A peer support group intervention to decrease epilepsy-related stigma in an onchocerciasis-endemic area in Mahenge, Tanzania: A pilot study

Effectiveness of Yoga Intervention in Reducing Felt Stigma in Adults With Epilepsy: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Persons with epilepsy are afflicted with comorbidities such as stigma, anxiety, and depression which have a significant impact on their quality of life. These comorbidities remain largely unaddressed in resource-limited countries. This randomized controlled trial (RCT) aimed to investigate whether yoga and psychoeducation were effective in reducing felt stigma (primary outcome), neuropsychiatric outcomes, and seizure frequency, as compared with sham yoga and psychoeducation in persons with epilepsy.

METHODS

This was an assessor-blinded, sham yoga-controlled RCT. Patients clinically diagnosed with epilepsy, aged 18-60 years, and scoring higher than the cutoff score for felt stigma as measured by the Kilifi Stigma Scale (KSS) in our population were randomly assigned to receive either yoga therapy plus psychoeducation (intervention) or sham yoga therapy plus psychoeducation (comparator) for a duration of 3 months. The primary outcome was a significant decrease in felt stigma as compared with the comparator arm as measured by the KSS. Primary and secondary outcomes (seizure frequency, quality of life, anxiety, depression, mindfulness, trait rumination, cognitive impairment, emotion regulation) were assessed at baseline, 3 months, and 6 months. Parametric/nonparametric analysis of covariance and the χ2 test were used to compare the 2 arms.

RESULTS

A total of 160 patients were enrolled in the trial. At the end of the follow-up period (6 months), the intervention arm reported significant reduction in felt stigma as compared with the control arm (Cohen's d = 0.23, 95% CI -0.08 to 0.55, p = 0.006). Significantly higher odds of >50% seizure reduction (odds ratio [OR] 4.11, 95% CI 1.34-14.69, p = 0.01) and complete seizure remission (OR 7.4, 95% CI 1.75-55.89, p = 0.005) were also observed in the intervention group. The intervention group showed significant improvement in symptoms of anxiety, cognitive impairment, mindfulness, and quality of life relative to the control group at the end of follow-up period (p < 0.05).

DISCUSSION

Yoga can alleviate the burden of epilepsy and improve the overall quality of life in epilepsy by reducing perceived stigma.

TRIAL REGISTRATION INFORMATION

Clinical Trials Registry of India (CTRI/2017/04/008385).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that yoga reduces felt stigma in adult patients with epilepsy.

Accessibility to formal education among persons with epilepsy in Mahenge, Tanzania

BACKGROUND

Epilepsy is estimated to affect 50 million people globally, with 80% living in sub-Saharan Africa (SSA). Children with epilepsy (CWE) in SSA are often socially isolated, and many do not get access to school. This study aimed to explore the barriers hindering accessibility to formal education among CWE in Mahenge, Tanzania.

METHODS

The study was conducted in June 2022 in four villages (Mdindo, Msogezi, Mzelezi and Sali) using quantitative and qualitative methods. The quantitative included 203 persons with epilepsy (PWE), while the qualitative involved six focus group discussions and 17 in-depth interviews. Quantitative and qualitative data were analyzed using Stata and Nvivo software, respectively.

RESULTS

Of the 203 PWE, 62 (30.5%) had never enrolled in school, while 77 (54.6%) of those enrolled dropped-out before completing it. The perceived barriers to accessing education were categorized as individual barriers (such as frequent seizures, learning difficulties, anti-seizure medication side effects and perceived stigma), Community barriers (such as stigma and discrimination, negative beliefs and misconceptions, relocation to farms and poor socio-economic status), and Institutional barriers (including lack of knowledge about epilepsy among stake-holders, topography and distance to schools).

CONCLUSION

There is a high rate of dropouts and non-enrolment of CWE in schools within the Mahenge area. Negative beliefs and low awareness of the community about epilepsy and formal education contribute to this issue. This calls for more advocacy to raise community awareness on epilepsy. The government should enforce an inclusive education policy and provide free and uninterrupted anti-seizure medication for seizure control.

Disability assessment among persons with epilepsy in Mahenge, an onchocerciasis-endemic area in Tanzania: A cross-sectional study

BACKGROUND

A high prevalence of epilepsy has been observed in the onchocerciasis-endemic focus of Mahenge, Tanzania. This study sought to assess the degree of disability experienced by persons with epilepsy (PWE) in Mahenge and identify associations with sociodemographic and clinical features.

METHOD

This cross-sectional study was conducted in Mahenge, Tanzania, between February and July 2020. PWE were recruited from the Mahenge epilepsy clinic and four neighbouring rural villages (Mdindo, Mzogezi, Mzelezi and Sali). Data were collected using the 36-item version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire for adults. For children aged 5-17 years, we used the Module on Child Functioning developed by UNICEF and the Washington Group. Questionnaires were administered by trained research assistants. Descriptive statistics were performed, and multivariable analyses (gamma and logistic regressions) were conducted.

RESULTS

A total of 321 adults (45.5% males) and 48 children (55.3% males) with epilepsy participated. The overall median WHODAS 2.0 score was 4.8% (IQR: 0.9-18.9). The most affected disability domain was 'participating in the society' (median score: 12.5%, IQR: 0-29.2). Fifteen (31.3%) of the children with epilepsy had a disability in at least one domain of the child functioning module, with the 'accepting change' domain harbouring the highest proportion of disabled children (12.5%). Higher seizure frequency and longer epilepsy duration were associated with more disability.

CONCLUSION

PWE in Mahenge experience variable degrees of disability. The affected domains indicate the need for societal rehabilitation of PWE in various community and/or social activities. Peer-support groups were instituted at the study sites to address these needs.

Impact of a bi-annual community-directed treatment with ivermectin programme on the incidence of epilepsy in an onchocerciasis-endemic area of Mahenge, Tanzania: A population-based prospective study

BACKGROUND

Community-directed treatment with ivermectin (CDTi) is used to eliminate onchocerciasis. However, despite 25 years of annual CDTi in Mahenge, Tanzania, the prevalence of onchocerciasis and onchocerciasis-associated epilepsy remained high in certain rural villages. Therefore, in 2019, bi-annual CDTi was introduced in the area. This study assessed the impact of the programme on the incidence of epilepsy in four villages.

METHODOLOGY

Door-to-door epilepsy surveys were conducted prior to (2017/18) and after (2021) implementing a bi-annual CDTi program. All household members were screened for epilepsy symptoms using a validated questionnaire, and suspected cases were examined by a medical doctor to confirm/reject the diagnosis of epilepsy. The prevalence and annual incidence of epilepsy, including nodding syndrome, were calculated with 95% Wilson confidence intervals with continuity correction. The latter was also done for CDTi coverage in 2016 and 2021.

RESULTS

Precisely 5,444 and 6,598 persons were screened for epilepsy before and after implementing the intervention. The CDTi coverage of the overall population was 82.3% (95%CI: 81.3-83.2%) in 2021 and sustained in both distribution rounds (81.5% and 76.8%). The coverage was particularly high in children and teenagers aged 6 to 18 years (93.2%, 95%CI: 92.1-94.2%). The epilepsy prevalence remained similar: 3.3% (95%CI: 2.9-3.9%) in 2017/18 versus 3.1% (95%CI: 2.7-3.5%) in 2021. However, the incidence of epilepsy declined from 177.6 (95%CI: 121.2-258.5) in 2015-2017 and 2016-2018 to 45.5 (95%CI: 22.2-89.7) in 2019-2021 per 100,000 persons-years. The incidence of probable nodding syndrome varied from 18.4 (95%CI: 4.7-58.5) to 5.1 (95%CI: 0.3-32.8). None of the nine incidence cases of epilepsy for which information on ivermectin intake was available took ivermectin in the year they developed their first seizures.

CONCLUSION

A bi-annual CDTi programme should be implemented in areas with high prevalence of onchocerciasis and epilepsy. High CDTi coverage among children is particularly important to prevent onchocerciasis-associated epilepsy.

Nodding syndrome, a case-control study in Mahenge, Tanzania: Onchocerca volvulus and not Mansonella perstans as a risk factor

BACKGROUND

Nodding syndrome (NS) has been consistently associated with onchocerciasis. Nevertheless, a positive association between NS and a Mansonella perstans infection was found in South Sudan. We aimed to determine whether the latter parasite could be a risk factor for NS in Mahenge.

METHODS

Cases of epilepsy were identified in villages affected by NS in Mahenge, Tanzania, and matched with controls without epilepsy of the same sex, age and village. We examined blood films of cases and controls to identify M. perstans infections. The participants were also asked for sociodemographic and epilepsy information, examined for palpable onchocercal nodules and onchocerciasis-related skin lesions and tested for anti-Onchocerca volvulus antibodies (Ov16 IgG4) by ELISA. Clinical characteristics of cases and controls, O. volvulus exposure status and relevant sociodemographic variables were assessed by a conditional logistic regression model for NS and epilepsy status matched for age, sex and village.

RESULTS

A total of 113 epilepsy cases and 132 controls were enrolled, of which, respectively, 56 (49.6%) and 64 (48.5%) were men. The median age in cases and controls was 28.0 (IQR: 22.0-35.0) and 27.0 (IQR: 21.0-33.3) years. Of the persons with epilepsy, 43 (38.1%) met the probable NS criteria and 106 (93.8%) had onchocerciasis-associated epilepsy (OAE). M. perstans infection was absent in all participants, while Ov16 seroprevalence was positively associated with probable NS (odds ratio (OR): 5.05, 95%CI: 1.79-14.27) and overall epilepsy (OR: 2.03, 95%CI: 1-07-3.86). Moreover, onchocerciasis-related skin manifestations were only found in the cases (n = 7, p = 0.0040), including persons with probable NS (n = 4, p = 0.0033). Residing longer in the village and having a family history of seizures were positively correlated with Ov16 status and made persons at higher odds for epilepsy, including probable NS.

CONCLUSION

In contrast to O. volvulus, M. perstans is most likely not endemic to Mahenge and, therefore, cannot be a co-factor for NS in the area. Hence, this filaria is unlikely to be the primary and sole causal factor in the development of NS. The main risk factor for NS remains onchocerciasis.

Quality of life of persons with epilepsy in Mahenge, an onchocerciasis-endemic area in Tanzania: A cross-sectional study

OBJECTIVE

This study investigated the quality of life (QoL) of adults with epilepsy living in Mahenge, an onchocerciasis-endemic area in Tanzania with a high prevalence of onchocerciasis-associated epilepsy (OAE).

METHODS

Between February and December 2020, persons with epilepsy (PWE) were recruited from four rural villages in Mahenge: Mdindo, Msogezi, Mzelezi, and Sali. For PWE who could not answer the questionnaire due to their mental or physical disability, a family member was asked to answer the questions instead. The Quality of Life in Epilepsy Inventory-31 (QOLIE-31) questionnaire used contained seven domains. The raw domain scores were transformed to 0-100% subscales, with higher scores indicating better QoL. The global QoL was calculated from the subscales using the overall QOLIE-31 score formula.

RESULTS

In total, 96 PWE were enrolled in the study with a median age of 28 (range: 18-60) years, of whom 45 (47%) were male. The questionnaires were answered by PWE (54.8%) or one of their family members (45.2%). Most PWE were single (81%), and half never attended school. About two-thirds (65%) of PWE were suspected of having OAE, and a third (31%) had a history of head nodding seizures. Most PWE were treated with phenobarbital (85.4%) and had high treatment adherence (96.9%). Still, the number of seizures per week ranged from 0 to 7, with a median of one. The mean global QOLIE-31 score was 66.9 (range: 38.3-92.1) out of 100.0. Predictors of lower QoL were living in Sali Village and experiencing seizures the week before the interview. In contrast, completing primary school and switching to second-line anti-seizure medication were predictors of higher QoL.

CONCLUSION

In order to improve the QoL of PWE in Mahenge, it is vital to optimize anti-seizure medication regimens to decrease the frequency of seizures and to increase the schooling of PWE.

Factors associated with low-uptake of ivermectin in Mahenge, an area with high prevalence of onchocerciasis and epilepsy in Tanzania: A qualitative perspective

Introduction

Despite over 20 years of community-directed treatment with ivermectin (CDTI) in Mahenge area in Tanzania, the prevalence of onchocerciasis has remained high (over 40% in children 6-10 years using antibody testing and 49% using skinsnips in adults). The area has one of the highest prevalence of epilepsy, exceeding 3.5% in some of rural villages.

Methods

Between June and July 2019, in four rural villages using qualitative methods, we assessed factors potentially associated with the persistence of high Onchocerca volvulus transmission.

Results

Eleven focus group discussions were organized with persons with epilepsy and their caretakers, community resource persons, and community drug distributors (CDDs), and two in-depth interviews with district programme coordinators of neglected tropical diseases (NTD). Factors considered being responsible for the persistence of onchocerciasis transmission included not taking ivermectin during CDTI for fear of adverse reactions such as itching, swelling and misconception that the drug causes infertility. Challenges for high CDTI coverage included, long walking distance by CDDs to deliver drugs to households, persons being away for farming, low awareness of the disease including the association between onchocerciasis and epilepsy and limited supervision by the NTD coordinators.

Conclusion

Ivermectin uptake in Mahenge should be optimised by continuous advocacy about the importance of taking ivermectin to prevent onchocerciasisassociated morbidity and by improving supervision during CDTI.