the idiom of  knowledge being power is applicable in a vast number of fields , yet rarely more so than in the context of academia , where the discussion of existing knowledge and the development and refinement of ideas forms the basis of academic work . the equally well - known concept of a  publish or perish culture in academic life stems directly from the perception that progress can only be made by contributing to , sharing and competing with the knowledge of peers . within the context of limited access to information and barriers to publishing , this reality adds another level to existing north - south inequalities ; the ability of researchers from resource - poor countries to fully participate in global academia is limited by the availability of information , expertise , equipment and financial resources . less than 2% of publications between 1992 and 2001 referenced within the science citation index and the social sciences citation index originated in low - income countries , and only one - fifth of these were from sub - saharan africa ( 1 ) . capitalising on academia 's need to publish , publishers have a seemingly endless supply of authors and , to an extent , readers . however , the academic publishing industry faces increasing risks from reduced library spending , demands to digitalise content and dissent from authors , libraries and academics regarding increasing subscription costs , which has led to falling revenue in recent years ( 2 , 3 ) . this has coincided with a demand for open - access journals , with subscription fees increasingly being replaced by alternative financing mechanisms , commonly an author - pays model ( 2 , 48 ) . under the author - pays model , journal production fees are typically met by the author 's employer or research funder and rarely by the individual researcher themselves ; however , in resource - poor settings this can mean that individual research funds may be cut to compensate for publication charges ( 9 ) . nevertheless , journals based on the author - pays model typically offer fee waiver or subsidy schemes in cases of financial hardship or for authors from developing countries . perceptible efforts have been made to address the challenges faced by academics in less - developed regions by european and american multinational publishing firms that dominate global academic publishing . most notably in the field of health , progress in improving access to information in low - income countries , facilitated by growing internet access , has improved the flow of global health information . additional efforts have been made to improve access to literature through philanthropic initiatives offering developing countries free or greatly subsidised access to large collections of otherwise subscription - only literature ( 10 ) . meanwhile , the international network for the availability of scientific publications ( inasp ) operates the program for the enhancement of research information ( peri ) , which strengthens research capacities in developing countries by reinforcing local efforts to produce , disseminate and gain access to scholarly information and knowledge ( 11 ) . other initiatives include hinari , authoraid , africa journals online , fame , bireme & scielo , each of which is contributing to the growing movement towards greater access to information and support for local journal publishing in resource - poor settings ( 10 , 1216 ) . together , these initiatives have , at least in part , been responsible for a rapid growth in the number of article downloads over recent years , illustrating growing awareness and uptake of such programmes ( 17 ) . nevertheless , the flow remains unbalanced  transfer of health information from south to north , and perhaps more importantly from south to south , is still grossly limited ( 18 , 19 ) . northern - generated information has been criticised for failing to fully reflect the information and market needs of a southern readership , and open - access schemes intended to improve global information provision may perpetuate dependency of developing - nation researchers on foreign aid and charitable subsidies . instead of promoting and publicising indigenous research , the content of much literature , open access or otherwise , can be of limited relevance to developing countries and there exists an imbalance of research in favour of northern - produced or northern - led research ( 20 ) . whilst there is much literature on the potential technical fixes that might narrow the information gap , very few attempts have been made to ask health researchers working in resource - poor settings for their views and experiences of such challenges . one attempt , conducted by the lancet in 2000 , surveyed international editorial advisors ( comprising senior academics with obvious insights into academic publishing ) and describes some of the challenges faced by researchers , concluding that information flow , research , publication capacities and indeed health are intimately linked ( 21 ) . by surveying end - users in 2005 from settings where access to literature and to publication is potentially limited , the present authors gathered the views and experiences of those at the early stages of their academic careers ( masters- and phd - level researchers in public health ) in order to capture some of the experiences of a new generation of computer literate and internet - savvy practitioners and researchers . taking advantage of international links within the ume international school of public health , sweden , in 2005 study participants were recruited using arbitrary convenience sampling methods . inclusion criteria were residence in a resource - poor setting and participation in health - related research activities . given the geographically dispersed nature of the sample and in order to maximise response , a mixed - methods approach ( drop - and - collect self - completion surveys ; email self - completion surveys ; face - to - face structured interviews ) was used to gather information on participants views and experiences of access and contribution to medical literature ( 22 ) . the use of interviews as well as self - completion questionnaires provided an opportunity for the researchers to develop a first - hand understanding of context as well as a chance to probe further in open - ended responses . detailed descriptions of the methods and study populations are described in detail elsewhere ( 23 ) ( attached as a separate file to this paper - see supplementary files under reading tools online ) . completed questionnaires and interview schedules were analysed using simple frequency analysis and qualitative thematic analysis , and attempts were made to make some general inferences in total , 49 individuals from asia , africa and south america were contacted and asked about their views and experiences ( 39 using self - completion questionnaires and 10 for interview ) . follow - up contact and reminder letters were sent to non - respondents , after which a total of 23 individuals responded ( 46.9% ; 16 males and 7 females ) : 15 from africa ( ethiopia , kenya , malawi , tanzania and uganda ) ; 7 from asia ( bangladesh , indonesia and vietnam ) ; and 1 from latin america ( nicaragua ) . some gender bias was indicated in the response rate , with approximately 80% response from males compared to 25% response from females . respondents from all settings described more frequent use of periodicals than reference text books , reflecting a widespread appreciation of the more timely content on specialised subjects that journals offer ( 24 , 25 ) . this desire for up - to - date content was also illustrated in respondents preference for online journals over print . seventy percent of respondents described online journal access as their preferred method , citing reasons such as more easily searchable content , remote access and the ability to save and print relevant articles . importantly , however , almost one - third of respondents  all from africa  described a preference for printed , hard - copy periodicals . more than half of the respondents ( n=12 , 52% ) expressed dissatisfaction with their access to print and online journals , directly relating this to inadequate university and research budgets . according to one respondent , providing access to relevant journals was simply not a priority for their employer . most recent headings could be up to five years out of date and , given the desperate need for any information , there was a tendency for any material to be displayed , including promotional pamphlets in a variety of languages . almost all respondents ( n=22 , 96% ) stated that they were expected to publish their own research papers in peer - reviewed journals as part of their work , yet more than half ( n=12 , 52% ) had yet to submit any work . of the individuals who had submitted work to a scientific or medical journal , more than one - fifth had their submissions rejected . when asked about their motivation for selecting a particular journal when submitting a manuscript , the most common reason given was the journal 's reputation , although the opportunity to reach an international audience was also cited . more than half of the individuals who had published or submitted articles stated that they had problems writing the articles in english and were required to edit and re - submit their work having reviewed language errors , often at an additional cost as external language editing was sometimes required . additional barriers highlighted were : perceptions that their work was not deemed relevant for an international journal ; inability to compete with many submissions within the same field ; lack of experience in preparing manuscripts ; unreasonably high expectations from editors and reviewers ; lack of a professional reputation within the academic community ; and insufficient access to existing information on the research subject . thirteen respondents ( 56% ) were opposed to the author - pays model of publishing . seventeen respondents ( 78% ) stated that they would be unwilling or unable to pay a fee to publish their work , although 4 of these individuals stated that they would be willing to publish in an author - pays journal if their employer or funder paid the fees . respondents from all settings described more frequent use of periodicals than reference text books , reflecting a widespread appreciation of the more timely content on specialised subjects that journals offer ( 24 , 25 ) . this desire for up - to - date content was also illustrated in respondents preference for online journals over print . seventy percent of respondents described online journal access as their preferred method , citing reasons such as more easily searchable content , remote access and the ability to save and print relevant articles . importantly , however , almost one - third of respondents  all from africa  described a preference for printed , hard - copy periodicals . more than half of the respondents ( n=12 , 52% ) expressed dissatisfaction with their access to print and online journals , directly relating this to inadequate university and research budgets . according to one respondent , providing access to relevant journals was simply not a priority for their employer . most recent headings could be up to five years out of date and , given the desperate need for any information , there was a tendency for any material to be displayed , including promotional pamphlets in a variety of languages . almost all respondents ( n=22 , 96% ) stated that they were expected to publish their own research papers in peer - reviewed journals as part of their work , yet more than half ( n=12 , 52% ) had yet to submit any work . of the individuals who had submitted work to a scientific or medical journal , more than one - fifth had their submissions rejected . when asked about their motivation for selecting a particular journal when submitting a manuscript , the most common reason given was the journal 's reputation , although the opportunity to reach an international audience was also cited . more than half of the individuals who had published or submitted articles stated that they had problems writing the articles in english and were required to edit and re - submit their work having reviewed language errors , often at an additional cost as external language editing was sometimes required . additional barriers highlighted were : perceptions that their work was not deemed relevant for an international journal ; inability to compete with many submissions within the same field ; lack of experience in preparing manuscripts ; unreasonably high expectations from editors and reviewers ; lack of a professional reputation within the academic community ; and insufficient access to existing information on the research subject . thirteen respondents ( 56% ) were opposed to the author - pays model of publishing . seventeen respondents ( 78% ) stated that they would be unwilling or unable to pay a fee to publish their work , although 4 of these individuals stated that they would be willing to publish in an author - pays journal if their employer or funder paid the fees . this small series of case studies reflects recognition among study respondents of their need to use and contribute to global knowledge in order to advance professionally . however , according to individuals surveyed , opportunities for information exchange is hindered by a persistent lack of access to up - to - date information and the skill set needed for publication . the focus on researchers at the early stages of their academic careers is a particular strength of this study . although no claims of representativity can be made based on the methods employed in this study , expressed views were relatively consistent between respondents , both within and between settings . this implies that personal experiences did not differ greatly between settings , and results may be of relevance to wider populations of health researchers in resource - poor contexts . the almost unanimous preference for printed over online articles among respondents from africa compared to those from other settings is striking . this difference perhaps reflects the weaker penetration and capacity of information technology systems in africa compared to asia and latin america , as well as the ease with which researchers from different settings use computers and internet searches . this preference merits further investigation and , if found to be representative of wider views in africa , warrants serious consideration by publishers should they decide to migrate to online - only platforms . several respondents described the unavailability of up - to - date literature as a primary challenge . institutional libraries in the poorest parts of the world often rely on donations of printed periodicals rather than direct subscription , resulting in second - hand , out - dated titles , irrelevant publications and inappropriate foreign language materials , and this appeared to be the case in the current study . therefore longstanding concerns that donor programmes intended to improve access to resources in low - income countries may actually supply irrelevant materials do not seem to be resolved ( 18 , 21 , 26 , 27 ) . the impact of new open - access initiatives on this issue will be an important outcome measure of their overall effectiveness . contrary to the findings from south asia in horton 's study ( 21 ) , whereby it was implied that publication might be perceived as a low priority for career progress , in the current study the reported ambition to publish reflects respondents recognition of publication as a high priority for personal and professional development . whether this is an artefact caused by sampling a population associated with an academic institution where publication is highly prioritised ( ume university ) , or a reflection of wider professional development ambitions in resource - poor settings , is unknown the fact that the majority of respondents cited international journals as a target for their work further suggests an acute awareness and desire to participate in global health debates . targeting such journals is likely to enhance real or perceived pressures to publish work in english . whilst this will undoubtedly increase the accessibility of one 's work , it also presents further barriers that must be overcome by researchers for whom english is a foreign language . as reported by several of the study respondents , the necessary skills and training to write and submit suitable academic publications in english is lacking . current open - access and aid - based initiatives are invaluable and have undoubtedly improved access to information . however , based on views expressed by study respondents , the author - pays model of open access appears to fall short of successfully overcoming unidirectional information flow . the fact that more than three - quarters of respondents stated that they would be unwilling or unable to pay author fees suggests that contributions from southern academics could remain limited . this resistance to the author - pays model is similar to findings from a study of published academics from more developed regions ( 28 ) . further investigation into the knowledge and attitudes of academics from resource - poor settings in relation to open - access and author - pays models is important in order to see whether reluctance or inability to pay to publish is based on a matter of principle , a lack of awareness of fee - waiver schemes or a poor understanding of open - access concepts . whatever the cause , however , there is a danger that this unwillingness or inability to pay to publish may perpetuate the imbalance of a north to south information flow , in that academics in resource - poor countries are still not contributing to academic literature and are most likely to only access those journals that are open access rather than a broad  and therefore balanced simultaneously addressing biases in information flow whilst building capacity for research and publication are key to international development in general and to health in particular ( 21 ) . building upon this series of case studies , there is a need for more in - depth , systematic research into the issues of access to publication , conducted on larger samples . nevertheless , a powerful message from the preliminary findings presented here is a need for more direct editorial support , coupled with efforts to improve access to academic literature , in order to open up bidirectional information flow . more innovative thinking around the entire publication process is therefore needed . along the lines of authoraid and inasp ( 11 , 13 ) , models offering author mentoring schemes ( scientific as well as editorial ) combined with low publication fees and open access platforms whilst maintaining scientific rigour are likely to play a significant role in addressing the gross inequality between north and south . publisher - led market research into the needs and desires of end - users and contributors from resource - poor settings may guide current developments in academic publishing in the right direction . given that they are unlikely to be lucrative business ventures ( at the outset at least ) , the new commercial pressures may be quite different from those that contributed to the evolution of northern - led academic publishing . whether this results in more equitable distribution and production of academic literature will be interesting to see . meanwhile , as new information highways are opened , experienced editors and authors from all settings have vital roles to play in supporting them and creating international solidarity . all must assume responsibility for directing the flow of global health information in both directions and this should be seen as a vital part of effective scientific communication , enabling effective global public health action .
backgroundless than 2% of scientific publications originate in low - income countries . 
 transfer of information from south to north and from south to south is grossly limited and hinders understanding of global health , while northern - generated information fails to adequately address the needs of a southern readership.methodsa survey of a new generation of health researchers from nine low - income countries was conducted using a combination of email questionnaires and face - to - face interviews . 
 data were gathered on personal experiences , use and aspirations regarding access and contribution to published research.resultsa total of 23 individuals from 9 countries responded . 
 preference for journal use over textbooks was apparent , however a preference for print over online formats was described among african respondents compared to respondents from other areas . 
 almost all respondents ( 96% ) described ambition to publish in international journals , but cited english language as a significant barrier.conclusionthe desire to contribute to and utilise contemporary scientific debate appears to be strong among study respondents . 
 however , longstanding barriers remain in place and innovative thinking and new publishing models are required to overcome them .