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Awareness and attitudes toward persons with epilepsy among teachers: A Moroccan study
Epilepsy & Behavior 102 (2020) 106633
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Awareness and attitudes toward persons with epilepsy among teachers: A Moroccan study Abdelkrim Janati Idrissi a,b,⁎, Abdelaziz Lamkaddem b,c, Saïd Boujraf a, Zouhayr Souirti a,b a b c
Neurology Department, Sleep center Hassan II University Hospital, Sidi Mohamed Ben Abdellah University, Morocco Clinical Neurosciences laboratory, Faculty of medicine and pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Morocco Cognitive Sciences Laboratory, Faculty of Letters and Humans Sciences, Sidi Mohamed Ben Abdellah University, Morocco
a r t i c l e
i n f o
Article history: Received 4 June 2019 Revised 23 October 2019 Accepted 23 October 2019 Available online xxxx Keywords: Epilepsy Teachers' attitudes Teachers' knowledge Teachers' awareness
a b s t r a c t Purpose: Many studies performed in Morocco showed an important lack of knowledge about epilepsy among persons with epilepsy and their families. The misconceptions about the disease are a source of suffering for both patients and their families and increase the costs of epilepsy care. We conducted this investigation for assessing the origins of misinterpretation of the disease in the Moroccan society. Objectives: The teachers' knowledge about epilepsy in the Fez-Meknes region in Morocco and their attitudes toward a person with epilepsy constitute the two major objectives of this study. We also assessed the impact of sociocultural parameters on Moroccan teachers' knowledge and attitudes toward a person with epilepsy. Material and methods: The data collection was based on the “Attitudes Toward Persons with Epilepsy” (ATPE) test. Results: The study showed a positive correlation between the level of teachers' knowledge of epilepsy and their attitudes toward a person with epilepsy. The results revealed the persistence of negative attitudes toward a person with epilepsy among teachers. The level of ATPE of teachers in Morocco was lower compared to high-middle income countries. Conclusion: There is still poor knowledge about epilepsy among teachers in Morocco. This unawareness is negatively affecting teachers' attitudes toward a person with epilepsy. Hence, we recommend integrating epilepsy in teaching and training programs of teachers in the Moroccan educational system. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy affects more than 70 million people in the world. According to a recent study, the prevalence of active epilepsy is estimated at 6.38 per 1000 persons, and the lifetime prevalence is 7.60 per 1000 persons. The incidence rate was 61.44 per 100,000 person-years [1]. In lowmiddle income countries, the incidence rate of epilepsy was higher than recorded scores in high-middle income countries [1,2]. Besides, nearly three-quarters of persons with epilepsy living in low- and middle-income countries have difficult access to epilepsy care [1]. There are almost no studies on epilepsy prevalence in Morocco. According to a study achieved in Casablanca in 1998, 1.1% of the Moroccans were affected by epilepsy [3]. In Morocco, people still believe that epilepsy is caused by supernatural external powers. About 75% of
⁎ Corresponding author at: Clinical Neurosciences Laboratory, Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, BP. 1893, Km 2.200, Sidi Hrazem Road, Fez 30000, Morocco. E-mail address: [email protected] (A. Janati Idrissi).
https://doi.org/10.1016/j.yebeh.2019.106633 1525-5050/© 2019 Elsevier Inc. All rights reserved.
relatives of persons with epilepsy claimed that they have used selected traditional and nonmedical practices for epilepsy care [4–6]. Teachers' knowledge and their attitudes toward a person with epilepsy have been studied in a large number of countries. These studies showed that the rate of awareness varied among teachers in these countries as well as their attitudes toward a person with epilepsy [7,9–22]. In Morocco, the sociocultural aspects of epilepsy were studied in people with epilepsy and their families. However, no study was conducted on teachers. Furthermore, according to a current systematic review, Moroccan teachers' awareness of epilepsy and their attitudes toward persons with epilepsy were studied in 27 countries around the world between 2000 and 2017. Unfortunately, Morocco did not appear in the list of these countries [7]. Thus, we drew two main objectives. First, we aimed to evaluate the Moroccan teachers' knowledge of epilepsy and their attitudes toward a person with epilepsy. Second, we targeted to study the parameters that are impacting the teachers' knowledge about epilepsy and their attitudes toward a person with epilepsy. The major aim of this research work was to contribute to fighting against the source of false representations about epilepsy in
2
A. Janati Idrissi et al. / Epilepsy & Behavior 102 (2020) 106633
2. Methods
A pilot and feasibility investigation were performed to assess any constraints that might occur during the study. Hence, we conducted a preliminary evaluation of 10 teachers to ensure the clarity of questions, and consistency.
2.1. Data collection
2.4. Statistical analysis
Data were collected using a questionnaire including five sections: The first section targeted sociodemographic information, specifically the age of participants, their education levels, their experience in the field of teaching, their teaching cycles, and the category of students they teach. The second section included questions on teachers' experiences with epilepsy (Whether the teacher has relatives, friends, or colleagues who have had epilepsy and if they discussed or taught an epileptic student). The third section of the questionnaire tackled the level of teachers' awareness of epilepsy and their attitudes toward persons with epilepsy. The questions were based on the “Attitudes toward Persons with Epilepsy” (ATPE) test, which is a scale that has been used and adapted to test both people's awareness of epilepsy and their attitudes toward people with epilepsy [8,9]. This scale comprised 28 questions, including 13 which intended to assess knowledge about the disease; the remaining 15 questions assessed individuals' attitudes toward a person with epilepsy. Teachers are invited to answer all the questions by marking a cross (×) in front of their choice either “Yes” or “No”. A set of thirteen questions are designed to evaluate the level of teacher's awareness of the disease; this included six correct questions, while seven others were false. Each answered question was scored 1 point for each correct answer, while scored 0 for false or the absence of a response; the final scale of knowledge will range from 0 to 13 points depending on the number of correct answers. The evaluation that addresses attitudes toward a person with epilepsy comprised 15 questions. Teachers were asked to answer either by marking a cross (×) in front of their choice “Yes” or “No”. This section included seven statements referring to positive attitudes if the answer is “No,” while the eight statements indicated a positive attitude when answered by the “Yes” option. Therefore, the positive attitude scale will range from 0 to 15 points. Also, the attitude score will be qualitatively scaled into three intervals as follows: “Poor Attitudes” was assigned to scores lower than 8, “Medium Attitudes” was assigned to scores ranging between 8 and 11, and “Positive Attitudes” was assigned to any score higher than 11. Many studies recommend developing educational and training programs to improve and correct the additional charges of the disease caused by misconceptions of epilepsy. The fourth section of the questionnaire included items related to teachers' information sources about epilepsy and their preferred channels of education.
The statistical analyses were carried out using Jeffrey's Amazing Statistics Program (JASP 0.9.2). We carried out a descriptive analysis, and we conducted a univariate analysis to measure the association between the mean knowledge, attitudes of teachers, and the sociodemographic parameters. The analysis was performed using t-test and analysis of variance (ANOVA). We used Pearson correlation analysis to evaluate the association between teachers' knowledge about epilepsy and their attitudes toward a person with epilepsy.
Moroccan society including teachers that are playing key cultural and educational roles.
2.2. Targeted population We evaluated the knowledge about epilepsy and attitudes toward people with epilepsy among Moroccan teachers working in the Fez-Meknes region including all levels of education. The Moroccan educational system includes three levels: primary (6 years of education), followed by lower-secondary (3 years of education), then highersecondary (3 years of education) crowned by baccalaureate degree, which allows the students to access the higher education and universities. 2.3. Ethical approval and pilot investigation The teachers who participated in this study disclosed their informed consent. We avoided asking for confidential information. Indeed, formal ethical approval was applied and granted by “Ethics Committee for Biomedical Research” of Moulay Ismail University of Meknes (Fez-Meknes region).
3. Results 3.1. Sociodemographic characteristics of the respondents This study was carried out in the Fez-Meknes region, with a population that is estimated at 4,231,164 inhabitants according to the general population assessment performed by the Moroccan government 2014. We targeted 300 teachers through 300 samples of the questionnaire. We recovered 126 with a response rate of 42%. Hence, the final size of our sample included 126 out of 25,518 teachers working in the region of the study. This represented 0.49% of all teachers working in the Fez-Meknes region. (See Table 1.) 3.2. Teachers' awareness and their attitudes toward people with epilepsy The results of teachers' ATPE are summarized in Tables 2 and 3. The effect of sociodemographic parameters on teachers' knowledge scores is shown in Fig. 1. The Fig. 2 shows the study of sociodemographic parameters impacting the teachers' attitudes score toward a person with epilepsy, the same figure is also reporting the three levels of scaling knowledge of teachers (i.e., “Poor Attitudes,” “Medium Attitudes,” and “Positive Attitudes”). The analysis of variance of the two independent groups of gender; age did not show any significant difference in the average attitudes of teachers toward persons with epilepsy. However, the analysis of variance of independent groups (group 1: primary cycle of education, group 2: lower secondary, and group 3: higher secondary) revealed a significant difference in the average of teachers attitudes toward person with epilepsy with a value of F (2) = 4114; and a p-value of p = .019. Indeed, the posthoc Tukey test showed that there is a significant Table 1 Distribution of teachers according to sociodemographic characteristics.
Gender
Age (Years)
Teaching cycle
Profession seniority (Years)
Diploma
Female (F) Male (M) b 30 (A1) 30–39 (A2) 40–49 (A3) ≥ 50 (A4) Primary school teachers (C1) Middle school teachers (C2) Qualifying school teachers (C3) b 5 (S1) 5–9 (S2) 10–14 (S3) 15–19 (S4) ≥ 20 (S5) Baccalaureates (B) Ph.D. (D) Bachelor degree (L) Master's degree (M)
Number
Percent %
49 77 34 48 28 16 20 48 58 44 25 17 16 24 6 7 69 44
38.9 61.1 27.0 38.1 22.2 12.7 15.9 38.1 46.0 34.9 19.8 13.5 12.7 19.0 4.8 5.6 54.8 34.9
A. Janati Idrissi et al. / Epilepsy & Behavior 102 (2020) 106633
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Table 2 Percentage of teachers who correctly answered each knowledge item. Total number of sample: N = 126 Knowledge items 1. Individuals with epilepsy are also mentally retarded. 2. The individual with epilepsy does not possess a normal life expectancy. 3. You can expect the condition of a person with epilepsy to deteriorate. 4. When their seizures were controlled by medication, persons with epilepsy are just like anyone else. 5. Individuals with epilepsy can cope with a 40-hour work week. 6. Persons with epilepsy can safely participate in strenuous activity. 7. Persons with epilepsy can safely operate machinery. 8. Individuals with epilepsy are accident-prone. 9. Epilepsy is a contagious disease 10. The offspring of parents with epilepsy will also have epilepsy. 11. Persons with epilepsy prefer to live with others of similar characteristics. 12. Children with epilepsy in regular classes have an adverse effect on the other children 13. Epilepsy and epilepsy medications can have a significant effect on the affected students' mood, memory, and learning
Correct answer
n
%
No No No Yes Yes Yes Yes No No No No No Yes
119 91 61 100 66 51 70 68 120 97 112 60 94
94.4 72.2 48.4 79.4 52.4 40.5 55.6 54 95.2 77 88.9 47.6 74.6
Distribution of teachers according to sociodemographic characteristics.
difference between the average attitude score of primary versus higher secondary school teachers (p = .027); the average attitude score of higher secondary cycle teachers is superior compared to the group of primary school teachers. The correlation between teachers' attitude scores toward a person with epilepsy and their awareness of the disease is significantly different, with a p-value p b .001. This correlation was shown to be positive, marking a better attitude toward a person with epilepsy with improved knowledge score about the disease. 3.3. Sources of teachers' information on epilepsy Up to 99.2% of teachers in this sample report that they have not taken any education and training on epilepsy. Moreover, 96.8% of them have not attended any first aid training that must be provided to students during a seizure in the classroom. On the other hand, 93.7% of teachers expressed their need for additional information on epilepsy. Audiovisual media was the most preferred tool for teachers to receive additional information or training on the disease. This tool was chosen by 73.8% of the teachers in our sample. The distribution of brochures was suggested by 54% of teachers while 55.6% preferred articles as secondary tools for learning more about the disease. 4. Discussion The results of our study showed a correlation between teachers' level of awareness of the disease and their attitudes toward a person with epilepsy. A better knowledge of the disease leads to Positive
attitudes toward a person with epilepsy. There was also an improvement in the knowledge and attitude score among a large population of teachers with relatives/family members with epilepsy. Several misconceptions about epilepsy were found among teachers despite their educational level. Age, gender, and teaching experiences did not reveal a significant effect on the improvement of both the means of teachers' knowledge and attitudes. While there was a significant difference in the teachers' average attitudes depending on their teaching cycle. The mean attitude score of higher secondary cycle teachers was higher compared to primary school teachers. The positive correlation between the level of awareness about epilepsy and attitudes toward a person with epilepsy has been reported in several studies [9–22]. This correlation depends on a variety of parameters. A Korean study showed that teachers' with relatives with epilepsy promoted their awareness and attitudes scores; an equivalent result was revealed in our study. Besides, the knowledge score and previous experience in teaching a student with epilepsy were both the main factors that significantly influence the Korean teachers' attitude score [17]. The positive attitudes were recorded among USA teachers despite the continuous lack of knowledge about the disease [19]. Indeed, several studies carried out in the last decade in many countries reported a lack of knowledge of epilepsy among the teaching community [9–22]. The ATPE test provides an opportunity to study each component of the test individually and thus provide better visibility on each test statement. In the list of statements related to the assessment of teachers' knowledge, there were questions 3, 5, 6, 7, 8, and 12 that can be considered as unknown by a large fraction of the population in our
Table 3 Attitudes correctly answered by teachers. Total number of sample: N = 126 Attitude items 1. Persons with epilepsy have the same rights as all people. 2. Equal employment opportunities should be available to individuals with epilepsy. 3. Insurance companies should not deny insurance to individuals with epilepsy. 4. Persons with epilepsy should be prohibited from driving. 5. Persons with epilepsy should not be prohibited from marrying. 6. The individual with epilepsy should not be prevented from having children. 7. The onset of epileptic seizures in a spouse is sufficient reason for divorce. 8. Persons with epilepsy are a danger to the public. 9. Persons with epilepsy are more likely to develop and express criminal tendencies than are other people. 10. Families of children with epilepsy should not be provided with supportive social services. 11. Parents should expect of their child who has epilepsy what they expect of other children. 12. The responsibility for educating children with epilepsy rests on the community. 13. Schools should not place children with epilepsy in regular classrooms. 14. Children need to be protected from classmates who have epilepsy. 15. Children with epilepsy should attend regular public schools. Bold percentages refer to high negative attitudes.
Positive attitude
n
%
Yes Yes Yes No Yes Yes No No No No Yes Yes No No Yes
119 120 125 39 112 89 120 118 113 118 121 112 91 80 117
94.4 95.2 99.2 31 88.9 70.6 95.2 93.7 89.7 93.7 96.0 88.9 72.2 63.5 92.9
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A. Janati Idrissi et al. / Epilepsy & Behavior 102 (2020) 106633
Fig. 1. Variation in teachers' knowledge average according to sociodemographic characteristics. Error bars indicate 95% confidence intervals. - Sex: F = Female, M = Male. - Age: A1 = b 30 years, A2 = between 30 and 39 years, A3 = between 40 and 49 year, A4 = greater than or equal to 50 year. - Teaching cycle: C1 = Primary school teachers, C2 = Middle school teachers and C3 = Qualifying school teachers. - Teachers' profession seniority: S1 = less than 5 years, S2 = between 5 and 9 years, S3 = between 10 and 14, S4 = between 15 –and 19 years and S5 = greater than or equal to 20 years. - Teachers' diploma: B = Baccalaureates, L = Bachelor degree, M = Master's degree and D = PhD.
sample. These questions were incorrectly answered by more than 40% of teachers. The first review of these questions allowed drawing the following remarks: First, questions 5, 6, 7, and 8 aimed to evaluate the opinions on the ability of people with epilepsy to tolerate hard work for a longer time. This suggests that teachers in Morocco believe that epilepsy is negatively affecting the physical and mental abilities of an affected person. Second, question 12 is intended to test the aggressive character of the person with epilepsy; nearly 52% of teachers believe that epilepsy is often accompanied by aggressive acts. Answers to questions 13 and 14 proved the aggressive character of people with epilepsy in the conviction of over half of teachers.
Up to 30% of teachers believe that a person with epilepsy should not have children because they consider epilepsy as an inherited disease. Up to 23% of teachers considered that children of a person with epilepsy will also have epilepsy. Despite multiple advantages of ATPE test mentioned above, it has still limitations. There are many types of epilepsy, so the questions cannot always be answered correctly without knowing what type of epilepsy is being considered. For instance, in knowledge list statements (Table 2), some people with epilepsy have a higher mortality rate than the general population (question 2), others have a worsening condition (question 3), and they should not handle heavy machinery and
Fig. 2. Variation in the average of teachers attitudes score toward persons with epilepsy according to sociodemographic characteristics: The error bars indicate the 95% confidence intervals. - Sex: F = Female, M = Male. - Age: A1 = b 30 years, A2 = between 30 and 39 years, A3 = between 40 and 49 year, A4 = greater than or equal to 50 year. - Teaching cycle: C1 = Primary school teachers, C2 = Middle school teachers and C3 = Qualifying school teachers. - Teachers' profession seniority: S1 = less than 5 years, S2 = between 5 and 9 years, S3 = between 10 and 14, S4 = between 15 –and 19 years and S5 = greater than or equal to 20 years. - Teachers' diploma: B = Baccalaureates, L = Bachelor degree, M = Master's degree and D = PhD.
A. Janati Idrissi et al. / Epilepsy & Behavior 102 (2020) 106633
dangerous materials if their seizures are not controlled (question 7). In attitudes list statements (Table 3), people with uncontrolled epilepsy should not drive (question 4). These remarks prove the need to review the expression of these questions to remove any ambiguity and possible insertions and thus the improvement of the test. Other obstacles were encountered in conducting this study. Teachers' contact information was not available or difficult to access, and a lower percentage of respondents, which resulted in a limited sample size. We demonstrated that the lack of knowledge about epilepsy in the teacher's community in Morocco might generate negative attitudes toward a person with epilepsy. Several studies have shown that teachers' knowledge has improved after further training and instruction on epilepsy. This improvement in knowledge has positively affected teachers' attitudes toward a person with epilepsy [23–28]. There is a real gap in epilepsy information and training programs in the curricula adopted by educational authorities in Morocco. Besides first aid supply, teachers need training courses on the disease and on how to deal with epileptic seizures. The inappropriate resources used by teachers to learn about the disease can be a likely cause of their misconceptions and negative attitudes. Scientific journals and audiovisual media are reliable sources of information. 5. Summary and conclusion In conclusion, teachers in Morocco still need awareness of epilepsy. False education resources lead to the persistence of negative attitudes in teachers' population toward persons with epilepsy. This key community is powerful and essential for the leverage toward combating the false representations of epilepsy that interferes with this neurologic disease. Such correction would allow fighting against all forms of marginalization and exclusion, resulting from the community representations about epilepsy. We recommend the integration of teaching and training programs on epilepsy for teachers in the Moroccan education system. Declaration of Competing Interest There is no conflict of interest in this article. References [1] Fiest KM, Sauro KM, Wiebe S, Patten SB, Kwon CS, Dykeman J, et al. Prevalence and incidence of epilepsy: a systematic review and meta-analysis of international studies. Neurology 2017;88(3):296–303. [2] Ngugi AK, Kariuki SM, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Incidence of epilepsy: a systematic review and meta-analysis. Neurology 2011;77:1005–12. [3] Itri M, Hadj Khalifa H. Enquéte épidémiologique sur les épilepsies de l'enfant. Les Cahiers du Médecin 1998;1(9):36–8. [4] Arib Safa, et al. Connaissances, attitudes et pratiques traditionnelles envers l'Épilepsie. Thése en médecine. Marrakech: Université Cadi Ayyad, Faculté de Médecine et de pharmacie; 2008. [5] Bahbiti Y, Benazzouz B, Moutaouakil F, Ouichou A, El Hessni A, Mesfioui A. Anthropological and epidemiological study of epilepsy in the region of Tangier (Morocco). J Neurol Sci 2013;e6:333.
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[6] Jacoby A. Stigma, epilepsy, and quality of life. Epilepsy Behav 2002(6S2):10–20. [7] Jones C, Atkinson P, Helen Cross J, Reilly C. Knowledge of and attitudes towards epilepsy among teachers: a systematic review. Epilepsy Behav 2018;87:59–68. [8] Antonak RF. Psychometric analysis and validation of the scale of attitudes toward persons with epilepsy. J Epilepsy 1990;3(1):11–6. [9] Bishop M, Boag EM. Teachers' knowledge about epilepsy and attitudes toward students with epilepsy: results of a national survey. Epilepsy Behav 2006;8(2): 397–405. [10] Al-Hashemi E, Ashkanani A, Al-Qattan H, Mahmoud A, Al-Kabbani M, Al-Juhaidli A, et al. Knowledge about epilepsy and attitudes toward students with epilepsy among middle and high school teachers in Kuwait. Int J Pediatr 2016;3:1–15. [11] Elhassan MA, Alemairy AA, Amara ZM, Hamadelneel AA, Mohamed AH, Elaimeri AA. Epilepsy: knowledge, attitude, and practice among secondary school teachers in Khartoum State. Neurol Ther 2017;6(2):225–35. [12] Berhe T, Yihun B, Abebe E, Abera H. Knowledge, attitude, and practice about epilepsy among teachers at Ethio-National School, Addis Ababa, Ethiopia. Epilepsy Behav 2017;70:150–3. [13] Gebrewold MA, Enquselassie F, Teklehaimanot R, Gugssa SA. Ethiopian teachers: their knowledge, attitude and practice towards epilepsy. BMC Neurol 2016;16 (1):167. [14] Kampra M, Tzerakis NG, Losidis S, Katsarou E, Voudris K, Mastroyianni S, et al. Teachers knowledge about epilepsy in Greece: information sources and attitudes towards children with epilepsy during school time. Epilepsy Behav 2016;60:218–24. [15] Karimi N, Heidari M. Knowledge and attitudes toward epilepsy among school teachers in West of Iran. Iran J Neurol 2015;14(3):130. [16] Owolabi LF, Shehu NM, Owolabi SD. Epilepsy and education in developing countries: a survey of school teachers' knowledge about epilepsy and their attitude towards students with epilepsy in Northwestern Nigeria. Pan Afr Med J 2014;18. [17] Lee SA, Yim SB, Rho YI, Chu M, Park HM, Lee GH, et al. Factors contributing to Korean teachers' attitudes toward students with epilepsy. Epilepsy Behav 2011;20(2): 378–81. [18] Kaleyias J, Tzoufi M, Kotsalis C, Papavasiliou A, Diamantopoulos N. Knowledge and attitude of the Greek educational community toward epilepsy and the epileptic student. Epilepsy Behav 2005;6(2):179–86. [19] Bishop M, Slevin B. Teachers' attitudes toward students with epilepsy: results of a survey of elementary and middle school teachers. Epilepsy Behav 2004;5(3): 308–15. [20] Rambe AS, Sjahrir H. Awareness, attitudes and understanding towards epilepsy among school teachers in Medan, Indonesia. Neurol J Southeast Asia 2002;7: 77–80. [21] Bekiroğlu N, Özkan R, Gürses C, Arpacı B, Dervent A. A study on awareness and attitude of teachers on epilepsy in Istanbul. Seizure 2004;13(7):517–22. [22] Lim KS, Hills MD, Choo WY, Wong MH, Wu C, Tan CT. Attitudes toward epilepsy among the primary and secondary school teachers in Malaysia, using the public attitudes toward epilepsy (PATE) scale. Epilepsy Res 2013;106(3):433–9. [23] Mecarelli O, Messina P, Capovilla G, Michelucci R, Romeo A, Beghi E, et al. An educational campaign about epilepsy among Italian primary school teachers. 2. The results of a focused training program. Epilepsy Behav 2015;42:93–7. [24] Aydin K, Yildiz H. Teachers' perceptions in Central Turkey concerning epilepsy and asthma and the short-term effect of a brief education on the perception of epilepsy. Epilepsy Behav 2007;10(2):286–90. [25] Dumeier HK, Neininger MP, Kaune A, Schumacher PM, Merkenschlager A, Kiess W, et al. Seizure management by preschool teachers: a training concept focussing on practical skills. Seizure 2017;50:38–42. [26] Martiniuk AL, Speechley KN, Secco M, Campbell MK, Donner A. Evaluation of an epilepsy education program for grade 5 students: a cluster randomized trial. Epilepsy Behav 2007;10(4):604–10. [27] Ibinda F, Mbuba CK, Kariuki SM, Chengo E, Ngugi AK, Odhiambo R, et al. Evaluation of Kilifi epilepsy education programme: a randomized controlled trial. Epilepsia 2014;55(2):344–52. [28] Sajatovic M, Herrmann LK, Van Doren JR, Tatsuoka C, Welter E, Perzynski AT, et al. A randomized prospective pilot trial of web-delivered epilepsy stigma reduction communications in young adults. Epilepsia 2017;58(11):1946–54.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Awareness and attitudes toward persons with epilepsy among teachers: A Moroccan study Abdelkrim Janati Idrissi a,b,⁎, Abdelaziz Lamkaddem b,c, Saïd Boujraf a, Zouhayr Souirti a,b a b c
Neurology Department, Sleep center Hassan II University Hospital, Sidi Mohamed Ben Abdellah University, Morocco Clinical Neurosciences laboratory, Faculty of medicine and pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Morocco Cognitive Sciences Laboratory, Faculty of Letters and Humans Sciences, Sidi Mohamed Ben Abdellah University, Morocco
a r t i c l e
i n f o
Article history: Received 4 June 2019 Revised 23 October 2019 Accepted 23 October 2019 Available online xxxx Keywords: Epilepsy Teachers' attitudes Teachers' knowledge Teachers' awareness
a b s t r a c t Purpose: Many studies performed in Morocco showed an important lack of knowledge about epilepsy among persons with epilepsy and their families. The misconceptions about the disease are a source of suffering for both patients and their families and increase the costs of epilepsy care. We conducted this investigation for assessing the origins of misinterpretation of the disease in the Moroccan society. Objectives: The teachers' knowledge about epilepsy in the Fez-Meknes region in Morocco and their attitudes toward a person with epilepsy constitute the two major objectives of this study. We also assessed the impact of sociocultural parameters on Moroccan teachers' knowledge and attitudes toward a person with epilepsy. Material and methods: The data collection was based on the “Attitudes Toward Persons with Epilepsy” (ATPE) test. Results: The study showed a positive correlation between the level of teachers' knowledge of epilepsy and their attitudes toward a person with epilepsy. The results revealed the persistence of negative attitudes toward a person with epilepsy among teachers. The level of ATPE of teachers in Morocco was lower compared to high-middle income countries. Conclusion: There is still poor knowledge about epilepsy among teachers in Morocco. This unawareness is negatively affecting teachers' attitudes toward a person with epilepsy. Hence, we recommend integrating epilepsy in teaching and training programs of teachers in the Moroccan educational system. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy affects more than 70 million people in the world. According to a recent study, the prevalence of active epilepsy is estimated at 6.38 per 1000 persons, and the lifetime prevalence is 7.60 per 1000 persons. The incidence rate was 61.44 per 100,000 person-years [1]. In lowmiddle income countries, the incidence rate of epilepsy was higher than recorded scores in high-middle income countries [1,2]. Besides, nearly three-quarters of persons with epilepsy living in low- and middle-income countries have difficult access to epilepsy care [1]. There are almost no studies on epilepsy prevalence in Morocco. According to a study achieved in Casablanca in 1998, 1.1% of the Moroccans were affected by epilepsy [3]. In Morocco, people still believe that epilepsy is caused by supernatural external powers. About 75% of
⁎ Corresponding author at: Clinical Neurosciences Laboratory, Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, BP. 1893, Km 2.200, Sidi Hrazem Road, Fez 30000, Morocco. E-mail address: [email protected] (A. Janati Idrissi).
https://doi.org/10.1016/j.yebeh.2019.106633 1525-5050/© 2019 Elsevier Inc. All rights reserved.
relatives of persons with epilepsy claimed that they have used selected traditional and nonmedical practices for epilepsy care [4–6]. Teachers' knowledge and their attitudes toward a person with epilepsy have been studied in a large number of countries. These studies showed that the rate of awareness varied among teachers in these countries as well as their attitudes toward a person with epilepsy [7,9–22]. In Morocco, the sociocultural aspects of epilepsy were studied in people with epilepsy and their families. However, no study was conducted on teachers. Furthermore, according to a current systematic review, Moroccan teachers' awareness of epilepsy and their attitudes toward persons with epilepsy were studied in 27 countries around the world between 2000 and 2017. Unfortunately, Morocco did not appear in the list of these countries [7]. Thus, we drew two main objectives. First, we aimed to evaluate the Moroccan teachers' knowledge of epilepsy and their attitudes toward a person with epilepsy. Second, we targeted to study the parameters that are impacting the teachers' knowledge about epilepsy and their attitudes toward a person with epilepsy. The major aim of this research work was to contribute to fighting against the source of false representations about epilepsy in
2
A. Janati Idrissi et al. / Epilepsy & Behavior 102 (2020) 106633
2. Methods
A pilot and feasibility investigation were performed to assess any constraints that might occur during the study. Hence, we conducted a preliminary evaluation of 10 teachers to ensure the clarity of questions, and consistency.
2.1. Data collection
2.4. Statistical analysis
Data were collected using a questionnaire including five sections: The first section targeted sociodemographic information, specifically the age of participants, their education levels, their experience in the field of teaching, their teaching cycles, and the category of students they teach. The second section included questions on teachers' experiences with epilepsy (Whether the teacher has relatives, friends, or colleagues who have had epilepsy and if they discussed or taught an epileptic student). The third section of the questionnaire tackled the level of teachers' awareness of epilepsy and their attitudes toward persons with epilepsy. The questions were based on the “Attitudes toward Persons with Epilepsy” (ATPE) test, which is a scale that has been used and adapted to test both people's awareness of epilepsy and their attitudes toward people with epilepsy [8,9]. This scale comprised 28 questions, including 13 which intended to assess knowledge about the disease; the remaining 15 questions assessed individuals' attitudes toward a person with epilepsy. Teachers are invited to answer all the questions by marking a cross (×) in front of their choice either “Yes” or “No”. A set of thirteen questions are designed to evaluate the level of teacher's awareness of the disease; this included six correct questions, while seven others were false. Each answered question was scored 1 point for each correct answer, while scored 0 for false or the absence of a response; the final scale of knowledge will range from 0 to 13 points depending on the number of correct answers. The evaluation that addresses attitudes toward a person with epilepsy comprised 15 questions. Teachers were asked to answer either by marking a cross (×) in front of their choice “Yes” or “No”. This section included seven statements referring to positive attitudes if the answer is “No,” while the eight statements indicated a positive attitude when answered by the “Yes” option. Therefore, the positive attitude scale will range from 0 to 15 points. Also, the attitude score will be qualitatively scaled into three intervals as follows: “Poor Attitudes” was assigned to scores lower than 8, “Medium Attitudes” was assigned to scores ranging between 8 and 11, and “Positive Attitudes” was assigned to any score higher than 11. Many studies recommend developing educational and training programs to improve and correct the additional charges of the disease caused by misconceptions of epilepsy. The fourth section of the questionnaire included items related to teachers' information sources about epilepsy and their preferred channels of education.
The statistical analyses were carried out using Jeffrey's Amazing Statistics Program (JASP 0.9.2). We carried out a descriptive analysis, and we conducted a univariate analysis to measure the association between the mean knowledge, attitudes of teachers, and the sociodemographic parameters. The analysis was performed using t-test and analysis of variance (ANOVA). We used Pearson correlation analysis to evaluate the association between teachers' knowledge about epilepsy and their attitudes toward a person with epilepsy.
Moroccan society including teachers that are playing key cultural and educational roles.
2.2. Targeted population We evaluated the knowledge about epilepsy and attitudes toward people with epilepsy among Moroccan teachers working in the Fez-Meknes region including all levels of education. The Moroccan educational system includes three levels: primary (6 years of education), followed by lower-secondary (3 years of education), then highersecondary (3 years of education) crowned by baccalaureate degree, which allows the students to access the higher education and universities. 2.3. Ethical approval and pilot investigation The teachers who participated in this study disclosed their informed consent. We avoided asking for confidential information. Indeed, formal ethical approval was applied and granted by “Ethics Committee for Biomedical Research” of Moulay Ismail University of Meknes (Fez-Meknes region).
3. Results 3.1. Sociodemographic characteristics of the respondents This study was carried out in the Fez-Meknes region, with a population that is estimated at 4,231,164 inhabitants according to the general population assessment performed by the Moroccan government 2014. We targeted 300 teachers through 300 samples of the questionnaire. We recovered 126 with a response rate of 42%. Hence, the final size of our sample included 126 out of 25,518 teachers working in the region of the study. This represented 0.49% of all teachers working in the Fez-Meknes region. (See Table 1.) 3.2. Teachers' awareness and their attitudes toward people with epilepsy The results of teachers' ATPE are summarized in Tables 2 and 3. The effect of sociodemographic parameters on teachers' knowledge scores is shown in Fig. 1. The Fig. 2 shows the study of sociodemographic parameters impacting the teachers' attitudes score toward a person with epilepsy, the same figure is also reporting the three levels of scaling knowledge of teachers (i.e., “Poor Attitudes,” “Medium Attitudes,” and “Positive Attitudes”). The analysis of variance of the two independent groups of gender; age did not show any significant difference in the average attitudes of teachers toward persons with epilepsy. However, the analysis of variance of independent groups (group 1: primary cycle of education, group 2: lower secondary, and group 3: higher secondary) revealed a significant difference in the average of teachers attitudes toward person with epilepsy with a value of F (2) = 4114; and a p-value of p = .019. Indeed, the posthoc Tukey test showed that there is a significant Table 1 Distribution of teachers according to sociodemographic characteristics.
Gender
Age (Years)
Teaching cycle
Profession seniority (Years)
Diploma
Female (F) Male (M) b 30 (A1) 30–39 (A2) 40–49 (A3) ≥ 50 (A4) Primary school teachers (C1) Middle school teachers (C2) Qualifying school teachers (C3) b 5 (S1) 5–9 (S2) 10–14 (S3) 15–19 (S4) ≥ 20 (S5) Baccalaureates (B) Ph.D. (D) Bachelor degree (L) Master's degree (M)
Number
Percent %
49 77 34 48 28 16 20 48 58 44 25 17 16 24 6 7 69 44
38.9 61.1 27.0 38.1 22.2 12.7 15.9 38.1 46.0 34.9 19.8 13.5 12.7 19.0 4.8 5.6 54.8 34.9
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Table 2 Percentage of teachers who correctly answered each knowledge item. Total number of sample: N = 126 Knowledge items 1. Individuals with epilepsy are also mentally retarded. 2. The individual with epilepsy does not possess a normal life expectancy. 3. You can expect the condition of a person with epilepsy to deteriorate. 4. When their seizures were controlled by medication, persons with epilepsy are just like anyone else. 5. Individuals with epilepsy can cope with a 40-hour work week. 6. Persons with epilepsy can safely participate in strenuous activity. 7. Persons with epilepsy can safely operate machinery. 8. Individuals with epilepsy are accident-prone. 9. Epilepsy is a contagious disease 10. The offspring of parents with epilepsy will also have epilepsy. 11. Persons with epilepsy prefer to live with others of similar characteristics. 12. Children with epilepsy in regular classes have an adverse effect on the other children 13. Epilepsy and epilepsy medications can have a significant effect on the affected students' mood, memory, and learning
Correct answer
n
%
No No No Yes Yes Yes Yes No No No No No Yes
119 91 61 100 66 51 70 68 120 97 112 60 94
94.4 72.2 48.4 79.4 52.4 40.5 55.6 54 95.2 77 88.9 47.6 74.6
Distribution of teachers according to sociodemographic characteristics.
difference between the average attitude score of primary versus higher secondary school teachers (p = .027); the average attitude score of higher secondary cycle teachers is superior compared to the group of primary school teachers. The correlation between teachers' attitude scores toward a person with epilepsy and their awareness of the disease is significantly different, with a p-value p b .001. This correlation was shown to be positive, marking a better attitude toward a person with epilepsy with improved knowledge score about the disease. 3.3. Sources of teachers' information on epilepsy Up to 99.2% of teachers in this sample report that they have not taken any education and training on epilepsy. Moreover, 96.8% of them have not attended any first aid training that must be provided to students during a seizure in the classroom. On the other hand, 93.7% of teachers expressed their need for additional information on epilepsy. Audiovisual media was the most preferred tool for teachers to receive additional information or training on the disease. This tool was chosen by 73.8% of the teachers in our sample. The distribution of brochures was suggested by 54% of teachers while 55.6% preferred articles as secondary tools for learning more about the disease. 4. Discussion The results of our study showed a correlation between teachers' level of awareness of the disease and their attitudes toward a person with epilepsy. A better knowledge of the disease leads to Positive
attitudes toward a person with epilepsy. There was also an improvement in the knowledge and attitude score among a large population of teachers with relatives/family members with epilepsy. Several misconceptions about epilepsy were found among teachers despite their educational level. Age, gender, and teaching experiences did not reveal a significant effect on the improvement of both the means of teachers' knowledge and attitudes. While there was a significant difference in the teachers' average attitudes depending on their teaching cycle. The mean attitude score of higher secondary cycle teachers was higher compared to primary school teachers. The positive correlation between the level of awareness about epilepsy and attitudes toward a person with epilepsy has been reported in several studies [9–22]. This correlation depends on a variety of parameters. A Korean study showed that teachers' with relatives with epilepsy promoted their awareness and attitudes scores; an equivalent result was revealed in our study. Besides, the knowledge score and previous experience in teaching a student with epilepsy were both the main factors that significantly influence the Korean teachers' attitude score [17]. The positive attitudes were recorded among USA teachers despite the continuous lack of knowledge about the disease [19]. Indeed, several studies carried out in the last decade in many countries reported a lack of knowledge of epilepsy among the teaching community [9–22]. The ATPE test provides an opportunity to study each component of the test individually and thus provide better visibility on each test statement. In the list of statements related to the assessment of teachers' knowledge, there were questions 3, 5, 6, 7, 8, and 12 that can be considered as unknown by a large fraction of the population in our
Table 3 Attitudes correctly answered by teachers. Total number of sample: N = 126 Attitude items 1. Persons with epilepsy have the same rights as all people. 2. Equal employment opportunities should be available to individuals with epilepsy. 3. Insurance companies should not deny insurance to individuals with epilepsy. 4. Persons with epilepsy should be prohibited from driving. 5. Persons with epilepsy should not be prohibited from marrying. 6. The individual with epilepsy should not be prevented from having children. 7. The onset of epileptic seizures in a spouse is sufficient reason for divorce. 8. Persons with epilepsy are a danger to the public. 9. Persons with epilepsy are more likely to develop and express criminal tendencies than are other people. 10. Families of children with epilepsy should not be provided with supportive social services. 11. Parents should expect of their child who has epilepsy what they expect of other children. 12. The responsibility for educating children with epilepsy rests on the community. 13. Schools should not place children with epilepsy in regular classrooms. 14. Children need to be protected from classmates who have epilepsy. 15. Children with epilepsy should attend regular public schools. Bold percentages refer to high negative attitudes.
Positive attitude
n
%
Yes Yes Yes No Yes Yes No No No No Yes Yes No No Yes
119 120 125 39 112 89 120 118 113 118 121 112 91 80 117
94.4 95.2 99.2 31 88.9 70.6 95.2 93.7 89.7 93.7 96.0 88.9 72.2 63.5 92.9
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Fig. 1. Variation in teachers' knowledge average according to sociodemographic characteristics. Error bars indicate 95% confidence intervals. - Sex: F = Female, M = Male. - Age: A1 = b 30 years, A2 = between 30 and 39 years, A3 = between 40 and 49 year, A4 = greater than or equal to 50 year. - Teaching cycle: C1 = Primary school teachers, C2 = Middle school teachers and C3 = Qualifying school teachers. - Teachers' profession seniority: S1 = less than 5 years, S2 = between 5 and 9 years, S3 = between 10 and 14, S4 = between 15 –and 19 years and S5 = greater than or equal to 20 years. - Teachers' diploma: B = Baccalaureates, L = Bachelor degree, M = Master's degree and D = PhD.
sample. These questions were incorrectly answered by more than 40% of teachers. The first review of these questions allowed drawing the following remarks: First, questions 5, 6, 7, and 8 aimed to evaluate the opinions on the ability of people with epilepsy to tolerate hard work for a longer time. This suggests that teachers in Morocco believe that epilepsy is negatively affecting the physical and mental abilities of an affected person. Second, question 12 is intended to test the aggressive character of the person with epilepsy; nearly 52% of teachers believe that epilepsy is often accompanied by aggressive acts. Answers to questions 13 and 14 proved the aggressive character of people with epilepsy in the conviction of over half of teachers.
Up to 30% of teachers believe that a person with epilepsy should not have children because they consider epilepsy as an inherited disease. Up to 23% of teachers considered that children of a person with epilepsy will also have epilepsy. Despite multiple advantages of ATPE test mentioned above, it has still limitations. There are many types of epilepsy, so the questions cannot always be answered correctly without knowing what type of epilepsy is being considered. For instance, in knowledge list statements (Table 2), some people with epilepsy have a higher mortality rate than the general population (question 2), others have a worsening condition (question 3), and they should not handle heavy machinery and
Fig. 2. Variation in the average of teachers attitudes score toward persons with epilepsy according to sociodemographic characteristics: The error bars indicate the 95% confidence intervals. - Sex: F = Female, M = Male. - Age: A1 = b 30 years, A2 = between 30 and 39 years, A3 = between 40 and 49 year, A4 = greater than or equal to 50 year. - Teaching cycle: C1 = Primary school teachers, C2 = Middle school teachers and C3 = Qualifying school teachers. - Teachers' profession seniority: S1 = less than 5 years, S2 = between 5 and 9 years, S3 = between 10 and 14, S4 = between 15 –and 19 years and S5 = greater than or equal to 20 years. - Teachers' diploma: B = Baccalaureates, L = Bachelor degree, M = Master's degree and D = PhD.
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dangerous materials if their seizures are not controlled (question 7). In attitudes list statements (Table 3), people with uncontrolled epilepsy should not drive (question 4). These remarks prove the need to review the expression of these questions to remove any ambiguity and possible insertions and thus the improvement of the test. Other obstacles were encountered in conducting this study. Teachers' contact information was not available or difficult to access, and a lower percentage of respondents, which resulted in a limited sample size. We demonstrated that the lack of knowledge about epilepsy in the teacher's community in Morocco might generate negative attitudes toward a person with epilepsy. Several studies have shown that teachers' knowledge has improved after further training and instruction on epilepsy. This improvement in knowledge has positively affected teachers' attitudes toward a person with epilepsy [23–28]. There is a real gap in epilepsy information and training programs in the curricula adopted by educational authorities in Morocco. Besides first aid supply, teachers need training courses on the disease and on how to deal with epileptic seizures. The inappropriate resources used by teachers to learn about the disease can be a likely cause of their misconceptions and negative attitudes. Scientific journals and audiovisual media are reliable sources of information. 5. Summary and conclusion In conclusion, teachers in Morocco still need awareness of epilepsy. False education resources lead to the persistence of negative attitudes in teachers' population toward persons with epilepsy. This key community is powerful and essential for the leverage toward combating the false representations of epilepsy that interferes with this neurologic disease. Such correction would allow fighting against all forms of marginalization and exclusion, resulting from the community representations about epilepsy. We recommend the integration of teaching and training programs on epilepsy for teachers in the Moroccan education system. Declaration of Competing Interest There is no conflict of interest in this article. References [1] Fiest KM, Sauro KM, Wiebe S, Patten SB, Kwon CS, Dykeman J, et al. Prevalence and incidence of epilepsy: a systematic review and meta-analysis of international studies. Neurology 2017;88(3):296–303. [2] Ngugi AK, Kariuki SM, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Incidence of epilepsy: a systematic review and meta-analysis. Neurology 2011;77:1005–12. [3] Itri M, Hadj Khalifa H. Enquéte épidémiologique sur les épilepsies de l'enfant. Les Cahiers du Médecin 1998;1(9):36–8. [4] Arib Safa, et al. Connaissances, attitudes et pratiques traditionnelles envers l'Épilepsie. Thése en médecine. Marrakech: Université Cadi Ayyad, Faculté de Médecine et de pharmacie; 2008. [5] Bahbiti Y, Benazzouz B, Moutaouakil F, Ouichou A, El Hessni A, Mesfioui A. Anthropological and epidemiological study of epilepsy in the region of Tangier (Morocco). J Neurol Sci 2013;e6:333.
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