- Email: [email protected]
Knowledge of, perceptions of, attitudes and practices regarding epilepsy among medical students in Turkey
Epilepsy & Behavior 58 (2016) 115–118
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Knowledge of, perceptions of, attitudes and practices regarding epilepsy among medical students in Turkey Ayşe Kartal Department of Child Neurology, Selçuk University, Faculty of Medicine, Konya, Turkey
a r t i c l e
i n f o
Article history: Received 12 January 2016 Revised 28 February 2016 Accepted 29 February 2016 Available online 9 April 2016 Keywords: Epilepsy Knowledge Attitude Medical students Turkey
a b s t r a c t Purpose: Medical practitioners' attitudes have a significant impact on the quality of care for patients with epilepsy. This study was conducted to assess the current level of knowledge about epilepsy and treatment together with attitudes and perception toward patients with epilepsy among medical students in Turkey. Method: The study was conducted using a structured questionnaire to assess knowledge, awareness, and practices about epilepsy among medical students at Selçuk University, Konya, Turkey. Results: Eight hundred and ninety subjects were interviewed, and 73.5% reported their awareness about epilepsy. Of these, 38.1% knew someone who had epilepsy, and 38.5% had witnessed an epileptic seizure. Although most of the students had heard about epilepsy, 38.4% of the students believed that epilepsy was primarily a genetic disease. About one-fifth of the students attributed the causes of epilepsy to vitamin deficiency (8.8%) and psychiatric (19.1%), infectious (19.5%), mental (4.4%), and hematological disorders (3.4%). According to 4.8% of the students, epilepsy could be a punishment from God, and 2.1% of students thought that it could be caused by an evil spirit. Eighty-eight percent considered epilepsy as a dangerous disease, and most of them thought that epilepsy is a lifelong condition. Fifty point six percent indicated that putting an object into the patient's mouth to prevent tonguebiting during a seizure is appropriate while 91.9% stated that drug therapy was the only treatment available for epilepsy. The most common negative attitudes toward people with epilepsy were students' objection to marrying someone with epilepsy and patients with epilepsy having children. Conclusion: Misconceptions about the causes, treatment, and nature of epilepsy are common among medical students at a Turkish medical school. Negative attitudes toward patients with epilepsy still exist. Medical school training programs should be designed to increase awareness of students about epilepsy. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is one of the most common neurological disorders, affecting 1% of the population worldwide. It is a major public health problem in developing countries like Turkey and has been associated with stigma and negative preconceptions among both educated and uneducated people [1]. The causes of these negative attitudes are the lack of basic knowledge of epilepsy, misunderstanding, and some cultural beliefs. Nevertheless, community-based studies have shown that welleducated individuals have greater knowledge and lesser negative attitudes regarding epilepsy [2–5]. Medical students represent a welleducated part of the society and are the future workforce in the field of neurology of every country. Thus, it is important that they obtain the right knowledge about epilepsy and maintain an appropriate attitude toward a patient with epilepsy. Assessing the knowledge, attitudes, and practices regarding epilepsy of medical students will allow for better designed and targeted educational programs. However, very few published papers have examined these issues among university students in Turkey, and none focused on medical students. The purpose E-mail address: [email protected].
http://dx.doi.org/10.1016/j.yebeh.2016.02.042 1525-5050/© 2016 Elsevier Inc. All rights reserved.
of this study was therefore to assess Turkish medical students' knowledge about epilepsy and treatment together with their attitudes and perception of patients with epilepsy. 2. Methods This study was a cross-sectional survey carried out at Selçuk University, Konya, Turkey, a tertiary institution located in the central part of Turkey. With an estimated student population of about 100,000, Selcuk University is regarded as the largest university in Turkey in terms of numbers. The study was designed as a cross-sectional questionnairebased study to assess the medical students' knowledge, attitudes, and practices on epilepsy. All students who were willing to take part in the study were included. Students who declined to participate in the study were excluded. Questionnaires were distributed to the participants while they were in their classrooms. Eight hundred and ninety medical students from years one to six completed and returned the questionnaires giving a response rate of 90%. The educational program at Selcuk University School of Medicine is structured into a six-year curriculum consisting of three years of basic medical sciences, two years of clinical sciences, and a year of internship. While the first half of the
116
A. Kartal / Epilepsy & Behavior 58 (2016) 115–118
program trains students in a nonclinical setting, the final three years are exclusively clinically oriented with a department-based educational program. Fourth- and fifth-year students reside invariably in the university hospital setting while sixth-year students work in the clinic as interns for a whole year by spending 1–2 months rotating in various departments. Therefore, sixth-year students are seen as members of the healthcare team who are made responsible for the basic medical care provided. Statistical analysis was carried out using SPSS for Windows Version 17.0 (SPSS Inc., Chicago, IL, USA). Results are expressed as frequencies, percentages, means, and standard deviations. The χ2 test was used to verify differences between variables. The study was approved by the Ethical Committee of Selcuk University. 3. Results A total of 890 out of 986 (response rate 90%) students completed the questionnaire; 53.3% of whom were female. Fifty-nine point one percent were in their third academic year and below while the rest were in their fourth academic year and above. The demographic characteristics of the students are listed in Table 1. 3.1. Familiarity with epilepsy Table 2 represents the responses to questions regarding familiarity with epilepsy. Of the 890 students, 73.5% answered that they had heard or read about epilepsy, 38.1% responded that they were personally acquainted with someone with epilepsy, and 38.5% reported that they had witnessed a seizure. These figures represent a moderate degree of familiarity with the disease and its clinical expression. The frequencies of hearing or reading about epilepsy or observing a seizure were significantly higher among students in their clinical years compared with those in their basic medical science years (p b 0.001). Of three different knowledge source categories concerning epilepsy, the primary source was medical textbooks or health workers, followed by family members or neighbors and mass media. 3.2. Knowledge of epilepsy The most commonly reported causes of epilepsy were neurologic (70.9%) and genetic (38.4%). About one-fifth of the students attributed the causes of epilepsy to vitamin deficiency (8.8%) and psychiatric (19.1%), infectious (19.5%), mental (4.4%) and hematological disorders (3.4%). According to 4.8% of the students, epilepsy could be a punishment from God, and 2.1% of the students believed that it could be caused by an evil spirit. However, 7.5% did not know of any cause of epilepsy. Significantly, a higher number of females than males reported neurologic causes as causes of epilepsy. On the other hand, more males reported punishment from God as the cause of epilepsy. When knowledge of clinical students was compared with that of their preclinical counterparts, Table 1 Demographic characteristics of the sample. Parameter
Frequency
Percentage
Class Preclinical (1–3 years) Clinical (4–6 years) 1st year 2nd year 3rd year 4th year 5th year 6th year
526 364 160 206 160 151 109 104
59.1 40.9 18 23.2 18 17 12.3 11.7
Gender Female Male
480 410
53.9 46.1
clinical students significantly more often reported vitamin deficiency and infectious, genetic and neurologic diseases as causes of epilepsy. These numbers showed that the level of medical student education did not appear to influence an appropriate response and also reflects a high degree of misunderstanding of the true nature of epilepsy. Regarding the symptoms of epilepsy known to the students, sudden loss of consciousness (78.2%) and tonic–clonic movements (70.1%) were the most commonly recognized manifestations of epilepsy, while uncontrolled urination (41.8%) was the least known. In general, clinical students had more information about epilepsy symptoms. The knowledge of the long-term prognosis of epilepsy among students was also investigated. Although more than half of the students agreed that it was treatable with proper management, the vast majority (88.1%) agreed that it is a dangerous illness and thought that epilepsy is a lifelong condition (81.9%). This belief was higher among female and clinical students compared with that among preclinical students and males (p b 0.001). More females and clinical students thought that epilepsy is a lifelong disease (p b 0.001). For treatment, the most commonly reported treatment options for epilepsy were modern medicine (91.6%), brain surgery (25.2%), the Holy Quran (21.2%), and acupuncture (11.4%). “Other methods” of treatment, such as special diets and herbal medicine, were reported by 7.1% and 5.8% of students, respectively. Significantly more preclinical students than clinical students reported acupuncture and herbal medicine as treatment options for epilepsy. The belief in the Holy Quran as a treatment method for epilepsy was commonly reported among the students who believed that epilepsy was a punishment from God and could be caused by an evil spirit. When asked what they would do if they witnessed an individual having an epileptic seizure, threequarters of the students (75.5%) said that they would keep the airway open, 74.7% of the students said that they would call an ambulance, and about half of the students (50.6%) said that they would insert an object in the patient's mouth. In almost equal proportions, students believed that “firmly holding the patient's hand and arm” and “praying for the patient” could help arrest the seizure. A small portion of the students believed that “onion-smell” or “cologne-smell”, splashing water on a patient’s face and returning the patient to a seated position could help arrest the seizure. More preclinical students and male students answered that smelling an onion or cologne could help arrest the seizure. Moreover, more preclinical students said that they would call an ambulance or do nothing when they witnessed a seizure. On the other hand, more clinical students said that they would keep the airway open when they witness a seizure. 3.3. Attitude toward epilepsy and a person with epilepsy A total of 71.8% of the students said that they would refuse to marry a person with epilepsy. Interestingly, 10.8% of respondents declined to express an opinion about marrying a person with epilepsy. There was no statistically significant relationship between gender and negative attitude toward marriage. Nearly all of the students (92.7%) felt that a person with epilepsy could have children. Most students (78.4%) believed that a person with epilepsy can be successful as any other person. In general, by comparing students based on their education years, preclinical students had significantly more negative attitudes than clinical students. 4. Discussion To our knowledge, this is the first study to examine the knowledge, attitudes, and practices regarding epilepsy among medical students in Turkey. The present findings revealed that the percentage of students who had heard about epilepsy was 73.1%, a finding which is similar to previous results from reports among the general public in Turkey [6,7]. Also, these results are less favorable than those reported from studies among university students in developing countries [8–11].
A. Kartal / Epilepsy & Behavior 58 (2016) 115–118
117
Table 2 Responses of students to questions on knowledge, attitudes, and practices. Question
Total
Male
Female
p
Preclinic
Clinic
p
Have you heard or read about epilepsy? (yes) Do you know someone with epilepsy? (yes) Have you ever witnessed a seizure? (yes) Do you think epilepsy is a lifelong disease? (yes) Do you think epilepsy is a dangerous disease? (yes)
73.5 38.1 38.4 81.9 88.1
68.8 36.1 42.2 75.6 88.5
77.5 39.8 35.2 87.3 88.7
p b 0.05
55.3 36.5 29.8 77.4 89.9
99.7 40.4 50.8 88.5 85.4
p b 0.001
What do you think causes epilepsy? (yes)a Brain injury Hereditary disease Psychological disorder İnfections Avitaminosis Punishment from God Mental disease Hematological disorders Evil spirit Don't know
70.9 38.4 19.7 18.4 8.5 4.4 3.9 3.5 2 7.6
64.1 41 20.5 18.8 9.8 8 3.7 5.1 3.4 10
76.7 36.2 19 18.1 7.5 1.2 4.2 2.1 0.8 5.6
p b 0.001
62.2 30.8 2.7 9.9 4.8 20 3.2 4.4 1.1 10.1
83.5 49.5 5.8 30.8 14 19.2 3.8 4.4 3.3 4.1
p b 0.05 p = 0.001
What do you think an epileptic attack is?a Sudden loss of consciousness Tonic–clonic movements Falling Foaming of mouth and biting the tongue Urinary and fecal incontinence
78.2 70.1 67 66.5 41.8
79.8 68 65.4 64.1 40
76.9 71.9 68.3 68.5 43.3
70.9 60.3 57 60.1 22.4
88.7 84.3 81.3 75.8 69.8
p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001
What do you do when you see a person having a seizure?a Keep the airway open Call an ambulance Insert an object between patient's teeth Pray for an end to seizure Hold the extremities of the patient Let the person smell an onion or cologne Throw water on patient's face Seat the patient Do nothing
75.5 74.7 50.6 22.6 22.5 3.6 2.7 2.2 10.7
72.4 76.8 44.4 22.4 21.7 6.1 3.4 2.2 13.7
78.1 72.9 55.8 22.7 23.1 1.5 2.1 2.5 8.1
p b 0.05
66.7 80.4 48.9 24.3 24.1 4.8 3.4 3 13.5
88.2 66.5 53 21 20.1 1.9 1.6 1.1 6.6
p b 0.001 p b 0.001
Treatment for epilepsy? (yes) Medical doctor Brain surgery God's help Acupuncture Special foods, diet Herbal medicine or traditional healer
91.9 25.2 21.8 12 7.5 7.5
87.3 27.1 23.2 11 6.1 9
95.8 23.5 20.6 12.9 8.8 6.2
p b 0.001
89.7 21.1 24 14.1 8.4 9.5
95.1 31 18.7 9.1 6.3 4.7
How effective is the medical treatment of epilepsy? Not effective Sometimes Always I don't know Would you marry a person with epilepsy? (yes) Do you think a person with epilepsy should have children? (yes) Do you think that, in general a person with epilepsy can be successful as other people? (yes)
5.2 55.2 20.2 19.4 28.2 92.7 78.4
6.1 54.6 18 21.2 28 89.5 54.8
4.4 55.6 22.1 17.9 28.3 95.4 77.5
6.8 52.1 13.7 27.4 25.5 90.9 52.3
2.7 59.6 29.7 8 32.1 95.3 91.7
p b 0.05 p b 0.001
p b 0.001
p = 0.001
p b 0.001
p b 0.001 p b 0.001 p b 0.05 p b 0.001 p b 0.001 p b 0.05 p b 0.001 p b 0.001
p b 0.05
p b 0.001
a
a
p = 0.001 p b 0.001
p = 0.001 p b 0.05 p b 0.05
p b 0.001 p = 0.001 p b 0.05 p b 0.001
Multiple answers allowed.
In our study, about 4 out of 10 students either knew someone with epilepsy or had witnessed a seizure, a figure which is low compared with previous study (40–88%) [12–14]. The present study showed that familiarity with epilepsy and seizures was better among clinical students than that among preclinical students. We assume that clinical students spend more time with patients than their preclinical peers. Therefore, clinical students are more likely to witness seizures or hear or read about epilepsy. The decreased awareness of epilepsy can be explained by the social–cultural situation in Turkey. The majority of patients with epilepsy are limited to participating in social activities, and people with epilepsy tend to hide their identity. Less than half of the students in this study had obtained their knowledge of epilepsy mainly from medical textbooks or professional medical sources. Although they are medical students, this finding showed that formal education on epilepsy is not sufficient. This finding emphasizes the need for formal education on epilepsy at all levels of education to curb the flow of incorrect information from public sources that is perpetuated.
Our results indicate that, though most of the students were aware of epilepsy, the level of knowledge about the causes of epilepsy was not adequate. While a vast majority of students considered epilepsy to be a neurological disease, more than one-third of the students believed that epilepsy was primarily a hereditary disease. This finding is consistent with that reported in Jordan and India [9,10]; however, a bit lower than percentages reported by others [6–13]. This belief is based on the idea that epilepsy is more prevalent among members of the same family. Nevertheless, about 20% and 4% of students considered epilepsy as a psychological problem and mental problem, respectively. This finding is slightly higher than rates reported from Yemen (18%) and Jordan [9,11]. Unfortunately, epilepsy in the sight of the public has been actively and falsely associated with mental illness and cognitive disorders. It was surprising to find that about 5% of students thought that epilepsy was a punishment from God for bad behavior and 2% of students thought that epilepsy was caused by evil spirits. This result compares favorably with the Malaysian students of whom 5.3% thought that epilepsy was caused by evil spirits [8]. Studies conducted from other
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Muslim countries (Kuwait, Yemen, Jordan, Saudia Arabia) have reported higher rates compared with our findings [10–12,15]. The concept of punishment by God in the Muslim society is an extremely complex issue. This belief may stem from an understanding that individuals may be cursed by God with epilepsy to test the will of the family and reward him or her in the other life. Furthermore, in many societies, it is believed that epilepsy is due to possession by evil spirits. This belief has been suggested to cause a large treatment gap in the population since patients will seek traditional or alternative treatment despite the availability of modern therapies. Regarding attitudes toward epilepsy, we observed a positive attitude in other matters except for marriage. Only 28.2% agreed to date someone with epilepsy, whereas 10.2% expressed no opinion. The attitudes of our medical students were similar to the general public's attitude toward epilepsy in Turkey [6,7]. In the present study, 7.3% of students answered that people with epilepsy must not have children. This result is lower than that reported previously by studies conducted among university students in Jordan, Canada, and Kuwait [10,12,13]. Male and preclinical students had more negative attitudes toward people with epilepsy. 5. Study limitations The questionnaires were delivered in a classroom environment so some students may have discussed questions or answers, and this could have led to similar responses. 6. Conclusion In conclusion, to our knowledge, this is the first study that investigated the knowledge, attitudes, and practices about epilepsy among medical students in Turkey. We have demonstrated that, though most of the students were aware of epilepsy, their knowledge of the causes of epilepsy was far below expectations. Clinical students had more accurate information and favorable attitudes than preclinical students, so we expect their knowledge, attitudes, and practices to improve considerably with time and exposure.
Conflict of interest statement The author has no conflicts of interest to declare.
References [1] 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. [2] Pandian JD, Santosh D, Kumar TS, Sarma PS, Radhakrishnan K. High school students' knowledge, attitude, and practice with respect to epilepsy in Kerala, southern India. Epilepsy Behav 2006;9:492–7. [3] Mirnics Z, Czikora G, Za’vecz T, Hala’sz P. Changes in public attitudes toward epilepsy in Hungary: results of surveys conducted in 1994 and 2000. Epilepsia 2001;42:86–93. [4] Hills MD, MacKenzie HC. New Zealand community attitudes toward people with epilepsy. Epilepsia 2002;43:1583–9. [5] Fong C-YG, Hung A. Public awareness, attitude, and understanding of epilepsy in Hong Kong Special Administrative Region, China. Epilepsia 2002;43:311–6. [6] Aydemir N. Familiarity with, knowledge of, and attitudes toward epilepsy in Turkey. Epilepsy Behav 2011;20:286–90. [7] Demirci S, Dönmez CM, Gündoğar D, Baydar CL. Public awareness of, attitudes toward, and understanding of epilepsy in Isparta, Turkey. Epilepsy Behav 2007;11:427–33. [8] AbRahman AF. Awareness and knowledge of epilepsy among students in a Malaysian university. Seizure 2005;14:593–6. [9] Panda SB, Prabhu K, Rao S, Rao A, Rao G, Datta A, et al. Evaluation of knowledge of and attitudes toward epilepsy among the health science students of Manipal University. Epilepsy Behav 2011;20:447–9. [10] Hijazeen JK, Abu-Helalah MA, Alshraideh HA, Alrawashdeh OS, Hawa FN, Dalbah TA, et al. Knowledge, attitudes, and beliefs about epilepsy and their predictors among university students in Jordan. Epilepsy Behav 2014;41:238–43. [11] Al-Eryani B, Saied KG, Alddin RS, Al-Sobaihi S, Lutf W, Al-Taiar A. Knowledge of, attitudes toward, and perceptions of epilepsy among university students in Yemen. Epilepsy Behav 2015;52:102–7. [12] Al-Rashed H, Al-Yahya D, Al-Kandari A, Shehab A, Al-Sabah R, Al-Taiar A. Knowledge of, perceptions of, and attitudes toward epilepsy among university students in Kuwait. Epilepsy Behav 2009;14:367–71. [13] Young GB, Derry P, Hutchinson I, John V, Matijevic S, Parrent L, et al. An epilepsy questionnaire study of knowledge and attitudes in Canadian college students. Epilepsia 2002;43:652–8. [14] Njamnshi AK, Tabah EN, Bissek AC, Yepnjio FN, Angwafor SA, Dema F, et al. Knowledge, attitudes and practices with respect to epilepsy among student nurses and laboratory assistants in the South West Region of Cameroon. Epilepsy Behav 2010; 17:381–8. [15] Obeid T, Abulaban A, Al-Ghatani F, Al-Malki AR, Al-Ghamdi A. Possession by ‘Jinn’ as a cause of epilepsy (Saraa): a study from Saudi Arabia. Seizure 2012;21:245–9.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Knowledge of, perceptions of, attitudes and practices regarding epilepsy among medical students in Turkey Ayşe Kartal Department of Child Neurology, Selçuk University, Faculty of Medicine, Konya, Turkey
a r t i c l e
i n f o
Article history: Received 12 January 2016 Revised 28 February 2016 Accepted 29 February 2016 Available online 9 April 2016 Keywords: Epilepsy Knowledge Attitude Medical students Turkey
a b s t r a c t Purpose: Medical practitioners' attitudes have a significant impact on the quality of care for patients with epilepsy. This study was conducted to assess the current level of knowledge about epilepsy and treatment together with attitudes and perception toward patients with epilepsy among medical students in Turkey. Method: The study was conducted using a structured questionnaire to assess knowledge, awareness, and practices about epilepsy among medical students at Selçuk University, Konya, Turkey. Results: Eight hundred and ninety subjects were interviewed, and 73.5% reported their awareness about epilepsy. Of these, 38.1% knew someone who had epilepsy, and 38.5% had witnessed an epileptic seizure. Although most of the students had heard about epilepsy, 38.4% of the students believed that epilepsy was primarily a genetic disease. About one-fifth of the students attributed the causes of epilepsy to vitamin deficiency (8.8%) and psychiatric (19.1%), infectious (19.5%), mental (4.4%), and hematological disorders (3.4%). According to 4.8% of the students, epilepsy could be a punishment from God, and 2.1% of students thought that it could be caused by an evil spirit. Eighty-eight percent considered epilepsy as a dangerous disease, and most of them thought that epilepsy is a lifelong condition. Fifty point six percent indicated that putting an object into the patient's mouth to prevent tonguebiting during a seizure is appropriate while 91.9% stated that drug therapy was the only treatment available for epilepsy. The most common negative attitudes toward people with epilepsy were students' objection to marrying someone with epilepsy and patients with epilepsy having children. Conclusion: Misconceptions about the causes, treatment, and nature of epilepsy are common among medical students at a Turkish medical school. Negative attitudes toward patients with epilepsy still exist. Medical school training programs should be designed to increase awareness of students about epilepsy. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is one of the most common neurological disorders, affecting 1% of the population worldwide. It is a major public health problem in developing countries like Turkey and has been associated with stigma and negative preconceptions among both educated and uneducated people [1]. The causes of these negative attitudes are the lack of basic knowledge of epilepsy, misunderstanding, and some cultural beliefs. Nevertheless, community-based studies have shown that welleducated individuals have greater knowledge and lesser negative attitudes regarding epilepsy [2–5]. Medical students represent a welleducated part of the society and are the future workforce in the field of neurology of every country. Thus, it is important that they obtain the right knowledge about epilepsy and maintain an appropriate attitude toward a patient with epilepsy. Assessing the knowledge, attitudes, and practices regarding epilepsy of medical students will allow for better designed and targeted educational programs. However, very few published papers have examined these issues among university students in Turkey, and none focused on medical students. The purpose E-mail address: [email protected].
http://dx.doi.org/10.1016/j.yebeh.2016.02.042 1525-5050/© 2016 Elsevier Inc. All rights reserved.
of this study was therefore to assess Turkish medical students' knowledge about epilepsy and treatment together with their attitudes and perception of patients with epilepsy. 2. Methods This study was a cross-sectional survey carried out at Selçuk University, Konya, Turkey, a tertiary institution located in the central part of Turkey. With an estimated student population of about 100,000, Selcuk University is regarded as the largest university in Turkey in terms of numbers. The study was designed as a cross-sectional questionnairebased study to assess the medical students' knowledge, attitudes, and practices on epilepsy. All students who were willing to take part in the study were included. Students who declined to participate in the study were excluded. Questionnaires were distributed to the participants while they were in their classrooms. Eight hundred and ninety medical students from years one to six completed and returned the questionnaires giving a response rate of 90%. The educational program at Selcuk University School of Medicine is structured into a six-year curriculum consisting of three years of basic medical sciences, two years of clinical sciences, and a year of internship. While the first half of the
116
A. Kartal / Epilepsy & Behavior 58 (2016) 115–118
program trains students in a nonclinical setting, the final three years are exclusively clinically oriented with a department-based educational program. Fourth- and fifth-year students reside invariably in the university hospital setting while sixth-year students work in the clinic as interns for a whole year by spending 1–2 months rotating in various departments. Therefore, sixth-year students are seen as members of the healthcare team who are made responsible for the basic medical care provided. Statistical analysis was carried out using SPSS for Windows Version 17.0 (SPSS Inc., Chicago, IL, USA). Results are expressed as frequencies, percentages, means, and standard deviations. The χ2 test was used to verify differences between variables. The study was approved by the Ethical Committee of Selcuk University. 3. Results A total of 890 out of 986 (response rate 90%) students completed the questionnaire; 53.3% of whom were female. Fifty-nine point one percent were in their third academic year and below while the rest were in their fourth academic year and above. The demographic characteristics of the students are listed in Table 1. 3.1. Familiarity with epilepsy Table 2 represents the responses to questions regarding familiarity with epilepsy. Of the 890 students, 73.5% answered that they had heard or read about epilepsy, 38.1% responded that they were personally acquainted with someone with epilepsy, and 38.5% reported that they had witnessed a seizure. These figures represent a moderate degree of familiarity with the disease and its clinical expression. The frequencies of hearing or reading about epilepsy or observing a seizure were significantly higher among students in their clinical years compared with those in their basic medical science years (p b 0.001). Of three different knowledge source categories concerning epilepsy, the primary source was medical textbooks or health workers, followed by family members or neighbors and mass media. 3.2. Knowledge of epilepsy The most commonly reported causes of epilepsy were neurologic (70.9%) and genetic (38.4%). About one-fifth of the students attributed the causes of epilepsy to vitamin deficiency (8.8%) and psychiatric (19.1%), infectious (19.5%), mental (4.4%) and hematological disorders (3.4%). According to 4.8% of the students, epilepsy could be a punishment from God, and 2.1% of the students believed that it could be caused by an evil spirit. However, 7.5% did not know of any cause of epilepsy. Significantly, a higher number of females than males reported neurologic causes as causes of epilepsy. On the other hand, more males reported punishment from God as the cause of epilepsy. When knowledge of clinical students was compared with that of their preclinical counterparts, Table 1 Demographic characteristics of the sample. Parameter
Frequency
Percentage
Class Preclinical (1–3 years) Clinical (4–6 years) 1st year 2nd year 3rd year 4th year 5th year 6th year
526 364 160 206 160 151 109 104
59.1 40.9 18 23.2 18 17 12.3 11.7
Gender Female Male
480 410
53.9 46.1
clinical students significantly more often reported vitamin deficiency and infectious, genetic and neurologic diseases as causes of epilepsy. These numbers showed that the level of medical student education did not appear to influence an appropriate response and also reflects a high degree of misunderstanding of the true nature of epilepsy. Regarding the symptoms of epilepsy known to the students, sudden loss of consciousness (78.2%) and tonic–clonic movements (70.1%) were the most commonly recognized manifestations of epilepsy, while uncontrolled urination (41.8%) was the least known. In general, clinical students had more information about epilepsy symptoms. The knowledge of the long-term prognosis of epilepsy among students was also investigated. Although more than half of the students agreed that it was treatable with proper management, the vast majority (88.1%) agreed that it is a dangerous illness and thought that epilepsy is a lifelong condition (81.9%). This belief was higher among female and clinical students compared with that among preclinical students and males (p b 0.001). More females and clinical students thought that epilepsy is a lifelong disease (p b 0.001). For treatment, the most commonly reported treatment options for epilepsy were modern medicine (91.6%), brain surgery (25.2%), the Holy Quran (21.2%), and acupuncture (11.4%). “Other methods” of treatment, such as special diets and herbal medicine, were reported by 7.1% and 5.8% of students, respectively. Significantly more preclinical students than clinical students reported acupuncture and herbal medicine as treatment options for epilepsy. The belief in the Holy Quran as a treatment method for epilepsy was commonly reported among the students who believed that epilepsy was a punishment from God and could be caused by an evil spirit. When asked what they would do if they witnessed an individual having an epileptic seizure, threequarters of the students (75.5%) said that they would keep the airway open, 74.7% of the students said that they would call an ambulance, and about half of the students (50.6%) said that they would insert an object in the patient's mouth. In almost equal proportions, students believed that “firmly holding the patient's hand and arm” and “praying for the patient” could help arrest the seizure. A small portion of the students believed that “onion-smell” or “cologne-smell”, splashing water on a patient’s face and returning the patient to a seated position could help arrest the seizure. More preclinical students and male students answered that smelling an onion or cologne could help arrest the seizure. Moreover, more preclinical students said that they would call an ambulance or do nothing when they witnessed a seizure. On the other hand, more clinical students said that they would keep the airway open when they witness a seizure. 3.3. Attitude toward epilepsy and a person with epilepsy A total of 71.8% of the students said that they would refuse to marry a person with epilepsy. Interestingly, 10.8% of respondents declined to express an opinion about marrying a person with epilepsy. There was no statistically significant relationship between gender and negative attitude toward marriage. Nearly all of the students (92.7%) felt that a person with epilepsy could have children. Most students (78.4%) believed that a person with epilepsy can be successful as any other person. In general, by comparing students based on their education years, preclinical students had significantly more negative attitudes than clinical students. 4. Discussion To our knowledge, this is the first study to examine the knowledge, attitudes, and practices regarding epilepsy among medical students in Turkey. The present findings revealed that the percentage of students who had heard about epilepsy was 73.1%, a finding which is similar to previous results from reports among the general public in Turkey [6,7]. Also, these results are less favorable than those reported from studies among university students in developing countries [8–11].
A. Kartal / Epilepsy & Behavior 58 (2016) 115–118
117
Table 2 Responses of students to questions on knowledge, attitudes, and practices. Question
Total
Male
Female
p
Preclinic
Clinic
p
Have you heard or read about epilepsy? (yes) Do you know someone with epilepsy? (yes) Have you ever witnessed a seizure? (yes) Do you think epilepsy is a lifelong disease? (yes) Do you think epilepsy is a dangerous disease? (yes)
73.5 38.1 38.4 81.9 88.1
68.8 36.1 42.2 75.6 88.5
77.5 39.8 35.2 87.3 88.7
p b 0.05
55.3 36.5 29.8 77.4 89.9
99.7 40.4 50.8 88.5 85.4
p b 0.001
What do you think causes epilepsy? (yes)a Brain injury Hereditary disease Psychological disorder İnfections Avitaminosis Punishment from God Mental disease Hematological disorders Evil spirit Don't know
70.9 38.4 19.7 18.4 8.5 4.4 3.9 3.5 2 7.6
64.1 41 20.5 18.8 9.8 8 3.7 5.1 3.4 10
76.7 36.2 19 18.1 7.5 1.2 4.2 2.1 0.8 5.6
p b 0.001
62.2 30.8 2.7 9.9 4.8 20 3.2 4.4 1.1 10.1
83.5 49.5 5.8 30.8 14 19.2 3.8 4.4 3.3 4.1
p b 0.05 p = 0.001
What do you think an epileptic attack is?a Sudden loss of consciousness Tonic–clonic movements Falling Foaming of mouth and biting the tongue Urinary and fecal incontinence
78.2 70.1 67 66.5 41.8
79.8 68 65.4 64.1 40
76.9 71.9 68.3 68.5 43.3
70.9 60.3 57 60.1 22.4
88.7 84.3 81.3 75.8 69.8
p b 0.001 p b 0.001 p b 0.001 p b 0.001 p b 0.001
What do you do when you see a person having a seizure?a Keep the airway open Call an ambulance Insert an object between patient's teeth Pray for an end to seizure Hold the extremities of the patient Let the person smell an onion or cologne Throw water on patient's face Seat the patient Do nothing
75.5 74.7 50.6 22.6 22.5 3.6 2.7 2.2 10.7
72.4 76.8 44.4 22.4 21.7 6.1 3.4 2.2 13.7
78.1 72.9 55.8 22.7 23.1 1.5 2.1 2.5 8.1
p b 0.05
66.7 80.4 48.9 24.3 24.1 4.8 3.4 3 13.5
88.2 66.5 53 21 20.1 1.9 1.6 1.1 6.6
p b 0.001 p b 0.001
Treatment for epilepsy? (yes) Medical doctor Brain surgery God's help Acupuncture Special foods, diet Herbal medicine or traditional healer
91.9 25.2 21.8 12 7.5 7.5
87.3 27.1 23.2 11 6.1 9
95.8 23.5 20.6 12.9 8.8 6.2
p b 0.001
89.7 21.1 24 14.1 8.4 9.5
95.1 31 18.7 9.1 6.3 4.7
How effective is the medical treatment of epilepsy? Not effective Sometimes Always I don't know Would you marry a person with epilepsy? (yes) Do you think a person with epilepsy should have children? (yes) Do you think that, in general a person with epilepsy can be successful as other people? (yes)
5.2 55.2 20.2 19.4 28.2 92.7 78.4
6.1 54.6 18 21.2 28 89.5 54.8
4.4 55.6 22.1 17.9 28.3 95.4 77.5
6.8 52.1 13.7 27.4 25.5 90.9 52.3
2.7 59.6 29.7 8 32.1 95.3 91.7
p b 0.05 p b 0.001
p b 0.001
p = 0.001
p b 0.001
p b 0.001 p b 0.001 p b 0.05 p b 0.001 p b 0.001 p b 0.05 p b 0.001 p b 0.001
p b 0.05
p b 0.001
a
a
p = 0.001 p b 0.001
p = 0.001 p b 0.05 p b 0.05
p b 0.001 p = 0.001 p b 0.05 p b 0.001
Multiple answers allowed.
In our study, about 4 out of 10 students either knew someone with epilepsy or had witnessed a seizure, a figure which is low compared with previous study (40–88%) [12–14]. The present study showed that familiarity with epilepsy and seizures was better among clinical students than that among preclinical students. We assume that clinical students spend more time with patients than their preclinical peers. Therefore, clinical students are more likely to witness seizures or hear or read about epilepsy. The decreased awareness of epilepsy can be explained by the social–cultural situation in Turkey. The majority of patients with epilepsy are limited to participating in social activities, and people with epilepsy tend to hide their identity. Less than half of the students in this study had obtained their knowledge of epilepsy mainly from medical textbooks or professional medical sources. Although they are medical students, this finding showed that formal education on epilepsy is not sufficient. This finding emphasizes the need for formal education on epilepsy at all levels of education to curb the flow of incorrect information from public sources that is perpetuated.
Our results indicate that, though most of the students were aware of epilepsy, the level of knowledge about the causes of epilepsy was not adequate. While a vast majority of students considered epilepsy to be a neurological disease, more than one-third of the students believed that epilepsy was primarily a hereditary disease. This finding is consistent with that reported in Jordan and India [9,10]; however, a bit lower than percentages reported by others [6–13]. This belief is based on the idea that epilepsy is more prevalent among members of the same family. Nevertheless, about 20% and 4% of students considered epilepsy as a psychological problem and mental problem, respectively. This finding is slightly higher than rates reported from Yemen (18%) and Jordan [9,11]. Unfortunately, epilepsy in the sight of the public has been actively and falsely associated with mental illness and cognitive disorders. It was surprising to find that about 5% of students thought that epilepsy was a punishment from God for bad behavior and 2% of students thought that epilepsy was caused by evil spirits. This result compares favorably with the Malaysian students of whom 5.3% thought that epilepsy was caused by evil spirits [8]. Studies conducted from other
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Muslim countries (Kuwait, Yemen, Jordan, Saudia Arabia) have reported higher rates compared with our findings [10–12,15]. The concept of punishment by God in the Muslim society is an extremely complex issue. This belief may stem from an understanding that individuals may be cursed by God with epilepsy to test the will of the family and reward him or her in the other life. Furthermore, in many societies, it is believed that epilepsy is due to possession by evil spirits. This belief has been suggested to cause a large treatment gap in the population since patients will seek traditional or alternative treatment despite the availability of modern therapies. Regarding attitudes toward epilepsy, we observed a positive attitude in other matters except for marriage. Only 28.2% agreed to date someone with epilepsy, whereas 10.2% expressed no opinion. The attitudes of our medical students were similar to the general public's attitude toward epilepsy in Turkey [6,7]. In the present study, 7.3% of students answered that people with epilepsy must not have children. This result is lower than that reported previously by studies conducted among university students in Jordan, Canada, and Kuwait [10,12,13]. Male and preclinical students had more negative attitudes toward people with epilepsy. 5. Study limitations The questionnaires were delivered in a classroom environment so some students may have discussed questions or answers, and this could have led to similar responses. 6. Conclusion In conclusion, to our knowledge, this is the first study that investigated the knowledge, attitudes, and practices about epilepsy among medical students in Turkey. We have demonstrated that, though most of the students were aware of epilepsy, their knowledge of the causes of epilepsy was far below expectations. Clinical students had more accurate information and favorable attitudes than preclinical students, so we expect their knowledge, attitudes, and practices to improve considerably with time and exposure.
Conflict of interest statement The author has no conflicts of interest to declare.
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