KNOWLEDGE , ATTITUDE AND PERCEPTION OF EPILEPSY AMONG TRADITIONAL HEALERS IN UYO , NIGERIA

The poor knowledge of epilepsy among traditional healers is due to cultural prejudices and environment. The resultant deep-rooted misconceptions and myths negatively affect the attitudes and encourage traditional care with high morbidity and mortality. The objectives of the study were to assess knowledge of epilepsy among traditional healers and to determine the modalities used in the care. One hundred and seventy three traditional healers from villages/communities in Uyo were assessed for knowledge; attitude and perception of epilepsy, using an interviewer assisted Attitude Questionnaire. Data from 166 (95.9%) healers, consisting of 123 (71.1%) males and 43 (24.8%) females were analyzed. Many of the healers, 139 (83.7%) had little or no formal education. Knowledge about causes, diagnosis and treatment of epilepsy was poor; 74 (44.6%) attributed the cause of epilepsy to witchcraft, 53 (31.9%) to spiritual attacks, 23 (13.9%) punishment for sins. A total of 121 (72%) of them diagnosed epilepsy through oracles/gods. Majority, 161 (97.0%) of the healers preferred native treatment; 54 (32.5%) appeased gods/ancestors, 47 (28.3%) used herbs, roots/animal residues as cure, 10 (6.0%) preferred spiritual/prayers; while 48 (28.9%) used a combination of the rituals. There were prevalent negative attitudes and perception about epilepsy among the healers, as 146 (88.0%) of them viewed it as contagious; 149 (89.8%) would decline either marrying or eating with epileptic persons. Although traditional healers are frequently involved in the care of epilepsy in our environment, they have little or no scientific knowledge about the condition. Adequate knowledge about epilepsy is essential for diagnosis and treatment. Therefore, there is need to improve the knowledge about epilepsy in order to encourage positive attitudes and care.


INTRODUCTION
Epilepsy is a chronic neurological disorder and one of the oldest conditions known to mankind.The World Health Organization (WHO) working group on the definition of Epilepsy defined it as a chronic disorder characterized by recurrent seizures due to excessive discharge of neurons.The term "epilepsy" is derived from the Greek word 'epilambanein' meaning 'to seize or attack'.It is therefore a phenomenon that seizes or attacks an individual with abnormality in the electrical activity of the brain.It is reported to affect an estimated 50 million people world wide (WHO, 2004).The global prevalence is estimated to be between 0.5-1.0percent.The rate is reported to be higher in developing countries with inadequate medical attention at childbirth, malnutrition, and infections (Hockaday, 1987).
Epilepsy is responsible for an enormous amount of suffering (WHO, 2000).Although, it affects all ages, studies have shown that it is more common in childhood, adolescence and the aging population (Asindi, 1986;Izuroa and Iloeje, 1989).Hall et al (1992) reported that children with febrile convulsion have 3 percent risk of developing the condition.Epilepsy is characterized by paroxysmal recurrent seizure, unprovoked by metabolic or central nervous infections and could result in psychic, motor, sensory and visceral complications (Bannister, 1992).It has been observed that people suffering from epilepsy are often discriminated against in terms of employment opportunities, social relationship and affiliations (Matuja and Rwiza, 1994;Diamantopoplous et al., 2006).The emotional, social and financial impacts of epilepsy are manifested directly by frequent use of medical services and indirectly by prejudices and stigmatizing attitudes toward persons with the disease (WHO, 2004).
The social and cultural melieu of African societies are surrounded and influenced by beliefs in supernatural deities, witchcraft, sorcery and magical powers, particularly with respect to complex illnesses.Anecdotal reports have shown that epilepsy is shrouded with misconceptions because of its perceived cause, presentation and difficulty in management (Carod and Vazquez-Cabrera, 1998;Jilek-Aall, 1999).Earlier studies (Nyame and Biritwum, 1997) have reported the use of herbs/roots or other plant and animal products with various rituals as the main ingredients of traditional remedy.The treatment methods, though popular and culturally acceptable are usually ill-defined, ineffective, and mostly dangerous.
Despite the chronicity and the widely reported high mortality of epilepsy, studies have shown that with proper care more than 70 percent of persons with the illness would live productive and fulfilling lives, free from seizures (WHO, 2004).The most important factor in the management of epilepsy is the clinical history and seizure types that can be identified by clinical characteristics and sometimes by electroencephalogram (EEG) patterns (Morgan et al., 2001).However, the poor level of knowledge about epilepsy results in diverse sentiments and many misconstrue it as mental illness.Therefore, care is usually influenced by deep-rooted societal/cultural beliefs and custom (Matuja and Rwiza, 1994).This perception has been reported to be responsible for the lack of tolerance and negative attitudes toward persons with epilepsy (WHO, 2004).
The combination of sociocultural belief and ignorance about many disease entities in our environment is a barrier to adequate care.With the increasing glamour for integration of traditional medicine into modern care, information on the efficacy of traditional herbs and rituals on neurological conditions are scanty.This study, therefore, aimed at assessing the knowledge of traditional healers in epilepsy, with respect to causes, diagnosis and management.It is hoped that the findings would help in allaying fears and encourage a change of attitude towards people with epilepsy.

Location of the study
The study was carried out in Uyo, the capital city of Akwa Ibom State, situated in the south-south geopolitical region of Nigeria.The State has a population of 3.9 million people, according to the 2006 National population census with half of this population residing in Uyo (WHO, 2007).The State is endowed with both human and natural resources, attracting influx of social and economic activities due to oil exploration in the area.There are many health care facilities including St. Luke's Hospital and the University of Uyo Teaching Hospital in Uyo as the capital.

Data collection
Between January and June 2007, 173 traditional healers from villages and communities in Uyo were assessed for knowledge, attitude to and perception of epilepsy, using an interviewerassisted Attitude Questionnaire.The questionnaire was designed in English and precoded by the researchers.It was later translated into Ibibio which is the local and major language of the area and back-translated into English, for the purpose of retaining the original meanings of items in the questionnaire.With the help of the village planning committees and the village heads, all known traditional healers in each village were identified and the questionnaire administered on them.
The questionnaire consisted of two parts; the first part elicited information on sociodemographic characteristics such as sex, age, marital status and level of education.The second part was used to gather information on causes, reactions to people with epilepsy, involvement and methods employed in the care.Responses were in multiple type form and the respondents were asked to choose the one(s) suitable to them.The Ibibio version was administered on those with little or no education.The interviews were also recorded on tape.These were later played back to extract useful information not captured in the questionnaire, such as details of herbs and types used in the Table 2 shows knowledge, attitude and perception of the healers to epilepsy.One hundred and thirty five (81.3%) healers had witnessed epilepsy in their life; 74 (44.6%) attributed the cause to witchcraft, 53 (31.9%) to spiritual attacks, while 23 (13.9%) claimed it results from punishment for sins and only 5 (3.0%) believed it is a medical condition.A total of 121 (72.9%) of the healers diagnosed epilepsy through oracles/gods, 34 (20.5%)knew it from fellow colleagues and 11 (6.6%) from medical personnel.One hundred and forty six (88.0%) of the healers believed epilepsy is contagious (spread from one person to the other by close contact), 149 (89.8%) would never eat with or marry someone suffering from epilepsy.Of the 166 healers assessed, 161 (97.0%) of them preferred native herbs and rituals as the best form of treatment, while 5 (3.0%) opted for modern care.A total of 47 (28.3%) used herbs, roots/plants and animal residues for treating epilepsy, 54 (32.5%) appeased the gods and ancestors; 48 (28.9%) used a combination of herbs, root/plant and animal residues in addition to appeasing ancestors/gods; 10 (6.0%) preferred spiritual/prayers while 5 (3.0%) would always advise their clients to go to the hospital.With respect to the duration of practice, a total of 142 (85.5%) of the healers had spent 10 years and more in practice, while 96 (57.8%) spent 16 years and above, 46 (27.7%) between 10-15 years and 24 (14.5%)spent less than 10 years in practice.care of epilepsy.Three assistants were recruited and helped in administering the questionnaire on the healers.Prior to the collection of data, the questionnaire was pretested in a pilot study by interviewing 20 traditional healers from a neighbouring community.This was done to acquire experience and determine its applicability among the healers.
The permission to carry out the study was obtained from the Ethics and Research Committee of the University of Uyo Teaching Hospital.

Data analysis
The results of the study were analyzed using Statistical Package for Social Sciences (SPSS 10.0).The qualitative data were precoded to facilitate data entry and analysis.The proportion of knowledge, attitude and reactions of the traditional healers to epilepsy was found from the study group from which simple frequency tables and percentages were created.

RESULTS
A total of 166 traditional healers consisting of 123 (71.1%) males and 43 (24.9%)females were evaluated and data from 7 (4.0%) were discarded due to incomplete information.Majority, 155 (93.4%) of the healers were 40 years and above.Eighty six (51.8%) of them had no formal education, 27 (16.3%)had secondary school and above level of education.Table I shows the sociodemographic characteristics of the healers.

DISCUSSION
The results of this study show the basic demographic characteristics of the healers and a preponderance of male respondents.Of the population of the healers studied, most of them were males and only 25 percent were females.This is in conformity with previous studies (Nyame and Biritwum, 1997).Several factors may have been responsible for the few number of women in the practice.One of such factors may have been the age of the healers.About 75 percent of them were 50 years and above, therefore, the vigor and the task involved in traditional practice are often more strenuous and women especially the older ones may find it difficult to cope.Also in our environment, the custom restrains women especially married ones from certain cultural practices.Furthermore, this study also shows that most of the healers had little or no education and only 16 percent attained secondary school and above level of education.Although this not surprising, it is pertinent to argue that the lack or low level of education could have a negative impact in an attempt to seek whatever available information that may be there about certain disease conditions.Therefore, learning or acquiring knowledge about epilepsy might be difficult.This may have contributed to the continuous and poor level of knowledge among the healers.It may also be reasonable to say that this kind of scenario could make the much vaunted-clamour for integrating traditional care with modern health care delivery system a daunting task, since this would entail the ability to read and seek for new ideas and information.
Another significant finding in this study is the poor level of knowledge in epilepsy among the traditional healers in our environment, with respect to cause, diagnosis and treatment.In this study, 46 percent of the healers attributed the cause of epilepsy to witchcraft, while 32 percent to spiritual attacks and 14 percent to punishment for sins.Thus, the three most common causes of epilepsy were found to be witchcraft, spiritual attacks and punishment for sins in that order.The findings are similar to reports in previous studies (Nyame and Biritwum, 1997;Carod and Vazquez-Cabrera, 1998;Jilek-Aall, 1999).The finding in this study is further supported by the widely held opinion in about 90 percent of the healers studied believing that epilepsy is not a medical condition.The unfounded general sentiment by most of them is not based on any proof.Unfortunately, this has a significant influence in the choice of care.Several reports have shown that the perception to illness determines the nature and type of care, especially in Africans (Erinosho, 1984).Therefore, this rather false perception has been reported to be responsible for the tortuous and long routes many patients take to seek help and care (Abiodun, 1995).With the increasing level of poverty and a strong cultural belief, the false perception could have a negative impact with serious consequences leading to poor quality of life.It has also been reported to have a greater influence on the attitudes of the people toward those with the illness.The revelation that only 3 percent of the healers in this study believed that epilepsy results from brain injury is very unfortunate.This is deceitful and could be dangerous as it has the tendency of forcing more people with epilepsy to regard and accept traditional method of care as the best form of treatment.

F. ABASIUBONG, J. U. EKOTT, E. A. BASSEY, AND E. E. NYONG
The poor knowledge of epilepsy among the healers is also seen in over 70 percent of them claiming to always make the diagnosis of epilepsy through oracles/gods.This is to say the least an ignorance of the importance of clinical history and seizure types that are essential in the diagnosis of epilepsy (Danesi, 1989;Morgan et al., 2001).Therefore, lack of accurate localization of lesions clinically; followed by rational choice of investigations to delineate the lesion and determine the aetiology has cast doubt on the reality and veracity of the oracles/gods.However, the adherence and reliance on deities for diagnosis of diseases is common among Africans and this has been known to affect clinical symptoms as well as health seeking behaviours (Abiodun, 1995;Baiyewu, 2001).It has also been found to be responsible for the mismanagement of many clinical conditions leading to high mortality rates in most cases.
The present study also reveals various modalities adopted by the traditional healers with respect to treatment of epilepsy.Most of the healers either appease gods, use incantations, herb/root/plant and animal products or a combination of the rituals in treating epilepsy.This is similar to reports in previous studies (Nyame and Biritwum, 1997).Evidence abounds of lack of therapeutic effects of traditional herbs/rituals in neurological conditions including epilepsy.The efficacy of these modalities is doubtful and several reports have shown that the identification of the syndrome provides important prognostic information and is always essential in the choice of antiepileptic drugs (Danesi, 1989;Brodie, 2000).It has rightly been observed that parts of the causes of high mortality in epilepsy may be due to lack of scientific methods employed by the carers, especially the traditional healers, and the inability to evaluate the therapeutic efficacies of different modalities used (Oyebola, 1982;Baiyewu, 2001).The implication could be serious with inestimable mental and physical suffering.
Also in this study, there were negative attitudes about epilepsy among the traditional healers.This is a very disturbing phenomenon, an indication of public negative views directed towards people with epilepsy.Although many of the healers claimed to be involved in the care, this study has shown that more than 85 percent of them believed that epilepsy is contagious and would neither eat with nor marry someone with the condition.These negative attitudes are possible origin and sources of public resentments, resulting in widespread discriminations and prejudices.Furthermore, the lack of tolerable attitudes toward people with epilepsy could have a considerable social, economic and emotional impact with the possibility of depriving the victims of necessary social supports and adequate care.Several reports have shown that there is a general apathy and less tolerable attitudes toward persons with epilepsy, including their family members (WHO, 2004).The implication is that those with the illness are usually abused, denied of their basic rights and exposed to public ridicule.Sometimes they are disowned and deliberately kept away from public places due to shame and in order to protect family name or status (Aronu, 1996).The emotional and psychological consequences resulting from this often lead to increased mortality from sudden and unexplained death.
This study had a major constraint in that the sample was not randomly selected since all the healers identified by the village committees or heads were recruited into it.Therefore, the findings cannot be generalized.
In conclusion, there is a general poor level of knowledge about epilepsy in our environment.Despite the involvement of traditional healers in the care, the prevailing attitude and perception to epilepsy are inimical to adequate care and support.Therefore, there is need for massive community enlightenment about epilepsy.Efforts aimed at improving the knowledge of those willing to offer help to the people with the illness should be encouraged.Routine exposure of the healers to workshops and seminars from time to time at the community/village level is necessary to equip them with the required knowledge in epilepsy.Among other things, this will enable them to offer therapeutic measures within the purview of their practice.In the light of high illiteracy level, poor health care facilities and shortage of manpower in many remote areas of our environment, there is need to encourage and supervise genuine traditional practice.This, apart from minimizing the hazards from the wrong choice of management procedure in high risk conditions, would help in reducing the morbidity and mortality associated with them.There is also an urgent need to embark on quality researches with an aim to widening the horizon of traditional medicine thereby uncovering the myth surrounding the practice.