





































 V38 N4 / 2023 

©2023 American Medical Writers Association. All rights reserved.  
ISSN 2163-5315

AMWAJournal.org     5

THEME ARTICLE

ABSTRACT 
Ethical publication practices apply universally, but dif-
fering cultural contexts can alter the interpretation and 
application of guidelines. In particular, collaborating with 
colleagues and authors in the Asia-Pacific region can some-
times be confusing and frustrating when attempting to align 
expectations between all parties involved in medical writing  
projects. Engaging with colleagues in other regions to 
develop flexible, culturally appropriate processes can help 
strengthen working relationships, expedite project comple-
tion, and adhere to publication best practices.

Research into international differences in adhering to publi-
cation ethics guidelines has historically suggested that stan-
dards in the Asia-Pacific region (APAC) are lagging behind 
those in North America and Europe.1 However, recent data 
suggest that awareness and adherence to the principles 
of publication ethics is increasing in APAC.2 In addition, 
there are a number of challenges regarding the applica-
tion of international guidelines in APAC, including limited 
engagement with regional representatives and relatively 
scarce resources to support regional research and guide-
line development.3 Despite this, a number of organic efforts 
have been initiated within APAC to better understand pub-
lication practices and to bridge differences in expectations 
between regions.1,4-9 This is similar to efforts made within 
APAC to adapt international medical treatment guidelines 
to account for the specific circumstances in APAC com-
pared with other regions.

THE DIFFICULTY IN ALIGNING EXPECTATIONS 
ACROSS CULTURES
Independent guidelines developed to improve ethical pub-
lication practices and industry internal standard operat-
ing procedures that use these guidelines as a framework 
are often applied on the basis of regional differences not 
materially impacting their application. Accordingly, many 
of the conventions surrounding how ethical publication 
practices and authorship are applied when developing 
English-language medical publications have been devel-
oped in predominantly English-speaking high-income 

countries.3 For example, every author is generally expected 
to openly share documents illustrating proposed changes 
and detailed comments with the authorship group and 
other stakeholders. Debate is expected, and encouraged, 
to improve the quality of the publication, and the opinions 
of individuals are considered on an equal basis. In addi-
tion, although communication has traditionally been via 
formal written correspondence (eg, email), the convenience 
of video calls also means that real-time verbal discussions 
between authors are now common.
 Some of these practices can be inconsistent with cul-
tural expectations and norms in APAC, so there is a risk that 
important clinical insights that could be offered by authors 
and other stakeholders may be missed if stakeholders are 
unable to fully articulate their ideas and/or feel hesitant to 
comment, especially speakers of English as a second lan-
guage. Likewise, alternative forms of communication that 
are prevalent in APAC, whether they be verbal feedback 
provided one-on-one during in-person meetings or via 
messaging apps (eg, WeChat), may not strictly align with 
standardized procedures for commenting or maintaining 
formal records that are applied in Western countries.8

 Here, we describe the cultural and communication 
norms in APAC and provide some recommendations 
on how these can be effectively navigated to ensure that 
important insights from all stakeholders are not overlooked.

THE CURRENT LANDSCAPE
Most discussions regarding medical publications are con-
ducted exclusively in English, which poses challenges for 
communicating complex ideas for those who do not speak 
English as a first language. Furthermore, there is a growing 
expectation to engage in situations that can be challenging 
for non-native English speakers from APAC, such as video 
conferences, in which it can be difficult to follow comments 
from numerous people who are often speaking quickly and 
with different accents. 
 In particular, East Asian cultures (eg, Japan, China, 
Korea) tend to favor consensus-seeking and collectivism 
over individualism. So, for example, although interrup-
tions can be routine and tolerated in video conferences, 

Jonathan Lee, PhD, CMPP1 and Blair Hesp, PhD, NZDipBus, CMPP2  / 1Takeda Pharmaceuticals International AG–
Singapore Branch, Singapore; 2First In Human, Kainic Medical Communications Ltd, Dunedin, New Zealand

Embracing Cultural Differences to Ensure Ethical Publication Practices

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AMWAJournal.org     6Embracing Cultural Differences to Ensure Ethical Publication Practices

many participants from APAC will default to agreeing 
with or approving statements from others to out of fear of 
embarrassing themselves or their colleagues and to avoid 
any potential conflict. Likewise, there can be a tendency 
for people from some parts of APAC to be careful to defer 
to more senior colleagues, especially in a public setting. 
Unwritten cultural protocols regarding marks of respect 
and how to politely interact with colleagues in APAC can 
also make it difficult for native English speakers to correctly 
interpret comments and remarks. Unless you are very famil-
iar with the person’s culture, this can be a source of substan-
tial confusion and frustration when working with colleagues 
and authors from APAC.

EFFECTIVELY NAVIGATING LANGUAGE AND 
CULTURAL DIFFERENCES
When engaging people in APAC professionally, we rec-
ommend consulting with someone with substantial local 
knowledge before initiating a project. People with regional 
expertise are generally eager to help their peers navigate 
cultural sensitivities and may help you avoid potential pit-
falls. The mere act of seeking guidance in advance is likely to 
be widely appreciated.
 Allowing for extended review times and less formal meth-
ods of communication that the local team and authors are 
familiar and comfortable with, such as WeChat in China, may 
be necessary. Likewise, utilizing the support of a person who 
can speak an author’s native language or meet with them in 
person can improve the volume and quality of comments. 
One-on-one engagement, in person or via email, can also 
facilitate effective communication by offering circumstances 
for individuals to speak freely without fear of disrespecting 
colleagues. When communicating in a group setting, requests 
for feedback should be individualized before being commu-
nicated in a consolidated, anonymized fashion.

NOVEL CHALLENGES IN 2023
The increasing prevalence of plain-language summaries 
and enhanced content offers new opportunities for engag-
ing APAC, but their limitations still need to be understood. 
For example, Lancet Global Health invites authors to submit 
translations of the abstract of an accepted manuscript. 
However, most journals do not offer such broad multilin-
gual opportunities, so most plain-language summaries need 
to comprise wording, imagery, and context that can survive 
translation across languages and cultures. Intended mes-
saging can be misinterpreted or literally lost in translation.
 Artificial intelligence is also rapidly evolving, and as of 
mid-2023, its utility in medical writing has not yet been fully 
established. Although likely offering two-way benefits for 
communicating across cultures and languages, the limita-
tions of artificial intelligence in writing and translating need 
to be remembered. 

CONCLUSION
Considering cultural and communication differences is 
important when working with authors outside of North 
America and Europe. Ensuring full access to the valuable 
insights of authors who are speakers of English as a second 
language, such as those from the APAC region, can improve 
the quality of medical writing when approached in a cultur-
ally appropriate manner, ultimately benefiting the patients 
we strive to support through our publications.

Author declaration and disclosures: Jonathan Lee is an 
employee of Takeda Pharmaceuticals International AG–
Singapore Branch, is a sponsor of clinical research performed in 
APAC, holds Takeda stock, and is also the current Asia-Pacific 
Trustee on the International Society of Medical Publication 
Professionals (ISMPP) Board of Trustees. Blair Hesp is the 
owner of a company offering medical communication services 
to pharmaceutical, medical device, and diagnostics industries 
and authors within APAC, including publication planning con-
sultancy and professional medical writing support, and is also 
a member of the ISMPP Asia-Pacific Collaborations Outreach 
Committee. The ideas presented are those of the authors and not 
intended to represent those of their employers or ISMPP.

Author contact: blairh@kainicmedical.com

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