Packages of care for epilepsy in low- and middle-income countries

Diagnostic pattern of mental, neurological and substance use disorders at primary health care facilities in Uganda

Integration of diagnosis and treatment for mental, neurological, and substance use (MNS) disorders into primary health care is a recommended strategy to improve access to services in low-and middle-income countries. Despite numerous initiatives for integration of mental health care in Uganda, there has not been an evaluation of health management information system (HMIS) records to determine whether MNS disorders are routinely diagnosed. We sought to determine diagnostic pattern of MNS disorders at primary health facilities in Wakiso and Kampala districts, the most populous regions of Uganda. Lower-level primary health facilities were visited to obtain records from HMIS registers, to document diagnoses of MNS disorders. Secondary data analysis was conducted and descriptive statistics reported. A total of 40 primary health care facilities were visited representing 58.6% of the health facilities in the study districts. More than half (54.8%) and almost all (87.5%) of the lower-level health facilities in Wakiso district and Kampala district respectively were visited. The proportion of MNS disorders diagnosed at lower-level primary health facilities in Uganda is very low with Epilepsy the most common MNS diagnosis recorded. Reasons for such low numbers of diagnoses at primary health facilities are discussed as are possible solutions.

Effects of an intervention program to improve mental health and epilepsy care in Madagascar

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.

Community-level prevalence of epilepsy and of neurocysticercosis among people with epilepsy in the Balaka district of Malawi: A cross-sectional study

Background

Epilepsy and neurocysticercosis (NCC) prevalence estimates in sub-Saharan Africa are still scarce but show important variation due to the population studied and different screening and diagnosis strategies used. The aims of this study were to estimate the prevalence of epileptic seizures and epilepsy in the sampled population, and the proportion of NCC among people with epilepsy (PWE) in a large cross-sectional study in a rural district of southern Malawi.

Methods

We conducted a community-based door-to-door screening study for epileptic seizures in Balaka, Malawi between October and December 2012. Past epileptic seizures were reported through a 15-item questionnaire answered by at least one person per household generating five major criteria. People who screened positive were further examined by a neurologist to establish diagnosis. Patients diagnosed with epilepsy were examined and offered Taenia solium cyst antigen and antibody serological tests, and a CT scan for the diagnosis of NCC.

Results

In total, screening information on 69,595 individuals was obtained for lifetime occurrence of epileptic seizures. 3,100 (4.5%) participants screened positive, of whom 1,913 (62%) could be followed-up and underwent further assessment. Lifetime prevalence was 3.0% (95% Bayesian credible interval [CI] 2.8 to 3.1%) and 1.2% (95%BCI 0.9 to 1.6%) for epileptic seizures and epilepsy, respectively. NCC prevalence among PWE was estimated to be 4.4% (95%BCI 0.8 to 8.5%). A diagnosis of epilepsy was ultimately reached for 455 participants.

Conclusion

The results of this large community-based study contribute to the evaluation and understanding of the burden of epilepsy in the population and of NCC among PWE in sub-Saharan Africa.

Magnetic resonance imaging and intractable epilepsy: A systematic review

OBJECTIVE

Epilepsy is a chronic neurological disorder that occurs due to irregular neuronal activity in the central nervous system. The main job of a radiologist is to investigate the structural etiology in epilepsy patients. This study was undertaken to find out the importance of magnetic resonance imaging (MRI) in the screening of intractable epilepsy through a systematic search of literature.

METHODS

A systematic review was performed using the PRISMA guidelines. Peer-reviewed studies on MRI and intractable epilepsy were retrieved from MEDLINE, ScienceDirect and Google Scholar. Moreover, studies cited in the key articles were also screened to increase the sensitivity and specificity of the systematic search.

RESULTS

The database search till March 2022 found a total of 112610 articles. Out of them, only 10 highly selected articles were included in the study. The pooled data point out that the rapid development in MRI techniques and the functional MRI (fMRI) has now become more and more critical in the diagnosis and management of patients with epilepsy. In addition, the data also pointed out that MRI-based approaches are also very useful for post-operative epilepsy patients as it gives information about the quality of the surgery. The data collected showed that the MRI is the choice technique for the evaluation of patients with epilepsy.

CONCLUSIONS

The applicability of MRI in epilepsy diagnosis is highly accessible in all over the globe. The pooled data concluded that the MRI-based surgical approaches are extremely useful for the surgeons to provide three-dimensional imaging with superimposed real-time pointer details that have proved successful for epilepsy patients.

Knowledge, attitudes, and practices of caregivers of children with epilepsy in Sudan

OBJECTIVE

To explore the knowledge, attitudes, and practices of caregivers of children with epilepsy.

METHODS

This cross-sectional study included 107 consecutive caregivers of children diagnosed with epilepsy, attending the neurology outpatient clinic in a Pediatric tertiary university hospital, in Khartoum, Sudan for regular check-up. Data were obtained by an interviewer through a structured questionnaire, while clinical parameters of children with epilepsy were taken from medical records.

RESULTS

Most respondents knew that epilepsy is not an infectious disease (92.5%), while the least proportion of caregivers (41.1%) knew that epilepsy did not emanate from a supernatural origin. The majority of caregivers were with the idea that epilepsy caused lost opportunities for study (66.4%) and that epilepsy was looked upon negatively by others (64.5%). Less than half (39.7%) of these caregivers rolled their child on to the side during a seizure, and more than a third (37.2%) admitted to sprinkling water over the child during his/her seizure. Caregivers' of children with Generalized Tonic-Clonic (GTC) convulsions, reported significantly lower knowledge scores than caregivers whose children did not experience GTC seizures (p = 0.016). Caregivers of children with GTC seizures were more likely to believe epilepsy was for the most part hereditary (p = 0.006), and that children with epilepsy lost consciousness during a seizure (p < 0.001).

CONCLUSION

Our findings suggest that caregivers require periodic epilepsy-related educational programs. This study is an invaluable tool for tailoring the delivery of information and support resources for caregivers in our region.

Long-Term Outcomes in Children Surviving Tropical Arboviral Encephalitis: A Systematic Review

BACKGROUND

Survivors of childhood encephalitis often suffer from physical and neurocognitive sequelae, particularly in tropical, resource-limited areas with a large burden of arboviral, neurotropic pathogens and limited resources with which to address chronic morbidities. Research into overall and pathogen-specific outcomes following childhood encephalitis may help identify risk factors for poor outcomes, quantify the burden of sequelae, assist with resource allocation and help focus rehabilitative efforts. However, such research is limited. To this end, we systematically reviewed the literature on this topic to identify gaps in knowledge worthy of future investigation.

METHODS

A search of PubMed, Web of Knowledge and the Cochrane databases was performed 10 January through 20 February 2020, using 17 search terms for sequelae and 14 for tropical, arboviral pathogens. Eligible reports demonstrated post-discharge follow-up of ≥3 months and assessment of clinical outcome in a child with an arboviral encephalitis ≤18 years of age at diagnosis.

RESULTS

Of 1513 articles, 35 were eligible, comprising 693 children. Japanese encephalitis accounted for 18 articles and 93.2% of all subjects (646 total). Sequelae were documented in ∼60% of subjects overall and in those with Japanese encephalitis. For non-Japanese encephalitis virus encephalitides (47 children), sequelae were found in 78.1%. No studies utilized comprehensive neurocognitive testing or assessed the efficacy of rehabilitative efforts. Only nine studies reported data from ≥1 follow-up visit.

CONCLUSION

Investigation into long-term outcomes following tropical childhood encephalitis is limited, particularly for neurocognitive sequelae, serial assessments over time and the effect of rehabilitative measures.

LAY SUMMARY

Encephalitis, an infection of the brain, is frequently caused by arboviruses (viruses spread via the bite of infected arthropods, such as mosquitoes) in tropical locales. Following infection, surviving children may be plagued with severe physical and cognitive deficits. Unfortunately, research into the type of deficits, their frequency and their responsiveness to rehabilitative efforts is lacking. We identified and reviewed 35 studies describing outcomes in children recovering from tropical, arboviral encephalitis at least 3 months following hospital discharge. Poor outcomes were common and found in up to 60% of children. Long-term and serial follow-up visits were rare, as was the use of comprehensive neurocognitive testing. No studies assessed the efficacy of rehabilitative measures. Further study into these areas is recommended.

Pluralistic and singular causal attributions for epilepsy in Uganda

OBJECTIVE

In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions.

METHODS

In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then utilized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann-Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups.

RESULTS

Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a potential cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the patterns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a biological etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p < 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p < 0.01), and there were significant differences in income across specific groups (p < 0.01).

CONCLUSIONS

Pluralistic attributions for epilepsy are common in Uganda, with the majority of community members drawing from biomedical and traditional concepts to construct complex explanations for seizures that transcend discrete belief categories traditionally depicted in the literature. These findings emphasize the need to understand cultural beliefs about epilepsy in order to design contextually specific interventions and education programs, which respect the fundamental beliefs and values of the community. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Burden of non-communicable diseases from infectious causes in 2017: a modelling study

BACKGROUND

Non-communicable diseases (NCDs) cause a large burden of disease globally. Some infectious diseases cause an increased risk of developing specific NCDs. Although the NCD burden from some infectious causes has been quantified, in this study, we aimed to more comprehensively quantify the global burden of NCDs from infectious causes.

METHODS

In this modelling study, we identified NCDs with established infectious risk factors and infectious diseases with long-term non-communicable sequelae, and did narrative reviews between April 11, 2018, and June 10, 2020, to obtain relative risks (RRs) or population attributable fractions (PAFs) from studies quantifying the contribution of infectious causes to NCDs. To determine infection-attributable burden for the year 2017, we applied estimates of PAFs to estimates of disease burden from the Global Burden of Disease Study (GBD) 2017 for pairs of infectious causes and NCDs, or used estimates of attributable burden directly from GBD 2017. Morbidity and mortality burden from these conditions was summarised with age-standardised rates of disability-adjusted life-years (DALYs), for geographical regions as defined by the GBD. Estimates of NCD burden attributable to infectious causes were compared with attributable burden for the groups of risk factors with the highest PAFs from GBD 2017.

FINDINGS

Globally, we quantified 130 million DALYs from NCDs attributable to infection, comprising 8·4% of all NCD DALYs. The infection-NCD pairs with the largest burden were gastric cancer due to H pylori (14·6 million DALYs), cirrhosis and other chronic liver diseases due to hepatitis B virus (12·2 million) and hepatitis C virus (10·4 million), liver cancer due to hepatitis B virus (9·4 million), rheumatic heart disease due to streptococcal infection (9·4 million), and cervical cancer due to HPV (8·0 million). Age-standardised rates of infection-attributable NCD burden were highest in Oceania (3564 DALYs per 100 000 of the population) and central sub-Saharan Africa (2988 DALYs per 100 000) followed by the other sub-Saharan African regions, and lowest in Australia and New Zealand (803 DALYs per 100 000) followed by other high-income regions. In sub-Saharan Africa, the proportion of crude NCD burden attributable to infectious causes was 11·7%, which was higher than the proportion of burden attributable to each of several common risk factors of NCDs (tobacco, alcohol use, high systolic blood pressure, dietary risks, high fasting plasma glucose, air pollution, and high LDL cholesterol). In other broad regions, infectious causes ranked between fifth and eighth in terms of crude attributable proportions among the nine risks compared. The age-standardised attributable proportion for infectious risks remained highest in sub-Saharan Africa of the broad regions, but age-standardisation caused infectious risks to fall below dietary risks, high systolic blood pressure, and fasting plasma glucose in ranked attributable proportions within the region.

INTERPRETATION

Infectious conditions cause substantial NCD burden with clear regional variation, and estimates of this burden are likely to increase as evidence that can be used for quantification expands. To comprehensively avert NCD burden, particularly in low-income and middle-income countries, the availability, coverage, and quality of cost-effective interventions for key infectious conditions need to be strengthened. Efforts to promote universal health coverage must address infectious risks leading to NCDs, particularly in populations with high rates of these infectious conditions, to reduce existing regional disparities in rates of NCD burden.

FUNDING

Leona M and Harry B Helmsley Charitable Trust.

Analysis of the aetiology of epilepsy in 3,216 adult patients attending a tertiary referral center enabled by an electronic patient record

•

Large scale studies examining the aetiologies of the epilepsies in existence worldwide are few.

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Assigning causation in epilepsy is a dynamic and evolving diagnostic process owing to continuous advances in science and technology.

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Electronic patient records offer immense clinical and research opportunities to clinicians.

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The data acquisition process used in this study utilised a bespoke extant dynamic clinically utilised electronic heath record.

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This is the first robust large analysis of aetiology following the publication of updated ILAE 2017 classification system.

Purpose

The aim of this study was to review the causes of the epilepsies in our institution, an adult tertiary referral center for neurology and neurosurgery in Dublin, Ireland. Data was obtained from a bespoke epilepsy electronic patient record (EPR).

Methods

Predetermined search parameters of well-established broad categories of epilepsy aetiology were used to identify patients with a diagnosis of epilepsy attending Beaumont Hospital, Dublin. There were 3216 patients that met the inclusion criteria for this study. We included living patients with epilepsy attending our institution. We then excluded patients with a diagnosis of pure non-epileptic attack disorder and patients found to have idiopathic generalised epilepsy (IGE) (n = 382) from our final cohort. We excluded IGE due to the complex polygenic basis underlying this patient group.

Results

An aetiology was identified in 54.3 % (n = 1747) of the total number of patients studied. Of the symptomatic epilepsies, 41.08 % (n = 1321) were acquired and 13.3 % (n = 426) were predominantly of genetic or developmental aetiology. The most common causes of the acquired epilepsies were hippocampal sclerosis (n = 380; 28.75 %), cerebral tumor (n = 279; 21.06 %), traumatic brain injury (n = 248; 18.77 %), stroke and cerebrovascular disease (n = 151; 11.43 %) and perinatal causes (n = 138; 10.45 %). The leading causes in the genetic / developmental category included cavernous haemangiomas (n = 62, 22.22 %), arteriovenous malformations (n = 59; 21.15 %) and cortical dysplasia (n = 55; 19.71 %). The aetiology of a patient’s epilepsy was undetermined in 45.68 % (n = 1469) of individuals.

Conclusion

This study emphasizes the clinical utility of the ILAE’s 2017 revised classification of the epilepsies and highlights the evolving dynamic nature of attributing causality in epilepsy. This is the largest single centre analysis of the aetiology of the epilepsies described in the literature. It is also the first large scale study examining aetiology utilising a bespoke electronic patient record in epilepsy.

Comic book-based educational program on epilepsy for high-school students: Results from a pilot study in the Gran Chaco region, Bolivia

INTRODUCTION

In low- and middle-income countries (LMIC), epilepsy still represents a significant health challenge. In the Bolivian Chaco, we have previously found high levels of stigma towards people with epilepsy (PWE) especially expressed by high school students. In order to increase the knowledge about epilepsy, we have tested a comic book-based intervention on a sample of high school students.

METHODS

The study has been conducted in the Bolivian Chaco region where two urban and two rural classrooms have been randomly selected. Students have been administered a knowledge, attitudes, and practices (KAP) questionnaire, and then they underwent a comic book-based educational program where they were randomly assigned either to an autonomous reading or a character interpretation methodology. The same KAP questionnaire has been administered after the teaching session and at a three months follow-up. Mean KAP scores at the baseline were compared with the after teaching and the three-month assessment.

RESULTS

Eighty-three students with a mean age of 15.5 ± 0.9 years, of whom 38 (45.8%) males, were recruited. After the comic book session, students improved in the global score (p < 0.001) and in the knowledge (p < 0.001), attitudes (p = 0.004), and practices (p < 0.001) subscores. Both the autonomous reading and the character interpretation groups significantly improved in the global score, but only the latter improved in all the subscores. At the three months follow-up, there were no differences in the global, knowledge, and attitudes subscores, compared with scores immediately after the intervention.

CONCLUSION

Using a comic book to teach about epilepsy led to a significant improvement in the knowledge, attitudes, and practices about the disease in high school students of LMIC. This teaching strategy can be easily implemented in LMIC.

Knowledge, attitude, and practice towards epilepsy among religious cleric and traditional healers of Addis Ababa, Ethiopia

PURPOSE

Understanding clerics and healers' knowledge, attitude, and practice towards epilepsy are crucial to identify the mechanisms of epilepsy stigma in Ethiopia. The objective of this study is to characterize the social and demographic determinants of knowledge, attitude, and practices of clerics and healers towards people with epilepsy in Addis Ababa, Ethiopia.

METHODS

A total of 440 clerics and healers were interviewed by trained data collectors using a pretested structured questionnaire. The count sum of outcome variables was grouped into "biological and cultural" knowledge attitude and practice scores. Ordinal regression analysis was performed for each outcome variable against socio-demographic variables of interest.

RESULTS

The percentage of responses matching cultural causes (58%) surpassed biological causes. The most frequently mentioned cultural cause was an evil spirit (22.5%). While the most frequently mentioned biological cause was a head injury (12%). Consistent with the above findings, cultural treatment responses (77%) exceeded biological treatment responses. The most commonly referred cultural treatment response was Church healing session (12%). The type of faith followed by the study participants positively correlated with higher cultural knowledge, attitude, and practice score.

CONCLUSIONS

Clerics and traditional healers in Ethiopia have a partiality to the cultural epilepsy explanation model. Cultural metaphors attached to an evil spirit, curse of God, and witchcraft have formed and fostered existing 'epilepsy societal norms' in Ethiopia. The findings of this study contribute to the understanding of epilepsy stigma and treatment gap. Besides, it provided direction to design and implement epilepsy stigma intervention programs in Ethiopia.

Contextualizing and pilot testing the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) to primary healthcare workers in Kilifi, Kenya

BACKGROUND

Little data exists about the methodology of contextualizing version two of the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in resource-poor settings. This paper describes the contextualisation and pilot testing of the guide in Kilifi, Kenya.

METHODS

Contextualisation was conducted as a collaboration between the KEMRI-Wellcome Trust Research Programme (KWTRP) and Kilifi County Government's Department of Health (KCGH) between 2016 and 2018. It adapted a mixed-method design and involved a situational analysis, stakeholder engagement, local adaptation and pilot testing of the adapted guide. Qualitative data were analysed using content analysis to identify key facilitators and barriers to the implementation process. Pre- and post-training scores of the adapted guide were compared using the Wilcoxon signed-rank test.

RESULTS

Human resource for mental health in Kilifi is strained with limited infrastructure and outdated legislation. Barriers to implementation included few specialists for referral, unreliable drug supply, difficulty in translating the guide to Kiswahili language, lack of clarity of the roles of KWTRP and KCGH in the implementation process and the unwillingness of the biomedical practitioners to collaborate with traditional health practitioners to enhance referrals to hospital. In the adaptation process, stakeholders recommended the exclusion of child and adolescent mental and behavioural problems, as well as dementia modules from the final version of the guide. Pilot testing of the adapted guide showed a significant improvement in the post-training scores: 66.3% (95% CI 62.4-70.8) v. 76.6% (95% CI 71.6-79.2) (p < 0.001).

CONCLUSION

The adapted mhGAP-IG version two can be used across coastal Kenya to train primary healthcare providers. However, successful implementation in Kilifi will require a review of new evidence on the burden of disease, improvements in the mental health system and sustained dialogue among stakeholders.

Community's Perception and Attitude towards People with Epilepsy in Ethiopia

Introduction

Most people with epilepsy suffer from a dual burden. In one hand, they struggle with the symptoms and disabilities on the other hand from misconceptions and stigma associated with it. But there are no recent studies which assess the community's perception and attitude.

Objective

To assess the perception and attitude of the community towards people with epilepsy and identify associated factors.

Methods

A community-based cross-sectional study was conducted in South Ethiopia from a total of 701 participants. Data were collected with face to face interview using a structured questionnaire developed based on the Health Belief Model (HBM). Data were presented with frequencies, tables, and figures. Univariate and multivariable logistic regression was done to identify significantly important variables. The presence of association was presented by odds ratio and 95% confidence interval. Ethical clearance was obtained from Wolaita Sodo University.

Results

The most frequently mentioned perceived causes for epilepsy were stress (91%), substance use (61.8%), and bad spirit (49.8%) while loss of consciousness and falling (80.7%) and sleep problems (78%) were considered symptoms of epilepsy. Only 13.1% of the participants think that they may be susceptible for epilepsy. Six hundred sixty (94.2%) participants will not employ a person with epilepsy while only 47 (6.7%) of the participants will allow a family member to marry a person with epilepsy. In multivariable analysis, understanding the illness as a medical problem was associated with perceived susceptibility and perceived benefit of modern treatment was significantly associated with having a current medical problem.

Conclusions

The knowledge about the cause, possible susceptibility, better treatment options, and attitude of the participants were similar to other low-income settings. The negative attitude was high and multidimensional. All stakeholders must work to increase awareness about the cause, symptoms, and treatment options for epilepsy and to decrease the negative attitude of the community.

Epilepsy in Papua New Guinea: a longitudinal cohort study

Epilepsy affects up to 1-4% of children living in low income and middle countries, however there are few studies of the problems faced by children with epilepsy in such settings. We aimed to document the situation for children with epilepsy in Port Moresby, an urban area in Papua New Guinea, a low-middle income country in the Western Pacific region. We conducted longitudinal cohort study using mixed methods, with serial data collected over 2 years which assessed seizure control, neurodevelopment, and structured interviews with children and parents. For quantitative data descriptive statistics are reported; for qualitative data common responses, themes, experiences and perceptions were grouped and reported in narrative. Forty-seven children with epilepsy were followed for a median of 18 months. Twenty six (55%) children had some associated neurodevelopmental disability. Children gave detailed and vivid descriptions of their experience of seizures. Most children and parents had a positive view of the future but faced many challenges including financial difficulties, fear of having seizures especially at school, restriction of activity that isolated them from peers, and significant stigma and discrimination. Seizure control improved over time for some children, but inconsistent supply of phenobarbitone hindered better control. Comprehensive care for children with epilepsy requires a good knowledge of the individual patient -including their seizure type and comorbidities, their family, and their strengths and vulnerabilities. Children with epilepsy face many problems that can lead to isolation, discrimination and restricted opportunities.

Barriers to epilepsy care in Central Uganda, a qualitative interview and focus group study involving PLWE and their caregivers

Background

Epilepsy is a common neurological disease with substantial impact on the subject and their caretakers. This exploratory study identified barriers to care for persons living with epilepsy (PLWE) to develop a culturally acceptable nurse led self-management intervention for PLWE previously developed in the United States.

Methods

The study involving 48 participants (31 PLWE and 17 caregivers) with in depth interviews and focus groups was conducted. We obtained insights into barriers to care in PLWE and their caregivers. Using a thematic analytic procedure emphasizing the dominant themes the qualitative responses were analyzed. Median age of PLWE was 24 years (IQR 19–30), and10 (52.6%) were male. The median age of epilepsy onset was 12 years (IQR 6–18), range of 1–37 years. The median age of caregivers was 50 years (IQR 45–50.5), with a range of 18–78 years. Seventy five percent of caregivers (6/8) were females.

Results

Three major areas of perceived barriers involving individual, family or community and provider and healthcare system barriers to epilepsy care emerged. Individual factors like limited epilepsy knowledge and medication non-adherence were reported to be key barriers to epilepsy care. Caregiver burden and lack of family support as well as poor health care access were identified from the family and health care systems.

Conclusions

The main barrier to epilepsy care is limited epilepsy knowledge in PLWE and their caregivers. Improving epilepsy care awareness and knowledge within communities and appropriate health care provider service for epilepsy would help reduce epilepsy barriers and improve care.

Knowledge, attitudes, and practices related to epilepsy in rural Burkina Faso

OBJECTIVES

The objective of this study was to assess knowledge, beliefs, attitudes, and practices regarding epilepsy and neurocysticercosis in the rural areas of Burkina Faso.

MATERIALS

The interviews were designed to assess general perception of epilepsy, cultural beliefs and practices regarding epilepsy and people with epilepsy (PWE), and knowledge about the link between human epilepsy and porcine cysticercosis. This qualitative study used in-depth interviews with different categories of community members, including PWE, healthcare providers (HCPs), and traditional healers in three villages in rural Burkina Faso.

RESULTS

All respondents showed a good knowledge of epilepsy symptoms but very little knowledge on causes of the disease. In this community, epilepsy was often associated with witchcraft (commonly termed "black magic"). People with epilepsy were marginalized and denied certain rights such as school education and marriage. They also relied mainly on traditional medicine with a prominent role played by traditional healers. While medical personnel knew that controlling seizures would depend on the cause, the traditional healers reported to be able to cure all kinds of epilepsy as long as the patient adhered to taboos. The main "treatments" prescribed by traditional healers were to stay away from fire and refrain from pork consumption. Pork fat was believed to reduce the effectiveness of the traditional medicine.

CONCLUSION

For effective monitoring and management of epilepsy in Burkina Faso, there is a need to promote better knowledge of the disease in the community, including HCPs, and traditional healers.

Implementation of mhGAP in Mozambique: integrating epilepsy care into the primary health care system

Background

Epilepsy remains the most frequent diagnosis in Psychiatric and Mental Health Services in Mozambique. Because it is a major concern, in 2013 a Program for “Reducing the Epilepsy Treatment gap” was launched in 16 districts of five provinces covering a population of over 1.9 million. Using the WHO Mental Health Gap Program (mhGAP), a pilot Program was developed to provide effective quality care and treatment for people with epilepsy at primary health care level. Implementation was against a background of a shortage of human resources trained to address epilepsy and difficulties in the availability of antiepileptic medicines.

Methods

The first step for implementation was advocacy from the Government level to relevant stakeholders in the community. mhGAP training materials were translated and adapted to the local context. Non-specialists health providers and community health workers were trained and supervised regularly. Population awareness raising and community involvement were key for acceptance of the Program.

Results

After 4 years of implementation, 177 health professionals and 1161 community health workers were trained and ensured services delivery for people living with epilepsy (PwE). The implementation led to 89,869 consultations, representing an increase of 67% since the Program’s inception. From 2015 to 2017 a total of 13,563 new cases were attended and the treatment gap was reduced from 99 to 96%. More than 60% of the new cases are children and adolescents. Awareness actions reached more than 14,000 people per year using all available broadcast means. Preliminary positive results were used as evidence for the Ministry of Health (MoH) to increase the purchase of antiepileptic drugs and improve delivery at district level.

Discussion

mhGAP is an important tool for reducing the treatment gap in low-income countries. Adapting guidelines to the country context and involving community stakeholders are key for Program sustainability. As in other settings, the strategy was cost-effective resulting in an increase in new cases and follow-up consultations.

Conclusions

Implementation of an adapted mhGAP strategy and the involvement of community stakeholders and commitment of the MoH resulted in significant increase in the number of PwE attending outpatient services in primary health care facilities.

Knowledge, stigma, and quality of life in epilepsy: Results before and after a community-based epilepsy awareness program in rural Bolivia

INTRODUCTION

Epilepsy represents around 0.7% of the overall global burden of diseases and is particularly prevalent and associated with significant disability in low- and middle-income countries (LMIC) in Latin American Countries (LAC). A community-based epilepsy awareness program was carried out by our group in the rural areas of the Chaco region, Plurinational state of Bolivia, to improve the knowledge about epilepsy, with a first part directed toward general practitioners and a second part toward nurses and community health workers (CHWs) of the rural communities with a positive outcome. The objective of the study was to assess the level of knowledge, attitudes, and practices toward epilepsy, the stigma related to epilepsy and the quality of life in people with epilepsy (PWE) before and after the interventional campaign directed toward representative members of the rural communities in the Chaco region in Bolivia.

METHODS

The study was conducted in three areas of Bolivia. Key subjects from each community were randomly selected. Before and after the courses they answered a questionnaire to assess their knowledge, attitudes, beliefs, and practices about epilepsy, a validated Stigma Scale of Epilepsy (SSE) and Quality of Life in Epilepsy Inventory-10 (QOLIE-10).

RESULTS

Two hundred sixteen subjects were involved in the program. Only 133 (61.6%) subjects completed the questionnaires a month after the educational program. A significant improvement was recorded in knowledge, attitudes, and practices toward epilepsy, and a significant reduction was found in the mean SSE total score (38.3 ± 14.7 vs. 28.5 ± 12.3; p < 0.01), reflecting a reduction of stigma levels. Regarding the quality of life, after the training, PWE stated to experience less depression, memory difficulties, work or social issues, and seizure worry.

CONCLUSION

Our study confirms that continuous educational campaigns can lead to a significant change in the social perception and attitudes toward epilepsy.

Prevalence and Associated Factors of Mental Distress among Caregivers of Patients with Epilepsy in Ethiopia: A Cross-Sectional Study Design

Background

Caregiving to individuals with mental illness is a broad responsibility, including not only practical help and care but also emotional support. Cross-sectional studies in different localities suggested a significant burden of mental distress among caregivers of patients with epilepsy, but we are not aware about the condition in Ethiopia. Therefore, the aim of the current study is to assess the prevalence and associated factors of mental distress among caregivers of patients with epilepsy in Ethiopia.

Methods

An institutional based cross-sectional study was conducted in Neuropsychiatric Department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Using systematic random sampling technique, 409 caregivers participated in the study. Data was collected by face to face interview using standardized and validated Kessler Psychological Distress Scale (K-10) to assess mental distress. Descriptive, bivariate, and multivariate logistic regression models were used for analysis. Adjusted Odd Ratio (AOR) with 95% Confidence Interval (CI) was used to show the odds, and P-value < 0.05 was considered as statistically significant.

Results

The mean age of respondents was 43.3 years with standard deviation of ±11.4 years. Two hundred eighteen (53.3%) of the respondents were male. The prevalence of mental distress was found to be 27.1% with 95% CI [22.6-31.1]. Relationship with patient of being mother [AOR: 5.67, 95% CI: (1.68-13.70)], father [AOR: 4.42, 95% CI: (1.25-12.58)], wife/husband [AOR: 10.59, 95% CI: (2.43-14.19)], and child [AOR: 5.37, 95% CI: (1.27-12.69)]; caring for young person below 20 years of age [AOR: 4.00, 95% CI: (1.43-11.21)]; poor social support [AOR: 7.26, 95% CI: (3.60-14.65)]); and experienced stigma [AOR: 3.03, 95% CI: (1.63-5.66)] were statistically and significantly associated factors of mental distress among caregivers of patients with epilepsy.

Conclusion and Recommendation

We found a lower prevalence of mental distress among caregivers of patients with epilepsy compared to other low- and middle-income settings. Being caring for young patients, being parents to the patient, poor social support, and stigma were statistically significant associated factors of mental distress among caregivers. Therefore, appropriate psychosocial interventions are warranted to be designed and implemented emphasizing the aforementioned associated factors.

Impact of district mental health care plans on symptom severity and functioning of patients with priority mental health conditions: the Programme for Improving Mental Health Care (PRIME) cohort protocol

BACKGROUND

The Programme for Improving Mental Health Care (PRIME) sought to implement mental health care plans (MHCP) for four priority mental disorders (depression, alcohol use disorder, psychosis and epilepsy) into routine primary care in five low- and middle-income country districts. The impact of the MHCPs on disability was evaluated through establishment of priority disorder treatment cohorts. This paper describes the methodology of these PRIME cohorts.

METHODS

One cohort for each disorder was recruited across some or all five districts: Sodo (Ethiopia), Sehore (India), Chitwan (Nepal), Dr. Kenneth Kaunda (South Africa) and Kamuli (Uganda), comprising 17 treatment cohorts in total (N = 2182). Participants were adults residing in the districts who were eligible to receive mental health treatment according to primary health care staff, trained by PRIME facilitators as per the district MHCP. Patients who screened positive for depression or AUD and who were not given a diagnosis by their clinicians (N = 709) were also recruited into comparison cohorts in Ethiopia, India, Nepal and South Africa. Caregivers of patients with epilepsy or psychosis were also recruited (N = 953), together with or on behalf of the person with a mental disorder, depending on the district. The target sample size was 200 (depression and AUD), or 150 (psychosis and epilepsy) patients initiating treatment in each recruiting district. Data collection activities were conducted by PRIME research teams. Participants completed follow-up assessments after 3 months (AUD and depression) or 6 months (psychosis and epilepsy), and after 12 months. Primary outcomes were impaired functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS), and symptom severity, assessed using the Patient Health Questionnaire (depression), the Alcohol Use Disorder Identification Test (AUD), and number of seizures (epilepsy).

DISCUSSION

Cohort recruitment was a function of the clinical detection rate by primary health care staff, and did not meet all planned targets. The cross-country methodology reflected the pragmatic nature of the PRIME cohorts: while the heterogeneity in methods of recruitment was a consequence of differences in health systems and MHCPs, the use of the WHODAS as primary outcome measure will allow for comparison of functioning recovery across sites and disorders.

Long-Term Electroclinical and Employment Follow up in Temporal Lobe Epilepsy Surgery. A Cuban Comprehensive Epilepsy Surgery Program

The purpose of this paper is to present a long- term electroclinical and employment follow up in temporal lobe epilepsy (TLE) patients in a comprehensive epilepsy surgery program. Forty adult patients with pharmacoresistant TLE underwent detailed presurgical evaluation. Electroencephalogram (EEG) and clinical follow up assessment for each patient were carried out. The occurrence of interictal epileptiform activity (IEA) and absolute spike frequency (ASF) were tabulated before and after 1, 6, 12, 24 and 72 months surgical treatment. Employment status pre- to post-surgery at the last evaluated period was also examined. Engel scores follow-up was described as follows: at 12 months 70% (28) class I, 10% (4) class II and 19% (8) class III-IV; at 24 months after surgery 55.2% (21) of the patients were class I, 28.9% (11) class II and 15.1% (6) class III-IV. After one- year follow up 23 (57.7%) patients were seizure and aura-free (Engel class IA). These figures changed to 47.3%, and 48.6% respectively two and five years following surgery whereas 50% maintained this condition in the last follow up period. A decline in the ASF was observed from the first year until the sixth year after surgery in relation to the preoperative EEG. The ASF one year after surgery allowed to distinguish “satisfactory” from “unsatisfactory” seizure relief outcome at the last follow up. An adequate social functioning in terms of education and employment in more than 50% of the patients was also found. Results revealed the feasibility of conducting a successful epilepsy surgery program with favorable long term electroclinical and psychosocial functioning outcomes in a developing country as well.

Anticonvulsant properties of methanol leaf extract of Laggera Aurita Linn. F. (Asteraceae) in laboratory animals

ETHNOPHARMACOLOGICAL RELEVANCE

Preparation of Laggera aurita Linn. (Asteraceae) is widely used in traditional medicine to treat various kinds of diseases such as epilepsy, malaria, fever, pain and asthma. Its efficacy is widely acclaimed among communities in Northern Nigeria.

AIM OF THE STUDY

The present study is aimed at establishing the possible anticonvulsant effects of the methanol leaf extract of Laggera aurita using acute and chronic anticonvulsant models.

MATERIALS AND METHOD

Median lethal dose (LD50) was determined in mice and rats via oral and intraperitoneal routes. Anticonvulsant screening of the extract was performed using maximal electroshock-induced seizure test in day-old chicks; pentylenetetrazole-, strychnine- and picrotoxin- induced seizure models in mice. Similarly; its effects on pentylenetetrazole-induce kindling in rats as well as when co-administered with fluphenamic and cyproheptadine in mice, were evaluated.

RESULTS

Median lethal dose (LD50) values were found to be >5000mg/kg, p.o. and 2154mg/kg, i.p., each for both rats and mice. The extract showed dose dependent protection against tonic hind limb extension (THLE) and significantly (p<0.05) decreased the mean recovery from seizure in the maximal electroshock-induced seizure. In the pentylenetetrazole-induced seizure model, the extract offered 50% protection at 600mg/kg and also increased the mean onset of seizure at all doses with significant (p<0.05) increase at the highest dose (600mg/kg). Similarly the extract produced significant (p<0.05) increase in the onset of seizures in both strychnine- and picrotoxin- induced seizure models, at all the doses except at 150mg/kg for the picrotoxin model. Co-administration of fluphenamic acid (FFA) (5mg/kg) and the extract (600mg/kg) showed an enhanced effect with percentage protection of 70% while co-administration of FFA (5mg/kg) and phenytoin (5mg/kg) as well phenytoin (5mg/kg) and the extract (600mg/kg) produced an additive effect. Administration of the extract (600mg/kg), phenytoin (20mg/kg) and cyproheptadine (4mg/kg) offered 40%, 100% and 0% protection against THLE, each respectively, while co-administration of cyproheptadine (4mg/kg) and the extract (600mg/kg) as well as co-administration of cyproheptadine (4mg/kg) and phenytoin (20mg/kg) offered reduced protection of 20% and 50% each respectively. The extract at all doses reduced the severity of seizure episodes induced by PTZ-induced kindling.

CONCLUSION

The results suggest that the methanol leaf extract of Laggera aurita possesses anticonvulsant and antiepileptogenic properties.

Epilepsy in transition from child care to adult service: a missing link in sub-Saharan Africa

Epilepsy is a common chronic neurological disease which predominantly affects children and young adults. The disease is highly stigmatised and transition from child care to adult services is not routine in many low- and middle-income countries. Where a treatment system follows routines which cannot be sustained in such countries because of specialised manpower challenges, it becomes imperative that appropriate care models be sought for patients whose seizures fail to remit in childhood. In teaching hospitals, well-organised, multidisciplinary meetings and a planned transfer between paediatric and adult neurologists will be feasible. However, an alternative model is advocated at the community level where the majority of the patients reside which involves task shifting to general practitioners and community healthcare workers. The latter can organise home visits to ensure management compliance. This will ensure better seizure outcomes and a good quality of life for epileptic patients.

Closing the mental health gap in low-income settings by building research capacity: perspectives from Mozambique

BACKGROUND

Neuropsychiatric disorders are the leading cause of disability worldwide, accounting for 22.7% of all years lived with disability. Despite this global burden, fewer than 25% of affected individuals ever access mental health treatment; in low-income settings, access is much lower, although nonallopathic interventions through traditional healers are common in many venues. Three main barriers to reducing the gap between individuals who need mental health treatment and those who have access to it include stigma and lack of awareness, limited material and human resources, and insufficient research capacity. We argue that investment in dissemination and implementation research is critical to face these barriers. Dissemination and implementation research can improve mental health care in low-income settings by facilitating the adaptation of effective treatment interventions to new settings, particularly when adapting specialist-led interventions developed in high-resource countries to settings with few, if any, mental health professionals. Emerging evidence from other low-income settings suggests that lay providers can be trained to detect mental disorders and deliver basic psychotherapeutic and psychopharmacological interventions when supervised by an expert.

OBJECTIVES

We describe a new North-South and South-South research partnership between Universidade Eduardo Mondlane (Mozambique), Columbia University (United States), Vanderbilt University (United States), and Universidade Federal de São Paulo (Brazil), to build research capacity in Mozambique and other Portuguese-speaking African countries.

CONCLUSIONS

Mozambique has both the political commitment and available resources for mental health, but inadequate research capacity and workforce limits the country's ability to assess local needs, adapt and test interventions, and identify implementation strategies that can be used to effectively bring evidence-based mental health interventions to scale within the public sector. Global training and research partnerships are critical to building capacity, promoting bilateral learning between and among low- and high-income settings, ultimately reducing the mental health treatment gap worldwide.

The epilepsy treatment gap in rural Tanzania: A community-based study in adults

PURPOSE

Most people with epilepsy (PWE) in low-income countries are not treated. We identified risk factors for the epilepsy treatment gap in rural Tanzania.

METHODS

We identified adult PWE in a community-based prevalence study. Factors associated with failure to access or default from medical care were identified using logistic regression modelling.

RESULTS

A total of 291 PWE were included, of whom 253 (86.9%) had presented to medical services. Failure to present was positively associated with using alcohol (odds ratio (OR) 4.20; 95% confidence interval (CI) 1.63 to 10.82) or attending traditional healers (OR 2.62; CI 1.00 to 6.83) and inversely associated with having completed primary education (OR 0.33; CI 0.11 to 0.96). Default from treatment was associated with being male (OR 3.35; CI 1.39 to 8.09), having a seizure-related injury (OR 2.64; CI 1.12 to 6.19), believing in a supernatural cause for epilepsy (OR 5.44; CI 1.48 to 19.94) or having no expressed knowledge of cause (OR 5.29; CI 1.60 to 17.52). Cases less likely to default had a duration of epilepsy greater than 10 years (OR 0.28; CI 0.09 to 0.90) or had previously received a seizure-related diagnosis (OR 0.25; CI 0.09 to 0.65). Of all 291 PWE included, 118 denied taking AEDs; the epilepsy treatment gap in this population was therefore 40.5% (95% CI 34.9 to 46.2).

CONCLUSION

Interventions to improve access to education and to support formal diagnoses may promote access to, and retention under, medical care for PWE in rural Tanzania and in other low-income countries.

Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model

OBJECTIVE

An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery.

METHODS

We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance.

RESULTS

All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure.

SIGNIFICANCE

Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Community knowledge of and attitudes toward epilepsy in rural and urban Mukono district, Uganda: A cross-sectional study

INTRODUCTION

The lack of adequate knowledge poses a barrier in the provision of appropriate treatment and care of patients with epilepsy within the community. The purpose of this study was to determine the knowledge of and attitude towards epilepsy and its treatment by community dwellers in Uganda.

METHODS

A cross sectional population survey was conducted in urban and rural Mukono district, central Uganda. Adult respondents through multistage stratified sampling were interviewed about selected aspects of epilepsy knowledge, attitudes, and perception using a pretested structured questionnaire.

RESULTS

Ninety-one percent of the study respondents had heard or read about epilepsy or knew someone who had epilepsy and had seen someone having a seizure. Thirty-seven percent of the respondents did not know the cause of epilepsy, while 29% cited genetic causes. About seventeen percent of the subjects believed that epilepsy is contagious. Only 5.6% (21/377) of the respondents would take a patient with epilepsy to hospital for treatment.

CONCLUSION

Adults in Mukono are very acquainted with epilepsy but have many erroneous beliefs about the condition. Negative attitudes are pervasive within communities in Uganda. The national epilepsy awareness programs need to clarify the purported modes of transmission of epilepsy, available treatment options, and care offered during epileptic seizures during community sensitizations in our settings.

Community perceptions of developmental and behavioral problems experienced by children living with epilepsy on the Kenyan coast: A qualitative study

Childhood epilepsy is common in Africa. However, there are little data on the developmental and behavioral problems experienced by children living with epilepsy, especially qualitative data that capture community perceptions of the challenges faced by these children. Identifying these perceptions using qualitative approaches is important not only to help design appropriate interventions but also to help adapt behavioral tools that are culturally appropriate. We documented the description of these problems as perceived by parents and teachers of children with or without epilepsy. The study involved 70 participants. Data were collected using in-depth interviews and focus group discussions and were analyzed using NVIVO to identify major themes. Our analysis identified four major areas that are perceived to be adversely affected among children with epilepsy. These included internalizing and externalizing problems such as aggression, temper tantrums, and excessive crying. Additionally, developmental delay, especially cognitive deficits and academic underachievement, was also identified as a major problematic area. There is a need to supplement these findings with quantitative estimates and to develop psychosocial and educational interventions to rehabilitate children with epilepsy who have these difficulties.

Burden, causes, and outcomes of people with epilepsy admitted to a rural hospital in Kenya

OBJECTIVE

People with epilepsy (PWE) develop complications and comorbidities often requiring admission to hospital, which adds to the burden on the health system, particularly in low-income countries. We determined the incidence, disability-adjusted life years (DALYs), risk factors, and causes of admissions in PWE. We also examined the predictors of prolonged hospital stay and death using data from linked clinical and demographic surveillance system.

METHODS

We studied children and adults admitted to a Kenyan rural hospital, between January 2003 and December 2011, with a diagnosis of epilepsy. Poisson regression was used to compute incidence and rate ratios, logistic regression to determine associated factors, and the DALY package of the R-statistical software to calculate years lived with disability (YLD) and years of life lost (YLL).

RESULTS

The overall incidence of admissions was 45.6/100,000 person-years of observation (PYO) (95% confidence interval [95% CI] 43.0-48.7) and decreased with age (p < 0.001). The overall DALYs were 3.1/1,000 (95% CI, 1.8-4.7) PYO and comprised 55% of YLD. Factors associated with hospitalization were use of antiepileptic drugs (AEDs) (odds ratio [OR] 5.36, 95% CI 2.64-10.90), previous admission (OR 11.65, 95% CI 2.65-51.17), acute encephalopathy (OR 2.12, 95% CI 1.07-4.22), and adverse perinatal events (OR 2.87, 95% CI 1.06-7.74). Important causes of admission were epilepsy-related complications: convulsive status epilepticus (CSE) (38%), and postictal coma (12%). Age was independently associated with prolonged hospital stay (OR 1.02, 95% CI 1.00-1.04) and mortality (OR, 1.07, 95% CI 1.04-1.10).

SIGNIFICANCE

Epilepsy is associated with significant number of admissions to hospital, considerable duration of admission, and mortality. Improved supply of AEDs in the community, early initiation of treatment, and adherence would reduce hospitalization of PWE and thus the burden of epilepsy on the health system.

Epilepsy is ubiquitous, but more devastating in the poorer regions of the world... or is it?

The incidence and prevalence of active epilepsy are greatest in Africa compared to all other continents, even those with equivalent poor settings. This is a reflection of the high levels of structural and metabolic causes and may reflect an increased risk in parts of the continent. The full burden of epilepsy, which includes the social and medical morbidity of the disorder and where people with epilepsy are heavily stigmatized and frequently untreated, cannot be fully assessed even using the disability adjusted life-years, since the assigned disability weights are not specific to these regions. The burden is further exacerbated by social, geographic, and economic barriers to care and the inability of African health systems to manage people with epilepsy effectively because of lack of trained personnel, limited facilities, and poor access to effective or sustained supplies of antiepileptic drugs, or even therapy at all. The situation is compounded by a probable underestimation of the prevalence and incidence of people with epilepsy related to the major stigma associated with the condition in Africa, and the limited training available to most health care workers who are the primary point of assessing most people with epilepsy. Finding innovative ways to address the huge barriers faced by people with epilepsy in Africa needs to be a major goal for the millennium. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Current beliefs and attitudes regarding epilepsy in Mali

PURPOSE

In Mali, epilepsy affects 15 individuals per thousand. Perceptions and attitudes have not seemingly evolved with advancing medical knowledge. The objective of this study was to assess parental beliefs and attitudes in families with and without affected children.

METHODS

We enrolled 720 pediatric patients, half of whom had epilepsy, at Mali's largest hospital. We conducted semistructured interviews with the accompanying parent. Control families with unaffected patients and also had affected children were excluded.

RESULTS

In total, 67% and 24% of families with and without epilepsy, respectively, lived in rural environments. Interviewees were mostly mothers in their 30s; 80% had not completed high school. About 22% of parents without an affected child had witnessed a seizure. During a seizure, 94% of parents with an affected child and 49% of parents without an affected child, respectively, would intervene; 7.5% and 21%, respectively, would wet the patient's face with cool water. Although parents with an affected child had more intimate knowledge of seizures, misconceptions prevailed, perhaps more so than in families without epilepsy: 79% and 66% of parents, respectively, considered epilepsy contagious; 43% vs. 69% thought that it inevitably led to psychosis; and 53% vs. 29% attributed epilepsy to supernatural causes. Finally, 63% of parents with an affected child reported consulting a traditional healer as first-line management for epilepsy.

CONCLUSIONS

Our study demonstrates widespread misconceptions in Mali regarding epilepsy. Our findings argue for more education initiatives focused on the entire population, including traditional healers, to provide knowledge, reduce stigma, and improve quality of life for individuals living with epilepsy.

The balanced care model for global mental health

BACKGROUND

For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings.

RESULTS

Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories.

CONCLUSIONS

The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

Epilepsy in poor regions of the world

Epilepsy is a common disorder, particularly in poor areas of the world, and can have a devastating effect on people with the disorder and their families. The burden of epilepsy in low-income countries is more than twice that found in high-income countries, probably because the incidence of risk factors is higher. Many of these risk factors can be prevented with inexpensive interventions, but there are only a few studies that have assessed the effect of reducing risk factors on the burden of epilepsy. The mortality associated with epilepsy in low-income countries is substantially higher than in less impoverished countries and most deaths seem to be related to untreated epilepsy (eg, as a result of falls or status epilepticus), but the risk factors for death have not been adequately examined. Epilepsy is associated with substantial stigma in low-income countries, which acts as a barrier to patients accessing biomedical treatment and becoming integrated within society. Seizures can be controlled by inexpensive antiepileptic drugs, but the supply and quality of these drugs can be erratic in poor areas. The treatment gap for epilepsy is high (>60%) in deprived areas, but this could be reduced with low-cost interventions. The substantial burden of epilepsy in poor regions of the world can be reduced by preventing the risk factors, reducing stigma, improving access to biomedical diagnosis and treatment, and ensuring that there is a continuous supply of good quality antiepileptic drugs.

Epilepsy treatment in sub-Saharan Africa: closing the gap

According to World Health Organization (WHO), the prevalence of epilepsy is highest in low- and lower middle-income countries, which include over eighty percent of the countries of sub-Saharan Africa, where the majority of people with epilepsy are not receiving appropriate care. In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. The number of people with epilepsy, particularly children, will continue to rise as a result of projected epidemiologic and demographic changes. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy.

Scale up of services for mental health in low-income and middle-income countries

Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally.

Perceptions of mental health and help-seeking behavior in an urban community in Vietnam: an explorative study

This explorative study assesses perceptions of mental health and help-seeking behavior among adults in Vietnam. Methods included questionnaires (200) and focus group discussions (eight). Respondents were often unable to name specific mental illnesses. Frequently mentioned symptoms of mental illness were talking nonsense, talking/laughing alone and wandering. Pressure/stress and studying/thinking too much were often identified causes. Most respondents showed a preference for medical treatment options, often in combination with family care. The results show that perceptions of mental health and help-seeking behaviour are influenced by a lack of knowledge and a mix of traditional and modern views.

Epilepsy Care in Developing Countries: Part II of II

Although 80% of people with epilepsy reside in resource poor, developing countries, epilepsy care in these regions remains limited and the majority of epilepsy patients go untreated. Cost-effective, sustainable epilepsy care services, delivering first-line antiepileptic drugs through established primary health care facilities, are needed to decrease these treatment gaps. Neurologists with local experience and knowledge of the culture, who are willing to serve as educators, policy advisors, and advocates, can make a difference. This is Part II of a two-part article. Part I reviewed the burden of epilepsy and the current state of resources for treatment in developing countries, while Part II will now discuss various aspects of care in these countries.

Optimizing mental health services in low-income and middle-income countries

PURPOSE OF REVIEW

Against the backdrop of a large burden and treatment gap for mental disorders in low-income and middle-income countries (LMICs), recently published articles were reviewed to assess strategies and actions for optimizing mental health services in LMICs.

RECENT FINDINGS

Key strategies and actions are as follows: (i) the adoption of a decentralized stepped care approach embracing task shifting to nonspecialists for those disorders for which it has been shown to be effective; (ii) ensuring adequate numbers of mental health specialists to provide a supportive supervisory framework and referral pathways; (iii) ensuring adequate infrastructure to support decentralized care; (iv) promoting mental health literacy; (v) adoption of a social inclusion and developmental model of disability in caring for people with chronic mental illness; and (vi) embracing a multisectoral community collaborative approach.

SUMMARY

Optimizing mental health services in LMICs requires legislation, policies and plans that are enabling of the above strategies and actions. Studies demonstrating the cost-effectiveness of integrated stepped packages of care embracing a task-shifting approach, and best practices for strengthening mental health literacy and collaborative arrangements with community caregivers and other sectors, can assist this process. Specialist mental health training programmes in LMICs also need to be responsive to the changing demands on service providers, incorporating a public health approach and equipping specialists for diversification of their roles within the task shifting model.

Three models of community mental health services In low-income countries

OBJECTIVE

To compare and contrast three models of community mental health services in low-income settings.

DATA SOURCES/STUDY SETTING

Primary and secondary data collected before, during, and after site visits to mental health programs in Nigeria, the Philippines, and India.

STUDY DESIGN

Qualitative case study methodology.

DATA COLLECTION

Data were collected through interviews and observations during site visits to the programs, as well as from reviews of documentary evidence.

PRINCIPAL FINDINGS

A set of narrative topics and program indicators were used to compare and contrast three community mental health programs in low-income countries. This allowed us to identify a diversity of service delivery models, common challenges, and the strengths and weaknesses of each program. More definitive evaluations will require the establishment of data collection methods and information systems that provide data about the clinical and social outcomes of clients, as well as their use of services.

CONCLUSIONS

Community mental health programs in low-income countries face a number of challenges. Using a case study methodology developed for this purpose, it is possible to compare programs and begin to assess the effectiveness of diverse service delivery models.

Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years

BACKGROUND

The burden of non-communicable chronic diseases, such as hypertension and diabetes, increases in sub-Saharan Africa. However, the majority of the rural population does still not have access to adequate care. The objective of this study is to examine the effectiveness of integrating care for hypertension and type 2 diabetes by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon.

METHODS

Of the 75 NPC facilities in the area, 69 (87%) received basic equipment and training in hypertension and diabetes care. Effectiveness was assessed after two years on status of equipment, knowledge among trained NPCs, number of newly detected patients, retention of patients under care, treatment cost to patients and changes in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients.

RESULTS

Two years into the programme, of 54 facilities (78%) available for re-assessment, all possessed a functional sphygmomanometer and stethoscope (65% at baseline); 96% stocked antihypertensive drugs (27% at baseline); 70% possessed a functional glucose meter and 72% stocked oral anti-diabetics (15% and 12% at baseline). NPCs' performance on multiple-choice questions of the knowledge-test was significantly improved. During a period of two years, trained NPCs initiated treatment for 796 patients with hypertension and/or diabetes. The retention of treated patients at one year was 18.1%. Hypertensive and diabetic patients paid a median monthly amount of 1.4 and 0.7 Euro respectively for their medication. Among hypertensive patients with ≥ 2 documented visits (n = 493), systolic BP decreased by 22.8 mmHg (95% CI: -20.6 to -24.9; p < 0.0001) and diastolic BP by 12.4 mmHg (-10.9 to -13.9; p < 0.0001). Among diabetic patients (n = 79) FPG decreased by 3.4 mmol/l (-2.3 to -4.5; p < 0.001).

CONCLUSIONS

The integration of hypertension and diabetes into primary health care of NPC facilities in rural Cameroon was feasible in terms of equipment and training, accessible in terms of treatment cost and showed promising BP- and FPG-trends. However, low case-detection rates per NPC and a very high attrition among patients enrolled into care, limited the effectiveness of the programme.

Treatment gap for people living with epilepsy in Madagascar

Using an indirect assessment technique we assessed the epilepsy treatment gap (ETG) in Madagascar. We estimate the ETG in Madagascar to be 92%. However, given the sociological, economic and sanitary conditions of the country, it is likely that the true ETG is even higher than our estimate. Our study also documents the lack of access to treatment for patients in this developing country. The indirect method could be used to assess the treatment gaps of other chronic medical conditions.

Altered firing rates and patterns in interneurons in experimental cortical dysplasia

Cortical dysplasia (CD) is associated with severe epilepsy in humans, and the in utero irradiation of fetal rats provides a model of this disorder. These animals show a selective loss of inhibitory interneurons, and the surviving interneurons have a reduced excitatory synaptic drive. The current study was undertaken to see how alterations in synaptic input would affect spontaneous firing of interneurons in dysplastic cortex. We recorded spontaneous action potentials and excitatory and inhibitory postsynaptic currents (EPSCs and IPSCs, respectively) from somatostatin (SST)-, parvalbumin (PV)-, and calretinin (CR)-immunoreactive (ir) interneurons. We found that SST- and PV-ir interneurons fired less frequently and with less regularity than controls. This corresponded to a relative imbalance in the ratio of EPSCs to IPSCs that favored inhibition. In contrast, CR-ir interneurons from CD showed no differences from controls in spontaneous firing or ratio of EPSCs to IPSCs. Additional studies demonstrated that synaptic input had a powerful effect on spontaneous firing in all interneurons. These findings demonstrate that a relative reduction in excitatory drive results in less active SST- and PV-ir interneurons in irradiated rats. This would further impair cortical inhibition in these animals and may be an important mechanism of epileptogenesis.

WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.