Epilepsia, 50(5):1262–1265, 2009 doi: 10.1111/j.1528-1167.2008.01809.x
BRIEF COMMUNICATION
Secondary school students’ knowledge, attitudes, and practice toward epilepsy in the Batibo Health District—Cameroon *yAlfred K. Njamnshi, zSamuel A. Angwafor, xPierre Jallon, and *Walinjom F. T. Muna *Department of Internal Medicine and Specialties, Neurology Unit, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon; yNeurology Department, Central Hospital Yaounde, Yaounde, Cameroon; zFaculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon; and xEpileptology and EEG Unit, Department of Neurology, University Hospitals of Geneva, Geneva, Switzerland
SUMMARY Using a 12-item questionnaire, we assessed knowledge, attitudes, and practice (KAP) toward epilepsy and identified determinants of inappropriate attitudes toward people with epilepsy (PWE) among 910 randomly selected secondary school students in Batibo (Cameroon). Ninety-five percent of the students had heard or read about epilepsy, 73.3% knew an epileptic, and 76.4% had witnessed a seizure. Those who would offer equal employment opportunities to PWE, refuse to associate with, or refuse to marry PWE repre-
sented 58.6%, 25.4%, and 64.2%, respectively. Negative attitudes appeared to be reinforced by beliefs that epilepsy is hereditary (25.7%), contagious (49.9%), or a kind of insanity (38%). Acquaintance with PWE tended to improve the misconception that epilepsy is contagious (p < 0.001), and to reinforce the view that it is a form of insanity (p < 0.01). A successful epilepsy education program must account for local beliefs, and secondary school students may constitute a good channel for community education. KEY WORDS: Epilepsy, Familiarity, Beliefs, Stigma, Education, Schools, Rural Cameroon.
Epilepsy has been perceived for a long time the world over as a sacred disease and carries a lot of social stigma and discrimination. In most African countries, traditional beliefs constitute a major challenge to treatment and may be responsible for the current treatment gap (WHO Regional Office for Africa and ILAE ⁄ IBE ⁄ WHO Global Campaign Against Epilepsy, 2004). In Cameroon, epilepsy is a serious public health problem, with a reported focus of high endemicity with prevalence rates between 4.9% and 6% in the Mbam Valley (Dongmo et al., 2000; Njamnshi et al., 2005) and suspected foci in areas like Batibo. Although many etiologic and risk factors for epilepsy have been demonstrated in Cameroon (Njamnshi et al., 2007), traditional indigenous medicine still plays an important role in epilepsy management, as up to 25% of our patients seek traditional treat-
ment (Dongmo et al., 2003). However, no study has so far focused on the knowledge, attitudes, and practices (KAP) concerning epilepsy in Cameroon. We hypothesized that young people in secondary schools could be an ideal target for epilepsy education given that recent studies among secondary school students in some African countries have shown a high level of stigma against people with epilepsy (PWE) (Matuja & Rwiza, 1994; Millogo et al., 2002). Successfully educated, this target population could then serve as communication channels, to transform the attitudes of the rest of the community toward PWE. The aim of this study was to contribute toward the development of an epilepsy education program within the framework of the National Epilepsy Control Programme.
Accepted July 28, 2008; Early View publication October 14, 2008. Address correspondence to Alfred K. Njamnshi, M.D., M.A., D.M.S., Department of Internal Medicine and Specialties, Neurology Unit, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon. E-mail:
[email protected]
Respondents Volunteer secondary school students between the ages of 11 and 28 years were randomly selected from three schools in the Batibo Health District, in the North West province of Cameroon, to complete our questionnaires. We excluded students below class three, those with
Wiley Periodicals, Inc. ª 2008 International League Against Epilepsy
Methods
1262
1263 KAP Toward Epilepsy in Cameroonian Secondary School Students previous or current seizures, the mentally ill, and those who did not give informed consent.
Q12: ‘‘If your relatives have epilepsy, what kind of treatment would you suggest?’’
Survey methods This survey was carried out in the three most populated secondary schools in the rural Batibo Health District: Government High School (2000 students), Presbyterian High school (750 students), and Government Technical School (300 students) Batibo. Batibo subdivision has six secondary schools with a student population of approximately 3,350. There were no demographic differences observed between the three student populations. The religious background of the students from the school records showed a predominance of Christianity (95%). We included a random sample of 920 students. The number of selected respondents in each school was proportionate to the school population. Participating classes and students in each class were randomly selected in each school. Instructions on how to complete the questionnaires were given to each class before the distribution of the questionnaires. A few explanations were made as needed, avoiding leads.
Ethical issues Ethical clearance was obtained from the National Ethics Committee and an Administrative Authorisation for Research was issued by the Minister of Public Health. All participants gave informed consent.
Survey questionnaire The questionnaire was adapted from that used in previous studies in Vietnam (Cuong et al., 2006) and Hungary (Mirnics et al., 2001). Our adaptation included two additional questions to the original 10-item questionnaire, designed to evaluate knowledge, attitudes, and practice (KAP) toward epilepsy in our local context: Q11: ‘‘If you think that epilepsy is contagious, how is it transmitted?’’
Nine hundred and ten (910) of the 920 volunteer secondary school students, aged 11 to 28 years (mean = 16.8 € 2) completed our questionnaire, giving a response rate of 98.9%. Data on familiarity with (Q1–3) and attitudes (Q4–6) toward epilepsy are shown in Table 1. Concerning the understanding of and practice toward epilepsy (see Table 2), about half of the students could
Data analysis Chi-square tests were used to examine the association between responses and each demographic variable in a univariate analysis, and also the association between responses to questions on attitudes and those on awareness and understanding, using EpiInfo version 3.3.2 software (Centers for Disease Control and Prevention, Atlanta; Division of Integrated Surveillance Systems and Services; Atlanta, GA, U.S.A.) The significance level was set at p < 0.05.
Results
Table 1. Responses to questions on familiarity with, and attitudes toward epilepsy according to demographic variables
Total Age (y) 11–15 16–20 21–25 26–30 Sex Male Female Class 3–5 6–7
No. of responses
Q1 Yes (%)
Q2 Yes (%)
Q3 Yes (%)
Q4 Yes (%)
Q5 Yes (%)
Q6 Yes (%)
910
95.1
73.3
76.4
25.4
64.2
58.6
251 621 36 02
93.2 95.5 100 100
66.1 74.9 94.4 100c
72.5 76.8 94.4 100a
28.7 24.2 22.2 50.0
64.9 63.4 72.2 50.0
53.4 60.4 63.9 50.0
450 460
94.2 95.9
72.9 73.7
78.7 74.0
26.4 24.3
65.7 62.7
61.3 55.8
547 363
93.6 97.2b
71.5 75.9
75.7 77.3
25.2 25.2
59.4 71.5d
54.8 64.0c
Values in boldface indicate statistical significance (within the columns): p < 0.05 and the p-values are given below: a p < 0.05; bp < 0.01; cp < 0.001; dp < 0.0001. Q1: Have you heard or read about the disease called ‘‘epilepsy’’ or convulsive seizures? Q2: Do you know anyone who has or had epilepsy? Q3: Have you ever seen someone who was having a seizure? Q4: Would you refuse to associate with someone who sometimes had seizures? Q5: Would you refuse to marry a person who sometimes had seizures? Q6: Do you think people with epilepsy should be employed in jobs like others?
Epilepsia, 50(5):1262–1265, 2009 doi: 10.1111/j.1528-1167.2008.01809.x
1264 A. K. Njamnshi et al. Table 2. Responses to questions on understanding of epilepsy Q7 Yes (%)
Q8 Yes (%)
Q10 Yes (%)
910
38.0
51.3
49.9
251 621 36 02
36.7 37.7 52.8 0.0
52.2 53.2 76.3 50.0
55.4b 49.1 25.0 0.0
450 460
40.2 35.7
50.9 51.8
51.3 48.5
547 361
44.8 58.2c
51.9 50.4
55.2d 41.8
667 243
39.9b 32.5
51.3 51.4
46.5 59.3c
695 215
38.7 35.5
51.7 50.2
47.6 57.2c
No. of responses Total Age (y) 11–15 16–20 21–25 26–30 Sex Male Female Class 3–5 6–7 Know an epileptic Yes No Seen a seizure Yes No
Table 3. Relationship between attitudes and understanding of epilepsy
Values in bold indicate statistical significance: p < 0.05 and the p-values are given below: b p < 0.01; cp < 0.001; dp < 0.0001. Q7: Do you think epilepsy is a form of insanity? Q8: Knowledge of cause of epilepsy (rephrased). Q10: Do you think epilepsy is contagious?
identify one of the three correct causes of epilepsy (hereditary, birth defect, and brain disease). For those who considered epilepsy to be contagious, the methods of transmission mentioned were: saliva (55.3%), blood (36.3%), sexual intercourse (15.6%), waste gas (15.4%), and urine (6.2%). Students mostly qualified epilepsy as witchcraft (25.9%), brain disease (25.7%), and hereditary (25.3%). About 25% could not provide a cause of epilepsy. Approximately 16% thought epilepsy to be a mental or emotional illness, whereas 13.6% attributed it to a blood disorder. Concerning the manifestation of an epileptic attack (Q9), 42.3% mentioned convulsions, 34.6% chose loss of consciousness, whereas 16.8% and 21.1%, respectively, chose periods of amnesia and changes of behavior. Twenty-three percent could not say what an epileptic attack is. The most recommended treatments for epilepsy (Q12) were Divine help (67.3%), medical doctor (64.4%), and a traditional healer (22.5%). About 4% would recommend a witchdoctor, whereas another 4% thought it was untreatable. Four students proposed putting the patient’s head in a toilet hole. Another four recommended that the patient be beaten, whereas two others suggested diet restriction and blood drinking. The relationship between beliefs and attitudes is summarized in Table 3. Epilepsia, 50(5):1262–1265, 2009 doi: 10.1111/j.1528-1167.2008.01809.x
Total Hereditary Yes No Witchcraft Yes No Contagious Yes No Insanity Yes No
No. of responses
Q4 Yes (%)
Q5 Yes (%)
Q6 Yes (%)
910
23.4
64.2
58.6
234 676
30.8 22.5
70.9b 61.8
62.4 57.2
236 674
22.9 26.3
68.2 62.8
60.2 58.0
454 456
30.0c 20.8
69.2c 59.2
54.6 62.5b
345 565
23.8 26.2
67.2 62.2
49.6 64.0d
Values in boldface indicate statistical significance: p < 0.05 and the p-values are given below: b p < 0.01; cp < 0.001; dp < 0.0001. Q4: Would you refuse to associate with someone who sometimes had seizures? Q5: Would you refuse to marry a person who sometimes had seizures? Q6: Do you think people with epilepsy should be employed in jobs like others?
Discussion On the whole, the level of familiarity among students was very high and close to that reported in 2006 among high school students in India (Santosh et al., 2000). Subjects living in a community with such a high prevalence rate of epilepsy (3% in Batibo) (Batibo District Hospital records, 2005, unpublished data) would have a high probability of being acquainted with PWE. This hypothesis is supported by our unpublished data showing lower familiarity with epilepsy in other communities in Cameroon where epilepsy is less prevalent (Ebolowa and Sangmelima) and high familiarity rates in a confirmed epileptic focus in Badissa (Njamnshi et al., 2005). The prejudice rates in our sample are very high compared to those among secondary school students in Poland (Zielinska et al., 2005) (where 92% would accept someone with epilepsy as their friend) and high school students in India (Santosh et al., 2000) (half of students considered epilepsy a hindrance to education, marriage, and employment). Beliefs that epilepsy is hereditary, contagious, or a form of insanity are probably responsible for this high level of discrimination (Table 3). The belief that epilepsy is caused by witchcraft did not seem to be a predictor of negative attitudes, probably because the conception of witchcraft in this area is not always negative.
1265 KAP Toward Epilepsy in Cameroonian Secondary School Students The discrimination rate against employment of people with epilepsy (41.4%) may not represent the true situation, as our respondents were not in a position to offer any employment. The percentage of students who considered epilepsy to be contagious (49.9%) was lower than results of a survey of Tanzanian secondary school students (Matuja & Rwiza, 1994) (60%). This misconception seems to be responsible for the high level of discrimination. The same observation was made in a survey of secondary school students in Burkina Faso (Millogo et al., 2002). We also found that familiarity with PWE and seizures apparently reduces the frequency of this belief. This finding corroborates with studies that have suggested that contact with patients could be an effective stigma-reducing strategy (Corrigan et al., 2001). The knowledge of a cause of epilepsy by the respondents (50%) was higher than the findings of a survey of Polish secondary school students (Zielinska et al., 2005) (22.3%). About 38% of students considered epilepsy to be a form of insanity. This contrasts with the 60% reported among students in India (Santosh et al., 2000). Most of our students would recommend God’s help (67.3%) or a physician (64.4%) for the treatment of epilepsy. In Batibo, as in traditional Cameroon, there is a high belief in witchcraft as a cause of disease and death. However, there is also a predominance of Christianity in this region, and since the Christian religion teaches that even problems caused by witchcraft can be solved by God, it is not surprising that there is high proportion of students that would choose God’s help for epilepsy treatment. The preference of a medical doctor over a traditional healer for treatment of epilepsy contrasts with views by secondary school students in Burkina Faso (Millogo et al., 2002). The difference may be explained by religious background of subjects and time of study. The proposals of putting a patient’s head into a toilet hole, beating them, or giving them their blood to drink represent beliefs that are generally prevalent in many parts of Cameroon. This information was confirmed during informal interviews with community leaders and traditional healers.
Conclusion There is a high level of awareness on epilepsy among secondary school students in the Batibo Health District. This may be a reflection of the magnitude of the problem of epilepsy in this area. There is also high level of stigma and discrimination against people with epilepsy in this district and traditional beliefs appear to be the determinants. For a successful epilepsy education program, local cultural beliefs have to be considered seriously and educated secondary school students may constitute a good channel for general community education.
Limitations Difficulties in the translation, especially of technical terms like ‘‘seizure,’’ ‘‘insanity,’’ ‘‘convulsion,’’ and ‘‘amnesia’’ into Pidgin English and the local Batibo language could be a source of bias.
Acknowledgments The authors thank the students and staff of the Government High School, Government Technical School, and Presbyterian Secondary School Batibo for their participation in and facilitation of this study, respectively. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Authors’ contribution and conflicts of Interest: AKN conceived the study; AKN, PJ, and WFTM designed the study. SAA collected the data. AKN and SAA analyzed the data and wrote the paper. AKN, SAA, PJ and WFTM made critical contributions to improve the scientific content of the manuscript. The authors have no conflicts of interest to declare.
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