World Federation of Neurosurgical Societies Young Neurosurgeons Survey: An Assessment of the Global Neurosurgery Research Environment, Capacity, Output and Barriers

Abstract

Background

The largest neurosurgical disease burden is found within low-and-middle-income countries. Despite this, a gap exists between the burden of disease and research output. This study explored the global neurosurgical research environment, with regards to capacity and output. We also explored the structural barriers to conducting research.

Methods

In this cross-sectional survey, we examined the global neurosurgical research environment by collecting data from neurosurgeons and trainees from six continental regions. The survey was conducted in five languages and stratified to the following themes: demographics, research capacity, research output, and barriers to participating in research.

Results

A total of 565 responses were received, and participants were split equally across trainees and consultants. The median years of practice was 8 years, and 60.2% of respondents worked at government hospitals with a university affiliation. The research databases available reflect the current neurosurgical disease burden, although only 81.6% have science and ethics approval. The biggest barriers to conducting research were the availability of human resources (68.4%) and time (62.9%).

Conclusion

The study reports on the current global neurosurgical research environment. The results show that the majority of neurosurgeons (98.2%) believe conducting research is important. Despite the challenges, there is a hunger to grow academic neurosurgery globally.

Keywords

education - global neurosurgery - research capacity - research equity - young neurosurgeons

Introduction

Neurological disorders are the leading cause of disability and account for the second-highest number of global deaths.[1] The majority of the world's population resides in low-and-middle-income countries (LMICs).[2] Compared with high-income countries (HICs), these nations collectively represent a higher proportion of people living with communicable and noncommunicable diseases.[3] Possible contributing factors to this are economic and health-related resource limitations. Africa and South East Asia shoulder a large percentage of the global neurosurgical cases with huge disparities between available workforce and surgical needs and consequently with over 5 million neurosurgical patients with treatable conditions unable to access neurosurgical care.[4] Health care systems are placed under significant strain because the demand for neurosurgical care far outstrips the availability of neurosurgeons.

Conducting research is a crucial step to bridging the gap between evidence-based medicine (EBM) and clinical practice. EBM encourages clinical decision-making based on scientific evidence rather than personal opinion.[5] It plays a vital role in health equity by standardizing and improving the quality of care offered to patients. Currently, a substantial imbalance exists in the academic output of LMICs when compared with HICs[6] [7] [8] with less than 5% of neurosurgical papers published by LMICs.[9] Literature shows that within clinical trials, conditions relevant to HICs are studied on average eight times more than those that affect LICs.[6] [10] This translates to diseases affecting the developing world being studied less[11] and the potential solutions to improve the populations' health being neglected. The imbalance between demand and resources may contribute to discrepancies in the global academic output of neurosurgeons, in addition to limitations in research resources and expertise. The World Federation of Neurosurgical Societies (WFNS) is committed to global improvement in neurosurgical care and recognizes that there is a paucity of studies that assess and address research resources, barriers, and needs of neurosurgeons.[12] [13] [14] [15] [16]

This study collected data on the current state of research infrastructure and output amongst neurosurgeons globally as a first step to identifying key priority areas to address in future strategic research capacity plans.

Methods

Study Design and Survey Instrument

This was a cross-sectional descriptive study which used an online self-administered survey on the Qualtrics (Provo, UT) (2022). It was open for 7 months from September 2021 to March 2022. The questionnaire was developed by the authors of the study, who are young neurosurgeons from eight countries (representative of all the continents) and have been active within global neurosurgery research. The survey included 28 multiple-choice and open-ended questions and utilized a skip-logic format. There were options to take the survey in English, French, Mandarin, Portuguese, and Spanish. The survey was stratified into the following sections: demographics, research capacity, research output, and barriers to participating in research. All responses were deidentified. The survey was authorized, approved, and supported by the WFNS. Ethics clearance was granted by the University of Cape Town (HREC: 110/2021).

Study Participants and Data Collection

The target population included all neurosurgical trainees and consultants, irrespective of years of experience or location. Participants were identified from databases of the WFNS, a professional organization that represents neurosurgeons worldwide. Databases from national, regional and continental neurosurgical societies were also utilized. The survey link was distributed via email and advertised on the WFNS websites, social media pages, and neurosurgical workshops.

The survey was conducted in accordance with CHERRIES guidelines for e-surveys.[17]

Data Analysis

Anonymized data were exported to IBM SPSS Statistics (Version 28) for analysis. Figures were generated using Microsoft Excel (Windows Version 10). We reported continuous variables using median (interquartile range) and categorical variables using frequencies and percentages, as appropriate. Responses were included only if a minimum of 70% of the questions had been answered. For some questions participants could select “Yes,” “No,” or “I don't know,” the data are presented as reported by the participant. Free text responses to open-ended questions were analyzed using the qualitative approach described by Hsieh and Shannon where answers were grouped into themes.[18]

Results

Demographics

Survey data were recorded from 838 participants, 565 (67.4%) of whom completed at least 70% of the questions. For the 565 participants, the largest number stemmed from Asia (42.1%), followed by Europe (19.7%), Africa (16.8%), Latin America and The Caribbean (13.6%), and Northern America (7.1%) ([Fig. 1]). Oceania accounted for only 0.5% of participants, and therefore, data from this region are limited.

Fig. 1 A heat map depicting the regional number of responses from n = 565 with a response rate of greater than 70%.

Most participants (66.5%) were ≤39 years of age and males (78.8%). Participants were evenly split between trainees (registrars and fellows) and consultants, the median years of practice was 8 (4–13) years, and most (60.2%) worked at a government hospital with a university affiliation, and several who worked in private practice maintained a university affiliation (13.1%) ([Table 1]).

Table 1 Demographics of the survey participants and study period date (n = 564)

Continental regions[a]	n	%
Africa	94	16.7
Asia	237	42.0
Europe	112	19.9
Latin America and the Caribbean	89	15.8
Northern America	29	5.1
Oceania	3	0.5
Age-group (y)
20–29	83	14.7
30–39	292	51.8
40–49	127	22.5
50–60	40	7.1
>60	22	3.9
Gender
Female	118	20.9
Male	445	78.9
Other	1	0.2
Professional category
Neurosurgery resident/registrar	199	35.3
Neurosurgery fellow	74	13.1
Neurosurgery consultant	291	51.6
Place of practice
Government hospital with university affiliation	339	60.1
Government hospital with no university affiliation	85	15.1
Private hospital with university affiliation	74	13.1
Private hospital	59	10.4
Not in clinical practice	7	1.2
Number of years in practice (median, range) (interquartile range)	8 (4–13)	—

Note: Frequency as number (n) and %.

^a One participant did not complete their location.

Research Capacity

Science and human research ethics committees were available for 435/533 (81.6%) participants. Only 511 (90.4%) participants reported that a research database was available at their institution. For these participants, 220 (43%) confirmed that their hospital or university had a database, 76.8% of these databases were known to have received appropriate approvals, the databases were largely electronic (91.3%), and the top five pathologies for which data were being collected included trauma, vascular, hydrocephalus, spine, and oncology. This was reflected in the regional data ([Fig. 2]). Across regions, more than 80% of participants reported publications generated from their databases.

Fig. 2 Represents the types of databases used by different continents study period, n = 568 (some regions had more than 1 database).

Postgraduate students were members of the team in 286/547 (52.3%) of participants, neuroscientists in 185/543 (34.1%), and research nurses in 107/535 (20%). By continental region, postgraduate students were most common in Africa (55.9%) and Northern America (52.8%), neuroscientists were most common in Europe (38%) and Latin America and The Caribbean (36%), and research nurses were similarly poorly represented ([Fig. 3]). Reasons for the absence of these ancillary team members included poor availability (41/201, 20.4%), lack of funding (111/201, 55.2%), lack of need (12/201, 6%), and unknown reasons (37/201, 18.4%).

Fig. 3 Represents postgraduate students, nurses, and neuroscientist per Continental region.

A biobank was available in 180/563 (32%) of participants, largely from Asia (85/180 [47.2%]) followed by Africa (33/180 [18.3%]). Similarly, research laboratories were available in 167/564 (29.6%) of participant centres, and largely in Asia (40.1%) followed by Latin America and The Caribbean (21%) with lab-based research occurring in only 131/564 (23.2%) of participant's units ([Fig. 4]). Most participants (528/563, 93.8%) were interested in a research registry or database nationally or internationally. Latin America and The Caribbean was the leading World Health Organization (WHO) region with interested participants 75/77 (97.4%) followed by Europe 108/111 (97.3%), Northern America 38/40 (95.0%), Asia 221/237 (93.3%), and Africa 83/95 (87.4%). All of the three participants from Oceania also reported interest (3/3, 100%). This interest was driven largely by consultants, across all regions—Northern America, 25/38 (65.8%), Latin America and the Caribbean, 40/75 (53.3%), Europe 57/108 (52.8%), Asia 115/221 (52.0%), Africa 32/83 (87.4%), and Oceania 1/3 (33.3%).

Fig. 4 Represent the frequency of available research resources, N = 138.

Research Output

Just over half of survey participants overall and across the WHO regions were engaged in collaborative research (321/564, 56.9%), these were largely interdepartmental within the same institution. Northern America reported the highest number of international collaborations, largely with LMICs ([Table 2]).

Table 2 Research collaborations

	Continental region
	Africa	Asia	Europe	Latin America and the Caribbean	Northern America	Oceania
Collaborative research
Yes	58/94 (61.7)	133/236 (56.4)	62/112 (55.4)	52/89 (58.4)	16/29 (55.2)	3/3 (100)
Level of Collaboration
Regional	13/57 (22.8)	13/129 (10.1)	8/59 (13.6)	5/51 (9.8)	0	0
Continental	2/57 (3.5)	4/129 (3.1)	0	1/45 (2.0)	0	0
International (LMIC's)	7/57 (12.3)	11/129 (8.5)	6/59 (10.2)	4/51 (7.8)	4/16 (25.0)	0
International (HIC's)	3/57 (5.3)	12/129 (9.3)	3/59 (5.1)	2/51 (3.9)	3/16 (18.7)	0
Interdepartmental	19/57 (33.3)	47/129 (36.4)	31/59 (52.5)	23/51 (45.1)	4/16 (25.0)	0
All of the above	13/57 (22.8)	42/129 (32.6)	11/59 (18.6)	16/51 (31.4)	5/16 (31.3)	0

Note: Data displayed as number (%).

Data Displayed as Number (Percent)

Publication was reported by 382/564 (67.7%) of participants, most of these from the Asian territories. Africa was a close third to Europe with publication rates of 19.4 and 17.8%, respectively ([Fig. 5]).

Fig. 5 Represents the percentage of participants who have published peer-reviewed papers across the Continental regions, N = 382.

Consultants were the main publishers 194/382 (50.8%) overall and across regions ([Fig. 6]). The median number of publications was 8 (3–30) per participant, the regional medians were for Africa 10 (2–39), Asia 10 (3–31), Europe 7 (3–21), Latin America and the Caribbean 7 (3–32), Northern America 5 (3–10), Oceania had a median of 5 publications, no range reportable due to low participant numbers. Publications were reported as case reports/series in 126/372 (33.9%), reviews in 36/372 (9.7%), original data 208/372 (55.9%), and opinion pieces 2/372 (0.5%). This was reflected in the regional data ([Fig. 7]). Participants were first or last author in a median of 6 (1–19) papers. Africa, Asia, and Latin American and The Caribbean had similar medians 6.5 (1–30), 7 (1–20), 6 (2–18), respectively, Europe had 4.5 (1–15) and Northern America had 1 (1–3).

Fig. 6 Represents peer-reviewed article publications within continental regions by level of seniority, N = 382.

Fig. 7 Represents the spread of publication types within Continental regions, N = 372.

Research Barriers

Overall participants felt that it was important to conduct research on their patient populations 542/552 (98.2%) and were keen to be involved 537/552 (97.3%). This was similar across regions. Most participants felt their environment was supportive of conducting research 419/546 (76.7%), this was common among most regions. To indicate the kind of research support required, participants could select multiple options. The greatest support needed was human resources 374/547 (68.4%), time 344/547 (62.9%), research resources 342/547 (62.5%), mentorship 331/547 (60.5%), and education 270/547 (49.4%). For regional data refer to [Supplementary Table S1] (available in the online version only). In addition to these barriers, others mentioned included a research culture (within participant institutions and beyond) that did not value research, a high administrative load/regulatory barriers, a lack of research ideas, and difficulties with access to patients, consent, and samples.

A total of 176/565 (31.2%) of participants reported applying for grants (for regional data refer to [Fig. 8]), with varying success rates; most participants reported a success rate of ≥50% (55/173, 31.8%). For Africa the most common success rate was <10% (18/47, 38.3%), for Asia it was 10 to 20% (23/69, 33.3%), for Europe and Latin American and the Caribbean it was ≥50% (8/24, 33.3%; 11/29, 37.9%, respectively). The response rate for Northern America and Oceania were low (n = 3 and 1 n = 1, respectively). These grants were largely national (58/173, 33.5%), followed by collaborative (45/173, 26%), and local (42/173, 24.3%), and fewer international (28/173, 16.2%).

Fig. 8 Represents the percentage of grants applied for within the Continental regions.

Discussion

This survey achieved a positive hit rate with more than 550 participants across the globe. Participants were largely from academic backgrounds and overwhelmingly demonstrated a desire to engage in research. Current outputs are promising, but more input is needed in terms of research resources and a supportive research environment/culture. Survey respondents originated largely from Asia, which is not unusual given the large geographical territory and high number of neurosurgeons in that part of the world. It was surprising to see such a low response rate from Northern America and Europe and the data need to be interpreted in light of what could be a skewed global distribution of participants. Low survey penetration rate in North America may be due to limited engagement of North American neurosurgery trainees in organized neurosurgery initiatives outside of the two leading regional societies, e.g. the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS).

Demographics

Neurosurgery is a male dominated specialty, with women accounting for less than 8% of the neurosurgical workforce.[19] [20] [21] [22] Majority of our respondents were male (77.6%), which is representative of the current global neurosurgical workforce. It is noteworthy that 73.3% of survey participants were university-affiliated; this suggests that the data are reflective of a cohort of neurosurgeons who likely favor doing research and building research capacity. However, given that this survey aimed to establish the current interest and resource availability for academic neurosurgery, this cohort was appropriate.

Research Capacity

The major pathologies for which data are being collected reflect the burden of disease, particularly in the government/university sector, and the high number of publications originating from these databases suggest the outputs are likely clinically relevant. Traumatic brain injury, hydrocephalus, and oncology (tumors) contribute to the majority of the essential neurosurgical caseload globally.[4] A research ethics committee is an independent body tasked with the important task of ensuring the dignity, rights, and welfare of research participants are protected, along with ensuring research is carried out in an ethical manner.[23] [24] It is concerning, however, that just under one quarter of databases were reported to be missing science and ethics approvals, although these committees were reported to be available by over 80% of participants. Although this percentage is low it is in keeping with the availability of global National Ethics Committee (NEC), where 44% are found within HIC, 27% in upper LMIC, and 10% in low-income countries (LIC).[15] This suggests that more stringent regulation around research approvals is required.

It is noteworthy that the number of postgraduate students and neuroscientists present in neurosurgical teams was similar across HICs and LMICs. Given the high clinical workload and the human resource constraints of LMICs, the inclusion of nonclinical staff can add substantial value to building and sustaining clinical translational research and can overcome employment barriers within the clinical service while contributing data that can increase the efficiency of that service. The relative shortage of research nurses is notable, it is possible that this reflects the fact that nursing salaries are higher than postgraduate student stipends, and neuroscientists commonly generate their own salaries through grant support. It could also reflect the availability of nurses with research background and therefore the interest of nursing staff to transition out of often permanent clinical posts into soft-funded contract-based research posts. Reasons for not having these ancillary members of staff were largely financial, but clearly, there is a recognized need for them.

The low number of reported available biobanks, research laboratories, and low prevalence of laboratory-based research in Europe and Northern America was unexpected, especially given that LMICs reported much higher numbers. This may reflect the lower representation of Northern America and Europe across participants or could reflect the differential focus of neurosurgical centres across the globe. The low rate of laboratory-based research likely reflects the lack of skills and access and is a major area to highlight for future growth.

Research Output

There is room to grow broader collaborations across continents and internationally. The higher rate of international collaboration from Northern American institutions with LMICs may reflect funding dynamics, with major medical funders like the NIH based in the United States, and a growing investment in global neurosurgery research driven by U.S. institutions.[7] [25] Two thirds of participants reported publishing, most of these senior neurosurgeons who likely have had more time to gather data and disseminate research findings. Although Asia is publishing more overall, African participants report a similar number of publications per participant. Publications were largely reported to be original data and it would have been valuable to obtain granular details about the nature of these original publications. However, the low number of laboratory-based research suggests these are unlikely to include basic science and probably reflect reviews of clinical practice and patient outcomes. Regrettably, we did not obtain data on involvement in clinical trials, this would have been relevant to determine where work that guides clinical protocols is being generated, and therefore the generalizability across global populations. A study done by Hauptman et al. stated that the United States is the leading contributor to neurosurgical scientific literature, producing 31.7% of first-author publications, followed closely by Japan with 20.2%.[26] It is noteworthy that Northern American participants reported the lowest number of first/last author publications. This could reflect the low response from that region. In addition, within our cohort Asia had the highest publication output which is in keeping with literature.

Barriers to Research

Time and human resources were the greatest reported needs to support research. This is consistent with the findings of our previous survey.[12] [13] [14] [15] In a busy clinical setting, access to ancillary staff/students who can perform the research functions that busy clinicians do not have time for, can be a tremendous resource for building and sustaining research. Similarly, by building a research enterprise that has meaningful outputs, a group places themselves in a stronger position to apply for funding and institutional support to build research resources. It is noteworthy that more participants requested mentorship than research education, which is an important indicator of where programs to build academic neurosurgery can focus their attention. This shows that neurosurgeons are willing to be engaged within research and the current environment needs to be nurtured in order to bear fruit.

Comments on an unsupportive research culture highlights the importance of demonstrating the value of research to real-world clinical care and to building institutional reputations through far-reaching impact. Part of facilitating a positive environment would necessitate the buy-in of regulators and administrators such that the already significant barriers to research do not become insurmountable.

Grant application rates were low (30%), but with higher success rates in Europe and Latin America and the Caribbean. Within academic medicine it is well known that surgeon–scientist have lower rates of grant applications and success rates.[27] [28] [29]

It is not clear whether grant success rates reflect greater access to grant funding, as might be expected from Europe, greater capacity to apply for grants, greater competitive advantage, or expertise/support in grant writing.

Limitations

Our study methodology was subject to selection bias. Only trainees and neurosurgeons connected to the WFNS network, and the personal networks of the study investigators received our survey invitation. Thus, our data do not capture the work of neurosurgeons who are not part of international societies or collaborations but are involved in local research activities in their respective countries. We tried to mitigate this by extensively promoting the survey link, until the point when we were no longer receiving regular responses. Social desirability bias is also unavoidable with self-administered surveys, and the participants' responses may be more ideal or optimistic than what is actually happening on the ground.

Conclusion

The data from this survey suggest that there is a hunger to grow academic neurosurgery globally. Possible avenues in the pursuit of this goal could include supplementing the clinical team with research personnel, focusing on research that demonstrates clear real-world impact, thereby becoming more competitive for funding and advocating for a more supportive research environment and culture. Collaborative work, which is truly equitable across partners, will be key.

Conflict of Interest

None declared.

Acknowledgement

We thank Dr Nelson M. Oyesiku for reviewing the manuscript and supporting the survey.

^* These authors share senior authorship.

^** The details of the committee are given in the [ Supplementary Appendix ] (available in the online version only).

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Publication History

Accepted Manuscript online:
06 November 2025

Article published online:
24 November 2025