Awareness and attitude of first‐year medical students toward epilepsy in University of Khartoum, Sudan

Abstract Purpose Very little is known about the knowledge and attitude of students about epilepsy at Sudanese universities. Therefore, we aimed to assess knowledge and attitude of undergraduate medical students toward epilepsy. Methods A 35‐items standardized questionnaire was self‐administered to 320 students between December 2020 and February 2021 with a recorded response rate of 61.8%. Google form was used to collect the data. The data was analyzed using R software. Results Overall, our findings showed a negative trend in the awareness and attitude towards epilepsy. While the majority of students (84.8%) had read or heard about epilepsy, only 43.9% of them had seen someone with epilepsy. Epilepsy was considered contagious and psychological by 1.7% and 56%, respectively. About 62.2% of students believed head / birth trauma is a cause of epilepsy. On the other hand, 15.7 % and 5.1 % of students thought evil eye and divine retribution are also causes of epilepsy, respectively. The latter beliefs were more uniform among participants from rural background (p < .05). Regarding attitude, 19.7% of students considered it inappropriate for a patient with epilepsy to have a child. This attitude correlates with the mother's education as the percentage was higher for students whose mothers had a lower education (pre‐college education) (p < .05). The majority of students were aware that certain people with epilepsy need long‐term drug treatment; this belief was more uniform among females than in males (p < .05). The vast majority of students (93.9%) thought that a child with epilepsy could succeed in a normal class. Compared to the corresponding group, this belief was found more common in students whose mothers had a higher education (university level and above) (p < .05). Conclusion This study concludes that Sudanese undergraduate students' understanding of epilepsy was minimal, necessitating a well‐directed educational campaign to develop a well‐informed and tolerant society.


INTRODUCTION
Epilepsy is a common chronic neurological disorder that is characterized by two or more unprovoked seizures. Seizures are involuntary movements that are caused by abnormally high electrical activity of neurons in the brain. Such an abnormal activity can result in various manifestations that range from dramatic convulsive activity of the body to a phenomenon that may end in a few seconds without even being recognized. Depending on the distribution of discharges, seizure may involve parts of the body (called partial) or the whole body (called generalized) and it may be associated with other various symptoms such as loss of consciousness, bowel/bladder incontinence, tonguebiting, or other involuntary movements (Kasper et al., 2015).
In general, epilepsy is considered the most common neurological disorder affecting the brain after stroke. While the global prevalence of epilepsy is estimated to be between 5-10 per 1000, the figure in developing countries like Sudan may reach up to 9 per 1000 (Benamer & Grosset, 2009;Hermann et al., 1990). Unfortunately, epilepsy affects at least 50 million patients worldwide (Organization WH, 2005) with almost 89% percent of them living in the developing world without receiving proper treatment (Hermann et al., 1990). Consequently, individuals living in these developing countries should have good knowledge on epilepsy and adequate practices for handling patients with epilepsy (PWE) during seizures.
For that, this study aimed to assess knowledge and attitudes towards epilepsy among first-year medical students as it is likely that most of their knowledge and attitude about diseases -before entering medical school-stems from beliefs held in their communities.

Survey setting and study design
This was a facility-based descriptive cross-sectional study that evaluated knowledge and attitude toward epilepsy among first-year medical students. The study was carried out over the period from December 2020 to February 2021 at the Faculty of Medicine, University of Khartoum. We included all undergraduate medical students who were studying their first year at this medical college. Students who refused to participate were excluded as well as students from other universities.

Instruments of investigation (data collection methods)
The data was collected from the participants using Google forms. As the study was conducted during a lockdown period due to COVID-19 pandemic, Google forms were used to help increase the number of participants and also aid the collection of data through personalized survey.
The questionnaire was adapted from a previous study by Nural Bekiroglu and his colleagues (Bekiroglu et al., 2004), and we used it for its reliability and validity as it was used in previous Studies (Alamri & Al Thobaity, 2020;Alamri et al., 2018;, Alqahtani, 2015;Bekiroglu et al., 2004;Bener et al., 1998;Hills & MacKenzie, 2002;Spatt et al., 2005). The design of the questionnaire was based on (35) questions, divided into five sections: socio-demo characteristics of the participants (6 questions), awareness about epilepsy (10 questions), attitude toward PWE (9 questions), management of the disease (5 questions), and a last section assessing the attitude of participants toward the ability of PWE to live as a normal person (5 questions). The questionnaire had been edited by adding mothers' education as this item was considered a good proxy indicator for the socioeconomic status.
To avoid any ambiguity, the questionnaire was translated to Arabic (the first spoken language in Sudan) and then it was pilot tested with five students who were not included in the study sample. After that, the questionnaire was distributed widely by posting it on social media groups that are specific to the batch.
The questionnaire was started with an introductory statement explaining the purpose and objectives of the study.
However, students were informed about the anonymous evaluation of their data and they were informed that by submitting the questionnaire, they are considered to have agreed to participate in the study.
The participation in the study was completely voluntary.
The information was collected in Excel and imported to a software program for advanced statistical analysis.

Data analysis
Data were analyzed using R software version 4.0.2. Whereas qualitative variables were presented as frequencies and percentages, quantitative variables were converted into mean and standard deviation. Chisquare test and Fisher's exact test were used to assess the differences between groups. A p-value less than .05 was considered statistically significant.

Ethical approval
This study was approved by the Department of Community Medicine at the Faculty of Medicine, University of Khartoum, Sudan. The participants were asked to give consent that they agree to participate in the study by filling the questionnaire for research purposes in the online Google form. where only a mere of 6.1% lived in rural areas (Table 1).

Awareness about epilepsy
The questions and answers for this section were shown in Table 2.
85.4% of participants had read or heard about epilepsy and 28.8% of them knew a person with epilepsy. Further analysis of the data showed an association between age and prior knowledge about epilepsy.
Younger participants (18 years old and less) were more likely to answer "NO" for the question "Have you ever read/heard something about epilepsy?" than older participants (19 years old and above) (p = .003).
Older participants (19 years and above) did not show any significant difference in knowing and seeing someone with epilepsy than younger participants (Table 2).
57 students (28.8%) have come across an individual with epilepsy.
Further analysis showed that students whose mothers had university level education and above did not know a patient with epilepsy (p = .038). 34.4% of students considered epilepsy a psychological disorder and, interestingly, males were more likely to hold this belief than females (p = .038). In addition, about 19.2 % of the participants felt that seizures are not likely to end in a few seconds without being recognized (

Attitude toward PWE
82.2% of participants reckoned that it is acceptable for a patient with epilepsy to get married. This positive attitude was commoner among older participants (19 years old and above) than their younger counterparts (p = .016) ( Table 3).
When it comes to attitudes toward marrying someone with epilepsy, 47% of students were found to be in favor of this. Such a positive attitude was more prevalent among female participants than in males (p = .021) and especially among those living in urban areas (p = .027) ( Table 3).
About 56.6% of students would approve for their son/daughter to marry a PWE. Females were more likely to approve this type of marriage than their counterparts (p = .026). Moreover, almost two thirds (65.2%) of students thought their society discriminates against people with epilepsy and this concept was higher among females than males (p = .018) ( Table 3).

Participants' response for management of epilepsy
The vast majority of participants (96.5%) realized that some individuals with epilepsy need life-long drug treatment. This finding was statistically higher among female participants than males (p = .005).
Furthermore, around one third of students (29.8%) believed that smelling eau de cologne or onion could help halt an epileptic seizure (Table 4).

Responses regarding social activities
The vast majority of participants (93.9%) perceived that a child with epilepsy could succeed in a normal class, while 77.3% felt that PWE could succeed in some high-ranking professions. The majority of students 82.8% regarded that PWE could participate in social activities and a similar percentage (80.3%) considered that PWE should not be prevented from participating in sports activities. There was no evidence that gender, age, or mothers' education had influenced these beliefs (Table 5).

Knowledge about the etiology of epilepsy
The most commonly reported causes of epilepsy in this study were head/birth trauma (62.6%), brain tumors (58.9%), and genetics (53%).
High fever was thought to be the cause of epilepsy by nearly a third of the students (35.9%). Females were more likely to hold this notion than males (p = .001) ( Table 6). We also found that about 15.7% of participants thought that epilepsy could be caused by evil spirits and that participants from rural areas were statistically more likely to express this belief (p = .024). Likewise, 5.1% of participants viewed epilepsy as a punishment from god for wrong deeds and this false belief was found to be more prevalent by eight times in participants from rural areas as compared to those residing in cities (p = .016) ( Table 6).

TA B L E 2 Awareness and knowledge of epilepsy among participants
On the other hand, 29.3% (n = 58) of students thought that accidents could lead to the development of epilepsy. This notion was found to be more prevalent among females (p = .033). In addition, 12.1% of students thought that epilepsy could be a result of metabolic disorders and this was commoner among females (p = .01) ( Table 6).

DISCUSSION
This cross-sectional study showed a poor understanding of epilepsy in addition to inadequate practices for handling patients during seizures among first-year medical students. Due to the prejudices and the stigma surrounding epilepsy, patients' quality of life is often significantly affected and -therefore-people in close contact with these patients should be aware of their disease.
In our study, 85.4% of students had heard or read about epilepsy.
This figure is comparable to the findings of similar studies conducted in Saudi Arabia (Obeid et al., 2012) and Malaysia (Ab Rahman, 2005), 81.8% and 86.5% respectively. When compared to more recent studies -however-, we found that our figure was lower than those reported in other studies conducted among German medical students (96.7%) (Mewes et al., 2020), Indian students (92.5%) (Panda et al., 2011), and Saudi students (95.3%) (Alomar et al., 2020).
Medical students, whose mothers' education was low, which might reflect lower socioeconomic status, were likely to come across individuals with epilepsy. In a study that had reached the same conclusions, it was suggested that epilepsy is more common among the lower socioeconomic population (Ngugi et al., 2010).
In addition to this, half of the students were against marrying someone with epilepsy and this was similar to the figure quoted by a Jordanian study (50.5%) (Hijazeen et al., 2014). In studies conducted among preclinical Turkish and Nigerian students (Ekeh & Ekrikpo, 2015;Kartal, 2016), higher rates were recorded with 74.5 % and 89.3 % of them, respectively, refusing to marry someone with epilepsy.
In our study, 19.7% and 16.7% of students felt that it was inappropriate for PWE to have children or get married, respectively. A relatively similar conclusions were reached in turkey (17.3% and 16.2%, respectively) (Kartal, 2016) and slightly lower percentages were reported in Yemen (14.0% and 11.8%, respectively) (Al-Eryani et al., 2015).
Also, we found that 81.3% and 56.6 % of students would allow their children to share activities with a friend with epilepsy or support them to marry a PWE, respectively. This positive attitude was higher than that reported in Uganda (68% and 14%, respectively) (Bigelow et al., 2015).
Our study also found 74.2% of students were aware that all PWE do not have the same symptoms and this was similar to the percentage reported among Saudi students (72.1 %) (Alomar et al., 2020). In this study, the most common reported causes of epilepsy were head/birth trauma (62.2%), brain tumor (58.9%), and genetic (52.5%).
For many decades, epilepsy has been believed to be a disease that results from evil spirits or supernatural powers (Eadie & Bladin, 2001;Obeid et al., 2012). In this study, only 15.7% and 18.2% of students believed that epilepsy could be caused by evils spirit and evil eye, respectively. In contrast, a considerable number of Jordanian students believed that epilepsy could be caused by the evil spirit (31.5%) and evil eye (28.1%) (Hijazeen et al., 2014). These numbers were nearly similar to results in a Kuwaiti study (24.6% and 34.1%, respectively) (Al- Rashed et al., 2009). In a Saudi study, "possession by Jinn" was reported as a cause of epilepsy by a half of students (Obeid et al., 2012 (Hijazeen et al., 2014) and Nigerian (26%) students (Ekeh & Ekrikpo, 2015).
To the best of our knowledge, this is the first ever study to evaluate the awareness and attitudes toward epilepsy among university students in Sudan. It raised the importance of structured epilepsy education at all levels of education in order to stop the spread of false beliefs and misleading information from public sources.
This study had several limitations that included the restriction to online data collection only using Google forms and the lack of face-toface interaction which could invite social desirability bias.

CONCLUSION
Unfortunately, the findings of the study provided poor knowledge about epilepsy, negative attitudes, and incorrect management of the disease. Poor knowledge of our students could be justified by the younger age and early enrollment in medical school. We anticipate that their knowledge, attitudes, and management of epilepsy will improve significantly over time and during clinical practice later in their career.
A well-directed educational program should be established to raise the awareness toward epilepsy among general population.

ACKNOWLEDGMENTS
The authors would like to thank the research agency: "Sudan Analytics

CONFLICT OF INTEREST
None of the authors has any conflict of interest to disclose

FUNDING INFORMATION
This project was not funded.

DATA AVAILABILITY STATEMENT
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

PEER REVIEW
The peer review history for this article is available at https://publons.