This article will focus on how open access publishing may add value to a number of health and social care professionals and their work in the health services. The results of two recent surveys are explored in relation to the research activity, barriers and awareness about open access publishing by health and social care professionals (HSCPs) working in the Irish health system.
The majority of peer-reviewed research is published in subscription journals, which are only accessible to those in institutions, or those willing or able to pay subscription fees. This causes research to lose its impact as it is only accessible to a small number of people . Open access (OA) provides a constructive solution to this problem. OA can be defined as free, unrestricted, immediate and online availability of high-quality scientific research results . OA is invaluable in that it can add value to the economy, to research and to society. OA research journals are not only unique because they provide a panacea to the high costs of paperback journals and subscription fees to scholarly journals, but because they offer new opportunities for niche and developing subject areas to establish resolute research outlets . Gold and green open access are two distinct ways of attaining open access to peer-reviewed research results. OA delivered by journals is referred to as gold open access, some journals may require the author to pay the subscription fee, and green open access concerns open access delivered by repositories . In terms of green open access, authors may have to seek permission to publish their work in a repository from the journal in which they also wish to publish. For example, The Lancet allows authors to publish the Word version of their peer-reviewed, accepted article on their personal or institutional Web sites any time after publication with a link to the publisher's version*. Repositories are digital collections of research results and articles, some are institutional repositories created by universities, while others are created for the sole purpose of disseminating open access research within a specific subject or discipline.
Traditionally, scholarly journals relied upon subscriptions to maintain their operations. OA has challenged this traditional modus operandi. With the advent of OA, publishers have had concerns over the viability of their business model and the value that they bring to the scholarly publishing process. Alternative business models are being put in place by some publishers which allow both publishers and societies to maintain revenue via other routes. Examples of alternative business models are available on the Open Access Directory Wiki in operation since 2008 .
OA research has been inhibited in the past as a result of misrepresentation and misconceptions about its concepts. However, at present the Registry of Open Access Repositories lists 3,817 repositories and this number is growing steadily. Notably, several open access repositories such as ‘arXiv’ (physics and mathematics), the Social Science Research Network, and PubMed Central dominate their respective disciplines. The Directory of Open Access Journals (DOAJ) reports that more than 67% of peer-reviewed journals charge no fees for publishing an article in their journals . It has been reported since 2006 that 75% of non-open access journals charge author-side fees, alongside reader subscription fees . The Study of Open Access Publishing (SOAP) project in 2011 also observed that these fees, termed as 'author fees' are paid by funders (59%) or by universities (24%); only 12% of fees are actually paid by the author . This indicates that the descriptor ‘author fees’ is misleading and this should be addressed since it is commonly used as a means of dismissing Open Access.
Academics are rated on how many publications they produce, how often they publish and the prestige of the journals in which they publish. This pressure is causally linked to the pressure on universities to improve their prestige . Many health and social care professionals (HSCPs) would also be expected to produce publications yearly, albeit not to as great an extent as academics. Although authors do not expect to be paid, due to funding issues, publishing in academic journals still remains essential due to the well known principle of ‘publish or perish’. Imperial College’s Department of Medicine is a prime example. The College insists that its affiliates publish at least three papers per annum, and one must be published in a respected journal with an impact factor of at least five . Researchers’ careers depend on achieving publication in the most prestigious and high-impact journals, which are usually the oldest and therefore non-open access journals, regrettably.
With the exception of the publishing companies, most practitioners in the world of scholarly publishing agree that there is a need for a complete overhaul of the current system. Open Access was developed to combat escalating subscription costs and support free and immediate access to research results. At present, researchers can only access limited amounts of research, as institutions are unable to subscribe to all relevant journals, and the public are denied valuable and reliable resources; instead receiving their information from frequently dubious Web sites. The objective of open access journals and repositories is not to replace existing journals and repositories, but to maximise research impact and access .
The value of Open Access to readers, authors, teachers, students, libraries, funders of research, governments and citizens has been well documented. But what about patients and health professionals?
Publishers allow free access to their journal content to developing countries, making it implicit that Open Access has both value and a positive impact on patient care. Initiatives include, for example, the Cochrane Library Collaboration, a gold standard in systematic reviews which is made openly accessible in developing countries, and the HINARI Access to Research in Health Programme. The vision of the Cochrane Library Collaboration is 'a world of improved health where decisions about health and health care are informed by high-quality, relevant and up-to-date synthesised research evidence.'  It uses bibliometrics to measure impact and reports that usage of the full text of Cochrane Reviews is high and increasing rapidly . HINARI content includes some 1,500 journals from six major publishers and provides free or very low-cost online access to the major journals in biomedical and related social sciences to local, not-for-profit institutions in developing countries. HINARI is one of four programmes that make up the Research4Life initiative. The impact of Research4Life has been documented in an online collection of case studies called “Making a Difference: Stories From the Field: How Access to Scientific Literature is Improving the Livelihoods of Communities Around the World”, with anecdotal evidence describing how this access to content is being used for elements including clinical practice and patient care . The current fight against Ebola demonstrates the value of Open Access to published scientific research for immediate patient care. Several publishers are allowing free unrestricted access to scientific and medical databases and journals to West Africa where the battle against Ebola continues .
In Ireland the organisation CORU is responsible for the regulation of HSCPs. There are currently 12 groups of HSCP professionals who are required by the Health and Social Care Professionals Act, 2005 to register with CORU. The 12 professional groups include: Clinical Biochemists, Dietitians, Medical Scientists, Occupational Therapists, Orthoptists, Physiotherapists, Podiatrists, Psychologists, Radiographers, Social Care Workers, Social Workers and Speech and Language Therapists. Part of the registration and renewal process includes mandatory continuing professional development (CPD). Research is regarded as CPD for these professions.
There were 15,844 people working in the Irish health system as health and social care professionals according to Health Service Executive statistics in 2013. They work in a variety of settings including primary care, disability and acute hospitals and increasingly in multidisciplinary teams. The Department of Health published an Action Plan for research (2009-2013) with specific actions to increase the research capacity of healthcare professionals. The Health Service Executive (HSE) responded to the action plan in part through the Health and Social Care Professionals Research Advisory Group. Along with hosting two annual research conferences (that included research methodology workshops) and publishing a research methodology guidebook for HSCPs , the Research Subgroup of the HSE’s HSCPs Education and Development Advisory Group undertook two surveys in 2011 and 2013 to build a picture of research capacity, skills and training needs of professionals working in the area of health and social care.
While both surveys generated a poor response rate, the second collated responses from 1,325 HSCPs and provided an important profile of the research capabilities and interests. It also provided a suite of recommendations to promote research competence and activity among our HSCPs. Results from the 2011 survey revealed that while 47.5% of the sample were involved in research, only 13% of their working time was spent on research. The results displayed that 84% of research-active participants and 73% of research-inactive participants reported a desire to spend more time involved in research. Lack of time dedicated to research and clinical pressures were identified as the main barriers to research. Participants suggested increased work time dedicated to research, additional funding and improved mentorship would enhance research activities .
Figure 1: Proportion of Research Active Participants in 2013
The 2013 survey reported that 40.7% of the sample had been research-active within the last two years. Research-active participants reported spending less than 10% of their working time engaged in research. Approximately one third of projects sampled were service evaluations, similarly a third of projects were part of an academic degree. Notably, a minority (18.8%) were funded . Similar to the 2011 survey, 89.4% and 78% of research-active and research-inactive participants stated a desire to designate more work time to research alone. In both surveys, ‘applying for funding’, ‘data analysis’ and ‘publishing research’ were reported as participants’ greatest weaknesses. Participants’ recommendations included protected time for research, developing HSCPs' weakest research skills, online learning supports to aid the development of research skills and the establishment of research opportunities that directly improve the functioning of services. The results of the 2013 study displayed that despite HSCPs desire for enhanced research engagement, there have been few advances in the research activities of HSCPs since 2011. This low level of research activity can be problematic as it results in a dependence on research from other jurisdictions. Different health services vary in terms of a number of significant factors, such as technology and clinical pressures; thus a service that is successful in one jurisdiction may not be applicable in the development efforts of a different jurisdiction . It is evident that health research is significantly beneficial, specifically, due to its capabilities to advance research, evaluate and improve the service, empower professions as well as the economic benefits it provides. Consequently, research should be an imperative component of all health and social care professionals' work. Open Access provides an innovative and more accessible way for HSCPs to engage in research.
Figure 2: Profile of percentage of work time engaged in research
Internationally, the policies on open access publishing differ in approach. Some countries favour the Gold over the Green Route eg the United Kingdom. Currently, in the UK over 90% of health science research is now produced under a mandatory open access policy. The majority of English-speaking countries have opted for the Green Route including the USA, Australia, Canada and Ireland. In Ireland, a National Steering Committee on Open Access Policy was set up in 2012. The impetus for this came from the Government’s declaration of support for the National Principles for Open Access Policy statement launched in 2012 . The Health Service Executive (HSE) is the main employer of HSCPs in the public health system in Ireland. In 2013 it set up an advisory group for open access research. Representatives from the HSCPs within the HSE are members of the advisory group. Not surprisingly, Ireland has one of the highest rates of green OA publishing in the European Union (15.8%), just behind Portugal (16.3%). The quantity of OA papers is steadily increasing. As a recent study reported, as of April 2014, more than 50% of the scientific papers published between 2007 and 2012 can be downloaded for free on the Web. It also found that fields with high availability of Gold OA included public health and health services (16%). In a sample of papers published between 2011 and 2013, 49.9% were made openly available in the area of public health and health services .
There is much debate over whether Open Access increases an article's probability of increased citations and impact. It has been suggested that open access articles have a higher rate of citations due to self-selection bias, because authors preferentially make higher-quality articles open access, and not because of causal reasons. Gagouri and his companions  observed that the rate of Open Access publishing is greater for more citable articles as a result of quality advantage, because users self-select what to use and cite, freed by Open Access from the usual restrictions of scholarly subscription journals, and not because of authors self-selecting the highest-quality articles for Open Access. The Open Citation Project maintain a bibliography of the effect of Open Access on downloads and citations. It displays an ‘Open Access impact advantage’ across all disciplines. The figure below displays the percentage increase of citations for open access articles in comparison to closed access articles in the same issue of the same journal .
Figure 3: Percentage increase in citations with Open Access
An important incentive for Open Access, and scholarly publishing generally, is undoubtedly impact. Impact is traditionally measured by the number of citations received following the completion of research. New models of altmetrics have emerged as an alternative or additional measure of impact. Research continues to confirm the citation advantage of publishing research and making it openly accessible. OA papers were between 26% and 64% more cited on average for any given year than all papers combined, whereas non-OA received between 17% and 33% fewer citations (based on a sample size of at least 10,000 papers any given year). Additionally, on average, Green OA (defined as researchers' self-archived papers in institutional and some thematic repositories listed in OpenDOAR and ROAR) papers have the greatest citation advantage, being cited 53% more frequently than all papers . As demonstrated by Archaembault in the table below, green OA archiving has greater impact in the field of public health and health services.
Figure 4: Impact contest by OA type by field, 2009-2011. Source: Archambault (2014)
In terms of research output in Ireland, a national portal called RIAN  captures research output from participating institutional repositories. This includes all Higher Education institutions in Ireland and the national health service via its repository Lenus . HSCPs working in hospitals or community settings are depositing research to Lenus, albeit slowly. In cases where HSCPs hold academic affiliations, their open access research may also be sourced from university repositories. In 2013 the HSE set up an advisory group for open access research. Part of the remit of the group is to increase awareness about open access publication and to ensure that all research conducted in the HSE will be made available through Open Access. In October 2014 during International Open Access Week, the group announced its first award for open access research . This is an initiative to raise awareness about open access research amongst healthcare professionals generally, and to recognise and reward research which demonstrates health service improvements.
The awareness about open access publishing is still quite low among HSCPs. In order to increase awareness of open access publishing and encourage Open Access as a default for health professionals working in the HSE, the HSE’s Open Access Research Advisory Group published a position statement on open access publication in 2013. In August/September 2014, a survey was carried out by the HSE’s library team who manage Lenus, the Irish Health Repository. It found that of the 413 responses from HSCPs, 62.5% had not heard of open access publishing. See Figure 5.
Figure 5: Responses to Lenus 2014 survey about open access publishing
The lack of awareness was further compounded by the finding that 94.89% of HSCPs had not heard of the HSE’s statement on open access publication. See Figure 6.
Figure 6: Responses to Lenus 2014 survey about open access publication statement
Barriers to conducting research persist for HSCPs working in the Irish health system. The main barrier cited was lack of time, followed by research not being valued by the organisational culture. See Figure 7. This is despite an interest in conducting research shown by respondents to the survey, with 179 health and social care respondents saying that they would like to spend more time conducting research. These findings are echoed by previous surveys conducted on speech and language therapists and social work practice in Ireland .
Figure 7: Responses to Lenus 2014 survey about barriers to research
Internationally, the awareness about Open Access is highest in research-inclined disciplines However, the SOAP project revealed that 90% of researchers in the field of humanities and social sciences, approximately 80% of medically related researchers and 90% of psychologists believed that Open Access was beneficial to their field . Gargouri and his colleagues' study portrayed the percentage of usage of open access publishing between the years 2005 and 2010. 17% of health research, 28% of psychology research and 36% of social science research were published in open access journals .
In Ireland the main source of funding for health services research, population health research, clinical and biological sciences research comes via the Health Research Board (HRB). The current strategic plan of the HRB includes one of its four top level goals as ‘building capacity to conduct high-quality population health sciences research and health services research’ . These are areas where HSCPs work and represents an opportunity for research output. According to a recent bibliometric study, the Irish health sector accounted for one third of HRB-funded research between 2000 and 2012 . Other sources of funding include Science Foundation Ireland (€74 million), the Higher Education Authority (€37 million) and the Industrial Development Authority (€23 million). Despite this expenditure, the 2011 study on HSCPs' research activity indicated that only a minority of the research projects of HSCPs are funded .
HSCPs working in the health service in Ireland have access to a number of platforms for continuing professional development and for profiling their research. Some are freely available to them such as HSEland which is a virtual learning environment for health workers in Ireland. Another example is open access platforms such as ResearchGate. At the time of writing, there are 520 HSE members registered on ResearchGate with a combined impact point of 120. However ResearchGate also has a number of other institutions in Ireland which are registered separately to the HSE where HSCPs could also work such as Children’s University Hospital, Temple Street, Dublin; Galway University Hospitals; Ireland’s Health Services; and St. Vincent’s University Hospital, Dublin. This makes data extraction and visibility of HSCPs from a platform such as ResearchGate cumbersome. Lenus, the Irish health repository, has a dedicated collection for HSCPs in which to make their research available. To date, this contains 329 items of research. Awareness about Lenus amongst HSCPs is low with 44.1% of HSCPs answering that they had never heard of it in the 2014 survey. Lenus is based on the DSpace platform and uses Google Analytics™ to track metrics and statistical use. Lenus has been available since February 2009 and items have been added on an ad-hoc basis by library professionals and health service professionals. The HSE has issued annual calls for research to all of the hospitals in Ireland since 2010, and many healthcare staff based in hospitals have responded by submitting research to Lenus. A brief analysis of the Health and Social Care collection in Lenus, as highlighted below, indicates that the collection is being viewed and items are being downloaded. Although the rate of deposit by health and social care practitioners is low in some disciplines, the collection is in use. Four health and social care disciplines are examined, they include Psychology, Social Work, Physiotherapy and Radiography.
There are 45 OA items in the Lenus Psychologists collection. The criteria to submit items to this collection require, for example, that the items are peer-reviewed, published and that the primary or named author is a psychologist working in a community setting. Research by psychologists who are working in acute settings are collected in separate hospital research collections within Lenus. Item statistics from this collection show that items have been viewed 470 times and downloaded 2,042 times in a six-month period. The most downloaded item in this collection was “Clinical Intake Interview Guidelines”, an article from the Irish Psychologist, September 2009. However the number of downloads an article receives is not an accepted measure of impact. This article is not indexed in Web of Science™, Scopus™ or PubMed, nor are any articles from the journal. This means that bibliometric reports of impact exclude articles such as these. The danger of this exclusion is that, arguably, psychologists may be missing out on opportunities for research funding when their research is not included by data used by commercial firms such as Thompson Reuters™ who are often used to report on national or European research output.
Figure 8: 6-month usage statistics for Psychologists collection in Lenus. Data from Google Scholar.
A search in Scopus™ using Affiliation Health Service Executive and Subject Psychology published since 1996 returns just 13 items. The result is that the h-index =5 (Of the 13 documents considered for the h-index, 5 have been cited at least 5 times.) Of the 13 documents, none are openly accessible. The items that have been submitted to Lenus by psychologists in the HSE are not being picked up by Scopus™. Although they are visible and openly available for viewing and downloading, the official reporting of impact will remain low as long as platforms such as Scopus™ exclude repository data.
There are only 3 items in the Social Workers collection of Lenus. Similarly to the Psychologists collection, the Social Workers collection is for the research of practitioners working in Irish community health settings. The statistics for 6 months show that despite the small collection, items are being viewed and downloaded. The most accessed item was a report on “The housing preference and assessment survey: an instrument to describe the subjective housing and support needs of mental health service users” which was downloaded 232 times in two years.
Figure 9: 6-month usage statistics for Social Work collection in Lenus. Data from Google Scholar.
There are only 6 items in the Lenus collection for Physiotherapy. This collection is for physiotherapists working in Irish community health settings. Research by physiotherapists working in hospitals is collected in separate hospital research collections in Lenus. The usage statistics are low. The most downloaded item in this collection was the ‘Item statistics for the effectiveness of a stratified group intervention using the StartBack screening tool in patients with LBF - a non randomised control trial’, which was downloaded 39 times.
Figure 10: 6-month usage statistics for Physiotherapists collection in Lenus. Data from Google Scholar.
Radiography holds 87 items, which is the highest number of items among the health and social professions in the Lenus Repository. This collection includes research by radiographers and radiation therapists working in Irish hospital settings. Despite the high number of items, the usage and download numbers are quite low.
Figure 11: 6-month usage statistics for Radiography and Radiation Therapy collection in Lenus. Data from Google Scholar.
Usage of OA publications by HSCP professionals is demonstrated by the analytical statistics in Lenus and the survey. A more telling answer about the usefulness of OA health-related publications was given by HSCPs to the question about how they used information that was found in Lenus. The majority answered that they used the information in practice for patient care. See Figure 12.
Figure 12: How information found in Lenus is used by HSCPs
Other collections in Lenus include:
|Health and Social Care Discipline||No. of items in collection|
|Speech and Language Therapists||7|
Rate of deposit by HSCPs in Ireland to Lenus, the Irish health repository, is low. Awareness of Open Access and understanding of its value is also low. The statistics provided by Lenus display that despite the accessibility of an open access repository, many researchers either do not publish their work in this repository or they are not engaging in research activity, as suggested in the HSCP survey in 2011 and 2014.
The current research landscape sees HSE HSCPs undertake research in collaboration with their HEI (Higher Education Insitution) colleagues. The former publish to promote their career advancement as per current performance-review criteria, and can hold a bias towards publishing in OA Journals. Again this demonstrates a fundamental misunderstanding about OA.
Open Access has been proven to improve impact and to benefit economic, research and societal needs. Research can only advance through the sharing of results, likewise the value of investment in research is only maximised through extensive use of its results. Unfortunately, due to restrictions on Open Access, research results are often not available to those who would make most use of them. It is imperative that results of publicly funded research should be made accessible in order to stimulate discovery and innovation, and to transform this knowledge into public benefits . It is evident that HSCPs' knowledge about Open Access is lacking or else inadequate. However, Open Access is imperative for the advancement of the research activity of HSCPs. The value of Open Access is evident in the many benefits it provides. At present, OA articles maintain a citation advantage over non-open access journals. OA offers a panacea to the problems many health professionals and academics face regarding funding and subscription fees. OA has progressed considerably since its establishment and it could provide HSCPs with a platform to develop their research activities.
Editor's note: Information for Authors, The Lancet, November 2014
The authors would like to thank Michael Byrne, Principal Psychology Manager, HSE West for his input.
Aoife Lawton is the repository manager of Lenus, the Irish health repository. She has a MLIS and BA in European Studies. She has worked in the Irish health system since 2001. Her interests include information systems, research, evidence based practice and library and information science.
Eimear Flynn is currently working as a research assistant in the Psychology Department of the HSE. She has a BA in Psychology and a MSc in Psychological Science.
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