Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding epilepsy

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Epilepsy & Behavior 10 (2007) 111–119

Zambian health care workers’ knowledge, attitudes, beliefs,and practices regarding epilepsy

Elwyn N. Chomba a,b,*, Alan Haworth c,d, Masharip Atadzhanov e,Edward Mbewe d, Gretchen L. Birbeck f,g

a Department of Pediatrics and Child Health, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambiab University Teaching Hospital, Lusaka, Zambia

c Department of Psychiatry, University of Zambia School of Medicine, Lusaka, Zambiad Chainama College of Health Sciences, P.O. Box 30066, Lusaka, Zambia

e Department of Medicine, University of Zambia School of Medicine, P.O. Box 50110, Lusaka, Zambiaf Michigan State University’s International Neurologic and Psychiatric Epidemiology Program (INPEP), 138 Service Road, A217,

East Lansing, MI, 48824-1313, USAg Chikankata Health Services Epilepsy Care Team, P.O. Box 670008, Mazabuka, Zambia

Received 12 June 2006; revised 31 July 2006; accepted 20 August 2006Available online 18 October 2006

Abstract

Objective. Zambia suffers from a physician shortage, leaving the provision of care for those with epilepsy to nonphysician health careworkers who may not be adequately trained for this task. These individuals are also important community opinion leaders. Our goal inthis study was to determine the knowledge, attitudes, beliefs, and practices of these health care workers with respect to epilepsy.

Methods. Health care workers in urban and rural districts of Zambia completed a self-administered, 48-item questionnaire containingitems addressing demographics, personal experience with epilepsy, social tolerance, willingness to provide care, epilepsy care knowledge,and estimates of others’ attitudes. Analyses were conducted to assess characteristics associated with more epilepsy care knowledge andsocial tolerance.

Results. The response rate was 92% (n = 276). Those who had received both didactic and bedside training (P = 0.02) and more recentgraduates (P = 0.007) had greater knowledge. Greater knowledge was associated with more social tolerance (P = 0.005), but having afamily member with epilepsy was not (P = 0.61). Health care workers were generally willing to provide care to this patient population,but �25% would not allow their child to marry someone with epilepsy and 20% thought people with epilepsy should not marry or holdemployment. Respondents reported that people with epilepsy are feared and/or rejected by both their families (75%) and their commu-nity (88.8%).

Conclusions. Knowledge gaps exist particularly in acute management and recognition of partial epilepsy. More recent graduates weremore knowledgeable, suggesting that curriculum changes instituted in 2000 may be improving care. Health care workers expressed bothpersonal and professional reservations about people with epilepsy marrying. In addition to improving diagnosis and treatment skills,educational programs must address underlying attitudes that may worsen existing stigmatizing trends.� 2006 Elsevier Inc. All rights reserved.

Keywords: Stigma; Quality of care; Person with epilepsy; Tolerance; Knowledge

1525-5050/$ - see front matter � 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.yebeh.2006.08.012

* Corresponding author. Fax +260 1 291607.E-mail address: [email protected] (E.N. Chomba).

1. Introduction

Decreasing the global burden of epilepsy and bringingthis condition ‘‘out of the shadows’’ require narrowingthe treatment gap [1] and reducing epilepsy-associated

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112 E.N. Chomba et al. / Epilepsy & Behavior 10 (2007) 111–119

stigma [1–3]. In sub-Saharan Africa, where the physicianshortage is ever more dire [4], nurses and clinical officersmust manage most cases of epilepsy. Zambia has only0.7 physicians for every 10,000 people. In contrast, thereare 12 nonphysician health care workers per 10,000 peo-ple [5]. Whether neurologic training for these profession-als is sufficient for adequate epilepsy care provisionwithout physician consultation is unclear. Clinical officersreceive 3 years of clinical training after secondary schoolwith a focus on managing the most common medicalproblems encountered in the region (e.g., malaria, gastro-enteritis). Nurses in Zambia are trained for supportivecare roles and, technically, are not supposed to prescribemedications or treatments, but clinics are often staffedonly by nurses who inevitably dispense medications.Data from rural regions of Zambia indicate that manynurses and clinical officers working in primary care clin-ics have no physician on site, and their patient popula-tion lacks the resources to access physician-level care[6,7].

In addition to their professional role, health careworkers represent one of the more highly educated andinfluential groups within African societies. Prior knowl-edge, attitudes, beliefs, and practice surveys conductedin Africa have been directed at the general public, stu-dents, or teachers [8–17]. Undoubtedly, health care work-ers’ perspectives of people with epilepsy impact theirprofessional interactions with this patient population.Furthermore, their social response to people with epilepsy,independent of their provision of medical care, mayinfluence others. In addition to their important role incare provision, nurses and clinical officers may be impor-tant social entities in determining how the communityviews people with epilepsy. Health care workers may alsobe able to provide us with insights into how people withepilepsy are viewed by their families and theircommunities.

We conducted a survey of Zambian health care workersto assess their epilepsy care knowledge, as well as theirsocial attitudes, beliefs, and practices with respect to peoplewith epilepsy, with some comparisons to other importantsocial entities previously surveyed.

1 For example, we had no group consensus on the ‘‘correct’’ answer forthose activities people with epilepsy can undertake (question 38), althoughwe felt it was important to ascertain what health care workers thoughtwere acceptable activities for someone with epilepsy.

2. Methods

2.1. Study population

All clinical officers and nurses employed in or training at registeredhealth care facilities in the Lusaka and Monze districts were eligible toparticipate in the study. Lusaka District encompasses health centers inthe capital and the surrounding urban region. Monze, located in theSouthern Province, serves a rural population. Health care workers wereinvited to participate during working hours. Those willing to completethe questionnaires did so outside of regular working hours and returnedthe surveys anonymously to a research assistant. Respondents were paidZMK 20,000 (�$US 4.00) for their transportation and participation. Thisstudy was reviewed and approved by the University of Zambia’s ResearchEthics Committee as well as Michigan State’s University Committee forResearch Involving Human Subjects.

2.2. Instrument

After reviewing several knowledge, attitudes, beliefs and practicesinstruments used by other groups studying epilepsy [11,18–23], we devel-oped a 48-item questionnaire that elicited information on demographics(6 items), personal experience with epilepsy (3 items), social tolerance (4items), epilepsy care knowledge (25 items, including five clinical vignettes),self-assessment of epilepsy care expertise (5 items), willingness to care forepilepsy (1 item), type of epilepsy care education received in the past(1 item), and perspective of how people with epilepsy/epilepsy are viewedby others (3 items). To assess willingness to provide epilepsy care, respon-dents were asked to indicate, on a scale ranging from 1 to 3, ‘‘how you feelabout providing care for patients’’ with epilepsy as well as eight othercommon conditions. The survey was piloted among health care workersin adjacent health districts to develop the final survey instrument (seeAppendix A). English is the official language in Zambia, the language ofeducation, and was the only language in which this survey was conducted.

2.3. Analysis

Data were double-entered into Microsoft Access for accuracy beforeimportation into EPI INFO Version 3.2.2 for analysis. In addition todescriptive details of the survey results, composite scores were calculatedfor social tolerance and epilepsy care knowledge. Among the items assess-ing personal experience with epilepsy, only the item ‘‘Do you have a closefamily member with epilepsy?’’ exhibited any variability, so no compositescore was developed for personal experience. Epilepsy care knowledgescores were calculated on the basis of the proportion of correct answerson the 22 epilepsy care items that had distinctly correct/incorrect answers,1

with a higher score reflecting more knowledge. Social tolerance scoreswere calculated on the basis of responses to four questions, with higherscores representing more tolerance. Epilepsy care knowledge and socialtolerance were treated as continuous variables in our analyses. Willingnessto provide care for various conditions was rank ordered. Student’s t test orthe v2 test was used to assess how demographic characteristics, type of epi-lepsy care education received, and health care workers’ self-assessment ofepilepsy care expertise related to epilepsy care knowledge scores.

3. Results

Of 300 health care workers eligible and invited to partic-ipate, 276 completed and returned surveys for a responserate of 92%. Demographic details, personal experience withepilepsy, and social tolerance information are provided inTable 1. The average age of respondents was 34, most werefemale (77%), and just more than half resided in urbanareas. More than 98% of respondents knew someone withepilepsy and had witnessed a seizure. A third reported hav-ing a close family member with epilepsy. More than 95% ofhealth care workers reported a willingness to allow theirown child to play with a child with epilepsy and indicatedthat children with epilepsy could attend school. Further-more, 75% of respondents would allow their son or daugh-ter to marry someone with epilepsy.

Tolerance scores ranged from 0 to 4 (mean 2.42, median3.0, mode 3.0, SD 0.96). Knowledge scores ranged from 11to 21 (mean 12.4, median 13.0, mode 13.0). Willingness toprovide epilepsy care ranked fourth among the nine

Table 1Demographic data, personal experience with epilepsy, and social tolerancefor epilepsy (n = 275)

Demographic dataAge

Mean 34.3Median 34.0Mode 28.0Range 19–62

Clinical officersa 22.9%

Male 23.0%

Years of formal educationMean 12.3Median 13Mode 13Range 9–13

Marital status (married) 50.0%

Number of childrenMean 2.5Median 2Mode 0Range 0–11

Urban residence 58.5%

Fluent in Englishb 98.1%

Personal experience with epilepsyHas heard of epilepsy 100%Knows someone with epilepsy 98.2%Has witnessed a seizure 98.2%Has a family member with epilepsy 33.2%

Social toleranceWould allow their child to play with a child with epilepsy 97.1%Would allow son to marry a person with epilepsy 74.8%Would allow daughter to marry a person with epilepsy 73.3%Believes a child with epilepsy should never attend school 3.6%

a Versus nurse.b Fluent in English.

Table 3Epilepsy care knowledge responses (n = 276)

Response %

Epilepsy is due to:Contagious/infectious disease 5.6Head injury 95.9Birth injury 86.2Brain disorder 62.3Mental illness 54.8

Every person who has a convulsionhas epilepsy (answered ‘‘yes’’)

2.9

Available treatments for epilepsyare ‘‘good’’ or ‘‘very good’’

98.8

Epilepsy is a public healthproblem (answered ‘‘yes’’)

52.3

Epilepsy requires chronictreatment (answered ‘‘yes’’)

89.8

Correctly identified drug as AEDa

Aminophylline 100ASA 96.4Carbamazepine 81.5Chlorpromazine 81.5Phenobarbital 88.4Phenytoin 79.3

Recommendations for whatto do when someone has a seizure:Stand back, away from the patient 1.5

E.N. Chomba et al. / Epilepsy & Behavior 10 (2007) 111–119 113

common conditions assessed. More than 95% of healthcare workers reported being willing to care for all of theconditions listed except mental illness, whereas more than15% of respondents indicated that they preferred not totake care of patients with mental illness (Table 2).

Table 2Willingness to provide care (n = 275)

Condition Willingness score ranking(% unwilling to provide carea)

Malaria 1 (0.8)Pneumonia 2 (1.5)Hypertension 3 (1.9)Epilepsy 4 (2.3)

Diabetes mellitis 5 (3.8)Gastroenteritis 6 (3.8)HIV/AIDS 7 (4.5)Tuberculosis 8 (4.9)Mental illness 9 (15.7)

a The higher the score, the less willingness to provide care.

Responses to epilepsy care knowledge-based questionsare provided in Table 3. Although most health care work-ers recognized that epilepsy is not a contagious condition,fewer than 40% characterized it as a brain disorder.Approximately 90% recognize epilepsy as a conditionrequiring chronic treatment, but health care workers’ acutemanagement recommendations were suboptimal andincluded recommendation that something hard be placedin the person’s mouth (58.8%) and the person should beheld down (38.6%). Clinical vignettes were designed todetermine whether health care workers could distinguishprovoked seizures from epilepsy and could diagnose epilep-sy in someone without generalized seizures. Twenty percentof health care workers failed to recognize recurrentcomplex partial seizures as epilepsy, and a similar

Put something hard in his or her mouth 58.8Hold him or her down 38.6Give oxygen 29.4Turn person on his or her side 92.6

VignettesCase 1: Knew that a malaria-induced

seizure was not epilepsy89.7

Case 2: Knew a febrile seizurewas not epilepsy

79.6

Case 3: Knew a hypoglycemic seizurewas not epilepsy

94.5

Case 4: Correctly diagnosed a patientwith generalized tonic–clonic seizures

95.6

Case 5: Correctly diagnosed epilepsyin a patient with complex partial seizures

80.8

a We included only anticonvulsants commonly available in Zambia(phenobarbital, phenytoin, carbamazepine).

Table 4Health care workers’ recommendations on activities people with epilepsycan undertake

Activity Yes (%) No (%) Possibly (%)

Attend school 88.4 0.7 10.8Breastfeed 87.2 0.8 12.0Be employed 81.1 0.4 18.6Marry 80.3 0.4 19.3Dance 62.9 6.4 37.1Do sports 33.6 16.0 50.4Cook 20.4 22.3 57.3See healer 19.8 41.9 38.3Travel 9.1 40.8 50.2Drink alcohol 5.4 73.1 21.5Drive 3.8 65.4 30.8Work with machine 3.8 71.2 25Climb trees 2.3 72.6 25.1Swim 1.9 85.1 13.0


proportion classified recurrent fever-provoked seizures asepilepsy.

Recommendations for activity limitations are summa-rized in Table 4. Overall, health care workers appearappropriately concerned about activities such as cooking(which generally involves exposure to open flames), driv-ing, and swimming, but 20% indicated that people with epi-lepsy should be limited in their capacity to marry or holdemployment.

Characteristics associated with higher epilepsy careknowledge are listed in Table 5. Epilepsy care knowledgescores were significantly higher for health care workerswho had received both theoretic and clinical demonstrationas part of their epilepsy care education (P = 0.02) andthose who had completed training more recently(P = 0.007). There was a trend toward clinical officers pos-sessing higher knowledge scores than nurses (P = 0.07).Health care workers’ reporting higher self-assessments ofepilepsy care knowledge had higher knowledge scores(P < 0.0001). The volume of epilepsy patients diagnosedor treated by the respondents in the past 3 months wasnot associated with knowledge scores (P = 0.61).

In terms of characteristics associated with more socialtolerance, health care workers who reported having afamily member with epilepsy did not demonstrate moresocial tolerance of the condition (3.4 vs 3.5, P = 0.61).

Table 5Characteristics associated with higher epilepsy care knowledge

Characteristic P value

Training (clinical officer 22.9% vs registered nurse 77.1%) 0.07Type of instruction (clinical demonstration + theory 42.9% vs

either alone 57.2%)

0.02

Fewer years since completing training (range 0–33, mean 9.8,

median 8.0)

0.007

Residential status (urban 58.5% vs rural 41.5%) 0.40Willingness to provide care scorea 0.51Has diagnosed case in past 3 months (55.9%) 0.58Has treated case in past 3 months (90.2%) 0.47Self-assessment of epilepsy knowledge (4-point Likert scale) <0.0001

a See Table 2.

With respect to how others view people with epilepsy,health care workers indicated that among their familymembers, people with epilepsy are usually feared (48.1%)or rejected (26.9%), with only 20% of health care workersreporting that people with epilepsy are accepted. Healthcare workers viewed the community as even less supportiveof people with epilepsy, reporting that the communityrejects or fears people with epilepsy 49.8 and 39.0%, respec-tively. Only 7% of health care workers feel that people withepilepsy are accepted by their community.

4. Discussion

Some limitations of this study deserve mention. First,there may have been a bias toward ‘‘socially acceptable’’answers from health care workers, particularly in light ofthe ongoing active campaign by the Epilepsy Associationof Zambia to bring epilepsy out of the shadows at the timethis survey was conducted. However, significant negativeattitudes toward people with epilepsy were still evidentamong health care workers despite these efforts. Our epi-lepsy care knowledge items used in the composite were,by necessity, multiple choice and required, for example,drug recognition rather than recall. And respondents werenot required to provide specific treatment regimens or diag-noses in the case-based scenarios. However, epilepsy careknowledge scores demonstrated reasonable variabilityand correlated well with knowledge self-assessments. Oursample did not include physicians, who may differ fromnonphysician health care workers with respect to medicalexpertise and social tolerance regarding epilepsy. However,because the vast majority of people with epilepsy inZambia cannot access physician-level care, [7], this surveycaptures data on the health care service personnel mostpeople with epilepsy are likely to encounter.

The response rate for our survey was exceptionally high,and the sampling frame (all district health clinic nurses andclinical officers in one urban region and one rural region)provides a representative sample of Zambian health careproviders and gives some valuable insights into epilepsycare in this region. The prevalence of epilepsy in this regionis high [24], and as expected, health care workers have sig-nificant professional and personal experience with the con-dition. Although more than half the health care workers inthis survey appeared to categorize epilepsy as a form ofmental illness, �98% were willing to treat people with epi-lepsy compared with 84% who were willing to treat mentalillness. Clearly, ‘‘mental illness’’ encompasses a number ofdiagnoses including depression, anxiety, and variousschizophrenias. We did not attempt to delineate willingnessto provide care across psychiatric conditions, but suspectsome symptoms represent types of mental illness thathealth care workers are particularly uncomfortable treating(e.g., psychosis).

Health care workers are more socially tolerant of peo-ple with epilepsy relative to Zambian clerics, more than50% of whom would not allow their son or daughter to


marry someone with epilepsy [25]. Zambian health careworkers are almost universally willing to provide carefor people with epilepsy. Unfortunately, significant gapsin epilepsy care knowledge are evident in both the diagno-sis and treatment realms, suggesting that unless peoplewith epilepsy have easier access to physician-level services,nurses and clinical officers require more epilepsy care edu-cation than they are presently receiving. Basic workshop-based training programs aimed at improving provision ofepilepsy care by nonphysician health care providers inZimbabwe have proven successful, at least in the shortterm [26]. In 2000, educational curricula for clinical offi-cers and nurses in Zambia were expanded and enhancedto include more topics in neurologic care. The findingsof this study, that more recent graduates have higher epi-lepsy care knowledge, suggests curriculum changes areassociated with improved knowledge in the long termand are encouraging. Educational programs containingboth didactic and bedside (i.e., practical) training in epi-lepsy care are associated with better knowledge andshould be incorporated into prequalification and contin-uing medical education programs for nonphysician healthcare providers in this region.

In addition to addressing diagnostic and treatmentissues, education programs must also address lifestyle rec-ommendations made by health care providers to peoplewith epilepsy and their families. Further qualitative studiesare needed to explore why �20% of the nurses and clinicalofficers surveyed thought people with epilepsy should notmarry or hold employment, as such negative beliefs aboutthe capacity of people with epilepsy to live full and func-tional lives may worsen stigmatizing attitudes already heldby the general public. Despite social marketing campaigns,from the perspective of health care workers, epilepsy inZambia is still a condition that results in fear andrejection by both the family and the community.

Acknowledgments

Funding for this work was provided by the U.S. NationalInstitutes of Health (NINDS R21 NS48060). Thanks to theChikankata Epilepsy Care Team for assisting with instru-ment pilot testing. We also acknowledge the assistanceprovided by the Zambia Epilepsy Association andDr. Kennedy Malama at Monze Mission Hospital for hiscritical support for this project.

Appendix A. Knowledge, Attitudes, beliefs and practices

survey—Health care workers’ version

1. Please provide the following information:

Age ______Sex hMale hFemaleHighest grade attained ________ Other training________

2. Marital status (please check one)

h Never marriedh Currently married (monogamous)h Currently married (polygamous)h Divorced/separated/widow/widower (not remarried)h Currently married (previously divorced)Number of children ____

3. Residence hCity hRural4. Please indicate your qualifications2:

hNursing studenthCO in traininghZRNhZENhCOGhCOPhOther __________________

5. Year of graduation ___________6. Employment hPublic clinic hPrivate clinic7. Please check the boxes below indicating the languages

you speak.(If nothing is checked, give ‘‘0’’.)

Fluent
Some None
English
Nyanja Bemba Tonga Lozi Other ( ___________ )
8. Have you ever heard or read about the disease called‘‘epilepsy’’?

h Noh Yes—If yes, please give the local names for thisdisease.

9. Have you ever known anyone with epilepsy?

h Yesh Noh Not familiar with epilepsy

10. Have you ever witnessed a seizure?

h Noh Yes—If yes, please check all those things youobserved

h Loss of consciousnessh Tongue bitingh Stiffening


h Loss of urine or stoolh Confusionh Staring

11. Would you allow your child to play with a child whohas epilepsy?


12. ‘‘A child with epilepsy should never attend school.’’

h Trueh Falseh Sometimes trueh Not familiar with epilepsy

13. Would you allow your son to marry a person withepilepsy?


14. Would you allow your daughter to marry a personwith epilepsy?


15. How much do you know about epilepsy?

h Nothingh Littleh Someh A great deal

16. What type of training have you received on epilepsy?

h Theory only (estimate the number oflectures _____ )h Clinical demonstrations only (estimate the number ofpatients seen _____ )h Theory + clinical demonstrations

17. ‘‘Every person who has a convulsion has epilepsy.’’

h Trueh False

18. ‘‘People with epilepsy should always be treated.’’

h Trueh False

19. How effective is the treatment for epilepsy?

h Very goodh Goodh Not helpful

20. Which of the following drugs is used in the treatmentof epilepsy?

(Tick all that apply)

h Aspirinh Carbamazepine/Tegretolh Chlorpromazineh Phenobarbitalh Methyldopah Aminophyllineh Phenytoin/Epineutin

21. List the kinds of epilepsy you know:22. What do you believe are the major causes of epilepsy

in Zambia? Name all that you can.23. What do you believe are the major causes of seizures

in Zambia? Name all that you can.24. Is it possible for some types of epilepsy to run in

families?

h Definitely yesh Possibleh Definitely not possible

25. Is epilepsy a contagious or infectious disease?


26. Can epilepsy be caused by head injury?


27. Can epilepsy be caused by birth asphyxia?


28. Is epilepsy always a brain disorder?



29. Can chronic alcohol drinking lead to epilepsy?


30. Do you think epilepsy can be treated?

h Alwaysh Sometimesh Never

31. Generally, what is the attitude of the family towardthe patient with epilepsy?

h Acceptingh Fearfulh Rejectingh Don’t know

32. What is the length of time people with epilepsy havethe disease?

h Daysh Weeksh Monthsh Years

33. ‘‘Epilepsy is a mental illness’’.

h Trueh False

34. What is the attitude of the community towardpatients with epilepsy?

h Acceptingh Fearfulh Rejectingh Don’t know

35. Health care workers take care of patients with manydifferent medical conditions. Please indicate below how you

feel about providing care for patients with various disordersusing the following scale:

1—I do not mind caring for these patients2—I prefer not to care for these patients3—I refuse to care for these patients

1
2 3
Tuberculosis
Malaria Gastroenteritis
Epilepsy
Hypertension AIDS Mental illness Pneumonia Diabetes
36. Do you believe that epilepsy is a major health prob-lem in Zambia?


37. Please indicate in the table below who may haveepilepsy in Zambia.

Age group
Common Sometimes Never
0–5 years
6–14 years 15–25 years 26–45 years 46–65 years 65+years
38. What activities can a person with epilepsy participatein?

Definitelyyes

Possible
Definitelynot
Get married
Breastfeed Take part in dancing Participate in sports Take beer or otheralcohol Have a job Swim Travel alone Go to healer Drive Cook Work with machines Attend school Climb trees
39. How much experience do you feel you have had inthe care of people with epilepsy?

h A great dealh Someh Fewh None


40. How many cases of epilepsy have you diagnosed inthe past 3 months?

41. How many cases of epilepsy have you treated in thepast 3 months?

42. What would you do for a patient who is having atonic–clonic seizure?

(Tick all that apply)

h Turn the patient on their sideh Give oxygenh Place a hard object in the mouthh Keep your distanceh Hold them down

For the following cases, please indicate if the patient has

epilepsy or not.

43. Case 1: A 2-year-old child with +MPs and a temper-ature of 40 �C has a generalized tonic–clonic seizure. Thechild has never had a seizure before.

h Epilepsyh Not epilepsyh Maybe epilepsyh Don’t know

44. Case 2: A 2-year-old child with +MPs and a tem-perature of 40 �C has a generalized tonic–clonic seizure.The child had a seizure last year, also during a highfever.

h Epilepsyh Not epilepsyh Don’t know

45. Case 3: A diabetic accidentally takes too much insu-lin and the glucose drops very low. While the blood glucoseis low, the patient has a seizure.


46. Case 4: A 14-year-old is brought from school after ageneralized tonic–clinic seizure. The child now looks fine(an hour after the seizure). You are told this has happenedbefore on at least two occasions.


47. Case 5: A patient is brought to you with episodes ofconfusion that begin with staring and sometimes involvestrange movements of the mouth. The patient has nevercompletely lost consciousness or fallen.


48. Do you have a close family member with epilepsy?


Thank you for participating in this survey. We welcomeany comments you have regarding this survey. Please placethem below.

A.1. Comment

2Co, clinical officer; ZRN, registered nurse; ZEN,enrolled nurse; COG, general clinical officer; COP, psychi-atric clinical officer.

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Documents

Zambian health care workers’ knowledge, attitudes, beliefs, and practices regarding epilepsy