Journal of Neurology Research Reviews & Reports

Introduction

Epilepsy is one of the most common serious neurological disorders, affecting people of all ages [1-3]. Its prevalence is higher in poorer countries and rural areas [4-10].

Low socioeconomic status is a risk factor for epilepsy even in low-income subjects in high-income countries [11-13]. Almost 80% of people with epilepsy live in poor countries, where over 75% have no access to treatment [14-16].

A real deficit is evident in these countries, in terms of human and financial resources [17]. In addition, stigmatization and misconceptions which regard epilepsy as a disease caused by a “spirit”, a curse or a bad spell cast [18,19].

This stigma can be profound, as it is considered contagious and associated with witchcraft [20, 21]. Leading to the highest proportion of severe epilepsies and a higher mortality rate [22,23]. Its diagnosis is clinical, so a seizure with a unilateral onset leads to classification as a focal seizure, otherwise as a generalized seizure [24-27].

Other pathologies such as syncope, parasomnias and abnormal movements can be difficult to distinguish from seizures, but neuroimaging and electroencephalography (EEG) allow classification of seizure type and epilepsy [28-29].

The epilepsy syndrome is made up of a constant and non-random association of clinical and paraclinical signs such as seizure type, EEG and imaging, all of which are age-dependent [30- 31].

The consequences are physical and psychological, including premature death, trauma and mental disorders [32]. The etiology (infectious, structural, genetic, metabolic, immune, unknown) of epilepsy should be known from the first seizure [33].

In Africa, parasitic diseases such as Taenia solium neurocysticercosis and malaria are at the forefront, while others include meningitis, toxoplasmosis, trauma and stroke [34-39].

Management must be based on a variety of approaches, taking into account patients from different cultural and family backgrounds, different ages or regions and different environments [40-54]. Some studies have focused on the treatment, etiologies and burden of disease of countries in the tropics, aiming to formulate appropriate policies for epileptics [55-71].

Access to medical treatment is limited for these poor countries, with gaps in treatment either due to a lack of drugs or insufficient doses [72-76].

One reality emerges throughout this literature review: the lack of care for epileptics in poor countries. To reverse this, we assessed the knowledge, attitude and practice of front-line healthcare staff in relation to epilepsy.

Methods

We conducted a cross-sectional, descriptive study based on a multicenter survey from August 1st to February 31st 2023 in six (06) medical centers (Coléah, coronthie, matam, flamboyan, miniere, ratoma) in the city of Conakry. Including front-line healthcare personnel such as doctors, specialists (pediatrics, gyneco-obstetrics, surgery) and state-qualified nurses/midwives. The form was based on the standardized epilepsy questionnaire developed by the Institut d’Epidémiologie Neurologique Tropicale de Limoges [77]. All personnel who completed the questionnaire correctly and agreed to participate were included. The data were collected on a survey form comprising both closed and open- ended questions, based on two parts: the first relating to socio- demographic data, and the second to the knowledge and attitudes of the respondents.

Explanations on the purpose of the survey and on how to fill in the questionnaire were given during a one-to-one or group interview. Once informed consent had been obtained, the questionnaire was given to those concerned, with instructions to complete it carefully and return it after one week. The data were analyzed using Epi Info version 7.2 and SPSS (statistical package for social staticians).

Discussion

Our observations illustrate the lack of equipment and training in this field for front-line staff, who are the pillars of epilepsy management, as well as the misperception and importance of erroneous beliefs about epilepsy already known in other regions [78-80].

This approach seems more informative, as questioning only epilepsy patients in the African socio-cultural context could only lead to biased results [81].

Questionnaires were distributed to 476 staff and only 382 completed them correctly, a rate of 80%. Our response rate is very good compared with those of other authors [82,83]. This can be explained by the active involvement of staff in the day-to-day care of patients and their desire to improve their skills.

Socio-Demographic Aspects

The age of the respondents ranged from 42 to 51 years, with an average of 41.12 years. This result corroborates that of Diallo F et al Dakar 2004 but contrasts with Alemayehu M et al, in Ethiopia in 2021 so that 45.28% of our surveys had been practising for more than 10 years, with an average of 17.07 years [84,85]. This predominance of relatively young staff can be explained by the fact that they represent the dynamic stratum of the African population, and indicates that age and seniority are not necessarily linked to knowledge of epilepsy. Although the level of knowledge influences seizure practices and our sharing of epilepsy knowledge [86].

Knowledge

Nearly half of those surveyed (47.2%) defined epilepsy as a contagious neurological disease. The same finding has been observed in several studies [87-90]. This can be explained by the socio-cultural effect of this condition, and reflects a lack of awareness of the disease, hence the need for more training. However, for (37.17%) there was a difference between epileptic seizure and epilepsy. According to the respondents, an epileptic seizure is the clinical manifestation of epilepsy.

However, the infectious etiology (82.98%) was the most widely known to our respondents. This result can be explained by the strong association of infectious pathologies with epileptic seizures, on the one hand, and by the lack of investigative resources for etiological research, on the other [91-93].

We found that for half (52.61%) of those surveyed, the EEG confirmed the diagnosis of epilepsy, although they claimed (69.63%) never to have witnessed this examination. This could be explained by the relative rarity of EEG equipment in our contexts [94-96].

Despite its important contribution to the diagnosis of epilepsy, a normal EEG does not eliminate the diagnosis of epilepsy, according to Pierre Thomas and Arzimanoglou [97].

We found that 52.87% of those surveyed received patients only after conventional treatment. Different designations of epilepsy such as “moon disease” and “spirit disease” may support beliefs and myths that traditional healers are the best people to treat epilepsy [98]. it is only the observation of several failures that motivates a hospital consultation [99-102].

Respondents’ Attitudes and Practices

However, 85.60% of our respondents received generalized tonic- clonic seizures as the reason for consultation, although focal seizures are still the most common in epilepsy [103].

This made a link between the high frequency of this type of seizure and the lack of knowledge of other types, and would merit training and diagnostic resources.

As for treatment, benzodiazepine was the best-known molecule (89.79%), followed by phenobarbital (39.26%) and carbamazepine (25%). [104]. Despite the availability and average cost, especially of first-generation drugs, there is a significant deficit in developing countries, due to a lack of financial, diagnostic and therapeutic resources [105].

The majority (81.67%) of respondents said they had witnessed one or more seizures, and their attitude consisted of inserting an object into their mouth to avoid biting their tongue (78.27%). This result is identical to that of Vasco F in Mozambique in 2022 [106].

In practice, outside the medical environment, it is recommended not to put anything between the teeth because of certain risks: the vomiting reflex, the possibility of breaking the teeth, dislocation of the jaw.

Thus 95.02% of our respondents received patients with a serious prognosis, the main one being intellectual retardation in 51.04% of cases.

This is explained by the risk of physical trauma, sudden death and the onset of status epilepticus during seizures, which explains the two-fold higher mortality rate compared to the normal population.

Conclusion

This study highlights the lack of training and equipment for front- line epilepsy staff, and the need for staff training with a focus on public awareness and education.

Conflict of Interest: None

References

1.Neligan A, Hauser WA, Sander JW (2012) The epidemiology of epilepsy. Handb Clin Neurol 107: 113-133.

2.Ettore Beghi, Giorgia Giussani, Emma Nichols, Foad Abd- Allah, Jemal Abdela, et al. (2019) World, regional, and national burden of epilepsy, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancette Neurol 18: 357-375.

3.Newton CR, Garcia H (2012) Epilepsy in poor regions of the world. Lancette 380: 1193-1201.

4.Ibinda F, Mbuba CK, Kariuki SM, Chengo E, Ngugi AK, et al. (2014) Evaluation of the Kilifi epilepsy education program: a randomized controlled trial. Epilepsy 55: 344-352.

5.Mateen F (2019) A cascade of care for people with epilepsy: learning from HIV/AIDS 90-90-90. Gates Open Res 3: 1502.

6.Debrock C, Preux Pm, Houinato D (2000) Estimation of the prevalence of epilepsy in the Benin region of Zinvié using the capture recapture method. Int J Epidemiol 29: 330-335.

7.Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2197-2223.

8.Diallo F, Sarr MM, Genton P, Szepetowski P, Diarra A, et al. (2004) Epilepsy in Senegal: setting up a genetic study. Epilepsies 16: 153-159.

9.Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR (2010) Estimating the burden of active and lifelong epilepsy: a meta-analytic approach. Epilepsy 51: 883-890.

10.Fiest KM, Sauro KM, Wiebe S, Patten SB, Kwon CS, et al. (2017) Prevalence and incidence of epilepsy: a systematic review and meta-analysis of international studies. Neurology 88: 296-303.

11.Hesdorffer DC, Tian H, Anad K (2005) Socioeconomic status is a risk factor for epilepsy in Icelandic adults but not in children. Epilepsy 46: 1297-1303.

12.Beghi E, Hesdorffer D (2014) Prevalence of epilepsy: an unknown quantity. Epilepsy 55: 963-967.

13.Kaiboriboon K, Bakaki PM, Lhatoo SD, Koroukian S (2013) Incidence and prevalence of treated epilepsy in unhealthy, low-income Americans. Neurology 80: 1942-1949.

14.World Health Organization. The world health report, 2019: mental health: new understanding, new hope. 20 Avenue Appia CH-1211 Geneva 27 Switzerland: World Health Organization.

15.Scheffer IE, Berkovic S, Capovilla G, Connolly MB, French J, et al. (2017) ILAE classification of epilepsies: position statement of the ILAE Commission on Classification and Terminology. Epilepsy 58: 512-521.

16.Fisher RS, Cross JH, French JA, Higurashi N, Hirsch E, et al. (2017) Operational classification of seizure types by the international league against epilepsy: position statement of the ilae Classification and Terminology Commission. Epilepsy 58: 522-530.

17.Belhocine M, de Boer H, Mandlhate C (2004) World Health Organization. In: epilepsy in the who african region. Geneva.

18.Domgmo L, Mbonda E, Motsoj, Mbede J (1994) Infantile epilepsy in Yaoundé: Analyse de 174 cas. Second Congress of Tropical Neurology 11: 124.

19.19. Farnarier G, Diop S (2000) Onchocerciasis and epilepsy: Epidemiological survey in Mali. Bull Soc Path Exot 83: 123- 193.

20.Mushi D, Hunter E, Mtuya C, Mshana G, Aris E, et al. (2011) Sociocultural aspects of epilepsy in the Kilimanjaro region, Tanzania: knowledge and experience of patients and caregivers. Epilepsy Behavior 20: 338-343.

21.Viteva E (2013) Impact of stigma on the quality of life of patients with refractory epilepsy. Crise d’épilepsie 22: 64-69.

22.Kaddumukasa M, Kaddumukasa MN, Buwembo W (2018) Epilepsy misconceptions and stigma reduction interventions in sub-Saharan Africa, a systematic review. Epilepsy Behavior 85: 21-27.

23.(2020) Institute for Health Measurement and Evaluation (IHME), University of Washington. Global burden of disease outcome tool. Seattle, Washington.

24.Cheffer IE, Berkovic S, Capovilla G (2017) ILAE classification of epilepsies: position statement of the ILAE Commission for Classification and Terminology. Epilepsy 58: 512-521.

25.Fisher RS, Cross JH, French JA, Norimichi Higurashi, Edouard Hirsch, et al. (2017) Operational classification of seizure types by the International League Against Epilepsy: position statement of the ilae Classification and Terminology Commission. Epilepsy 58: 522-530.

26.Winkler AS, Schaffert M, Schmutzhard E (2008) The epilepsy scheme in a rural African hospital - an approach adapted to local circumstances. Trop Doct 39: 44-47.

27.Moshe L, Douglas R Nordli, Emilio Perucca, Torbjorn Tomson, Samuel Wiebe, et al. (2017) (ILAE) Classification of Epilepsies: Document establishing the position of the ILAE Commission for Classification and Terminology. The International League Against Epilepsy 1-10.

28.Mushi D, Hunter E, Mtuya C, Mshana G, Aris E, et al. (2011) Sociocultural aspects of epilepsy in the Kilimanjaro region, Tanzania: knowledge and experience of patients and caregivers. Epilepsy Behavior 20: 338-343.

29.Ba Diop A, Marin B, Druet Cabanac M, Ngoungou EB, Newton CR, et al. (2014) Epidemiology, causes and treatment of epilepsy in sub-Saharan Africa. Lancette Neurol 13: 1029- 1044.

30.(1985) Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for classification of epilepsies and epileptic syndromes. Epilepsia 26: 268-278.

31.Robert S Fisher, Walter van Emde Boas, Warren Blume, Christian Elger, Pierre Genton, et al. (2005) Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsy 46: 470-472.

32.Nabbout R (2013) FIRES and IHHE: Delimitation of syndromes. Epilepsy 6: 54-56.

33.Ingrid E Scheffer, Samuel Berkovic, Giuseppe Capovilla, Mary B Connolly, Jacqueline French, Laura Guilhoto, Edouard Hirsch, Satish Jain, Gary W. Mathern, Solomon

34.Edgard Brice Ngoungou, Olivier Dulac, Belco Poudiougou, Michel Druet Cabanac, Alassane Dicko, et al. (2006) Epilepsy secondary to cerebral malaria in a malaria-endemic area of Mali, West Africa. Epilepsy 47: 873-879.

35.Wilmshurst JM, Cross JH, Newton C, Kakooza AM, Wammanda RD, et al. (2013) Children with epilepsy in Africa: recommendations from the International Association of Child Neurology/African Association of Child Neurology workshop. J Enfant Neurol 28: 633-724.

36.Oguni H, Otsuki T, Kobayashi K, Inoue Y, Watanabe E, et al. (2013) Clinical analysis of catastrophic epilepsy in infancy and early childhood: results from the Far East Asian Catastrophic Epilepsy (FACE) Study Group. Brain Development 35: 786-792.

37.Assadeck H, Toudou Daouda M, Mamadou Z, Moussa Konate M, Hassane Djibo F, et al. (2019) Clinical and etiological characteristics of epilepsy in the elderly: a hospital study of a tertiary care referral center in Niamey, Niger. J Neurosci Pratique Rurale 10: 571-575.

38.Bongomin F, Katabira E, Sajatovic M, Kaddumukasa M (2021) Epilepsy in the elderly in sub-Saharan Africa: a systematic review. Treatment of neuropsychiatric disorders 17: 2309-2314.

39.Colebunders R, Kaiser C, Basáñez MG, Olliaro P, Lakwo T, et al. (2022) Reducing onchocerciasis-associated morbidity in onchocerciasis-endemic foci with high ongoing transmission: focus on children. Int J Infecter Dis 116: 302-305.

40.Tsega SS, Yazew BG, Mekonnen K (2021) Sleep quality and associated factors in adult epilepsy patients attending follow- up care at referral hospitals in the Amhara region, Ethiopia. Plos One 16: e0261386.

41.Kaddumukasa M, Kakooza A, Kayima J, Kaddumukasa MN, Ddumba E, et al. (2016) Community knowledge and attitudes towards epilepsy in rural and urban Mukono district, Uganda: a cross-sectional study. Epilepsy Behavior 54: 7-11.

42.Josué SP, Mahapatra AK (2013) Epilepsy in the tropics: an Indian perspective. J Neurosci Pratique Rurale 4: 171-175.

43.Zheng G, Li F, Chen Y, Liu H, Wang S, et al. (2021) An epidemiological survey of epilepsy in rural tropical China. Open Epilepsy 6: 323-330.

44.Quet F, Rafael F, Ngoungou EB, Diagana M, Druet-Cabanac M, et al. (2011) Epilepsy survey in Africa: 10 years of data collection using a standardized questionnaire from 2,269 people with epilepsy. Epilepsy 52: 1868-1876.

45.Gilkinson C, Kinney M, Olaniyan T, Murtala B, Sipilon M, et al. (2022) Perceptions about mental health care for people with epilepsy in Africa. Epilepsy Behavior 127: 108504.

46.Bruno E, Bartoloni A, Zammarchi L, Strohmeyer M, Bartalesi F, et al. (2013) Epilepsy and neurocysticercosis in Latin America: a systematic review and meta-analysis. Plos Négl Trop Dis 7: e2480.

47.Medina MT, Durón RM, Martínez L, Osorio JR, Estrada A, et al. (2005) Prevalence, incidence and etiology of epilepsy in rural Honduras: the Salamá study. Epilepsy 46: 124-131.

48.Mond C, Duke T, Vince J (2019) Epilepsy in Papua New Guinea: a longitudinal cohort study. Arch Dis Enfant 104: 941-946.

49.Winkler AS, Blocher J, Auer H, Gotwald T, Matuja W, et al. (2009) Epilepsy and neurocysticercosis in rural Tanzania - An imaging study. Epilepsy 50: 987-993.

50.Suryani G, Jehosua SY, Herlyani K, Zhi Jien C, Kheng-Seang L (2021) Attitudes towards epilepsy in Indonesia. Epilepsy Behavior 123: 108244.

51.Pomeroy SL, Holmes SJ, Dodge PR, Feigin RD (1990) Convulsions and other neurologic sequelae of bacterial meningitis in children. N Engl J Med 323: 1651-1657.

52.Tollman SM, Kahn K, Sartorius B, Collinson MA, Clark SJ, et al. (2008) Implications of mortality transition for primary health care in rural South Africa. Lancette 372: 893-901.

53.Muchada IF, Wilmshurst JM, Laing N, Haf Davies E, Fieggen K (2021) A qualitative study exploring caregivers’ experiences, perspectives and expectations of precision medicine in epilepsy in South Africa. Epilepsy Behavior 117: 107873.

54.Sengxeu N, Dufat H, Boumediene F, Vorachit S, Chivorakoun P, et al. (2020) Availability, affordability and quality of essential antiepileptic drugs in Lao PDR. Open Epilepsy 5: 550-561.

55.Owolabi LF, Owolabi SD, Adamu B, Jibo AM, Alhaji ID (2020) Epilepsy treatment gap in sub-Saharan Africa: meta- analysis of community studies. Acta Neurol Scand 142: 3-13.

56.Chin JH (2012) Epilepsy treatment in sub-Saharan Africa: closing the gap. Afr Santé Sci 12: 186-192.

57.Winkler AS (2012) Measuring the epilepsy treatment gap in sub-Saharan Africa. Lancette Neurol 11: 655-657.

58.Nau AL, Mwape KE, Wiefek J, Schmidt.K,Abatih E, Dorny P (2018) Cognitive impairment and quality of life in people with epilepsy and neurocysticercosis in Zambia. Epilepsy Behavior 80: 354-359.

59.Nsengiyumva G, Druet-Cabanac M, Ramanankandrasana B, Bouteille B, Nsizabira L, et al. (2003) Cysticercosis as a major risk factor for epilepsy in Burundi, East Africa. Épilepsie 44: 950-955.

60.Elliott I, Jerome A, Angwafor SA, Smith ML, Takougang I, et al. (2013) Epilepsy and cysticercosis in northwest Cameroon: a serological study. Epilepsy crisis 22: 283-296.

61.Mbuba CK, Ngugi AK, Newton CR, Carter JA (2008) the epilepsy treatment gap in developing countries: a systematic review of magnitude, causes, and intervention strategies. Epilepsy 49: 1491-1503.

62.Sahlu I, Carabin H, Ganaba R, Preux PM, Cissé AK, et al. (2019) Estimation of the association between cysticercosis seropositivity and the prevalence of epilepsy and severe chronic headache in 60 rural villages of Burkina Faso. Plos Négl Trop Dis 13: e0007101.

63.Carrizosa Moog J, Kakooza-Mwesige A, Tan CT (2017) Epilepsy in the tropics: emerging etiologies. Epilepsy crisis 44: 108-112.

64.2005 OPL136 Indigenous and isolated epilepsy in tropical Australia. J Neurol Sci 238: S80-S81.

65.Deresse B, Shaweno D (2016) Knowledge, attitudes and practices of the general public towards people with epilepsy in southern Ethiopia: a community-based comparative cross- sectional study. Epilepsy Behavior 58: 106-110.

66.Mbelesso P, Luna J, Yangatimbi E, Mboukou C, Preux PM (2019) Sociocultural representations of epilepsy in the Central African Republic: a door-to-door survey. Epilepsy crisis 67: 23-26.

67.Molla A, Mekuriaw B, Habtamu E, Mareg M (2021) Knowledge and attitudes towards epilepsy among rural residents of southern Ethiopia: a cross-sectional study. Public Health BMC 21: 420.

68.Wagner RG, Norström F, Bertram MY, Tollman S, Forsgren L, et al. (2021) Community health workers to improve antiepileptic medication adherence in rural South Africa: is it cost-effective?. Epilepsy 62: 98-106.

69.Adebiyi A, Lagunju I, Ogunniyi A (2017) Epilepsy in transition from childcare to adult services: a missing link in sub-Saharan Africa. Trop Doct 47: 273-275.

70.Nkole KL, Kawatu N, Patel AA, Kanyinji C, Njobvu T, et al. (2020) Ketogenic diet in Zambia: management of drug- resistant epilepsy in a low- and middle-income country. Epilepsy Behavior Representative 14: 100380.

71.Acevedo C (2015) Latin American strategic plan for the prevention and treatment of epilepsy. J Neurol Sci 357: 503.

72.Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR (2010) Estimating the burden of active and lifelong epilepsy: a meta-analytic approach. Epilepsy 51: 883-890.

73.Fredrick Ibinda, Peter Odermatt, Symon M Kariuki, Angelina Kakooza Mwesige, Ryan G Wagner, et al. (2017) Magnitude and factors associated with non-adherence to antiepileptic drug treatment in Africa: a multisite cross-sectional study. Open Epilepsy 2: 226-235.

74.Dolo H, Mandro M, Wonya’Rossi D, Ngave F, Fraeyman J, et al. (2018) Community perceptions of epilepsy and its treatment in an onchocerciasis-endemic region in Ituri, Democratic Republic of Congo. Infecting poverty 7: 115.

75.Alexandra Cameron, Amit Bansal, Tarun Dua, Suzanne R Hill, Solomon L Moshe, et al. (2012) Mapping the availability, price and affordability of antiepileptic drugs in 46 countries. Epilepsy 53: 962-969.

76.Cameron A, Roubos I, Ewen M, Mantel Teeuwisse AK, Leufkens HG, et al. (2011) Differences in the availability of medicines for chronic and acute conditions in the public and private sectors of developing countries. World Health Organization Bull 89: 412-421.

77.Preux P, Druet Cabanac M, Debrock C, Tapie P, Dumas M (2000) the Comité de Recherche sur l’Epilepsie de l’Institut d’Epidémiologie Neurologique et de Neurologie Tropicale de Limoges Questionnaire d’investigation de l’épilepsie dans les pays tropicales. Bull Soc Pathol Exot 93: 276-278.

78.Watts AE (1989) A model for managing epilepsy in a rural community in Africa. British Medical Journal 298: 805-807.

79.WHO (2000) Global Campaign Against Epilepsy; Bringing epilepsy out of the shadows in Africa. Geneva 20-35.

80.OMS (2001) Epilepsy: social consequences and economic aspects. Geneva WHO 1-166.

81.Maiga Y, Napon C, Dicko F, Fofana T, Traore B, et al. (2008) Connaissances A propos De l’epilepsie Et Attitudes Des Parents d’enfant Au Mali. Revue Neurologique I64: A49-A91.

82.Jack Ide IO, Maliki AE, Onasoga O (2015) Community members’ perception of epilepsy and their attitude towards persons living with epilepsy disorders in a rural Community of Bayelsa State, Nigeria 4: 161-167.

83.Babikar SE, Abbas IM (2011) Epilepsy knowledge, practices and attitudes among primary and secondary school teachers in South Gezira locality, Gezira State, Sudan. J Fam Communauté Med18: 17.

84.Diallo F, Sarr MM, Genton P, Szepetowski P, Diarra A, et al. (2004) Epilepsy in Senegal: setting up a genetic study. Epilepsies 16: 153-159.

85.Alemayehu Molla, Birhanie Mekuriaw, Endashaw Habtamu, Moges Mareg (2021) Knowledge and attitudes towards epilepsy among rural residents of southern Ethiopia. a cross- sectional study Public Health BMC 21: 420.

86.Ofhani Prudance Musekwa, Lufuno Makhado, Angelina Maphula (2023) Knowledge, attitudes and practices (KAP) of caregivers and family members towards epilepsy in rural Limpopo and Mpumalanga. South Africa Int J Environ Res Public Health 20: 5222.

87.Millogo A, Etienne D, Traore ED (2001) Etude des connaissances en matière d’épilepsie en milieu scolaire à Bobo-Dioulasso (Burkina-Faso). Epilepsies 13: 103-179.

88.Ojinnaka NC (2002) Teachers’ perception of epilepsy in Nigeria: a community-based study. Seizure 11: 386-391.

89.Akhtar SW, Aziz H (2004) Perception de l’épilepsie dans l’histoire musulmane; avec le scénario actuel. Neurology Asia 9: 59-60.

90.Rambe AS, Sjahrir H (2000) Awareness, attitude and understanding toward epilepsy among school teachers in Medan, Indonesia. Neurol J Southeast Asia 5: 55-60.

91.Mbelesso Pascal, Sénékian Vincent de Paul, Yangatimbi Emmanuel, Tabo André, Iya Julien (2015) Epilepsy knowledge, attitudes and practices of frontline healthcare workers in Bangui (Central African Republic). North African and Middle East Epilepsy Journal 4.

92.Yang C, Kang B, Mao Y, Xu Q, Yu D, et al. (2020) Anxiety among caregivers of children with epilepsy in western China: a cross-sectional survey. Medicine 99: e19237.

93.Muchada IF, Wilmshurst JM, Laing N, Davies EH, Fieggen K (2021) A qualitative study exploring caregivers’ experiences, perspectives and expectations of precision medicine in epilepsy in South Africa. Epilepsy Behavior 117: 107873.

94.Samanta D, Elumalai V, Hoyt ML, Modi AC, Sajatovic M (2022) A qualitative study of barriers and facilitators to epilepsy self-management among black children and caregivers in Arkansas. Epilepsy Behavior 126: 108491.

95.Lamine Thiam, Ndiogou Seck, François Niokhor Diouf, Djibril Boiro, Babacar Niang, et al. (2020) Clinical and paraclinical aspects of childhood epilepsy at the Hôpital de la Paix de Ziguinchor: a literature review. Pan Afr Med J 37: 387.

96.Camara O (2006) Prise en charge et recherche de facteurs parasitaires d’épilepsie dans le cadre d’une recherche action en réseau sur l’épilepsie à Markacoungo à propos de 317 cas. Thèse Med Dakar Cheikh Anta Diop University 1-112.

97.Kaputu Kalala Malu C (2016) Epilepsy and acute seizures in children in sub-Saharan Africa: challenges and hopes. Pan Afr Med J 23: 58.

98.Thomas P, Arzimanoglou A (2003) Epilepsie Abregés de médecine 3eme ed Paris. Masson.

99.Langa AP, Gouveia ML, Nhantumbo B, Andrassone P, Nhabinde A, et al. (2012) Département de Saúde Mental. Maputo Mozambique.

100.Danesi MA, Adetunji JB (1994) Use of alternative medicine by patients with epilepsy: a survey of 265 epileptic patients in a developing country. Epilepsia 35: 344-351.

101.Dale JR, Ben Tovim DI (1984) Modern or traditional? À study of treatment preference for Neuropsychiatric disorders in Botswana. Br J Psychiatry 145: 187-192.

102.Adotevi F, Stephany J (1984) Cultural representations of epilepsy in Senegal (Cape Verde and Cap-Vert et du Fleuve). Med Trop 41: 283-288.

103.Aka Anghui Diarra Evelyne, Assi Berthe, Folquet Amorrissani Madeleine (2015) Kadjo Annick North African and Middle. East Epilepsy Journal 4.

104.Persefoni Ioannou, Daniella L Foster, Josemir W Sander, Sophie Dupont, Antonio Gil Nagel, et al. (2022) The burden of epilepsy and unmet needs in people with focal seizures Brain Behavior. September 12: e2589.

105.Espinosa Jovel C, Toledano R, Aledo Serrano Á, García Morales I, Gil Nagel A (2018) Epidemiological profile of epilepsy in low-income populations. The Journal of the British Epilepsy Association 56: 67-72.

106.Joyce A Cramer, Zhixiao J Wang, Eunice Chang, Annette Powers, Ronda Copher, et al. (2014) Health care utilization and costs in adults with stable, uncontrolled epilepsy. Epilepsy and Behavior 31: 356-362.

107.Vasco Francisco Japissane Cumbe, Claire Greene, Afonso Mazine Tiago Fumo, Hélder Fumo, Dirceu Mabunda, et al. (2022) Knowledge, attitudes and practices of community health workers towards epilepsy in Sofala. central Mozambique. Int J Environ Res Santé Publique 19: 15420.