Epilepsy is considered one of the most important chronic neurological disorder (1,2), characterized by synchronous recurrent unprovoked seizures due to uncontrolled electrical discharges from the brain neurons (2, 3). Infections either parasitic, viral or bacterial and birth trauma are suggested to be some factors contributing to the disease (2, 4, 5).
The disease has high prevalence estimated that about 50 millions people affected worldwide (6, 7, 8). The global burden of the disease is about 1% in both industrialized and developing countries being more in the developing one such as Sudan (80-85% of the cases) (1,2,4) with high incidence 100-190 per 100,000 people per year in developing countries (4,5).
Epilepsy affect lifestyle of primary school epileptic pupils (9,10,11) both academically because of social barriers (9) and psychologically including anxiety, depression and social stigma (12,13,6,14,15,16). Also make people with epilepsy are low self-esteemed (14) and with low achievement educationally (17,18,19,20).The poorly negative attitude of non-epileptic children and primary school teachers toward those with epilepsy makes the life so difficult to them (1,9,21,22).
Social stigma of epilepsy differ from area to another one being very difficult to overcome causing many of patients avoid seeking medical advice and increasing the 'treatment gap' which exaggerates the condition more than the convulsions and the disease itself (23). Disappointingly the stigmatization and social discrimination applied by the community will increase the burden of this disease regarding management and also other aspects of disease (6,14).
Some epileptic pupils were banned because of their recurrent attacks of seizures and some teachers feel uncomfortable of their presence in the classroom representing the severity of disease's stigma and resulting in social rejection (7,24,25).
Community especially primary school teachers must have to play a great role in eradication of this social disacceptance because they are regarded one of the educated sectors in the community (17,26,27,28) and also by their fundamental participation in the education of the epileptic pupils (20) . We need to minimize epilepsy-associated social stigma (17) by good lightening of the main problem which is teacher's awareness about epilepsy causes, management and attitude (17,26). Clarification to the teachers and rest of the community that pupils with epilepsy have the same intelligence of their colleges and can participate in the same activities with special limitations (1).
Understanding the misconceptions and false beliefs of teachers about epilepsy putting in mind that there is no formal instructions about epilepsy during their training (1,29), so there is need to design a program to antagonize these misunderstands.
There are several studies show that despite of improvement in perception (30,31) and community attitude, there is still misconceptions (12,32). Up to date, there is still a little researches had been conducted in this part of the disease especially in Middle East (6,33,34) and Sudan (1).
This study aimed to investigate and examine the knowledge, attitude and practice of primary school teachers toward epilepsy regarding causes, clinical presentations and management of convulsing epileptic pupils.
Materials and methods
Study design and population
A descriptive cross-sectional study was conducted. All teachers at pensionable age employed in or training at registered public schools in Alshohda and Soba unit and present at the time of the study were eligible to participate in the study. We exclude those with previous or current seizures, mentally ill and those who did not give verbal consent.
Study area
Alshohda and Soba unit is a big area locating in the center of Khartoum locality, consist of 8 districts with 58 public schools, 82 private schools and 2 universities.
Sampling (size and technique)
The actual sample size calculated with prevalence of 0.09 , margin of error 0.0025 and calculated to be 114 then was shrunken to 132 using modified formula due to limited resources and time .
Questionnaires were given to the directors of schools to distribute them to all eligible teachers to complete them and then returned back to research assistant. Instructions on how to complete questionnaires with few explanations were given avoiding leads.
Study carried out in 8 schools as clusters which were selected randomly, then a total coverage to the selected schools were done. Each school involve about 20 teachers and total sample of 132 was taken. This study was reviewed and approved by university of Khartoum faculty of medicine department of community medicine.
Data collection
The data was collected using semi- structured closed ended self-administered questionnaire and the questions were designed to cover KAP with respect to epilepsy.
In order to maintain the standard of the survey material other similar studies were identified and relevant questions were selected and modified to make them appropriate to the local culture. The selected questions were first forward translated into Arabic the official language of the country, and then back translated into the English using the standard translation procedure. The translated questionnaire was then pretested randomly on selected school teachers which had helped to further redirect and rephrase some of the questions. Participants were asked to complete a self- administered questionnaire, comprising of 21 questions. Consisting of 4 parts, sociodemographic data, knowledge questions, attitude and practice.
Each questionnaire was checked for completion, assigned a code, kept in secured file and entered into electronic database for analysis.
Data analysis
Data was analyzed using SPSS software v21.0.
Results
This research was done to assess the degree of knowledge, attitude and practice of primary school teachers toward epileptic pupils to design a program for raising their awareness about this disease because no formal instructions were given to them during their training. So the study was conducted in (132) primary school teachers with response rate of 100%. The main age of them was found to be (47) years old with interval of (20-70) years with female being the predominant sex ( male : female ratio was 1:2.9). Most of them were married (69.5%) and reported that they were university graduate (60.3%) and. Thirty teachers (22.8%) had teaching experience of (11-20) years (see table 1).
As all the participants heard about epilepsy before, they reported that community (32.1%) and media (29.1%) were the main source of information and few of them (7.2%) gained their information about epilepsy from Health Care Givers. Regarding the causes of epilepsy, most of the participants believed that epilepsy was due to genetic factors (25.4%) and head injuries (18.2%), while seventeen (12.7%) of them thought it was due to evil spirits. About (51.9%) of the participants thought that the most useful treatment was medical treatment in form of tabs and injections and minority of them; nine (6.9%) thought of traditional treatment and eight (6.1%) believed of electrical shock to be the best one (see table 2).
Ninety eight (74.6%) of the participants they believed that epilepsy was a contagious disease. Majority of the participants thought that convulsions should had to occur during episode of epilepsy (65.2%) and about thirty one teachers (23.5%) thought that it wasn't necessarily to occur. Sixty three (47.2%) of them believed that epileptic pupils can contribute in ALL sport activities as healthy one can do while forty four (33.6%) thought that they can't (see table 3).
Concerning attitude of the participants, most of them (77.1%) allow epileptic patients to learn with other healthy one. Those whom don’t allow, more than (51.5%) of them they thought that epileptic patients can harm others, (12.1%) had difficulties to learn, (12.1%) not qualified to work later on and (21.2%) they thought that others can harm them. Most of them they thought that epileptic patients were not socially separated by their colleges (71.8%) . Almost all of the participant they show empathy to a convulsing pupil and a very minor group feel afraid of him. Ninety- two (73%) of teachers revised for an epileptic pupil who missed a class because of his illness (see table 4).
Forty two (31.5%) of the teachers taught an epileptic pupil before. About (18.2%) of the teachers did first aid management to an epileptic patient and from this percent (18.2%); (34.5%) remove the sharp object, (13.8%) secure the patient, calculate the duration of convulsion, (22.4%) put the patient in his lateral side, (29.3%) ensure airway patency. (26.1%) do all the management steps. Regarding those who didn't carry out first aid before have knowledge of following: (29.6%) removing the sharp objects and secure the patient, (20%) putting a piece of clothes or spoon in his mouth (see table 5). In our study, we noticed that some of the questions were answered in a manner to be a politically correct and this might not reflect their own opinions (35,36). Also we noticed that most of primary school teachers were female in a ratio of (1:2.9). this tendency may be because in our society, females are more kind and more polite to children than males that is why they predominate primary schools. The study was conducted in the teachers because they were considered the educators and advisors in any societies especially here in Sudan.
All teachers (100%) participating in this research heard about epilepsy before. Thinking of this to be a very good thing in raising their confidence in dealing with these epileptic pupils and to teach other pupils on how to deal with them. This result was similar to that reported in study done in Assuit, Egypt 2010 (38) and in Sudan in Gezira state (1), slightly higher than value reported in school teachers in Pakistan 99% ( 38), higher than value obtained from teachers in India 97% (37) and in Nigeria 2018 95.5% (20) and much higher than those conducted in Pakistan 90.9% (39), Ethiopia 90%( 40) and Nigeria 84.8% (41).
Majority of teachers in our study got their information about epilepsy from the community 32.1% and media 29.1% highlighting the necessity to encourage health educational public campaign to be community- based and encourage media to disseminate knowledge about the disease. In addition, this was considered to be a good thing, as media became a popular way nowadays and almost all people have an easy access to media. Our result was similar to that obtained from India and Thailand (42,43,44) and in contrast to study done in Ethiopia 2016 in which public media played a minor role (42). Few of our participants gained their information about epilepsy for health care workers 7.2%, this in contrast to that done in Ethiopian teachers (42), in which health care workers represent a common source of information.
Some previous studies reported that teachers had high knowledge about epilepsy (39,45). Despite of that, they had a defected knowledge and some misconceptions about the disease (36,39,46,47). One of this misinformation was the believed that the epilepsy was a contagious disease 74% (20,46,43,48,49, 50,51,52,53) and in contrast to that done in Saudi Arabia (50). This thought play a miserable role in increase the stigma and social barriers and this should be a warning alarm to establish an interventional program to the raise teacher's awareness. This result was similar to other studies (46,54).
In addition of believing of epilepsy as an infectious disease, some studies reported the thought of teachers in epilepsy to be a risk for increasing insanity of the individual with disease (20,43,55). Teachers believed that children with epilepsy has increased tendency to be insane later on. In this regard, there was observation that developing countries teachers believing that there is a relation between epilepsy and insanity in percent of (23.6%) in Vietnam(56), (16%) in China (57) and (7%) in Taiwan (58). These percentages compared to studies carried out in developed countries such as USA , Denmark and Italy which reported a negative relationship between epilepsy and insanity (59,60,61).
On other hand, a significant percentage (28.2% , 44%) of teachers participating in a previous studies (1,39) reported that they believed that epilepsy affect growth and development of children despite their greater years of experience. This misconception also increases stigmatization and discrimination more and more. The importance of teachers attitude is that it affects other children attitude affecting their own development.
Other aspect defected in their knowledge, evil spirits being one of the causes of epilepsy and this also contribute in increasing social stigma (20). Few of participants 12.7% still believe in evil spirits as a cause of epilepsy compared to 21.1% reported in Sudan 2017 (62), 26% reported in Nigerian teachers (63). 10% of Sudanese doctors believe in evil spirits as a possible cause of epilepsy (64). There was study done in Pakistan reported good knowledge of the teachers about clinical presentations and causes of epilepsy knowing that it isn't due to evil spirit or even supernatural abilities (39). This is in contrast to study carried out in India reporting that teachers rate of awareness was found to be 97% (65).
Similarly about causes of epilepsy, a part of those didn’t know the cause, most of our participants report genetics 25.4% and head injuries 18.2% as a common causes of epilepsy compared to study done in Sudan 2017 in which 78% of teachers believe epilepsy was due to neurological problems and slightly less than this value reported in Ethiopia (40) and Pakistan (38).
More than half of our teachers thought of medical treatment to be the most useful one. This proportion is lower than that reported in Nigerian which was found to be two third (66). In Ethiopia 98% of participants thought about medical treatment as the most useful one. 6.9% of our participants believed of traditional one as best in contrast to study done in Zambia reported that about 84.5% of teachers thought of traditional healer as the best rather than doctors (67) and also in contrast to another study done in Ethiopia which reported that near half of the teachers were believing of those healers (42). In study done in Sudan, 9.4% believed in traditional treatment as a curative one compared to 51% who didn’t.
More than two third of the teachers reported in our study that they allowed epileptic pupils to learn with their healthy colleges in the same classroom. Despite this high proportion, a significant percent of them (12.2%) didn't allow comparable to study done in Nigeria (7%), India (20.8%) and in Thailand (15.1%) (20,43,55). Even severely, there was study reported that 4.5% of teachers refused to teach epileptics at all (39) and another one reported 13% refused also (68). Our teachers whom didn't allow, 51.5% of them believed that epileptics can harm other similar to study done in Egypt 46.6% (37) or might be not able to worker later on 12.1% similar to studies which reported that teachers thought epileptics can't be a good teacher in the future and can't succeed in their life (46,69,39). This believed reflect the great gap that teachers think of epilepsy as a disease affecting the cognitive functions of the patient as reported in similar study leading us to think of their inferior misconception about epilepsy(46).
Most of our participants 71.8% think epileptics were not socially separated by their colleges reflecting teachers with some positive attitude. In our study, almost half of the teachers allow epileptics to participate and contribute in activities with healthy one similar to previous studies with high percentage also (39,67). Despite that we need to tell them that there must be some special limitations in those activities like swimming or driving.
Luckily, only 5.6% of teachers in this research felt afraid of epileptics when seeing them convulsing which is much lower than that reported in study done in Saudi Arabia (50) and more than ninety percent of teachers said that they felt sympathic to a fitting child which is higher than that reported in Egypt 76.8%, Nigeria which reported that more than half of them afraid of those students, 32% of teachers afraid of epileptic in study done in India and 9.8% afraid of epileptics in study done in Thailand (20,43,55) reflecting good attitude of our teachers in this regard. The feeling of fear toward epileptics affect them both psychosocially and academically raising the stigmatization and discrimination upon them.
We think of necessity to establish an educational program including during teacher's training course taking about epilepsy understanding and management procedures that at least should be done because our study reported that a considerable percent of teachers ever did first aid or management before similar to study done in Saudi Arabia (50). Those who didn't carry out first aid before the reason behind this may be not seeing an epileptic pupil convulsing before (1) or might get in panic attack when see this act. One-fourth of the teachers who did first aid before, carried out all the steps of management correctly. Unfortunately, some of them did the procedures in a wrong way as reported in similar studies by pulling the tongue or putting objects like spoon inside the mouth (46,69,20,70,71, 39). Because of that, there must be school health services as the teachers being always in contact with epileptic pupils. Regarding these services, physicians also should contribute by sharing the knowledge and the medications that can help the teachers to deal with such a situation.
Conclusion
This study assess knowledge, attitude and practice among primary school teachers in Khartoum. In conclusion, the knowledge of the teachers vary at time of this research. There was a misunderstandings and misconceptions in some aspects of the disease like causes of epilepsy being evil spirit and being a contagious disease and good knowledge reported in area of treatment. The more educated teachers about epilepsy the less likely for having negative attitude. Teachers of our study were considered to have negative attitude toward epilepsy which badly affect their awareness. Lack of awareness is a warning alarm of establishing educational programs about epilepsy. Bad attitude increases stigma and social barriers. The practice of teachers was considered to be in need of improvement as there is no formal instructions about epilepsy during their training.
Recommendations
We need further researches in context of knowledge of primary school teachers about epilepsy in order to explore areas of deficiencies that teachers suffered from. Also we need these researches aiming to investigate about the practical aspect of epilepsy as teachers form the cornerstones in the educational process of those epileptic pupils. The need for educational health public programs is of the greatest importance recommended to erase all myths and misconceptions about epilepsy which is the main cause of the social stigmatization and discrimination