Participants
People with epilepsy aged 12 years and over were recruited as participants via systematic sampling between April 15/2019–May 30/2019 at the neurologic outpatient department of Ayder Comprehensive Specialized Hospital and Mekelle General Hospital.
Study design
An institutional-based cross-sectional study was conducted.
Eligibility criteria
Newly diagnosed epileptic patients and those who were in regular follow-up treatment at the age of 12 years and above were included in the study. However, outpatients unable to speak & hear, and those PWE aged from 12 to 17 years come alone was excluded from the study.
Sample size and sampling procedure
Sample size
The sample size of 296 was determined based on the formula for a single population proportion by assuming the prevalence of depression among epileptic patients was 43.8% [26], confidence level 95%, margin of error 5 and 5% for non-response rate.
Sampling technique and procedure
A systematic random sampling technique was used to select participants from both hospitals. The k value was calculated by dividing the total population to the total sample size (1103/296 ≈ 3). The data was collected in a 6-week duration; the total patient follows in one month was obtained by calculating the average of the previous year of 12 months. The required sample size was proportionally allocated for each hospital. Finally, every 3rd person the data collector was selected the patient from the respected hospital.
Data collection
Data were collected by trained 2 BSc degree health professionals using an interviewer-administered pre-tested questionnaire. The questionnaire consisted of the socio-demographic characteristics (age, sex, marital status, educational level and others) and questions that address the factors associated with depression. Depression was assessed using patient health questionnaires (PHQs).
Data collection procedure
PHQ-9 is one of the most widely used self-report measures of depression. It is a reliable and valid measure of depression in a range of cultural groups and has been validated with psychiatric and non-psychiatric populations with Cronbach’s α range from 0.84 to 0.915 in most of the countries including Africa [30, 31]. In Ethiopia, it was also validated in Afaan Oromo Cronbach’s alpha, 0.84 [32]. It consists of 9 items, and each item four-point Likert scores (not at all ‘0’up to nearly every day ‘3’) to describe a specific behavioral manifestation of depression. A score ≥ 10 is considered as having depression.
Perceived stigma was measured using the KSSE which was developed and validated in Kilifi, Kenya with high internal consistency, Cronbach’s α of 0.91 [22] and adopted to Ethiopia [33, 34]. It is a simple three-point Likert scoring system scored as “not at all” (score of 0), “sometimes” (score of 1), and “always” (score of 2). It has fifteen items and a total score was calculated by the addition of all item scores. The lowest score was 0 and the highest was 30. The 66th percentile was used to categorize the scores [22, 33,34,35].
Social support was assessed by Oslo 3-item social support scale, Oslo 3-item social support scale is a 3-item questionnaire commonly used to asses’ social support. The scale asks about the ease of getting help from neighbors, the number of people the subjects can count on when there are serious problems, and the level of concern people show in what the subject is doing. A sum-index is obtained by adding the raw scores of the three items. The range is 3–14. The scores are interpreted as; 3–8 (poor social support), 9–11 (moderate social support), and 12–14 (strong social support) [36, 37].
For screening of substance use a modified form of ASSIST, developed by the World Health Organization (WHO) an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings was used.
To assess anxiety and stress GAD-7 and modified form of DASS, respectively, were used. GAD-7 is mostly used tool for screening of anxiety by remembering the past 2 weeks. It also contains 7 items with a four Likert item. The tool is cross-culturally validated with the internal consistency of Cronbach’s α = 0.915 [38]. A score greater than or equal to 10 is considered as having moderate to severe anxiety [39].
The DASS 21 is a 21-item self-report questionnaire designed to measure the severity of a range of symptoms common to both Depression and Anxiety stress. However, for this study, I used the modified form of DASS-21 contains 7 items only, which scored from 0 (did not apply to me at all over the last week) to 3 (applied to me very much or most of the time over the past week) with the main focus on to assess the severity of the core symptoms Stress only. This tool is cross-culturally valid measures in China with a Cronbach alpha of = 0.86 and adopted in Ethiopia [40]. A score > 9 is considered as having moderate to severe stress. For that PHQ-9, GAD-7 and the modified form of DASS-21 scores > 9 and the patients become voluntary, they were linked to the psychiatry outpatient department for further screening and management.
Operational definitions
Anxiety: According to Generalized Anxiety Disorder-7 scale people with epilepsy, those who scored > 9 were concluded to have anxiety [39].
Comorbidity: is defined as greater than the coincidental presence of two disorders in the same person without inferring a causal relation [41].
Depression: According to Patient Health Questionnaire-9 scale people with epilepsy, those who score > 9 was concluded to have depression [30, 32, 39].
Nonstigmatized patient: People with epilepsy who score less than or equal to the 66th percentile of the Kilifi stigma scale of epilepsy [22, 33,34,35].
People with epilepsy: People who experienced At least two unprovoked (or reflex) seizures occurring greater than 24 h apart [42].
Perceived stigmatized patient: People with epilepsy who score above the 66th percentile of the Kilifi stigma scale of epilepsy [22, 33,34,35].
Physical abuse: Those acts commission by other persons that cause actual physical harm or have the potential for harm on people with epilepsy [43].
Sexual abuse: Those acts where another person uses an epileptic patient for sexual gratification forcefully [43].
Stress: According to the modified form of depression, anxiety & stress scale people with epilepsy, those who scored > 9 was concluded to have stress [40].
Suicidal ideation: After starting the illness any thoughts about self-harm with deliberate consideration or planning of possible techniques of causing one’s own death [4].
Suicidal attempt: After starting epilepsy any attempt to end one’s own life [44].
Data quality assurance
To keep the quality of the study’s data, the questionnaires were translated into Tigrigna (local language) by professional Tigrigna speaker individuals who had experience and knowledge in mental illness and back-translation to English was performed by a senior specialist who had clinical experiences in institutions for its simplicity and clarity for use.
Two weeks before the actual data collection pre-test was carried out on 5% of the total sample of people with epilepsy in Qiuha General Hospital to ascertain clarity, feasibility, and applicability of the study tools, to estimate the proper time required for answering the questionnaire, and to identify obstacles that may be faced during data collection. The sample in the pre-test was excluded from the entire sample of research work.
In addition, the principal investigator gave a 1-day training for data collectors on the techniques of data collection. Throughout the whole process of data collection confidentiality of the participants was maintained. The collected data were checked daily for completeness.
Data analysis procedure
Data were entered and cleaned using Epi-info version 4.4.3.1 and transferred to Statistical Package for Social Sciences version 25 (SPSS-25) for further analysis. Descriptive statistical analysis was used to estimate the frequencies and percentages of the variables. Binary logistic regression and adjusted odds ratio with a 95% confidence interval was used to identify the associated factors of the outcome variable. All factors with a p value < 0.30 in the bivariate logistic regression were directly entered into the multivariate model. Finally, all p value less than 0.05 will be considered statistically significant.
Ethical consideration
Ethical approval was obtained from the ethical review board of Mekelle University, College of Health Science. A verbal and then written consent form was taken from each participant. For those aged from 12 to 17, written assent was taken from their relatives that s/he comes with them. An information sheet was attached to each questionnaire to provide study details & to tell the rights of the participants. All the collected data were used for this study only. Hard copy completed questionnaires and computer data was kept confidentially.
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