Journal selection

We performed a cross-sectional analysis from data collected on OA policies from scientific journals. Top journals were identified using the Google Scholar Top Publication database, an online catalogue of the most impactful academic journals as determined by h-5 index, which is the largest number “h” such that “h” articles published by the journal in the last five years have at least “h” citations each. We included only the highest reach publications because they are the journals that are most likely to affect clinical practice and scientific guidelines, and thus are likely to be most meaningful for LMIC authors and readers. We selected the 20 top journals in the “Life Sciences & Earth Sciences” category (e.g., Nature), the 20 top journals in the “Health & Medical Sciences” category (e.g., The New England Journal of Medicine), the 20 top journals in the “Surgery” subcategory (e.g., JAMA Surgery).

Relevant variables

Variables relevant to LMIC authors included each Journal Impact Factor (IF), calculated by Clarivate [12], and publicly available OA policies. Variables relevant to LMIC readers included subscription costs, current level of free to access articles in the most recent issue of the journal, and availability on HINARI, a database of publishers willing to grant LMICs free access to select journals and articles. From the authors’ perspective, the IF indicates the potential reach of their research, and the APCs required by some journals to publish with OA were used as a metric to evaluate costs incurred to disseminate research. From the readers’ perspective, subscription prices demonstrate affordability to the journals researched in our study; availability on HINARI demonstrates accessibility specifically for LMIC readers.

Open access policies

To define OA policies, we used the SHERPA RoMEO database, an online resource that aggregates and analyzes publisher OA policies and each journal’s publicly available publishing protocols. Policies where a payment is required by either the author or reader include the Gold OA model, subscription model, and hybrid model; Green OA and HINARI do not require payment by either party. Gold OA journals publish articles with immediate access after payment of APCs by the authors. Subscription journals publish articles free of significant charge to authors and provide access only to readers who pay subscription or pay-per-view fees, which range from journal to journal. Hybrid journals are those that allow authors the option to publish either by the subscription model, with little to no publishing fees, or with an APC, making the article Gold OA upon its publication. Delayed OA offers full access after an embargo period usually of 6–12 months. Subscription fees and APCs were recorded in US dollars. The Green OA model involves the use of platforms such as arXiv.org, an open-access repository of electronic preprints and post-prints approved for posting after moderation (but not peer review), to publish the accepted or submitted versions of a manuscript free of charge. The use of the paid models and Green OA is not mutually exclusive. Availability on HINARI was assessed by determining whether each journal’s publishing company was listed on Research4Life’s website as a “HINARI Partner.” Finally, in order to gauge each journal’s current level of accessibility to those in LMICs, the most recent issue of each journal was evaluated for the percentage of articles freely available.

Statistical analysis

Categorical variables were summarized using frequency with percentage. Continuous variables were reported as median and interquartile range (IQR). Nonparametric tests like Wilcoxon rank sum test, Wilcoxon rank sum exact test (for two sample comparisons), Kruskal-Wallis test (ANOVA or more than two-samples comparisons) were performed in case of hypothesis testing status quo. Significance of all hypothesis tests was considered at alpha level of significance less than 5%. All analyses were performed with R software version 4.1.0 (https://cran.r-project.org/).

Open access policies

A total of 55 journals were included after the removal of duplicates due to category overlap. Of these, 6 journals (11%) were classified as Gold OA, 2 (3.6%) were defined as subscription only journals, 4 (7.3%) were delayed OA, and 43 (78%) were defined as hybrid (Table 1, Figure 1). A total of 50 journals (91%) offered an option to self-publish with Green OA (no payment required by authors or readers), and 47 (85%) were considered to be HINARI partners. We found that that the median percentage of articles in surgical, life sciences, and medical journals that were freely available to readers was 14%, although this result was not statistically significant.

Relevance to authors

The median APC was the highest for life sciences journals at $4,850 ($3,500–$8,900), followed by medical journals at $4,592 ($3,500–$5,000), and surgical journals at $3,550 ($3,200–$3,860) (p = 0.054) (Table 2, Figure 1). The median h-5 index was 154 (137–221) for life sciences journals, 164 (149–192) for medical sciences journals, and 54 (50–68) for surgical journals (p < 0.001) (Table 2, Figure 2). The median h-5 index was 2.85 and 3.04 times higher for life sciences and medical journals compared to surgical journals, respectively, meaning that the largest number “h” such that “h” articles published in the last five years have at least “h” citations is about three times greater in life sciences and medical journals than in surgical journals. The median IF was 15 (9–32) for life sciences journals, 24 (21–35) for medical sciences journals, and 4 (3–5) for surgical journals (p < 0.001) (Table 2, Figure 2). OA policies did not seem to affect journal reach, as there was no significant difference across journal OA policies in relation to IF (p = 0.140) or h-5 index (p = 0.100) (Figure 3).

Relevance to readers

The median US individual subscription cost (USD/Year) was $259 ($209–$282) for life sciences journals, $365 ($212–$744) for medical journals, and $455 ($365–$573) for surgical journals (p = 0.038) (Table 2). The international individual subscription costs were $259 ($209–$282) for life sciences journals, $378 ($216–$962) for medical journals, and $514 ($374–$618) for surgical journals (p = 0.052). The cost of an institutional subscription, which may be purchased for use by large groups such as hospitals or universities, was $9,850 ($6,933–$12,768) for life sciences journals, $2,338 ($1,938–$4,326) for medical journals, and $1,587 ($1,324–$2,052) for surgical journals (p = 0.025). Finally, 17 journals (42%) had a subscription price that was higher for international readers than for US readers (Table 1).

Authors

Current policies are heavily skewed towards a hybrid model; authors seeking to publish in top journals may be forced to choose between high cost with greater reach publishing under the Gold OA model and low cost with less reach publishing under the subscription model. This can be an issue for many LMIC authors, because although fully Gold OA Journals will waive APCs for LMIC authors, hybrid journals do not have uniform policies on this issue. Additionally, it has been shown that while a majority (72.9%) of publications from low-income countries are published with OA, authors from high-income countries utilize these options only 45.1% of the time [14]. This indicates that LMIC authors understand the importance of publishing with OA. However, as the journals in this study require such high APCs, LMIC authors can lose incentives to publish regularly in top-tier journals with OA, causing an imbalance in the flow of information in research.

Our results show that the median APC is highest for life sciences journals and lowest for surgical journals. However, publishing costs bear little correlation with the impact of the journal; paying a larger APC does not necessarily correlate to a greater number of citations [15]. Moreover, OA articles on average receive 18% more citations than non-OA articles [16]. Currently, however, a majority (69.0%) of global health research publications are not freely available online, and 60.8% of researchers do not self-archive their work with Green OA [13]. Implementing OA policies can help shift incentives. Expanding “Waive Fees” policies at hybrid journals for LMIC authors and advocating for greater utilization of Green OA through repositories such as arXiv.org are alternative solutions. Additionally, annual research budgets from governments or international bilateral/multilateral donors can include a line item to cover publishing fees for those from LMICs [17].

Readers

LMIC readers of top journals are forced to choose between exorbitant subscription costs and HINARI, a resource which is promising for the future if deployed correctly, but one which is currently underutilized. Our results showed that surgical journals are more likely to have a higher international subscription price compared to non-surgical journals. Professionals and researchers in LMICs interested in learning about surgery face skewed barriers in accessing published literature, putting them at a great disadvantage. This is concerning, as research shows that life-saving surgical and anesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed [18]. The development and delivery of surgical care in LMICs is under-prioritized in global health [18]. Health professionals should be vigilant towards the fact that LMICs, which have a great need to access more surgical information, have a skewed disadvantage in accessing published research. Strategies to ensure equitable access must expand beyond sole reliance on HINARI given variable awareness of this resource among those in LMICs.

In a study of 1,150 clinicians and researchers in 12 tertiary health institutions that had access to HINARI, only 35.1% had formal training on how to use it, and 50.0% encountered problems in accessing resources [19]. Moreover, poor internet connectivity and poor electricity have been cited as barriers to using HINARI [20]. In addition to facing challenges in a campus setting, LMICs may face unique challenges in their country at-large, including lack of funding, poorly developed national research programs, and a lack of cohesion between research and policy-making. Research also shows that some LMICs are emerging from decades of conflict and have lost skills and experience to other countries or regions through displacement or economic necessity [21]. Finally, the presence of variation in waiver guarantees may be particularly challenging for non-English speakers who might be at a greater disadvantage when navigating and requesting these waivers from English journals [22]. Variability in policies may also create a backlog for editorial boards that oftentimes receive many requests. Possible future directions include increasing LMIC readers’ awareness of access options by creating tools to help people find OA versions published through Green OA and improving the HINARI interface.

Limitations

There are several limitations to this study. Importantly, some journals do present policies by which they are willing to accept requests for waive-fees for those in need. However, we were unable to include these policies in our analysis as there is lack of standardized guidelines and public awareness of these options. Other limitations include the fact that only top journals that are published in English were evaluated. Additionally, subscription costs and APCs are subject to change. The Health InterNetwork Access to Research Initiative is used as the primary method of evaluating greater access to publications for LMICs; however, not all institutions in LMICs use HINARI, and there may be other programs available of which we are unaware. Finally, lower-profile journals were excluded in the analysis, meaning that these trends may not be the same across all levels of journals.