Knowledge and Awareness of Authorship Practices Among Health Science Students: A Cross-Sectional Study

Introduction

Authorship in the research field has several definitions, yet most of these definitions agree that the author is the one with significant contributions to the published research. Authorship belongs not only to the actual writers but also to the individuals who made substantial contributions and held significant responsibility for the data, concepts, and interpretation of results for a published work.¹ Those who do not meet these criteria should be acknowledged. For the most part, the first author is the individual who made the greatest contribution to the work, while the corresponding author is the person who assumes primary responsibility for communicating with the journal staff during the submission of manuscripts and peer review and generally ensures that all requirements of the journal and the publisher are properly met. The order of the authors shall be determined by the consensus among the co-authors.²

In the extremely competitive world of scholarly activities, authorship-related issues are increasing. Not crediting authors for their work, disagreements between collaborators, or assigning noncontributing persons as authors are among the most common issues. Ghost and guest authorships are also common authorship malpractices.³ A ghost author is one who participates in discussions and provides ideas in research but is not listed as an author in the final publication.¹ An honorary author is one who does not meet the criteria for inclusion in the authorship list but is named as an author.⁴

To reduce these unethical authorship practices, different groups, such as the Committee on Publication Ethics (COPE) and the International Committee of Medical Journal Editors (ICMJE), have created and published many guidelines.^5,6 The ICMJE’s recommendations are mostly adopted in the biomedical field and implemented by almost all peer-reviewed journals. Usually, these recommendations are published on journal websites. Authors must prove commitment to these recommendations upon submitting their manuscripts.⁶

According to ICMJE definitions, authors must meet four criteria to be listed in the authorship line:

1. They should contribute intellectually to the research concept or design.
2. They should significantly contribute to the review process of the paper.
3. They should provide the final approval of the paper before the submission process.
4. They should take public responsibility for all aspects of the research.

In case an individual does not meet these criteria, they could be listed in the acknowledgments section. Over the past few decades, publishing research has played fundamental roles for scientists and healthcare professionals across all scholarly disciplines. The importance of writing research papers could be categorized into social and economic benefits. Gaining a reputation and recognition by peers or experts in the field is one of the social aspects of publishing papers. Furthermore, on a personal level, publishing research is considered an individual achievement in terms of advancing knowledge in this particular field. Moreover, research is used as an evaluation tool for promotion in academic institutions.⁷

The case is different when it comes to health science students. Depending on the surrounding environment, health science students may engage in research for several reasons, such as fulfilling the school’s graduation requirements and building strong Curriculum Vitae to compete on residency seats. Others may engage voluntarily in research projects in order to stimulate their research interest. Previous evidence focused primarily on the influence of students’ characteristics on voluntary engagement in scientific research and examining the rate of publication after graduation in those who engaged in undergraduate extracurricular research activities.^8,9

To the best of our knowledge, there is a lack of studies that explored the knowledge of health science students regarding the authorship guidelines and practices. For this reason, we conducted this study to examine the knowledge of health science students at the King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) regarding authorship guidelines and practices.

Methods

Study Design

We conducted a cross-sectional study at KSAU-HS in Riyadh, Saudi Arabia. We included students from different academic years enrolled in different health science colleges, including medicine (COM), pharmacy (COP), dentistry (COD), nursing (CON), and applied medical sciences (COAMS). No sampling technique was used, as all students were asked to fill out an online self-administered questionnaire. For the sample selection approach, a non-probabilistic method, including purposive and convenience sampling techniques, was employed. A survey was distributed between March and December 2019. All survey answers were collected anonymously without identification information. The study protocol and survey were reviewed and approved by the institutional review board at King Abdullah International Medical Research Center (KAIMRC) in Riyadh, Saudi Arabia. All students were asked to signify their agreement on a consent form before taking the survey.

Survey Development

The survey was developed to evaluate the knowledge of KSAU–HS students about authorship and its malpractices. The questionnaire was derived from several previously published surveys and modified to fit the scope of this study.^10–12 Since health science students at KSAU-HS are taught using the English language, the language of the survey was not translated into Arabic. The survey consisted of four main domains and subdomains. The first domain was intended to collect the specific demographic characteristics of participants. The second domain was intended to assess the participants’ attitudes regarding authorship practices. The third domain was intended to examine the participants’ knowledge and experience with ghost and guest authorships. The fourth domain was intended to assess the participants’ knowledge of their institutional authorship policies.

Statistical Analysis

We used descriptive statistics to analyze the data. Continuous variables were summarized using mean ± SD and median (IQR, interquartile range), and proportions were used for categorical variables. A continuous knowledge score (KS) was constructed from seven questions that mainly reflected respondents’ knowledge about authorship credits, allocation, contribution, order, and guidelines. The questionnaire considers the respondents’ gender, college, and research experience (maximum score = 35; higher scores reflect higher knowledge). A logistic regression model was used to examine the association between the KS as the dependent variable and other parameters as independent variables. The collected data were compiled using Microsoft Excel 2010 (Office 365, Microsoft Ltd., USA) and analyzed using Statistical Package for Social Sciences 20.0 version (SPSS Inc. Chicago, USA).

Results

Demographic Characteristics of Participants

As shown in Table 1, the total number of students who agreed to participate in this study was 321. Close to 50% were female. The majority of the respondents were in their first three academic years and came from the COM, COP, and COD colleges—29.3%, 28.0%, and 34.0%, respectively. There were participants as well from the CON and the COAMS—3.7% and 4.0%, respectively.

Table 1 Demographic Characteristics of Participants N=321

The percentage of respondents who participated in previous research and have completed at least one publication was 12.1%. Around 47% of the respondents participated in research projects with more than four authors. However, close to 18% of them were part of research projects with less than four authors. Close to 68% of the respondents have been assigned as corresponding authors previously, and almost 60% of the respondents obtained information regarding authorship guidelines from didactic lectures.

Participant’s Attitude Regarding Authorship Practices

As shown in Table 2, when participants were asked if they agree that the authorship listing and order were discussed at the beginning of a new collaboration, only 9% expressed their disagreement, 16.5% were neutral, and 16% were unsure, leaving over half of the responses within the agreement domain. The survey offered four approaches to allocate credit to multi-authored articles:

1. Authors’ order and credit should be allocated according to the contributions to the project in the following order: greatest contribution first.
2. Authors’ order and credit should be allocated according to the contributions to the manuscript writing in the following order: greatest contribution first.
3. Authors’ order and credit should be allocated according to the contributions to the project in the following order: least contribution first.
4. Authors’ order and credit should be allocated according to one’s needs (promotion, application for a position, etc.).

Table 2 Frequency Distribution of the Participant’s Experiences and Attitude Regarding Authorship Practices

Approximately 60% of the respondents agreed with and supported the first two mentioned approaches. It is worth mentioning that the difference between agreeing and strongly disagreeing is significant only in these two statements. On the other hand, a small minority supported the later mentioned two methods (11% either strongly agreed or agreed that the authors with the least contributions should be mentioned first, and 22% either strongly agreed or agreed that the order should be allocated according to one’s needs).

When it comes to the complexity of establishing definitive criteria for authorship of a research article, approximately 40% strongly agreed or agreed on the difficulty of tailoring such definitive criteria. When 152 (47.4%) subjects agreed/strongly agreed with the statement that the team’s relationships would influence authorship allocation, only 50 (15.7%) participants disagreed/strongly disagreed. In response to the ninth statement, at your institution, allocating authorship credit is done by following specific authorship guidelines; close to one-third of those surveyed agreed/strongly agreed to the statement. Close to 50% of the respondents either strongly agreed or agreed with acknowledging individuals who contributed to the work but were not qualified to be listed as authors. Over half of those surveyed agreed that students might be forced to include their mentors as authors as mentors.

Participant’s Knowledge Regarding Authorship List and Public Responsibility

As shown in Table 3, most of the students (72.1%) agreed that the owner of the research idea should be listed as an author in manuscripts even without a substantial contribution to the work. Regarding the research and lab technicians and the funding provider, a large proportion of the participants, up to one-third of the respondents, were not sure if they should be listed as authors of a manuscript (29.7% and 24.5%) and another third (34.4% and 40.9%) were in favor of listing the name in the acknowledgments section. Regarding the roles of biostatistician and manuscript technical writer, the percentages were very close as 29.6% and 28.0% agreed that these individuals needed to be added as authors. However, 32.1% and 28.3% said these people needed to be added in the acknowledgment part, respectively. Close to 35% of the respondents stated that all authors should take public responsibility for the published work.

Table 3 Frequency Distribution of the Participant’s Knowledge Regarding Authorship List and Public Responsibility

Guest and Ghost Authorships

As shown in Table 4, approximately more than half (63.6%, 65.4%, respectively) of the respondents were unaware of guest or ghost authorship before this time. A large percentage of participants (82.6%, 85.0%) said that guest or ghost authoring was not granted in any manuscript/project in which they were authors. Around 17.0% and 11% of the respondents were influenced to include or remove authors from their manuscripts before being sent to publications, respectively. Approximately 24% entered into a dispute about the order of authorship. Close to 66% of the respondents agreed that courses and workshops should be provided for all students to ensure that they obtained a proper background in research ethics.

Table 4 Frequency Distribution of the Participant’s Knowledge and Experience of Ghost and Guest Authors and Authorship Malpractices

Participants’ Knowledge Regarding Institutional Authorship Policy

As shown in Table 5, close to 70% of the respondents were not aware of their institutional research and publication policies. Thus, they did not know if the policy defined gift authorship or the authors’ criteria and listing order.

Table 5 Frequency Distribution of the Participant’s Knowledge Regarding Authorship Institutional Policy

Knowledge Score

As shown in Table 6, a continuous knowledge score (KS) was constructed from seven questions that mainly reflect the respondent’s knowledge about authorship credits, allocation, contribution, order, and guidelines. The standardized Cronbach’s Coefficient Alpha of the score was 0.81. The mean score (STD) was 22.5 (7.8), with a max score of 35. Higher scores reflect higher knowledge. Our results showed that students who were assigned as corresponding authors had statistically significant higher KSs by 4.9 points than those who were not assigned as corresponding authors. Also, students who were aware of the institutional authorship guidelines had significantly higher KSs, by 2.2 points.

Table 6 Knowledge Score

Discussion

This study aimed to assess the knowledge of KSAU-HS health science students about authorship guidelines and practices. To the best of our knowledge, this is the first study to assess the authorship practices among health science students. Previous studies in this field mainly assessed this matter among faculty members or among particular health science students such as medical students. For example, in a comparative study that included medical and pharmacy faculty members, which included 54 and 41 individuals, respectively, the authors reported that pharmacy faculty had a better and clearer idea about authorship ethics than medical faculty. When they were asked regarding the ICMJE guidelines, only 22.2% of the medical faculty and 39% of the pharmacy faculty knew these guidelines. Gift authorship was prevalent in more than 80% of the medical faculty and 29% of the pharmacy faculty.¹³ In another study that used a national survey to assess the medical student experience with authorship, the investigators found that two-thirds of the medical students never received formal training in authorship guidelines previously.¹⁴ Moreover, close to 25% of the respondents indicated that the criteria for authorship were never clarified to them.¹⁴ Our findings showed that most of the included sample of health science students agreed that the author’s order should be allocated according to the contributions to the project or manuscript writing, and those with the greatest contributions should be listed first, which is the most common practice.

There was a lack of knowledge and understanding regarding the authorship list and public responsibility among participants. Our results showed a large percentage of the respondents believed that data collectors and the owner of the research idea would qualify these individuals to be authors, which contradicts with the ICMJE criteria that should be met before being listed as an author. When asked about public responsibility, only 36.3% reported that all authors should take it to be listed as an author. Many factors could explain this gross lack of knowledge and misunderstanding. First, the percentages of students who have no publications or projects are 87.9% and 65.4%, respectively. Second, the majority of the students were not aware of their institution’s authorship guidelines. Potential solutions to address this issue include integrating the institution’s guidelines into the curriculum, involving students in research from the first year of the professional program, and conducting workshops for the students to enhance their research skills and ethics. The lack of awareness of institutional guidelines may not be limited to students only but may include faculty members, notably after reporting the lack of knowledge of authorship guidelines among medical and pharmacy faculty members in a study conducted in India9. It is also important to raise faculty awareness regarding authorship ethics and practices and encourage them to discuss these ethics and practices with their students.

More than half of the participants were not aware of guest or ghost authorships, and around 17.4% and 15.0% of the participants reported that guest or ghost authoring was granted in at least one of their projects. A previous study suggested that the prevalence of honorary and ghost authorship in medical journals is close to 20% and 11%, respectively.¹⁵ As science and healthcare practice must be based on honesty and trust, more efforts are needed to increase their knowledge and awareness about ghost and guest authorship, which can sometimes be used to boost research quality. Ghost and guest authorships may compromise the validity and integrity of any research.¹⁶ To minimize that, some solutions can be implemented, such as integrating research ethics within the curricula and providing courses and workshops for all students and researchers, notably after identifying that 65.9% of the participants are willing to obtain courses and workshops on research ethics.

Universities and research centers have an important role in implementing authorship institutional policy and guidelines. More stringent guidelines may prevent unethical research malpractice. One study showed significant improvement in medical schools that implemented stringent guidelines that forbid ghost authorship.¹⁷ Therefore, frequent assessment of institutional authorship policy is required to ensure improvement in the quality of research. Surprisingly, our findings showed that 69% of students were not aware of the institution’s research authorship and publication conduct policy, which creates another obstacle. This could be minimized by exposing students to the institutional guidelines and implementing a standardized strategy that protects authors’ rights and minimizes unethical practices.

The KS was higher among students who were corresponding authors before or were aware of institutional authorship guidelines. This reflects the importance of exposing students to journals and institutional guidelines. Since corresponding authors have to read the journal’s requirements and authorship guidelines, this would explain their higher KS. It highlights the importance of exposing students to the institution’s authorship guidelines to build their knowledge and ethical practices.

Our study has several strengths. First, to the best of our knowledge, it is the first study to assess knowledge about authorship guidelines from students’ perspectives. Second, it included students from different healthcare specialties and compared their knowledge scores. Additionally, our findings emphasized the importance of implementing a standardized strategy to improve research quality and minimize research malpractice at institutional and faculty levels, notably after identifying many variations in attitudes and gaps in knowledge and understanding research ethics and authorship guidelines among students.

Our study has several limitations. First, most participants were in their first three years of the professional programs and had no publications or completed research projects. Second, our study is at risk of selection bias, which is associated with the online survey. Finally, our results may not be extrapolated to last year’s students, given the small number of participants representing that group. However, we believe that this study is one of the few that assessed the attitudes and knowledge of health science students about authorship guidelines, and the results of this study will be utilized to increase students’ knowledge and awareness of research ethics and authorship guidelines at the institutional, faculty, and student levels.

Conclusion

In conclusion, our findings revealed that health science students may have limited knowledge about authorship guidelines and unethical behaviors involved in scientific publications. Universities and research centers should make more efforts to ensure a clear understanding of and compliance with authorship guidelines among health science students.