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The beliefs among patients with epilepsy in Saudi Arabia about the causes and treatment of epilepsy and other aspects
Epilepsy & Behavior 53 (2015) 135–139
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
The beliefs among patients with epilepsy in Saudi Arabia about the causes and treatment of epilepsy and other aspects Hadeel A. Alkhamees ⁎, Caroline E. Selai, Simon D. Shorvon Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, UK
a r t i c l e
i n f o
Article history: Received 9 August 2015 Revised 6 October 2015 Accepted 8 October 2015 Available online 12 November 2015 Keywords: Epilepsy Religious and cultural beliefs Faith healing Saudi
a b s t r a c t Purpose: The current survey sought to identify the religious and cultural beliefs about the causes and treatment of epilepsy in people with epilepsy from Saudi Arabia and a number of other aspects relating to the possibility of cure, coping with the condition, and public awareness. Methods: Study instruments were developed on the basis of the literature, a focus group of people with epilepsy, and feedback from people in the field with local knowledge. These were then piloted. A survey was then carried out among a total of 110 adults with epilepsy. Participants were asked to complete questionnaires inquiring into their beliefs about the causes and range of treatments used for epilepsy. Each participant was allowed to choose more than one cause and more than one treatment method. The questionnaires were administered face to face by a clinical psychologist (HAA) to improve the quality of the responses. Results: We found that most adults with epilepsy in Saudi Arabia believe that epilepsy is a condition with multifactorial causation and for which more than one treatment method should be applied. A test from God was the most commonly ascribed cause (83% as well as 40% who believed that some cases of the illness were a punishment from God). The belief in the concept of God's will helped many in the cohort to accept their illness as part of their destiny. Ninety-six percent of the patients believed that there were also medical causes (such as an illness, brain insult, inflammation, heredity, contagion), and a similar proportion believed that there were also religious causes. Smaller proportions believed epilepsy could be due to cultural (78%) or psychosocial causes (64%). Thirty-four percent of people believed that there could be sometimes no cause, but only 2% thought that epilepsy never had any identifiable cause. Most patients did not believe that one treatment alone would help. Ninety-three percent of patients believed in medical treatment, 93% in religious treatment, and 64% in traditional treatments, and 7% believed in changing lifestyle (eating balanced food and positive thinking). Seventy-eight percent of the sample believed that their epilepsy was a curable illness. Ninety-six percent believed that faith and practicing religious rituals helped in coping with epilepsy, and 92% believed that family support helped in coping with epilepsy. Nine percent of patients had stopped their medication for religious reasons or because of a sense of shame, and 7% had at one time been forced by their family to stop their medication. Ninety-two percent of the sample reported having enough family support. Ninety-five percent believed that Saudi society needs more awareness to understand epilepsy. Conclusion: In Saudi Arabia, religious and cultural beliefs about the causes and treatment of epilepsy exist alongside medical beliefs. The holding of religious beliefs, the practicing of religious rituals, and the presence of family support were found to be of great importance in coping with epilepsy, and their role needs to be fully appreciated in the medical management of the condition. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The degree of understanding about epilepsy varies between different religions, cultures, and ethnic groups. Historically, in Judaism, epilepsy has sometimes been understood as a consequence of a sexual sin [1], and in Christianity, epilepsy has sometimes been explained as being caused by sin and/or by supernatural powers [1]. In Islam, “there is no sickness for which God did not provide a remedy” [1] is a fundamental ⁎ Corresponding author. E-mail address: [email protected] (H.A. Alkhamees).
http://dx.doi.org/10.1016/j.yebeh.2015.10.008 1525-5050/© 2015 Elsevier Inc. All rights reserved.
tenet of the Islamic faith, and Islamic medicine was established on this principle. Nonbiological beliefs about the cause of epilepsy and the use of nonmedical treatments in treating epilepsy have been recorded in previous studies in both the developed and the developing world [2–7]. In Saudi Arabia, the prevalence of epilepsy is 6.54 per 1000 [8], similar to that in other countries. The concepts of magic and evil eye are widely accepted among people from Saudi Arabia as a cause of various forms of physical and psychological illnesses, and as a result, many people in Saudi Arabia visit faith healers for treatments even though there is easy access to public and private hospitals. Previous studies have reported that, despite the improved standards of general education, there is
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H.A. Alkhamees et al. / Epilepsy & Behavior 53 (2015) 135–139
2. Materials and methods
The next section covered medical therapies (antiepileptic drugs (AEDs), surgery); religious therapies (rehearsing the Holy Quran (rugyah), drinking or washing by zamzam, using holy water, honey, and oil, visiting faith healers, washing by seder (Zizyphus)); traditional therapies: (cupping, cauterization, head massage, alternative medicine, special mixtures, using olive oil); lifestyle (eating balanced food and positive thinking); and other treatments (other suggestions from patients). Further questions covered whether epilepsy was considered a curable illness, the use of faith and religious rituals and family support in coping with the illness, whether medication was ever discontinued for religious reasons, because of feelings of shame, or because of family pressure or beliefs, whether there was sufficient family support, and whether Saudi society needed a greater degree of awareness about epilepsy. The questionnaires were adjusted for clarity and ease of use, on the basis of the pilot, and a version was created for the main survey.
2.1. Participants
2.3. Data analysis
Eligible patients were recruited from Prince Sultan Military Medical City (PSMMC) in Riyadh, Kingdom of Saudi Arabia over a three-month period (January to March 2012). The PSMMC is a secondary and tertiary care hospital in Riyadh, the capital city of Saudi Arabia. The epilepsy unit at PSMMC is one of the specialized units in the Kingdom of Saudi Arabia to which people with epilepsy will be admitted for investigations. Patients who participated in this study (n = 110) were either selected from the National Epilepsy Registry database or through direct referral by the neurologist; their ages ranged from 18 to 60 years, all had a minimum level of education of at least the primary school level, and their diagnosis of epilepsy was confirmed by clinical history, EEG, and brain MRI studies. Inclusion criteria were the following: (1) all patients with any type of epilepsy and (2) males and females between the ages of 18 and 60 years. Exclusion criteria were the following: (1) patients with IQs below 80, (2) patients with severe cognitive impairment, learning difficulties, and severe sensory deficits and those who are not able to give informed consent, (3) patients who are illiterate (unable to read and write), and (4) patients with a history of or with active psychosis. Ethics approval was obtained from the ethics committee at PSMMC.
Data were analyzed using SPSS version 21 (SPSS IBM, New York, U.S.A.). Descriptive analysis was used to analyze data collected from people with epilepsy regarding their beliefs about different causes and different treatment methods of epilepsy.
still considerable misunderstanding of epilepsy among the general public in Saudi Arabia [9–11]. Previous studies, carried out among the general population or health professionals, have mentioned religious rituals such as praying, visiting temples and mosques, reading the Holy Quran, and family support to be important mechanisms in coping with the burden of epilepsy [12–17]. In this study, we investigated beliefs about the causes of epilepsy and the treatment methods among people with epilepsy from Saudi Arabia, what mechanisms people with epilepsy in Saudi Arabia use to cope with their epilepsy, beliefs about the curability of epilepsy, and opinion about public awareness. The current study is the first study in Saudi Arabia, to our knowledge, in which these beliefs were ascertained in a cohort of people with epilepsy.
2.2. Methods and development of the questionnaire 2.2.1. Phase 1: focus group A preliminary list of possible causes and therapies was drawn up on the basis of a literature review and on local knowledge, and these were used as prompts at a focus group where suggestions of further causes and therapies were also solicited. The focus group raw data were transcribed and then read and reread to identify themes and categories as they emerged from the data [18]. Key themes arising from the analysis of the qualitative data from the focus groups were the causes of epilepsy — medical, religious, cultural, psychosocial, lifestyle, no attributable cause, and others; and treatment for epilepsy — medical, religious, traditional, lifestyle, and others (see below). The focus group discussions also led to the drafting of questions about whether epilepsy was believed to be a curable illness or not, the effects of faith, practicing religious rituals, family support and other methods for coping with epilepsy, compliance with medication, and the need for better social awareness. On the basis of this preliminary work, questionnaires, with an opportunity also for free text, were drafted and piloted. These comprised the following: medical causes (illness, brain insult, result of other disease, inflammation, heredity, contagion); religious causes (test from God, punishment from God); psychosocial causes (psychosocial problems, exhaustion); cultural beliefs about causes (evil eye, magic, possessed by jinn (spirits)); lifestyle (eating fatty food and sleeping under air-conditioning with wet hair); others (other suggestions of causes by patients); and no cause for epilepsy (some patients identified no cause for their epilepsy).
3. Results In the main survey, 110 patients were recruited, and there were no missing data fields. Most participants believed that there were multiple causes of epilepsy and multiple methods of treatment. A test from God was the most commonly ascribed cause (83% as well as 40% who believed that some cases of the illness were a punishment from God). The range of individual causes is shown in Table 1. The belief in the concept of God's will helped many in the cohort to accept their illness as part of their destiny. Ninety-six percent of the patients also believed that there were medical causes in some cases (such as an illness, brain insult, inflammation, heredity, contagion), and a similar proportion believed that there were religious causes. Smaller proportions believed the same cases were due to cultural causes (78%) or psychosocial causes (64%). Thirty-four percent of people believed that there could be sometimes no cause, but only 2% thought that there was never any attributable cause. The range of individual causes is shown in Table 1. No patient believed exclusively in any one category of cause.
Table 1 The beliefs of people with epilepsy about the causes of epilepsy (n = 110).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Cause
Percentage (%)
Test from God Illness Evil eye Brain insult Psychosocial problems Heredity Exhaustion Punishment from God Magic Possessed by jinn (spirits) Result of other diseases No cause Inflammation Contagion Eating fatty food Sleeping under air-conditioning with wet hair Others
83 74 62 61 51 44 41 40 37 35 16 34 10 6 10 10 11
Note: Others (any other causes suggested by the patient and not listed such as: using a computer, spending long hours on mobile phones, PlayStation games, staying up late, missing a vaccine, drug abuse, food poisoning). Note: Each patient is allowed to choose more than one cause for epilepsy.
H.A. Alkhamees et al. / Epilepsy & Behavior 53 (2015) 135–139
We categorized the causes of epilepsy, and the results showed the following: Medical, religious, cultural, psychosocial, and others (11%); medical, religious, cultural, and psychosocial (53%); medical, religious, and cultural (14%); medical and religious (18%); no cause (2%); and lifestyle (2%). In relation to treatment, patients believed in mixtures of different treatment approaches, and no patient believed exclusively in any one category of treatment. The range of individual treatments is shown in Table 2. We categorized the treatments of epilepsy, and results showed the following: Medical, religious, traditional, and others (8%); medical, religious, and traditional (55%); medical and religious (29%); and lifestyle (7%). Both religion and the family play an important role in the Saudi society. The large proportion of cases who believed in religious treatments can be explained by the Muslims' belief in what prophet Mohamed said, “For each disease God creates, there is a treatment he creates for that disease” . The great majority of patients expressed strong gratitude for the power of faith and the practice of religious rituals such as praying and giving charity (96%) and to family support for helping them in coping with their epilepsy (92%) (Table 3). Most participants (92%) felt that they had sufficient family support, but only 4% of the participants were satisfied by the level of awareness about epilepsy in the Saudi society. They pointed to widespread misconceptions about epilepsy and the need for education. Finally, less than 10% of the participants had stopped their medication for religious reasons or because of shame, and only 7% had been persuaded by members of their family to stop their medication.
4. Discussion In the Kingdom of Saudi Arabia, as in any other Islamic country, the great majority of people believe that whatever goes on in their lives, including having any illness, is under the full will and control of God. People with epilepsy hold this view, and many also, simultaneously, hold other beliefs and explanations of the causes of their illness, which may include medical, cultural, and psychosocial causes. Almost all people with epilepsy hold a variety of beliefs about treatment. They generally and sincerely believe that God's will determines whether or not a person will be cured or whether treatment (including medical treatment) will be effective. The traditional perception among many cultures, including some in Saudi Arabia, is that epilepsy or Saraa ( ) as it is
Table 2 The beliefs of people with epilepsy about the treatment of epilepsy (n = 110).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Treatment
Percentage (%)
Rehearsing Holy Quran (rugyah) Drinking or washing by zamzam (curative water) Using antiepileptic drugs (AEDs) Using holy water, honey, and oil Visiting faith healers Washing by seder (Zizyphus) Good sleep and balanced food Positive thinking Using olive oil by drinking or smearing on head and body Cupping Head massage Alternative medicine Surgery Cauterization Special mixtures Others
90 86 81 78 73 62 48 45 43 32 29 28 27 20 15 8
Note: Others (other treatments suggested by the patient and not listed such as: meditation, vitamins, eating garlic, marriage, listening to music). Note: Each patient is allowed to state more than one treatment for epilepsy.
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Table 3 Patients' beliefs about curability of epilepsy, faith, family support, and society awareness (n = 110).
Epilepsy is a curable illness Faith and religious rituals are important in coping with epilepsy Family support is important in coping with epilepsy Does your family provide you with enough support? Medication has been discontinued/refused for religious reasons Medication has been discontinued/refused because of shame Has anyone in your family forced you to discontinue medications? Does Saudi society need more awareness about epilepsy?
Yes (%)
No (%)
Not sure (%)
78 96
4 3
17 1
92 92 8
5 5 91
3 3 1
9
91
0
7
93
0
95
4
1
called in Arabic, is caused by supernatural powers such as jinn possession or witchcraft, and this perception is one reason for people with epilepsy to pursue religious and/or traditional treatments. Most people with epilepsy in our study held a number of beliefs about the causes and treatments simultaneously. That the cause of epilepsy could be religious is believed by 96% of patients, and a similar proportion believed that it could be medical. Smaller proportions believed that it could have cultural (78%) or psychosocial (64%) causes. Only 2% of the patients believed that there were no attributable causes for any case of epilepsy. Almost all patients used treatments based on religious beliefs and medical treatment (97%) and sometimes other traditional therapies as well (64%), either voluntarily or responding to family pressure. The fact that most people with epilepsy in Saudi Arabia still consider medical interventions, despite their strong belief in God's will and destiny and other religious beliefs, indicates that these beliefs do not prevent patients from seeking medical treatments. Prior to the study, we had hypothesized that their religious beliefs might encourage patients to refuse or withdraw from medical therapy, but the study found little evidence of this. However, this may partly reflect the fact that all the patients were recruited from a hospital setting, and these results might not be generalizable to the wider population. It is instructive to compare the current survey findings with those from other parts of the world. Two studies from the UK showed that up to 40% of the sample used alternative medicine to treat epilepsy [4,19]; findings from other studies done in Arabic and Islamic countries show similar results to the current survey as do studies among Muslims living in other countries [9–11,13,17,20–27]. Participants in the current study showed a greater tendency to believe in the religious causes of epilepsy and religious treatment methods, in comparison to other Islamic countries. In contrast, the findings of the current study show clear differences between those of studies from Europe where participants' beliefs revolved around medical causes and where there is little mention of religious causes [28]. The fact that 78% of patients in the current sample believe that epilepsy can be cured can be explained by the general belief among Muslims that God is able to cure all diseases, as he has created a cure for each disease. This strong religious conviction in the power of God is demonstrated by the widespread conviction that the practice of religious rituals such prayers, giving charity, and reading the Holy Quran will result in cure and help in tolerating the burden of their illness. This was mentioned in the Hadith (prophetic sayings): which means, in English, “cure your patients with charity” (Saheeh AlJamee, 3358). In our study, the succor that religious belief provides proved to be a very positive feature of the lives of patients in Saudi Arabia. The family is at the core of Saudi society. In Saudi culture, almost everything in a person's life is linked to the family. The central importance of the family can be a burden when it comes to making individual or personal decisions, as family approval is usually required. Nevertheless,
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the family is an essential source of support and security for the family member suffering from an illness or crisis. The family usually will play a supportive emotional and financial role in a person's life. This applies to epilepsy and to any other condition. Sometimes, the family can be overprotective, and this can prevent the patient with epilepsy from being able to act independently. The findings from our study make it clear that patients rely significantly on family support in coping with their epilepsy. This importance of family role in patients' lives in Saudi Arabia should also be taken into consideration when the patients are seen by health professionals such as a doctor, a nurse, a clinical psychologist, a social worker, or a psychiatrist. The family has great influence on the patient's perception of the illness and decisions regarding treatments. The family can be a positive factor in encouraging the patient to take his/her medication, or they can discourage this. It is not clear how far the findings from this study can be generalized to the whole population of Saudi Arabia. The study was conducted in Riyadh, the capital city of Saudi Arabia, at Prince Sultan Military Medical City. Because of the time limitation and the complexity of obtaining ethics approval from other hospitals, it was not possible to expand the research to cover other hospitals in Riyadh or in other cities in the Kingdom, although it would have been interesting to expand the study in this way. However, participants in this study were from various different regions in the country, and their answers can reasonably be considered to reflect opinions from the urban populations of other regions. Saudi citizens who live in rural and Bedouin areas were not included in this study. These people are less likely to seek medical treatments, and it is possible that a greater proportion of people in these groups believe that epilepsy is a nonmedical illness, therefore, they will seek nonmedical treatment. Unfortunately, these groups are difficult to reach, and our results may not reflect those among the Bedouin and other rural people. In general, people from Saudi Arabia are considered to be reserved, usually reluctant to give personal information and sometimes suspicious, but we had no difficulty in recruiting subjects or obtaining cooperation, and few who were approached refused to take part. The study was conducted in a face-to-face setting by the first author (HAK, a clinical psychologist) and a trained psychologist, and the impression gained was that the subjects were being open and honest in their responses. The face-to-face technique improved the quality of the data which, in our view, would not have been possible through distributing anonymous questionnaires. Beliefs and attitudes are influenced by the prevailing culture in every country of the world. A person's religious and cultural heritage is a powerful determinant of daily activities, and this includes the way medical illness is perceived and managed. Epilepsy is a medical condition that seems particularly susceptible to cultural interpretation. Historically, in many cultures, explanations about its cause have varied from supernatural powers to a medical illness. Health professionals working in the field of epilepsy need to be aware of these different beliefs. In a clinical interview, information will not be complete or meaningful if the clinician does not give full attention to his/her patient's religious and cultural beliefs. The Understanding of epilepsy varies between different cultures and religions, therefore, the perception of the person with epilepsy can be affected by this understanding. The importance of understanding these different religious and cultural beliefs is to anticipate how a person with epilepsy will react toward his/her illness and what treatment approach he/she will consider. The clinician needs to show the patient and the relatives that he/she is aware of the patient's background, and this is necessary to build trust and respect and will encourage the patients to be more honest about and open to different treatments. Equally important is an understanding of how much the family influences an individual's life in some cultures. Therefore, it is not enough to work only with the patient without engaging the family because the patient will rely on the approval of the family before accepting treatment. The family will exert a powerful influence over what medical or nonmedical treatments
are adhered to, and in some cases they may encourage termination of medical treatments. The family plays a major role in a person's life in Saudi Arabia. Their opinions, suggestions, and approval of a person's decisions in life could be essential most of the time. Family members are also influenced by cultural and religious beliefs, and in the case of illnesses like epilepsy where supernatural powers are deemed to play a role, the family will usually advise their sick relative to seek nonmedical treatments before visiting a doctor. Many have very strong beliefs that doctors and medications will not help cure epilepsy, rather, the only cure will be through faith healers and nonmedical treatments. To make the most of the understanding of the importance of beliefs about causes and treatments, a clinician might wish to expand the medical team, for instance, by including a health educator to empower the patient and the family to have a role in management. A similar understanding of the religious and cultural influence on epilepsy and people with epilepsy can also be very useful for health professionals in Europe and elsewhere in the world where patients with Islamic backgrounds are encountered. Formal guidelines incorporating religious and cultural beliefs would be helpful.
Acknowledgments I would like to thank all the patients who participated in this study and thank Dr. Mohammed Sofi, Dr. Afag Othman, and Dr. Sadagah Alawi who helped in referring patients from the neurology clinic at PSMMC and Ms. Basma Bin Shayieg who helped in the focus group. Also, I would like to thank Drs. Khadija Rantell and Zoe Fox and Dr. Khalid Algahtani for their help in statistical analysis. Conflict of interest No conflict of interest.
References [1] Paladin AV. Epilepsy according to the Christian, Jewish and Islamic religions: an overview. J Turk Chapter ILAE 1995;1(1):38–41. [2] 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(4):368–75. [3] Baskind R, Birbeck GL. Epilepsy-associated stigma in Sub-Saharan Africa: the social landscape of a disease. Epilepsy Behav 2005;7(1):68–73. [4] Easterford K, Clough P, Comish S, Lawton L, Duncan S. The use of complementary medicines and alternative practitioners in a cohort of patients with epilepsy. Epilepsy Behav 2005;6(1):59–62. [5] Carod-Artal FJ, Vázquez-Cabrera CB. An anthropological study about epilepsy in native tribes from Central and South America. Epilepsia 2007;48(5):886–93. [6] Liow K, Ablah E, Nguyen JC, Sadler T, Wolfe D, Tran K-D, et al. Pattern and frequency of use of complementary and alternative medicine among patients with epilepsy in the midwestern United States. Epilepsy Behav 2007;10(4):576–82. [7] Magiorkinis E, Sidiropoulou K, Diamantis A. Hallmarks in the history of epilepsy: epilepsy in antiquity. Epilepsy Behav 2010;17(1):103–8. [8] Al Rajeh S, Awada A, Bademosi O, Ogunniyi A. The prevalence of epilepsy and other seizure disorders in an Arab population: a community-based study. Seizure 2001; 10(6):410–4. [9] Bamogaddam F, El Mubarak M. Religious beliefs about epilepsy among Saudi population: community based study. Epilepsia 2009;50:445. [10] 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(4):245–9. [11] Alaqeel A, Alebdi F, Sabbagh AJ. Epilepsy: what do health-care professionals in Riyadh know? Epilepsy Behav 2013;29(1):234–7. [12] Mrabet H, Mrabet A, Zouari B, Ghachem R. Health-related quality of life of people with epilepsy compared with a general reference population: a Tunisian study. Epilepsia 2004;45(7):838–43. [13] Otoom SA, Al-Safi SA, Sequeira RP, Alkofahi AS. Knowledge of management of epilepsy in young adults in Jordan. Epilepsy Behav 2006;9(2):349–54. [14] Khwaja G, Singh G, Chaudhry N. Epilepsy and religion. Ann Indian Acad Neurol 2007;10(3):165–8. [15] Neni SW, Lua PL. Relationships between awareness, knowledge, attitudes and coping mechanisms in epilepsy. ASEAN J Psychiatry 2011;12(2):131–42. [16] Bahou YG, Jaber MS, Kasasbeh AS. Quality of life in epilepsy at Jordan University Hospital. Neurosciences (Riyadh) 2011;16(1):18–23.
H.A. Alkhamees et al. / Epilepsy & Behavior 53 (2015) 135–139 [17] Alrawi S, Fetters MD, Killawi A, Hammad A, Padela A. Traditional healing practices among American Muslims: perceptions of community leaders in southeast Michigan. J Immigr Minor Health 2012;14(3):489–96. [18] Pope C, Ziebland S, Mays N. Analysing qualitative data. Qual Res Health Care 2000; 320(7227):114–6. [19] Donker GA, Foets M, Spreeuwenberg P. Epilepsy patients: health status and medical consumption. J Neurol 1997;244(6):365–70. [20] Bener A, al-Marzooqi FH, Sztriha L. Public awareness and attitudes towards epilepsy in the United Arab Emirates. Seizure 1998;7(3):219–22. [21] Ismail H, Wright J, Rhodes P, Small N. Religious beliefs about causes and treatment of epilepsy. Br J Gen Pract 2005;55(510):26–31. [22] Kabir M, Iliyasu Z, Abubakar IS, Kabir ZS, Farinyaro AU. Knowledge, attitude and beliefs about epilepsy among adults in a northern Nigerian urban community. Ann Afr Med 2005;4(3):107–12. [23] Daoud A, Al-Safi S, Otoom S, Wahba L, Alkofahi A. Public knowledge and attitudes towards epilepsy in Jordan. Seizure 2007;16(6):521–6.
139
[24] Demirci S, Dönmez CM, Gündoğar D, Baydar CL. Public awareness of, attitudes toward, and understanding of epilepsy in Isparta, Turkey. Epilepsy Behav 2007; 11(3):427–33. [25] Alrashed H, Alyahya D, Alkandari A, Shehab A, AlSabah R, AlTaiar A. Knowledge of, perceptions of, and attitudes toward epilepsy among university students in Kuwait. Epilepsy Behav 2009;14(2):367–71. [26] Degirmenci Y, Ozişik Karaman HI, Bakar C. Perceptions of epilepsy of three different groups in Turkey. Epilepsy Behav 2010;19(3):315–22. [27] Bartolini E, Bell GS, Sander JW. Multicultural challenges in epilepsy. Epilepsy Behav 2011;20(3):428–34. [28] Jacoby A, Gorry J, Gamble C, Baker GA. Public knowledge, private grief: a study of public attitudes to epilepsy in the United Kingdom and implications for stigma. Epilepsia 2004;45(11):1405–15.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
The beliefs among patients with epilepsy in Saudi Arabia about the causes and treatment of epilepsy and other aspects Hadeel A. Alkhamees ⁎, Caroline E. Selai, Simon D. Shorvon Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, UK
a r t i c l e
i n f o
Article history: Received 9 August 2015 Revised 6 October 2015 Accepted 8 October 2015 Available online 12 November 2015 Keywords: Epilepsy Religious and cultural beliefs Faith healing Saudi
a b s t r a c t Purpose: The current survey sought to identify the religious and cultural beliefs about the causes and treatment of epilepsy in people with epilepsy from Saudi Arabia and a number of other aspects relating to the possibility of cure, coping with the condition, and public awareness. Methods: Study instruments were developed on the basis of the literature, a focus group of people with epilepsy, and feedback from people in the field with local knowledge. These were then piloted. A survey was then carried out among a total of 110 adults with epilepsy. Participants were asked to complete questionnaires inquiring into their beliefs about the causes and range of treatments used for epilepsy. Each participant was allowed to choose more than one cause and more than one treatment method. The questionnaires were administered face to face by a clinical psychologist (HAA) to improve the quality of the responses. Results: We found that most adults with epilepsy in Saudi Arabia believe that epilepsy is a condition with multifactorial causation and for which more than one treatment method should be applied. A test from God was the most commonly ascribed cause (83% as well as 40% who believed that some cases of the illness were a punishment from God). The belief in the concept of God's will helped many in the cohort to accept their illness as part of their destiny. Ninety-six percent of the patients believed that there were also medical causes (such as an illness, brain insult, inflammation, heredity, contagion), and a similar proportion believed that there were also religious causes. Smaller proportions believed epilepsy could be due to cultural (78%) or psychosocial causes (64%). Thirty-four percent of people believed that there could be sometimes no cause, but only 2% thought that epilepsy never had any identifiable cause. Most patients did not believe that one treatment alone would help. Ninety-three percent of patients believed in medical treatment, 93% in religious treatment, and 64% in traditional treatments, and 7% believed in changing lifestyle (eating balanced food and positive thinking). Seventy-eight percent of the sample believed that their epilepsy was a curable illness. Ninety-six percent believed that faith and practicing religious rituals helped in coping with epilepsy, and 92% believed that family support helped in coping with epilepsy. Nine percent of patients had stopped their medication for religious reasons or because of a sense of shame, and 7% had at one time been forced by their family to stop their medication. Ninety-two percent of the sample reported having enough family support. Ninety-five percent believed that Saudi society needs more awareness to understand epilepsy. Conclusion: In Saudi Arabia, religious and cultural beliefs about the causes and treatment of epilepsy exist alongside medical beliefs. The holding of religious beliefs, the practicing of religious rituals, and the presence of family support were found to be of great importance in coping with epilepsy, and their role needs to be fully appreciated in the medical management of the condition. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The degree of understanding about epilepsy varies between different religions, cultures, and ethnic groups. Historically, in Judaism, epilepsy has sometimes been understood as a consequence of a sexual sin [1], and in Christianity, epilepsy has sometimes been explained as being caused by sin and/or by supernatural powers [1]. In Islam, “there is no sickness for which God did not provide a remedy” [1] is a fundamental ⁎ Corresponding author. E-mail address: [email protected] (H.A. Alkhamees).
http://dx.doi.org/10.1016/j.yebeh.2015.10.008 1525-5050/© 2015 Elsevier Inc. All rights reserved.
tenet of the Islamic faith, and Islamic medicine was established on this principle. Nonbiological beliefs about the cause of epilepsy and the use of nonmedical treatments in treating epilepsy have been recorded in previous studies in both the developed and the developing world [2–7]. In Saudi Arabia, the prevalence of epilepsy is 6.54 per 1000 [8], similar to that in other countries. The concepts of magic and evil eye are widely accepted among people from Saudi Arabia as a cause of various forms of physical and psychological illnesses, and as a result, many people in Saudi Arabia visit faith healers for treatments even though there is easy access to public and private hospitals. Previous studies have reported that, despite the improved standards of general education, there is
136
H.A. Alkhamees et al. / Epilepsy & Behavior 53 (2015) 135–139
2. Materials and methods
The next section covered medical therapies (antiepileptic drugs (AEDs), surgery); religious therapies (rehearsing the Holy Quran (rugyah), drinking or washing by zamzam, using holy water, honey, and oil, visiting faith healers, washing by seder (Zizyphus)); traditional therapies: (cupping, cauterization, head massage, alternative medicine, special mixtures, using olive oil); lifestyle (eating balanced food and positive thinking); and other treatments (other suggestions from patients). Further questions covered whether epilepsy was considered a curable illness, the use of faith and religious rituals and family support in coping with the illness, whether medication was ever discontinued for religious reasons, because of feelings of shame, or because of family pressure or beliefs, whether there was sufficient family support, and whether Saudi society needed a greater degree of awareness about epilepsy. The questionnaires were adjusted for clarity and ease of use, on the basis of the pilot, and a version was created for the main survey.
2.1. Participants
2.3. Data analysis
Eligible patients were recruited from Prince Sultan Military Medical City (PSMMC) in Riyadh, Kingdom of Saudi Arabia over a three-month period (January to March 2012). The PSMMC is a secondary and tertiary care hospital in Riyadh, the capital city of Saudi Arabia. The epilepsy unit at PSMMC is one of the specialized units in the Kingdom of Saudi Arabia to which people with epilepsy will be admitted for investigations. Patients who participated in this study (n = 110) were either selected from the National Epilepsy Registry database or through direct referral by the neurologist; their ages ranged from 18 to 60 years, all had a minimum level of education of at least the primary school level, and their diagnosis of epilepsy was confirmed by clinical history, EEG, and brain MRI studies. Inclusion criteria were the following: (1) all patients with any type of epilepsy and (2) males and females between the ages of 18 and 60 years. Exclusion criteria were the following: (1) patients with IQs below 80, (2) patients with severe cognitive impairment, learning difficulties, and severe sensory deficits and those who are not able to give informed consent, (3) patients who are illiterate (unable to read and write), and (4) patients with a history of or with active psychosis. Ethics approval was obtained from the ethics committee at PSMMC.
Data were analyzed using SPSS version 21 (SPSS IBM, New York, U.S.A.). Descriptive analysis was used to analyze data collected from people with epilepsy regarding their beliefs about different causes and different treatment methods of epilepsy.
still considerable misunderstanding of epilepsy among the general public in Saudi Arabia [9–11]. Previous studies, carried out among the general population or health professionals, have mentioned religious rituals such as praying, visiting temples and mosques, reading the Holy Quran, and family support to be important mechanisms in coping with the burden of epilepsy [12–17]. In this study, we investigated beliefs about the causes of epilepsy and the treatment methods among people with epilepsy from Saudi Arabia, what mechanisms people with epilepsy in Saudi Arabia use to cope with their epilepsy, beliefs about the curability of epilepsy, and opinion about public awareness. The current study is the first study in Saudi Arabia, to our knowledge, in which these beliefs were ascertained in a cohort of people with epilepsy.
2.2. Methods and development of the questionnaire 2.2.1. Phase 1: focus group A preliminary list of possible causes and therapies was drawn up on the basis of a literature review and on local knowledge, and these were used as prompts at a focus group where suggestions of further causes and therapies were also solicited. The focus group raw data were transcribed and then read and reread to identify themes and categories as they emerged from the data [18]. Key themes arising from the analysis of the qualitative data from the focus groups were the causes of epilepsy — medical, religious, cultural, psychosocial, lifestyle, no attributable cause, and others; and treatment for epilepsy — medical, religious, traditional, lifestyle, and others (see below). The focus group discussions also led to the drafting of questions about whether epilepsy was believed to be a curable illness or not, the effects of faith, practicing religious rituals, family support and other methods for coping with epilepsy, compliance with medication, and the need for better social awareness. On the basis of this preliminary work, questionnaires, with an opportunity also for free text, were drafted and piloted. These comprised the following: medical causes (illness, brain insult, result of other disease, inflammation, heredity, contagion); religious causes (test from God, punishment from God); psychosocial causes (psychosocial problems, exhaustion); cultural beliefs about causes (evil eye, magic, possessed by jinn (spirits)); lifestyle (eating fatty food and sleeping under air-conditioning with wet hair); others (other suggestions of causes by patients); and no cause for epilepsy (some patients identified no cause for their epilepsy).
3. Results In the main survey, 110 patients were recruited, and there were no missing data fields. Most participants believed that there were multiple causes of epilepsy and multiple methods of treatment. A test from God was the most commonly ascribed cause (83% as well as 40% who believed that some cases of the illness were a punishment from God). The range of individual causes is shown in Table 1. The belief in the concept of God's will helped many in the cohort to accept their illness as part of their destiny. Ninety-six percent of the patients also believed that there were medical causes in some cases (such as an illness, brain insult, inflammation, heredity, contagion), and a similar proportion believed that there were religious causes. Smaller proportions believed the same cases were due to cultural causes (78%) or psychosocial causes (64%). Thirty-four percent of people believed that there could be sometimes no cause, but only 2% thought that there was never any attributable cause. The range of individual causes is shown in Table 1. No patient believed exclusively in any one category of cause.
Table 1 The beliefs of people with epilepsy about the causes of epilepsy (n = 110).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Cause
Percentage (%)
Test from God Illness Evil eye Brain insult Psychosocial problems Heredity Exhaustion Punishment from God Magic Possessed by jinn (spirits) Result of other diseases No cause Inflammation Contagion Eating fatty food Sleeping under air-conditioning with wet hair Others
83 74 62 61 51 44 41 40 37 35 16 34 10 6 10 10 11
Note: Others (any other causes suggested by the patient and not listed such as: using a computer, spending long hours on mobile phones, PlayStation games, staying up late, missing a vaccine, drug abuse, food poisoning). Note: Each patient is allowed to choose more than one cause for epilepsy.
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We categorized the causes of epilepsy, and the results showed the following: Medical, religious, cultural, psychosocial, and others (11%); medical, religious, cultural, and psychosocial (53%); medical, religious, and cultural (14%); medical and religious (18%); no cause (2%); and lifestyle (2%). In relation to treatment, patients believed in mixtures of different treatment approaches, and no patient believed exclusively in any one category of treatment. The range of individual treatments is shown in Table 2. We categorized the treatments of epilepsy, and results showed the following: Medical, religious, traditional, and others (8%); medical, religious, and traditional (55%); medical and religious (29%); and lifestyle (7%). Both religion and the family play an important role in the Saudi society. The large proportion of cases who believed in religious treatments can be explained by the Muslims' belief in what prophet Mohamed said, “For each disease God creates, there is a treatment he creates for that disease” . The great majority of patients expressed strong gratitude for the power of faith and the practice of religious rituals such as praying and giving charity (96%) and to family support for helping them in coping with their epilepsy (92%) (Table 3). Most participants (92%) felt that they had sufficient family support, but only 4% of the participants were satisfied by the level of awareness about epilepsy in the Saudi society. They pointed to widespread misconceptions about epilepsy and the need for education. Finally, less than 10% of the participants had stopped their medication for religious reasons or because of shame, and only 7% had been persuaded by members of their family to stop their medication.
4. Discussion In the Kingdom of Saudi Arabia, as in any other Islamic country, the great majority of people believe that whatever goes on in their lives, including having any illness, is under the full will and control of God. People with epilepsy hold this view, and many also, simultaneously, hold other beliefs and explanations of the causes of their illness, which may include medical, cultural, and psychosocial causes. Almost all people with epilepsy hold a variety of beliefs about treatment. They generally and sincerely believe that God's will determines whether or not a person will be cured or whether treatment (including medical treatment) will be effective. The traditional perception among many cultures, including some in Saudi Arabia, is that epilepsy or Saraa ( ) as it is
Table 2 The beliefs of people with epilepsy about the treatment of epilepsy (n = 110).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Treatment
Percentage (%)
Rehearsing Holy Quran (rugyah) Drinking or washing by zamzam (curative water) Using antiepileptic drugs (AEDs) Using holy water, honey, and oil Visiting faith healers Washing by seder (Zizyphus) Good sleep and balanced food Positive thinking Using olive oil by drinking or smearing on head and body Cupping Head massage Alternative medicine Surgery Cauterization Special mixtures Others
90 86 81 78 73 62 48 45 43 32 29 28 27 20 15 8
Note: Others (other treatments suggested by the patient and not listed such as: meditation, vitamins, eating garlic, marriage, listening to music). Note: Each patient is allowed to state more than one treatment for epilepsy.
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Table 3 Patients' beliefs about curability of epilepsy, faith, family support, and society awareness (n = 110).
Epilepsy is a curable illness Faith and religious rituals are important in coping with epilepsy Family support is important in coping with epilepsy Does your family provide you with enough support? Medication has been discontinued/refused for religious reasons Medication has been discontinued/refused because of shame Has anyone in your family forced you to discontinue medications? Does Saudi society need more awareness about epilepsy?
Yes (%)
No (%)
Not sure (%)
78 96
4 3
17 1
92 92 8
5 5 91
3 3 1
9
91
0
7
93
0
95
4
1
called in Arabic, is caused by supernatural powers such as jinn possession or witchcraft, and this perception is one reason for people with epilepsy to pursue religious and/or traditional treatments. Most people with epilepsy in our study held a number of beliefs about the causes and treatments simultaneously. That the cause of epilepsy could be religious is believed by 96% of patients, and a similar proportion believed that it could be medical. Smaller proportions believed that it could have cultural (78%) or psychosocial (64%) causes. Only 2% of the patients believed that there were no attributable causes for any case of epilepsy. Almost all patients used treatments based on religious beliefs and medical treatment (97%) and sometimes other traditional therapies as well (64%), either voluntarily or responding to family pressure. The fact that most people with epilepsy in Saudi Arabia still consider medical interventions, despite their strong belief in God's will and destiny and other religious beliefs, indicates that these beliefs do not prevent patients from seeking medical treatments. Prior to the study, we had hypothesized that their religious beliefs might encourage patients to refuse or withdraw from medical therapy, but the study found little evidence of this. However, this may partly reflect the fact that all the patients were recruited from a hospital setting, and these results might not be generalizable to the wider population. It is instructive to compare the current survey findings with those from other parts of the world. Two studies from the UK showed that up to 40% of the sample used alternative medicine to treat epilepsy [4,19]; findings from other studies done in Arabic and Islamic countries show similar results to the current survey as do studies among Muslims living in other countries [9–11,13,17,20–27]. Participants in the current study showed a greater tendency to believe in the religious causes of epilepsy and religious treatment methods, in comparison to other Islamic countries. In contrast, the findings of the current study show clear differences between those of studies from Europe where participants' beliefs revolved around medical causes and where there is little mention of religious causes [28]. The fact that 78% of patients in the current sample believe that epilepsy can be cured can be explained by the general belief among Muslims that God is able to cure all diseases, as he has created a cure for each disease. This strong religious conviction in the power of God is demonstrated by the widespread conviction that the practice of religious rituals such prayers, giving charity, and reading the Holy Quran will result in cure and help in tolerating the burden of their illness. This was mentioned in the Hadith (prophetic sayings): which means, in English, “cure your patients with charity” (Saheeh AlJamee, 3358). In our study, the succor that religious belief provides proved to be a very positive feature of the lives of patients in Saudi Arabia. The family is at the core of Saudi society. In Saudi culture, almost everything in a person's life is linked to the family. The central importance of the family can be a burden when it comes to making individual or personal decisions, as family approval is usually required. Nevertheless,
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the family is an essential source of support and security for the family member suffering from an illness or crisis. The family usually will play a supportive emotional and financial role in a person's life. This applies to epilepsy and to any other condition. Sometimes, the family can be overprotective, and this can prevent the patient with epilepsy from being able to act independently. The findings from our study make it clear that patients rely significantly on family support in coping with their epilepsy. This importance of family role in patients' lives in Saudi Arabia should also be taken into consideration when the patients are seen by health professionals such as a doctor, a nurse, a clinical psychologist, a social worker, or a psychiatrist. The family has great influence on the patient's perception of the illness and decisions regarding treatments. The family can be a positive factor in encouraging the patient to take his/her medication, or they can discourage this. It is not clear how far the findings from this study can be generalized to the whole population of Saudi Arabia. The study was conducted in Riyadh, the capital city of Saudi Arabia, at Prince Sultan Military Medical City. Because of the time limitation and the complexity of obtaining ethics approval from other hospitals, it was not possible to expand the research to cover other hospitals in Riyadh or in other cities in the Kingdom, although it would have been interesting to expand the study in this way. However, participants in this study were from various different regions in the country, and their answers can reasonably be considered to reflect opinions from the urban populations of other regions. Saudi citizens who live in rural and Bedouin areas were not included in this study. These people are less likely to seek medical treatments, and it is possible that a greater proportion of people in these groups believe that epilepsy is a nonmedical illness, therefore, they will seek nonmedical treatment. Unfortunately, these groups are difficult to reach, and our results may not reflect those among the Bedouin and other rural people. In general, people from Saudi Arabia are considered to be reserved, usually reluctant to give personal information and sometimes suspicious, but we had no difficulty in recruiting subjects or obtaining cooperation, and few who were approached refused to take part. The study was conducted in a face-to-face setting by the first author (HAK, a clinical psychologist) and a trained psychologist, and the impression gained was that the subjects were being open and honest in their responses. The face-to-face technique improved the quality of the data which, in our view, would not have been possible through distributing anonymous questionnaires. Beliefs and attitudes are influenced by the prevailing culture in every country of the world. A person's religious and cultural heritage is a powerful determinant of daily activities, and this includes the way medical illness is perceived and managed. Epilepsy is a medical condition that seems particularly susceptible to cultural interpretation. Historically, in many cultures, explanations about its cause have varied from supernatural powers to a medical illness. Health professionals working in the field of epilepsy need to be aware of these different beliefs. In a clinical interview, information will not be complete or meaningful if the clinician does not give full attention to his/her patient's religious and cultural beliefs. The Understanding of epilepsy varies between different cultures and religions, therefore, the perception of the person with epilepsy can be affected by this understanding. The importance of understanding these different religious and cultural beliefs is to anticipate how a person with epilepsy will react toward his/her illness and what treatment approach he/she will consider. The clinician needs to show the patient and the relatives that he/she is aware of the patient's background, and this is necessary to build trust and respect and will encourage the patients to be more honest about and open to different treatments. Equally important is an understanding of how much the family influences an individual's life in some cultures. Therefore, it is not enough to work only with the patient without engaging the family because the patient will rely on the approval of the family before accepting treatment. The family will exert a powerful influence over what medical or nonmedical treatments
are adhered to, and in some cases they may encourage termination of medical treatments. The family plays a major role in a person's life in Saudi Arabia. Their opinions, suggestions, and approval of a person's decisions in life could be essential most of the time. Family members are also influenced by cultural and religious beliefs, and in the case of illnesses like epilepsy where supernatural powers are deemed to play a role, the family will usually advise their sick relative to seek nonmedical treatments before visiting a doctor. Many have very strong beliefs that doctors and medications will not help cure epilepsy, rather, the only cure will be through faith healers and nonmedical treatments. To make the most of the understanding of the importance of beliefs about causes and treatments, a clinician might wish to expand the medical team, for instance, by including a health educator to empower the patient and the family to have a role in management. A similar understanding of the religious and cultural influence on epilepsy and people with epilepsy can also be very useful for health professionals in Europe and elsewhere in the world where patients with Islamic backgrounds are encountered. Formal guidelines incorporating religious and cultural beliefs would be helpful.
Acknowledgments I would like to thank all the patients who participated in this study and thank Dr. Mohammed Sofi, Dr. Afag Othman, and Dr. Sadagah Alawi who helped in referring patients from the neurology clinic at PSMMC and Ms. Basma Bin Shayieg who helped in the focus group. Also, I would like to thank Drs. Khadija Rantell and Zoe Fox and Dr. Khalid Algahtani for their help in statistical analysis. Conflict of interest No conflict of interest.
References [1] Paladin AV. Epilepsy according to the Christian, Jewish and Islamic religions: an overview. J Turk Chapter ILAE 1995;1(1):38–41. [2] 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(4):368–75. [3] Baskind R, Birbeck GL. Epilepsy-associated stigma in Sub-Saharan Africa: the social landscape of a disease. Epilepsy Behav 2005;7(1):68–73. [4] Easterford K, Clough P, Comish S, Lawton L, Duncan S. The use of complementary medicines and alternative practitioners in a cohort of patients with epilepsy. Epilepsy Behav 2005;6(1):59–62. [5] Carod-Artal FJ, Vázquez-Cabrera CB. An anthropological study about epilepsy in native tribes from Central and South America. Epilepsia 2007;48(5):886–93. [6] Liow K, Ablah E, Nguyen JC, Sadler T, Wolfe D, Tran K-D, et al. Pattern and frequency of use of complementary and alternative medicine among patients with epilepsy in the midwestern United States. Epilepsy Behav 2007;10(4):576–82. [7] Magiorkinis E, Sidiropoulou K, Diamantis A. Hallmarks in the history of epilepsy: epilepsy in antiquity. Epilepsy Behav 2010;17(1):103–8. [8] Al Rajeh S, Awada A, Bademosi O, Ogunniyi A. The prevalence of epilepsy and other seizure disorders in an Arab population: a community-based study. Seizure 2001; 10(6):410–4. [9] Bamogaddam F, El Mubarak M. Religious beliefs about epilepsy among Saudi population: community based study. Epilepsia 2009;50:445. [10] 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(4):245–9. [11] Alaqeel A, Alebdi F, Sabbagh AJ. Epilepsy: what do health-care professionals in Riyadh know? Epilepsy Behav 2013;29(1):234–7. [12] Mrabet H, Mrabet A, Zouari B, Ghachem R. Health-related quality of life of people with epilepsy compared with a general reference population: a Tunisian study. Epilepsia 2004;45(7):838–43. [13] Otoom SA, Al-Safi SA, Sequeira RP, Alkofahi AS. Knowledge of management of epilepsy in young adults in Jordan. Epilepsy Behav 2006;9(2):349–54. [14] Khwaja G, Singh G, Chaudhry N. Epilepsy and religion. Ann Indian Acad Neurol 2007;10(3):165–8. [15] Neni SW, Lua PL. Relationships between awareness, knowledge, attitudes and coping mechanisms in epilepsy. ASEAN J Psychiatry 2011;12(2):131–42. [16] Bahou YG, Jaber MS, Kasasbeh AS. Quality of life in epilepsy at Jordan University Hospital. Neurosciences (Riyadh) 2011;16(1):18–23.
H.A. Alkhamees et al. / Epilepsy & Behavior 53 (2015) 135–139 [17] Alrawi S, Fetters MD, Killawi A, Hammad A, Padela A. Traditional healing practices among American Muslims: perceptions of community leaders in southeast Michigan. J Immigr Minor Health 2012;14(3):489–96. [18] Pope C, Ziebland S, Mays N. Analysing qualitative data. Qual Res Health Care 2000; 320(7227):114–6. [19] Donker GA, Foets M, Spreeuwenberg P. Epilepsy patients: health status and medical consumption. J Neurol 1997;244(6):365–70. [20] Bener A, al-Marzooqi FH, Sztriha L. Public awareness and attitudes towards epilepsy in the United Arab Emirates. Seizure 1998;7(3):219–22. [21] Ismail H, Wright J, Rhodes P, Small N. Religious beliefs about causes and treatment of epilepsy. Br J Gen Pract 2005;55(510):26–31. [22] Kabir M, Iliyasu Z, Abubakar IS, Kabir ZS, Farinyaro AU. Knowledge, attitude and beliefs about epilepsy among adults in a northern Nigerian urban community. Ann Afr Med 2005;4(3):107–12. [23] Daoud A, Al-Safi S, Otoom S, Wahba L, Alkofahi A. Public knowledge and attitudes towards epilepsy in Jordan. Seizure 2007;16(6):521–6.
139
[24] Demirci S, Dönmez CM, Gündoğar D, Baydar CL. Public awareness of, attitudes toward, and understanding of epilepsy in Isparta, Turkey. Epilepsy Behav 2007; 11(3):427–33. [25] Alrashed H, Alyahya D, Alkandari A, Shehab A, AlSabah R, AlTaiar A. Knowledge of, perceptions of, and attitudes toward epilepsy among university students in Kuwait. Epilepsy Behav 2009;14(2):367–71. [26] Degirmenci Y, Ozişik Karaman HI, Bakar C. Perceptions of epilepsy of three different groups in Turkey. Epilepsy Behav 2010;19(3):315–22. [27] Bartolini E, Bell GS, Sander JW. Multicultural challenges in epilepsy. Epilepsy Behav 2011;20(3):428–34. [28] Jacoby A, Gorry J, Gamble C, Baker GA. Public knowledge, private grief: a study of public attitudes to epilepsy in the United Kingdom and implications for stigma. Epilepsia 2004;45(11):1405–15.