The Glasgow Coma Scale (GCS) is a neurological tool used to assess the severity of traumatic brain injury. Developed over 40 years ago by Bryan Jennett and Graham Teasdale, it evaluates three parameters: verbal response, eye-opening, and motor response. It is a numerical scale with a total score ranging from 3 to 15 points. This total score helps determine the severity of a head injury. A traumatic brain injury is classified as severe when the GCS is ≤8 after hemodynamic stabilization. Since its creation, the GCS has played a crucial role in prognostic assessment, monitoring, and the follow-up of patients’ neurological status [1] . The GCS has not only been deemed clinically useful but also considered very easy to learn. Physicians and nurses at the Glasgow Institute of Neurology, where the scale was developed, have also demonstrated its reliability through the consistency of scores among different evaluators [2] . Although the GCS fulfilled its objective and was quickly adopted, its memorization for daily practical use was not as straightforward, posing a significant challenge [3] [4] . Despite its limitations and the noted lack of inter-observer reliability, numerous assessment tools for evaluating consciousness have emerged. However, the applications of the GCS have significantly expanded, even beyond the context of trauma, aiding in the assessment of consciousness across nearly all types of conditions. Given that this tool is widely used in various clinical settings, it is crucial for healthcare professionals to assess it accurately, as specific intervention measures must be implemented based on the severity level.

Unfortunately, numerous studies assessing healthcare professionals’ knowledge of the GCS have reported a lack of familiarity with this important tool. In Switzerland, an evaluation of GCS assessment by military physicians in patients with traumatic brain injury revealed poor practical application despite a good theoretical understanding of the scale [5] . In India, a study on nurses’ knowledge of the GCS reported that 70.2% of nurses had a poor understanding of the tool [6] . Similar studies conducted in Malaysia, Jordan, and Iraq have also reported insufficient knowledge of the GCS among nurses [7] [8] . In Vietnam, while 90% of nurses surveyed in a study were able to correctly answer basic questions about the GCS, 52.1% responded incorrectly to questions based on clinical scenarios requiring the application of fundamental knowledge [9] .

In the sub-region of Nigeria, 45% of physicians did not accurately know the components of the GCS. In the same country, 33% of nurses demonstrated insufficient knowledge of the tool [10] . In Ghana, more than half of the physicians demonstrated poor practice in assessing the GCS [11] .

This concerning trend of healthcare professionals’ lack of familiarity with such a simple and potentially life-saving tool in many countries highlights the need for an assessment of the situation in Togo, where, to our knowledge, no such study has ever been conducted. Our study thus provides a solid foundation for future research in this important field in Togo.

We hypothesize that 65% of healthcare professionals demonstrate good practice in GCS assessment. The primary objective was to evaluate the level of practice among healthcare professionals in assessing the GCS in traumatic brain injury (TBI) cases across the Maritime, Lomé-Commune, and Kara regions. The secondary objective was to identify factors associated with good practice.

To conduct this study, we selected three (03) health regions out of the six (06) available in Togo. These were the Lomé-Commune, Maritime, and Kara regions. This selection was justified by the strong representation of the healthcare system pyramid in these regions.

The Glasgow Coma Scale (GCS) is a universally recognized tool for assessing patients’ levels of consciousness. Initially developed for use in traumatic brain injury (TBI) cases in neurosurgery, it has gradually been adopted in other medical fields. Given the high incidence of head trauma, it is crucial for healthcare professionals to be able to assess the severity of a TBI. This study was therefore conducted to evaluate good clinical practice in GCS assessment.

The majority of surveyed healthcare professionals belonged to the 20 - 30 age group. Our results are similar to those of Andualem et al. (2022), who observed a high representation (57%) of nurses aged between 20 and 30 years [1] . In Vietnam, a similar observation was made in 2011 by Hien et al., with 64.9% of nurses working in intensive care units [9] . However, Ehwarieme et al. in Nigeria reported a high representation of nurses aged between 30 and 40 years, accounting for 64.6% [10] .

This difference could be explained by the heterogeneity of the surveyed healthcare workers in our study, which included various professional groups.

We observed a male predominance of 66%, similar to the findings of Andualem et al., who reported a high proportion of men at 57.3% [1] . In contrast to Ahamed et al. and Ehwarieme et al., who reported a female predominance of 85.6% and 67.8%, respectively [10] [14] .

This difference could be explained by the sociodemographic characteristics specific to each region. Additionally, the ongoing feminization of the medical field in some Maghreb countries may also play a role.

The present study indicates that only 35.96% of participants correctly assessed the GCS. Our results remain lower than those found in Vietnam, where 47.9% of nurses correctly evaluated the GCS [9] . However, our results are significantly higher than those found in Ghana, where only 5.2% of nurses correctly recorded the GCS [15] . This observed disparity could be explained by differences in the quality of theoretical and practical training received by respondents. Additionally, variability in healthcare policies and the availability of assessment tools for the GCS in different healthcare facilities may also contribute to this gap.

In this study, sex did not significantly influence the accurate measurement of the GCS. Our results differ from those of Alhassan et al. (2019) in Ghana, who reported a statistically significant relationship between gender and clinical practice. [15] . Nurses demonstrated better practice. Similarly, Andualem et al. reported a higher level of good practical attitudes among male nurses compared to female nurses [1] . We believe that gender, whether male or female, could influence the assessment of the GCS. This assumption is based on the fact that the three parameters used to evaluate the GCS involve nociception, especially when the score decreases. Physiologically, male voices tend to be deeper and more aggressive compared to the generally softer and more nurturing female voices. Additionally, due to greater muscle mass, male healthcare providers may generate a more intense pain stimulus than female providers under the same conditions. Consequently, a male healthcare provider might theoretically obtain a higher GCS score compared to a female provider for the same patient, under identical conditions, and assuming proper evaluation criteria are followed.

In each of the studies we have referenced, clinical scenarios were used as the primary criterion for assessing good practice. It is possible that factors such as sample selection and knowledge updates contribute to the observed differences. The use of qualitative methods, such as bedside patient evaluations, could help determine whether biological differences related to gender—such as voice depth and physical build—affect the accurate assessment of the GCS. While previous studies have objectively evaluated inter-examiner reliability in GCS assessment, none have reported a statistically significant difference based on gender. Conducting an in-depth study on this aspect would therefore be of great interest.

A high frequency of GCS use was found to be associated with good practice. Healthcare professionals who reported using the GCS almost always in their daily practice performed better than those who used it only occasionally. Our findings align with those of Yusuf et al., who observed a correlation between daily practice and the ease of recalling GCS components [11] . However, this contrasts with the findings of Alhassan et al., who reported better performance in GCS assessment among healthcare providers who used it occasionally compared to those who used it regularly [15] . Although surprising, this difference suggests that frequency of use alone may not be sufficient to influence good practice and that other factors could be involved.

In our study, the level of qualification was not identified as a factor associated with good GCS practice. Our findings are consistent with those reported by Holdgate et al. (2006) and Juarez et al., who observed excellent inter-rater reliability between physicians and nurses in GCS assessment. [16] [17] .

This could be explained by the fact that, in most public hospitals in Togo, although patient examination is typically the physician’s responsibility, this is not always the case in rural settings. Due to a shortage of physicians, paramedical staff often play a primary role in patient assessment. Additionally, evaluating the level of consciousness using the GCS is a routine component of patient examination. Previous studies have reported that inter-observer reliability is linked to the experience of healthcare providers in performing the assessment.

In the present study, years of experience were not identified as a factor associated with good practice. This contrasts with the findings of Mattar et al. (2013), who observed that good practice among nurses working in intensive care units improved with experience [18] . Similarly, Rowley et al. found that the accuracy of GCS assessment varied depending on the level of experience [3] .

This finding may suggest the importance of continuous professional training and the retention of knowledge acquired during academic education among young healthcare professionals.

The practical assessment of the Glasgow Coma Scale (GCS) by healthcare professionals remains insufficient, despite a generally good theoretical understanding of the tool. This issue is particularly concerning given that it is not limited to the Togolese context; studies conducted in other countries have also highlighted a low level of proficiency in GCS assessment among physicians and nurses. It is therefore essential to reconsider how this skill is taught. The teaching approach should be more structured and continuous, incorporating practical demonstrations. We recommend a comparative study on best practices in GCS evaluation between developing and developed countries to identify more effective strategies for its implementation

We extend our gratitude to the University of Lomé, the Faculty of Health Sciences, the management of the various study centers where data collection was conducted, the data collection agents, and the healthcare professionals who chose to participate in the study.