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Epilepsy: Knowledge and Attitudes of Primary School Teachers in the City of Bouake/Ivory Coast
We report the results of a two-month descriptive observational survey to assess the knowledge about epilepsy among primary school teachers in Bouake in Ivory Coast. This study included 310 teachers who were randomly chosen from three Primary School Inspections (PSI). Almost all the teachers who were included had shown inaccurate information about epilepsy. 46.45% of the respondents thought that epilepsy was contagious and 47.74% recommanded to avoid contacting with salivary secretions of the patient during seizure. For 16.45% of them, persons living with epilepsy (PWE) could be not married and 19.7% believed that PWE could not have children due to the risk of transmission. This study highlights the urgent need of awareness campaigns among primary school teachers.
Epilepsy is a common neurological disorder with multiple and often curable causes 1. Epilepsy affects approximately 50 million people worldwide making it the most common neurological disorder globally 2. Most people living with epilepsy (PWE) live in low and middle income countries 3. The prevalence of epilepsy in Africa is greater than 10‰ 4. In Sub-Saharan Africa (SSA), the prevalence of active convulsive epilepsy is high and range from 2.2 to 58 per 1000 affecting and estimared 4.4 million people 5.
In Ivory Coast, the prevalence of epilepsy has been estimated at 7‰ by Kouassi and al. 6. The PWE are still too often stigmatized because of the lack of knowledge about this disease and supernatural beliefs in the population 7. In Ivory Coast, several studies have demonstrated focused on the sociocultural aspects of the epilepsy in different population groups. Assi and al. carried out a study in a population of students in Abidjan 8. Boa and al. assessed the knowledges and beliefs on epilepsy in next of kin of PWE hospitalised in neurology 9. Akani and al. conduced a study on the knowledges of medical traditional health practitionners on epilepsy 10.
Increased attention is currently scope to the quality of life, that is to say to the psychological and social problems faced by PWE, including access to education. Doumbia and al. have found 35.2‰ epilepsy in the preparatory course (C.P.1) students in their study carried out in one commune of abidjan in Ivory Coast 11. Schools should offer some useful information and assistance in health issues, such as epilepsy. Therefore, teachers should have sufficient knowledge for this purpose. Our study aims at assessing the level of knowledge of primary school teacher in the city of Bouake in Ivory Coast.
That was a two-month descriptive observational study in the city of Bouake. Bouake, the second largest city, is located at the central part of Ivory Coast about , 355 km of Abidjan wich is the economic capital. The study was carried out based on the anonymous questionnaire on the socio-demographic characteristics, knowledge, beliefs and practical attitudes of respondents regarding to the epilepsy. It included both open and closed questions. The questionnaire was distributed to the respondents during the break and retrieved at the end of the same day for each school identified. It was validated after two pre-tests with two different groups of teachers from Bouake. This study was done in 3 Primary School Inspections (PSI) wich were randomly choosen among 5 PSI of the city in Bouake. We founded the maximum size of the sample with EPI Info 7.2 software. As a result , 310 teachers were recruited from 10 primary schools.
Most of the respondents were men (73.87%) and the average age was 43.08 years. Muslims were predominant (46.45%), followed by christians (33.87%) and animists (19.68%). 59.03% of the respondents had a high school level and (40.97%) had university level. Table 1 show the demographic characteristics of the respondents.Table 1. Demographic characteristics of the respondents (N=310)
|Characteristics||Frequency (n)||Percentage (%)|
|Level of education||Secondary||183||59,03|
|Had a student living with epilepsy in their classes||yes||21||6,77|
84.84% of respondents had little knowledge about epilepsy. However 62.58% thought that epilepsy was a brain disorder of medical origin wich may lead to madness within 32.9% of respondents While 17.4% of respondents believed that it was a spiritual illness caused by devil or God). 11.9% of respondents considered it as an hereditary disease (Table 2).Table 2. Knowledge about epilepsy
|Awareness on epilepsy||No||42||13,55|
|Origin of epilepsy||Brain disorder||194||62,58|
|Lead to madness||102||32,9|
|Spiritual illness (evil or God)||54||17,4|
|Clinical signs||Foamy drooling||247||79,68|
|Loss of consciousness||168||54,2|
|Loss of urine||57||18,39|
|Favouring factors||Head trauma||78||25,2|
|Contagiousness of epilepsy||Yes||144||46,45|
|Way of contagion||Body fluid (drool)||125||40,32|
|Contact with patient in seizure||109||35,16|
|Eat in the same plates||10||3,23|
|Share same clothes||1||0,32|
61.9% of teachers knew the generalized tonic-clonic seizure. For most of respondents (79.68%), the foamy drooling was a clinical sign of epileptic seizures. A loss of consciousness was reported in 54.2% of respondents, stiffness and muscle twitching were in 53.23% and 48.39% cases, respectively. The urinary incontinence and the tongue biting occured in 18.39% and 11.3% respectively. None of the respondents reported the the « absence » seizure. 6.77% of teachers had an epileptic patient in their classrooms.
Respondents had little knowledge about contributing factors of the epileptic seizures. The head traumatism was the main favouring factor among 25.2% of respondents, while alcohol, insomnia and infections were considered as causes in 7.74%, 6.77% and 6.45% of participants respectively.
46.45% of the respondents believed in the contagiousness of epilepsy 40.32% by body fluids (drool), and 35.16% in contact with the seizure patient. 85.87% of the respondents regarded epilepsy as curable disease.
Among the teachers, 35.16% recommended avoiding the contact with the patient during seizures and 47.74% insisted on the avoidance of the foaming drool. Actions such as "pouring water or powder on the subject" and "praying during the crisis" were mentioned in 10% and 10.96% cases, respectively. However, 25.16% of the teachers suggested to prevent the patient from falling during seizures and 37.74% mentioned to take him immediately to the hospital.
99.35% of the respondents admitted that PWE should not be excluded from school, and thus, they should continue their normal education. 56% of participants considered that the PWE should not hold a position of responsibility in the community or working setting asvillage chief orcompany manager. The occupational setting of PWE should not be informed of their condition in 51.94% cases. Moreover, the PWE go to nightclub, eat with, play video games have children and get married in 65.48%, 46.13%, 37.5%, 19.70% and 16.45% cases of respondents, respectively. According to 50,32% of teachers, the PWE could drive a vehicle and 3.87% of whom would be in agreement with driving a public transport vehicle. 34.19% of teachers supposed that the PWE should not be buried in the same cemeteries with the others. Table 3 shows the beliefs on epilepsy.Table 3. Beliefs on epilepsy
|Attitude toward PWE in seizure||Avoidness of the foaming drool||148||47,74|
|Take immediately to hospital||117||37,74|
|Avoid contact with the patiente in seizure||109||35,16|
|Prevent from falling during seizure||78||25,16|
|Praying during seizure||34||10,96|
|Pouring water or powder||31||10|
|Epilepsy and daily life||PWE could continue normal education||Yes||308||99,35|
|PWE should go to nightclub||Yes||107||34,52|
|PWE could hold a position of responsibility||Yes||136||44|
|The professionnal community of PWE should be informe of its state||Yes||149||48.06|
|PWE should eat on the same plate as the others||Yes||167||53,87|
|PWE Could drive a vehicle||Yes||156||50,32|
|PWE Could drive a public transport vehicle||Yes||12||3,87|
|PWE should play video games||Yes||194||62,6|
|PWE should have children||Yes||249||80,30|
|PWE should get married||Yes||259||83,55|
|PWE should be buried in the same cimeteries as the others||Yes||204||65,81|
Our study revealed that all teachers needed thorough information about epilepsy. The information tools used were distribution of flyers (44.5%), audiovisual media (32.26%), availability of scientific papers (16.77%). The majority of respondents suggested that PWE should join associations of patients, friends and parents of patients (96.15%). This membership would help to better understand the epilepsy (63,87%), raise awareness (56,45%), access to the treatment (27,74%) and improve the management of epilepsy (43.55%).
This study has been done in a young and high educatied population. We found that the majority of primary school teachers, who have completed higher education, indicated that they were not enough informed about the epilepsy. This finding was also reported by Maïga (58.7% of the teachers) in Mali 7, Kiwanuka in Uganda 3 and Owolabi in a study conduced in a school teachers population in Nigeria 12. Despite this fact, they knew that epilepsy was a brain disorder from a medical origin. In contrast , some teacher considered it as a supernatural disease due the deep-rooted beliefs in population. This finding agrees with the studies in Abidjan 8, in Benin 1, in Nigeria 12, 13, in Ouganda 3, in Zimbabwe 14 and in Brazil 15.The confusion between epilepsy and mental illness remains, since 32.9% of the respondents admitted that the epilepsy was related to madness.
Many teachers have recognized the spectacular tonic-clonic seizure, associated with stiffness, convulsion, loss of consciousness, tongue biting and urinary incontinence. The tonic-clonic seizure, generally known as the "great evil" seizure, considered as the major symptome of the epilepsy, wich is well describe by our participants 8. This finding agrees with other reports 12, 16. None of the respondents knew the absence seizure. It rarely helps to diagnose the epilepsy since it highly unseen 10. This finding reported by Owolabi has great implication for in-school recognition of non convulsive seizure 12. The « absence » seizure mostly occurs in school-aged children, with poor school performance implications. Hereby, it is relevant for teachers to be aware of this disease so that they will contribute to diagnose it early. Futher more, they should aware of the factors favouring the occurrence of seizures. The concept of contagiousness still remains. 79.68% of teachers identified the foamy drooling as clinical sign of epilepsy, and 39.14% believed that epilepsy could be spread by touching with the patient during the seizure. This fact was also identified by Owolabi 12 and increases the attitudes of fear and rejection of the patient 10, 12. The conceptions including "avoid touching PWE in seizure" and "avoid his drool" are strongly indicated by the teachers despite their high education level and explain the high rate of accidents occurring within PWE during seizures 8.
The daily life of PWE is characterized by these misconceptions and thus, leading to social, professional, and family prohibitions as also described by Assi and al 8. All teachers have admitted that thePWE can maintain normal schooling. Objectively, education of epileptic children, can be hindered by several problems, including psychomotor disorder, fear of discrimination, fear of falling in the crowd, and family guilt 17. 56% of teachers have revelead that the PWE should not have a position of responsibility. Assi and al. have made the same observation in a student population in Abidjan in Ivory Coast and have linke dit it with the suddenness and disabling nature of epileptic seizures 8. The professional environment of PWE should not be informed according to 51.94% of the teachers because of the fear of exclusion or dismissal 8. Therefore the awareness of the occupational community may help to take actions during seizures or to obtain a job adaptation 8.
The lack of knowledge about epilepsy will perpetuate the misconceptions. In addition, the PWE must not only have leisure, such as disco and video games but also eat on the same plates as other members of the family. This fact is a major factor of exclusion in traditional African settings7, 8, 18. In some cultures, the epilepsy is still considered as a reason to prohibit or cancel a weddingamong16.45% of our study respondents 19 due to the risk of transmission to offspring. All respondents would like to get more information about epilepsy through flyers or audiovisual media. The Ivoirian Association against Epilepsy (A.I.L.E) should implement a social marketing strategy on epilepsy awareness flyers and to increase the sensibility campaign for teachers in Bouake so that they would eliminate the misconceptions about epilepsy. This awareness activity could be done in collaboration with the association "stop epilepsie", an Ivorian association of PWE and PWE family.
This study has some limitations which should be considered in the interpretation of our findings. Explanations were provided to the participant on some questions and this might have affected their responses. The study took place over two months and some teachers interviewed could have given information to their colleagues or read documents. This might have affected theirs spontaneous responses. Despite these limitations, the benefit of this study is that it provide responses that can be considered as baseline for the A.I.L.E social marketing strategy, and considered as base line for comparison with the next studies.
Primary school teachers play a vital role in educational and psychosocial development of student as an important part of their life is spent at school. The epilepsy is still, an unknown neurological disorder due to several misconceptions and the lack of knowledge in view of this study. Primary school teachers have erroneous knowledge about epilepsy Hereby, this study should carefully suggest to enhance the understanding or perception of this disease among the populations, particularly in primary school teachers under the management of the Ivoirian Association against Epilepsy (A.I.L.E).