Barriers to Publication: Examining Bias Against Manuscript Acceptance from Low- and Middle-Income Countries

Carolyn Sun, PhD, RN, ANP-BC, FAAN, FAMIA ^1; Christina Litavec, BSN, RN, CCRN ²

1. Hunter-Bellevue School of Nursing, City University of New York
   ORCID: orcid.org/0000-0001-9628-6901
2.  New York-Presbyterian Hospital
   ORCID: orcid.org/0009-0003-9166-3271

OPEN ACCESS

PUBLISHED: 31 December 2025

CITATION: Sun, C., and Litavec, C., 2025. Barriers to Publication: Examining Bias Against Manuscript Acceptance from Low- and Middle-Income Countries. Medical Research Archives, [online] 13(12). https://doi.org/10.18103/mra.v13i12.7085

COPYRIGHT: © 2025 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i12.7085

ISSN 2375-1924

Abstract

Despite increasing global contributions to science, researchers from low-and middle-income countries (LMICs) continue to face disproportionate barriers to publishing in high-impact, peer-reviewed journals. These barriers are not solely due to the quality of research but are also shaped by structural inequities and implicit biases embedded within the global publishing ecosystem. This paper examines the mechanisms and consequences of such bias, including disparities in editorial representation, linguistic hurdles, topic devaluation, and systemic underfunding. Drawing on recent studies, experiences, and our own global initiatives to improve access to mentorship in scholarly writing, we highlight the persistence of these biases and their impact on the visibility, credibility, and influence of LMIC scholarship. We further explore how the gendered nature of the nursing profession, and broader patriarchal structures in academia, contribute to the suppression of knowledge produced by women and nurses in LMICs. Finally, we propose actionable recommendations to improve equity and representation in global scientific publishing. By improving equitable publishing practices, more diverse research can be disseminated. We hope readers find this editorial helpful in examining their own perspectives, identities, and potential biases and how they may influence their work.

Keywords

publication bias, low- and middle-income countries, peer review, global health, gender bias, equity in research, scientific publishing, nursing

Introduction

The dissemination of scientific knowledge through peer-reviewed publications is foundational to academic advancement, policy influence, and evidence-based practice. However, systemic disparities persist in the global publishing ecosystem. It has long been demonstrated that researchers in low- and middle-income countries (LMICs) often face structural barriers that prevent equitable participation in scientific discourse, including limited access to research funding, linguistic biases, and geographic underrepresentation in editorial boards and peer review networks. These challenges are not only logistical but also reflect implicit biases rooted in colonial and patriarchal academic structures.

This issue is confounded by language barriers, as many LMIC authors may not be native English speakers. Even when the scientific writing is sound, some research suggests that both editors and peer-reviewers may reject content citing poor English-language skills, or manuscripts that are not submitted in English may ignored altogether. Rather than increasing scientific rigor, these mechanisms may instead serve as gate-keeping mechanisms, further marginalizing scholars from LMICs and the global south.

One domain where this is especially evident is nursing—a historically gendered profession. Nursing research, particularly from LMICs, often receives less editorial attention and acceptance, especially when focused on community-based interventions, caregiving, or culturally embedded health practices that fall outside the dominant biomedical paradigms favored by high-impact journals. The global nursing workforce is over 90% female, and the structural devaluation of work and knowledge produced by women contributes to the persistent marginalization of nursing science. Epistemic silencing has also been applied broadly to exclude people of color, and the LGBTQ+ community. This devaluation is compounded for women nurses in LMICs, who must navigate intersecting axes of bias based on geography, gender, discipline, and topic.

High article processing charges (APCs) may also prohibit those from LMICs, further increasing the barriers to publication. While some journals offer APC waivers to those in LMICs, waivers are not consistently offered, and journals with higher APCs are less likely to offer waivers. The dominance of pay-to-publish models exacerbates disparities, particularly for researchers in countries with underfunded academic infrastructures. Further exacerbating the issue, predatory journals target less-experienced researchers so even funds spent on publication may not lead to publication in high-impact or professionally influential journals.

We implemented a program (the Writing to Improve Nursing Science (WINS) initiative) to help address these and other issues. While we were able to demonstrate that capacity-building models rooted in mentorship, community, and equity can improve publication outcomes for LMIC authors, efforts to address these disparities must go beyond individual capacity-building and confront the structural biases embedded in editorial practices and publication economies. Although there has been some improvement in including LMIC research in high-impact journals, more work needs to be done. With most of the world’s population falling within at least one of these domains (female, person of color, or living in LMICs), global health research must consider what more can be done to disseminate the scholarly work of those falling within these groups. Therefore, the purpose of this editorial is to discuss the factors that influence lower dissemination as well as strategies to mitigate these barriers.

Discussion

The system of academic publishing remains structurally biased against authors from low- and middle-income countries (LMICs), and these disparities translate directly into what science gets communicated, cited, and used. Evidence shows that research from LMICs is underrepresented in high-impact journals: a comprehensive review revealed that peer reviewers were significantly more favorable toward manuscripts from high-income nations, even when methodological rigor was held constant. This geographic bias reflects deeper structural hierarchies in knowledge production: journals and reviewers tend to privilege research stemming from familiar institutional networks, dominant languages (English), and topics aligned with Global North priorities. A bibliometric analysis of over 10,000 articles in top medical journals found that the vast majority of publications originated from a handful of Anglophone countries, while LMIC contributions remained peripheral. Other research suggests that research within southern and eastern African counties is primarily driven by funding from the United States and Europe, rather than within-country nursing research priorities. As a result, the rich diversity of health systems, cultural practices, and nursing scholarship in LMICs remains under-represented and underutilized in global health debates.

The gendered nature of nursing further compounds these disparities. Nursing is overwhelmingly female-dominated—globally, the profession comprises over 90 % women—but nursing research continues to be marginalized in academic hierarchies. Relative to their representation in the nursing workforce, men are disproportionately represented in leadership roles; this is also true for positions in editorial roles. Male editors should be practicing publishing with an equitable lens, taking into account marginal and intersectional identities. However, a cross-sectional study found that male editors more often published work with male authors in high-ranking authorship positions. This reality perpetuates the disparity since being published is the main way that researchers can grow professionally. Additionally, studies demonstrate that nursing scholarship, especially when led by women in LMICs, is often undervalued or viewed as less rigorous compared with biomedical research. The intersection of being a nurse (often conceptualized as a “caring” rather than “leading,” or “research” position) and being a woman from a less-resourced setting creates multiple layers of disadvantage. For example, qualitative and community-oriented nursing research—frequently conducted in LMICs—was found to be 20 % less likely to lead to leadership roles or citations when topics were framed as “feminine” or home-bound. Additionally, organizational studies in Tanzania found that male nurses were more likely to receive professional development opportunities than female nurses, despite similar clinical practices. A scoping review of studies that examine gender equity in health research publishing found that much of the work studied occurred in the United States and was completed without funding, two factors that limit generalizability of current gender equity research globally. These findings underscore that beyond geography and economics, profession-based and gender-based biases contribute to the suppression of valuable scholarship.

Addressing these layered biases requires systemic interventions that target both the publishing infrastructure and the support ecosystem around authors. Recent work suggests that interventions—such as double-anonymized peer review, diversification of editorial boards, fee waivers for LMIC authors, and capacity-building mentorship programs—hold promise in reducing biases, though evidence remains nascent. For instance, a scoping review found that while various activities aimed at reducing publication bias exist, few have been rigorously evaluated for effectiveness. The decentralization of editorial boards and regional citation databases has been recommended to shift power toward LMIC-led scholarship. Programs dedicated to writing-skills, mentorship, and targeted support—for example in nursing—provide concrete models to bridge the divide. When nurse faculty in LMICs participate in structured writing programs, they gain not only technical skills but also access to peer networks, editorial insight, and confidence navigating publishing norms.

Ultimately, equity in scholarly publishing is essential not only for academic fairness but for global health justice. When LMIC nurse researchers cannot access publication pipelines, the global evidence base becomes skewed toward the priorities of wealthier countries, overlooking local realities and potentially misdirecting policy and practice. A vibrant and inclusive scholarly ecosystem must deliberately elevate under-represented voices, recognize the legitimacy of nursing science, and dismantle the layers of bias that prevent knowledge from contributing to health equity worldwide.

Table 1: Summary of Strategies to Improve Representation of Socially Disadvantaged in Publication

Case Examples and Counterstrategies

In response to these barriers, the Writing to Improve Nursing Science (WINS) program was launched as a capacity-building initiative to support LMIC nurse scholars in manuscript development. Through mentorship, AI-supported writing tools, and peer-review guidance, WINS has enabled dozens of nurse faculty to prepare and submit manuscripts that might otherwise have been dismissed. Importantly, the program also fosters solidarity and confidence among participants navigating systemic academic gatekeeping.

However, even with extensive mentorship and guidance in partnership with a publishing company, several manuscripts co-authored by scholars in the Eastern Mediterranean and Southern and Eastern African regions faced significant resistance in the peer-review process. Topics such as prenatal care access among women with disabilities, health-related quality of life among refugee women, and trends in national nursing research, were initially dismissed for perceived lack of generalizability, despite rigorous methodology.

In our work with nurse scholars in the Caribbean, Eastern Mediterranean, and African regions, we found that the most persistent barrier was not methodological quality but editorial perceptions of relevance: manuscripts on community-based care, women’s health, or traditional therapies were repeatedly dismissed. Strategic support—such as aligning the research framing to global health priorities, co-authoring with mentors in high-visibility journals and explicitly addressing publishing norms—resulted in successful outcomes. This experience aligns with the literature: bias is not simply about access to journals but about whose questions count, who frames them, and who gets to participate fully in the global research conversation.

Conclusion

The underrepresentation of LMIC scholars in global scientific publishing is not simply a matter of resources—it is a reflection of deep-rooted systemic biases in academia. When layered with the gendered nature of professions such as nursing, and patriarchal attitudes embedded in both local and global institutions, the effect is a profound suppression of vital knowledge. Programs like WINS demonstrate that these challenges can be addressed through intentional mentorship, structural reform, and advocacy. The ethics of conducting global research relies on HIC; journals, funders, and institutions must commit to dismantling these barriers to build a truly inclusive global research enterprise.

Disclosures

The authors have no conflicts to declare. No funding was obtained for this article. The authors used ChatGPT to assist with English language editing and formatting.

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