Understanding of plagiarism amid North-African post-graduate dental students: A cross sectional pilot study

Study design

The study was conducted following the guidelines established by the STROBE statement.²¹This cross-sectional pilot study was conducted at the Faculty of Dental Medicine of Monastir (FDMM), Tunisia, from May 2, 2022, to October 30, 2022. The research protocol was determined to be exempt from human subjects’ research review by the FDMM Ethics Committee, and therefore, formal approval was not required. For the “paper method“(Figure 1), informed written consent was obtained from each participating student. For the “electronic method” (Figure 1), the fact that the participant responded to our email and sent us the filled questionnaire as an attached file indicates his/her consent to participate in the study. The survey was administered anonymously, ensuring confidentiality. Detailed information regarding the study objectives was provided to the students, ensuring their understanding of the research purposes.

Figure 1. Study flowchart.

TAOM: Tunisian Association of Oral Medicine. PGDSs: Post-Graduated Dental Students.

Study population

The study population consisted of all PGDSs enrolled at the FDMM during the 2022 academic year. The FDMM is the sole institution in Tunisia that offers dental medicine education, admitting approximately 30 to 40 new PGDSs each year. For the specific year under investigation (ie; 2022), the total number of PGDSs was 147, distributed as follows: 38 in the 1^st year, 33 in the 2^nd year, 38 in the 3^rd year, and 38 in the 4^th year. These PGDSs are residents who have completed their medical studies and passed the Tunisian national exam to obtain a specialist diploma.

All 147 PGDSs were invited to participate in the survey, and a five-step recruitment process, outlined in Figure 1, was implemented. To summarize, the following three recruitment methods were utilized: i) Individual emails were sent to all 147 PGDSs; ii) Announcements were disseminated through the Facebook pages of the 14 medical dental departments of the FMDM; and iii) Convenience sampling was employed, where questionnaires were distributed to PGDSs who had attended a medical congress or were acquainted with individuals involved in the study. During steps 1 to 3, which involved the electronic recruitment method, a total of 59 PGDSs were recruited. In steps 4 and 5, which involved the paper-based recruitment method, an additional 47 PGDSs were recruited.

Sample size calculation

The sample size for this study was estimated using the following formula²²: n = [(Z_α/2)² × P × (1 - P) × D]/E²; where «P» represents the proportion of the main event of interest (ie; low UP), «E» is the margin of error, «Z_α/2» is the normal deviate for a two-tailed alternative hypothesis at the desired level of significance, and «D» represents the design, which is equal to 1 for simple random sampling.

According to a study conducted in Saudi Arabia,²⁰ it was found that 17.9% of dental students (p = 0.179) were unaware of the meaning of the term “plagiarism” among a sample of 246 participants. Assuming a confidence interval of 99.9% (Z_α/2 = 3.29) and a «E» of 0.065, the calculated sample size (n) was determined to be 376 participants [376 = [(3.29)² × 0.179 × (1 – 0.179) × 1]/0.065²]. However, since our descriptive study involves a finite population (ie; a population with a limited number of participants), a correction was applied to the sample size.²² The number of students to be included after correction is given by the formula n’ = (N x n)/(N + n), where “n'” represents the corrected sample size, “N” is the size of the finite population (which is 147 in our study), and “n” is the sample size calculated from the standard formula (n=376). Therefore, the corrected minimum sample size (n’) is equal to 106 participants [106 = (147 x 376)/(147+376)].

Applied questionnaire

The study employed a questionnaire written in French (See extended data Appendix A⁷⁶ for the French version and Appendix B⁷⁷ for the English version), and participants were not given a time limit for completing it. The questionnaire was divided into two sections. The first section focused on gathering general characteristics of the students, including age (in years), sex (ie; male/female), department such as biomaterials, dental anatomy, general anatomy, microbiology, oral physiology, oral radiology, dental surgery, endodontics, fixed prosthodontics, maxillofacial prosthesis, orthodontics, pedodontics, periodontology, and removable prosthodontics, discipline (ie; differentiating between basic sciences and clinical sciences), post-graduate level (ie; 1^st year, 2^nd year, 3^rd year, 4^th year), experience level (ie; non-experienced for 1^st and 2^nd years, experienced for 3^rd and 4^th years), response modality (ie; electronic or paper), and dental doctor graduation (ie; yes, not yet).

The second section of the questionnaire focused on the French survey, which comprised 11 questions related to UP.²³ The survey was an online quiz accessible on the Laval University website.²³ Each question provided three answer choices (ie; yes, no, may be), with one point awarded for each correct answer.²³ A total score was calculated for each participant, and based on this score, three levels of UP were identified:

For statistical purposes, two objective levels of UP were considered: “excellent or acceptable” and “low”.⁴

An additional question regarding self-assessment of UP by the PGDSs was added at the beginning of the questionnaire⁴: how do you evaluate your UP? Is it “low”, “acceptable” or “excellent”? Two subjective levels of understanding of plagiarism were retained: “excellent or acceptable” and “low”.⁴

Statistical analysis

The distribution of variables was analyzed using the Kolmogorov-Smirnov test.²⁴ The latter involves comparing the cumulative distribution functions of the observed data with those of a theoretical distribution, typically a standard distribution like the normal or uniform distribution.²⁴ It assesses whether the observed data follow the specified distribution or not.²⁴ Quantitative data were presented as mean ± standard deviation (SD) with a 95% confidence interval and range [minimum-maximum]. Categorical data were presented as relative frequencies. The two-sided Chi-2 test was used to compare the percentages of PGDSs based on subjective (self-assessment) and objective (survey) assessments of UP. All statistical procedures were performed using a statistical software (StatSoft, Inc. (2014). STATISTICA (data analysis software system), version 12. www.statsoft.com, RRID: SCR_014213). The significance level was set at 0.05.

UP level

The mean score for UP was low at 4.7±2.2, with 80.4% of PGDSs showing a low level of UP. Of concern was the finding that a significant percentage of PGDSs underestimated their level of UP (Table 2). These alarming results closely resemble those reported in a previous study conducted among Tunisian UHDs.⁴ Using the same French survey,²³ Khemiss et al.⁴ reported that UHDs had a low mean score of UP (5.4±1.9), with 74% of them demonstrating low levels. Our findings suggest that Tunisian PGDSs have not received adequate guidance regarding plagiarism, a growing issue with the widespread availability of internet resources and artificial intelligence.³⁸ This lack of understanding may be a primary reason for the prevalence of plagiarism in North African states, such as Tunisia.⁴ The findings also confirm a lack of awareness about plagiarism among both academics and students in Tunisian universities.

The observed low average score of UP (4.7±2.2 out of 11 questions) was intermediate compared to studies conducted among postgraduate and undergraduate dental students (Table 4). On one hand, this score was consistent with an Iranian study involving 452 PGDSs, where the mean number of correct answers to 25 plagiarism knowledge questions was low at 6.9±3.3¹⁸ (Table 4). On the other hand, the local score contradicted findings from a Saudi Arabian study involving 246 dental students, where the mean plagiarism knowledge scores, assessed through 15 questions,^17,39 were high at 10.4±1.1 for males and 10.5±1.2 for females²⁰ (Table 4).

The high percentage of PGDSs displaying a low level of UP (80.4%) was also intermediate compared to percentages reported in the literature (Table 4). On one hand, our percentage aligned with findings from some studies^14,16,17,19 (Table 4). For instance, 53% and 69% of 1153 dental students from 62 American and Canadian dental schools believed they should not be responsible for monitoring the academic integrity of other students and did not consider cheating a serious problem at the university.¹⁴ In a Brazilian study involving 186 dental students, 78%, 74%, 69%, 48%, and 44% of students reported a lack of respect for image copyrights, a lack of understanding of direct quotes and paraphrasing, ignorance about the different types of plagiarism, and the belief that authors can be wrongly referenced, respectively.¹⁶ An Indian study of 248 dental master’s degree students revealed that 51%, 49%, and 49% of students did not recognize plagiarism as a punishable offense, were unaware of its adverse effects on the community’s health, and did not know that software is available for plagiarism checking, respectively.¹⁷ Similarly, an Iranian study involving 102 dental students, found that 77%, 56%, 53%, 48%, and 45% of students believed using previous method descriptions was justified, self-plagiarism was not punishable, plagiarized parts of a paper could be ignored if they had scientific value, using one’s own previously published work without citation was allowed, and copying with a colleague’s permission was not wrong, respectively.¹⁹ On the other hand, the percentage in our study differed from that in some reported studies^15–17 (Table 4). For instance, among Australian undergraduate students, 56% of nine postgraduate students considered plagiarism a problem, and 90% of 103 first-year students in the Bachelor of Oral Health (BOralH) and Bachelor of Dental Science (BDSc) program reported that their school had clear guidelines for dealing with plagiarism.¹⁵ In addition, 88%, 84%, and 74% of Indian dental master’s degree students were familiar with the term “plagiarism”, recognized it as an act of academic malpractice, and were aware of the mandatory dental council of India point system for scientific publications in academics.¹⁷ Some authors also reported that 100% of Brazilian students enrolled in a dentistry course were aware that plagiarism constitutes a crime.¹⁶

A significant percentage of PGDSs underestimated their low level of UP. While 62.26% of PGDSs considered their UP to be low, objective evaluation increased this percentage to 81.13% (Table 2). No previous study has evaluated this issue in dental students. Our result was similar to that reported for Tunisian UHDs, where 44.8% of them perceived their UP as low, but objective evaluation raised this percentage to 74.0%.⁴ Our finding was partially aligned with another study comprising doctoral candidates at the Faculty of Medicine and comparing attitudes towards scientific misconduct and self-reported behavior (eg, plagiarized publication).⁴⁰ This discrepancy between subjective and objective evaluations can be explained by the Kruger-Dunning effect,⁴¹ a cognitive bias in which individuals with low ability or knowledge in a particular domain tend to overestimate their competence in that domain.⁴² The overestimation of knowledge observed in our study aligns with results reported in various subject areas, such as logical reasoning aptitude among university students and clinical practice among specialist physicians.^41–44

What is the profile of a Tunisian PGDS with a low level of UP?

The two groups of PGDSs with “low” and “acceptable/excellent” UP levels showed comparable characteristics, including age, sex, discipline, post-graduate level, experience level, graduation, and response modalities (Table 3). To the best of the authors’ knowledge, no previous specific study has aimed to identify the profile of a PGDS with a low level of UP. Our finding aligns with a 2017 study that evaluated the role of plagiarism in 761 conference abstracts written by graduate students and early- to late-career faculty from approximately 70 countries.⁴⁵ The study examined patterns of plagiarism among professional academic writers and found that demographic categories such as geographical location of the current institution, geographical location of the institution where the highest degree was obtained, rank, position, citizenship information, sex, and discipline were not consistent indicators of text-matching.⁴⁵ However, it appears that the post-graduate level, academic year, and students’ age influence the UP level of dental students^15,18 (Table 4). First, one study¹⁵ reported that the percentages of Australian undergraduate students who considered plagiarism a problem were 56%, 63%, and 83% among post-graduate students, fifth-year students of the BDSc program, and first-year students of the BOralH and BDSc program, respectively. Second, in the same study,¹⁵ the percentages of undergraduate students who believed their school had clear guidelines for dealing with plagiarism were 90%, 56%, and 44% among first-year students of the BOralH and BDSc program, post-graduate students, and fifth-year students of the BDSc program, respectively. Third, an Indian study¹⁸ identified that UP increased as the age and academic year of dental post-graduate students progressed. In contrast to our study, some authors⁴⁶ reported that first-year medical dental students exhibited the highest negative attitude towards plagiarism, followed by second-year and then third-year students.

How to explain the low level of UP among Tunisian PGDSs?

Four factors may contribute to the observed low level of UP amid Tunisian PGDSs. First, there appears to be a perception of permissiveness towards plagiarism within dental medical faculties, with institution leaders exhibiting tolerance towards plagiarists, despite Tunisia implementing initiatives to combat this issue.⁴⁷ Although a decree was introduced in 2008 allowing universities to autonomously sanction plagiarists, research integrity remains under-discussed, and there is a lack of initiatives to address this concern.⁴ The absence of comprehensive policies may explain the low level of UP among PGDSs. Fifteen years after the decree’s publication,⁴⁷ it is crucial to evaluate whether policies against plagiarism in the medical field are being effectively implemented in Tunisia. Second, a significant reason for the prevalence of plagiarism is the inadequate emphasis by institutions on addressing the problem.⁴⁸ The absence of mandatory training modules on research and medical writing within medical curricula may account for the observed low level of UP.⁴⁹ Writing a thesis or article or dissertation is a complex task for medical students, requiring training and practice similar to any other academic skill.^25,50,51 PGDSs require support from qualified supervisors to improve the quality of their academic and scientific work.^50,51 Qualified supervisors play a vital role in ensuring the integrity of manuscripts produced by their students, as responsibility for suspected plagiarism is shared between senior researchers and young scientists.⁵² Our results are expected since some previous Tunisian studies including UHDs from different specialties including dentistry, reported a low level of awareness regarding plagiarism.^4,7 These results reinforce the notion that academics who themselves lack knowledge or understanding in a particular subject (eg; UP) are less likely to effectively teach or transmit that knowledge to their students. The adage “One who lacks something cannot give it” aptly applies. Third, the low level of UP may be attributed to the lack of plagiarism detection software tools in medical faculties.⁵³ The implementation of plagiarism detection tools has the potential to reduce the prevalence of plagiarism within institutions.^4,54,55 However, it is important to consider different perspectives on the effectiveness of these tools. While Stappenbelt and Rowles.⁵⁶ found that allowing students to check their own work can be beneficial and improve their skills, Youmans⁵⁷ reported that the availability of such software for students does not necessarily reduce plagiarism in their own work. Additionally, Rodafinos⁵⁸ concluded that expecting students to self-check their work may inadvertently encourage them to “cheat” by avoiding matches with the original sources. Since 2022, the FDMM has implemented plagiarism checker software (Turnitin), providing all teachers with access to this tool. This initiative aims to effectively raise awareness about plagiarism among students, encouraging them to use the software to check their theses and articles prior to submission. The faculty authorities are committed to promoting awareness of plagiarism and provide training to prevent its occurrence. Ford and Hughes¹⁵ found that dental students and staff expressed support for the use of Turnitin across all courses. However, a significant proportion (44%) of PGDSs expressed uncertainty regarding their stance on the use of Turnitin.¹⁵ However, it is important to note that existing plagiarism detection software tools are often limited to specific languages and can only identify copied words, while figures and other content may not be adequately compared.^4,52,59,60

Recommendations

Misunderstanding plagiarism is a common occurrence, and the lack of clarity surrounding the concept makes UP essential to prevent this misconduct. However, it should be noted that UP alone is not sufficient. As highlighted by Iloh et al.,³⁵ despite the awareness of plagiarism among Nigerian students, instances of violations were still detected. Therefore, it is crucial to focus on enhancing researchers’ knowledge and attitudes towards plagiarism, particularly among junior researchers. According to Poorolajal et al.,⁶⁵ there is a significant association between the prevalence of plagiarism and an increase in scores of knowledge and attitude towards plagiarism, with a decrease of 13% and 16% per one-unit increase, respectively. This highlights the importance of researchers’ awareness regarding plagiarism. Therefore, it is crucial for scholastic programs to focus on enhancing knowledge and improving the attitude of researchers, particularly junior ones, towards plagiarism. Achieving the following three goals, as proposed by Muthanna,⁷³ should be the target: i) Develop skills in creative, critical, and scientific thinking; ii) Encourage creative writing, translation, and publication across various disciplines; and iii) Advance knowledge through scientific research in all fields. To address these concerns, it is recommended to organize workshops, seminars, and scientific writing courses specifically focused on plagiarism.^25,73 Interactive seminars have shown effectiveness in addressing this issue, as suggested by Marshal et al.⁷⁴ Dedicated modules on medical research ethics and writing should be integrated into undergraduate medical curricula in North Africa to proactively prevent plagiarism.⁴ Combatting plagiarism is a shared responsibility, and each medical school should establish its own institutional policies to effectively address this growing phenomenon.⁷³ Table 5 presents ten recommendations aimed at preventing plagiarism among dental medical students. By implementing these recommendations, dental medical schools can promote a culture of academic integrity and equip students with the necessary skills and knowledge to avoid plagiarism.