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 http://www.amwajournal.org 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 References 1. Hesp BR, Arai K, Bose N, et al. Applying the Good Publication Practice 2022 guidelines in the Asia-Pacific region: a practical guide. Curr Med Res Opin. 2023;39(6):919-931. 2. Lee J, Carruthers A, Chung H, Crawford R, Lee J, Li X. Familiarity and implementation of global publication guidelines in Asia- Pacific (APAC): a cross-sectional survey. Curr Med Res Opin. 2023;39(suppl 1):S21. doi:10.1080/03007995.2023.2194075 3. Khan M, Abimbola S, Aloudat T, Capobianco E, Hawkes S, Rahman-Shepherd A. Decolonising global health in 2021: a roadmap to move from rhetoric to reform. BMJ Glob Health. 2021;6(3):e005604. 4. Hesp BR, Arai K, Chu MYS, et al. A guide to applying the Good Publication Practice 3 guidelines in the Asia-Pacific region. Res Integr Peer Rev. 2019;4(1):21. 5. Carruthers A, Chung H, Crawford R, Lee J, Li X, Lee J. 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