Togo is a low-income, French-speaking country in West Africa, with an estimated population of 8.8 million as of 2023. The country’s gross domestic product (GDP) was approximately USD 8.6 billion, and the gross national income per capita reached around USD 880. The CFA franc (XOF) serves as Togo’s currency, with an exchange rate of approximately 600 XOF to the US dollar. In 2021, the life expectancy at birth was 62.3 years, and the working-age population (ages 15 - 64) comprised nearly 55% of the total population. Urban residents constituted 43.5% of the population, while the national poverty rate remained high at 45.5%. The minimum monthly wage is roughly USD 33.

The national health system is organized into three levels: primary care at health centers, secondary care in regional hospitals, and tertiary care in university hospitals, such as CHU Sylvanus Olympio in Lomé. This referral center provides emergency and neurosurgical services, but it faces challenges related to intensive care capacity and equipment shortages.

Since 2021, the Togolese government has gradually introduced a Universal Health Insurance program, known as Assurance Maladie Universelle (AMU), to reduce financial barriers to healthcare access. However, as of 2024, insurance coverage remains limited, and most patients still pay out of pocket for their healthcare needs, including consultations, diagnostic tests, medications, and surgeries. Hospitalization costs range from USD 10 to USD 12 per day, and a brain CT scan costs between USD 42.50 and USD 150, depending on the institution.

We conducted a descriptive, cross-sectional, and analytical study over three months, from March 1 to June 30, 2024, in the neurosurgery department of Sylvanus Olympio University Teaching Hospital (CHU Sylvanus Olympio) in Lomé, Togo.

The target population included all patients aged 18 years and older admitted to the neurosurgery department.

Patients were eligible for inclusion if they:

We excluded:

Data were collected using a structured questionnaire that was developed after a review of previous studies on patient attitudes toward neurosurgery and healthcare-seeking behavior in sub-Saharan Africa [2] [6] [10] . The questionnaire items were adapted to the Togolese context in consultation with neurosurgeons and public health specialists. Before data collection, the tool was pre-tested with a pilot group of 20 patients at the same hospital to assess clarity and cultural appropriateness.

The following variables were assessed:

The Bioethics Committee approved this study for Health Research from the Togo Ministry of Health (“Comité de Bioéthique pour la Recherche en Santé (CBRS),” Ref No: 0101/2016/MS/CAB/DGS/DPLET/CBRS). Data were anonymized to ensure confidentiality. Written informed consent was obtained from all participants before enrollment.

Data were analyzed using Epi Info version 7.5.2.0. Associations between categorical variables were assessed using the chi-square test, with significance set at p < 0.05.

The study included 374 participants. The mean age was 41.79 ± 15.38 years, with a range of 22 to 85 years. There were 213 men (56.95%) and 161 women (43.05%), giving a sex ratio of 1.32. 48.93% of participants had completed secondary school, 16.84% had completed primary school, 21.66% had reached the university level, and 12.57% had never attended school. The socio-economic level was classified as unfavorable for 78.34% (n = 293) of the participants.

Table 1 shows that 78.08% of participants were unable to define neurosurgery. Furthermore, 67.91% of participants were unaware of its existence in Togo. Among those who were aware of it, only 8.56% were able to estimate the number of neurosurgeons practicing in the country.

Table 2 summarizes participants’ different perceptions:

A total of 266 participants (71.12%) reported having been sufficiently informed about the diagnosis. 242 (90.98%) received information from the neurosurgeon. Among them, 199 (82.33%) stated they understood the explanations given.

The analysis of factors influencing patients’ attitudes revealed multiple associations across socio-demographic and perception-related variables.

Patients from lower socioeconomic backgrounds were significantly more likely to perceive neurosurgical procedures as expensive (p = 0.02). However, age, sex, and educational level were not significantly associated with cost perception ( Table 3 ).

Several factors influenced the acceptance of a neurosurgical procedure. Younger patients (18 - 25 years) had the lowest acceptance (35.19%), while older patients (75 - 85 years) showed the highest acceptance (81.82%). The relation between age and acceptance is statistically significant (p = 0.013). Individuals with higher education were more accepting (p = 0.02). Patients who believed neurosurgery could result in a cure were more willing (p = 0.04). Those who understood their diagnosis accepted surgery more frequently (66.22%) than those who did not (46.31%) (p = 0.002).

A preference for the type of surgeon was associated with educational level (p = 0.047). University-educated patients were more likely to prefer being operated on by a professor of neurosurgery. Age, sex, and understanding of diagnosis showed no significant influence.

Belief in a favorable outcome after neurosurgery was associated with age (p = 0.02). Younger patients were more optimistic about recovery.

The ability to define neurosurgery was strongly associated with educational level (p = 0.001). University-level participants were significantly more likely to provide an accurate definition compared to those with no schooling or only primary education.

Awareness of the existence of neurosurgery in Togo was also significantly associated with educational level (p < 0.001). Higher education was correlated with greater knowledge of service availability.

Two hundred ninety-two participants (78.08%) were unable to define neurosurgery or were unaware of its existence in Togo (n = 254; 67.91%). Ikwuegbuenyi et al. [6] reported in a cross-sectional survey conducted across 16 African countries that 76.3% of respondents provided a complete definition of neurosurgery. In our study, knowledge was strongly linked to educational attainment, with university-educated patients being significantly more informed. This knowledge gap represents a significant barrier to the utilization of neurosurgical care. Targeted awareness campaigns, particularly among populations with limited or no formal education, are necessary to enhance understanding of the specialty. A cross-sectional survey conducted across 16 African countries reveals that while a basic knowledge of neurosurgery may be high, barriers such as rural residence, perceiving care as expensive, and a lack of awareness of local services significantly reduce the willingness to use in-country care [6] .

The striking contrast between the low knowledge level reported in the multi-country African Survey [6] may be explained by several factors. First, the Togolese cohort was hospital-based and included a large proportion of patients with limited or no formal education. In contrast, the multi-country survey likely sampled more literate and urban populations with internet access [6] .

The perceptions of LMIC patients toward neurosurgery are strongly influenced by socioeconomic status [10] - [12] . In our study, 333 participants (89.04%) perceived neurosurgery as expensive, a finding strongly associated with unfavorable socio-economic status. This perception reflects the lack of universal health coverage and the prevalence of out-of-pocket payments in Togo, which serve as significant barriers to access. Similar concerns have been reported by Ikwuegbuenyi et al. in a cross-sectional survey across 16 African countries, where high surgical costs discourage timely care-seeking [6] . The socioeconomic determinants of health are amenable to targeted individual and communal interventions [2] [13] . Expanding financial protection mechanisms could therefore reduce inequities in access to neurosurgical services.

Only 58.3% of patients indicated that they would accept surgery if medically indicated. Acceptance was influenced by educational level, belief in the possibility of recovery, and understanding of the diagnosis. Patients who understood their condition were significantly more willing to undergo surgery, highlighting the central role of physician-patient communication [2] . This result underscores the importance of health education and counseling in promoting adherence to neurosurgical treatment. Although this study primarily assessed patients’ attitudes and intentions rather than direct behaviors, these findings are closely tied to HSB. Attitudes such as mistrust of local neurosurgeons, perceived high costs, and preference for care abroad are likely to shape actual care-seeking patterns. Framing these attitudes within the broader concept of HSB enhances the interpretation of our results, as patient willingness to undergo surgery or seek treatment abroad represents a critical step in the healthcare-seeking pathway.

Belief in recovery is influenced by health literacy and cultural expectations of outcomes [2] [10] . Our results demonstrated that less than one-third of participants associated neurosurgery with a cure, while nearly 38% feared disability. Belief in recovery was significantly associated with age, with younger patients being more optimistic. In Ethiopia [10] , patients admitted that their religion played a critical role in their attitude toward neurosurgical procedures. These findings suggest that sociocultural factors continue to influence expectations, underscoring the need for culturally sensitive awareness campaigns to address misconceptions and restore confidence in neurosurgical outcomes.

134 patients (61.47%) who accepted surgery preferred to be operated on by a professor of neurosurgery rather than a doctor. In the Togolese medical system, the title “professor of neurosurgery” generally refers to a senior academic neurosurgeon who holds a university faculty appointment in addition to clinical responsibilities. In contrast, a “doctor of neurosurgery” designates a qualified neurosurgeon without such an academic title. This distinction carries symbolic authority and prestige, which may explain patients’ stronger preference for professors.

The educational level was the primary determinant of this preference. This reflects both the symbolic authority of academic titles and patients’ need for reassurance about the competence of their surgeon [2] [10] . Non-African patients prefer older and professionally dressed neurosurgeons [2] [14] . In South Korea, Mun et al. [15] reported that patients preferred their neurosurgeons to wear name tags and neurosurgery professors to be tidy and formally dressed. Strengthening public confidence in all categories of trained neurosurgeons is crucial to enhancing the acceptance of care.

Two-thirds of respondents stated that they would prefer to seek care abroad, mainly due to perceptions of better infrastructure. Awareness of the existence of local neurosurgical services was limited and was more prevalent among individuals with higher educational levels. This tendency toward medical migration reflects both a lack of confidence in national health facilities and insufficient visibility of neurosurgical services in Togo. In their systematic review, Ikwuegbuenyi et al. [6] found that a significant proportion of respondents were unwilling to use neurosurgical services in their countries because they did not trust the skill level of their neurosurgeons or the local infrastructure. Respondents were more likely not to trust their neurosurgeons if they regularly collaborated with foreign neurosurgeons, had trained abroad, or were recommended by an acquaintance [6] . Strengthening infrastructure, improving communication on available services, and highlighting local expertise could help reduce this outflow.

Taken together, these findings demonstrate that patients’ attitudes toward neurosurgery in Togo are shaped not only by structural barriers such as cost and infrastructure but also by socio-demographic and cultural determinants, including education and health literacy [16] . Addressing these determinants through targeted education, improved physician-patient communication, financial protection, and investment in local facilities is crucial to fostering more positive attitudes and enhancing access to neurosurgical care [17] . Additional efforts must also be directed toward making neurosurgery a more attractive career option in Togo, as suggested by Doléagbénou et al. [18] .