Sociocultural and psychological features of perceived stigma reported by people with epilepsy in Benin

Psychosocial and sociodemographic associates of felt stigma in epilepsy

BACKGROUND

Lack of a sufficient range in socioeconomic status (SES) in most prior studies of felt stigma and epilepsy has hampered the ability to better understand this association.

METHODS

We assessed the burden and associates of felt stigma in 238 individuals with prevalent epilepsy aged 18 and older, comparing low SES with high SES.

RESULTS

Reported levels of stigma were higher in low SES than in high SES (p<0.0001), and all psychosocial variables were associated with stigma, including depression severity (p<0.0001), knowledge of epilepsy (p=0.006), quality of life (p<0.0001), social support (p<0.0001), and self-efficacy (p=0.0009). Stigma was statistically significantly associated with quality of life in the low SES group and with depression severity and social support in the high SES group.

CONCLUSIONS

Low SES alone did not account for felt stigma; rather, we found that quality of life, depressive symptoms, and social support have the greatest impact on reported felt stigma in individuals with prevalent epilepsy.

Knowledge and attitudes towards epilepsy in Zambia: a questionnaire survey

Misconception and stigma towards epilepsy have a profound impact on this disease in Africa. An unselected sample of Zambian people was interviewed to investigate their knowledge and attitudes towards epilepsy. Proper/improper answers were scored, and a composite score was developed with negative values for unsatisfactory awareness and high stigma levels. The sample comprised 231 people residing in urban (107) or in rural (124) areas. The median and interquartile range of scores for epilepsy awareness and stigma were, respectively, -1 (-3; +1) and +1 (-1; +6). Poor education was the only significant predictor of unsatisfactory awareness (p=0.0131), while education and residency were significantly associated with stigma (p<0.0001 and p=0.0004). Rural people were mostly in the highest stigma level (44.2%) and urban people in the lowest stigma level (60.4%). Misconception and negative attitudes towards epilepsy among Zambian people reflect poor education and rural residency.

Methodological difficulties in the conduct of neuroepidemiological studies in low- and middle-income countries

BACKGROUND

The majority of people with epilepsy (PWE) live in low- and middle-income countries (LMICs). However, they remain largely untreated and the bulk of resources are used to treat patients in the developed world. This disparity constitutes a challenge for neuroepidemiological studies on a global scale. In the past, several studies have focused on diverse populations in disparate countries at various periods of time and for particular purposes. The specificity of different contexts and circumstances makes it difficult to analyse PWE as a group either qualitatively or quantitatively. Such methodological limitations are further complicated by a lack of logistical support. There is a lack of interest in conducting studies, which results in inadequate funding and, in addition, there is the considerable challenge of publishing research reports from LMICs in peer-reviewed international journals.

METHODS

This paper focuses on methodological problems related to studies in LMICs and attempts to give the reasons for their limitations using epilepsy as an example.

RESULTS

Regional conditions and environmental factors must be given careful consideration in the research design because of the importance of understanding the challenges of living in these environments. There are further limitations to the successful implementation of studies. Existing information on epilepsy is often not readily accessible; there is a lack of census data, and migratory patterns into cities make enumeration and sampling even more challenging. As there is usually no well-developed healthcare system a door-to-door screening process is often the only way to identify those with convulsive epilepsy. The questionnaire and study design should preferably be adapted from standardized protocols, and pre-tested and validated in local conditions.

CONCLUSIONS

Systematic reviews and meta-analyses of studies in LMICs can provide data on the burden, risk factors, treatment and outcome of epilepsy only if the primary studies used are properly conducted using uniform and comparable methodology. The use of consistent replicable neuroepidemiological methods in primary studies and systematic reviews enable reduction of the treatment gap and better epilepsy care.

Factors associated with perceived stigma of epilepsy in Croatia: a study using the revised Epilepsy Stigma Scale

PURPOSE

It is believed that a large number of factors influence feelings of stigma, but their relative contribution is not yet entirely clear. Most studies to date were conducted using the Epilepsy Stigma Scale (ESS); only one used a revised version of the ESS (rESS). The following study aims to determine factors contributing to epilepsy stigma in outpatients with chronic epilepsy in Croatia, and to analyze some psychometric properties of the Croatian translation of the rESS.

METHODS

Alongside standard testing for validity of the scale, a simulation model of the original ESS (smESS) was created. This model, which does not include a grading Likert 0-3 scale, was compared with the rESS.

RESULTS

In total, 159 out of 298 subjects (53%) reported feeling stigmatised, with 136 (45%) mild to moderately and 23 (8%) highly. Internal consistency of the Croatian translation of the rESS was 0.887. Feelings of stigma were significantly associated with age ≤ 50 years, younger age of epilepsy onset, more than 50 seizures to date, generalized tonic-clonic seizures, and a shorter seizure-free period. Multiple stepwise regression showed number of seizures to date as a significant variable (Beta=0.246). By adapting data into the smESS significant associations with younger age and age of epilepsy onset were lost. Internal consistency of the smESS was 0.849.

CONCLUSIONS

The Croatian translation of the rESS has been proved to be a suitable instrument for diagnosing epilepsy stigma. The results of our model point to the possibility that the rESS might be more sensitive than the original ESS.

Describing perceived stigma against Alzheimer's disease in a general population in France: the STIG-MA survey

BACKGROUND

Alzheimer's disease (AD) causes progressive loss of memory and disability, especially in older people. As worldwide population grows older, AD is responsible for an important social and economical burden in many nations. People suffering from AD may experience health-related stigma that influences their attitudes towards seeking assistance. The STIG-MA survey describes perceived stigma against AD in a French population.

METHODS

The STIG-MA questionnaire was completed anonymously by people attending an awareness campaign about AD in Creuse, France, in September 2010. Participants answered 10 questions about how they would feel or react if they had AD. Stigma scores were compared by age, activity, and interest in AD.

RESULTS

Thirty-three percent of people attending the campaign filled out the survey. Most were women (85%) younger than 50 years (59%); 10% were older people (older than 75 years). Twenty-one percent worked in health or social fields. Interest in AD was professional (48%), related to family (41%), or personal (11%). Professionals in health fields expressed the highest levels of stigma (p = 0.02). Low stigma was most frequent in older people (p = 0.05). Type of interest did not influence stigma. Shame, loss of self-esteem, and fear of exclusion were expressed the most.

CONCLUSION

The STIG-MA survey confirms that AD is a stigmatizing condition in France. The difference between perceived stigma of older people, those most exposed to AD, and that of health professionals may influence attitudes towards screening and care. Further studies of perceived stigma in these populations are necessary to adapt intervention strategies.

Peer support groups as an intervention to decrease epilepsy-associated stigma

Eighty percent of people with epilepsy (PWE) reside in low-income countries where stigma contributes substantially to social and medical morbidity. Peer support groups (PSGs) are thought to be beneficial for people with stigmatized conditions, but little data exist regarding PSG effectiveness. We facilitated monthly PSG meetings for men, women, and youth from three Zambian clinics for one year. Pre- and post-intervention assessments measured internalized stigma, psychiatric morbidity, medication adherence, socioeconomic status, and community disclosure. Of 103 participants (39 men, 30 women, and 34 youth), 80 PWE (78%) attended ≥ 6 meetings. There were no significant demographic differences between PWE who attended ≥ 6 meetings and those who attended <6 meetings. Among youth attending ≥ 6 meetings, internalized stigma decreased (p<0.02). Among adults, there was a non-significant stigma decrease. No differences were detected in medication use, medication adherence, or psychiatric morbidity. Peer support groups effectively reduce stigma for youth and may offer a low-cost approach to addressing epilepsy-associated stigma in resource-poor settings.

Population-based study of epilepsy in Cambodia associated factors, measures of impact, stigma, quality of life, knowledge-attitude-practice, and treatment gap

Purpose

Identify epilepsy-associated factors and calculate measures of impact, stigma, quality of life (QOL), knowledge-attitude-practice (KAP) and treatment gap in Prey Veng, Cambodia.

Methods

This first Cambodian population-based case-control study had 96 epileptologist-confirmed epilepsy cases and 192 randomly selected matched healthy controls. Standard questionnaires, which have been used in similar settings, were used for collecting data on various parameters. Univariate and multivariate regression was done to determine odds ratios. Jacoby stigma, 31-item QOL, KAP etc were determined and so were the factors associated with them using STATA software. Treatment gap was measured using direct method.

Key findings

Multivariate analyses yielded family history of epilepsy, difficult or long delivery, other problems beside seizures (mainly mental retardation, hyperthermia), and eventful pregnancy of the subject's mother as factors associated with epilepsy. There was high frequency of seizure precipitants esp. those related to sleep. Population attributable risk (%) was: family history (15.0), eventful pregnancy of subject's mother (14.5), long/difficult birth (6.5), and other problem beside seizures (20.0). Mean stigma (1.9±1.1, on a scale of 3) was mainly related to treatment efficacy. Mean QOL (5.0±1.4 on a scale of 10) was mainly related to treatment regularity. Cause or risk factor could be determined in 56% of cases. Treatment gap was 65.8%.

Significance

Factors in pre- and perinatal period were found to be most crucial for epilepsy risk in Cambodia which inturn provides major prevention opportunities. A global action plan for treatment, stigma reduction and improvement of QOL should be set-up in this country.

Stigmatization of patients with epilepsy: a review of the current problem and assessment of the perceived stigma in Bulgarian patients

No study of stigmatization in patients with epilepsy has thus far been conducted in Bulgaria. Our aim was to assess the perceived stigma of Bulgarian patients with refractory epilepsy (RE) and the factors associated with stigmatization. A study based on questionnaires and a purposeful interview on clinical and social factors were conducted in 94 patients with RE and 70 patients with pharmacosensitive epilepsy (PSE). Stigmatization was found in 43.62% of the participants with RE and in 5.71% of those with PSE. Stigmatization was associated with depression and mental status impairment. In conclusion, stigmatization in Bulgarian patients with RE was confirmed. Stigmatization was frequently severe, especially in cases with concomitant personality and behavioral impairment and depression. The study participants explained the existence of stigmatization as being due to fear of seizures and due to inadequate education on the special features of the disease or on administering first aid during seizures.

Epilepsy-associated stigma in Bolivia: a community-based study among the Guarani population: an International League Against Epilepsy/International Bureau for Epilepsy/World Health Organization Global Campaign Against Epilepsy Regional Project

Epilepsy is associated with a significant burden of social stigma that appears to be influenced by psychosocial and cultural factors. Stigma has a negative effect on the management of people with epilepsy (PWE), representing one of the major factors that contribute to the burden of epilepsy. To assess stigma perception among the Guarani population, one hundred thirty-two people living in Guaraní communities in Bolivia were invited to complete the Stigma Scale of Epilepsy questionnaire. The main determinants of stigma identified were: the fear linked to loss of control, the feelings of sadness and pity toward PWE, the difficulties faced by PWE in the professional and relationship fields, the level of education and type of seizure. Our study pointed out that, in this population, PWE face difficulties in everyday life because of epilepsy-associated stigma and the results attest to the importance of promoting community-based educational programs aimed at reducing the stigmatization process.

Epilepsy care challenges in developing countries

PURPOSE OF REVIEW

This review discusses recent literature relevant to the diagnosis and treatment of epilepsy in developing countries with particular attention to underlying causes, natural history, and advances made toward optimizing systems of care and bridging the treatment gap.

RECENT FINDINGS

Prospective data suggest that cerebral malaria-induced brain injury may explain the high prevalence of epilepsy in malaria-endemic regions. Population-based mortality studies support the long proposed hypothesis that seizure-related deaths contribute to excessive premature mortality. WHO guidelines have the potential to improve care, but macrolevel barriers related to pharmaceutical regulation and distribution continue to contribute to the treatment gap. Evidence-based guidelines endorsed by the WHO and American Academy of Neurology regarding the optimal management of comorbid epilepsy and HIV may raise awareness regarding critical drug interactions between antiepileptic drugs and antiretrovirals, but are also problematic as the treatment regimen and diagnostic facilities routinely available in developing countries will prevent most healthcare providers from following the recommendations.

SUMMARY

New insights into the causes, natural history and best care practices for epilepsy in developing countries are available but without prioritization and action from policy makers, the present treatment gap will likely to persist.

The social and economic impacts of epilepsy on women in Nigeria

BACKGROUND

Persons with epilepsy in sub-Saharan Africa experience stigma and social marginalization. There is paucity of data on the social and economic impacts of epilepsy in these patients and in particular, groups like women. We sought to determine the social and economic impacts of epilepsy on Nigerian women and especially how it affects their treatment and outcomes.

METHODS

We carried out a cross-sectional survey of 63 women with epilepsy (WWE) and 69 controls matched for age, social status and site of care. A structured questionnaire was used to document information on demographic characteristics, education, employment status, economic status, health care use, personal safety and perceived stigma. The data were collated and analyzed with SPSS version 15.

RESULTS

Unemployment, fewer years of formal education, lower marriage rates and higher stigma scores were more frequent among WWE than controls. Physical and sexual abuse with transactional sex was also reported among WWE. We also noted poorer environmental and housing conditions and lower mean personal and household incomes among WWE compared to the control group.

CONCLUSION

WWE in this sample from Nigeria have worse social and economic status when compared with women with other non-stigmatized chronic medical conditions.

Development and validation of the Kilifi Stigma Scale for Epilepsy in Kenya

The aim of this study was to develop and validate a tool to measure perceived stigma among people with epilepsy (PWE) in Kilifi, Kenya. We reviewed existing scales that measured stigma, particularly of epilepsy. We conducted a qualitative study to determine salient concerns related to stigma in Kilifi. Themes were generated, and those related to stigma were used to construct an 18-item stigma scale. A descriptive cross-sectional survey was then conducted among 673 PWE to assess the reliability and validity of the scale. Internal consistency was calculated using Cronbach's alpha and test-retest reliability with an interclass correlation coefficient. The final scale had 15 items, which had high internal consistency (Cronbach's α=0.91) and excellent test-retest reliability (r=0.92). Factor analysis indicated that the scale was unidimensional with one factor solution explaining 45.8% of the variance. The Kilifi Stigma Scale for Epilepsy is a culturally appropriate measure of stigma with strong psychometric properties.

[Methodology of neuroepidemiological studies in tropical countries: a challenge?]

The purpose of this paper is to highlight the difficulties of applying neuroepidemiological methods in low income countries or developing countries, which are mostly tropical countries, taking advantage of the experience of the Institute of Neuroepidemiology and Tropical Neurology, which was created in Limoges in 1982. These difficulties could be related to several aspects: methodological, logistical, political or economical, linked to ethical issues, even difficulties to publish the studies. However, concept and neuroepidemiological methods should stay the same worldwide, even if their translation into practice could sometimes raise some problems in developing countries. Study protocol should be more detailed. Some specific epidemiological methods could be useful. Collection of data should be standardized. True cooperation at every level is needed for these researches to be valid.

Standards for epidemiologic studies and surveillance of epilepsy

Worldwide, about 65 million people are estimated to have epilepsy. Epidemiologic studies are necessary to define the full public health burden of epilepsy; to set public health and health care priorities; to provide information needed for prevention, early detection, and treatment; to identify education and service needs; and to promote effective health care and support programs for people with epilepsy. However, different definitions and epidemiologic methods complicate the tasks of these studies and their interpretations and comparisons. The purpose of this document is to promote consistency in definitions and methods in an effort to enhance future population-based epidemiologic studies, facilitate comparison between populations, and encourage the collection of data useful for the promotion of public health. We discuss: (1) conceptual and operational definitions of epilepsy, (2) data resources and recommended data elements, and (3) methods and analyses appropriate for epidemiologic studies or the surveillance of epilepsy. Variations in these are considered, taking into account differing resource availability and needs among countries and differing purposes among studies.

Associates of stigma in an incident epilepsy population from northern Manhattan, New York City

OBJECTIVE

Stigma is associated with prevalent epilepsy, but its association with incident epilepsy is unknown.

METHODS

We identified 209 children and adults with incident seizures from the diverse impoverished community of northern Manhattan. We interviewed 94 participants, aged 16 and older, about lifetime history of depression, health status, medical history, and stigma.

RESULTS

At baseline, 18 (22.5%) participants reported experiencing stigma. Stigma was reported by 9 (50.0%) with depression and 9 (14.5%) without depression (P=0.002). At 1 year, 7 (8.1%) participants reported experiencing stigma. Stigma was reported by 5 (31.3%) with depression versus 1 (1.6%) without depression (P<0.0001). At both time points, odds of stigma increased when lifetime history of depression and fair/poor health was present.

CONCLUSIONS

Previous work revealed negative effects of prevalent epilepsy on stigma. In the low-income, predominantly Hispanic community of northern Manhattan, we found incident epilepsy was associated with stigma when lifetime history of depression or fair/poor health was present.

Epilepsy-associated stigma in Zambia: what factors predict greater felt stigma in a highly stigmatized population?

Epilepsy-associated stigma in Africa has been described largely in terms of enacted stigma or discrimination. We conducted a study of 169 adults with epilepsy attending epilepsy clinics in Zambia's Lusaka or Southern province using a three-item instrument (maximum score = 3). Potential determinants of felt stigma including age, gender, education, wealth, disclosure status (meaning whether or how their community members knew of their condition), seizure type (generalized vs partial), seizure frequency, the presence of visible epilepsy-associated stigmata, personal contagion beliefs, and community contagion beliefs. The median stigma score was 2.5, suggesting some ceiling effect in the instrument. People with epilepsy who believed their condition to be contagious, who thought their community believed epilepsy to be contagious, and whose condition had been revealed to their community against their wishes reported more felt stigma. Community and clinic-based educational campaigns to dispel contagion beliefs are needed.