Anesthesia and Analgesia (15.5%) had the most articles among the 116 studies. The South African Medical Journal (6.9%) was the first African journal in third place, and the Southern African Journal of Anaesthesia and Analgesia (1.7%) was the first specialty African journal in eleventh place ex aequo. Epiu I had the greatest number of first author articles (2.6%), and the African Surgical Outcomes Study by Biccard et al. was among the most influential papers. Dubowitz et al. had the highest H-index among the references of the most cited articles.
Visibility and citations
African research has lower scientometric measures than Western research.[10] The small number of articles with ≥ 2 citations is alarming but not surprising. Citation metrics are a measure influenced by the relevance and novelty of the study findings, but the visibility equally influences them. High impact journals offer visibility and prestige, but they are very selective. Unfortunately, African researchers often lack the funds, support, and experience to design and carry out studies that are susceptible to be published in high impact factor journals but interestingly both the U.S.A. and Africa share the same top specialty target journals.[9, 10]
Open access equally increases article visibility and citation; however, the open-access costs in some high impact factor journals can be prohibitive.[6, 7, 12] Few African authors can afford the open access fee in high impact factor journals and will either have to opt for a subscription-based journal or a less expensive journal that that will lead to decreased visibility.[12] Most local journals have lower or no publication fees but tend to have smaller readerships and impact factors.[13] Fortunately, an increasing number of high impact factor journals are offering open access fee waivers to authors from low-income countries and reductions for authors from lower- and upper-middle-income countries.[13] Hence, prohibitive publication charges might explain the lower citation metrics in African research.
Another way authors can improve the visibility of their articles is to design and disseminate visual abstracts, organize post-publication journal clubs, and write op-eds on their findings.[12, 14, 15] Little is known about the post-publication practices in African ACCM research. The lack of or inadequate post publication practices in African ACCM research may be responsible for lower visibility and citation metrics.
Keywords
There appears to be a keyword transition from critical care ("severe sepsis" and "septic shock") to anesthesia ("surgery") among the most cited articles on the practice of anesthesia and critical care medicine. The nodes of sepsis were smaller and less connected than those of anesthesia. Also, sepsis was peripheral, while anesthesia was central. The most cited critical care articles were focused on the outcomes of sepsis. This is evidenced by the fact that "severe sepsis," and "septic shock" had strong links with "anesthesia," "mortality," and "Africa."
Sepsis is the most common cause of death from infectious diseases, and Africa has an enormous burden of infectious diseases.[16–18] In particular, the African region is among the most affected by the human immunodeficiency virus and Mycobacterium tuberculosis, the first and second causes of sepsis in Africa, respectively.[17, 19] Moreover, sepsis is responsible for USD 10-469 billion in financial loss among African families and states.[20] Despite the considerable clinical and financial burden of sepsis in Africa, it remains under-reported and under-researched.[16] This scientometric analysis highlights the need to increase the visibility of articles on other aspects of critical medicine. For example, research on the other components of the continuum of care such as surveillance, prevention, prehospital care, and rehabilitation must be highlighted.
Although the terms "global health," "low-income countries," and "developing countries" were prominent, there was no noticeable "global anesthesia" node. It appears that global anesthesia research is accessible in Africa, but the term "global anesthesia" is not as popular. Global anesthesia is a growing field that studies and advocates for universal access to safe, timely, and affordable anesthesia care.[21, 22] The year 2010 was a marquee year for global anesthesia as Dubowitz et al. highlighted specialist workforce shortage in low-and middle-income countries and its impact on patient outcomes. [23] In the same year, McQueen published two articles on global anesthesia.[24, 25]
While the three global anesthesia articles were not focused on African anesthesia, they inspired research in the region. This fact is evidenced by Dubowitz et al. 's high H-index among the 116 articles. It is therefore attractive that a decade after the publication of the seminal global anesthesia studies, the term does not figure among the most influential keywords in African anesthesia research.
Biccard et al. identified ten research priorities for Africa: ACCM education, service delivery, peripartum hemorrhage, non-technical skills, infrastructure, context-specific evidence-based practice, economic analyses, information management, quality improvement, and perioperative outcomes.[26] Other than perioperative outcomes (keywords: "mortality" and "surgery"), the other research priorities do not appear among the most cited African ACCM studies. Four of the ten priorities are health systems research, and only two are clinical. This corresponds with our finding that the field of global anesthesia is increasingly popular on the continent.
Author and country contributions
Biccard et al. published the most cited article by a predominantly African team (88 total citations). The study by Biccard et al. was a prospective study of 7-day postoperative mortality in 25 African countries entailing 247 hospitals and 11 422 patients.[27] Moreover, the study was published open access in the Lancet, and unsurprisingly, it tallied a record high number of citations in just three years. The African research collaborative set a precedent for high-impact clinical research in Africa. We anticipate there will be similar initiatives and publications in the next few years. Such initiatives will need to build on the experience of researchers from Southern and East African regions (South Africa, Uganda, Tanzania, Malawi, Mozambique, Madagascar, Uganda, and the Democratic Republic of Congo) given that they had the most cited articles. This is essential because the connections between African countries were sparse.
The U.S.A. and the U.K. contributed more to impactful African ACCM research. On the one hand, this highlights the importance of collaboration between institutions in the "South" and those from the "North." On the other hand, it draws attention to the lack of representation of African researchers among the most cited African studies. In a systematic review of authorship in African medical research, Hedt-Gauthier et al. found that 68.3% of papers had a collaborator from the "North" and only 23.0% of first authors were local researchers.[28] While we must correct this inequity, we must avoid gift authorship. It is crucial, therefore, that researchers from the host and visiting countries do their parts. Host researchers should contribute significantly, and visiting researchers should make sure their colleagues get the opportunity to contribute early on and often.
Limitations
There are several limitations to the present study. First, the definition of African ACCM research excludes articles by African researchers on the practice Anesthesia abroad. To include such studies would have been time-consuming and incomplete, mainly if African researchers used a foreign affiliation. Next, few African journals can be found on the major search databases. As a result, we might have missed a significant proportion of articles on local practice. We wish to note, however, that articles that are not found in one of the standard databases are less likely to have citation data.