People with epilepsy obtain added value from education in groups: results of a qualitative study

Confidence College – an online education tool for neurology patients

COVID-19 and its aftermath highlight the importance of patient self-care and involvement in monitoring and improving their health. Resources to guide this are essential. Our objective was to create a web-based patient education tool, to facilitate patient education and empowerment for people with epilepsy, multiple sclerosis and Parkinson’s disease, available without cost to patients, carers and clinicians. This project was conducted within community and secondary neurology services. Patients and their carers were involved in designing, reviewing and revising the tool, as equal partners with clinicians and digital engineers. A web-based design template was developed with graphics and links to enable patients to create personalised plans. Participants are patients, carers, clinicians (neurology consultants and specialist nurses), neurological charities, the London Neuroscience Clinical Network, NHS England and Shift.ms (a service design team with experience in creating digital services for individuals living with neurological conditions). Shift.ms conducted in-depth interviews. Clinicians used evidence from personal and PubMed databases. Shift.ms analysed and co-ordinated the responses, and designed the pilot tool. Confidence College provides a delivery model for patient education relating to multiple sclerosis, epilepsy and Parkinson’s disease. It requires follow-up evaluation regarding uptake. This web-based accessible patient empowerment tool has no limit on recurrent use, low maintenance costs and no additional costs in up-scaling the number of users. It is ideally suited for use during and after the COVID-19 pandemic.

A journey into the unknown: An ethnographic examination of drug-resistant epilepsy treatment and management in the United States

Patients often recognize unmet needs that can improve patient-provider experiences in disease treatment management. These needs are rarely captured and may be hard to quantify in difficult-to-treat disease states such as drug-resistant epilepsy (DRE). To further understand challenges living with and managing DRE, a team of medical anthropologists conducted ethnographic field assessments with patients to qualitatively understand their experience with DRE across the United States. In addition, healthcare provider assessments were conducted in community clinics and Comprehensive Epilepsy Centers to further uncover patient-provider treatment gaps. We identified four distinct stages of the treatment and management journey defined by patients' perceived control over their epilepsy: Gripped in the Panic Zone, Diligently Tracking to Plan, Riding a Rollercoaster in the Dark, and Reframing Priorities to Redefine Treatment Success. We found that patients sought resources to streamline communication with their care team, enhanced education on treatment options beyond medications, and long-term resources to protect against a decline in control over managing their epilepsy once drug-resistant. Likewise, treatment management optimization strategies are provided to improve current DRE standard of care with respect to identified patient-provider gaps. These include the use of digital disease management tools, standardizing neuropsychiatrists into patients' initial care team, and introducing surgical and non-pharmacological treatment options upon epilepsy and DRE diagnoses, respectively. This ethnographic study uncovers numerous patient-provider gaps, thereby presenting a conceptual framework to advance DRE treatment. Further Incentivization from professional societies and healthcare systems to support standardization of the treatment optimization strategies provided herein into clinical practice is needed.

Barriers and facilitators to implementation of epilepsy self-management programs: a systematic review using qualitative evidence synthesis methods

BACKGROUND

Epilepsy affects nearly 50 million people worldwide. Self-management is critical for individuals with epilepsy in order to maintain optimal physical, cognitive, and emotional health. Implementing and adopting a self-management program requires considering many factors at the person, program, and systems levels. We conducted a systematic review of qualitative and mixed-methods studies to identify facilitators and barriers that impact implementation and adoption of self-management programs for adults with epilepsy.

METHODS

We used established systematic review methodologies for qualitative and mixed-methods studies. We included studies addressing facilitators (i.e., factors that aided) or barriers (i.e., factors that impeded) to implementation and adoption of self-management interventions for adults with epilepsy. We conducted a narrative thematic synthesis to identify facilitators and barriers.

RESULTS

The literature search identified 2700 citations; 13 studies met eligibility criteria. Our synthesis identified five themes that categorize facilitators and barriers to successful implementation epilepsy self-management: (1) relevance, intervention content that facilitates acquisition of self-management skills; (2) personalization, intervention components that account for the individual's social, physical, and environmental characteristics; (3) intervention components, components and dosing of the intervention; (4) technology considerations, considerations that account for individual's use, familiarity with, and ownership of technology; and (5) clinician interventionist, role and preparation of the individual who leads intervention. We identified facilitators in 11 of the 13 studies and barriers in 11 of the 13 studies and classified these by social-ecological level (i.e., patient/caregiver, program, site/system).

CONCLUSION

Identification of facilitators and barriers at multiple levels provides insight into disease-specific factors that influence implementation and adoption of self-management programs for individuals with epilepsy. Our findings indicate that involving individuals with epilepsy and their caregivers in intervention development, and then tailoring intervention content during the intervention, can help ensure the content is relevant to intervention participants. Our findings also indicate the role of the clinician (i.e., the individual who provides self-management education) is important to intervention implementation, and key issues with clinicians were identified as barriers and opportunities for improvement. Overall, our findings have practical value for those seeking to implement and adopt self-management interventions for epilepsy and other chronic illnesses.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number is CRD42018098604.

Reported service needs at diagnosis of epilepsy and implications for quality of life

AIM

This paper reports on contributing factors to Quality of Life (QoL) in an Australian community sample of people with epilepsy (PWE).

METHOD

Three hundred and ninety-three respondents or 29.6% of people on the Australian Epilepsy Research Register participated in Wave 4 of a longitudinal survey. A quantitative analysis was undertaken and a qualitative investigation examined open-ended responses by 44 PWE on the support services that they received following diagnosis of epilepsy.

RESULTS

Total Quality of Life in Epilepsy-31 Items (QOLIE-31) score for the community-based sample was 55.99 (SD 19.85) [Range 6.34-96.20]. Age, paid employment, seizure frequency, number of antiepileptic drugs (AEDs), and perceived prosperity had significant impacts on QoL. In addition, use of support services showed that availability of a first seizure clinic, accurate information on support services and peer support were associated with the highest QoL. A qualitative investigation revealed that on first diagnosis, a lack of information was the main theme. Furthermore, PWE reported a lack of understanding of available supports by a range of health professionals, schools, and in the general community.

DISCUSSION

Psychosocial factors were important in explaining QoL, and the positive effects of first seizure clinics, accurate information on support services, and of peer support have been confirmed in the literature. The lack of knowledge of support services on being diagnosed with epilepsy is a problem evident in the community and pathways are required to support people dealing with their epilepsy.

CONCLUSION

More emphasis is needed in providing availability of supports to enhance the future wellbeing and QoL of people when epilepsy is diagnosed.

Not Just a Headache: Qualitative Study About Web-Based Self-Presentation and Social Media Use by People With Migraine

BACKGROUND

To help with a long-term but invisible medical condition such as migraine, many people seek information and support on social media. The effect of using social media for people with migraine is not fully understood and remains to be investigated.

OBJECTIVE

The aim of this study was to describe how people with migraine use social media and how social media use affects their identity and sense of self.

METHODS

A total of 20 participants who experienced migraine were recruited via migraine-specific charities. Semistructured interviews were conducted with questions based on a topic guide. Interviews were transcribed verbatim, and transcripts were analyzed using thematic analysis.

RESULTS

People with migraine are using social media to obtain information to better understand their condition and treatment options. Social media offers instant access to continuous information and social support. This exchange of social support and information was viewed as mutually beneficial. Participants viewed social media as an outlet to vent frustrations and validate the migraine experience. Several participants pointed out that the invisible and episodic nature of migraine can lead to societal misunderstanding of the impact and or severity of their condition. Some participants masked their online migraine-related behavior using different sites or closed online groups to control who saw their migraine-related content. Participating in closed social media groups sometimes changed Web-based behavior in other areas of the platform. This illustrates the complex relationship between migraine, social media, and identity.

CONCLUSIONS

How migraine is part of an individual's identity and how this is represented online can vary. Social media can provide people who experience migraine with instant and continuous access to support and information, from a group of empathic others with similar lived experiences. Social media is used to validate the illness experience, as well as provide reassurance and help reduce feelings of isolation.

Self-Management education for adults with poorly controlled epILEpsy [SMILE (UK)]: a randomised controlled trial

BACKGROUND

Epilepsy is a common neurological condition resulting in recurrent seizures. Research evidence in long-term conditions suggests that patients benefit from self-management education and that this may improve quality of life (QoL). Epilepsy self-management education has yet to be tested in a UK setting.

OBJECTIVES

To determine the effectiveness and cost-effectiveness of Self-Management education for people with poorly controlled epILEpsy [SMILE (UK)].

DESIGN

A parallel pragmatic randomised controlled trial.

SETTING

Participants were recruited from eight hospitals in London and south-east England.

PARTICIPANTS

Adults aged ≥ 16 years with epilepsy and two or more epileptic seizures in the past year, who were currently being prescribed antiepileptic drugs.

INTERVENTION

A 2-day group self-management course alongside treatment as usual (TAU). The control group received TAU.

MAIN OUTCOME MEASURES

The primary outcome is QoL in people with epilepsy at 12-month follow-up using the Quality Of Life In Epilepsy 31-P (QOLIE-31-P) scale. Other outcomes were seizure control, impact of epilepsy, medication adverse effects, psychological distress, perceived stigma, self-mastery and medication adherence. Cost-effectiveness analyses and a process evaluation were undertaken.

RANDOMISATION

A 1 : 1 ratio between trial arms using fixed block sizes of two.

BLINDING

Participants were not blinded to their group allocation because of the nature of the study. Researchers involved in data collection and analysis remained blinded throughout.

RESULTS

The trial completed successfully. A total of 404 participants were enrolled in the study [SMILE (UK), n = 205; TAU, n = 199] with 331 completing the final follow-up at 12 months [SMILE (UK), n = 163; TAU, n = 168]. In the intervention group, 61.5% completed all sessions of the course. No adverse events were found to be related to the intervention. At baseline, participants had a mean age of 41.7 years [standard deviation (SD) 14.1 years], and had epilepsy for a median of 18 years. The mean QOLIE-31-P score for the whole group at baseline was 66.0 out of 100.0 (SD 14.2). Clinically relevant levels of anxiety symptoms were reported in 53.6% of the group and depression symptoms in 28.0%. The results following an intention-to-treat analysis showed no change in any measures at the 12-month follow-up [QOLIE-31-P: SMILE (UK) mean: 67.4, SD 13.5; TAU mean: 69.5, SD 14.8]. The cost-effectiveness study showed that SMILE (UK) was possibly cost-effective but was also associated with lower QoL. The process evaluation with 20 participants revealed that a group course increased confidence by sharing with others and improved self-management behaviours.

CONCLUSIONS

For people with epilepsy and persistent seizures, a 2-day self-management education course is cost-saving, but does not improve QoL after 12-months or reduce anxiety or depression symptoms. A psychological intervention may help with anxiety and depression. Interviewed participants reported attending a group course increased their confidence and helped them improve their self-management.

FUTURE WORK

More research is needed on self-management courses, with psychological components and integration with routine monitoring.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57937389.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 21. See the NIHR Journals Library website for further project information.

Views of People With Epilepsy About Web-Based Self-Presentation: A Qualitative Study

Background

Web-based media, particularly social networking sites (SNSs), are a source of support for people with long-term conditions, like epilepsy. Living with epilepsy can reduce opportunities for accessing information and social support owing to transportation difficulties and stigma leading to self-isolation. However, some people with epilepsy (PWE) overcome these barriers using SNSs and other Web-based media. At present, little is known about Web-based identity and self-presentation of PWE; this study aims to address this gap.

Objective

This study aims to describe how the use of digital technologies, such as SNSs, impacts sense of identity in PWE.

Methods

We used qualitative research methods to examine Web-based media use and self-presentation in a group of 14 PWE (age range: 33-73 years; 7 men and 7 women). The median diagnosis duration was 25 years. Semistructured interviews ranged from 40 to 120 minutes, held at participants’ homes or in a public place of their choice, in the United Kingdom. QSR Nvivo 11 software was used to perform an inductive thematic analysis.

Results

In this study, 9 participants used Web-based media to “silently” learn from other PWE by reading user posts on SNSs and epilepsy-related forums. When asked about self-presentation, 7 participants described feeling cautious about disclosing their epilepsy to others online. Six participants presented themselves in the same manner irrespective of the situation and described their identity as being presented in the same way both online and offline.

Conclusions

PWE can deploy SNSs and Web-based media to manage aspects of their condition by learning from others and obtaining social support that may otherwise be difficult to access. Some PWE share openly, whereas others silently observe, without posting. Both benefit from the shared experiences of others. Privacy concerns and stigma can act as a barrier to sharing using Web-based media and SNSs. For some, Web-based media offers a chance to experiment with identity and change self-presentation, leading to gradually “coming out” and feeling more comfortable discussing epilepsy with others.

"Seizures have become a means of somehow learning things about myself" - A qualitative study of the development of self-efficacy and mastery during a psychotherapeutic intervention for people with epilepsy

BACKGROUND

Psychological interventions may enhance health-related quality of life in people with epilepsy. The concepts of self-efficacy and mastery may be particularly relevant in the context of epilepsy. To date, the investigation of psychological interventions has not included a qualitative analysis of the effects of such interventions on the interrelation between mastery and general and epilepsy-specific self-efficacy. This qualitative study aimed to explore the relationship between the lived experiences of these concepts in people with epilepsy who participated in a resource-oriented and mindfulness-based psychotherapeutic intervention delivered on a one-to-one basis in an outpatient setting.

METHODS

Semi-structured pre- and postintervention interviews were conducted with people with epilepsy who participated in a six-month resource-oriented and mindfulness-based intervention. The formulation of intervention goals was based on the preintervention interviews. The intervention involved regular one-to-one interactions with the therapist, journal-keeping, and mindfulness-based relaxation. Qualitative content analysis of pre- and posttherapy interviews was conducted to characterize changes in subjective experiences.

RESULTS

Nine people with epilepsy aged 18-59 years participated in 9 to 22 (median 13) sessions. The following six main themes emerged: (A) Encouragement of individual solutions, (B) Awareness of the link of personal traits with seizure-related worries, (C) How to develop self-efficacy, (D) Shaping everyday life in a way that is good for oneself (general self-efficacy), (E) Coping with seizures (seizure-related self-efficacy), (F) Epilepsy as a means of increasing self-knowledge and control over one's life (sense of mastery). The patients' development of self-efficacy was motivated by their personal initial goals and facilitated by the encouragement to find individual solutions and an increased awareness of the link of personal traits with seizure-related worries. A sense of mastery only emerged through the development of general self-efficacy and as a result of the active self-examination prompted by the challenge of living with epilepsy.

CONCLUSION

The qualitative differences observed before and after a psychotherapeutic intervention for individuals with epilepsy increase our understanding of the complex process of psychotherapy-associated change involving self-efficacy and mastery and highlight the contribution that qualitative research approaches can make.

The effectiveness of a group self-management education course for adults with poorly controlled epilepsy, SMILE (UK): A randomized controlled trial

OBJECTIVE

Epilepsy is one of the most common neurological conditions affecting about 1% of adults. Up to 40% of people with epilepsy (PWE) report recurring seizures while on medication. And optimal functioning requires good self-management. Our objective was to evaluate a group self-management education courses for people with epilepsy and drug-resistant seizures by means of a multicenter, pragmatic, parallel group, randomized controlled trial.

METHODS

We recruited adults with epilepsy, having ≥2 seizures in the prior 12 months, from specialist clinics. Consenting participants were randomized 1:1 to a group course or treatment as usual. The primary outcome measure was quality of life 12 months after randomization using Quality of Life 31-P (QOLIE-31-P). Secondary outcome measures were seizure frequency and recency, psychological distress, impact and stigma of epilepsy, self-mastery, medication adherence, and adverse effects. Analysis of outcomes followed the intention-to-treat principle using mixed-effects regression models.

RESULTS

We enrolled 404 participants (intervention: n = 205, control: n = 199) with 331 (82%) completing 12-month follow-up (intervention: n = 163, control: n = 168). Mean age was 41.7 years, ranging from 16 to 85, 54% were female and 75% were white. From the intervention arm, 73.7% attended all or some of the course. At 12-month follow-up, there were no statistically significant differences between trial arms in QOLIE-31-P (intervention mean: 67.4, standard deviation [SD]: 13.5; control mean: 69.5, SD 14.8) or in secondary outcome measures.

SIGNIFICANCE

This is the first pragmatic trial of group education for people with poorly controlled epilepsy. Recruitment, course attendance, and follow-up rates were higher than expected. The results show that the primary outcome and quality of life did not differ between the trial arms after 12 months. We found a high prevalence of felt-stigma and psychological distress in this group of people with drug-resistant seizures. To address this, social and psychological interventions require evaluation, and may be necessary before or alongside self-management-education courses.

Implementation fidelity of a self-management course for epilepsy: method and assessment

BACKGROUND

Complex interventions such as self-management courses are difficult to evaluate due to the many interacting components. The way complex interventions are delivered can influence the effect they have for patients, and can impact the interpretation of outcomes of clinical trials. Implementation fidelity evaluates whether complex interventions are delivered according to protocol. Such assessments have been used for one-to-one psychological interventions; however, the science is still developing for group interventions.

METHODS

We developed and tested an instrument to measure implementation fidelity of a two-day self-management course for people with epilepsy, SMILE(UK). Using audio recordings, we looked at adherence and competence of course facilitators. Adherence was assessed by checklists. Competence was measured by scoring group interaction, an overall impression score and facilitator "didacticism". To measure "didacticism", we developed a novel way to calculate facilitator speech using computer software. Using this new instrument, implementation fidelity of SMILE(UK) was assessed on three modules of the course, for 28% of all courses delivered.

RESULTS

Using the instrument for adherence, scores from two independent raters showed substantial agreement with weighted Kappa of 0.67 and high percent agreement of 81.2%. For didacticism, the results from both raters were highly correlated with an intraclass coefficient of 0.97 (p < 0.0001). We found that the courses were delivered with a good level of adherence (> 50% of scored items received the maximum of 2 points) and high competence. Groups were interactive (mean score: 1.9-2.0 out of 2) and the overall impression was on average assessed as "good". Didacticism varied from 42% to 93% of total module time and was not associated with the other competence scores.

CONCLUSION

The instrument devised to measure implementation fidelity was reproducible and easy to use. The courses for the SMILE(UK) study were delivered with a good level of adherence to protocol while not compromising facilitator competence.

TRIAL REGISTRATION

ISRCTN57937389 .