Training the Next Generation of Academic Global Neurosurgeons: Experience of the Association of Future African Neurosurgeons

Introduction: Although the past decade has seen a substantial increase in African neurosurgeons' academic productivity, productivity remains low compared to their colleagues from other regions. Aspiring neurosurgeons can contribute to the academic neurosurgery workforce by taking care of less technical and time-consuming research tasks. Fortunately, global neurosurgery institutions have also made efforts to increase research exposure and scholarly output in academic global neurosurgery. The Association of Future African Neurosurgeons (AFAN) created a research incubator for aspiring academic global neurosurgeons in Africa to provide enrollees with mentorship, skills, and experience. This study assesses and reports the activities and results of the research incubator. Methods: Aspiring academic global neurosurgeons were enrolled in the AFAN Research Incubator Program (ARIP), whose primary objective was to provide enrollees with foundational skills in all aspects of the research cycle. ARIP enrollees participated in didactic and practical activities with the aim of publishing ≥1 article and presenting ≥1 abstracts at international conferences in one year. Results: Fifteen AFAN members aged 25.0 ± 3.0 years enrolled in ARIP: 7 (46.7%) medical students, 4 (26.7%) general practitioners, and 4 (26.7%) residents. Eleven (73.3%) were male, 6 (40.0%) were from Cameroon and 6 (40.0%) had no previous research experience. Two (13.3%) enrollees dropped out. ARIP enrollees published a total of 28 articles, and enrollees published a median of 1.0 (IQR = 2) first-author articles on neurosurgical system strengthening. Additionally, ARIP enrollees presented 20 abstracts with a median of one abstract (IQR = 3.0). Conclusion: South-South research collaborations like ARIP can contribute to improving global neurosurgery research capacity and output. These collaborations can set up the foundations for robust research in low- and middle-income countries.

Introduction: Although the past decade has seen a substantial increase in African neurosurgeons' academic productivity, productivity remains low compared to their colleagues from other regions. Aspiring neurosurgeons can contribute to the academic neurosurgery workforce by taking care of less technical and time-consuming research tasks. Fortunately, global neurosurgery institutions have also made efforts to increase research exposure and scholarly output in academic global neurosurgery. The Association of Future African Neurosurgeons (AFAN) created a research incubator for aspiring academic global neurosurgeons in Africa to provide enrollees with mentorship, skills, and experience. This study assesses and reports the activities and results of the research incubator.
Methods: Aspiring academic global neurosurgeons were enrolled in the AFAN Research Incubator Program (ARIP), whose primary objective was to provide enrollees with foundational skills in all aspects of the research cycle. ARIP enrollees participated in didactic and practical activities with the aim of publishing ≥1 article and presenting ≥1 abstracts at international conferences in one year.
Conclusion: South-South research collaborations like ARIP can contribute to improving global neurosurgery research capacity and output. These collaborations can set up the foundations for robust research in low-and middle-income countries.
Keywords: Africa, capacity building, global neurosurgery, neurosurgery, research INTRODUCTION Despite substantial increases over the past decade, African neurosurgeons' academic productivity remains low compared to their colleagues from other regions. More than one-third of African countries have no peer-reviewed neurosurgery articles, and the median number of articles for African countries with peer-reviewed articles is six publications (1). The low academic output is primarily due to a workforce shortage, and for the few neurosurgeons available, the patient workload is an impediment to research (2)(3)(4). Other barriers include a lack of exposure, lack of protected research time, limited access to articles, and lack of mentorship (5,6). For example, more than 60% of aspiring African neurosurgeons do not have a mentor and have never presented an abstract at a conference, participated in a journal club, or contributed to a manuscript (7). One reason for the lack of exposure is that academic neurosurgeons do not have time for research activities (3,4). Aspiring neurosurgeons can contribute to the academic neurosurgery workforce by taking care of less technical and time-consuming research tasks, creating time for academic neurosurgeons to do more research. The early involvement of aspiring neurosurgeons in research activities equally benefits them because it increases their exposure and skills.
Global neurosurgery institutions have made efforts to increase research exposure and scholarly output in academic global neurosurgery. For example, the World Federation of Neurosurgical Societies' Global Neurosurgery Committee has set-up a mentorship program and funding mechanisms (8). to promote research in low-and middle-income countries, no study, to our knowledge, has described a formal capacity-building initiative aiming to increase academic global neurosurgery exposure among aspiring neurosurgeons (5,6).
The Association of Future African Neurosurgeons (AFAN), a 460-member neurosurgery interest group, created a research incubator for aspiring academic global neurosurgeons in Africa to provide enrollees mentorship, skills, and experience. This study aimed to assess and report the activities and results of the research incubator.

METHODS
On August 29, 2019, aspiring academic global neurosurgeons (medical students and general practitioners) were enrolled in the AFAN Research Incubator Program (ARIP) (Figure 1). ARIP was organized and led by the first author (USK), an experienced global neurosurgery researcher. Monthly lectures and journal clubs were organized on the first and second Saturday of each month at 5 p.m. GMT on Zoom (Zoom Inc., California, USA). The videos were recorded and shared with the enrollees for offline viewing. The authors obtained institutional review board approval before starting the project. Completion is color coded: green (completed task), orange (uncompleted task and deadline past), red (major setback), and white (previous task has not been completed).

ARIP Description
The primary objective of ARIP was to provide enrollees with foundational skills in all aspects of the research cycle: from study design to post-publication communication. The didactic courses were followed by practical exercises during which enrollees had to contribute significantly to a study.
Enrollees had to contribute significantly to five manuscripts, submit at least one article as a first-author, present at least one abstract at an international conference, design more than two visual abstracts, create an ORCiD account, create a ResearchGate account, and curate their social media accounts over 1-year.
The first author taught 28 90-min-lectures (60-min presentations and 30-min discussions). At the end of the lectures, each enrollee developed and proposed an idea for their first-author paper. Priority for first-author papers was given to studies involving human subjects if the first author was in their final year of medical school or residency and reviews (systematic, scoping, and narrative) if the first-author was not in their final year. This choice was made to avoid delays and costs related to institutional review board approvals, given that participants in their final year could get ethical approval easily.
All research projects were logged in Google Sheets (Google Inc., California, USA) using a traffic light coding system along with target journals, target conferences, deadlines, and co-author lists (Figure 2). Priority was given to openaccess journals without article processing charges and virtual conferences to maximize visibility and decrease expenses. The manuscripts were written on Google Docs (Google Inc., California, USA) and co-authors contributed using the suggestion mode. The online document history function was used to quantify the contributions of co-authors and to determine authorship positions. This was chosen to ensure transparency and accountability. Each research team held a monthly meeting with the first author during the study period. Day-to-day communications were done on WhatsApp (WhatsApp Inc., California, USA).
All abstracts accepted at conferences were first presented internally and reviewed by other ARIP enrollees before being presented at international conferences. Also, English and French visual abstracts were designed for all published articles and disseminated on AFAN and via the co-authors' social media handles.

Statistical Analysis
Summary descriptive statistics were generated (gender, age, number of peer-reviewed articles pre-ARIP, number of peerreviewed articles post-ARIP, and number of abstracts post-ARIP). A Wilcoxon signed-rank test was used to evaluate the difference in scholarly output before and after ARIP, and the P-value was considered statistically significant when <0.05.
ARIP enrollees published a total of 28 articles and a median of 1.0 (IQR = 2) first-author articles. The increase in peerreviewed publications was statistically significant (post-ARIP median = 8.0, IQR = 8.0 articles vs. pre-ARIP median = 0.0 articles; P = 0.01). Of note, the article titled Barriers to the management of non-traumatic neurosurgical diseases at 2 Cameroonian neurosurgical centers: A cross-sectional study was selected as an editor's choice in World Neurosurgery (9). The publications covered all the aspects of a neurosurgical system: workforce and infrastructure (10), finance, governance, information management (11), and service delivery (12). ARIP enrollees presented 20 abstracts, of which 5 were presented at the World Federation of Neurosurgical Societies Global Neurosurgery 2020 Conference, and 3 were presented at The Neurology and Neurosurgery Interest Group -Society of British Neurological Surgeons Conference ( Table 2). The enrollees presented a median of one abstract (IQR = 3.0).
All enrollees had designed ≥2 visual abstracts, created ORCiD and ResearchGate accounts and curated their Twitter and Facebook accounts. Eight (53.3%) enrollees had met the target set initially (≥five peer-reviewed articles, ≥one first-author article, ≥one abstract, ≥two visual abstracts, and curation of ORCiD, ResearchGate, and other social media accounts) at the time of publication.
The enrollees were asked about their experience, and the majority (86.7%) had positive feedback. Direct quotes from the enrollees are below: • "[ARIP] is the best research experience I have had. The course director and my peers are very helpful and always available." • "I love that [ARIP] is goal-oriented and transparent. It motivates me to do my best." • "Publishing in respectable specialty journals and being awarded the Editor's choice is the consecration of our individual and team efforts." Participants identified project administration as the most challenging aspect of their research experience.
• "I find it hard to keep my co-authors motivated. I often have to do more work than was initially planned." • "I struggle to organize meetings and set deadlines."

DISCUSSION
This global neurosurgery research capacity-building initiative is the first of its kind in Africa. We enrolled aspiring academic global neurosurgeons from all career levels. This program provides a framework for global neurosurgery research projects in low-resource settings and contributes to the attainment of research objectives set by the World Federation of Neurosurgical Societies' Global Neurosurgery Committee (8).

Impact
ARIP has significantly increased the scholarly output of enrollees, and its publications and abstracts were featured in prestigious journals and conferences.
Locally-driven research is critical for the attainment of universal neurosurgical care. For this to happen, there must be a critical mass of experienced researchers within local academic institutions, locally-driven research agendas, stakeholder buy-in, and integration of research findings into high-level decisionmaking (13). ARIP is working to grow the local academic neurosurgeon workforce and map out research gaps through literature reviews. ARIP offers hands-on experience, provides medical students and physicians opportunities from multiple African countries, and is output-oriented. In addition, ARIP is a South-South partnership focused on research that is mindful of local realities -lack of funding, difficulties obtaining ethical clearance, and limited mentorship (6,14). All these characteristics make ARIP a sustainable model for research capacity-building in Africa.
Rosenberg et al. (15) developed a similar research capacitybuilding project for emergency medicine physicians in Rwanda. At the end of the training, they presented six abstracts, published six manuscripts, and offered advanced-degree scholarships to 11 participants (15). While ARIP presented many more abstracts and published more articles, none of our participants were awarded an advanced degree scholarship. Advanced degrees further contribute to research capacity building and are correlated with increased scholarly output (16). Unfortunately, the cost of these degrees can be prohibitive even in low-

Challenges and Limitations
We faced some challenges during ARIP. First, we lacked the resources to run more granular research. For example, we chose to avoid research involving human subjects to minimize the cost of institutional review board applications. Clinical research is an indispensable aspect of academic neurosurgery that evaluates the impact of systems-level changes on individual patients. Mindful of this, we intend to expand our research portfolio by collaborating with African neurosurgery centers. Next, our choice of open-access journals was restricted because we could not afford article processing charges. Often, one or more of our members was from a lower-middle or middleincome country, which meant that we were ineligible for a full waiver of article processing charges. Similarly, our choice of conferences for abstract submissions was limited because we could not afford registration fees. The transition of conferences to an online format due to COVID-19 from mid-2020 was a windfall for ARIP because most conferences waived registration fees. While we were able to accomplish a lot with limited resources, we acknowledge that some financial resources will be necessary to expand ARIP (15). To achieve this goal, AFAN has set up a grant development unit within the research department.
ARIP enrollees had to work on a tight schedule because the program was not integrated into their formal education. This meant that most projects took more time than necessary, especially during the exam period.
Despite the challenges faced, ARIP enrollees were satisfied with the program's quality and were willing to give back by training the new cohort of enrollees.

CONCLUSION
In summary, ARIP aims to build skills and increase the exposure of aspiring academic global surgeons to increase the scholarly output in Africa. ARIP enrollees showed dedication, passion, and tremendous potential, suggesting that greater gains will be noted if this program is implemented in a more resourceful setting. We intend to expand this program and report on the progress of the first and subsequent cohorts (H-index, recruitment in academic institutions, successful grant applications, peer-review journal positions, and postgraduate education).

UK:
conceptualization, methodology, investigation, visualization, and writing -original draft. YZ, SN, FT, LS, GE, DS, RT, and NG: writing -review and editing. DJ: supervision, methodology, validation, and writing -review and editing. All authors contributed to the article and approved the submitted version.