This study is the first comprehensive analysis of A.C.C.M. research in Africa. African A.C.C.M. publication had cycles of increasing amplitude organized around three peaks. Also, we noted an essential increase in the scholarly output over the last 20 years. The articles were published in a variety of journals, and most studies had an observational study design. Moreover, researchers from Nigeria and South Africa contributed the most to the scholarly output.
Academic output
Malawi, Sierra Leone, and Togo had the highest number of articles per P.A.P. Malawi ranked among the highest contributors in publications, publications per P.A.P.s, and publications per P.A.P. density. This indicates that Malawian P.A.P.s are proficient researchers despite a higher workload. Both Sierra Leone and Togo have median articles per P.A.P. density below the African median. Moreover, Sierra Leone was adversely affected by the Ebola virus disease and benefited from international aid.[15] This aid fostered the creation of partnerships between local PAPS and foreign P.A.P.s. On the other hand, Togo has trained local P.A.P.s and P.A.P.s from neighboring French-speaking countries, thereby increasing the quantity of Anesthesia research and researchers.[16] Furthermore, Togo and Sierra Leone have relatively small populations (less than 9 million) than other African countries. Hence, increases in the absolute number of articles and P.A.P.s lead to more remarkable changes in the number of articles per P.A.P.s and P.A.P. density.
One-third (18, 33.3%) of African countries did not have first-author publications. This finding is not surprising because African researchers face numerous barriers to publication.
Barriers faced by African A.C.C.M. researchers include lack of funding, institutional support, inexperience, and lack of mentorship.[13] Researchers lack funding to conduct research and to pay for the time spent away from clinical duties. Fortunately, most high impact open access journals offer a sizable discount to researchers from low- and middle-income countries.
African countries, without first author publications, should collaborate with higher-performing countries. The more experienced African researchers can mentor and build capacity among less experienced researchers in neighboring countries. The African Perioperative Research Collaborative is an excellent example of the potential of inter-African A.C.C.M. research collaboratives. The African Perioperative Research Collaborative is a group led by members of the South African Perioperative Research Collaborative that has facilitated A.C.C.M. clinical research among African researchers via technical support, mentorship, and capacity building.[4, 17]
A sizable proportion (25, 40.3%) of the first authors were affiliated to non-African institutions, most of them from high-income countries. This might explain why some countries did not have first-author publications. African researchers often assume the role of middle authors when they collaborate with researchers from high-income countries.[18] The lack of first author publications could equally be due to publications in journals that are not indexed in the major databases. Young African researchers often target foreign journals to increase their articles' visibility because most local journals have low impact factors and small readerships.[19–22] However, African researchers face numerous barriers to publish in international journals, especially if they have high impact factors, and some researchers eventually resort to publishing in predatory journals.[22] These predatory journals do not offer transparent and rigorous peer-review and do not meet the indexation criteria in major databases.[23] Further research is needed to understand the causes of the non-representation of the 18 countries.
The most substantial increase in publications occurred during the early 2000s, and they can be explained by increased interest in Global Anesthesia. Global Anesthesia is a field at the crossroads between anesthesia and public health that focuses on access to safe, timely, and affordable anesthesia care in the world. The World Federation of Societies of Anesthesiologists (W.F.S.A.) and prominent specialty journals supported research on access to and safety in anesthesia care. For example, the W.F.S.A. was a founding member and a sponsor of LifeBox and the World Health Organization Safe Surgery checklist, respectively.[3,5,7] Moreover, the W.F.S.A., high-income country academic centers, and non-governmental organizations have developed global anesthesia fellowships in South Africa, Ethiopia, Kenya, and Tanzania, contributing significantly to A.C.C.M. research in Africa. This is evidenced by the sizeable contribution of authors affiliated with non-African institutions to African A.C.C.M. research.
Hierarchy of evidence
There were few systematic reviews and guidelines among the African A.C.C.M. articles. These two forms of information synthesis are among the highest forms of scientific evidence and should inform practice.[24] The integration of evidence-based medicine to A.C.C.M. is common practice today.[25] However, the implementation of international guidelines to A.C.C.M. practice in Africa is faced with numerous challenges that require adaptation.[26, 27] The adaptation of international guidelines is necessary because the guidelines are based on evidence generated in resource-rich milieus, and there is a dearth of evidence-based and context-specific African guidelines.[28, 29] African researchers must develop these context-specific African guidelines from high-quality scientific evidence. To increase the quality of the evidence generated, African researchers must hone existing skills and acquire new ones. In systematic reviews, researchers can train using the Cochrane Interactive Learning online resource that offers free access to most African nationals.[30]
Also, there were few animal studies among the African A.C.C.M. publications. Although animal studies generate lower-grade scientific evidence, they are essential to the development of A.C.C.M.. For example, animal research played an essential role in developing the Guedel cannula, curarisation, and motor blocks.[31] Africa's rich biodiversity and ethnopharmacology are likely to house the next essential drug in A.C.C.M..[32] This untapped potential could lead to the discovery and production of more affordable drugs for African patients. Unfortunately, African basic science researchers face more barriers than clinical researchers. Researchers are challenged by lack of funding, difficulties obtaining ethical approvals, and inadequate infrastructure.[33, 34] Balogun et al. have proposed the engagement of local and international funding agencies by researchers, the use of invertebrates, and innovative low-cost research methods.[35]
Journals
A significant proportion of the top 50 journals were specialty journals, and only one of the specialty journals was African. Unsustainable financial models can explain the dearth of African specialty journals, lack of editorial expertise, and low submissions quality.[36] All these factors precipitate the failure of young journals. Young specialty journals can curtail the effects of these challenges if they collaborate with more experienced journals. The African Journal Partnership Program provides mentorship and capacity from leading journals of high-income countries to African journals' editorial teams.[37]
The African Journal Partnership Program model should be supplemented by inter-African partnerships between more and less experienced journals. The top contributing journal was South African, and the only African specialty journal was equally South African and emphasized the critical role of South African journals in A.C.C.M. research. The prominence of South African journals is an opportunity for other journals to learn from a successful African editorial staff.
A considerable number of articles were published in non-local high impact factor specialty journals. Similar trends have been observed in Europe and South Asia.[38, 39] Publication in a high impact journal does not guarantee visibility or recognition.[40] Citation metrics are better measures of visibility and recognition;[41] however, we did not collect data on citations. Future studies should evaluate the quantitative and qualitative impact of African A.C.C.M. research. Notwithstanding, the publication of African articles in high impact factor journals attests to the quality of research emanating from the continent.
The future of A.C.C.M. research in Africa
Going forward, African A.C.C.M. research must adopt a "no woman/man left behind" approach. Continental-level professional groups like the Africa Regional Section of the World Federation of Societies of Anesthesiologists should oversee a continental research agenda focused on capacity-building, especially in countries without first author publications. The capacity-building could be organized online and in-person (concomitantly with continental meetings). These training sessions should be opened not only to specialist physicians but equally to nurse anesthetists, residents, and medical students. Nurse anesthetists, residents, and medical students can help decrease the research workload by contributing to data curation, project administration, and writing of original manuscript drafts. In the absence of protected research time, this strategy can “buy” some time for specialist physicians and build capacity among non-physicians.
Limitations
We acknowledge the following limitations in our study: our definition of African research excluded Africans' research about A.C.C.M. in other continents. Next, we considered studies to be equal irrespective of their citation metrics or study design. Therefore, we did not factor the impact of the studies into the contributions. Hence, a letter to the editor with lower citation metrics was considered equal to a systematic review with higher citation metrics. Finally, we limited our analysis to prominent author positions. As such, we failed to capture a detailed picture of the contributors to African A.C.C.M. research. In addition, our search strategy could have been more explicit. We initially opted for a more comprehensive search strategy, but the results returned many irrelevant results. Given our limited resources, we opted for a less broad search. Despite these limitations, we believe our study adds value to existing research.