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Outcome of a school-based health education program for epilepsy awareness among schoolchildren
Epilepsy & Behavior 57 (2016) 77–81
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Outcome of a school-based health education program for epilepsy awareness among schoolchildren Meena Kolar Sridara Murthy a,⁎, Lakshmana Govindappa b,1, Sanjib Sinha c a b c
Department of Mental Health Education, National Institute of Mental Health and Neuro Sciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India Department of Social Work, Central University of Karnataka, Kadaganchi, Aland Road, Gulbarga, Karnataka 585 367, India Department of Neurology, National Institute of Mental Health and Neuro-Sciences (NIMHANS), Hosur Road, Bangalore, Karnataka 560029, India
a r t i c l e
i n f o
Article history: Received 7 November 2015 Revised 1 January 2016 Accepted 15 January 2016 Available online 27 February 2016 Keywords: Epilepsy Health education Attitude Behavior Practice
a b s t r a c t Background: A diagnosis of epilepsy has a major effect on children; especially among schoolchildren. Studies have shown that a significant proportion of teachers and students have negative attitude and misunderstanding towards epilepsy making it difficult for a child with epilepsy. At the same time, there is a dearth is dearth of literature regarding interventions to bring about a change in the attitudes of children. Methodology: The aim of the present study was to study the outcome of a school-based health education program for epilepsy awareness among schoolchildren. The objectives were to assess the level of knowledge, attitude, and practices about epilepsy and relationship among these variables. A total of 70 children, from 8th–10th grades were selected randomly for the study. For the study purpose, knowledge, attitude, and practices of epilepsy instrument were developed and face validated by experts. Results: Results show that the mean, median, and mode age of the respondents in the study were 14.55 (±1.33), 15, and 14 years, respectively. The gender distribution of the respondents was 54.9% boys and 45.1% girls. With regard to knowledge, attitude, and practices in epilepsy, knowledge strongly and positively correlated with attitude (p = 0.001, r = .423) and practice domains (p = 0.001, r = .486). Postattitude and (p = 0.001, r = .338) practice were positively correlated, which shows that positive attitude brings positive practice. Hence, it is concluded that a training program brings desirable change in the knowledge, attitude, and practice domains among children. Conclusion: Health education programs for schoolchildren are very important to bring changes in their attitude, behavior, and practices. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is one of the most common neurological disorders, affecting approximately 70 million people worldwide. It is a major public health problem, not only because of its health implications but also for its social, cultural, psychological, and economic effects [1–4]. Although knowledge, attitude, and beliefs towards epilepsy have improved in most countries, there is still misperception [5]. The fear and misunderstanding of epilepsy may lead to social stigma, resulting in social discrimination, particularly in teenagers [6]. Studies have shown that a significant proportion of teachers and students have negative attitudes and misunderstanding towards epilepsy. At the same time, there is a dearth of literature regarding interventions to bring about a change in the attitudes of children and teachers. With sufficient training and knowledge, stigma towards children with epilepsy can be changed. ⁎ Corresponding author. Tel.: +91 9901942852. E-mail addresses: [email protected] (M. Kolar Sridara Murthy), [email protected] (L. Govindappa), [email protected] (S. Sinha). 1 Tel.: +91 538088859, +91 847 2264327 (O).
http://dx.doi.org/10.1016/j.yebeh.2016.01.016 1525-5050/© 2016 Elsevier Inc. All rights reserved.
Educating schoolchildren during the initial school years can be highly effective in looking at their classmate suffering from epilepsy with empathy. Studies have shown that providing accurate information to children about epilepsy at an early age may result in decreased stigma and secrecy and more positive attitudes towards epilepsy. It is also important to have medically accurate health education programs for parents, school teachers, and students to dispel myths and misconceptions about epilepsy. The hypothesis of the present study was that a health education program on epilepsy would enhance the knowledge, attitude, and practices about epilepsy. The aim was to study the outcome of a school-based health education program for epilepsy awareness among schoolchildren. The objectives were to assess the level of knowledge, attitude, and practices about epilepsy and relationship among these variables. 2. Materials and methods This study was carried out between September 2014 and June 2015 among 70 school students. The nearest government school was
78
M. Kolar Sridara Murthy et al. / Epilepsy & Behavior 57 (2016) 77–81
identified, and permission to conduct the intervention study was obtained by the principal of the school and Department of Education, Government of Karnataka. The study was reviewed and approved by the institute's ethics committee. Written informed consent from children and from their parents was obtained to participate in the study. 2.1. Assessment An assessment of the commonly recommended school textbooks was undertaken to identify the epilepsy-related content within them. None of the textbooks had any content to educate the teachers and schoolchildren about epilepsy. Within the school, students from 8th– 10th grades were eligible for participation. From each grade, 25 students were selected randomly. Five students dropped out from the study. Hence, the final analysis included 70 students. 2.2. Tools Based on the review of literature and discussions with experienced clinicians on epilepsy, a tool to assess knowledge, attitude, and practices [KAP] was formulated. The developed instrument was given to subject experts for face validity. Based on the suggestions, the tool was modified and used in the study. The investigators finalized the tool with a case vignette of a child having a seizure to help the students understand a seizure better, along with the KAP tool. The finalized tool had 8 items each in knowledge and attitude domains. The practice domain had 9 items. Right answers were given 1 mark, and wrong answers were given 0. The domain scores were calculated by summing up right answers from each domain. The data were collected using an interview method by a third party, who was not related to the study and was trained for the study purpose. 2.3. Intervention package An intervention package was developed by the investigators based on the results of the baseline assessment, literature, and suggestions of health professionals. The intervention package had contents on epilepsy awareness for the students with respect to their existing knowledge, attitude, and myths and misconceptions of epilepsy; first aid in epilepsy; belief and practices about epilepsy; and role of students in school. As a part of the intervention package, the following information, education, and communication (IEC) materials were developed by the investigators to impart the health education program. 2.3.1. Knowledge domain Health education materials on psycho-education about epilepsy, nature, causes, symptoms, treatment options, and prognosis were developed by validating the material by a team of faculty from a multidisciplinary team comprised of neurologists, child psychiatrists, social workers, psychologists, and nursing and health educators. Posters and brochures on myths and misconceptions and awareness about epilepsy were prepared by the investigators which were used during the session and also kept on display for a few days. Apart from this, role-plays, focus group discussions, and group activities were also used as a medium to deliver the intervention. 2.3.2. Attitude domain To increase favorable attitudes among students, sessions were included on dealing with empathy towards a student having epilepsy; in addition, myths and misconceptions were clarified. Students were shown posters which explained how they can reach out to their peer by being supportive in times of absenteeism, sharing notes, group studying, and reminding to take medications. Also, the researcher discussed how students can develop a more favorable attitude towards a student with epilepsy and their right for work and education.
2.3.3. Practice domain To educate the students on providing accurate first aid in epilepsy as a part of the intervention strategy, a twelve-minute video on first aid in epilepsy was developed by the investigators. The script to prepare the video was approved by a team of neurologists from the institute. There was also discussion on the need to follow the right practices when they see a person having a seizure, including proper first aid, the need for appropriate medical treatment, and the importance of providing need-based information to the family. The study also worked towards incorporating epilepsy education as a part of the syllabus for the students by the teachers. The study was conducted in three batches; each batch consisted of 18–25 children. The training was spaced out over a period of three days. The training sessions were observed and notes made on the training process. Each session was immediately evaluated by taking feedback from the students about the perceived quality, content, and relevance of the content; duration of health education sessions; and suggestions for improvements. Postassessment was carried out a week after the intervention. The obtained data were analyzed using IBM SPSS version 20. 3. Results The ages of the sample were normally distributed. The mean, median, and mode age of the respondents in the study were 14.55 (±1.33), 15, and 14 years, respectively. The gender distribution of the respondents shows that 54.9% were boys and 45.1% were girls. Table 1 details the students' knowledge about epilepsy. Results show that before the intervention, knowledge was not adequate for in most of the items. For the question as to whether epilepsy can be caused by touching the person with epilepsy, only 17% had adequate knowledge. After the intervention, most of the respondents understood the cause for epilepsy. Table 2 describes the students' attitudes about epilepsy. Results show that, before the intervention, most of the respondents had negative attitudes, whereas, after the intervention for most of the items, respondents' attitudes changed. For example, with regard to the question as to whether it is difficult for persons with epilepsy to study, about 11% had adequate knowledge. After the intervention, the majority (93%) of the respondents changed their attitude. Table 3 describes the students' practices about epilepsy. Results show that, before the intervention, most of the respondents had wrong practices, whereas, after the intervention for in most of the items, respondents had positive practices. For example, regarding the question as to whether sharp objects should be removed from near a person having a seizure, about 19% had adequate knowledge. After the intervention, the majority (77%) of the respondents understood the right practice. Table 4 presents the participants knowledge, attitudes, and practices about epilepsy before and after the training program. To test the difference between pre- and posttraining paired sample ‘t’ test was done. In three domains, there was a statistically significant difference between pre- and posttraining mean scores (p = 0.000). In the knowledge domain, the pre-intervention mean score was 3.47 ± 1.13; in the postassessment, it increased to 7.60 ± 0.52. In the attitude domain, the pre-intervention mean score was 0.64 ± 0.94, which increased to 7.59 ± 0.55; in the practice domain, the pre-intervention mean score was 1.36 ± 0.96, and this increased to 7.67 ± 0.50 in the postassessment. Table 5 shows the correlation among various domains. Pre-intervention knowledge, attitude, and practice domains were significantly related. Knowledge and attitude were positively correlated (p = 0.01, r = 0.641), which indicates that the greater the knowledge, the more favorable the attitude towards persons with epilepsy. Knowledge and attitude were negatively correlated with the practice domain. Knowledge was strongly and positively correlated with the attitude (p = 0.001, r = .423) and practice domains (p = 0.001, r = .486). This strongly suggests that knowledge leads to positive attitudes and good practices among children. Likewise, post-intervention attitudes and
M. Kolar Sridara Murthy et al. / Epilepsy & Behavior 57 (2016) 77–81
79
Table 1 Students' knowledge about epilepsy. Knowledge domain
1. 2. 3. 4.
Epilepsy is not a kind of mental illness. Epilepsy is a disease of the brain. Epilepsy is a hereditary disease that is passed through generations (N). Epilepsy is caused by ancestor's sin or bad karma or that maybe that person did something wrong in his previous janam [previous birth] (N). Epilepsy is not caused by touching the person. Most people suffering from epilepsy need not to take treatment for life time. Missing medicines once in a while is harmful for people suffering with epilepsy. Person with epilepsy do not cause harm to others.
5. 6. 7. 8.
Preassessment N = 70
Postassessment N = 70
Yes
Yes
No
No
N
%
N
%
N
%
N
%
61 57 31 34
87.1 81.4 44.3 48.6
9 13 39 36
12.9 18.6 55.7 51.4
66 67 1 4
94.3 95.7 1.4 5.7
4 3 69 66
5.7 4.3 98.6 94.3
12 30 10 8
17.1 42.9 14.3 11.4
58 40 60 62
82.9 57.1 85.7 88.6
64 66 61 65
91.4 94.3 87.1 92.9
6 4 9 5
8.6 5.7 12.9 7.1
N = Negatively worded.
Table 2 Students' attitude about epilepsy. Attitude domain
Preassessment Yes
1. 2. 3. 4. 5. 6. 7. 8.
It is not difficult for person with epilepsy to study if he/she has this problem. Epilepsy does not cause disturbances in leading a happy life. One should not avoid playing with a person with epilepsy. One can share books/pencils/things with a person with epilepsy. Children with epilepsy should go to special schools (N). Children with epilepsy have adequate intelligence. Children with epilepsy can take part in sports. Persons with epilepsy can achieve big success in life.
Postassessment No
Yes
No
N
%
N
%
N
%
N
%
8 15 14 12 17 17 17 23
11.4 21.4 20.0 17.1 24.3 24.3 24.3 32.9
62 55 56 58 53 53 53 47
88.6 78.6 80.0 82.9 75.7 75.7 75.7 67.1
65 64 66 64 65 57 65 61
92.9 91.4 94.3 91.4 92.9 81.4 92.9 87.1
5 6 4 6 5 13 5 9
7.1 8.6 5.7 8.6 7.1 18.6 7.1 12.9
N = Negatively worded.
practices were positively correlated (p = 0.001, r = .338), which shows that positive attitude brings positive practice. 4. Discussion Negative social attitudes and discrimination against children with epilepsy at times are more devastating than the disease itself. Creating
awareness brings desirable behavior and attitude change among children and teachers. he present study adopted a hypothesis-driven classical experimental design. The present study highlights that KAP about epilepsy were minimal among the schoolchildren and, during the posttraining program, their knowledge increased significantly (p b 0.001). Though the children were in a metropolitan city and had access to different means of
Table 3 Students' practices about epilepsy. Practice domain
1. 2. 3. 4. 5. 6. 7. 8. 9.
We should not run away when we see a person having a seizure. We have to make the person hold a bunch of keys when he or she is having a seizure (N). We have to take the person having a seizure to the hospital. We have to sprinkle water over the person's face when he or she is having a seizure (N). We have to give mouth to mouth resuscitation when the person is having a seizure (N). If the person is having a seizure, we have to immediately call the family members and inform them at the earliest. We have to hold the person tightly when he or she is having a seizure (N). We have to try to put a spoon in between the teeth when the person is having a seizure (N). We have to remove any sharp objects near the person who is having an a seizure.
Preassessment
Postassessment
Yes
Yes
No
No
N
%
N
%
N
%
N
%
19 22 11 31 21 9 8 25 13
27.1 31.4 15.7 44.3 30.0 12.9 11.4 35.7 18.6
51 48 59 39 49 61 62 45 57
72.9 68.6 84.3 55.7 70.0 87.1 88.6 64.3 81.4
64 61 65 63 66 65 3 10 54
91.4 87.1 92.9 90.0 94.3 92.9 4.3 14.3 77.1
6 9 5 7 4 5 67 60 16
8.6 12.9 7.1 10.0 5.7 7.1 95.7 85.7 22.9
N = Negatively worded.
Table 4 Students' knowledge, attitude, and practices about epilepsy. Domain
Levels of assessment
Mean
Std. deviation
T
df
Sig. level (2-tailed)
Knowledge of epilepsy
Pretest Posttest Pretest Posttest Pretest Posttest
3.47 7.60 .64 7.59 1.36 7.67
1.13 .52 .94 .55 .96 .50
−28.715
69
.000⁎⁎⁎
−47.574
69
.000⁎⁎⁎
−55.432
69
.000⁎⁎⁎
Attitude of children towards epilepsy Practices of children towards epilepsy NS = Not significant. ⁎⁎⁎ Significant at 0.001 level.
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M. Kolar Sridara Murthy et al. / Epilepsy & Behavior 57 (2016) 77–81
Table 5 Knowledge, attitude and practices correlation. Preknowledge Preawareness
Preattitude
Prepractice
Postknowledge
Postattitude
Postpractice
Pearson correlation Sig.(2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N
Preattitude
Prepractice
Postknowledge
Postattitude
Postpractice
1 70
.641⁎⁎ .000
70 −.261⁎ .029 70 .102 .399 70 .062 .612 70 .148 .222 70
1 70 −.255⁎ .033 70 .088 .470 70 .101 .406 70 .085 .486 70
1 70 .058 .636 70
1 70
.064 .597 70 −.053 .661 70
70
70
.423⁎⁎ .000 .486⁎⁎ .000
1 70
70
.338⁎⁎ .004
1 70
⁎⁎ Correlation is significant at the 0.01 level (2-tailed). ⁎ Correlation is significant at the 0.05 level (2-tailed).
communication, their baseline mean KAP scores were low. This definitely would affect their attitude and behavior towards their fellow classmates with epilepsy. Having minimal awareness about epilepsy can foster stigma, wrong beliefs, and negative attitudes. The dramatic effect of having a seizure inside the classroom can be very devastating for the child, and children suffering from epilepsy are often stigmatized because of fear of the unexpected and public loss of self-control. Teachers usually do not have any formal instructions on epilepsy during their training; there is a lack of appropriate knowledge in handling the child during a seizure [7,10]. Children affected by epilepsy may face severe discrimination at school, with high rates of school dropouts and discrimination by their own classmates and teachers. There are many misconceptions surrounding the illness when a child has a seizure — e.g., giving shoes to smell and a key ring to hold. In India, especially in the rural population, it is a common belief to give a seizing person keys to hold, and this is considered as a way to stop seizures; other practices such as holding the child over a fire or giving her/him cow’s urine to name [11] worsens the outlook towards a child having epilepsy. In developing countries like India, studies have documented that students lack awareness and knowledge about epilepsy and first aid during a seizure. This could be largely due to the fear of witnessing a child having a seizure in the classroom or the misconceptions that the community or media have projected over a period of time. Various wrong practices and myths associated with epilepsy have also been reported among students [1,2,11,12]. Goel et al. [13] reported that KAP for epilepsy in Uttarakhand were very poor in comparison with those in other parts of the country. Large proportions of students believed that epilepsy is a mental disease that runs in the family, and a person with epilepsy should not be married and employed. Wrong practices like the use of onion and smelling a shoe for acute attacks were still common in their community. There was a significant relationship between post-intervention knowledge and attitude and practice. Where knowledge was high, positive attitude was seen towards epilepsy. Knowledge on epilepsy creates positive and receptive attitudes towards a person with epilepsy. More knowledge would likely lead to less stigma, isolation, and avoidance of person with epilepsy. Similarly, attitude and practice were positively correlated. This indicates that positive attitude leads to good practices such as being more adoptive, supportive, and accommodative, nondiscrimination, and fewer misconceptions. The awareness program on epilepsy brought about a change in knowledge, attitude, and practice. A larger and comprehensive community-based educational program involving parents and children, perhaps using mass media, is very essential to bring about a change in
the negative attitudes toward epilepsy. At the same time, there is dearth of literature regarding interventions to bring about a change in the attitudes of children and teachers. A Chandigarh study [14] reported that the knowledge about various aspects of epilepsy was average among school students. However, there was no significant difference in KAP between students who lived in urban, urban slum, and rural areas. It recommended that clinicians devote more time with their patients to address the social issues that they faced because of epilepsy. Hari Joshi et al. [15], in their study, confirmed gaps in knowledge and a negative attitude about various aspects of epilepsy, which is in agreement with the studies conducted among elementary schoolchildren [8]. Pandian et al. [9], in 2006, quantified KAP with respect to epilepsy among 1213 10th-grade students of Kerala, Southern India. Ninety-eight percent of them had heard or read about epilepsy. However, nearly 60% of students thought that epilepsy was a form of insanity. Allopathic treatment was preferred by more than half of the respondents; however, many had faith in exorcism and visiting religious places as ways to cure epilepsy. Half of the students considered epilepsy as a hindrance to education, employment, and marriage. Thirteen percent would be unwilling to sit adjacent to or play with a child with epilepsy. The authors concluded that, although familiarity with epilepsy was high among high school students in Kerala, misconceptions and negative attitudes were alarmingly high. The present study suggests a need to promote epilepsy awareness programs as a means of increasing public knowledge of epilepsy. It is therefore fundamental that there should be destigmatization campaigns provided to correct information and provide appropriate education. Persistent and effective information campaigns, therefore, are necessary to change the attitudes towards fellow students with epilepsy. The intervention used in the present study is simple and easy to follow. School teachers, administrators, and the government would find it easy to adopt the program. It is advisable to include a chapter on epilepsy in the school curriculum. This will bring the needed changes in attitudes and practices among teachers and students. The main limitation of this study was the small sample size and the inclusion of only one school, which limit generalizability of the findings. Future work should be conducted with large samples at multiple schools. 5. Conclusion This study was undertaken to determine the effectiveness of a health education program for epilepsy awareness among schoolchildren. The findings support the further development and implementation of
M. Kolar Sridara Murthy et al. / Epilepsy & Behavior 57 (2016) 77–81
epilepsy education programs for schoolchildren as a means of increasing public knowledge about epilepsy. The findings will be incorporated into a brief report for the Department of Public Instruction, Government of Karnataka and National Council of Educational Research and Training with a goal of incorporating epilepsy education at the state and national levels into the curriculum to raise awareness among schoolchildren.
Acknowledgment This project was funded by National Institute of Mental Health and Neuro-Sciences, Bangalore. Project code: NIMH/Proj/M/537/2013-14.
References [1] Kabir M, Iliyasu Z, Abubakar IS, Kabir ZS, Farinyaro AU. Knowledge, attitude and beliefs about epilepsy among adults in a Northern Nigerian urban community. Ann Afr Med 2005;4:107–12. [2] Yoo J-K, Jung K-Y, Park K-W. Familiarity with, understanding of and attitudes toward epilepsy among people with epilepsy and healthy controls in South Korea. Epilepsy Behav 2009;16:260–7. [3] Yemadje LP, Houinato D, Quet F, Druet-Cabanac M, Preux PM. Understanding the differences in prevalence of epilepsy in tropical regions. Epilepsia 2011;52:1376–81. [4] Jacoby A. Stigma, epilepsy, and quality of life. Epilepsy Behav 2002;3:10–20.
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[5] Austin JK, Shafer PO, Deering JB. Epilepsy familiarity, knowledge, and perceptions of stigma: report from a survey of adolescents in the general population. Epilepsy Behav 2002;3:368–75. [6] Bener A, al-Marzooqi FH, Sztriha L. Public awareness and attitudes towards epilepsy in the United Arab Emirates. Seizure 1998;7:219–22. [7] Baker GA. People with epilepsy: what do they know and understand, and how does this contribute to their perceived level of stigma? Epilepsy Behav 2002;3:26–32. [8] Fernandes PT, Cabral P, Araujo U, Noronha AA, LiL M. Kids’ perception about epilepsy. Epilepsy Behav 2005;6:601–3. [9] Pandian JD, Santosh D, Kumar TS, Sarma PS, Radha krishnan K. High school students’ knowledge, attitude, and practice with respect to epilepsy in Kerala, southern India. Epilepsy Behav 2006;9:492–7. [10] Birbeck GL, Chomba E, Atadzhanov M, Mbewe E, Haworth A. Zambian teachers: what do they know about epilepsy and how can we work with them to decrease stigma? Epilepsy Behav 2006;9(2):275–80. [11] Singh AJ, Walia I, Sohi D. Seizure management practices adopted by the families of epileptics in North India. Ind Med Gaz 1995;129:29–32. [12] Sawhney IM, Singh A, Kaur P, Suri G, Chopra JS. A case control study and one year follow-up of registered epilepsy cases in a resettlement colony of North India, a developing tropical country. J Neurol Sci 1999;165:31–5. [13] Goel D, Dhanai JS, Agarwal A, Mehrotra V, Saxena V. Knowledge, attitude and practice of epilepsy in Uttarakhand, India. Ann Indian Acad Neurol 2011;14(2):116–9. [14] Goel S, Singh N, Lal V, Singh A. Knowledge, attitude and practices of students about first aid epilepsy seizures management in a Northern Indian City. Ann Indian Acad Neurol 2013;16:538–43. [15] Joshi HS, Mahmood SE, Bamel A, Agarwal AK, Shaifali I. Perception of epilepsy among the urban secondary school children of Bareilly district. Ann Indian Acad Neurol 2012;15:125–7.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Brief Communication
Outcome of a school-based health education program for epilepsy awareness among schoolchildren Meena Kolar Sridara Murthy a,⁎, Lakshmana Govindappa b,1, Sanjib Sinha c a b c
Department of Mental Health Education, National Institute of Mental Health and Neuro Sciences [NIMHANS], Hosur Road, Bangalore, Karnataka 560029, India Department of Social Work, Central University of Karnataka, Kadaganchi, Aland Road, Gulbarga, Karnataka 585 367, India Department of Neurology, National Institute of Mental Health and Neuro-Sciences (NIMHANS), Hosur Road, Bangalore, Karnataka 560029, India
a r t i c l e
i n f o
Article history: Received 7 November 2015 Revised 1 January 2016 Accepted 15 January 2016 Available online 27 February 2016 Keywords: Epilepsy Health education Attitude Behavior Practice
a b s t r a c t Background: A diagnosis of epilepsy has a major effect on children; especially among schoolchildren. Studies have shown that a significant proportion of teachers and students have negative attitude and misunderstanding towards epilepsy making it difficult for a child with epilepsy. At the same time, there is a dearth is dearth of literature regarding interventions to bring about a change in the attitudes of children. Methodology: The aim of the present study was to study the outcome of a school-based health education program for epilepsy awareness among schoolchildren. The objectives were to assess the level of knowledge, attitude, and practices about epilepsy and relationship among these variables. A total of 70 children, from 8th–10th grades were selected randomly for the study. For the study purpose, knowledge, attitude, and practices of epilepsy instrument were developed and face validated by experts. Results: Results show that the mean, median, and mode age of the respondents in the study were 14.55 (±1.33), 15, and 14 years, respectively. The gender distribution of the respondents was 54.9% boys and 45.1% girls. With regard to knowledge, attitude, and practices in epilepsy, knowledge strongly and positively correlated with attitude (p = 0.001, r = .423) and practice domains (p = 0.001, r = .486). Postattitude and (p = 0.001, r = .338) practice were positively correlated, which shows that positive attitude brings positive practice. Hence, it is concluded that a training program brings desirable change in the knowledge, attitude, and practice domains among children. Conclusion: Health education programs for schoolchildren are very important to bring changes in their attitude, behavior, and practices. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is one of the most common neurological disorders, affecting approximately 70 million people worldwide. It is a major public health problem, not only because of its health implications but also for its social, cultural, psychological, and economic effects [1–4]. Although knowledge, attitude, and beliefs towards epilepsy have improved in most countries, there is still misperception [5]. The fear and misunderstanding of epilepsy may lead to social stigma, resulting in social discrimination, particularly in teenagers [6]. Studies have shown that a significant proportion of teachers and students have negative attitudes and misunderstanding towards epilepsy. At the same time, there is a dearth of literature regarding interventions to bring about a change in the attitudes of children and teachers. With sufficient training and knowledge, stigma towards children with epilepsy can be changed. ⁎ Corresponding author. Tel.: +91 9901942852. E-mail addresses: [email protected] (M. Kolar Sridara Murthy), [email protected] (L. Govindappa), [email protected] (S. Sinha). 1 Tel.: +91 538088859, +91 847 2264327 (O).
http://dx.doi.org/10.1016/j.yebeh.2016.01.016 1525-5050/© 2016 Elsevier Inc. All rights reserved.
Educating schoolchildren during the initial school years can be highly effective in looking at their classmate suffering from epilepsy with empathy. Studies have shown that providing accurate information to children about epilepsy at an early age may result in decreased stigma and secrecy and more positive attitudes towards epilepsy. It is also important to have medically accurate health education programs for parents, school teachers, and students to dispel myths and misconceptions about epilepsy. The hypothesis of the present study was that a health education program on epilepsy would enhance the knowledge, attitude, and practices about epilepsy. The aim was to study the outcome of a school-based health education program for epilepsy awareness among schoolchildren. The objectives were to assess the level of knowledge, attitude, and practices about epilepsy and relationship among these variables. 2. Materials and methods This study was carried out between September 2014 and June 2015 among 70 school students. The nearest government school was
78
M. Kolar Sridara Murthy et al. / Epilepsy & Behavior 57 (2016) 77–81
identified, and permission to conduct the intervention study was obtained by the principal of the school and Department of Education, Government of Karnataka. The study was reviewed and approved by the institute's ethics committee. Written informed consent from children and from their parents was obtained to participate in the study. 2.1. Assessment An assessment of the commonly recommended school textbooks was undertaken to identify the epilepsy-related content within them. None of the textbooks had any content to educate the teachers and schoolchildren about epilepsy. Within the school, students from 8th– 10th grades were eligible for participation. From each grade, 25 students were selected randomly. Five students dropped out from the study. Hence, the final analysis included 70 students. 2.2. Tools Based on the review of literature and discussions with experienced clinicians on epilepsy, a tool to assess knowledge, attitude, and practices [KAP] was formulated. The developed instrument was given to subject experts for face validity. Based on the suggestions, the tool was modified and used in the study. The investigators finalized the tool with a case vignette of a child having a seizure to help the students understand a seizure better, along with the KAP tool. The finalized tool had 8 items each in knowledge and attitude domains. The practice domain had 9 items. Right answers were given 1 mark, and wrong answers were given 0. The domain scores were calculated by summing up right answers from each domain. The data were collected using an interview method by a third party, who was not related to the study and was trained for the study purpose. 2.3. Intervention package An intervention package was developed by the investigators based on the results of the baseline assessment, literature, and suggestions of health professionals. The intervention package had contents on epilepsy awareness for the students with respect to their existing knowledge, attitude, and myths and misconceptions of epilepsy; first aid in epilepsy; belief and practices about epilepsy; and role of students in school. As a part of the intervention package, the following information, education, and communication (IEC) materials were developed by the investigators to impart the health education program. 2.3.1. Knowledge domain Health education materials on psycho-education about epilepsy, nature, causes, symptoms, treatment options, and prognosis were developed by validating the material by a team of faculty from a multidisciplinary team comprised of neurologists, child psychiatrists, social workers, psychologists, and nursing and health educators. Posters and brochures on myths and misconceptions and awareness about epilepsy were prepared by the investigators which were used during the session and also kept on display for a few days. Apart from this, role-plays, focus group discussions, and group activities were also used as a medium to deliver the intervention. 2.3.2. Attitude domain To increase favorable attitudes among students, sessions were included on dealing with empathy towards a student having epilepsy; in addition, myths and misconceptions were clarified. Students were shown posters which explained how they can reach out to their peer by being supportive in times of absenteeism, sharing notes, group studying, and reminding to take medications. Also, the researcher discussed how students can develop a more favorable attitude towards a student with epilepsy and their right for work and education.
2.3.3. Practice domain To educate the students on providing accurate first aid in epilepsy as a part of the intervention strategy, a twelve-minute video on first aid in epilepsy was developed by the investigators. The script to prepare the video was approved by a team of neurologists from the institute. There was also discussion on the need to follow the right practices when they see a person having a seizure, including proper first aid, the need for appropriate medical treatment, and the importance of providing need-based information to the family. The study also worked towards incorporating epilepsy education as a part of the syllabus for the students by the teachers. The study was conducted in three batches; each batch consisted of 18–25 children. The training was spaced out over a period of three days. The training sessions were observed and notes made on the training process. Each session was immediately evaluated by taking feedback from the students about the perceived quality, content, and relevance of the content; duration of health education sessions; and suggestions for improvements. Postassessment was carried out a week after the intervention. The obtained data were analyzed using IBM SPSS version 20. 3. Results The ages of the sample were normally distributed. The mean, median, and mode age of the respondents in the study were 14.55 (±1.33), 15, and 14 years, respectively. The gender distribution of the respondents shows that 54.9% were boys and 45.1% were girls. Table 1 details the students' knowledge about epilepsy. Results show that before the intervention, knowledge was not adequate for in most of the items. For the question as to whether epilepsy can be caused by touching the person with epilepsy, only 17% had adequate knowledge. After the intervention, most of the respondents understood the cause for epilepsy. Table 2 describes the students' attitudes about epilepsy. Results show that, before the intervention, most of the respondents had negative attitudes, whereas, after the intervention for most of the items, respondents' attitudes changed. For example, with regard to the question as to whether it is difficult for persons with epilepsy to study, about 11% had adequate knowledge. After the intervention, the majority (93%) of the respondents changed their attitude. Table 3 describes the students' practices about epilepsy. Results show that, before the intervention, most of the respondents had wrong practices, whereas, after the intervention for in most of the items, respondents had positive practices. For example, regarding the question as to whether sharp objects should be removed from near a person having a seizure, about 19% had adequate knowledge. After the intervention, the majority (77%) of the respondents understood the right practice. Table 4 presents the participants knowledge, attitudes, and practices about epilepsy before and after the training program. To test the difference between pre- and posttraining paired sample ‘t’ test was done. In three domains, there was a statistically significant difference between pre- and posttraining mean scores (p = 0.000). In the knowledge domain, the pre-intervention mean score was 3.47 ± 1.13; in the postassessment, it increased to 7.60 ± 0.52. In the attitude domain, the pre-intervention mean score was 0.64 ± 0.94, which increased to 7.59 ± 0.55; in the practice domain, the pre-intervention mean score was 1.36 ± 0.96, and this increased to 7.67 ± 0.50 in the postassessment. Table 5 shows the correlation among various domains. Pre-intervention knowledge, attitude, and practice domains were significantly related. Knowledge and attitude were positively correlated (p = 0.01, r = 0.641), which indicates that the greater the knowledge, the more favorable the attitude towards persons with epilepsy. Knowledge and attitude were negatively correlated with the practice domain. Knowledge was strongly and positively correlated with the attitude (p = 0.001, r = .423) and practice domains (p = 0.001, r = .486). This strongly suggests that knowledge leads to positive attitudes and good practices among children. Likewise, post-intervention attitudes and
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Table 1 Students' knowledge about epilepsy. Knowledge domain
1. 2. 3. 4.
Epilepsy is not a kind of mental illness. Epilepsy is a disease of the brain. Epilepsy is a hereditary disease that is passed through generations (N). Epilepsy is caused by ancestor's sin or bad karma or that maybe that person did something wrong in his previous janam [previous birth] (N). Epilepsy is not caused by touching the person. Most people suffering from epilepsy need not to take treatment for life time. Missing medicines once in a while is harmful for people suffering with epilepsy. Person with epilepsy do not cause harm to others.
5. 6. 7. 8.
Preassessment N = 70
Postassessment N = 70
Yes
Yes
No
No
N
%
N
%
N
%
N
%
61 57 31 34
87.1 81.4 44.3 48.6
9 13 39 36
12.9 18.6 55.7 51.4
66 67 1 4
94.3 95.7 1.4 5.7
4 3 69 66
5.7 4.3 98.6 94.3
12 30 10 8
17.1 42.9 14.3 11.4
58 40 60 62
82.9 57.1 85.7 88.6
64 66 61 65
91.4 94.3 87.1 92.9
6 4 9 5
8.6 5.7 12.9 7.1
N = Negatively worded.
Table 2 Students' attitude about epilepsy. Attitude domain
Preassessment Yes
1. 2. 3. 4. 5. 6. 7. 8.
It is not difficult for person with epilepsy to study if he/she has this problem. Epilepsy does not cause disturbances in leading a happy life. One should not avoid playing with a person with epilepsy. One can share books/pencils/things with a person with epilepsy. Children with epilepsy should go to special schools (N). Children with epilepsy have adequate intelligence. Children with epilepsy can take part in sports. Persons with epilepsy can achieve big success in life.
Postassessment No
Yes
No
N
%
N
%
N
%
N
%
8 15 14 12 17 17 17 23
11.4 21.4 20.0 17.1 24.3 24.3 24.3 32.9
62 55 56 58 53 53 53 47
88.6 78.6 80.0 82.9 75.7 75.7 75.7 67.1
65 64 66 64 65 57 65 61
92.9 91.4 94.3 91.4 92.9 81.4 92.9 87.1
5 6 4 6 5 13 5 9
7.1 8.6 5.7 8.6 7.1 18.6 7.1 12.9
N = Negatively worded.
practices were positively correlated (p = 0.001, r = .338), which shows that positive attitude brings positive practice. 4. Discussion Negative social attitudes and discrimination against children with epilepsy at times are more devastating than the disease itself. Creating
awareness brings desirable behavior and attitude change among children and teachers. he present study adopted a hypothesis-driven classical experimental design. The present study highlights that KAP about epilepsy were minimal among the schoolchildren and, during the posttraining program, their knowledge increased significantly (p b 0.001). Though the children were in a metropolitan city and had access to different means of
Table 3 Students' practices about epilepsy. Practice domain
1. 2. 3. 4. 5. 6. 7. 8. 9.
We should not run away when we see a person having a seizure. We have to make the person hold a bunch of keys when he or she is having a seizure (N). We have to take the person having a seizure to the hospital. We have to sprinkle water over the person's face when he or she is having a seizure (N). We have to give mouth to mouth resuscitation when the person is having a seizure (N). If the person is having a seizure, we have to immediately call the family members and inform them at the earliest. We have to hold the person tightly when he or she is having a seizure (N). We have to try to put a spoon in between the teeth when the person is having a seizure (N). We have to remove any sharp objects near the person who is having an a seizure.
Preassessment
Postassessment
Yes
Yes
No
No
N
%
N
%
N
%
N
%
19 22 11 31 21 9 8 25 13
27.1 31.4 15.7 44.3 30.0 12.9 11.4 35.7 18.6
51 48 59 39 49 61 62 45 57
72.9 68.6 84.3 55.7 70.0 87.1 88.6 64.3 81.4
64 61 65 63 66 65 3 10 54
91.4 87.1 92.9 90.0 94.3 92.9 4.3 14.3 77.1
6 9 5 7 4 5 67 60 16
8.6 12.9 7.1 10.0 5.7 7.1 95.7 85.7 22.9
N = Negatively worded.
Table 4 Students' knowledge, attitude, and practices about epilepsy. Domain
Levels of assessment
Mean
Std. deviation
T
df
Sig. level (2-tailed)
Knowledge of epilepsy
Pretest Posttest Pretest Posttest Pretest Posttest
3.47 7.60 .64 7.59 1.36 7.67
1.13 .52 .94 .55 .96 .50
−28.715
69
.000⁎⁎⁎
−47.574
69
.000⁎⁎⁎
−55.432
69
.000⁎⁎⁎
Attitude of children towards epilepsy Practices of children towards epilepsy NS = Not significant. ⁎⁎⁎ Significant at 0.001 level.
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Table 5 Knowledge, attitude and practices correlation. Preknowledge Preawareness
Preattitude
Prepractice
Postknowledge
Postattitude
Postpractice
Pearson correlation Sig.(2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N
Preattitude
Prepractice
Postknowledge
Postattitude
Postpractice
1 70
.641⁎⁎ .000
70 −.261⁎ .029 70 .102 .399 70 .062 .612 70 .148 .222 70
1 70 −.255⁎ .033 70 .088 .470 70 .101 .406 70 .085 .486 70
1 70 .058 .636 70
1 70
.064 .597 70 −.053 .661 70
70
70
.423⁎⁎ .000 .486⁎⁎ .000
1 70
70
.338⁎⁎ .004
1 70
⁎⁎ Correlation is significant at the 0.01 level (2-tailed). ⁎ Correlation is significant at the 0.05 level (2-tailed).
communication, their baseline mean KAP scores were low. This definitely would affect their attitude and behavior towards their fellow classmates with epilepsy. Having minimal awareness about epilepsy can foster stigma, wrong beliefs, and negative attitudes. The dramatic effect of having a seizure inside the classroom can be very devastating for the child, and children suffering from epilepsy are often stigmatized because of fear of the unexpected and public loss of self-control. Teachers usually do not have any formal instructions on epilepsy during their training; there is a lack of appropriate knowledge in handling the child during a seizure [7,10]. Children affected by epilepsy may face severe discrimination at school, with high rates of school dropouts and discrimination by their own classmates and teachers. There are many misconceptions surrounding the illness when a child has a seizure — e.g., giving shoes to smell and a key ring to hold. In India, especially in the rural population, it is a common belief to give a seizing person keys to hold, and this is considered as a way to stop seizures; other practices such as holding the child over a fire or giving her/him cow’s urine to name [11] worsens the outlook towards a child having epilepsy. In developing countries like India, studies have documented that students lack awareness and knowledge about epilepsy and first aid during a seizure. This could be largely due to the fear of witnessing a child having a seizure in the classroom or the misconceptions that the community or media have projected over a period of time. Various wrong practices and myths associated with epilepsy have also been reported among students [1,2,11,12]. Goel et al. [13] reported that KAP for epilepsy in Uttarakhand were very poor in comparison with those in other parts of the country. Large proportions of students believed that epilepsy is a mental disease that runs in the family, and a person with epilepsy should not be married and employed. Wrong practices like the use of onion and smelling a shoe for acute attacks were still common in their community. There was a significant relationship between post-intervention knowledge and attitude and practice. Where knowledge was high, positive attitude was seen towards epilepsy. Knowledge on epilepsy creates positive and receptive attitudes towards a person with epilepsy. More knowledge would likely lead to less stigma, isolation, and avoidance of person with epilepsy. Similarly, attitude and practice were positively correlated. This indicates that positive attitude leads to good practices such as being more adoptive, supportive, and accommodative, nondiscrimination, and fewer misconceptions. The awareness program on epilepsy brought about a change in knowledge, attitude, and practice. A larger and comprehensive community-based educational program involving parents and children, perhaps using mass media, is very essential to bring about a change in
the negative attitudes toward epilepsy. At the same time, there is dearth of literature regarding interventions to bring about a change in the attitudes of children and teachers. A Chandigarh study [14] reported that the knowledge about various aspects of epilepsy was average among school students. However, there was no significant difference in KAP between students who lived in urban, urban slum, and rural areas. It recommended that clinicians devote more time with their patients to address the social issues that they faced because of epilepsy. Hari Joshi et al. [15], in their study, confirmed gaps in knowledge and a negative attitude about various aspects of epilepsy, which is in agreement with the studies conducted among elementary schoolchildren [8]. Pandian et al. [9], in 2006, quantified KAP with respect to epilepsy among 1213 10th-grade students of Kerala, Southern India. Ninety-eight percent of them had heard or read about epilepsy. However, nearly 60% of students thought that epilepsy was a form of insanity. Allopathic treatment was preferred by more than half of the respondents; however, many had faith in exorcism and visiting religious places as ways to cure epilepsy. Half of the students considered epilepsy as a hindrance to education, employment, and marriage. Thirteen percent would be unwilling to sit adjacent to or play with a child with epilepsy. The authors concluded that, although familiarity with epilepsy was high among high school students in Kerala, misconceptions and negative attitudes were alarmingly high. The present study suggests a need to promote epilepsy awareness programs as a means of increasing public knowledge of epilepsy. It is therefore fundamental that there should be destigmatization campaigns provided to correct information and provide appropriate education. Persistent and effective information campaigns, therefore, are necessary to change the attitudes towards fellow students with epilepsy. The intervention used in the present study is simple and easy to follow. School teachers, administrators, and the government would find it easy to adopt the program. It is advisable to include a chapter on epilepsy in the school curriculum. This will bring the needed changes in attitudes and practices among teachers and students. The main limitation of this study was the small sample size and the inclusion of only one school, which limit generalizability of the findings. Future work should be conducted with large samples at multiple schools. 5. Conclusion This study was undertaken to determine the effectiveness of a health education program for epilepsy awareness among schoolchildren. The findings support the further development and implementation of
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epilepsy education programs for schoolchildren as a means of increasing public knowledge about epilepsy. The findings will be incorporated into a brief report for the Department of Public Instruction, Government of Karnataka and National Council of Educational Research and Training with a goal of incorporating epilepsy education at the state and national levels into the curriculum to raise awareness among schoolchildren.
Acknowledgment This project was funded by National Institute of Mental Health and Neuro-Sciences, Bangalore. Project code: NIMH/Proj/M/537/2013-14.
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