Knowledge, attitude and practice among adult Lebanese patients with epilepsy and impact on seizure control: a cross sectional descriptive study

doi:10.21203/rs.3.rs-4979174/v1

Purpose: Epilepsy is the fourth most prevalent neurological disorder accounting for more than 50 million cases worldwide. Religious and sociocultural beliefs influence the nature of treatment and care received by epileptic patients. According to the World Health Organization (WHO), almost 94% of epileptic patients in developing nations are not taking the appropriate therapy to control their seizure leading to a higher incidence of lifelong active epilepsies in these regions. With no related data in Lebanon, this study sought to assess the knowledge, the attitude, and the practice towards epilepsy among adult Lebanese epileptic patients and the associated factors

Methods:This was a cross-sectional descriptive study approved by the ethical committee at the Lebanese international university. The sample was drawn randomly from community pharmacies based on stratified cluster sampling and the strata were the six districts of Lebanon. Sixty community pharmacies constituted the primary sampling units, and ten pharmacies were randomly selected from the districts using the Research Randomizer computer program. Patients aged eighteen years and above with at least two years of diagnosis with epilepsy, who came for normal medications or para-pharmaceuticals were enrolled in the study. The enrolled participants were directly interviewed by the clinical pharmacists after providing their oral informed consent. The data collection sheet was established based on validated and standardized questionnaires including The Epilepsy Patient Knowledge Profile (EPQK) and The Kilifi Epilepsy Beliefs and Attitudes tool (KEBAS). Data were analysed using the Statistical Package of the Social Sciences software (SPSS, version 21).

Results: A Total of 134 epileptic patients (53% females, 47% males) with a mean age of 36.53 ± 13.15 years were included in this study. Most respondents had attained a minimum of secondary school education (91.3%). The most-reported seizure type was generalized seizure (26%). Approximately 64% of the studied patients had good seizure control. Most of the patients had good knowledge (82%) and a positive attitude (98%) toward their disease with almost two-thirds having a good practice (63%) as well. There were no statistically significant associations between the level of knowledge, attitude, or practice with seizure control (p= 0.14, p=1 and p=0.25, respectively). However, a statistically significant association was identified between the knowledge and educational level (p<0.001), Knowledge and Occupation, and between Practice and the educational levels of patients (P=0.015).

The Epilepsy Patient Knowledge Profile (EPQK)

Epilepsy Beliefs and Attitudes tool (KEBAS)

Neuropsychological assessment

Epilepsy is a neurological “brain” disorder during which the brain function becomes abnormal giving rise to bizarre behaviour, perception, and in some cases loss of consciousness. Epilepsy and seizure are different. A formal definition of seizure and epilepsy) was released in 2005 by the International League of Epilepsy Association (ILAE). Seizure is the event and epilepsy is the disorder of recurrent seizure episodes (1, 2) Globally, epilepsy is the fourth most prevalent neurological disorder. More than 50 million people worldwide have epilepsy. Approximately, 80% of epileptic patients live in low- and middle-income countries (3). The average incidence of epilepsy each year in the United States is estimated at 150,000 or 48 for every 100,000 people (4). An estimated 724500 people with epilepsy live in the Arab world. The prevalence in the Arab world varies between 0.9 per 1000 in Sudan and 6.5 per 1000 in Saudi Arabia, with a median of 2.3 per 1000 (5). In developing countries like Lebanon, up to 94% of epileptic patients are not taking the appropriate therapy to control their seizure according to the World Health Organization (WHO), leading to a higher incidence of lifelong active epilepsies in these regions (8).

Serious medical, psychological, social and economic consequences are the results of uncontrolled seizures where it accounts for 0.6% of the global burden of diseases and the risk of premature death is 3 times higher in epileptic patients compared to the normal population in the low and middle-income countries (6, 9, 10).

The term “epilepsy” in such regions is replaced by “Supernatural Power”, “traditional healer”, and “stigma”. These false misconceptions, in addition to inadequate treatments and lack of medical infrastructures, may limit the implementation of individual or collective strategies to improve the quality of life for patients suffering from epilepsy (11).

The misconception, poor attitude, and practice toward epilepsy will contribute to the further deterioration of epilepsy control and subsequent physical, cognitive, psychological, and social burdens (7). Because previous studies have shown that people with epilepsy know only a little about their condition in the developing countries, and because of all the listed factors in these areas, it is important to evaluate the level of awareness among these populations.

Due to the lack of data in Lebanon about the prominent concerns, we conducted this study to assess the knowledge, the attitude, and the practice towards seizure among adult Lebanese patients with epilepsy. This study will raise awareness on how the Lebanese epileptic patients

3.1. Study Design

This research is a cross-sectional, descriptive study. A questionnaire (appendix C) was formulated based on the combination of existing international and local tools that can be simulated to evaluate knowledge, attitude, and practice among epileptic patients towards their illness in different socio-cultural backgrounds. A pilot study was conducted before relying on the used questionnaire. The study protocol was approved by the ethical committee at the Lebanese International University (LIU).

3.2. Study Location

The sample was drawn randomly from community pharmacies based on stratified cluster sampling and the strata were the six districts of Lebanon (Beirut, Bekaa, North, South, and Mount Lebanon). Sixty community pharmacies constituted the primary sampling units and ten pharmacies were randomly selected from the districts using the Research Randomizer computer program. The study is based on the data collected from the answered questionnaires by patients with epilepsy.

3.3. Study Population

Patients aged eighteen years and above with at least two years of diagnosis with epilepsy, who came for normal medications or para-pharmaceuticals were enrolled in the study. Those not meeting the inclusion criteria or have mental illnesses were excluded.

Mental illnesses are described as any mental disease that leads to mild to severe perturbation in thoughts and/or behaviours, causing an incapacity to deal with normal life demands. Examples include mental retardation and psychiatric disorders.

3.4. Sample Size Calculation

To calculate the size of our sample, we used epiinfo™. There is no data regarding the actual prevalence of epilepsy in Lebanon. The Lebanese population (> 15 years) is 4,953,754 (July 2016) and our study is a descriptive study, for CI 95% the sample size should be 384 patients with epilepsy.

However, because our study included only patients that are 18 years old and older with an old diagnosis (2 years and more), and because similar studies were done in other countries larger than Lebanon that included a maximum of 220 patients, so the sample size could be adjusted to approximately 160 to 180 patients.

3.5. Sampling and Recruitment

Data was collected by distributing the questionnaires for 5 months between December 2018 and April 2019.

Patients attending pharmacies and clinics were informed about the study and invited to participate in it. Finally, patients who fulfilled the inclusion criteria and have accepted to be enrolled by oral formal consent were recruited in the study.

3.6. Study Procedure

The enrolled participants were directly interviewed by the clinical pharmacists after providing their oral informed consent. The questionnaire was filled by the patients themselves without any assistance.

The questionnaires included all questions that assessed the socio-demographic and clinical information such as employment status, level of education, the onset of seizure, the type of seizure, frequency of the seizure, last seizure, prescribed medication, and validated questions to assess knowledge, attitudes, and practices of patients living with epilepsy from local and international tools. The data collection sheet was established based on validated and standardized questionnaires including The Epilepsy Patient Knowledge Profile (EPQK) (Appendix A) and The Kilifi Epilepsy Beliefs and Attitudes tool (KEBAS) (Appendix B). Scores were generated using these questionnaires to classify knowledge (poor, moderate, or good), attitude (positive or negative), and practice (poor or good) (Appendix D)

The Epilepsy Patient Knowledge Profile (EPQK) which carries true/ false items (medical knowledge items and social knowledge items) chosen by a chain of specialists in the field of epilepsy and is reputed to be objective, sensitive, and unambiguous in its evaluation of medical knowledge levels in accordance to epilepsy (Appendix A).
The Kilifi Epilepsy Beliefs and Attitudes tool (KEBAS) was formulated to assess quantitatively the attitudes and beliefs of patients suffering from epilepsy (Appendix B).

The questionnaire was translated into Arabic and was back translated into English by trained, independent linguists. This facilitated the use of the questionnaire by the population under study.

3.7. Study Outcomes

3.7.1. Primary outcomes

The results of this study are expected to shed the light on the knowledge, attitude, and practice of people living with epilepsy in Lebanon in terms of the causes, diagnosis, and treatment modalities and determining the relationship between KAP and seizure control.

3.7.2. Secondary outcomes:

As secondary outcomes, we expect to identify the factors that may affect KAP and the inadequacy of seizure control. These outcomes may improve health outcomes by raising the awareness of the importance of seizure knowledge, good attitudes, and practices that lead to good seizure control.

3.8. Statistical Analysis

Data were analysed using the Statistical Package of the Social Sciences (SPSS), version 21. Discrete variables (as socio-demographic and clinical characteristics) were summarized by using frequencies and percentages. Continuous variables were presented by mean, median, and standard deviation. Univariate associations were assessed for statistically significant differences using the Chi-square test or Fisher’s exact test for categorical variables, as appropriate. All reported p-values are two-sided, with alpha set at a significance level of 0.05 percentages. Continuous variables were presented by mean, median, and standard deviation. Univariate associations were assessed for statistically significant differences using the Chi-square test or Fisher’s exact test for categorical variables, as appropriate. All reported p-values are two-sided, with alpha set at a significance level of 0.05.

4.1. Patients Screening

During the 12 weeks, a total of 165 were consecutively screened of the outpatient’s neurology clinics and pharmacies; 25 in total were excluded; 8 suffering from severe mental retardation, 12 were below 18 years old and 5 were recently diagnosed with epilepsy. 140 patients met the inclusion criteria, 6 declined consents, and were further excluded. Thus, 134 (81.21 % of total screened) were recruited. Fig1 represents the flow diagram for patient enrolment.

4.2. Demographic information and Epidemiological Characteristics

The mean age of the study patients was 36.53 (SD±13.513) with a range of (17; 61). Of the 134 patients recruited, 71 (53%) were female and 63 (47%) were male with a female-male ratio of 1.12:1, and 75 (56%) of the study subjects were married. The mean age of the first attack is 19.87% (SD=13.145), with a range of (2; 65). Whereas the mean disease duration is 16.17 (SD=8.796) with a range of (3; 47).

Most respondents (65.7%) had attained a minimum of secondary school education with 22.4 % are currently university students and around 63 (47%) have low income.

The majority of participants (84.3%) did not identify the type of their epilepsy, and the most common epilepsy type of the others was the generalized tonic-clonic (61.9% of responders). The demographic distribution is also shown in Table 1.

Around half of the patients, 66 (49.3%) are on monotherapy and the other half 68(50.7%) are on polytherapy, knowing that Valproic acid and carbamazepine are the most common type of medication used with (39.7%) and (34.9%) respectively. Table 2 represents the epidemiological/disease characteristics.

Most of the study subjects, 123 (91.8%), were aware of the importance of taking their medications regularly, but only 80 patients (59.7%) do take them on this regular basic, mainly because of forgetting (50%). The majority of the study population 114 (85.1%) do agree with their medications and only a small sample, around 34 (25.4%) do believe in traditional healers as alternatives. Table3 shows the compliance of respondents.

Table 1. Demographic distribution of respondents

*Characteristic*		*Frequency (%)*
Region	North	34 (25.4%)
	Beirut	31 (23.1%)
	South	28 (20.9%)
	Mount Lebanon	21 (15.7%)
	Bekaa	20 (14.9%)
Age	18-36	76 (56.7%)
	37-55	44 (32.8%)
	56-60	14 (10.4%)
Gender	Male	63 (47.0%)
Gender	Female	71 (53.0%)
Marital status	Single	44 (32.8%)
	Married	75 (56.0%)
	Divorced	9 (6.7%)
	Widowed	6 (4.5%)
Occupation	Unemployed	20 (14.9%)
	Employed	58 (43.3%)
	Student	20 (14.9%)
	Housewife	28 (21.6%)
	Retired	4 (3%)
	Others	3 (2.2%)
Education	No formal	13 (9.7%)
	Primary	33 (24.6%)
	Secondary	41 (30.6%)
	University	30 (22.4%)
	Postgraduate	17 (12.7%)
Income	Low	63 (47.0%)
	Moderate	66 (49.3%)
	High	5 (3.7%)

Table 2. Disease characteristics of the respondents

*Disease characteristics*		*Mean ± SD*
Age		36.53 ± 13.513
Age at first seizure		19.67 ± 13.162
Disease duration		16.36 ± 8.539
		*N (%)*
Seizure type	Partial simple	10 (17.2%)
	Partial complex	6 (10.3%)
	Generalized	36 (62.1%)
	Unidentified	6 (10.3%)
Medication regimen	Monotherapy	66 (49.3%)
Medication regimen	Polytherapy	68 (50.7%)
Type of drug	Carbamazepine	22 (34.9%)
	Valproic acid	25 (39.7%)
	Phenytoin	4 (6.3%)
	Levetiracetam	7 (11.1%)
	Pregabalin	4 (6.3%)
	Others	1 (1.6%)

Table 3. Compliance characteristics of the respondents

*Compliance characteristics*		*Frequency (%)*
Regularly missed medication	Yes	80 (59.7%)
Regularly missed medication	No	54 (40.3%)
Reasons for missing medication	Financial	13 (23.2%)
	Inaccessible	4 (7.1%)
	Side effects	10 (17.9%)
	Forgetting	28 (50%)
	Others	1 (1.8%)

4.3. knowledge, attitude, and practice scores

35.1% of the study population knew that epilepsy is caused by brain neuron disturbances and most of them (94.8%) denied that epilepsy is contagious. Around 79.9% thought that epilepsy is curable, and the majority also (85.1%) believed in modern medications as treatment. Only 25.4% of respondents mentioned that they do believe in alternative traditional healers and a large group (67.25%) answered that epilepsy is diagnosed based on EEG.

A positive attitude was observed with respect to working (96.3%), studying (87.3%), and having children (93.3%). However, around 34.6% stated that they are discriminated against by others. Among the practice behaviours, going to the hospital in case of seizure attacks, was the first choice for the majority of the study sample (33.8%). Table 4 shows the knowledge, attitude, and practice among 134 respondents with epilepsy.

Table 4. Knowledge, attitude, and practice answers of the respondents

*Variables*		*Frequency (%)*
*Knowledge of causes*
What is the cause of epilepsy?	I don’t know	15 (11.2%)
	Supernatural power	9 (6.7%)
	Hunger	1 (0.73%)
	Infection	2 (1.47%)
	Depression and anger	14 (10.4%)
	Psychological disorder	10 (7.3%)
	Mental illness	15 (10.95%)
	Genetic	21 (15.7%)
	Brain neuron disturbances	47 (35.1%)
Can epilepsy be contagious?	Yes	7 (5.2%)
Can epilepsy be contagious?	No	127 (94.8%)
*Knowledge of treatment*
Can epilepsy be treated?	Yes	107 (79.9%)
Can epilepsy be treated?	No	27 (20.1%)
Can epilepsy be treated with medication?	Yes	114 (85.1%)
Can epilepsy be treated with medication?	No	20 (14.9%)
Do you believe in traditional healers?	Yes	34 (25.4%)
Do you believe in traditional healers?	NO	100 (74.6%)
*Knowledge of diagnosis*
How is epilepsy diagnosed?	Can’t be diagnosed	2 (1.5 %)
	I don’t know	10 (7.5%)
	Blood test	11 (8.2%)
	Based on signs and symptoms	21 (15.7%)
	Based on EEG	90 (67.25%)
*Knowledge of the cause of the relapse*
Relapse may be due	I don’t know	14 (10.5%)
	Infection and Inflammation	14 (10.5%)
	Disease progression	33 (24.8%)
	Medication overdose	1 (0.8%)
	Medication side effects	13 (9.8)
	Medication failure	23 (17.3%)
	Medication noncompliance	35 (26.3%)
*Attitude*
Can epileptic patient work?	Yes	129 (96.3%)
Can epileptic patient work?	No	5 (3.7%)
Can epileptic patient study?	Yes	117 (87.3%)
Can epileptic patient study?	No	17 (12.7%)
Can epileptic patient have children?	Yes	125 (93.3%)
Can epileptic patient have children?	No	9 (6.7%)
Are you discriminated by others?	Yes	46 (34.6%)
Are you discriminated by others?	No	87 (65.4%)
*Practice*
What do you do in new seizure attack?	Nothing	19 (14.3%)
	Smell a shoe	1 (0.8%)
	Put a metal in your hand	3 (2.3 %)
	Put a spoon in your mouth	3 (2.3%)
	Pray	22 (16.5%)
	Keep you away from danger places	15 (11.3%)
	Positioning	25 (18.8%)
	Go to the hospital	45 (33.8%)

Patients answered multiple choices questions to assess their knowledge of epilepsy ranging from causes, causes of relapses, diagnosis, and treatment modalities to their attitude and practices. The majority of patients 110(82.7%) had good knowledge, scoring in the 80th percentile, 85(63.9%) had good practice towards their disease, scoring in the 60th percentile. These results are shown in detail in the following bar chart in figure 2, where most of the studied patients had good knowledge toward their disease cause (75.7%), diagnosis (90%), cause of relapse (78.9%), and treatment (84.3%).

Most respondents were revealed to have a positive attitude, scoring in the 90th percentile (97.7%) of the 3 patients with negative attitudes, their responses were found to be around the theme of they are rejected and discriminated against by their families and community. In response to the impact of epilepsy on their daily living, the studied patients were aware and did not feel that the disease should limit living a normal life in terms of employment, studying, and making families.

The knowledge, attitude, and practice distributions of respondents are depicted below in Table 5.

Table 5. Distribution of respondents by knowledge, attitude, and practice

*Scores*	*Frequency (%)*
*Knowledge score*
Poor Knowledge	23 (17.3)
Good Knowledge	110 (82.7)
*Practice score*
Poor Practice	48 (36.1)
*Good Practice*	85 (63.9)
*Attitude score*
Negative attitude	3 (2.3)
Positive attitude	130 (97.7)

4.4. Seizure Control

Poor seizure control was defined as more than 1 episode of epilepsy in the previous six months. As mentioned in figure 3, approximately 86 (64.2%) of studied patients had good seizure control, while 48(35.8 %) had poor seizure control. Poor seizure control was higher in patients (70%) who were unemployed. 61.5% of patients who had only primary education were found to have poor seizure control. And 60.4% of poor seizure control patients were reported to regularly failing to take their medication, with 46.75% citing as forgetting difficulties as the reason. Though using bivariate analysis there was statistical significance (P < 0.001) between failure of regular treatment and adequacy of seizure control.

4.5. relationship between baseline characteristics, KAP, and seizure control

Male and female patients scored equally in knowledge (82.3% vs 81.1%), attitude score (62.9% vs 64.8%) while in practice score, Male respondents are mentioned with a more positive attitude than female respondents (100% vs 95.8%). Furthermore, 9(75%) of non-formally educated patients were to have poor knowledge of their illness but subsequently scored well on attitude and practice scores. The majority of primary educating patients (20:60.66%) were found to have poor practice. Employed studied patients scored 87.9% on knowledge score compared to 57.9% for unemployed patients, while they were approximately scored equally in attitude (98.9% vs 95%) and practice scores (64.9% vs 70%). For patients who had epilepsy more than 30 years were found to be more knowledgeable (87.5% vs 82.4%), had a positive attitude (100% vs 97.6%), and good practice (87.5 % vs 62.4%) than patients that lived less than 30 years with epilepsy. The statistical significance was observed between education and knowledge scores(P-value<0.001), education and practice score(P-value=0.015), and occupation and knowledge score (P-value=0.002). Overall patients who were female, primary educated, and had disease less than 30 years were less likely to have the knowledge, a positive attitude, and good practice but I was not statistically significant.

All these results are discussed extensively in table 6 below.

Table 6. Relationships between baseline characteristics and knowledge, attitude, and practice

Knowledge

Attitude

Practice

Good

N

(%)

Poor

N

(%)

P-value

Positive

N

(%)

Negative N

(%)

P-value

Good

N

(%)

Poor

N

(%)

P-value

Gender

Male

51

(82.3%)

11

(17.7%)

1

62

(100%)

0

(0 %)

0.248

39

(62.9%)

23

(37.1%)

0.858

Female

59

(81.1%)

12

(16.9%)

130

(95.8%)

3

(4.2%)

46

(64.8%)

25

(35.2%)

Education

No formal education

3

(25%)

9

(75%)

<0.001

13

(100%

0

(0%)

0.71

10

(76.9%)

3

(23.1%)

0.015

Primary

23

(69.7%)

10

(30.3%)

31

(93.9%)

2

(6.1%)

13

(39.4%)

20 (60.6%)

Secondary

37

(90.2%)

4

(9.8%)

39

(97.5%)

1

(2.5%)

27

(67.5%)

13

(32.5%)

University

30

(100%)

0

(0%)

30

(100%)

0

(0%)

22

(73.3%)

8

(26.7%)

Postgraduate

17

(100%)

0

(0%)

17

(100%)

0

(0%)

13

(76.5%)

4

(23.5%)

Occupation

Unemployed

11

(57.9%)

8

(42.1%)

0.002

19

(95%)

1

(5%)

0.879

14

(70%)

6

(30%)

0.419

Employed

51

(87.9%)

7

(12.1%)

56

(98.2%)

1

(1.8%)

37

(64.9%)

20

(35.1%)

Student

20

(100%)

0

(0%)

20

(100%)

0

(0%)

15

(75%)

5

(25%)

Housewife

24

(82.8%)

5

(17.2%)

28

(96.6%)

1

(3.4%)

16

(55.2%)

13

(44.8%)

Retired

3

(75%)

1

(25%)

4

(100%)

0

(0%)

1

(25%)

3

(75%)

Others

1

(33.3%)

2

(66.7%)

3

(100%)

0

(0%)

2

(66.7%)

1

(33.3%)

Disease Duration

≤ 30years

103 (82.4%)

22 (17.6%)

1

122 (97.6%)

3

(2.4%)

1

78

(62.4 %)

47 (37.6%)

0.258

>30 years

7

(87.5%)

1

(12.5%)

8

(100%)

0

(0%)

7

(87.5%)

1

(12.5%)

4.6. Relationship between Seizure control and Knowledge, attitude, and practice

As represented in table 7, Out of 110 patients with good knowledge about their disease, 75(68.2%) had good seizure control. And of 130 who had scored with a positive attitude, 83 (63.8%) were found to have good seizure control. Meanwhile, most patients with good practice (63.5%) had also good seizure control. In otherwise, nearly half the patients with poor knowledge (52.2%) were stated as having poor seizure control. In contrast, the majority of patients with a negative attitude (100%) and poor practice (66.7%) were found to have good seizure control. But there was no statistically significant difference between knowledge, attitude and practice, and seizure control.

Table 7. Relationship between knowledge, attitude and practice and seizure control

Seizure control

P-value

Good

N (%)

Poor

N (%)

Knowledge score

Good Knowledge

75

(68.2%)

35

(31.8%)

0.258

Poor Knowledge

11

(47.8%)

12

(52.2 %)

Attitude score

Positive attitude

83

(63.8%)

47

(36.2%)

0.552

Negative attitude

3

(100%)

0

(0%)

Practice score

Good practice

54

(63.5%)

31

(36.5%)

0.85

Poor practice

32

(66.7%)

16

(33.3%)

5.1. Results Discussion

Our study was conducted to evaluate the knowledge, attitude, and practice of epileptic adult patients attending pharmacies, and neurological clinics in Lebanon using validated collecting data tools and finally to determine the relevance of seizure control and analyse its relationship with knowledge, attitude, and practice. There are no similar studies conducted neither in Lebanon nor in other Arab countries to compare results with ours. Meanwhile, several studies worldwide have shown that knowledge, attitude, and practice are key factors to deal with epilepsy. Our patients had chronic epilepsy and the majority of them were young adults (36.53±13.513), approximately equally distributed between Lebanese governorates, the majority of them were female, employed, with a moderate level of income and higher literacy rate. A demographic characteristics summary of previous similar studies is shown in Table 8 to compare results with the current study.

Table 8. Demographic characteristics summary of previous similar studies

*Author(s)* *Region* *year*		*Udaya Seneviratne et al* *Sri Lanka* *2002*	*MGouri-Devi et al* *India* *2010*	*Yousuf RM et al* *Malaysia* *2017*
Sample size		207	120	132
*Gender*	Males	55%	60%	51.5%
*Gender*	Females	45%	40%	48.5%
*Age*		10-30: 59.9% 31-50: 30.9% 51-70: 8.2% >70: 1%	<30: 69.2% 31-45: 27.5% 46-60: 3.3%	<20:18.9% 20-40: 59.09% 41-60: 17.42 >60: 4.5%
*Education*		89.4%< grade 10	Illiterate:24.2% School 64.2% Graduate and above: 5%	No formal Education: 8.3% Primary:15.2% Secondary: 61.4% University:15.2%
*Occupation*	Unemployed	54.1%	43.3%	37.1%
	Employed	32.4%	25.2%	43.3%
	Students	13.5%	30.8%	17.$%
*Income*			Low:90.8% Middle:9.2%
*Marital status*			Married: 50.8% Unmarried: 49.2%	Married:37.1% Single:62.1% Widowed: 0.8%

We found that most of the respondents are knowledgeable (82.5%), have a good practice (63.9%), positive attitude (79.7%), and good seizure control (68.2%) irrespective of their age, gender, and disease duration (p-value were not significant). The possible reason behind these convenient results could be the high educational level of our sample, where up to 65.7% have achieved a minimum of secondary education. This is proved by the positive association found between the educational level of our patients and their knowledge toward their disease on one hand (p < 0.001), and their practice in another hand (p=0.015). Realizing the importance of education opens doors to gain knowledge, which helps in guiding a better sense of right from wrong.

A KAP assessment study, M Gourie-Devie et al (13), found to have relatively comparable results in terms of knowledge, where we can see that the most common answer in the two samples was brain neuron disturbances when asked about the cause of epilepsy (35.1% vs 55% for Indian sample), and also similar percentage (10.95% % in our study sample and 14.2% in the other study sample) answered that epilepsy is a mental disorder. On the other hand, regarding also the epilepsy definition, only 6.7 % in our study sample believed that epilepsy is caused by supernatural power versus 16.7 % in the Indian study sample and only a small group in the two samples doe believe in traditional faith healers (only 25.4% in our study sample versus 19.2% in the comparable study). And when asked about epilepsy transmitting, only 1 patient (0.8%) in the other study thought that epilepsy is contagious whereas 7 patients (5.2 %) do have these thoughts. About treatment, a good percentage in both studies believe that their disease is treatable with modern drugs (85.1% vs 91.7%). Similar attitude results are also seen between the two studies, where most of the two samples believe that epileptic patients can have children (93.3% vs 92.5 %), can study (87.3% vs 80.8%), and can effectively work (96.3% vs 90.8%). Moving to the practice field, some percentages make difference in the two groups, for example, only 1 patient (0.8%) in our study population rely on smelling a shoe during seizure attack versus 15 patients (12.5%) in the other study. But despite this small gap, going to the hospital, remain the first to do after seizure attacks (33.8 vs 96%). In summary, M Gourie-Devie et al had found similar results to our study in the Indian population (good knowledge, good attitude, good practice), knowing that the sample study had similar demographic characteristics to ours; beginning with the age, where around 83 (69.2%) of this study population is below 30, versus 76(56.7%) of our sample is between 18-36, so the majority of the two sample populations are known to be young adults, moving to the socioeconomic status, where the population is classified to have low to moderate-income, which is close to the Indian sample where the majority is found to get a low income (90.8%) and finally, regarding the education, the two studies show also very comparable results, so we can find that around 74 % of our population and around 77% of the other study sample have attained a base of primary education. The only two differences in the demographic characteristics are the occupation and the gender, where our sample is found to be almost half female half male, whereas most of the second study patients (62%) are males, and the majority of our patients are employed (58%) versus 28% in the Indian sample.

Our positive knowledge results were not seen in the Yousef RM et al study (14), where 90.9% were unaware about their disease cause, regardless of age, educational background, or disease duration. On the other hand, results were comparable for attitude and practice questions.

Table 9 below is a review comparing the results with previous studies.

Table 9. Comparison of results between studies

Author(year)

Sample size

Region

Cause of Disease

Epilepsy is curable

Epilepsy can be treated by medication

Believing in Faith healers

Take regular treatment

Regular follow up

Cause of Relapse

Practice in case of attacks

Current study

35.5 % Brain disorder

79.9%

85.1%

25.4%

91.8%

87.3%

26.3% due to non-compliance

33.8 % go the hospital

Yousef RM et al (2017)

132 Malaysia

90.9% don’t know

97.9%

93.9%

22.7%

97.7%

90.9%

76% due to non -compliance

0.8% Go to the hospital

Udaya Seneviratne et al (2002)

207

Sri Lanka

41.5% Brain disorder

71%

41.5%

Gizat Kassie et al (2014)

180

Ethiopia

32.2%

Don’t know

36.6%

60%

53.33% Positioning

Udaya Seneviratne ET al (12) found that the majority of Sri Lanka patients are male 55%, ranging between 10 to 30 years old (59.9%), Their education level was low, up to 89% in contrast to Lebanese epileptic patients that this current study showed a high level of education (up to 65% were educated). A large part of them was unemployed (54.1%). In contrast, in this study, most epileptic Lebanese patients (58.2 %) were employed. In Contra wise to our results, the majority here were on monotherapy (75.4% vs 49.3%) with carbamazepine the major drug choice (48.3% vs 34. 9%). Most of their respondents had also a positive attitude as in the Lebanese sample (75.8 vs 97.7%); where Lebanese patients had a remarkable high attitude; and good seizure control, whereas they appeared to have bad knowledge despite the similar level of literacy to our study sample. Also, in contrast to this study, a large group of their patients does believe in spiritual healers.

In Gizat Kassie et al study (15), like our study sample, most of the patients (58%) are young adults between 20 and 35 years old, with low income (74%). Regarding occupation status, both samples are employed in the majority, but the noticeable in the Ethiopian sample is that the majority employed specifically farmers (28.28%). Two demographic differences exist between the two samples, where our sample is almost half male (47%), half female (53.0%), whereas most are male in the other study (40%), and most of our study is married (56%) whereas most of the second study is single (32.2%). The two samples are also comparable in terms of education where our sample as already discussed (30.6%) have achieved a minimum of secondary education, and in the other study, 22.22% of the Ethiopian sample had achieved a level between grad1 – grad8. A big difference is also in the disease duration recordings, where our patients tend to have a mean of 16.36 years of epilepsy duration, much longer than the Ethiopian sample when the majority suffer from epilepsy for only 1-5 years. As a result of knowledge scoring, the two samples tend to know, in the majority, that epilepsy is a disease of the brain (53.1% vs 74.44%). On the other hand, for practice results, the highest percentages are seen for positioning where most of our study tend to go to the hospital, and what was remarkable is that none of the patients rely on praying in this situation, while a small percentage in our study (16.5%) do believe in praying. Overall, like our sample, the Ethiopian sample has an acceptable treatment knowledge (60%), a positive attitude (70%), and good practice (53.3%). Also, the association analysis done separately between knowledge and attitude with the demographic characteristics had shown not only that the knowledge is positively associated with educational level in our study, but also with age, income, and duration of the disease. In contrast to this study, the attitude was found to be associated with several variables (age, gender, literacy, mental status, and income).

The studies mentioned above could demonstrate that education is not the only variable affecting knowledge, which could be affected by many other factors, such as the social cultures, religious background, technological facilities that facilitate internet access, and the research about the disease process.

5.2. Cofactors of KAP

When managing an individual living with epilepsies there are unmodifiable factors such as the age of onset, etiology of the disease, and its pattern. Besides, despite adequate medication, it has been found that seizures will persist. It is necessary therefore to identify other modifiable factors that could improve seizure control in our patient population.

Knowledge can be defined as awareness or understanding of facts which is acquired through experience and education perceiving. Many factors may influence the knowledge of patients toward their illness: their socioeconomic status, education, and interaction with health care providers.

When reinforcing these factors, we will strengthen respectively their knowledge. As a knowledge, additional factors affect also the attitude and practice of patients; mainly highlighted in low and middle-income countries; as the stigma, religious beliefs, lack of psychosocial support, Health care assistance, and health awareness clubs. Because of these precipitating factors, epileptic patients may become victims due to their misconceptions about the disease.

5.3. Recommendations:

We recommend the development of a standardized comprehensive association to raise awareness about epilepsy and educate patients about their disease cause, treatment, the necessity of taking treatment on daily basis, how to deal with epilepsy attacks and their rights to be incorporated into society. And we recommend further studies on other factors that may contribute to knowledge, attitude, practice, and seizure controls.

5.4. Strengths and Limitations

This study is the first to record the knowledge, attitude, and practice of adult epileptic patients in Lebanon. The results of our study can aid the regulatory and consultative agencies in helping epileptic patients to deal with their conditions.

Our study has several limitations. First, our sample size is less than the number calculated as discussed in the methods part. The pharmacies and neurologic clinics for recruitment are chosen by convenience, which can be considered as a second limitation. Additionally, because it is time-consuming, and because of some critical questions (information Bias), we couldn’t use the structured questionnaire, and new assumptions were made to overcome this barrier.

The Lebanese patients suffering from epilepsy had basic good knowledge, attitude, and practice towards their disease with good seizure control. Meanwhile, the seizure control was not associated with the knowledge, attitude, and practice of the patient toward their disease, whereas a remarkable association was found between the education level of patients and their knowledge and their practice.

KAP: knowledge, attitude, and practice

ILAE: International league of epilepsy association

CBZ: Carbamazepine

PA: Valproic acid

LEV: Levetiracetam

Ethics Approval and Consent to Participate

This study was approved by the Ethical Committee of the Lebanese International University. Oral consent was obtained from all patients participating in the study. Given the nature of the study, the Ethics Committee waived the requirement for written consent.

Consent for Publication

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' Contributions

Nada Kassem, Soumaya Houssein and Iqbal Fahs conceived and designed the study.

Iqbal Fahs and Marwan Akel assisted with data collection, reviewed and revised the manuscript.

Nada Kassem and Soumaya Houssein Were responsible for the data collection, entry organization, assisted with data analysis, data curation and contributed to manuscript writing.

Nada Kassem performed statistical analysis, interpreted results, writing and revised the final draft of the manuscript.

Nathalie Lahoud provided critical insights on study design and methodology.

All authors reviewed and approved the final manuscript and agreed to be accountable for all aspects of work.

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No competing interests reported.

Supplemantarymaterials.docx

Knowledge, attitude and practice among adult Lebanese patients with epilepsy and impact on seizure control: a cross sectional descriptive study

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Abstract

Figures

1. INTRODUCTION

2. OBJECTIVE

3. METHODS

3.1. Study Design

3.2. Study Location

3.3. Study Population

3.4. Sample Size Calculation

3.5. Sampling and Recruitment

3.6. Study Procedure

3.7. Study Outcomes

3.7.1. Primary outcomes

3.7.2. Secondary outcomes:

3.8. Statistical Analysis

4. RESULTS

5. DISCUSSION

6. CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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