Hudelson, Patricia M.

Perneger, Thomas V.

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EditorialHow international is the InternationalJournal for Quality in Health Care?The International Society for Quality in Health Care strivesto ‘improve the quality and safety of healthcare worldwidethrough education, research, collaboration and the dissemina-tion of evidence-based knowledge.’ The Society’s Journalaims to contribute to this goal, particularly the disseminationof (worldwide) evidence-based knowledge. But do we reallyreﬂect an international perspective?This is not simply an issue of formal adhesion to thesociety’s values or of political correctness. Today’s world can bedescribed as a ‘global village,’ and increasing contact betweenpeoples of diverse origins and backgrounds can have con-siderable positive value for science and development [1].A number of efforts have been developed to speciﬁcally encou-rage a more global in perspective in health research [2, 3].In the hard sciences, it could be argued that the research-er’s culture or country of origin is of little relevance, becausethe questions probed by the researchers are universal.Human DNA, for instance, will function much the same wayregardless of social context or location. However, in thesocial sciences, the converse is true. Social constructs, suchas quality of care, will vary from one society to the next.More importantly, health care itself is a human artefact andthe ways in which health systems operate vary widely fromone society to another. By facilitating the exchange of diverseideas and experiences, we can contribute to a broader under-standing of health care.But how well does the International Journal for Quality inHealth Care do at contributing to international exchanges ofideas? In order to explore this question, we examined thedistribution of countries of origin of articles published in theJournal, using the ‘Web of Science’ online database. We didthis for papers published in the Journal over time, in 1995–97, 1998–2000, 2001–03 and 2004–06. For the latterperiod, we also examined similar distributions for otherscientiﬁc journals in the ﬁeld of health care quality: Qualityand Safety in Health Care, the American Journal of MedicalQuality, Health Services Research, Medical Care and BioMed Central(BMC) Health Services Research.As it turns out, about half of the articles that we publishare from developed English-speaking countries (Table 1).More than a third are from continental Europe, one-tenthare from Asia and only a handful of papers are from Africaor Latin America. Little change has occurred over time, themain being a progression of the share of continental Europe.Looking at individual countries (Appendix), the number ofpapers from the USA has progressed, papers from Canadahave seen a strong surge in the past three years andpublications from Australia, The Netherlands, Scandinaviancountries, France and Switzerland have also increased. Incontrast, papers from the United Kingdom are relativelyfewer. The share of published papers from developingcountries has remained very low over time, with no sign ofimprovement. Globally, the Journal provides good access topapers from North America, Europe and Australia andNew Zealand, but has not achieved a truly worldwide reach.Our competition is not doing any better. Quality and Safetyin Health Care publishes mostly papers from English-speakingdeveloped countries—the United Kingdom, North Americaand Australia. Three other journals—the American Journal ofMedical Quality, Health Services Research and Medical Care—publish predominantly papers from the United States, whichis understandable, as they are all linked with US national pro-fessional societies. Only BMC Health Services Research has asdiverse a pool of countries of origin for their papers as ourJournal.Diversity can be quantiﬁed. The simplest indicator is thenumber of countries represented. Furthermore, biologistshave developed tools for measuring the diversity of speciesin a given biotope, the Simpson index [4] and the Shannonindex [5]. Economists use an indicator of market dominance,the Kwoka index [6]. These indices can be applied to the dis-tributions of countries of origin of published papers. TheSimpson index is a summation over all countries of the pro-portion of papers from this country squared, i.e.P1npi2. Thisindex equals the probability that two papers randomlyselected from a journal originated from the same country; alow Simpson index reﬂects high diversity. The Shannondiversity index is computed as 2P1npi ln (pi). It increaseswith both the number of countries involved and the even-ness of the distribution of papers across the countries. Thisindex has a strong theoretical foundation in informationtheory; a higher value reﬂects greater diversity. The Kwokaindex is the sum of squared differences in ‘market share’ (p)between pairs of competitors arranged in decreasing order ofmarket share (i.e. p1 represents the share of the largest ﬁrmand pn the share of the smallest ﬁrm), speciﬁcally asP1n21(pi 2 piþ1)2. A low Kwoka index reﬂects high diversity.These more formal analyses conﬁrm the generalimpression derived from a visual examination of the distri-butions of countries of origin of published papers (Table 1).Our Journal and BMC Health Services Research publish papersfrom more than 40 countries, whereas the pool of their com-petitors is about half that number. The Simpson index islowest for the same two journals, intermediate for QualityInternational Journal for Quality in Health Care vol. 19 no. 6# The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 329International Journal for Quality in Health Care; Volume 19, Number 6: pp. 329–333 10.1093/intqhc/mzm053. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Table 1 Distribution of papers published in the International Journal for Quality in Health Care and other health services journals, by regionYear International Journal for Quality in Health Care Quality andSafety inHealth CareAmericanJournal ofMedicalQualityHealthServicesResearchMedicalCareBMC HealthServices Research1995–97 1998–00 2001–03 2004–06 2004–06 2004–06 2004–06 2004–06 2004–06Region of the worldAnglophonecountriesa89 (54.3) 110 (52.9) 99 (46.9) 127 (48.7) 281 (86.7) 105 (97.2) 316 (94.9) 509 (94.1) 206 (56.9)Continental Europe 49 (29.9) 59 (28.4) 84 (39.8) 99 (37.9) 37 (11.4) 2 (1.9) 7 (2.1) 24 (4.4) 115 (31.8)Asia 20 (12.2) 24 (11.5) 15 (7.1) 25 (9.6) 6 (1.9) 1 (0.9) 6 (1.8) 6 (1.1) 23 (6.4)Africa 3 (1.8) 4 (1.9) 6 (2.8) 6 (2.3) 0 0 2 (0.6) 0 13 (3.6)Latin America 3 (1.8) 11 (5.3) 7 (3.3) 4 (1.5) 0 0 2 (0.6) 2 (0.4) 5 (1.4)Total countriesb 164 208 211 261 324 108 333 541 362Total papers 163 180 172 180 263 108 310 508 274Indicators of diversityNumber of countries 34 41 41 44 19 6 18 21 43Simpson’s index, byregion0.40 0.37 0.38 0.39 0.76 0.95 0.90 0.89 0.43Simpson’s index, bycountry0.12 0.11 0.10 0.10 0.24 0.87 0.78 0.69 0.10Shannon’s diversityindex, by region1.10 1.17 1.12 1.09 0.45 0.14 0.26 0.27 1.04Shannon’s diversityindex, by country2.66 2.80 2.85 2.90 1.83 0.34 0.63 0.84 2.80Kwoka’s dominanceindex, by region0.10 0.09 0.11 0.10 0.58 0.91 0.86 0.80 0.13Kwoka’s dominanceindex, by country0.020 0.025 0.026 0.027 0.042 0.824 0.708 0.563 0.006aAustralia, Canada, Ireland, New Zealand, United Kingdom, United States of America; bTotal countries identiﬁed exceed the number of papers as some papers have more than one countryof origin.Editorial:T.V.PernegerandP.M.Hudelson330and Safety in Health Care and highest for the three journalsbased in the United States. The pattern is similar for theKwoka dominance index, and inverse for the Shannon diver-sity index.While we are pleased to be among the more accessiblejournals for researchers from developing and transitionalcountries, a word of caution is in order. Indeed, a largeportion of papers from developing countries stem frominternational cooperation projects, in which several or evenall authors come from developed countries. For instance, ofthe 10 papers from Africa and Latin America we publishedin 2004–06, only ﬁve—three from South Africa [7–9], onefrom Mexico [10], and one from El Salvador [11]—werefully local products. This suggests that an important cause ofthe relative lack of papers from some countries is lack oflocal research capacity.Can we do anything to increase the international appeal ofthe Journal? Clearly, development of research capacity in faraway countries is beyond our scope of activity, but we believein the value of examples and will always err on the side ofgiving a chance to papers from under-represented countries.We try to encourage submissions from Spanish-speakingcountries by offering a preliminary evaluation by Dr RosaSunol, deputy editor at the Journal, of manuscripts written inSpanish (more on this in an upcoming editorial). Thus far,this policy has not led to increasing numbers of submissionsfrom Latin countries. We are also intrigued by the broad inter-national scope of BMC Health Services Research. This journal doesnot advertise a particular interest in international sub-missions, nor is it linked with an international society and itseditorial board is as North Atlantic as they come, yet, itmanages to publish papers from as many countries as we do.Possibly, the open access publication model is the reason forits international appeal. The International Journal for Quality inHealth Care is not an open access journal, but the publisher(Oxford University Press) will give free access to the Journalcontents to institutions located in developing countries. Moregenerally we are open to exploring alternative publicationmodels that would favour successful submissions fromunder-represented countries.To close on diversity: geographic diversity is but one facetof diversity. Diversity in terms of profession, disciplinarytraining, gender, role in the health care system, etc. and fore-most in research interests, are equally important to us. Theﬁeld of quality in health care can only gain from a confronta-tion of diverse experiences and opinions.Thomas V. Perneger1 and Patricia M. Hudelson21Clinical Epidemiology Service and 2Department ofCommunity Medicine and Primary Care,University Hospitals of Geneva,Geneva,SwitzerlandE-mail: thomas.perneger@hcuge.chReferences1. UNESCO Universal Declaration on Cultural Diversity. http://unesdoc.unesco.org/images/0012/001271/127160m.pdf2. Council on Health Research for Development (COHRED).Annual report 2006. http://www.cohred.org/main/Annual_Report_2006.php3. Global Forum for Health Research: Helping correct the 10/90gap. 2006 Report: Innovating for Better Health. http://www.global-forumhealth.org/ﬁlesupld/Annual%20review/2006Review.pdf4. Simpson EH. Measurement of diversity. Nature 1949;163: 688.5. Shannon CE. A mathematical theory of communication. BellSyst Tech J 1948;27: 379–423, 27:623–56.6. Kwoka JE. Large ﬁrm dominance and price-cost margins inmanufacturing industries. Southern Econ J 1977;44:183–9.7. Puoane T, Sanders D, Ashworth A et al. Improving the hospitalmanagement of malnourished children by participatoryresearch. Int J Qual Health Care 2004;16:31–40.8. Hongoro C, McPake B, Vickerman P. Measuring the quality ofhospital tuberculosis services: a prospective study in fourZimbabwe hospitals. Int J Qual Health Care 2005;17:287–92.9. Myburgh NG, Solanki GC, Smith MJ et al. Patient satisfactionwith health care providers in South Africa: the inﬂuences ofrace and socioeconomic status. Int J Qual Health Care2005;17:473–77.10. Jimenez-Corona ME, Ponce-De-Leon-Rosales S, Rangel-Frausto S et al. Epidemiology of medical complaints in Mexico:identifying a general proﬁle. Int J Qual Health Care2006;18:220–3.11. Agurto I, Sandoval J, de la Rosa M et al. Improving cervicalcancer prevention in a developing country. Int J Qual HealthCare 2006;18:81–6.Editorial331. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Appendix Distribution of papers published in the International Journal for Quality in Health Care and other health services journals,by countryInternational Journal for Qualityin Health CareQualitySafety inHealthCareAmericanJournal ofMedicalQualityHealthServicesResearchMedicalCareBMCHealthServicesResearch1995–97 1998–00 2001–03 2004–06Anglophone countries 89 110 99 127 281 105 316 509 206Australia 12 17 14 19 40 1 1 8 19Canada 4 7 3 18 16 3 14 41 51Ireland 1 1 1 1 5New Zealand 2 2 2 1 11 1 3United Kingdom 27 26 23 23 115 6 13 69United States ofAmerica44 57 56 65 99 101 294 446 59Continental Europe 49 59 84 99 37 2 7 24 115Austria 1 1Belgium 1 2 2 2 2 3Czech Republic 1Denmark 4 6 1 1 2Estonia 2 2Finland 1 2 4 2 1 5France 11 6 11 16 5 1 1 2Germany 1 3 11 6 2 1 3 8Greece 1 2 1 6Hungary 1 1Italy 2 2 4 4 1 4 10Lithuania 1 1 2Macedonia 1Norway 1 2 3 3 5 17Poland 1Portugal 1 2 6Serbia 1Slovenia 1 1 1Spain 6 9 6 6 1 1 1Sweden 7 4 8 9 1 4 4Switzerland 7 5 11 14 7 3 19The Netherlands 9 22 17 23 10 3 5 29Asia 20 24 15 25 6 1 6 6 23Bahrain 1 1 1Bangladesh 1 1 1China (PR) 2 1 1 1 5India 1 1 2 1IndonesiaIran 1 1Israel 9 7 3 5 2 3Japan 1 2 6 2 4 1 5Jordan 1 1Kuwait 1Lebanon 1 1Malaysia 1 1Pakistan 2Saudi Arabia 2 2 2Singapore 1 1 3South Korea 1 1 1 1Taiwan 1 2 2 2 1 2 1 4(continued )Editorial: T. V. Perneger and P. M. Hudelson332. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Appendix ContinuedInternational Journal for Qualityin Health CareQualitySafety inHealthCareAmericanJournal ofMedicalQualityHealthServicesResearchMedicalCareBMCHealthServicesResearch1995–97 1998–00 2001–03 2004–06Thailand 1 1 3 1Turkey 1 2 1UAE 1 1 1Vietnam 1Africa 3 4 6 6 0 0 2 0 13Botswana 1Burkina Faso 1Congo 3Egypt 2 1Ethiopia 1Kenya 1 1 1 2Malawi 1 1Morocco 1Namibia 1Niger 1 1Nigeria 1Sierra Leone 1South Africa 2 1 3 1Tanzania 1 1 1Zambia 1 1Latin America 3 11 7 4 0 0 2 2 5Argentina 2 1Brazil 1 2 1 1 1Chile 1 2 1Colombia 1Costa Rica 1Cuba 1 1Ecuador 2 1El Salvador 1 1Mexico 1 1 2 1 1Nicaragua 1Peru 1Trinidad Tobago 2Uruguay 1Venezuela 1Editorial333

How international is the International Journal for Quality in Health Care?

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