Abstract
Introduction
Women are still underrepresented in prestigious author positions in medical publications. This study was done to evaluate gender differences in the first authorship of cardiology-related publications in South Asia over the past two decades.
Methodology
This is a cross-sectional study, and we strictly followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. An electronic search was conducted in PubMed on January 15, 2023, using specific MeSH terms and keywords for articles published from 2002 to 2022. The easyPubMed package of R statistical software was used to retrieve articles. The gender of the author was determined by first name. We used the
Results
A total of 5,105 publications are included in the final analysis. The study found that a total of 1,470 (28.8%) studies have female first authors, and 3,632 (71.1%) have male first authors. According to the countries, 29 (31.5%) in Afghanistan, 104 (24.1%) in Bangladesh, 2 (33.3%) in Bhutan, 879 (27.8%) in India, 1 (25%) in Maldives, 84 (28.9%) in Nepal, 322 (33.4%) in Pakistan, and 49 (33.1%) in Sri Lanka publications have female first authors. It was found that from 2002 to 2022, there has been a significant increase in female first authors. Only 16.3% of publications had a female first author in 2002, which increased to 32.9% in 2022.
Conclusion
Gender disparities in the authorship of cardiology research publications persist despite the declining trend.
In cardiology, it is known that males are more represented in the publications. There is consistently low representation of females. However, most of the studies are mainly from Europe and the United States.
Our study found a consistent disparity in first authorship in cardiology publications in South Asia over the past two decades. In 2002, only 16.3% of the first authors were female, and it increased to 32.9% in 2022. From 2002 to 2022, there has been a significant increase in female first authors.
Introduction
Professional gender equality is linked to higher organizational performance, more creative idea development, and increased production and national economic growth. 1 The World Bank categorizes Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka as South Asian countries. 2 Despite tremendous economic growth in these countries over the past two decades, critical gender gaps do persist. 3 South Asia’s female labor force participation percentage is only 23.6% compared with 80% in men. 4
The different communities in South Asia have an impact on the region’s gender equality through cross-cultural exchanges, disputes, inequity, and social exclusion. 5 Social expectations, gender stereotypes, gendered jobs, and organizational rules and practices are determined to be the most significant and prevalent impediments for women in the region. 6 The burden of caregiving and housekeeping, an increased presence of men in managerial positions, and fewer female role models may be barriers to the progress of women in employment. 7 A significant proportion of employers have stated that it is difficult to hire women because of workplace disruption ranging from 28% in India, 30% in Pakistan, 39% in Afghanistan, and 45% in Bangladesh. 8 South Asian nations offer lesser maternity benefits than non-Asian countries, and only a few nations, including Sri Lanka and Pakistan, prevent women from losing their jobs while they are on maternity leave. 6
Unconscious sex prejudices play a significant role in enabling ongoing sex discrepancies in academic medicine. 9 Two-thirds of women continue to experience discrimination, nearly three times the rate in men. 10 Gender disparities in hiring, salaries, funding, and patenting still exist, despite the fact that there are more female undergraduate and graduate students in many countries. 11 There has not been equality for male and female faculty in terms of rank achievement, leadership responsibilities, remuneration, or treatment by coworkers and superiors, despite the inflow of women into academic medicine over the previous three decades. 12 Despite the rise in female cardiologists, there are still a number of professional and personal barriers that only affect women, such as taking maternity leave and limiting radiation exposure before and during pregnancy. 9 Considering the role of women in academia in these countries, despite the rising number of women in academics, several studies from Europe and the United States have shown that fewer women pursue careers in cardiology, publish research in this field of medicine, or conduct clinical trials, in comparison to their male colleagues.13–17 Despite the slight increase in the number of women pursuing research, a low representation of women persists, especially in senior positions. 18 Furthermore, according to the American College of Cardiology survey, gender-related prejudice was faced by more than two-thirds of female cardiologists. 9
Gender diversity is important in the healthcare sector. The goal of gender mainstreaming is to incorporate men’s and women’s concerns and experiences into the creation, implementation, monitoring, and evaluation of all sectoral policies and programs, including those pertaining to health. 19 To achieve the best health outcomes, the health workforce should be diverse. 19 Research publications are an objective measure of a researcher’s scholarly acumen and productivity. It is also a criterion for academic promotions for medical professionals.20, 21 The rising global burden of cardiovascular diseases highlights the importance of clinical practice and research in cardiology. Understanding the effects of gender disparity in research is important, as it influences future clinical practice. 22 Studies from other continents have demonstrated that women in medical disciplines with low representation, such as cardiology, are likely to have fewer publications. 16 This study was done to evaluate gender differences and to determine the trends in the first authorship of cardiology-related publications in South Asia over the past two decades.
Methods
Study Design
This cross-sectional study strictly follows the Strengthening the Reporting of Observational Studies in Epidemiology guidelines 23 (Supplementary Table 1). The study was exempt from the Institutional Review Board, as it was conducted by using the openly available database, PubMed.
Search Strategy and Data Collection
We conducted an electronic search on January 15, 2023, in PubMed. We used the MeSH terms “Heart,” “Myocardium,” “Sri Lanka,” “India,” “Bangladesh,” “Nepal,” “Bhutan,” “Afghanistan,” “Pakistan,” “Maldives,” “Case-Control Studies,” “Observational Studies,” “Clinical Studies” and keywords such as “case-control study,” “cohort,” “cohort study,” “original study” (Supplementary Table 2). We restricted our search from 2002 to 2022. We used the easyPubMed package of R statistical software to retrieve articles from our search strategy. It is an R interface that allows easy and smooth programmatic access to PubMed. PubMed search strategies were run as a query in the easyPubMed in R. It resulted in downloading the articles retrieved through a search strategy. Study characteristics such as title, first author’s name (first and last), affiliation, year of publication, and journal were retrieved. The results are then exported to Excel, and gender was determined by the first name of the author. Two different methods were used for determining gender. We first use
Statistical Analysis
The statistical analysis was done by using R statistical software. We represented the data in proportions. The results were stratified according to the year. Mann–Kendall’s trend test was used to know the trend for gender disparities in first authorship. It is a non-parametric test, hence can be applied without any population assumption. Fisher’s t-test was used to compare between the two groups. The data were divided into four groups based on the range of years, and odds ratio (OR) of female first author was calculated by taking 2003-2007 as the reference year. For the yearly comparison, we used 2002 as the reference year. Analysis was represented as OR with a 95% confidence interval (CI). A P value of < .05 was considered significant. All statistical tests were two-sided.
Results
A total of 5,105 studies were included in the final analysis. There were 92 (1.8%) studies from Afghanistan, 431 (8.4%) from Bangladesh, 6 (0.1%) from Bhutan, 3,170 (62.1%) from India, 4 (0.1%) from Maldives, 291 (5.7%) from Nepal, 963 (18.9%) from Pakistan, and 148 (2.9%) from Sri Lanka.
In total, there were 1,470 (28.8%) female first authors and 3,632 (71.1%) male first authors, and gender of 3 (0.05%) authors was not determined. We found that 29 (31.5%) studies in Afghanistan, 104 (24.1%) in Bangladesh, 2 (33.3%) in Bhutan, 879 (27.8%) in India, 1 (25%) in Maldives, 84 (28.9%) in Nepal, 322 (33.4%) in Pakistan, and 49 (33.1%) in Sri Lanka had female first authors. Table 1 shows the year-wise distribution of the number of studies published and studies with female first author.
Year-Wise Distribution of Studies and Trends in Publications by Female Authors in Cardiology in South Asia between 2003 and 2022.
We used the Mann–Kendall’s test to see the trend. We found that from 2002 to 2022, there has been a significant increase in female first authors in cardiology research in South Asia (z-value = 3.47, P value < .001), along with that there is a significant decrease in male representation from 2002 to 2022 (z-value = −3.47, P value < .001) (Figure 1). We also divided publications year into a 4-year group and compared the odds of the female first author. We found that there were 34% (OR = 1.34, 95% CI: 0.99-1.81, P value = .04) higher odds of a female first author from the years 2008 to 2012 in comparison to between 2003 and 2007 (Table 2). This increases to 67% between 2018 and 2022 (P value < .01). While comparing yearly with 2002 as the reference year, it was found that in the years 2012, 2014, 2019, 2021, and 2022, there were statistically significantly higher odds of female first authors in cardiology research (P value < .05).
Female and male authorship in cardiology publication stratified by year from 2002 to 2022.
Country-wise Trends in Publications by Female Authors in Cardiology in South Asia between 2003 and 2022.
Discussion
This cross-sectional study was conducted to evaluate gender differences and to determine the trend in the first authorship of cardiology publications in South Asia from 2002 to 2022. This is the first study exploring gender difference in published cardiology research in South Asia.
Among the 5,105 studies included, the majority were from India (62.1%), followed by Pakistan (18.9%) and Bangladesh (8.4%). Over the past 10 years, South Asia has enhanced possibilities for women by enacting laws, earning 10 points on the Women Business and the Law Index. 24 Despite this, gender disparities persist in medical research. Our study showed that female first authors in cardiology were less than 50% in all South Asian countries. This is in accordance with the study by Bendels et al, wherein a slow harmonization of authorships between male and female authors was predicted. 25 Ouyang et al found that women were more likely to be represented as middle authors rather than first or senior authors. 16 Over the past 20 years, unprecedented progress has been made to eliminate gender inequities in medicine, yet this underrepresentation of women continues to be a source of concern. 13
Women’s academic advancement has been hindered by traditional sex roles, gender-based discrimination in the medical industry, and a lack of effective mentors. 26 In the study by Limacher et al, most women (71%) reported gender discrimination and expressed dissatisfaction with their ability to achieve professional goals. 27 Female researchers have been found to receive fewer and smaller research grants, and fewer women serve as principal investigators for trials. 16 Lack of mentorship, leading to fewer opportunities for original research, has also been suggested as a reason for low female authorship. 16 Composition of editorial boards may also indirectly affect female researchers’ success in publication. 22
We saw that Bangladesh, India, Maldives, and Nepal had less than 30% female first author publications, while Afghanistan, Bhutan, Pakistan, and Sri Lanka had more than 30% female first author publications over the past two decades. For the countries such as Maldives and Bhutan, very few studies have been done, and hence their results cannot be generalized. In Afghanistan, most publications are done by foreign authors and is not the true presentation. After removing the authors from other countries, all the publications in Afghanistan have male first author.
From 2002 to 2022, there has been a significant increase in female first authors in cardiology research in South Asia. In 2002, only 16.3% of publications had a female first author, while this increased to 32.9% in 2022. A reason for the increasing trend could be the increase in women working at academic medical centers, at higher ranks, and in more leadership positions. 16 Similar findings were seen in the study by Jagsi et al wherein it was also seen that the upward trend matched the general trend in authorship in medical literature and the increasing number of female cardiologists. 28 Lerchenmüller et al found that over the last decade, women have started to receive first authorships 5% more frequently than men in the cardiovascular sciences. 17 According to the study by Ouyang et al, over the past four decades, there have been more female researchers in published cardiology studies, but women still do not have a good representation among senior authors, first authors, and publications. 16 In journals with the highest impact factors, female authors still have significantly lower rates of first authorship than male authors. 17 Despite the increasing trend in female authors, women are underrepresented in prestigious authorships compared with men. 22 Finally, even though the gap between female and male first authors is decreasing, there is still a significant difference between first authorship of cardiology publications.
The strength of our study lies in the fact that overall, we analyzed 5,105 studies and used different methods to determine the female gender, with only three studies where gender could not be determined. Hence, it gives us a quite accurate measurement of gender disparity in the South Asia region.
Limitations
In some countries such as the Maldives, Bhutan, and Sri Lanka, there are only a few studies and cannot definitely represent the gender disparities of that country. Also, some studies have authors from different countries and hence are not the true representation of the gender difference for that country. We only included publications from PubMed not from other databases. Even though it is the most commonly used database and most comprehensive database, many journals are not indexed in it.
Conclusion
Gender disparities in the authorship of cardiology research publications persist despite the declining trend. The representation of women in cardiology research in South Asia, as measured by scientific authorships, has increased significantly over the past two decades, although female authors still contribute to less than half of the publications. Strategies to help reduce the gender gap in cardiology-related research will improve the representation of women and indirectly influence healthcare policies and standards of patient care.
Footnotes
Authors’ Contribution
A.S.—generator of the idea, analysis, manuscript writing, supervised, and helped in mediating study.
A.V., F.N.U.S., and U.V.—manuscript writing and final reviewing.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethics Approval
The authors confirm that patient consent is not applicable to this article, as it is done by using publicly available data.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Informed Consent
Not applicable. The study is done by using publicly available data.
