The international character of Pediatric Physical Therapy reminds us of our social responsibility as physical therapists to improve care for children with movement dysfunction not just in our home countries but also throughout the world. We bring differing perspectives of our social responsibility within our national borders and internationally, but our journal unites us in this effort. Accepting this social responsibility inherently requires ongoing personal responsibility to improve our science and communication. This article addresses both personal and social responsibility and possibilities for improving the science of pediatric physical therapy.
STRENGTHENING THE SCIENCE OF PEDIATRIC PHYSICAL THERAPY
Our Personal Responsibility
Construction of sound science lies with individual researchers. Building personal capacity to conduct research leads to stronger science and greater value to pediatric physical therapy. Benjamin Franklin said: “Either write something worth reading or do something worth writing.” I echo Franklin's sentiment: Do research worth reporting and write a report worth reading.
Ioannidis et al1 identified several common weaknesses in published research. These include insufficient consideration of existing literature, poorly developed protocols weakening research design, inattention to statistical power, and misconceptions regarding our research contributions to building science. Such weaknesses can lessen the value of one's research. In my experience, journal reviewers commonly detect weaknesses too often overlooked by investigators. Reviewers are both knowledgeable and careful in their assessments and often find these weaknesses to invalidate the findings of studies submitted for publication. This discovery, as the last step in the research process, is disconcerting and heart breaking.
Lack of Knowledge of the Topic
Failure to consider existing literature on the research topic is a surprising weakness. Investigators are expected to be familiar with the contributions of others' research in their area of investigation. We expect that those with deep knowledge of a topic should be preeminent in driving research. Some might suggest that the competitiveness of those with strong knowledge could lead to discounting the work of others, but strong scholars are in close communication with others and share knowledge in their area of research. Being connected with other scholars and constantly seeking recent publications is fundamental to develop deep knowledge of the topic.
Well-connected senior researchers should teach their research students not just what they know about the topic but also how to use effective strategies to stay connected and well versed in the area. This includes strategies to search and obtain the latest information on their topic and to form working relationships with librarians and researchers with similar interests. Senior investigators as role models should mentor their students in building collaborative relationships. We should envision ourselves as members of a relay team, picking up the baton where others have left off, so that we might, carry the baton forward, and add to the existing body of literature. As each individual picks up the baton, the responsibility to advance the science builds on past efforts and provides a foundation for those who will follow.
Need for Knowledge of Research Design and Avoiding Bias
Ioannidis and colleagues1 suggested that investigators might lack full understanding of research design and bias. When serving as editor of our journal, submissions too often reflected poor research design. Senior scientists in pediatric physical therapy can address this weakness by working to ensure that postprofessional students have rigorous training in research design to minimize and control bias. These students need to take coursework from scholars in research design and develop the ability to discuss strengths and weaknesses of alternate research designs, and clearly articulate reasons for selecting a specific design.
Study design problems also arise from manipulating inclusion and exclusion criteria to carve out a narrow sample. This practice biases results and limits external validity of studies, leading to the inability to generalize findings. We need to employ the strength of the random sample drawn from a representative clinical population.
Need for Stronger Grounding in Analytical Science
Postprofessional doctoral aspirants need to be able to develop a plan of statistical analyses matched to the research design. Some would argue that a beginning researcher does not have sufficient knowledge of statistics to accomplish this, but without such knowledge the next generations of researchers are at the mercy of others to make decisions about the analysis of their findings and thus potentially sacrifice the validity of their work.
My preference is for students first to focus on research design and then spend time studying the models and assumptions of statistical tests. Understanding models used to develop statistical tests and the assumptions on which they are based is a critical skill used to match statistical tests to the research design and allows the investigator to recognize threats to validity arising when test assumptions are not met.
A common threat to validity is applying parametric analyses to data from very small samples. Yet, far too many researchers are unprepared to assess threats to validity that arise from the use of inappropriate statistics. Nonparametric tests, known as distribution-free tests, are available to analyze data from small samples, which are not normally distributed. Assumptions regarding the distribution of the data are fundamental to statistical models. Inappropriate use of parametric tests commonly leads to the investigator's suggestion that the lack of significant findings resulted from a small sample size, and the recommendation that the study be repeated with larger numbers of subjects. But the sample size problem would be better managed if investigators considered statistical power prior to conducting the study. Although greater attention is being paid to statistical power in published articles, too often this reflects post hoc power calculations performed in response to requests of reviewers.
Failure to consider power initially is critical when conducting research with human subjects. Inadequately powered studies waste not just the time of researchers by not allowing for valid conclusions, but also the time that subjects provide to the research project. One well-designed and appropriately powered study would be more efficient.
Possibilities for Improving Personal Responsibility for Research
Our contributions to building a global science in our discipline are based in the validity of our research endeavors. Senior researchers need to train new investigators who are grounded in strong content knowledge, research design, and analytical expertise, with the capacity to build a research program with defensible design and conduct standards. We should appropriately power studies, obtain subjects through unbiased sampling procedures, apply rigorous methods to collect data, and see the study to conclusion by applying appropriate statistical tests.
Developing a repository of research protocols that would be publically available could help strengthen investigators' efforts. The need to complete a formal process of developing a research protocol that is openly available to colleagues would further ensure careful consideration of design and analytic procedures. Protocols included in a repository should be updated while the study is in progress to reveal decision-making associated with any modification of the design and data analysis. Following publication of the study, the repository should house raw data and analytic algorithms for open review.
We must continue to strengthen our research and journal review panels. This is not a criticism of current reviewers, but rather recognition that our ongoing expansion of clinical practice and the concomitant need for continuing growth in our science. This requires us to grow our research review panels with well-qualified senior scientists, as our scope of practice and research expands.
With rigorous training of PT researchers that fosters development of strong content expertise, deep knowledge of design and analysis, public reporting of research protocols and analyses, and the continued strengthening of peer review of research reports, we will continue to build a strong knowledge base for pediatric physical therapy worthy of global recognition.
STRENGTHENING THE SCIENCE OF PEDIATRIC PHYSICAL THERAPY
Our Social Responsibility
Building a strong science of pediatric physical therapy depends on effective international collaboration and communication. These responsibilities, shared among research groups and nations, and possibilities for strengthening our science are discussed next.
Effective International Collaboration
A prerequisite for effective international collaboration is mutual respect among colleagues from different countries. Our nations bring a variety of strengths to pediatric physical therapy. Humility allows us to recognize, respect, and embrace the contributions of every country to the global advancement of pediatric physical therapy. Our journal partners contribute immensely to the strength of our journal, bringing broadened expertise and knowledge to our readers. They bring unique capacities and excellence in content areas that are less well developed in the United States. We should acknowledge, celebrate, and seek to learn from their accomplishments. Furthermore, each country in this world has a unique culture, and unless we understand and respect those cultures, attempts at partnerships and collaborations will not thrive.
My perspectives on global collaboration for improving science have been informed by the work of Caroline Wagner, now on faculty at the Ohio State University. Wagner,2 a global scholar of collaboration in science and technology, prepared a report for the World Bank back in 2001. Unfortunately, and likely because of the global economic downturn during the last decade, this report has not been updated. Wagner, however, continues to contribute to the knowledge base in this area and influence priorities in developing science capacity throughout the world. Despite the length of time that has passed since her World Bank Report, her findings can inform our understanding of how we might best exercise social responsibility to advance the science of pediatric physical therapy. Data in the following tables and figures are from Dr Wagner's report. Table 1 presents a list of the top 22 nations in science capacity in 2001. The list was generated using a formula that includes the number of scientists, journal articles, and patents produced in each nation, and importantly the percentage of the gross national product the nation spends on research, adjusted for the size of the nation's population. Figure 1 shows the location of these top 22 countries on a world map. With the exception of Australia, these top 22 countries are located in the northern hemisphere, illustrating what is known as the “north-south divide.”
TABLE 1 -
Top 22 Nations in Science Capacity2
Nations italicized have partnerships with Pediatric Physical Therapy.
One additional national partner, New Zealand, is among the countries with above average scientific proficiency (see Table 2
TABLE 2 -
24 Scientifically Proficient Countries
aNew Zealand is a publishing partner of Pediatric Physical Therapy.
Another 24 nations are considered to be scientifically proficient (see Table 2) and are above average in their capacity to contribute to science and technology. Among them is our publishing partner, New Zealand. Notably, the majority of countries with significant investment in science and technology are located in the northern hemisphere (colored in red or orange in Figure 2). Only, Brazil, New Zealand, and South Africa have bridged the “north-south” divide. The list of scientifically proficient countries (Table 2) also highlights the potential of countries such as China, India, and former communist bloc countries to contribute to science, and can be used to inform the future of the science in pediatric physical therapy.
A third group of countries (see Table 3) termed “developing countries” represents nations whose governments are investing in science and technology, with an expectation that this investment would bring positive economic returns.1 National buy-in is important for the scientists of all countries, but particularly important for those in developing countries. Figure 2 illustrates how the “scientifically developing countries” (colored in yellow) are breaking the “north-south divide.” Although we often consider developing countries to have limited economic capacity, we should remember that despite limited resources, the countries listed in Table 3 consider science a worthy investment.
TABLE 3 -
24 Scientifically Developing Countries
Finally, we must recognize that a number of nations have not invested in science (see Figure 2, countries appearing in black). The map in Figure 2 causes one to contemplate the reasons for variable patterns of commitment to science and technology. In these countries internal debate on the value of investment in science continues, but this debate often takes place in environments where basic human needs are not being fully met, or political unrest dominates national decision-making.
Economic priorities are also influenced by cultures that inform attitudes and beliefs related to science and technology. When we consider cultural factors affecting attitudes toward science and technology, we need to consider that language is an integral part of culture. Since English is considered the official language for communication in science and technology, language barrier likely influences the lower level of support for scientific and technologic development. When examining Figure 2, other factors influencing national views of science and technology will come to mind.
International Collaboration Among Neighbors
International collaboration is commonly envisioned as intercontinental alliances that may bridge the “north-south” divide. Scholars in countries with well-developed research capacity sometimes view such collaborations as opportunity for growth of scholars from less advantaged countries. Yet, such intracontinental collaboration needs closer examination. The African continent provides an example for examining growth of international scientific collaboration over more than 25 years. The pattern of growth in collaborative research that arose between 1990 and 2000 from unexpected regions within Africa is an encouraging example. In 1990, examination of international coauthorships of scientific publications revealed 3 hubs of scientific collaboration among African nations2 (see Table 4). These hubs were Ivory Coast, Senegambia, and South Africa. Ten years later, Wagner3 found that international linkages between scientists had increased despite a lack of significant increases in government investment.
TABLE 4 -
Growth of International Research Collaboration
||Top 10 Countries 1990
||Different Countries in Collaboration, n
||Top 10 Countries 2000
||Different Countries in Collaboration, n
||Cote d' Ivoire
||Cote d' Ivoireb
aSenegambia became 2 nations between 1990 and 2000: Senegal and Gambia.
bCote d' Ivoire is the official name—reported in 1990 as both Cote d' Ivoire and Ivory Coast.
Wagner3 revealed that self-organizing research groups look for partners rather than onlookers. Research partners might include recognized researchers who are publishing and being cited, rich databases or other resources that can be used to further a research program, or innovation in approaching a problem of importance across nations within the region. Wagner suggested that collaborative science is moving away from a model of international science with developed countries as the hubs to a model of regional hubs that bring smaller countries into a larger international network. Neighboring countries often share a common history, common language, and cultural practices. Neighbors also are more likely to share common problems. Collaboration with scientists in nearby countries is enhanced by the possibility for face-to-face meetings and shared regional priorities for science and technology. For example, HIV-AIDs, malnutrition, and other health disparities are particularly important in African nations. Although countries on other continents with strong research capacity also face these problems, close-by scientific collaborations allow sharing of resources including equipment and expertise. Regions that share problems often have institutions and individuals with world-class expertise even in countries still developing their science capacity.
Since the turn of the century, 2 notable plans for development of science and technology have been published by the African Union to guide science and technology development across the African continent. The first plan addressed the period from 2005 to 2014,4 and the second elaborated goals for the period 2014 to 2024.5 The first plan focused on agriculture, natural resources, and capacity building. The second focused on transforming the continent into a society based on knowledge and innovation. Recognizing that most development in Africans resulted from unsustainable outside investment, the most recent plan calls upon Africans to invest in their own development.
The priorities in the 2014-2024 plan include childhood nutrition, prevention and control of diseases, and the strengthening of communication networks. Although the earlier (2005-2014) plan is not emphasized here, it is notable that the current priorities are more directed toward the human health needs than to developing natural resources of member nations.
Possibilities for International Collaboration
What role might we play in international science and technology development? My message to pediatric physical therapists in developed nations is to remember that researchers in other countries need to be equal partners in collaboration; they need to benefit from collaboration, not just provide resources to others. When therapists from developing countries come to more developed countries for postprofessional education, and intend to return to their native lands, we should foster their involvement in research relevant to their regional needs and be available to support them, as they build networks on their return home. We need to provide them with the most rigorous doctoral training we can provide and serve as role models for the concept of equal partners in collaborative research networks.
EFFECTIVE INTERNATIONAL COMMUNICATION
Global Content Knowledge
Good science and effective international communication go hand in hand. Good science requires global knowledge related to our content area. Is the problem we are studying local or is it seen in other parts of the world—and if so, is it being studied in other regions and what are those findings? How do international findings relate to the problem seen in our home country? To be effective in carrying out our societal responsibility, we need to clearly place our research in a global context. What we study needs to be informed by the work of others both in our native country and as abroad.
If you speak to a man in a language he understands, you speak to his head. If you speak to a man in his own language, you speak to his heart.
Pediatric Physical Therapy is published in English. In fact, 92% of scientific journals are published in English; 92% of search tools only include English documents; and 97% of journal editors are native English speakers.6 Yet, more individuals in this world speak Spanish than English, and Mandarin is the most common language spoken by more than 3 times the number of native English speakers.7 Our journal seeks to serve pediatric physical therapists across the globe including our publishing partners, and not all are native English speakers. This issue is of great concern for clinicians in partner countries, who do not use English on a daily basis in their clinical practice. We must face and work to eliminate this barrier.
Considering rapid advances in technology, the language barrier should begin to fall within the foreseeable future. Translation services are being used by some journals, although these require service of professionals who are both bilingual and well versed in the discipline. We are benefiting from translations of article abstracts for our Taiwanese partners, thanks to the volunteer efforts of Hua-Fang Liao, MS, PT, at the National Taiwan University. An increasing trend for multilingual publications is apparent in the online medical literature and will likely spread as translation technology improves and becomes more accessible.
The language barrier affects both our readers and authors. One solution, known as author's boot camp, was developed at the National Autonomous University of Mexico, considered a prestigious Mexican University.6 These camps are typically 3 to 6 weeks and require internships in English-speaking countries following the course. Similar programs are offered at other campuses in the United States, Canada, and China, and online offerings are also available. All of these programs, however, face issues related to cultural differences and author commitment.6
ACCESS TO PUBLISHED REPORTS
We have a social responsibility to ensure our research publications are available to clinicians throughout the world, especially disadvantaged countries. In the past the editor mailed back copies of our journal to individuals in economically disadvantaged countries. As a result of electronic publication, articles are increasingly freely available to readers with Internet access.
Open access (OA) is the term used to indicate that at the time of publication an article can be read, and printed for noncommercial purposes with attribution, and without charge. But OA is controversial, and the term itself means different things to different audiences.
Electronic publishing came about with publishers investing significantly in technology. Not only did journals begin to appear online, but publishers also acquired and sold access to information systems such as Ovid. Institutions were offered collections, or bundles, of electronic journals, databases of published materials in those journals and search engines that allowed searching the content of those collections. The cost of development of these systems in part led to escalating journal prices.8 Academic and clinical institutions were often unable to pay publishers such high prices. Some believed that costs to produce and deliver an electronic journal should be less than that for a print and mail issue and questioned exorbitant pricing by publishers. Resistance to these high costs led to the development of alternate platforms for publication of research and scholarly articles. These platforms were supported by governmental and nonprofit organizations that sponsored research to ensure their supported studies were freely available. Additional publishing platforms were developed by academic organizations, which provided faculty members' scholarly papers available for free online. Other organizations published OA articles largely funded through author fees. In each of these instances, publication costs were absorbed by the sponsoring agency or organization or by the authors rather than by individual and institutional subscribers.
Publication costs are not trivial. Although the critical review process for articles submitted for publication is carried out primarily by volunteers, paid professionals perform copy-editing, layout, and composition of the material into formats that meet professional standards and are accessible to readers using various types of electronic devices. Additional costs are associated with developing and maintaining journal Web sites and electronic archives. Shifting costs from subscribers to research sponsors, universities, and authors represents a significant change in scholarly publication.
Thus, OA publishing involves the shifting of costs from subscribers to authors and sponsoring groups. Obviously, not all researchers have funding to support OA publication of their work, and most authors without such support struggle to pay the costs of OA publishing. The new funding stream is not the only barrier to OA publishing. Indexing systems (eg, Science Citation Index and Medline) do not routinely include OA journals. Thus, OA publications are difficult to discover when conducting literature searches. In addition, academics have been critical of OA publications based on perceptions that anyone who can pay the author's fee can publish in an OA journal. Senior faculty who participate in university promotion and tenure reviews are skeptical of the pay to publish system worrying that authors' dollars are driving acceptances rather than peer review. Questions regarding the role and quality of peer review in OA journals led to new faculty members being cautioned against publishing in OA journals.
One seemingly successful OA publishing story is the Public Library of Science (PLOS). A nonprofit science, technology, and medical publisher, the PLOS began OA publishing in 2003.9 Authors, institutions, or funding sources pay publishing fees for accepted articles, and the PLOS has achieved indexing.10 In 2013, the PLOS published more than 31 000 articles, the largest number of scientific articles of any journal in the world,11 but Davis12 reports this growth trend has stopped and the number of published articles is declining, down by 30% in 3 years, and suggests that competition from other more selective OA journals may be the cause of this decline.
The PLOS success story is not the norm. Authors must assume responsibility not only for publishing fees but also for due diligence in checking the capacity of the OA publishing house to provide high-quality peer review, indexing, and archiving of published articles.
The reasons for the continuation of subscriber-based journals are first and foremost the value of the publication to its subscriber base, indexing of the publication, the availability of a cadre of strong peer reviewers, and the continued use of traditional journals in decision-making for academic promotion and tenure. The business model that provides support for traditional research journals continues to depend on subscription fees, but the economic challenge that led to exorbitant journal pricing has produced important change that allows readers wider and earlier access to current scientific literature.
Alternatives to Author-Sponsored Open Access
Free Access. Free access after a subscriber-access-only period is increasingly common among traditional journals. Pediatric Physical Therapy provides free access to all articles 1 year after publication. Downloading and reading the article is limited to individual use. Printed versions of the articles cannot be distributed without permission from the publisher, and payment of required fees. The time varies from when an article is available to subscribers to when the material is provided without charge to readers. Typically, journals published more frequently (monthly) are freely available after a shorter period than are quarterly journals. The free access has made past issues of our journal freely available throughout the world.
The Health Inter-Network Access Research Initiative
Measures have been taken by the World Health Organization (WHO) to assure researchers and clinicians in developing countries have access to health and medical science articles at the time of their publication. The Health Inter-Network Access Research Initiative (HINARI) sponsored by WHO in collaboration with Yale University was designed to provide developing countries access to prestigious biomedical journals.13 More than 14 000 journals and 53 000 e-books are provided by the HINARI to 115 countries with limited financial resources. More than 4100 organizations use the HINARI and 45 different languages are represented among the electronic resources available to subscribers. Open access is provided in the poorest countries and reduced cost access in other developing countries. The current cost to the latter group is $1000 per year, per institution for access to the complete HINARI collection.
The initiative is supported in part by 170 publishers including Wolters Kluwer, publisher of Pediatric Physical Therapy, which is provided through the HINARI to those who are registered subscribers.
The HINARI is a wonderful initiative; yet after nearly 15 years access, infrastructure to support Internet access continues to be a significant hurtle, and publishers too commonly rethink their commitment and withdraw journals from the HINARI.14
Possibilities for Strengthening International Collaboration and Communication
Our academy should actively engage with international organizations that promote research collaboration in pediatric physical therapy. We should continue to support international conferences and symposia that develop the science of pediatric physical therapy.
I envision a future in which technological advances and personal commitment ensure translation of abstracts and articles published in Pediatric Physical Therapy for subscribers who are nonnative speakers, and eventually publication of the journal in multiple languages. Free and affordable access to Pediatric Physical Therapy articles must be maintained for researchers in disadvantaged countries through our continued support of the HINARI.
As we assume greater responsibility for a sound science of pediatric physical therapy, our journal should ensure high standards of scholarship informed by global knowledge of research topics. We should support best practice in research collaboration and demonstrate leadership in assuring international access to our journal. The future of the science of pediatric physical therapy is bright. With continued commitment to and leadership in strengthening our science and international communication of research, we are fulfilling our personal and social responsibility to improved care for children with movement dysfunction.