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Awareness and attitudes toward epilepsy among medical and allied healthcare students — A survey study in a teaching hospital in Jeddah
Epilepsy & Behavior 102 (2020) 106815
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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Awareness and attitudes toward epilepsy among medical and allied healthcare students — A survey study in a teaching hospital in Jeddah Soha Alomar a,⁎, Mai Kadi b, Doaa Alabbas c, Mohammed Aljeddawi c, Sama Alsulaiman c, Saleh Baeesa a, Abdulrahman Sabbagh a a b c
King Abdulaziz University, Faculty of Medicine, Department of Surgery, Division of Neurosurgery, Jeddah, Saudi Arabia King Abdulaziz University, Faculty of Medicine, Department of Community Medicine, Jeddah, Saudi Arabia King Abdulaziz University, School of Medicine, Jeddah, Saudi Arabia
a r t i c l e
i n f o
Article history: Received 23 August 2019 Revised 18 November 2019 Accepted 19 November 2019 Available online xxxx Keywords: Epilepsy Awareness Medical students Healthcare Education
a b s t r a c t Purpose: Epilepsy affects individuals of all ages and genders and places high physical, mental, financial, and social burdens on these individuals. In Saudi Arabia, its prevalence is 6.5 cases per 1000 individuals. Physicians and healthcare professionals have a key role in increasing the knowledge and awareness of the general population about epilepsy. The purpose of this study was to assess the level of awareness of different aspects of epilepsy, such as, presentation; causes; social aspects of epilepsy in school, work, and social life; treatment options; and attitudes toward epilepsy of students at King Abdulaziz University (KAU) in medical and allied healthcare specialties. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students to clinical-year students. Method: This cross-sectional study included 255 participants from multiple health specialties studying at KAU. Surveys from prior validated publications were used. We divided the respondents into two categories (preclinical [2nd, 3rd, 4th-year students] and clinical [5th, 6th, and internship year]) to evaluate if knowledge and attitude are different among these two groups. Results: In general, medical students had more awareness than did students from other specialties about what to do if someone was having a seizure. A total of 17.3% of medical students answered that they would put a spoon or cloth in the mouth of someone having a seizure, whereas 21% of nursing students thought this answer was appropriate (p = .04). The proportion of clinical-year students who were knowledgable of the symptoms and causes of epilepsy was significantly higher than that of students in preclinical years (p b .0001). Only 12.3% of the clinical-year students thought epilepsy was an untreatable disease versus 35.5% of preclinical-year students (p = .02). Interestingly, nursing students had the highest percentage of respondents who answered yes to surgical options (p = .009) (57.9%, n = 11), followed by dental students (50%, n = 6), medical students (46.4%, n = 78), and finally clinical pharmacy students (45.5%, n = 20). Conclusion: The level of awareness among medical students was higher than that among students of other specialties, with progressive improvement over the study years. However, knowledge about surgical options was minimal. Thus, further emphasis is needed in teaching and educational campaigns, particularly for allied healthcare students. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a chronic, noncommunicable, and neurological disorder of the brain that is characterized by two or more unprovoked seizures.
Abbreviations: ILAE, International League Against Epilepsy; KAU, King Abdulaziz University. ⁎ Corresponding author at: King Abdulaziz University, P.O. Box 80215, Jeddah 21589, Saudi Arabia. E-mail address: [email protected] (S. Alomar).
https://doi.org/10.1016/j.yebeh.2019.106815 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Seizures are episodes of involuntary movements that may involve parts of the body (partial) or the whole body (generalized) and may be associated with various symptoms, such as, loss of consciousness, loss of control of bowel and bladder function, lip-smacking, and other involuntary movements [1]. Seizures result from abnormally high electrical activity of brain cells in any part of the brain. As such, a seizure is not a disease per se, but rather a symptom of many disorders affecting the brain [2]. Epilepsy affects individuals of all ages and genders and imposes high physical, mental, financial and social burdens on these individuals. In
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particular, the social stigma is a significant burden that exposes patients to unnecessary social discrimination and hinders appropriate treatment. The financial burden of epilepsy is often underestimated. A study conducted in India in 1998 estimated that the cost of epilepsy treatment per patient was as high as 88.2% of the country's Gross National Product per capita, and epilepsy-related expenses, which included medical expenses, travel, and lost work time, exceeded $2.6 billion/year in 2013 [3]. In the Kingdom of Saudi Arabia, the prevalence of epilepsy is 6.54 cases per 1000 people. A study conducted in the city of Riyadh, Saudi Arabia, showed that the Saudi population lacks sufficient awareness of epilepsy and knowledge of the causes, symptoms, and management of an epileptic episode. The study revealed that 21.3% of respondents are not aware of any cause of epilepsy, 50.6% would not seek medical advice if one of their relatives had epilepsy, and 31.4% do not know how to deal with an individual experiencing an epileptic episode [4]. Several international studies have revealed a lack of awareness regarding epilepsy among the general population and even among healthcare professionals [4–8]. For example, a significant number of healthcare students and professionals think that epilepsy is a form of insanity or mental illness. Healthcare professionals' knowledge of epilepsy is crucial for their practice and contact with patients because it affects the knowledge of patients and their close contacts directly and public perception of individuals with the condition indirectly [4]. However, no studies with a similar aim have been conducted among medical students and healthcare professionals in Jeddah. According to the International League Against Epilepsy (ILAE), drug-resistant epilepsy is defined as the failure of adequate trials of two tolerated and appropriately chosen and used antiepilepticdrug schedules (as monotherapies or in combination with other treatment modalities) to achieve a sustained seizure-free status [9]. The seizures of most people with epilepsy can be adequately controlled with appropriate medication regimens. However, 20–30% of people with epilepsy are refractory to all forms of medical therapy and may require surgical interventions [10]. Despite the importance of surgical options for the treatment of refractory seizures, this topic is seldom addressed in relevant studies. Only 25.2% of Turkish medical students think brain surgery could be a treatment choice. On the other hand, 74.5% of medical students in Slovenia are aware of the surgical treatment of epilepsy. The purpose of this study was to assess the level of awareness of different aspects of epilepsy, such as, presentation; causes; social aspects of epilepsy in school, work, and social life; treatment options; and attitudes toward epilepsy of students at King Abdulaziz University (KAU), a teaching hospital in Jeddah in medical and allied healthcare specialties. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students (2nd, 3rd, and 4th year) to clinical-year students (5th, 6th, and internship year). 2. Methods Ethical approval for this study was obtained from the Institutional Review Board at KAU, Jeddah, Saudi Arabia (ethics approval number: 399-17).
Three medical interns were instructed by their principal instructor on how to direct the participants to fill out the standardized questionnaire. The questionnaire was pilot tested with ten students who were not included in the study sample, and the original survey was adjusted accordingly before being converted into an electronic form. The questionnaire was distributed throughout January 2018 using a convenient sampling technique for all participants who agreed to take part in the study by providing their names on the questionnaire. The questionnaire comprised 29 questions developed and validated after reviewing relevant articles and literature considering the social aspects of epilepsy and its associated stigma [4,11–20]. The survey was divided into four main groups: demographics and personal information (Q1–Q5), awareness of epilepsy and its presentation/causes (Q6– Q17), social aspects of epilepsy (school [Q18–Q19], work [Q20–Q22], marriage, and children [Q23–Q26]), and treatment options (Q27– Q29). The internal validity of the questionnaire was calculated using Cronbach's alpha. Fifteen questions had yes/no answers that mandated that respondents chose only one answer. Other questions comprised multiple choices in which the respondents could select more than one answer. These questions were designed to assess the depth of perception and the attitudes of the respondents toward epilepsy and its medical presentation, social impressions, and treatment options. 2.2. Data analysis To describe the study participants, we used absolute numbers and frequencies for categorical variables and the mean and standard deviation for continuous variables. Differences in the distributions of knowledge and attitudes toward epilepsy between specialties and study years were estimated using Pearson's Chi2 or Fisher's exact test for categorical variables. We performed stratified analysis by categorizing participants from all specialties to preclinical years (2nd, 3rd, and 4th-year students) and clinical-year students (5th, 6th, and internship year). We considered a p-value smaller than 0.05 (p b .05) statistically significant. For all statistical analyses, we used a statistical software for data science (STATA® software, version 14). 3. Results The internal validity of the questionnaire was calculated using Cronbach's alpha, which was equal to 0.79. A total of 255 respondents filled out our questionnaire. The mean age of the respondents was 22.8 years. The majority of the participants were single (87.7%, n = 221). Married participants constituted 11.9% of the sample (n = 30) and only one participant was divorced (0.4%). Medical students accounted for the highest percentage of participants (68%), followed by those studying pharmacy (17.8%), nursing (7.7%), and dentistry (4.9%). Internship among all educational years had the highest number of participants that filled out the questionnaire with 41.1%, followed by third-year students (18.2%). Fourth and sixth-year students had the same percentage (both 12.1%), followed by fifth-year students (11.3%) and second-year students with the lowest percentage of participation (5.2%) (Table 1). 3.1. Awareness
2.1. Survey setting This study was a cross-sectional study conducted in January 2018 within KAU Hospital in Jeddah, which is a major city on the western coast of Saudi Arabia and is home to 3.4 million people, accounting for 12.6% of the country's population [9]. The KAU Hospital is home to over 5000 medical students and healthcare professionals (physicians, nurses, pharmacists, dentists, etc.).
In total, 242 (95.3%) of the students had heard about epilepsy, and only 87 (34.2%) personally knew someone with epilepsy diagnosis. One hundred and thirty-six students (53.5%) reported witnessing a seizure, and 16 (6.3%) reported that they had experienced a seizure. When comparing preclinical-year to clinical-year students regardless of the specialty, we found that clinical-year students had more knowledge about epilepsy (Table 2).
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
be significant causes of epilepsy. Only 6.3% (n = 16) of the respondents believed that epilepsy is due to demonic possession or supernatural powers (Fig. 2). More than half of the respondents (59.1%, n = 150) thought that people with epilepsy cannot live alone and should not drive (58.5%, n = 148). When asked about what to do if someone was having a seizure, 76.9% answered that they would take the individual having the seizure away from danger, 22% responded that putting a spoon or a piece of clothing inside the individual's mouth would be the most appropriate action, 18.4% answered that holding or tying the person down would be the best thing to do, 14.9% did not know what to do, 4% suggested putting the individuals' heads near the toilet, and 3.9% believed it was best to force medications into the patient's mouth. In general, medical students had more awareness of what to do if someone was having a seizure in front of them than did students from other specialties. A total of 17.3% of medical students answered that they would put a spoon or cloth in the mouth of someone having a seizure compared to 21% of nursing students and 36.4% of pharmacy students (p = .04).
Table 1 Characteristics of participants in the survey. Characteristic
n (%)
Age mean (SD) Marital status Single Married Divorced Specialty Medicine Nursing Pharmacy Dentist Other College year 2nd 3rd 4th 5th 6th Internship
22.8 (1.9)
3
221 (87.7) 30 (11.9) 1 (0.4) 168 (68) 19 (7.7) 44 (17.8) 12 (4.9) 4 (1.6) 13 (5.2) 45 (18.2) 30 (12.1) 28 (11.3) 30 (12.1) 102 (41.1)
3.2. Social aspects One question was who the respondent would inform if they had epilepsy. Only 31.9% answered “anyone,” whereas the majority (41.5%) said that they would only tell close family members. The remaining answers were divided between 11.6% who would only tell friends, 7.9% who would tell relatives, and 7% who would be completely discrete about their epilepsy. Overall, 72% of the respondents agreed that people with epilepsy do not share the same symptoms, whereas 23.6% answered that they did not know. Only 4.3% thought that epilepsy has always the same symptoms. Convulsions or shaking were thought to be the most predominant symptoms of epilepsy (91.4%). Loss of consciousness was selected as the second most predominant symptom (78.8%), followed by foaming of the mouth (55.3%), behavioral (42.7%) and intellectual abnormalities (43.1%). A total of 6.7% did not know the symptoms of epilepsy (Fig. 1). The proportion of clinical-year students who were knowledgeable about the symptoms and causes of epilepsy were significantly higher than that of students in preclinical years (p b .001). When asked about the possibility of seizures passing without being noticed, such as, partial and absence of seizures, 73.6% agreed, 20.9% stated that they did not know, and only 5.5% said a seizure cannot pass unnoticed. One hundred and seventy-nine respondents (70.3%) believed that brain tumors are the primary cause of epilepsy. Accidents (67.6%), inherited diseases (59.4%), and stroke (48.8%) were also reported to
The majority of participants (88.9%) agreed that children with epilepsy can succeed academically, whereas 4% disagreed and 7.1% were uncertain. A total of 57.5% of the respondents believed that having epilepsy would not prevent the person from performing recreational activities, whereas 21.3% thought otherwise and 21% did not have an answer. Similarly, the majority (86.2%) thought people with epilepsy should be employed similar to any other employee and 86% believed that these individuals can be successful in a specific demanding profession, such as, physicians, executives, and scientists, whereas 10% did not know and 4% did not agree. A total of 78.8% said that they would generally continue working with their colleagues even after discovering that they had epilepsy, 13% stated they would contact their colleague's primary physician once they found that they had epilepsy, and 2.4% stated that they would stop working with them. The rest agreed that they would be more careful in assigning tasks to colleagues with epilepsy and would further educate themselves about epilepsy. The concept of marriage and childbearing seemed acceptable among the respondents because 94.1% thought that it was appropriate for people with epilepsy to get married, and 92.1% thought that it would be appropriate for people with epilepsy to have children. The rest was divided between disagreeing and not knowing. Despite those results, 92 respondents (36.2%) stated that they would not allow their children
Table 2 Response to the questions regarding general knowledge of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (yes and no answers). Preclinical yearsa
Total
Heard or read about epilepsy Personally, know someone with epilepsy Seen someone having a seizure Ever had a seizure All patients with epilepsy have the same symptoms Seizures may end in few second without anyone recognizing them a
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. c Chi2 test. ⁎ Fisher's exact test. b
Clinical yearsb
p valuec
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
12 (4.7) 160 (63) 118 (46.5) 238 (93.7) 183 (72.1)
242 (95.3) 87 (34.2) 136 (53.5) 16 (6.3) 11 (4.3)
– 7 (2.8) – – 60 (23.6)
9 (10.2) 58 (65.9) 53 (60.2) 81 (92.1) 42 (47.7)
79 (89.8) 28 (31.8) 35 (39.8) 7 (7.9) 2 (2.3)
– 2 (2.3) – – 44 (50)
3 (1.9) 97 (60.6) 62 (38.8) 151 (94.4) 135 (84.4)
157 (98.1) 58 (36.3) 98 (61.2) 9 (5.6) 9 (5.6)
– 5 (3.1) – – 16 (10)
0.005⁎ 0.76⁎ 0.001 0.47 b0.000⁎
14 (5.5)
187 (73.6)
53 (20.9)
8 (9.1)
41 (46.6)
39 (44.3)
6 (3.8)
140 (87.5)
14 (8.7)
b0.000
4
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
Fig. 1. Response to the questions about epilepsy manifestation among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
to associate with children with epilepsy in schools or on playgrounds. Approximately half of the respondents (45.1%) did not know about the probability of epilepsy inheritance, 23.9% thought that the likelihood of epilepsy being inherited is relatively small, and 20% and 9% thought that the risk is moderate and high, respectively. It was evident that clinical-year students had overall a better attitude toward patients with epilepsy compared with students in preclinical years. In clinical years, 25.6% thought that a person with epilepsy can live alone compared to 18.1% in preclinical years (p = .04). The vast majority (96.9%) of students in clinical years thought that a person with epilepsy can get married compared to 88.6% in preclinical years (p = .002), and 95% thought that they can have children compared to 88.6% in preclinical years (p = .04). However, 39.4% of clinical-year students stated that they would object that their child plays with a child with epilepsy, while 29.5% of preclinical-year students answered that they would object (p = .03) (Table 3). 3.3. Treatment For the question about which treatment would be the most appropriate, the respondents could give more than one answer. The students in the most advanced college years stated that they would ask for a doctor. About a third (35.5%) of preclinical-year students suggested herbal medicine, whereas only 10.5% of clinical-year students provided this answer (p = .01). Overall, 7.1% thought epilepsy is untreatable. From the preclinical students, 35.5% answered that epilepsy is untreatable, whereas 12.3% of clinical-year students provided this answer (p = .02, Fig. 3). Faith and spiritual healing were chosen by 5.6%, and the rest were divided between acupuncture or cautery (2.8% and 1.6%, respectively). Additionally, when asked about whether they thought epilepsy could be radically cured, approximately half of the respondents (45.7%) stated that they did not know, 17.7% said that a radical cure is often possible, 14.6% believed that epilepsy is rarely cured, and 11.4%
thought that epilepsy cannot be cured. Only 10.6% reported that epilepsy can be radically cured. Furthermore, 48.2% of the respondents believed that surgical management is possible for refractory seizures, whereas 34% thought no surgical treatment is available and 17.8% did not know the answer. Interestingly, the nursing students had the highest percentage of respondents who answered yes to surgical options (p = .009) (57.9%, n = 11), followed by dental students (50%, n = 6), medical students (46.4%, n = 78), and clinical pharmacy students (45.5%, n = 20) (Table 4.). 4. Discussion Our study aimed to investigate the awareness and attitude of medical and allied healthcare students toward different aspects of epilepsy, including causes, social issues, and treatment options. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students (2nd, 3rd, and 4th year) to clinical-year students (5th, 6th, and internship year). This approach was similar to previous studies conducted in Saudi Arabia and other countries, which used a similar investigation instrument but shared common systematic problems, such as, how to deliver the surveys and achieve a high response rate. In our study, the response rate was better for medical students than for allied healthcare students (68% of the respondents were medical students). Many recent studies have been conducted in different regions in Saudi Arabia, mostly among the general public [4,11,12,21–23], and all of them have shown that epilepsy awareness in Saudi Arabia should be improved and that more campaigns are needed. The current study showed that 95.3% of the respondents had heard or read about epilepsy, 34.2% knew someone with epilepsy, and 53.5% had seen someone having a seizure. Compared to a study done among healthcare professionals in Riyadh, in which 100% of respondents have heard or read about epilepsy, 76% knew someone with epilepsy, and 45.7% have seen someone with epilepsy [11]. A study among healthcare students in India showed
Fig. 2. Response to the questions about causes of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
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Table 3 Response to the questions regarding attitude toward epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (yes and no answers). Preclinical yearsa
Total
A person with epilepsy can live alone A person with epilepsy can drive A child with epilepsy can succeed in school Epilepsy can prevent recreational activities People with epilepsy should be employed like others People with epilepsy can be successful in some professions People with epilepsy can get married People with epilepsy can have children Would object my healthy child to play with a child with epilepsy
Clinical yearsb
p valuec
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
150 (59.1) 148 (58.5) 10 (4) 146 (57.7) 20 (7.9)
59 (23.2) 51 (20.2) 224 (88.9 54 (21.3) 219 (86.2)
45 (17.7) 54 (21.3) 18 (7.1) 53 (21) 15 (5.9)
49 (55.7) 56 (64.4) 5 (5.8) 43 (48.9) 6 (6.8)
16 (18.1) 8 (9.2) 72 (82.8) 17 (19.3) 74 (84.1)
23 (26.1) 23 (26.4) 19 (11.5) 28 (31.8) 8 (9.1)
97 (60.6) 89 (55.6) 5 (3.1) 99 (62.2) 14 (8.8)
41 (25.6) 41 (25.6) 147 (92.5) 37 (23.3) 139 (86.9)
22 (13.8) 30 (18.8) 7 (4.4) 23 (14.5) 7 (4.4)
0.005 b0.27⁎
10 (4)
216 (86)
25 (10)
5 (5.8)
69 (80.2)
12 (14)
5 (3.1)
142 (89.3)
12 (7.6)
0.13⁎
6 (2.4) 6 (2.4) 116 (45.7)
239 (94.1) 234 (92.1) 92 (36.2)
9 (3.5) 14 (5.5) 46 (18.1)
2 (2.3) 3 (3.4) 38 (43.2)
78 (88.6) 76 (86.4) 77 (86.4)
8 (9.1) 9 (10.2) 24 (27.3)
4 (2.5) 3 (1.9) 75 (46.9)
155 (96.9) 152 (95) 63 (39.4)
1 (0.6) 5 (3.1) 22 (13.8)
0.002⁎ 0.04⁎ 0.03
0.04 0.007 0.06⁎
a
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. Chi2 test. ⁎ Fisher's exact test. b c
that 92.5% of respondents have heard about epilepsy and 41.6% have seen someone with epilepsy. A survey among university students in Malaysia showed that 86.5% of respondents have heard or read about epilepsy, 55.6% have seen someone with epilepsy, while only 6.3% knew a family member with epilepsy [24]. A study among medical students in Turkey showed that 73.5% of respondents have heard or read about epilepsy, 38.4% have seen someone with epilepsy, and 38.1% know someone with epilepsy [25]. While 100% of health workers in Zambia heard about epilepsy, 98.2% have seen someone with epilepsy, and 98.2% knew someone with epilepsy [7]. In our study, 4.3% of our respondents thought that all patients with epilepsy have the same symptoms compared to 39.1% in Istanbul teachers [13] and 82.4% in the Riyadh general public [12]. This finding shows that knowledge about epilepsy symptoms is better among medical and allied healthcare students than among the general population. The present study showed that convulsions (91.4%) were the most commonly described symptom of all epilepsy manifestations, followed by loss of consciousness (78.8%), foaming from the mouth (55.3%), and behavioral changes (42.7%). A study conducted in Riyadh among
healthcare professionals showed a higher level of awareness regarding epilepsy manifestations [11]. This difference probably was due to the different populations in our study (students and interns only) compared to the population in the Riyadh study, which included practicing healthcare professionals and 5th-year medical students. A survey done among healthcare students in India showed that convulsions were the most commonly described manifestation followed by loss of consciousness (77.3% and 28.5%, respectively). Similarly, a study among medical students in Turkey showed that loss of consciousness and convulsion were the two most commonly described manifestations of epilepsy (78.2% and 70.1%, respectively). More education about the various manifestations of epilepsy other than convulsion and loss of consciousness should be carried out among healthcare students and professionals. Regarding the causes of epilepsy, our respondents believed that tumors cause epilepsy (70.3%), followed by brain trauma (67.6%), stroke (48.8%), metabolic diseases (44.5%), and insanity (30.9%). In our study, only 6.3% of the respondents believed that epilepsy is a result of demonic possession and supernatural powers (n = 16). However, the studies of AlKharj [22] and Riyadh [12] showed that the public
100 90 80 70 60 50 40 30 20 10 0 2nd
3rd
Medical treatment (p=.04)
4th Herbal treatment (p=.01)
5th
6th
Cautery (p=.05)
Internship Untreatable (p=.02)
Fig. 3. Response to the questions about epilepsy treatment among medical and allied healthcare students at King Abdulaziz University; stratified by study year: a survey study in a teaching hospital (more than one answer).
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Table 4 Responses to the questions regarding causes of epilepsy answered by allied healthcare students of KAU. Causes of epilepsy, yes (n (%))
Preclinical years
Accidents Inherited diseases Insanity Brain tumors Birth defects Stroke Blood disease Metabolic disease Psychological Jinn (supernatural power)
36 (40.9) 37 (42) 20 (22.7) 45 (51.1) 23 (26.1) 28 (31.8) 6 (6.8) 23 (26.1) 26 (29.6) 5 (5.6)
a
Clinical years 133 (83.1) 111 (69.4) 56 (35) 129 (80.6) 83 (51.9) 94 (58.8) 30 (18.7) 89 (55.6) 65 (40.6) 10 (6.3)
b
c
80 70
p value
60
b0.000 b0.000 0.05 b0.000 b0.000 b0.000 0.01⁎
50
b0.000 0.08 0.9⁎
10
a
40 30 20
0 Medicine
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. c Chi2 test. ⁎ Fisher's exact test.
Nursing No
b
Pharmacy Yes
Dentist
Other
Don't know (p=0.009)
Fig. 4. Response to the questions about surgical treatment of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
considered a Jinn possession or supernatural power as one of the leading causes of epilepsy (46.5% and 78.5%, respectively), which could be because of mythical beliefs in the Arabian culture and lack of awareness about the disease. This belief is less evident among healthcare students than among the public, as shown in our study in which only a minority believed in supernatural power as the etiology of epilepsy. A study conducted among the general public in Emirates showed that 13.8% of people who were familiar with epilepsy thought that epilepsy is caused by Jinn possession, which was a lower percentage than that of the two studies discussed above [16]. Alaqeel et al. conducted a similar survey on healthcare professionals in Riyadh and showed that 10.5% believed that Jinn possession causes epilepsy [11]. This issue is critical because this belief is common in the Arab world beyond Saudi Arabia, and thus more educational campaigns are needed to address this issue. In Malaysia, 5.3% of university students thought that epilepsy can be caused by an evil spirit [24], while only 2% of medical students in Turkey thought so [25]. From various studies, it seems that there is a significant number of healthcare students and professionals who think that epilepsy is a form of insanity or mental illness. This represented 31% of our sample, 38.4% of medical students in Turkey [25], and 54.5% of healthcare workers in Zambia [7]. This could be explained by epilepsy being associated with mental and psychological disorders or as a side effect of some antipsychotic medications. More education should be focusing on differentiating epilepsy and mental and psychological disorders. (See Table 4.) Most of the study participants were aware of epilepsy and expressed positive attitudes toward people with epilepsy. Although a few were concerned about people with epilepsy and their professional life, 4% of the respondents in our study disapproved of having a person with epilepsy working similar to other people compared with 11% in an Italian public survey, 9% in the United States public survey [17] and in 2.1% in Riyadh among healthcare professionals [11]. In India, 77.7% of healthcare students thought that people with epilepsy could share work opportunities similar to other people [26]. Many studies, including our own, have attempted to measure the attitude toward the social life of a person with epilepsy, such as, marrying a person with epilepsy, persons with epilepsy having children, and permitting their children to play with a child with epilepsy. A total of 94.1% of our respondents thought that a person with epilepsy can get married, and 92.1% thought that having children of their own was appropriate, which reflected that our respondents were not concerned that epilepsy is an inheritable disease. However, 59.4% thought that inheritance is one of the causes and 36.2% would not allow their children to interact or play with a child with epilepsy compared with 14% of respondents in Greece [18], 11% in Austria [20], and 4% in the United States [19]. The relatively higher proportion of such negative attitudes in our study is likely to be because of mythical beliefs of supernatural powers and the
possibility of transmitting epilepsy to their healthy child. Another concern was that it could traumatize their children psychologically if they witnessed another child having an epileptic episode. In Turkey, 92.7% of the medical students thought that it is appropriate for a person with epilepsy to have children [25], and 97.1% of health workers in Zambia answered that they would allow their children to play with children with epilepsy [7]. Regarding epilepsy treatment, a large proportion thought that a medical consultation to treat epilepsy is essential (82%). This response rate reflects that medical and allied healthcare students have a higher awareness of the importance of seeking medical help than the general population. On the other hand, 8.6% thought that they would treat epilepsy with herbal medicine and 5.6% believed in faith healing. Approximately one-third (34%) of the respondents did not know that surgical intervention is a treatment option compared to 73.8% in Riyadh [12] and 49.50% in AlKharj [22] among the general public, which shows that awareness about different epilepsy treatments, especially surgical interventions, is lacking in our society. Nursing students were more aware of the surgical options than medical students and those studying other specialties, but this difference could reflect the small sample size in each group. About a quarter (25.2%) of Turkish medical students thought brain surgery could be a treatment option [25]. Interestingly, 74.5% of medical students in Slovenia were aware of the surgical treatment of epilepsy [27]. Overall, we noticed that there was a better level of knowledge and attitude toward epilepsy among clinical-year students compared to preclinical-year students. This could be explained by the fact that more knowledge about epilepsy is acquired throughout healthcare training, and this leads to fewer stigmas and a better attitude toward people with epilepsy. (See Fig. 4.)
5. Conclusion The results of our study show that awareness about epilepsy, including treatment modalities, causes, and manifestations, among Saudi Arabian medical and allied healthcare students, could be improved. The knowledge level about epilepsy was better among medical students than among those studying other specialties. Additionally, students in clinical years have overall better knowledge and attitude toward people with epilepsy compared to preclinical-year students. Misconceptions about epilepsy might exist because of different beliefs and different reading references, which could be targeted in future campaigns and conferences and in curricula designed to help to improve knowledge and attitudes toward epilepsy. Furthermore, knowledge about surgical options for the management of medically intractable epilepsy should be improved.
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
5.1. Limitations of the study Our study is limited by the relatively small sample size, especially of allied healthcare students. Additionally, our results do not reflect the knowledge and attitude of the general population. Students who are more aware of epilepsy may be more likely to take part than students who have limited information about epilepsy, which could be a source of bias in our study. Future directions include conducting further studies with the general population with a larger sample size and different socioeconomic and racial backgrounds to reflect the diversity of Saudi Arabian nationals and residents. Declaration of Competing Interest None. Funding This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets generated and analyzed in the current study are available from the corresponding author on request. References [1] World Health Organization. Epilepsy in the WHO Eastern Mediterranean region: bridging the gap. Cairo (EG). http://applications.emro.who.int/dsaf/dsa1039.pdf; 2010. [2] Steven C, S.M.. What is a seizure? http://www.epilepsy.com; 2014, Accessed date: 19 March 2014. [3] Megiddo I, Colson A, Chisholm D, Dua T, Nandi A, Laxminarayan R. Health and economic benefits of public financing of epilepsy treatment in India: an agent-based simulation model. Epilepsia 2016;57(3):464–74. [4] Alaqeel A, Sabbagh AJ. Epilepsy; what do Saudi's living in Riyadh know? Seizure 2013;22(3):205–9. [5] Jensen R, Dam M. Public attitudes toward epilepsy in Denmark. Epilepsia 1992;33 (3):459–63. [6] Al-Adawi S, Al-Ismaily S, Martin R, Al-Naamani A, Al-Riyamy K, Al-Maskari M, et al. Psychosocial aspects of epilepsy in Oman: attitude of health personnel. Epilepsia 2001;42(11):1476–81. [7] Chomba EN, Haworth Alan, Atadzhanov Masharip, Mbewe Edward, Birbeck Gretchen L. Zambian health care workers' knowledge, attitudes, beliefs, and practices regarding epilepsy. Epilepsy Behav 2007;10(1):111–9.
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[8] Vancini RL, Benedito-Silva Ana Amélia, Sousa Bolivar Saldanha, da Silva Sergio Gomes, Souza-Vancini Maria Iones, Vancini-Campanharo Cássia Regina, et al. Knowledge about epilepsy among health professionals: a cross-sectional survey in Sao Paulo, Brazil. BMJ Open 2012;2(2):e000919-e000919. [9] Kwan P, Arzimanoglou A, Berg AT, Brodie MJ, Allen Hauser W, Mathern G, et al. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2010;51(6):1069–77. [10] Kobau R, Zahran H, Thurman DJ, Zack MM, Henry TR, Schachter SC, et al. Epilepsy surveillance among adults—19 states, behavioral risk factor surveillance system, 2005. MMWR Surveill Summ 2008;57(6):1–20. [11] Alaqeel A, Alebdi F, Sabbagh AJ. Epilepsy: what do health-care professionals in Riyadh know? Epilepsy Behav 2013;29(1):234–7. [12] Alaqeel A, Kamalmaz H, Abou Al-Shaar H, AlZahrani I, Alaqeel A, Aljetaily S, et al. Evaluating the initial impact of the Riyadh epilepsy awareness campaign. Epilepsy Behav 2015;52:251–5. [13] Bekiroglu N, Ozkan R, Gürses C, Arpaci B, Dervent A. A study on awareness and attitude of teachers on epilepsy in Istanbul. Seizure 2004;13(7):517–22. [14] Chung M-Y, Chang YC, Lai YH, Lai CW. Survey of public awareness, understanding, and attitudes toward epilepsy in Taiwan. Epilepsia 1995;36(5):488–93. [15] Lai CW, Huang XS, Lai YH, Zhang ZQ, Liu GJ, Yang MZ. Survey of public awareness, understanding, and attitudes toward epilepsy in Henan province, China. Epilepsia 1990;31(2):182–7. [16] Bener A, al-Marzooqi FH, Sztriha L. Public awareness and attitudes towards epilepsy in the United Arab Emirates. Seizure 1998;7(3):219–22. [17] Canger R, Cornaggia C. Public attitudes toward epilepsy in Italy: results of a survey and comparison with U.S.A. and West German data. Epilepsia 1985;26(3):221–6. [18] Diamantopoulos N, Kaleyias J, Tzoufi M, Kotsalis C. A survey of public awareness, understanding, and attitudes toward epilepsy in Greece. Epilepsia 2006;47(12): 2154–64. [19] Caveness WF, Gallup Jr GH. A survey of public attitudes toward epilepsy in 1979 with an indication of trends over the past thirty years. Epilepsia 1980;21(5): 509–18. [20] Spatt J, Bauer G, Baumgartner C, Feucht M, Graf M, Mamoli B, et al. Predictors for negative attitudes toward subjects with epilepsy: a representative survey in the general public in Austria. Epilepsia 2005;46(5):736–42. [21] Alhazzani AA, Alqahtani AM, Abouelyazid A, Alqahtani AM, Alqahtani NA, Asiri KM, et al. Public awareness, knowledge, and attitudes toward epilepsy in the Aseer region, Saudi Arabia — a community-based cross-sectional study. Epilepsy Behav 2016;63:63–6. [22] Al-Dossari KK, Al-Ghamdi S, Al-Zahrani J, Abdulmajeed I, Alotaibi M, Almutairi H, et al. Public knowledge awareness and attitudes toward epilepsy in Al-Kharj Governorate Saudi Arabia. J Family Med Prim Care 2018;7(1):184–90. [23] Neyaz HA, Aboauf Hana A, Alhejaili Maha E, Alrehaili Mona N. Knowledge and attitudes towards epilepsy in Saudi families. J Taibah Univ Med Sci 2017;12(1):89–95. [24] Ab Rahman AF. Awareness and knowledge of epilepsy among students in a Malaysian university. Seizure 2005;14(8):593–6. [25] Kartal A. Knowledge of, perceptions of, attitudes and practices regarding epilepsy among medical students in Turkey. Epilepsy Behav 2016;58:115–8. [26] Panda SB, Prabhu K, Rao S, Rao A, Rao G, Datta A, et al. Evaluation of knowledge of and attitudes toward epilepsy among the health science students of Manipal University. Epilepsy Behav 2011;20(3):447–9. [27] Zupan G, Lorber B. Knowledge and awareness of epilepsy surgery among medical students. J Epilepsy Res 2017;7(1):50–3.
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Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Awareness and attitudes toward epilepsy among medical and allied healthcare students — A survey study in a teaching hospital in Jeddah Soha Alomar a,⁎, Mai Kadi b, Doaa Alabbas c, Mohammed Aljeddawi c, Sama Alsulaiman c, Saleh Baeesa a, Abdulrahman Sabbagh a a b c
King Abdulaziz University, Faculty of Medicine, Department of Surgery, Division of Neurosurgery, Jeddah, Saudi Arabia King Abdulaziz University, Faculty of Medicine, Department of Community Medicine, Jeddah, Saudi Arabia King Abdulaziz University, School of Medicine, Jeddah, Saudi Arabia
a r t i c l e
i n f o
Article history: Received 23 August 2019 Revised 18 November 2019 Accepted 19 November 2019 Available online xxxx Keywords: Epilepsy Awareness Medical students Healthcare Education
a b s t r a c t Purpose: Epilepsy affects individuals of all ages and genders and places high physical, mental, financial, and social burdens on these individuals. In Saudi Arabia, its prevalence is 6.5 cases per 1000 individuals. Physicians and healthcare professionals have a key role in increasing the knowledge and awareness of the general population about epilepsy. The purpose of this study was to assess the level of awareness of different aspects of epilepsy, such as, presentation; causes; social aspects of epilepsy in school, work, and social life; treatment options; and attitudes toward epilepsy of students at King Abdulaziz University (KAU) in medical and allied healthcare specialties. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students to clinical-year students. Method: This cross-sectional study included 255 participants from multiple health specialties studying at KAU. Surveys from prior validated publications were used. We divided the respondents into two categories (preclinical [2nd, 3rd, 4th-year students] and clinical [5th, 6th, and internship year]) to evaluate if knowledge and attitude are different among these two groups. Results: In general, medical students had more awareness than did students from other specialties about what to do if someone was having a seizure. A total of 17.3% of medical students answered that they would put a spoon or cloth in the mouth of someone having a seizure, whereas 21% of nursing students thought this answer was appropriate (p = .04). The proportion of clinical-year students who were knowledgable of the symptoms and causes of epilepsy was significantly higher than that of students in preclinical years (p b .0001). Only 12.3% of the clinical-year students thought epilepsy was an untreatable disease versus 35.5% of preclinical-year students (p = .02). Interestingly, nursing students had the highest percentage of respondents who answered yes to surgical options (p = .009) (57.9%, n = 11), followed by dental students (50%, n = 6), medical students (46.4%, n = 78), and finally clinical pharmacy students (45.5%, n = 20). Conclusion: The level of awareness among medical students was higher than that among students of other specialties, with progressive improvement over the study years. However, knowledge about surgical options was minimal. Thus, further emphasis is needed in teaching and educational campaigns, particularly for allied healthcare students. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a chronic, noncommunicable, and neurological disorder of the brain that is characterized by two or more unprovoked seizures.
Abbreviations: ILAE, International League Against Epilepsy; KAU, King Abdulaziz University. ⁎ Corresponding author at: King Abdulaziz University, P.O. Box 80215, Jeddah 21589, Saudi Arabia. E-mail address: [email protected] (S. Alomar).
https://doi.org/10.1016/j.yebeh.2019.106815 1525-5050/© 2019 Elsevier Inc. All rights reserved.
Seizures are episodes of involuntary movements that may involve parts of the body (partial) or the whole body (generalized) and may be associated with various symptoms, such as, loss of consciousness, loss of control of bowel and bladder function, lip-smacking, and other involuntary movements [1]. Seizures result from abnormally high electrical activity of brain cells in any part of the brain. As such, a seizure is not a disease per se, but rather a symptom of many disorders affecting the brain [2]. Epilepsy affects individuals of all ages and genders and imposes high physical, mental, financial and social burdens on these individuals. In
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particular, the social stigma is a significant burden that exposes patients to unnecessary social discrimination and hinders appropriate treatment. The financial burden of epilepsy is often underestimated. A study conducted in India in 1998 estimated that the cost of epilepsy treatment per patient was as high as 88.2% of the country's Gross National Product per capita, and epilepsy-related expenses, which included medical expenses, travel, and lost work time, exceeded $2.6 billion/year in 2013 [3]. In the Kingdom of Saudi Arabia, the prevalence of epilepsy is 6.54 cases per 1000 people. A study conducted in the city of Riyadh, Saudi Arabia, showed that the Saudi population lacks sufficient awareness of epilepsy and knowledge of the causes, symptoms, and management of an epileptic episode. The study revealed that 21.3% of respondents are not aware of any cause of epilepsy, 50.6% would not seek medical advice if one of their relatives had epilepsy, and 31.4% do not know how to deal with an individual experiencing an epileptic episode [4]. Several international studies have revealed a lack of awareness regarding epilepsy among the general population and even among healthcare professionals [4–8]. For example, a significant number of healthcare students and professionals think that epilepsy is a form of insanity or mental illness. Healthcare professionals' knowledge of epilepsy is crucial for their practice and contact with patients because it affects the knowledge of patients and their close contacts directly and public perception of individuals with the condition indirectly [4]. However, no studies with a similar aim have been conducted among medical students and healthcare professionals in Jeddah. According to the International League Against Epilepsy (ILAE), drug-resistant epilepsy is defined as the failure of adequate trials of two tolerated and appropriately chosen and used antiepilepticdrug schedules (as monotherapies or in combination with other treatment modalities) to achieve a sustained seizure-free status [9]. The seizures of most people with epilepsy can be adequately controlled with appropriate medication regimens. However, 20–30% of people with epilepsy are refractory to all forms of medical therapy and may require surgical interventions [10]. Despite the importance of surgical options for the treatment of refractory seizures, this topic is seldom addressed in relevant studies. Only 25.2% of Turkish medical students think brain surgery could be a treatment choice. On the other hand, 74.5% of medical students in Slovenia are aware of the surgical treatment of epilepsy. The purpose of this study was to assess the level of awareness of different aspects of epilepsy, such as, presentation; causes; social aspects of epilepsy in school, work, and social life; treatment options; and attitudes toward epilepsy of students at King Abdulaziz University (KAU), a teaching hospital in Jeddah in medical and allied healthcare specialties. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students (2nd, 3rd, and 4th year) to clinical-year students (5th, 6th, and internship year). 2. Methods Ethical approval for this study was obtained from the Institutional Review Board at KAU, Jeddah, Saudi Arabia (ethics approval number: 399-17).
Three medical interns were instructed by their principal instructor on how to direct the participants to fill out the standardized questionnaire. The questionnaire was pilot tested with ten students who were not included in the study sample, and the original survey was adjusted accordingly before being converted into an electronic form. The questionnaire was distributed throughout January 2018 using a convenient sampling technique for all participants who agreed to take part in the study by providing their names on the questionnaire. The questionnaire comprised 29 questions developed and validated after reviewing relevant articles and literature considering the social aspects of epilepsy and its associated stigma [4,11–20]. The survey was divided into four main groups: demographics and personal information (Q1–Q5), awareness of epilepsy and its presentation/causes (Q6– Q17), social aspects of epilepsy (school [Q18–Q19], work [Q20–Q22], marriage, and children [Q23–Q26]), and treatment options (Q27– Q29). The internal validity of the questionnaire was calculated using Cronbach's alpha. Fifteen questions had yes/no answers that mandated that respondents chose only one answer. Other questions comprised multiple choices in which the respondents could select more than one answer. These questions were designed to assess the depth of perception and the attitudes of the respondents toward epilepsy and its medical presentation, social impressions, and treatment options. 2.2. Data analysis To describe the study participants, we used absolute numbers and frequencies for categorical variables and the mean and standard deviation for continuous variables. Differences in the distributions of knowledge and attitudes toward epilepsy between specialties and study years were estimated using Pearson's Chi2 or Fisher's exact test for categorical variables. We performed stratified analysis by categorizing participants from all specialties to preclinical years (2nd, 3rd, and 4th-year students) and clinical-year students (5th, 6th, and internship year). We considered a p-value smaller than 0.05 (p b .05) statistically significant. For all statistical analyses, we used a statistical software for data science (STATA® software, version 14). 3. Results The internal validity of the questionnaire was calculated using Cronbach's alpha, which was equal to 0.79. A total of 255 respondents filled out our questionnaire. The mean age of the respondents was 22.8 years. The majority of the participants were single (87.7%, n = 221). Married participants constituted 11.9% of the sample (n = 30) and only one participant was divorced (0.4%). Medical students accounted for the highest percentage of participants (68%), followed by those studying pharmacy (17.8%), nursing (7.7%), and dentistry (4.9%). Internship among all educational years had the highest number of participants that filled out the questionnaire with 41.1%, followed by third-year students (18.2%). Fourth and sixth-year students had the same percentage (both 12.1%), followed by fifth-year students (11.3%) and second-year students with the lowest percentage of participation (5.2%) (Table 1). 3.1. Awareness
2.1. Survey setting This study was a cross-sectional study conducted in January 2018 within KAU Hospital in Jeddah, which is a major city on the western coast of Saudi Arabia and is home to 3.4 million people, accounting for 12.6% of the country's population [9]. The KAU Hospital is home to over 5000 medical students and healthcare professionals (physicians, nurses, pharmacists, dentists, etc.).
In total, 242 (95.3%) of the students had heard about epilepsy, and only 87 (34.2%) personally knew someone with epilepsy diagnosis. One hundred and thirty-six students (53.5%) reported witnessing a seizure, and 16 (6.3%) reported that they had experienced a seizure. When comparing preclinical-year to clinical-year students regardless of the specialty, we found that clinical-year students had more knowledge about epilepsy (Table 2).
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
be significant causes of epilepsy. Only 6.3% (n = 16) of the respondents believed that epilepsy is due to demonic possession or supernatural powers (Fig. 2). More than half of the respondents (59.1%, n = 150) thought that people with epilepsy cannot live alone and should not drive (58.5%, n = 148). When asked about what to do if someone was having a seizure, 76.9% answered that they would take the individual having the seizure away from danger, 22% responded that putting a spoon or a piece of clothing inside the individual's mouth would be the most appropriate action, 18.4% answered that holding or tying the person down would be the best thing to do, 14.9% did not know what to do, 4% suggested putting the individuals' heads near the toilet, and 3.9% believed it was best to force medications into the patient's mouth. In general, medical students had more awareness of what to do if someone was having a seizure in front of them than did students from other specialties. A total of 17.3% of medical students answered that they would put a spoon or cloth in the mouth of someone having a seizure compared to 21% of nursing students and 36.4% of pharmacy students (p = .04).
Table 1 Characteristics of participants in the survey. Characteristic
n (%)
Age mean (SD) Marital status Single Married Divorced Specialty Medicine Nursing Pharmacy Dentist Other College year 2nd 3rd 4th 5th 6th Internship
22.8 (1.9)
3
221 (87.7) 30 (11.9) 1 (0.4) 168 (68) 19 (7.7) 44 (17.8) 12 (4.9) 4 (1.6) 13 (5.2) 45 (18.2) 30 (12.1) 28 (11.3) 30 (12.1) 102 (41.1)
3.2. Social aspects One question was who the respondent would inform if they had epilepsy. Only 31.9% answered “anyone,” whereas the majority (41.5%) said that they would only tell close family members. The remaining answers were divided between 11.6% who would only tell friends, 7.9% who would tell relatives, and 7% who would be completely discrete about their epilepsy. Overall, 72% of the respondents agreed that people with epilepsy do not share the same symptoms, whereas 23.6% answered that they did not know. Only 4.3% thought that epilepsy has always the same symptoms. Convulsions or shaking were thought to be the most predominant symptoms of epilepsy (91.4%). Loss of consciousness was selected as the second most predominant symptom (78.8%), followed by foaming of the mouth (55.3%), behavioral (42.7%) and intellectual abnormalities (43.1%). A total of 6.7% did not know the symptoms of epilepsy (Fig. 1). The proportion of clinical-year students who were knowledgeable about the symptoms and causes of epilepsy were significantly higher than that of students in preclinical years (p b .001). When asked about the possibility of seizures passing without being noticed, such as, partial and absence of seizures, 73.6% agreed, 20.9% stated that they did not know, and only 5.5% said a seizure cannot pass unnoticed. One hundred and seventy-nine respondents (70.3%) believed that brain tumors are the primary cause of epilepsy. Accidents (67.6%), inherited diseases (59.4%), and stroke (48.8%) were also reported to
The majority of participants (88.9%) agreed that children with epilepsy can succeed academically, whereas 4% disagreed and 7.1% were uncertain. A total of 57.5% of the respondents believed that having epilepsy would not prevent the person from performing recreational activities, whereas 21.3% thought otherwise and 21% did not have an answer. Similarly, the majority (86.2%) thought people with epilepsy should be employed similar to any other employee and 86% believed that these individuals can be successful in a specific demanding profession, such as, physicians, executives, and scientists, whereas 10% did not know and 4% did not agree. A total of 78.8% said that they would generally continue working with their colleagues even after discovering that they had epilepsy, 13% stated they would contact their colleague's primary physician once they found that they had epilepsy, and 2.4% stated that they would stop working with them. The rest agreed that they would be more careful in assigning tasks to colleagues with epilepsy and would further educate themselves about epilepsy. The concept of marriage and childbearing seemed acceptable among the respondents because 94.1% thought that it was appropriate for people with epilepsy to get married, and 92.1% thought that it would be appropriate for people with epilepsy to have children. The rest was divided between disagreeing and not knowing. Despite those results, 92 respondents (36.2%) stated that they would not allow their children
Table 2 Response to the questions regarding general knowledge of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (yes and no answers). Preclinical yearsa
Total
Heard or read about epilepsy Personally, know someone with epilepsy Seen someone having a seizure Ever had a seizure All patients with epilepsy have the same symptoms Seizures may end in few second without anyone recognizing them a
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. c Chi2 test. ⁎ Fisher's exact test. b
Clinical yearsb
p valuec
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
12 (4.7) 160 (63) 118 (46.5) 238 (93.7) 183 (72.1)
242 (95.3) 87 (34.2) 136 (53.5) 16 (6.3) 11 (4.3)
– 7 (2.8) – – 60 (23.6)
9 (10.2) 58 (65.9) 53 (60.2) 81 (92.1) 42 (47.7)
79 (89.8) 28 (31.8) 35 (39.8) 7 (7.9) 2 (2.3)
– 2 (2.3) – – 44 (50)
3 (1.9) 97 (60.6) 62 (38.8) 151 (94.4) 135 (84.4)
157 (98.1) 58 (36.3) 98 (61.2) 9 (5.6) 9 (5.6)
– 5 (3.1) – – 16 (10)
0.005⁎ 0.76⁎ 0.001 0.47 b0.000⁎
14 (5.5)
187 (73.6)
53 (20.9)
8 (9.1)
41 (46.6)
39 (44.3)
6 (3.8)
140 (87.5)
14 (8.7)
b0.000
4
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
Fig. 1. Response to the questions about epilepsy manifestation among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
to associate with children with epilepsy in schools or on playgrounds. Approximately half of the respondents (45.1%) did not know about the probability of epilepsy inheritance, 23.9% thought that the likelihood of epilepsy being inherited is relatively small, and 20% and 9% thought that the risk is moderate and high, respectively. It was evident that clinical-year students had overall a better attitude toward patients with epilepsy compared with students in preclinical years. In clinical years, 25.6% thought that a person with epilepsy can live alone compared to 18.1% in preclinical years (p = .04). The vast majority (96.9%) of students in clinical years thought that a person with epilepsy can get married compared to 88.6% in preclinical years (p = .002), and 95% thought that they can have children compared to 88.6% in preclinical years (p = .04). However, 39.4% of clinical-year students stated that they would object that their child plays with a child with epilepsy, while 29.5% of preclinical-year students answered that they would object (p = .03) (Table 3). 3.3. Treatment For the question about which treatment would be the most appropriate, the respondents could give more than one answer. The students in the most advanced college years stated that they would ask for a doctor. About a third (35.5%) of preclinical-year students suggested herbal medicine, whereas only 10.5% of clinical-year students provided this answer (p = .01). Overall, 7.1% thought epilepsy is untreatable. From the preclinical students, 35.5% answered that epilepsy is untreatable, whereas 12.3% of clinical-year students provided this answer (p = .02, Fig. 3). Faith and spiritual healing were chosen by 5.6%, and the rest were divided between acupuncture or cautery (2.8% and 1.6%, respectively). Additionally, when asked about whether they thought epilepsy could be radically cured, approximately half of the respondents (45.7%) stated that they did not know, 17.7% said that a radical cure is often possible, 14.6% believed that epilepsy is rarely cured, and 11.4%
thought that epilepsy cannot be cured. Only 10.6% reported that epilepsy can be radically cured. Furthermore, 48.2% of the respondents believed that surgical management is possible for refractory seizures, whereas 34% thought no surgical treatment is available and 17.8% did not know the answer. Interestingly, the nursing students had the highest percentage of respondents who answered yes to surgical options (p = .009) (57.9%, n = 11), followed by dental students (50%, n = 6), medical students (46.4%, n = 78), and clinical pharmacy students (45.5%, n = 20) (Table 4.). 4. Discussion Our study aimed to investigate the awareness and attitude of medical and allied healthcare students toward different aspects of epilepsy, including causes, social issues, and treatment options. We also aimed to assess if the level of knowledge and attitude improves throughout the study years by comparing preclinical-year students (2nd, 3rd, and 4th year) to clinical-year students (5th, 6th, and internship year). This approach was similar to previous studies conducted in Saudi Arabia and other countries, which used a similar investigation instrument but shared common systematic problems, such as, how to deliver the surveys and achieve a high response rate. In our study, the response rate was better for medical students than for allied healthcare students (68% of the respondents were medical students). Many recent studies have been conducted in different regions in Saudi Arabia, mostly among the general public [4,11,12,21–23], and all of them have shown that epilepsy awareness in Saudi Arabia should be improved and that more campaigns are needed. The current study showed that 95.3% of the respondents had heard or read about epilepsy, 34.2% knew someone with epilepsy, and 53.5% had seen someone having a seizure. Compared to a study done among healthcare professionals in Riyadh, in which 100% of respondents have heard or read about epilepsy, 76% knew someone with epilepsy, and 45.7% have seen someone with epilepsy [11]. A study among healthcare students in India showed
Fig. 2. Response to the questions about causes of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
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Table 3 Response to the questions regarding attitude toward epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (yes and no answers). Preclinical yearsa
Total
A person with epilepsy can live alone A person with epilepsy can drive A child with epilepsy can succeed in school Epilepsy can prevent recreational activities People with epilepsy should be employed like others People with epilepsy can be successful in some professions People with epilepsy can get married People with epilepsy can have children Would object my healthy child to play with a child with epilepsy
Clinical yearsb
p valuec
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
No n(%)
Yes n(%)
Do not know n(%)
150 (59.1) 148 (58.5) 10 (4) 146 (57.7) 20 (7.9)
59 (23.2) 51 (20.2) 224 (88.9 54 (21.3) 219 (86.2)
45 (17.7) 54 (21.3) 18 (7.1) 53 (21) 15 (5.9)
49 (55.7) 56 (64.4) 5 (5.8) 43 (48.9) 6 (6.8)
16 (18.1) 8 (9.2) 72 (82.8) 17 (19.3) 74 (84.1)
23 (26.1) 23 (26.4) 19 (11.5) 28 (31.8) 8 (9.1)
97 (60.6) 89 (55.6) 5 (3.1) 99 (62.2) 14 (8.8)
41 (25.6) 41 (25.6) 147 (92.5) 37 (23.3) 139 (86.9)
22 (13.8) 30 (18.8) 7 (4.4) 23 (14.5) 7 (4.4)
0.005 b0.27⁎
10 (4)
216 (86)
25 (10)
5 (5.8)
69 (80.2)
12 (14)
5 (3.1)
142 (89.3)
12 (7.6)
0.13⁎
6 (2.4) 6 (2.4) 116 (45.7)
239 (94.1) 234 (92.1) 92 (36.2)
9 (3.5) 14 (5.5) 46 (18.1)
2 (2.3) 3 (3.4) 38 (43.2)
78 (88.6) 76 (86.4) 77 (86.4)
8 (9.1) 9 (10.2) 24 (27.3)
4 (2.5) 3 (1.9) 75 (46.9)
155 (96.9) 152 (95) 63 (39.4)
1 (0.6) 5 (3.1) 22 (13.8)
0.002⁎ 0.04⁎ 0.03
0.04 0.007 0.06⁎
a
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. Chi2 test. ⁎ Fisher's exact test. b c
that 92.5% of respondents have heard about epilepsy and 41.6% have seen someone with epilepsy. A survey among university students in Malaysia showed that 86.5% of respondents have heard or read about epilepsy, 55.6% have seen someone with epilepsy, while only 6.3% knew a family member with epilepsy [24]. A study among medical students in Turkey showed that 73.5% of respondents have heard or read about epilepsy, 38.4% have seen someone with epilepsy, and 38.1% know someone with epilepsy [25]. While 100% of health workers in Zambia heard about epilepsy, 98.2% have seen someone with epilepsy, and 98.2% knew someone with epilepsy [7]. In our study, 4.3% of our respondents thought that all patients with epilepsy have the same symptoms compared to 39.1% in Istanbul teachers [13] and 82.4% in the Riyadh general public [12]. This finding shows that knowledge about epilepsy symptoms is better among medical and allied healthcare students than among the general population. The present study showed that convulsions (91.4%) were the most commonly described symptom of all epilepsy manifestations, followed by loss of consciousness (78.8%), foaming from the mouth (55.3%), and behavioral changes (42.7%). A study conducted in Riyadh among
healthcare professionals showed a higher level of awareness regarding epilepsy manifestations [11]. This difference probably was due to the different populations in our study (students and interns only) compared to the population in the Riyadh study, which included practicing healthcare professionals and 5th-year medical students. A survey done among healthcare students in India showed that convulsions were the most commonly described manifestation followed by loss of consciousness (77.3% and 28.5%, respectively). Similarly, a study among medical students in Turkey showed that loss of consciousness and convulsion were the two most commonly described manifestations of epilepsy (78.2% and 70.1%, respectively). More education about the various manifestations of epilepsy other than convulsion and loss of consciousness should be carried out among healthcare students and professionals. Regarding the causes of epilepsy, our respondents believed that tumors cause epilepsy (70.3%), followed by brain trauma (67.6%), stroke (48.8%), metabolic diseases (44.5%), and insanity (30.9%). In our study, only 6.3% of the respondents believed that epilepsy is a result of demonic possession and supernatural powers (n = 16). However, the studies of AlKharj [22] and Riyadh [12] showed that the public
100 90 80 70 60 50 40 30 20 10 0 2nd
3rd
Medical treatment (p=.04)
4th Herbal treatment (p=.01)
5th
6th
Cautery (p=.05)
Internship Untreatable (p=.02)
Fig. 3. Response to the questions about epilepsy treatment among medical and allied healthcare students at King Abdulaziz University; stratified by study year: a survey study in a teaching hospital (more than one answer).
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S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
Table 4 Responses to the questions regarding causes of epilepsy answered by allied healthcare students of KAU. Causes of epilepsy, yes (n (%))
Preclinical years
Accidents Inherited diseases Insanity Brain tumors Birth defects Stroke Blood disease Metabolic disease Psychological Jinn (supernatural power)
36 (40.9) 37 (42) 20 (22.7) 45 (51.1) 23 (26.1) 28 (31.8) 6 (6.8) 23 (26.1) 26 (29.6) 5 (5.6)
a
Clinical years 133 (83.1) 111 (69.4) 56 (35) 129 (80.6) 83 (51.9) 94 (58.8) 30 (18.7) 89 (55.6) 65 (40.6) 10 (6.3)
b
c
80 70
p value
60
b0.000 b0.000 0.05 b0.000 b0.000 b0.000 0.01⁎
50
b0.000 0.08 0.9⁎
10
a
40 30 20
0 Medicine
2nd, 3rd, 4th years combined. 5th, 6th, internship years combined. c Chi2 test. ⁎ Fisher's exact test.
Nursing No
b
Pharmacy Yes
Dentist
Other
Don't know (p=0.009)
Fig. 4. Response to the questions about surgical treatment of epilepsy among medical and allied healthcare students at King Abdulaziz University: a survey study in a teaching hospital (more than one answer).
considered a Jinn possession or supernatural power as one of the leading causes of epilepsy (46.5% and 78.5%, respectively), which could be because of mythical beliefs in the Arabian culture and lack of awareness about the disease. This belief is less evident among healthcare students than among the public, as shown in our study in which only a minority believed in supernatural power as the etiology of epilepsy. A study conducted among the general public in Emirates showed that 13.8% of people who were familiar with epilepsy thought that epilepsy is caused by Jinn possession, which was a lower percentage than that of the two studies discussed above [16]. Alaqeel et al. conducted a similar survey on healthcare professionals in Riyadh and showed that 10.5% believed that Jinn possession causes epilepsy [11]. This issue is critical because this belief is common in the Arab world beyond Saudi Arabia, and thus more educational campaigns are needed to address this issue. In Malaysia, 5.3% of university students thought that epilepsy can be caused by an evil spirit [24], while only 2% of medical students in Turkey thought so [25]. From various studies, it seems that there is a significant number of healthcare students and professionals who think that epilepsy is a form of insanity or mental illness. This represented 31% of our sample, 38.4% of medical students in Turkey [25], and 54.5% of healthcare workers in Zambia [7]. This could be explained by epilepsy being associated with mental and psychological disorders or as a side effect of some antipsychotic medications. More education should be focusing on differentiating epilepsy and mental and psychological disorders. (See Table 4.) Most of the study participants were aware of epilepsy and expressed positive attitudes toward people with epilepsy. Although a few were concerned about people with epilepsy and their professional life, 4% of the respondents in our study disapproved of having a person with epilepsy working similar to other people compared with 11% in an Italian public survey, 9% in the United States public survey [17] and in 2.1% in Riyadh among healthcare professionals [11]. In India, 77.7% of healthcare students thought that people with epilepsy could share work opportunities similar to other people [26]. Many studies, including our own, have attempted to measure the attitude toward the social life of a person with epilepsy, such as, marrying a person with epilepsy, persons with epilepsy having children, and permitting their children to play with a child with epilepsy. A total of 94.1% of our respondents thought that a person with epilepsy can get married, and 92.1% thought that having children of their own was appropriate, which reflected that our respondents were not concerned that epilepsy is an inheritable disease. However, 59.4% thought that inheritance is one of the causes and 36.2% would not allow their children to interact or play with a child with epilepsy compared with 14% of respondents in Greece [18], 11% in Austria [20], and 4% in the United States [19]. The relatively higher proportion of such negative attitudes in our study is likely to be because of mythical beliefs of supernatural powers and the
possibility of transmitting epilepsy to their healthy child. Another concern was that it could traumatize their children psychologically if they witnessed another child having an epileptic episode. In Turkey, 92.7% of the medical students thought that it is appropriate for a person with epilepsy to have children [25], and 97.1% of health workers in Zambia answered that they would allow their children to play with children with epilepsy [7]. Regarding epilepsy treatment, a large proportion thought that a medical consultation to treat epilepsy is essential (82%). This response rate reflects that medical and allied healthcare students have a higher awareness of the importance of seeking medical help than the general population. On the other hand, 8.6% thought that they would treat epilepsy with herbal medicine and 5.6% believed in faith healing. Approximately one-third (34%) of the respondents did not know that surgical intervention is a treatment option compared to 73.8% in Riyadh [12] and 49.50% in AlKharj [22] among the general public, which shows that awareness about different epilepsy treatments, especially surgical interventions, is lacking in our society. Nursing students were more aware of the surgical options than medical students and those studying other specialties, but this difference could reflect the small sample size in each group. About a quarter (25.2%) of Turkish medical students thought brain surgery could be a treatment option [25]. Interestingly, 74.5% of medical students in Slovenia were aware of the surgical treatment of epilepsy [27]. Overall, we noticed that there was a better level of knowledge and attitude toward epilepsy among clinical-year students compared to preclinical-year students. This could be explained by the fact that more knowledge about epilepsy is acquired throughout healthcare training, and this leads to fewer stigmas and a better attitude toward people with epilepsy. (See Fig. 4.)
5. Conclusion The results of our study show that awareness about epilepsy, including treatment modalities, causes, and manifestations, among Saudi Arabian medical and allied healthcare students, could be improved. The knowledge level about epilepsy was better among medical students than among those studying other specialties. Additionally, students in clinical years have overall better knowledge and attitude toward people with epilepsy compared to preclinical-year students. Misconceptions about epilepsy might exist because of different beliefs and different reading references, which could be targeted in future campaigns and conferences and in curricula designed to help to improve knowledge and attitudes toward epilepsy. Furthermore, knowledge about surgical options for the management of medically intractable epilepsy should be improved.
S. Alomar et al. / Epilepsy & Behavior 102 (2020) 106815
5.1. Limitations of the study Our study is limited by the relatively small sample size, especially of allied healthcare students. Additionally, our results do not reflect the knowledge and attitude of the general population. Students who are more aware of epilepsy may be more likely to take part than students who have limited information about epilepsy, which could be a source of bias in our study. Future directions include conducting further studies with the general population with a larger sample size and different socioeconomic and racial backgrounds to reflect the diversity of Saudi Arabian nationals and residents. Declaration of Competing Interest None. Funding This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets generated and analyzed in the current study are available from the corresponding author on request. References [1] World Health Organization. Epilepsy in the WHO Eastern Mediterranean region: bridging the gap. Cairo (EG). http://applications.emro.who.int/dsaf/dsa1039.pdf; 2010. [2] Steven C, S.M.. What is a seizure? http://www.epilepsy.com; 2014, Accessed date: 19 March 2014. [3] Megiddo I, Colson A, Chisholm D, Dua T, Nandi A, Laxminarayan R. Health and economic benefits of public financing of epilepsy treatment in India: an agent-based simulation model. Epilepsia 2016;57(3):464–74. [4] Alaqeel A, Sabbagh AJ. Epilepsy; what do Saudi's living in Riyadh know? Seizure 2013;22(3):205–9. [5] Jensen R, Dam M. Public attitudes toward epilepsy in Denmark. Epilepsia 1992;33 (3):459–63. [6] Al-Adawi S, Al-Ismaily S, Martin R, Al-Naamani A, Al-Riyamy K, Al-Maskari M, et al. Psychosocial aspects of epilepsy in Oman: attitude of health personnel. Epilepsia 2001;42(11):1476–81. [7] Chomba EN, Haworth Alan, Atadzhanov Masharip, Mbewe Edward, Birbeck Gretchen L. Zambian health care workers' knowledge, attitudes, beliefs, and practices regarding epilepsy. Epilepsy Behav 2007;10(1):111–9.
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