Development and validation of the Kilifi Epilepsy Beliefs and Attitude Scale

Community Health Workers' Knowledge, Attitudes, and Practices towards Epilepsy in Sofala, Central Mozambique

BACKGROUND

Epilepsy is the most common neurological disease in the world, affecting 50 million people, with the majority living in low- and middle-income countries (LMICs). A major focus of epilepsy treatment in LMICs has been task-sharing the identification and care for epilepsy by community health workers (CHWs). The present study aimed to assess the knowledge, attitudes, and practices (KAPs) of CHWs towards epilepsy in Mozambique.

METHODS

One hundred and thirty-five CHWs completed a questionnaire that included socio-demographic characteristics and 44-items divided into six subscales pertaining to KAPs towards epilepsy (QKAP-EPI) across nine districts of Sofala, Mozambique. The internal consistency was examined to evaluate the reliability of the instrument (QKAP-EPI). The association between sociodemographic variables and QKAP-EPI subscales was examined using linear regression models.

RESULTS

The internal consistency was moderate for two subscales (causes of epilepsy, α = 0.65; medical treatment, α = 0.694), acceptable for cultural treatment (α = 0.797) and excellent for 2 subscales (safety and risks, α = 0.926; negative attitudes, α = 0.904). Overall, CHWs demonstrated accurate epilepsy knowledge (medical treatment: mean = 1.63, SD = 0.28; safety/risks: mean = 1.62, SD = 0.59). However, CHWs reported inaccurate epilepsy knowledge of the causes, negative attitudes, as well as culturally specific treatments for epilepsy, such as: "if a person with epilepsy burns when set on fire they cannot be treated". Knowledge about how to manage epileptic seizures varied across the different emergency care practices, from the accurate belief that it is not advisable to place objects in the individual's mouth during an epileptic seizure, to the wrong perception of the need to hold the person in seizures to control seizures. Heterogeneity in the level of epilepsy knowledge was observed among CHWs, when considering epilepsy according to the local names as treatable ("Dzumba") and other forms as untreatable ("Nzwiti").

CONCLUSION

CHWs knowledge of medical treatment and epilepsy safety/risks were adequate. However, information on the causes of epilepsy, stigmatizing attitudes, cultural treatment, and some knowledge of epileptic seizure management were low. These areas of poor knowledge should be the focus of educating CHWs in increasing their ability to provide quality care for patients with epilepsy in Mozambique.

Investigation of factors associated with stigma and social support in patients with epilepsy in Turkey: A cross-sectional study

AIM

The purpose of this study was to identify the stigma and multidimensional perceived social support levels of patients with epilepsy, as well as the factors affecting them.

METHOD

The sample of the study consisted of 115 patients with epilepsy followed up in a university hospital in eastern Turkey. The data of the study were collected using the descriptive information form, the Jacoby Stigma Scale, and the Multidimensional Scale of Perceived Social Support. Data analysis was performed using t-test, one-way analysis of variance (ANOVA), and Pearson correlation coefficient.

RESULTS

The rate of exposure to stigma of the patients in the study was 62.4%. Those under 30 years of age, single, with low economic status, and living with their parents and siblings had higher stigma scale mean scores than the other groups (p = 0.001, p < 0.001, p = 0.001, p = 0.019, respectively). Multidimensional Scale of Perceived Social Support total scores were higher in women and married people (p = 0.020, p = 0.01, respectively). A statistically significant negative moderate correlation was found between the patients' Stigma scale mean values and Multidimensional Perceived Social Support Scale mean values (r = -0.568. p < 0.01).

CONCLUSION

According to the study's findings, stigma is prevalent among patients with epilepsy. Increasing social awareness in order to augment social support in patients with epilepsy and providing the patient with positive coping strategies may be effective in reducing stigma in patients with epilepsy.

Knowledge and attitude towards epilepsy among rural residents in southern Ethiopia: a cross-sectional study

BACKGROUND

Although epilepsy is one of the most prevalent neurological problems, it is highly surrounded by stigma and prejudice, which results in negative attitude towards the illness. Due to numerous misconceptions and beliefs attributed towards epilepsy, most people in rural communities have poor understanding and perception about epilepsy. Studying knowledge and attitude of this major neurologic problem among rural residents is crucial to add knowledge and show area of interventions. Therefore, the aim of this study was to assess the knowledge and attitude towards Epilepsy among rural residents in Ethiopia.

METHODS

This was a community based cross-sectional study conducted in rural parts of Gedeo zone, Southern Ethiopia. A total of 732 randomly selected adult residents were interviewed using a pre-tested questionnaire. The collected data were entered to Epi-data version 3.1 and analyzed using SPSS version 20. Descriptive statistics and logistic regressions were performed. Multivariable binary logistic regression analysis was conducted to determine the presence of a statistically significant association between explanatory variables and outcome variables at corresponding 95% CI.

RESULTS

The magnitude of poor knowledge and unfavorable attitude towards epilepsy were 27.0 and 51.6%, respectively. Participants who can't read and write, having stigma related to epilepsy, participants who did not live with epileptic patients; unfavorable attitude and age were factors associated with poor knowledge towards epilepsy. On the other hand, Stigma related to epilepsy, poor knowledge, age and perceiving epilepsy as a God punishment for sinful activities were variables significantly associated with unfavorable attitude of epilepsy.

CONCLUSIONS

There is a gap regarding the knowledge and attitude towards epilepsy among community residents in southern Ethiopia. This demonstrates a need for community educational program regarding epilepsy which can increase community awareness particularly in rural areas to decrease stigma and negative beliefs towards epilepsy.

Treatment-Seeking Behavior Towards Epilepsy Among Rural Residents in Ethiopia: A Cross-Sectional Study

BACKGROUND

Even though a large number of patients live with epilepsy, few of them receive effective treatment. Most people with epilepsy, particularly those from rural communities, do not seek medical care as they are convinced that solutions lie only with traditional healers (traditional leaders, prophets and community elders). Therefore, studying treatment-seeking behavior regarding this major neurological problem would provide additional knowledge and help to identify a gap which needs to be addressed when tackling related problems.

PARTICIPANTS AND METHODS

This rural community-based cross-sectional study was conducted in Gedeo zone, Ethiopia, among 755 participants. Data were collected using face-to-face interview-based questionnaires. Collected data were entered into EpiData version 3.01 and analyzed using SPSS version 20. Bivariate and multivariate logistic regression analysis was conducted to identify associated factors. The strengths of associations were presented as adjusted odds ratios with 95% confidence intervals.

RESULTS

The prevalence of poor treatment-seeking behavior was 54.6% (95% CI 51.4, 58.2). Poor knowledge (adjusted odds ratio [AOR]=3.21, 95% CI 2.14, 4.81), poor social support (AOR=2.48, 95% CI 1.12, 5.53), unfavorable attitude (AOR=1.84, 95% CI 1.34, 2.54) and having no history of experiencing others' seizures (AOR=2.17, 95% CI 1.47, 3.2) were variables strongly associated with poor help-seeking behavior towards epilepsy.

CONCLUSION

The study showed that more than half of the participants had poor treatment-seeking behavior towards epilepsy. This indicates the need to implement measures to raise community awareness regarding treatment options for epilepsy.

A home-based, primary-care model for epilepsy care in India: Basis and design

OBJECTIVES

A cluster-randomized trial of home-based care using primary-care resources for people with epilepsy has been set up to optimize epilepsy care in resource-limited communities in low- and middle-income countries. The primary aim is to determine whether treatment adherence to antiepileptic drugs is better with home-based care or with routine clinic-based care. The secondary aims are to compare the effects of the two care pathways on seizure control and quality of life.

METHODS

The home-based intervention comprises epilepsy medication provision, adherence reinforcement, and epilepsy self-management and stigma management guidance provided by an auxiliary nurse-midwife equivalent. The experimental group will be compared to a routine clinic-based care group using a cluster-randomized design in which the unit of analysis is a cluster of 10 people with epilepsy residing in an area cared for by a single accredited government grass-roots health care worker. The primary outcome is treatment adherence as measured by monthly tablet counts supplemented by two self-completed questionnaires. The secondary outcomes include monthly seizure frequency, time to first seizure (in days) after enrollment, proportion of patients experiencing seizure freedom for the duration of the study, and quality of life measured by the "Personal Impact of Epilepsy Scale," all assessed by an independent study nurse.

RESULTS

The screening phase and neurologic evaluations and randomizations have been recently completed and follow-up is underway.

SIGNIFICANCE

The results of the trial are likely to have substantial bearing on the development of governmental policies and strategies to provide coverage and care for patients with epilepsy in resource-limited countries.

A systematic review of tools used to screen and assess for externalising behaviour symptoms in low and middle income settings

BACKGROUND

Mental health issues, often manifested as behavioural difficulties, in children are estimated to be high in low and middle-income countries (LMIC) settings. There is a paucity of definitive data due to a lack of well-validated tools to use across settings. This review aims to provide evidence on what tools are used and which have been adapted and validated in LMIC settings.

METHODS

We performed a systematic review to identify tools used to assess or screen externalising behaviour problems in children and adolescents in LMIC and assess their cultural adaptations. We searched for studies measuring externalising behaviour in children from 0 to 19 years published up to September 2018. Articles were assessed to identify tools used and analysed using the Ecological Validity Framework.

RESULTS

We identified 82 articles from over 50 LMICs who had studied externalising behaviour in children. Twenty-seven tools were identified, with a predominance of studies using tools from the USA and Europe. Most studies did not describe an adaptation and evaluation process, with only one study following recommended criteria. New tools were identified which both screen and assess externalising behaviour which have not yet been utilised across settings.

CONCLUSIONS

Although tools from the USA and Europe are often utilised to screen and assess for externalising behaviour problems in children in LMICs, the conceptual frameworks behind the use of these tools in other cultural contexts are not always carefully examined. In order to have valid data across cultures, we should aim to adapt and validate tools before use. Provision of processes to validate tools across LMIC settings would be beneficial.

Ghanaian traditional and faith healers' explanatory models for epilepsy

Epilepsy is the most common neurological condition in sub-Saharan Africa. A significant number of people with epilepsy in low- and middle-income countries do not receive formal biomedical care. They utilize the services of various traditional and alternative medicine practitioners. However, there is relatively little information about the beliefs and methods of alternative healthcare providers about epilepsy in many African countries. Using explanatory models of illness framework, we interviewed thirty-six traditional and faith healers in Ghana on their beliefs and perceptions about epilepsy, as well as how they would treat epilepsy. The healers' beliefs about the nature of epilepsy were reflected in the labels they assigned to the condition. These indicated a belief in the influence of the moon in epilepsy. Furthermore, the participants held multiple, simultaneous explanatory models of causes for epilepsy, including biological, social, and supernatural causes. Epilepsy was also considered to have serious social implications for patients, especially for women. Finally, their treatment methods involved a range of herbal and spiritual practices. These varied based on the identified cause of the condition, as well as the orientation of the healer. We discuss these findings with reference to their implications for potential collaboration between biomedical and alternative healthcare systems.

"It is always HIV/AIDS and TB": Home-based carers' perspectives on epilepsy in Cape Town, South Africa

The study highlights the complex cultural religious factors affecting epilepsy and a need for integrated home-based care services. Two focus group discussions exploring home-based carers’ (HBCs) perspectives on epilepsy were conducted using a semi-structured focus group interview guide, which was based on Kleinman's explanatory model framework. The audio-recorded data were transcribed verbatim, and a thematic analysis was done. The three main themes were epilepsy names and metaphors, religious beliefs about the cause and treatment of epilepsy, and HBCs’ perceived roles and strategies for engaging in epilepsy care. Findings provide some insights for research, policy, and practice.

'A thing full of stories': Traditional healers' explanations of epilepsy and perspectives on collaboration with biomedical health care in Cape Town

The experience of epilepsy is profoundly culturally mediated and the meanings attributed to the condition can have a great impact on its social course. This qualitative study used Kleinman's Explanatory Model framework to explore traditional healers' perspectives on epilepsy in an urban township in Cape Town, South Africa. The healers who participated in the study were Xhosa-speaking, had experience caring for patients with epilepsy, and had not received any training on epilepsy. Six individual in-depth interviews and one focus group with nine traditional healers were conducted using a semi-structured interview guide. Traditional healers identified several different names referring to epilepsy. They explained epilepsy as a thing inside the body which is recognized by the way it presents itself during an epileptic seizure. According to these healers, epilepsy is difficult to understand because it is not easily detectable. Their biomedical explanations of the cause of epilepsy included, among others, lack of immunizations, child asphyxia, heredity, traumatic birth injuries and dehydration. These healers believed that epilepsy could be caused by amafufunyana (evil spirits) and that biomedical doctors could not treat the supernatural causes of epilepsy. However, the healers believed that western medicines, as well as traditional medicines, could be effective in treating the epileptic seizures. Traditional healers were supportive of collaboration with western-trained practitioners and highlighted that the strategy must have formal agreements in view of protection of intellectual property, accountability and respect of their indigenous knowledge. The findings suggest a need for interventions that promote cultural literacy among mental health practitioners. Research is urgently needed to assess the impact of such collaborations between biomedical services and traditional healers on epilepsy treatment and care.

Living with epilepsy in Lubumbashi (Democratic Republic of Congo): epidemiology, risk factors and treatment gap

Introduction

Epilepsy is the most common of serious neurological disorders, yet despite considerable efforts, good access to medication, appropriate social and societal acceptance and acceptable quality of life (QoL) are difficult to achieve especially in developing countries. It is estimated that over 500,000 people suffer from epilepsy in the DRC. There is no report, in our knowledge on the epilepsy in Lubumbashi.

Methods

A descriptive study was undertaken in individuals with a clinical diagnosis of epilepsy who presented at the CNPJG outpatient clinic in Lubumbashi over a 12 months period. A 64-item questionnaire was used to collect information from the patients. Case records were reviewed and relevant demographic, social, professional, medical history, medical condition data were extracted.

Results

Among 3,540 patients who presented to a neuropsychiatric clinic run by the Fracarita charity over a 1-year period, 423 (11.9%) were identified as having epilepsy, and 179 were subsequently included in the survey after they (or their parent/guardian) provided informed consent and completed an EEG investigation. Data were collected using a standardized, 64-item questionnaire. Epilepsy had negative impact on the lives of individuals with the condition; 40.8% had either no education or had completed primary education only, 38.0% were unemployed and the majority (64.6%; n = 113) were unmarried or divorced. Family history of epilepsy (first or second degree) was present in 23.5% of cases. Other reported factors that could potentially precipitate epilepsy included obstetric and perinatal factors (15.1%) and central nervous system infections during infancy (8.4%). Consumption of alcohol or recreational drugs accounted for 10.6%. The treatment gap was above 67% and the delay between first seizure and first consultation was 15 months. When asked to describe their condition, or its cause, 55.3% of participants (or their families) considered epilepsy to be of spiritual/ religious origin, while 25.1% had almost no insight and could not provide any description.

Conclusion

This first epidemiological study shows a high prevalence of epilepsy among patients presenting to the clinic in Lubumbashi, DRC, and reveals a significant treatment gap.

Evaluation of Kilifi epilepsy education programme: a randomized controlled trial

Objectives

The epilepsy treatment gap is largest in resource-poor countries. We evaluated the efficacy of a 1-day health education program in a rural area of Kenya. The primary outcome was adherence to antiepileptic drugs (AEDs) as measured by drug levels in the blood, and the secondary outcomes were seizure frequency and Kilifi Epilepsy Beliefs and Attitudes Scores (KEBAS).

Methods

Seven hundred thirty-eight people with epilepsy (PWE) and their designated supporter were randomized to either the intervention (education) or nonintervention group. Data were collected at baseline and 1 year after the education intervention was administered to the intervention group. There were 581 PWE assessed at both time points. At the end of the study, 105 PWE from the intervention group and 86 from the nonintervention group gave blood samples, which were assayed for the most commonly used AEDs (phenobarbital, phenytoin, and carbamazepine). The proportions of PWE with detectable AED levels were determined using a standard blood assay method. The laboratory technicians conducting the assays were blinded to the randomization. Secondary outcomes were evaluated using questionnaires administered by trained field staff. Modified Poisson regression was used to investigate the factors associated with improved adherence (transition from nonoptimal AED level in blood at baseline to optimal levels at follow-up), reduced seizures, and improved KEBAS, which was done as a post hoc analysis. This trial is registered in ISRCTN register under ISRCTN35680481.

Results

There was no significant difference in adherence to AEDs based on detectable drug levels (odds ratio [OR] 1.46, 95% confidence interval [95% CI] 0.74–2.90, p = 0.28) or by self-reports (OR 1.00, 95% CI 0.71–1.40, p = 1.00) between the intervention and nonintervention group. The intervention group had significantly fewer beliefs about traditional causes of epilepsy, cultural treatment, and negative stereotypes than the nonintervention group. There was no difference in seizure frequency. A comparison of the baseline and follow-up data showed a significant increase in adherence—intervention group (36–81% [p < 0.001]) and nonintervention group (38–74% [p < 0.001])—using detectable blood levels. The number of patients with less frequent seizures (≤3 seizures in the last 3 months) increased in the intervention group (62–80% [p = 0.002]) and in the nonintervention group (67–75% [p = 0.04]). Improved therapeutic adherence (observed in both groups combined) was positively associated with positive change in beliefs about risks of epilepsy (relative risk [RR] 2.00, 95% CI 1.03–3.95) and having nontraditional religious beliefs (RR 2.01, 95% CI 1.01–3.99). Reduced seizure frequency was associated with improved adherence (RR 1.72, 95% CI 1.19–2.47). Positive changes in KEBAS were associated with having tertiary education as compared to none (RR 1.09, 95% CI 1.05–1.14).

Significance

Health education improves knowledge about epilepsy, but once only contact does not improve adherence. However, sustained education may improve adherence in future studies.

Risk factors associated with the epilepsy treatment gap in Kilifi, Kenya: a cross-sectional study

Background

Many people with epilepsy in low-income countries do not receive appropriate biomedical treatment. This epilepsy treatment gap might be caused by patients not seeking biomedical treatment or not adhering to prescribed antiepileptic drugs (AEDs). We measured the prevalence of and investigated risk factors for the epilepsy treatment gap in rural Kenya.

Methods

All people with active convulsive epilepsy identified during a cross-sectional survey of 232 176 people in Kilifi were approached. The epilepsy treatment gap was defined as the percentage of people with active epilepsy who had not accessed biomedical services or who were not on treatment or were on inadequate treatment. Information about risk factors was obtained through a questionnaire-based interview of sociodemographic characteristics, socioeconomic status, access to health facilities, seizures, stigma, and beliefs and attitudes about epilepsy. The factors associated with people not seeking biomedical treatment and not adhering to AEDs were investigated separately, adjusted for age.

Findings

673 people with epilepsy were interviewed, of whom 499 (74%) reported seeking treatment from a health facility. Blood samples were taken from 502 (75%) people, of whom 132 (26%) reported taking AEDs, but 189 (38%) had AEDs detectable in the blood. The sensitivity and specificity of self-reported adherence compared with AEDs detected in blood were 38·1% (95% CI 31·1–45·4) and 80·8% (76·0–85·0). The epilepsy treatment gap was 62·4% (58·1–66·6). In multivariable analysis, failure to seek biomedical treatment was associated with a patient holding traditional animistic religious beliefs (adjusted odds ratio 1·85, 95% CI 1·11–2·71), reporting negative attitudes about biomedical treatment (0·86, 0·78–0·95), living more than 30 km from health facilities (3·89, 1·77–8·51), paying for AEDs (2·99, 1·82–4·92), having learning difficulties (2·30, 1·29–4·11), having had epilepsy for longer than 10 years (4·60, 2·07–10·23), and having focal seizures (2·28, 1·50–3·47). Reduced adherence was associated with negative attitudes about epilepsy (1·10, 1·03–1·18) and taking of AEDs for longer than 5 years (3·78, 1·79–7·98).

Interpretation

The sensitivity and specificity of self-reported adherence is poor, but on the basis of AED detection in blood almost two-thirds of patients with epilepsy were not on treatment. Education about epilepsy and making AEDs freely available in health facilities near people with epilepsy should be investigated as potential ways to reduce the epilepsy treatment gap.

Funding

Wellcome Trust.