KNOWLEDGE AND ATTITUDES AMONG SCHOOL TEACHERS TOWARDS SCHOOL STUDENTS WITH EPILEPSY IN HAIL REGION, KSA.

Background: The knowledge and attitude of school teachers can affect significantly the academic achievement, social development and the quality of life of epileptic students. Objective: To assess the knowledge and attitude of school teachers towards students with epilepsy in Hail, KSA. Methods: This cross-sectional study used a pretested, self-administered, 5-item questionnaire to evaluate the basic knowledge and attitude of Elementary, intermediate, and secondary schools‟ teachers as regards epilepsy. Schools were chosen at random and included private and public schools for male and female students. Results: The study included 342 teachers. 98.8% of the respondents heard about the disease, with no significant association with age (p = 0.205) or gender (p = 0.593). The common reported causes for epilepsy

145 sociodemographic characteristics was assessed using Pearson"s Chi square test for independence, Fisher exact test or Fisher-Freeman-Halton exact test as appropriate. P-value less than 0.05 was considered as statistically significant.

Results:-
In this study, 342 teachers responded to the questionnaire. Table 1 summarizes the sociodemographic characteristics of the respondents. Teachers aged 25 -35 and 36 -45 accounted for 32.7% and 33.9%, respectively. The vast majority were Saudi (99.4%). Female teachers outnumbered the male teachers (68.4% and 31.6%, respectively). Table 2 shows that the vast majority of respondents reported having heard about the disease (98.8%), with no statistically significant difference between the age groups (p = 0.205) or gender (p = 0.593). Figure 1 demonstrates the causes of epilepsy as reported by the respondents. The most frequent causes included mental disease (62.6%), spiritual possession (11.1%), electric charges in the brain (9.9%) and disturbed nerves or nervous system (5.3%). Table 3 shows knowledge of the respondents about epilepsy causes. Only two respondents believed that epilepsy is contagious. There was a significant association between age of the respondents and their beliefs about the causes of epilepsy (p = 0.008). A significantly higher proportion of all age groups thought epilepsy is a mental disease. A significant percentage of those who were aged above 45 years attributed epilepsy to spiritual possession (23.8%) compared to the other age groups. There was no significant association between the respondents" knowledge about epilepsy and gender (p = 0.979).
The attitude of the respondents towards epileptic students is shown in Table 4. About two thirds of respondents admitted that they would not treat epileptic children as their peers. Most respondents (71.3%) stated that they would provide first aid during an epileptic fit. The majority (97.7%) thought that epileptic students should not be prevented from studying. A significant association existed between age and the readiness to provide first aid during epileptic fits (p = 0.012), as the highest percentage was in respondents aged more than 45 years old (84%). There was no significant association between age and each of equal treatment or prevention from studying (p = 0.063 and 0.097). Gender was not significantly associated with attitude (p = 0.812, 0.448 and 0.984).

Discussion:-
This study was conducted to investigate the knowledge and attitude of school teachers towards epilepsy in Hail Region, KSA. Only a limited number of studies have investigated this point in KSA in the regions of Jeddah 19,21 and Khamis Mushate. 20 Up to the best of the researchers" knowledge, the present study is the first of its type in Hail.
The vast majority of teachers in our study reported having heard about the disease (98.8%). In agreement to this result, several studies stated that a high percentage of teachers (70 -97%) reported previous knowledge about epilepsy in Jeddah, KSA 19,21 as well as in other countries including Korea, 22 Turkey, 23 India, 24 Georgia, 25 Nigeria, 26 Pakistan, 27 and Iran. 28 We found that the knowledge of teachers in our study about epilepsy and its causes was inadequate and showed many misconceptions such as epilepsy being a mental disease (62.6%) or caused by spiritual possession (11.1%). Similarly, one study in Jeddah, KSA found that spiritual possession or evil eye were reported by 27% and 22% of teachers as causes of epilepsy, 21 while another study found that epilepsy was considered to be a psychiatric disease or a possession in 43.1% and 40.3% of school teachers. 19 This confusion between mental illness, spiritual possession and epilepsy can be explained by examining the dominant culture in KSA. The Arabic word of "epilepsy" is "Saraa"" and is used by some laypeople as a synonym for the word ""jnoon"" (insanity). Also, it is rooted in the culture of many Arabic countries that possession by "Jinn" could result in convulsions and disturbed consciousness which are the manifestations of epileptic fit [29][30][31] A positive point was that almost all teachers in the present study (except for two) agreed that epilepsy is not contagious. In line with this finding, a study in Khamis Mushate, KSA found that most schoolteachers (82.2%) believed that epilepsy was not infectious 20 . Also, studies in Turkey, 23 Korea, 22 and India 24 found only a small percentage of participating teachers (0.6 -3.3%) who believed epilepsy to be infectious.

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Investigation of the potential effect of age and gender on teachers" knowledge revealed that agebut not genderwas significantly associated with knowledge about causes of epilepsy. A significant percentage of teachers aged above 45 years in our study attributed epilepsy to spiritual possession compared to the other age groups. This could be explained by susceptibility of older people in general to retain cultural beliefs, while the youth may be skeptical about old cultural beliefs and look for other sources of knowledge. Meanwhile, other studies have found an association of good knowledge with female gender. 5,32 A study in KSA found a lack of significant association between teachers" age or gender with their knowledge about epilepsy. 21 The defects in knowledge found in this study and similar previous studies highlight the importance of launching educational programs for epilepsy to school teachers.
As regards the attitudes of teachers towards epileptic children, we found that two thirds agreed that they would not treat epileptic children as their peers. Similar attitudes were reported by previous studies which showed a considerable percentage of teachers refusing to allow their children to play with epileptic patients (38.4%) 24 or to have them in their classrooms (25 -32.2%). 21, 24 Improved educational programs should be able to reduce misconceptions and fears about epilepsy, and thereby minimize the effects of the associated social stigma. 33 The fear of seizures and rejection of epileptic children may contributing to the problem of not knowing how to manage children with epilepsy. 34 Most teachers in the current study (71.3%) were willing to provide first aid during an epileptic fit. However, a study in Thailand showed that half the respondents used improper and potentially harmful measures while providing aid. 35 Also, in a study in Italy, 66% of the teachers declared they were unable to manage a seizing child. 36 Moreover, a study in Khamis Mushate 20 found most of the teachers who witnessed fits of seizures were not able to provide first aid to students as they were not equipped to give care. 20 Misconceptions on first aid may be related to poor educational programs for epilepsy. Therefore, educational programs for epilepsy must be provided to teachers on routine basis and must include training on first aid measures, in order to improve the quality of life for people with epilepsy. 17,37 The majority of teachers in our study (97.7%) thought that epileptic students should not be prevented from studying, which is in agreement with many previous studies. 20,21,38,39 . This attitude appears to be mainly based on the teachers" belief that epileptic students had normal mental and learning abilities. 20,36 We did not find significant association between the attitude of teachers and gender. For age, the highest percentage of teachers who were willing to provide first aid during epileptic fits was in those above 45 years old with statistical significance. This may be attributed to their dealing with different kinds of students with chronic diseases during their long teaching experience.
In conclusion, the school teachers in Hail, KSA had misconceptions about the causes of epilepsy and their attitude is generally positive. Educational programs about diseases among school students -particularly epilepsy -must be a part of the routine preparation and training of school teachers; practical training should encompass also the proper technique of first aid measures during epileptic fits.