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Research ArticleOriginal Research

Authorship Inequity in Global Health Research Conducted in Low- and Middle-Income Countries and Published in High-Income Country Family Medicine Journals

Alyssa Vecchio, Bridget Nandawula, Kelsey Sawyer, James Akiruga Amisi, Daria Szkwarko and Kathy Z. Chang
The Annals of Family Medicine May 2025, 23 (3) 223-230; DOI: https://doi.org/10.1370/afm.240431
Alyssa Vecchio
1University of New Mexico, Albuquerque, New Mexico
2The Warren Alpert Medical School of Brown University, Providence, Rhode Island
MD
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  • For correspondence: alyssa_vecchio@brown.edu
Bridget Nandawula
3Engeye, Inc, Albany, New York
MPH
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Kelsey Sawyer
2The Warren Alpert Medical School of Brown University, Providence, Rhode Island
MS
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James Akiruga Amisi
4Moi University School of Medicine, Eldoret, Kenya
MBChB, MMed
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Daria Szkwarko
2The Warren Alpert Medical School of Brown University, Providence, Rhode Island
DO, MPH
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Kathy Z. Chang
1University of New Mexico, Albuquerque, New Mexico
MD, MPH
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  • Figure 1.
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    Figure 1.

    PRISMA Flow Diagram for Article Identification, Screening, and Inclusion

    PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

    Note: Diagram is based on the PRISMA 2020 statement.25

  • Figure 2.
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    Figure 2.

    Trends in First and Senior Author Representation Over Time

    HIC = high-income country; LMIC = low- or middle-income country (includes low-income, lower-middle-income, and upper-middle-income countries).

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    Figure 3.

    Heat Maps of Study Country Income Level With the Country Income Level of the Associated Articles’ First and Senior Authors

    Studies conducted in low-income countries and lower-middle-income countries

    Note: Powered by Bing (Microsoft Corp). Copyright Australian Bureau of Statistics, GeoNames (Unxos GmbH), Microsoft Corp, NavInfo (China Siwei Surveying & Mapping Technology Co, Ltd), Open Places, OpenStreetMap (OpenStreetMap Foundation), TomTom (TomTom NV), Zenrin (Zenrin Co Ltd).

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    Figure 4.

    First and Senior Author Country Income Level by Study Country Income Level

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    Table 1.

    Article Characteristics by Family Medicine Journal (N = 431 Articles)

    JournalEditorial officeImpact factoraNo. of articlesStudy country income level, No. (%)Authors from LMICs, No. (%)
    LowLower middleUpper middleMultipleFirst authorsSenior authors
    Annals of Family MedicineUnited States4.4900726 (67)4 (44)
    Asia Pacific Family MedicineJapanNAb602405 (83)4 (67)
    Australian Journal of General PracticeAustralia1.613049012 (92)9 (69)
    Australian Journal of Rural HealthAustralia1.911047010 (91)8 (73)
    BMC Primary CareUnited Kingdom2.010683951890 (85)80 (75)
    British Journal of General PracticeUnited Kingdom5.3804314 (50)6 (75)
    Canadian Family PhysicianCanada2.4500140 (0)1 (20)
    European Journal of General PracticeNetherlands2.31202649 (75)8 (67)
    Family MedicineUnited States1.8601231 (17)4 (67)
    Family Medicine and Community HealthUnited States2.63941613628 (72)23 (59)
    Family PracticeUnited States2.46011246155 (92)47 (78)
    Journal of General and Family MedicineUnited States1.8503113 (60)3 (60)
    Journal of Primary Health CareNew Zealand1.1100101 (100)1 (100)
    Journal of the American Board of Family MedicineUnited States2.4500505 (100)4 (80)
    Rural and Remote HealthAustralia2.01449408510107 (74)92 (64)
    Scandinavian Journal of Primary Health CareSweden1.9100010 (0)0 (0)
    Overall……43122 (5.1)127 (29.4)241 (55.9)41 (9.5)336 (78)294 (68)
    • LMIC = low- or middle-income country (includes low-income, lower-middle-income, and upper-middle-income countries).

    • ↵a As of 2023. Number of times journal’s articles are cited in the last 2 years divided by total number of publications in journal in those 2 years. Higher values indicate greater yearly mean number of citations of articles published.

    • ↵b Asia Pacific Family Medicine ceased to be published by BioMed Central on December 31, 2018.

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    Table 2.

    Article Characteristics by Author Country Income Level

    Author country income levelAll Articles, No. (N = 431)Study country income level, No. (%)Funded, No. (%)aAverage times cited
    Low (n = 22)Lower middle (n = 127)Upper middle (n = 241)Multiple (n =41)
    First author
        Low1110 (45)0 (0)0 (0)1 (2)7 (64)5.5
        Lower middle03 (14)87 (69)2 (1)1 (2)33 (35)4.4
        Upper middle00 (0)6 (5)221 (92)5 (12)113 (49)4.8
        High09 (41)34 (27)18 (7)34 (83)37 (39)8.8
    Senior author
        Low158 (36)3 (2)0 (0)4 (10)9 (60)5.4
        Lower middle720 (0)70 (55)2 (1)0 (0)22 (31)5.7
        Upper middle2073 (14)7 (6)189 (78)8 (20)96 (46)4.9
        High13711 (50)47 (37)50 (21)29 (71)63 (46)7.9
    • ↵a Of articles by author country income level.

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  • PLAIN-LANGUAGE SUMMARY

    Original Research

    Authorship Inequity in Global Health Research Published in Family Medicine Journals in High-Income Countries

    Background and Goal: Authors from low- and middle-income countries are underrepresented in published family medicine work. This study examined authorship inequities for research that was conducted in low- and middle-income countries and published in family medicine journals based in high-income countries.

    Study Approach:Researchers analyzed journals listed on the World Organization of Family Doctors (WONCA) Global family doctor website that focused on low-income countries, lower-middle-income countries, and upper-middle-income countries. They selected journals with editorial offices in high-income-countries. Inclusion criteria included research conducted in low- or middle-income countries, available in English language, and had human study participants. They summarized the proportions of first and senior authors by country income level and other publication characteristics.

    Main Results: 431 of 1,030 articles met criteria for research conducted in low- or middle-income countries.                                           

    • Over time, there was an increase in publication of research articles from low- and middle-income countries in the family medicine journals, with the majority of the studies conducted in upper-middle-income countries (55.9%).          

    • The proportion of senior authors from high-income countries was highest in articles with research conducted in low-income countries (50%) compared with those reporting research done in lower-middle-income countries (37%) and upper-middle-income countries (21%). 

    • There was a trend toward higher average citation rate for articles having high-income countries first and senior authors compared with articles having lower-middle-income countries first and senior authors. 

    Why It Matters: Quantifying authorship inequities highlights systemic barriers to research leadership in low- and middle-income settings. To support authorship equity, family medicine researchers should reconsider the definition of authorship criteria, promote culturally humble mentorship, and encourage institutions to adapt promotion criteria to empower equitable global health partnerships. 

    Authorship Inequity in Global Health Research Conducted in Low- and Middle-Income Countries and Published in High-Income Country Family Medicine Journals

    Alyssa Vecchio, MD, et al 

    University of New Mexico, Albuquerque, New Mexico

    The Warren Alpert Medical School of Brown University, Providence, Rhode Island

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The Annals of Family Medicine: 23 (3)
The Annals of Family Medicine: 23 (3)
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May/June 2025
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Authorship Inequity in Global Health Research Conducted in Low- and Middle-Income Countries and Published in High-Income Country Family Medicine Journals
Alyssa Vecchio, Bridget Nandawula, Kelsey Sawyer, James Akiruga Amisi, Daria Szkwarko, Kathy Z. Chang
The Annals of Family Medicine May 2025, 23 (3) 223-230; DOI: 10.1370/afm.240431

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Authorship Inequity in Global Health Research Conducted in Low- and Middle-Income Countries and Published in High-Income Country Family Medicine Journals
Alyssa Vecchio, Bridget Nandawula, Kelsey Sawyer, James Akiruga Amisi, Daria Szkwarko, Kathy Z. Chang
The Annals of Family Medicine May 2025, 23 (3) 223-230; DOI: 10.1370/afm.240431
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