardiothoracic surgery journals in the current era.

METHODS

A cross-sectional analysis was performed of gender representation in editorial board members of 2 North American cardiothoracic surgery journals from 2008 to 2023. Member names and roles were collected from available monthly issues. Validated software programming was used to classify gender. The annual proportion of women representation was compared to the thoracic surgery workforce.

RESULTS

During the study period, 558 individuals (3641 names) were identified, 14.3% of whom were women. The total number of editorial board women increased for both journals. The proportion of women also increased from 2.5% (3 out of 118) in 2008 to 17.8% (71 out of 399) in 2023 (P < .001), exceeding the percentage of women in the thoracic surgery workforce, which increased from 3.8% in 2007 to 8.3% in 2021 (P < .001). The average duration of participation was longer for men than for women (53.8 vs 44.5 months; P = .01). Women in editorial board senior roles also increased from 3.3% (1 out of 30) in 2008 to 28.6% (42 out of 147) in 2023 (P < .001), almost triple the increase in nondesignated roles from 2.3% (2 out of 88) in 2008 to 11.5% (29 out of 252) in 2023 (P < .001).

CONCLUSIONS

In recent years, the appointment of women to the editorial boards of high-impact cardiothoracic surgery journals and senior roles have proportionally exceeded the overall representation of women in cardiothoracic surgery. These findings indicate progress in inclusive efforts and offer insight toward reducing academic gender disparities.

Resilience and strengths in the Black autism community in the United States: A scoping review

Gaps in research knowledge pertaining to resiliency factors and strengths among the Black autism community, inclusive of autistic persons and their support system exist. A scoping review was conducted to further explore quantitative, qualitative, and mixed methods studies that investigate resiliency factors and related strengths in the Black autism community in the United States. A total of 436 articles were identified, with 28 studies included in the final review. Results demonstrated that (1) strengths of Black autistic persons across the life course have been disregarded in research; (2) Black caregiver advocacy, while common, is also a developmental process that can be supported by community-based interventions; (3) informal supports including family and friends play an instrumental role in supporting the well-under investigated being of Black parents of autistic children; and (4) spirituality is often endorsed by Black caregivers of autistic children, such as playing a role in acceptance of the autism diagnosis and with coping with difficult life situations. Research and practice implications are discussed.

Applying a health equity lens to the perioperative anesthetic management for coronary artery bypass grafting

BACKGROUND

Disparities in healthcare based on race, ethnicity, and socioeconomic status (SES) remain a public health crisis, especially in perioperative anesthetic management. This study applies a health equity lens to intraoperative pain and postoperative nausea and vomiting (PONV) for patients undergoing coronary artery bypass grafting (CABG).

METHODS

This retrospective cohort study included 1404 adult patients who underwent coronary artery bypass grafting (CABG) between 2017 and 2022 at a single, multi-site, academic healthcare system. The primary outcomes were PONV as well as moderate-to-severe post-operative pain. Secondary outcomes were administration of prophylactic antiemetics, compliance with guideline-recommended antiemetic prophylaxis, and opioid morphine milligram equivalents (MME) administered intraoperatively. Independent variables included patient race and ethnicity, healthcare payor type, and community-level SES (using Area Deprivation Index [ADI]). Multivariable logistic regression models that controlled for relevant covariates were utilized.

RESULTS

The findings showed no significant disparities in experiencing PONV, post-operative pain, or receiving high opioid MME based on race, ethnicity, payor type, and ADI. There were also no differences in the receipt of antiemetics nor compliance with guideline-recommended antiemetic prophylaxis.

CONCLUSIONS

Our study did not find racial, ethnic, or SES disparities in intraoperative anesthetic pain management, postoperative pain, nor PONV management. Applying a health equity lens to quality outcomes during the perioperative period is necessary to ensure equitable care among diverse populations.

A Cross-Sectional Evaluation of Publication Bias in the Plastic Surgery Literature

BACKGROUND

Publication bias (PB) is the preferential publishing of studies with statistically significant results. PB can skew findings of systematic reviews (SRs) and meta-analyses (MAs), with potential consequences for patient care and health policy. This study aims to determine the extent to which SRs and MAs in the plastic surgery literature evaluate and report PB.

METHODS

This cross-sectional study assessed PB reporting and analysis from plastic surgery studies published between January 1, 2015, and June 19, 2020. Full texts of SRs and MAs were assessed by two reviewers for PB assessment methodology and analysis. Post hoc assessment of studies that did not originally analyze PB was performed using Egger regression, Duval, Tweedie trim-and-fill, and Copas selection models.

RESULTS

There were 549 studies evaluated, of which 531 full texts were included. PB was discussed by 183 studies (34.5%), and formally assessed by 97 studies (18.3%). Among SRs and MAs that formally assessed PB, PB was present in 24 studies (10.7%), not present in 52 (23.1%), and inconclusive in eight (3.6%); 141 studies (62.7%) did not report the results of their PB assessment. Funnel plots were the most common assessment method [ n = 88 (39.1%)], and 60 studies (68.2%) published funnel plots. The post hoc assessment revealed PB in 17 of 20 studies (85.0%).

CONCLUSIONS

PB is inadequately reported and analyzed among studies in the plastic surgery literature. Most studies that assessed PB found PB, as did post hoc analysis of nonreporting studies. Increased assessment and reporting of PB among SRs and MAs would improve the quality of evidence in plastic surgery.

Primary Author Characteristics Associated With Publication in the Journal of Pain and Symptom Management

CONTEXT

Scientific journals are the primary source for dissemination of research findings, and this process relies on rigorous editorial and peer-review. As part of continuing efforts by the Journal of Pain and Symptom Management (JPSM) to advance equity, diversity, and inclusion, JPSM's leadership requested an external evaluation of their publication decisions.

OBJECTIVES

1) Describe primary author characteristics associated with final decisions to accept or reject manuscripts submitted for publication; 2) Report on whether there are potential publication biases in the JPSM editorial or peer-review processes.

METHODS

Data consisted of self-reported primary author demographic characteristics associated with manuscript submissions between June 18, 2020, and December 31, 2022. Characteristics included region of residence, race, gender, and ethnicity. A multiple logistic regression model was used to estimate adjusted odds of rejection for each author characteristic.

RESULTS

A total of 1940 submissions were evaluated. Compared to authors residing in North America, authors residing in Asia had six-fold greater odds of rejection, authors residing in Europe had four-fold greater odds of rejection, and authors residing in other regions had two-fold greater odds of rejection. Female authors submitted 1.7 times more papers than males, but there was no difference in acceptance rates of their papers in adjusted analysis.

CONCLUSION

In this analysis of publication decisions by the JPSM, there were differences in acceptance rates by region of residence, ethnicity, and race but not by gender. Asian authors and authors residing in regions outside of North America had greater odds of rejection compared to White or North American authors.

Brain morphological variability between whites and African Americans: the importance of racial identity in brain imaging research

In a segregated society, marked by a historical background of inequalities, there is a consistent under-representation of ethnic and racial minorities in biomedical research, causing disparities in understanding genetic and acquired diseases as well as in the effectiveness of clinical treatments affecting different groups. The repeated inclusion of small and non-representative samples of the population in neuroimaging research has led to generalization bias in the morphological characterization of the human brain. A few brain morphometric studies between Whites and African Americans have reported differences in orbitofrontal volumetry and insula cortical thickness. Nevertheless, these studies are mostly conducted in small samples and populations with cognitive impairment. For this reason, this study aimed to identify brain morphological variability due to racial identity in representative samples. We hypothesized that, in neurotypical young adults, there are differences in brain morphometry between participants with distinct racial identities. We analyzed the Human Connectome Project (HCP) database to test this hypothesis. Brain volumetry, cortical thickness, and cortical surface area measures of participants identified as Whites (n = 338) or African Americans (n = 56) were analyzed. Non-parametrical permutation analysis of covariance between these racial identity groups adjusting for age, sex, education, and economic income was implemented. Results indicated volumetric differences in choroid plexus, supratentorial, white matter, and subcortical brain structures. Moreover, differences in cortical thickness and surface area in frontal, parietal, temporal, and occipital brain regions were identified between groups. In this regard, the inclusion of sub-representative minorities in neuroimaging research, such as African American persons, is fundamental for the comprehension of human brain morphometric diversity and to design personalized clinical brain treatments for this population.

Does clinical research account for diversity in deploying digital health technologies?

Digital health technologies (DHTs) should expand access to clinical research to represent the social determinants of health (SDoH) across the population. The frequency of reporting participant SDoH data in clinical publications is low and is not known for studies that utilize DHTs. We evaluated representation of 11 SDoH domains in 126 DHT-enabled clinical research publications and proposed a framework under which these domains could be captured and subsequently reported in future studies. Sex, Race, and Education were most frequently reported (in 94.4%, 27.8%, and 20.6% of publications, respectively). The remaining 8 domains were reported in fewer than 10% of publications. Medical codes were identified that map to each of the proposed SDoH domains and the resulting resource is suggested to highlight that existing infrastructure could be used to capture SDoH data. An opportunity exists to increase reporting on the representation of SDoH among participants to encourage equitable and inclusive research progress through DHT-enabled clinical studies.

Diversity, Equity, and Inclusion on Editorial Boards of Global Health Journals

Journals have been described as “duty bearers” of upholding fundamental ethical principles that are essential for maintaining the ethical integrity of newly generated and disseminated knowledge. To play our part, we evaluated diversity and inclusion in the leadership and management of global and international health journals. We developed Journal Diversity Index (JDI) to measure three parameters of diversity and representation (gender, geographic, socioeconomic status). Relevant information regarding editorial board members of systematically screened journals was sequentially extracted and job titles were categorized into five editorial roles. Chi-squared test was utilized to study associations between gender and geographic distribution of editors along with the Medline indexing of the journal and its impact factor. Out of 43 journals included, 62.7% were published from two high-income countries. Women comprised 44% of the total editors. Among all the editorial board members, we did not find any information suggesting the representation of non-binary and transgender individuals. Furthermore, 68.2% of editors were based in high-income countries with 67.3% of the editors belonging to the Global North. This disparity in geographic region and socioeconomic level was observed across all five editorial roles. Among all women editors, more than 70% worked in non-Medline and non-impact factor journals. Only two journals scored “excellent” on JDI. Despite the continuous evolution of the definition of global health ethics, marginalized individuals, and their perspectives remain underrepresented in this field. Thus, we call for swift action regarding the decentralization and redistribution of global and international health journal editorial boards.

The measurable impact of a diversity, equity, and inclusion editor on diversifying content, authorship, and peer review participation in the Journal of Vascular Surgery

OBJECTIVE

Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content.

METHODS

The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ² tests.

RESULTS

During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001).

CONCLUSIONS

The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.

Diversity-related Factors in Research Mentorship and Publishing in the ACBS Community and the Journal of Contextual Behavioral Science

Gender, racial, and ethnic disparities persist in the scientific community despite increasing attention to research-related equity. Men publish in biomedical, scientific journals more frequently than women researchers and have more leadership roles (e.g., first authorship) in these submissions. Similar differences in scientific publishing appear among under-represented minority (URM) authors compared to White counterparts. These findings of authorship disparities are not consistent across all journals and may relate to mentorship variables. This study aimed to investigate gender and racial patterns of publishing and research mentorship within the Association for Contextual Behavioral Science (ACBS) community, including in the Journal of Contextual Behavioral Science (JCBS). Two hundred and eighty-two ACT for Professionals listserv members responded to the anonymous 31-item survey. Men reported significantly more publications and more first author manuscripts than women, both in scientific journals generally and in JCBS specifically. White versus URM respondents more frequently reported publishing in JCBS, but not in other scientific journals. There were no differences in the total number of barriers noted between men and women or between White respondents and URM respondents. The top barriers to publishing among all respondents were lack of time, institutional support, and funding. Women more frequently reported lack of adequate research mentorship or collaboration as a barrier to publishing in scientific journals, as well as in JCBS specifically; men more frequently reported experiencing publishing barriers related to embargos and not having research that was appropriate for JCBS. Identifying as the same gender as one's primary research mentor did not relate to any areas of training. However, participants whose race differed from their mentor were significantly more likely to report training in running a study and receiving positive encouragement. Being matched in terms of gender or race with one's mentor did not relate to publishing variables. Findings highlight the continued gender and racial disparities in publishing within the ACBS community and in JCBS. Recommendations for decreasing these differences through research mentorship and structured training efforts are provided.

Menstrual cycles during COVID-19 lockdowns: A systematic review and meta-analysis

Coronavirus disease 2019 lockdowns produced psychological and lifestyle consequences for women of reproductive age and changes in their menstrual cycles. To our knowledge, this is the first systematic review to characterize changes in menstrual cycle length associated with lockdowns compared to non-lockdown periods. A search on 5 May 2022 retrieved articles published between 1 December 2019, and 1 May 2022, from Medline, Embase, and Web of Science. The included articles were peer-reviewed observational studies with full texts in English, that reported menstrual cycle lengths during lockdowns and non-lockdowns. Cross-sectional and cohort studies were appraised using the Appraisal tool for Cross-Sectional Studies and the Cochrane Risk of Bias Tool for Cohort Studies, respectively. Review Manager was used to generate a forest plot with odds ratios (OR) at the 95% confidence interval (CI), finding a significant association between lockdown and menstrual cycle length changes for 21,729 women of reproductive age (OR = 9.14, CI: 3.16-26.50) with a significant overall effect of the mean (Z = 4.08, p < 0.0001). High heterogeneity with significant dispersion of values was observed (I 2 = 99%, τ = 1.40, χ2 = 583.78, p < 0.0001). This review was limited by the availability of published articles that favored high-income countries. The results have implications for adequately preparing women and assisting them with menstrual concerns during lockdown periods.

Prospective analyses of sex/gender-related publication decisions in general medical journals: editorial rejection of population-based women's reproductive physiology

OBJECTIVE

To assess whether editorial desk rejection at general medical journals (without peer review) of two clinical research manuscripts may relate to author gender or women's physiology topics. Given evidence for bias related to women in science and medicine, and editorial board attitudes, our hypothesis was that submissions by women authors, on women's reproductive, non-disease topics received differential editorial assessment.

DESIGN

A prospective investigation of publications, author gender and topics in general medical journals in two issues following the editorial rejections of two clinical research manuscripts by five major English-language general medical journals. The rejected manuscripts (subsequently published in lower impact journals) described research funded by national granting bodies, in population-based samples, authored by well-published women scientists at accredited institutions and describing innovative women's reproductive physiology results.

SETTING

Tertiary academic medical centre.

MAIN OUTCOME MEASURES

All clinical research published in the two issues following rejection date by each of the five major general medical journals were examined for first/senior author gender. The publication topic was assessed for its gendered population relevance, whether disease or physiology focused, and its funding. Rejection letters assessed editor gender and status.

RESULTS

Women were underrepresented as original research authors; men were 84% of senior and 69% of first authors. There were no, non-disease focused publications relating to women's health, although most topics were relevant to both genders. The majority (80%) of rejection letters appeared to be written by junior-ranked women editors.

CONCLUSION

Sex/gender accountability is necessary for clinical research-based editorial decisions by major general medical journals. Suggestions to improve gender equity in general medical journal publication: (1) an editorial board sex/gender champion with power to advocate for manuscripts that are well-performed research of relevance to women's health/physiology; (2) an editorial rejection adjudication committee to review author challenges; and (3) gender parity in double-blind peer review.