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Mioramalala S, Mroueh L, Bruand PE, Raharinivo MM, Rafanomezantsoa RM, Gérard D, Ratsimbasoa A, Preux PM, Boumédiène F. Effects of an intervention program to improve mental health and epilepsy care in Madagascar. Compr Psychiatry 2024; 132:152484. [PMID: 38626596 DOI: 10.1016/j.comppsych.2024.152484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Despite the high prevalence of mental disorders and epilepsy in low- and middle-income countries, nearly 80% of patients are not treated. In Madagascar, initiatives to improve access to epilepsy and mental health care, including public awareness and training of general practitioners (GPs), were carried out between 2013 and 2018. Our study's main objective was to assess the effectiveness of these initiatives, two to five years post-intervention. METHODS This quasi-experimental study (intervention vs. control areas) included five surveys assessing: general population's Knowledge Attitudes and Practices (KAP), GPs' KAP , number of epilepsy and mental health consultations at different levels of the healthcare system, diagnostic accuracy, and treatments' availability. OUTCOMES In the general population, KAP scores were higher in intervention areas for epilepsy (11.4/20 vs. 10.3/20; p = 0.003). For mental disorders, regardless of the area, KAP scores were low, especially for schizophrenia (1.1/20 and 0.1/20). Among GPs, KAP scores were higher in intervention areas for schizophrenia (6.0/10 vs. 4.5/10; p = 0.008) and epilepsy (6.9/10 vs. 6.2/10; p = 0.044). Overall, there was a greater proportion of mental health and epilepsy consultations in intervention areas (4.5% vs 2.3%). Although low, concordance between GPs' and psychiatrists' diagnoses was higher in intervention areas. There was a greater variety of anti-epileptic and psychotropic medications available in intervention areas. INTERPRETATION This research has helped to better understand the effectiveness of initiatives implemented in Madagascar to improve epilepsy and mental health care and to identify barriers which will need to be addressed. FUNDING Sanofi Global Health, as part of the Fight Against STigma Program.
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Affiliation(s)
- Sedera Mioramalala
- Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France; Université de Fianarantsoa, Faculté des Sciences, ED GEOCHIMED, Chimie Médicinale, Fianarantsoa, Madagascar
| | - Lara Mroueh
- Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France
| | - Pierre-Emile Bruand
- Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France
| | | | | | - Daniel Gérard
- Ville Evrard Public Hospital, Department 93G10, Neuilly sur Marne, France
| | - Arsène Ratsimbasoa
- Université de Fianarantsoa, Faculté de Médecine, Fianarantsoa, Madagascar
| | - Pierre-Marie Preux
- Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France
| | - Farid Boumédiène
- Inserm U1094, IRD UMR270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth, Limoges, France.
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Hailemariam FH, Shifa M, Kassaw C. Availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia. Epilepsia Open 2023; 8:1123-1132. [PMID: 37469205 PMCID: PMC10472410 DOI: 10.1002/epi4.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Up to 70% of people living with epilepsy could become seizure-free with the appropriate use of antiseizure medicines. However, three quarters of people with epilepsy living in low-income countries do not get the treatment they need and also do not access antiseizure medicines. The purpose of this study was to assess the availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia. METHODS A cross-sectional study was done in selected pharmacies using a questioner developed after the modification of World Health Organization/Health Action International methodology. Data on the availability and price of lowest-priced generics and originator brand antiseizure medicines from essential medicines list in Ethiopia were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community and two Red Cross Pharmacies) in Addis Ababa between 09 May and 31 2022. The data were analyzed using the modified World Health Organization/Health Action International workbook part I excel sheet. Descriptive results were reported in text and table format. RESULTS The overall availability of lowest-priced generics medication was 52%. The availability of lowest-priced generics was 62.86%, 30%, 55%, and 50% in public, private, Red Cross, and Kenema Public Community Pharmacies, respectively. The median price ratio in the public, private, Red Cross, and Kenema Public Community Pharmacy was 1.45, 3.72, 1.46, and 1.7, respectively. All the medications were unaffordable. Patients may be required to pay more than 6-month wage to purchase standard treatment for 1 month only. SIGNIFICANCE The overall availability of antiseizure medicines was lower than the WHO target for noncommunicable diseases. All the available medicines were unaffordable.
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Affiliation(s)
- Fikreselam Habte Hailemariam
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health ScienceAddis Ababa UniversityAddis AbabaEthiopia
| | - Mekdes Shifa
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health ScienceAddis Ababa UniversityAddis AbabaEthiopia
| | - Chalelgn Kassaw
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health ScienceAddis Ababa UniversityAddis AbabaEthiopia
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Ooms GI, van Oirschot J, de Kant D, van den Ham HA, Mantel-Teeuwisse AK, Reed T. Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104078. [PMID: 37276779 DOI: 10.1016/j.drugpo.2023.104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/14/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA. METHODS A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework. RESULTS The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices. CONCLUSION This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.
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Affiliation(s)
- Gaby I Ooms
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands; Health Action International, Amsterdam, the Netherlands.
| | | | | | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, the Netherlands
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Ralta A, Prakash A, Kumar_M P, Kumar R, Sarma P, Bhatia A, Medhi B, Chakrabarti A. Neuroprotective Effect of Celastrus Paniculatus Seed Extract on Epilepsy and Epilepsy-associated Cognitive Deficits. Basic Clin Neurosci 2023; 14:155-166. [PMID: 37346867 PMCID: PMC10279989 DOI: 10.32598/bcn.2021.3154.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 07/09/2021] [Accepted: 08/16/2021] [Indexed: 11/02/2023] Open
Abstract
Introduction Cognitive deficit is one of the common comorbidity accompanying epilepsy. The present study evaluated the effect of Celastrus paniculatus seed extract on seizure severity and cognitive deficit following the pentylenetetrazole (PTZ)-induced chemical kindling model. Methods PTZ kindling model was developed by daily administration of the sub-convulsive dose of PTZ 30 mg/kg for four weeks. After four weeks of induction, the following treatment, namely sodium valproic acid (SVA) 200 mg/kg, C. paniculatus 500 mg\kg, pergolide 2 mg/kg, C. paniculatus (250 mg\kg)+ Pergolide (1 mg/kg), and C. paniculatus (250 mg\kg)+ SVA (100 mg/kg) were administered 30 minutes prior to PTZ (30 mg/kg) injection for a period of next 14 days. Neurobehavioral parameters, including superoxide dismutase (SOD), Catalase (CAT), glutathione (GSH), and dopamine levels were assessed and the Morris water maze test (MWM) and Grip strength test (GPS) were performed. Hematoxylin & Eosin (H&E) staining of hippocampal cornu ammonis (CA1), CA2, CA3, dentate gyrus (DG), and frontal cortex was performed. Results C. paniculatus (500 mg/kg) alone and in combination (C. paniculatus (250 mg\ kg)+ pergolide (1 mg/kg) and C. paniculatus (250 mg\kg)+ SVA (100 mg/kg)) significantly (P<0.05) reduced the seizure score, mean latency time, and distance traveled in the MWM. However, no significant effect was seen in GPS. Biochemical analysis showed elevated antioxidant markers, namely GSH, CAT, and SOD, and also elevated dopamine levels. C. paniculatus and its combination also significantly (P<0.05) protected against neuronal loss in the hippocampus and frontal cortex evidenced by H&E staining. Conclusion C. paniculatus alone and in combination with other agents may have the potential to treat epilepsy and associated cognitive deficits.
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Affiliation(s)
- Arti Ralta
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ajay Prakash
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Praveen Kumar_M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rohit Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Phulen Sarma
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Alka Bhatia
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amitava Chakrabarti
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Ashigbie PG, Rockers PC, Laing RO, Cabral HJ, Onyango MA, Mboya J, Arends D, Wirtz VJ. Phone-based monitoring to evaluate health policy and program implementation in Kenya. Health Policy Plan 2021; 36:444-453. [PMID: 33724372 PMCID: PMC8128015 DOI: 10.1093/heapol/czab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/01/2022] Open
Abstract
Monitoring and evaluating policies and programs in low- and middle-income countries are often difficult because of the lack of routine data. High mobile phone ownership in these countries presents an opportunity for efficient data collection through telephone interviews. This study examined the feasibility of collecting data on medicines through telephone interviews in Kenya. Data on the availability and prices of medicines at 137 health facilities and 639 patients were collected in September 2016 via in-person interviews. Between December 2016 and December 2017, monthly telephone interviews were conducted with health facilities and patients. An unannounced in-person interview was conducted with respondents to validate the telephone interview within 24 h. A bottom-up itemization costing approach was used to estimate the costs of telephone and in-person data collection. In-depth interviews were conducted with data collectors and respondents to explore their perceptions on both modes of data collection. The level of agreement between data on medicines availability collected through phone and in-person interviews was strong at the health facility level [kappa = 0.90; confidence interval (CI) 0.88–0.92] and moderate at the household level (kappa = 0.50, CI 0.39–0.60). Price data from telephone and in-person interviews showed strong intra-class correlation at health facilities [intra-class correlation coefficient (ICC) = 0.96] and moderate intra-class correlation at households (ICC = 0.47). The cost per phone interview at health facilities and households were $19.73 and $16.86, respectively, compared to $186.20 for a baseline in-person interview. Participants considered telephone interviews to be more convenient. In countries with high cell phone penetration, telephone data collection should be considered in monitoring and evaluating public health programs especially at health facilities. Additional strategies may be needed to optimize this mode of data collection at the household level. Variations in cell phone ownership, telecommunication network and data collection costs across different settings may limit the generalizability of the findings from this study.
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Affiliation(s)
- Paul G Ashigbie
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Peter C Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Richard O Laing
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA.,Faculty of Community Health Sciences, School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Cape Town, Republic of South Africa
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Monica A Onyango
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - John Mboya
- Innovations for Poverty Action, Sandalwood Lane, Westlands, Nairobi, Kenya
| | - Daniella Arends
- Faculty of Sciences, Department of Pharmaceutical Sciences and School of Pharmacy, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
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Sengxeu N, Aon C, Dufat H, Boumediene F, Chan S, Ros S, Preux PM, Ratsimbazafy V, Jost J. Availability, affordability, and quality of essential anti-seizure medication in Cambodia. Epilepsia Open 2021; 6:548-558. [PMID: 34101380 PMCID: PMC8408618 DOI: 10.1002/epi4.12514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/22/2023] Open
Abstract
Objective Epilepsy is a major neurological disorder that requires long‐term medical treatment. Once epilepsy is diagnosed, people with epilepsy face many difficulties in accessing treatment (treatment gap). Our objective was to assess the situation regarding the availability, price, affordability, and quality of anti‐seizure medication (ASM), which are major determinants of access to treatment. Method A cross‐sectional study was performed in provincial/district hospitals and private pharmacies in urban and rural areas in Cambodia. Data on ASM availability and price were obtained through drug suppliers. Affordability was estimated as the number of day wages the lowest‐paid government employee must work to purchase a monthly treatment. Samples of ASM were collected, and the quality of ASM was assessed through Medicine Quality Assessment Reporting Guidelines. Results Out of 138 outlets visited, only 72 outlets (52.2% [95% CI 43.5‐60.7]) had at least one ASM available. Phenobarbital 100 mg was the most available (35.5%), followed by carbamazepine 200 mg (21.7%), phenobarbital 50 mg (11.6%), sodium valproate 500 mg (9.4%), and phenytoin 100 mg (9.4%). In provincial/district hospitals, ASM was provided free of charge. In private pharmacies, affordability for phenobarbital 50 mg and 100 mg was the best, with 0.6 and 0.5 days, respectively, compared to phenytoin 100 mg (1.8 days), and other ASM. No counterfeit ASM was found in this study. Phenytoin sample presented the worst quality (33.0%) compared to carbamazepine (27.8%), and other ASM. Significance A lack of access to affordable and effective ASM due to low availability and poor quality of ASM was identified. Our research highlights the need for future policy efforts to ensure the quality of ASM and improve their availability. This can be achieved by involving the calculation of their annual needs for these drugs and increasing the national production of ASM.
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Affiliation(s)
- Noudy Sengxeu
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Faculty of Pharmacy, University of Health Sciences, Vientiane, Lao PDR
| | - Chanraksmey Aon
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Hanh Dufat
- Natural Products, Analysis and Synthesis, CiTCoM (Cibles Thérapeutiques et Conception de Médicaments)-UMR 8038 CNRS/Université de Paris, Faculty of Health-Pharmacie, Université de Paris, Paris, France
| | - Farid Boumediene
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Samleng Chan
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Sina Ros
- Cambodian Society of Neurology, Calmette Hospital, Phnom Penh, Cambodia
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Voa Ratsimbazafy
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Department of Pharmacy, CHU Limoges, Limoges, France
| | - Jeremy Jost
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.,Department of Pharmacy, CHU Limoges, Limoges, France
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Anand P, Othon GC, Sakadi F, Tassiou NR, Hamani ABD, Bah AK, Allaramadji BT, Barry DN, Vogel A, Cisse FA, Mateen FJ. Epilepsy and traditional healers in the Republic of Guinea: A mixed methods study. Epilepsy Behav 2019; 92:276-282. [PMID: 30731293 PMCID: PMC6433505 DOI: 10.1016/j.yebeh.2019.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/11/2019] [Accepted: 01/11/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to characterize the reasons, extent, and impact of traditional medicine use among people with epilepsy (PWE) in the Republic of Guinea. METHODS Guinea is a low-income country in sub-Saharan Africa (SSA) with limited healthcare resources. People with epilepsy and their caregivers were seen at a public referral hospital in Conakry, the capital city, where they completed semi-structured interviews with physicians regarding their beliefs about epilepsy, medical care, and engagement with traditional healers. RESULTS Of 132 participants (49% children, 44% female, 55% with a university-educated head of household), 79% had seen a traditional healer, and 71% saw a traditional healer before seeing a medical provider for their epilepsy. Participants were treated by a traditional healer for a mean of 39 months before seeing a medical provider. By contrast, 58% of participants reported taking antiepileptic drugs (AEDs) regularly; 46% reported having undergone a head computed tomography (CT) scan; 58% reported having had an electroencephalogram, and 4% reported having had a brain magnetic resonance imaging (MRI) scan. CONCLUSIONS Traditional healers in Guinea provide frontline care for PWE in Guinea with considerable delays in AED initiation, even among a cohort of PWE actively seeking medical care. Engaging with these healers is critical for both influencing community perceptions and appropriately managing epilepsy throughout the country.
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Affiliation(s)
- Pria Anand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Foksouna Sakadi
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea,Department of Clinical Neurophysiology, Ibn Sina Hospital Center, Rabat, Morocco
| | | | | | - Aissatou Kenda Bah
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | | | - Djenabou Negue Barry
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Andre Vogel
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Fodé Abass Cisse
- Department of Neurology, Ignace Deen Teaching Hospital, Conakry, Republic of Guinea
| | - Farrah Jasmine Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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