Epilepsy & Behavior 36 (2014) 2–5
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Dental students' knowledge and attitudes toward patients with epilepsy Yazan M. Hassona a,⁎, Ahmad Abd Al-Aziz Mahmoud b, Soukaina M. Ryalat a, Faleh A. Sawair a a b
Department of Oral Surgery, Oral Medicine and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan Department of Prosthodontics, Faculty of Dentistry, The University of Jordan, Amman, Jordan
a r t i c l e
i n f o
Article history: Received 22 February 2014 Revised 27 March 2014 Accepted 12 April 2014 Available online xxxx Keywords: Epilepsy Problem-based learning Systemic diseases in dentistry Jordan
a b s t r a c t Background: Inadequate knowledge and negative attitudes toward epilepsy can affect the provision of health services for patients with epilepsy. Aim: The aim of the present study was to assess the knowledge and attitudes toward epilepsy among clinical dental students in Jordan. Method: The study was conducted using a 21-item questionnaire to assess professional experience with epilepsy, knowledge about epilepsy, social tolerance, and willingness to care for patients with epilepsy among dental students at the University of Jordan. Results: More than one-third of dental students believed that epilepsy is due to insanity or mental illness. Only 45% were able to identify convulsion or shaking as a sign of epilepsy, and more than one-third did not know how to act in case of an epileptic seizure in the dental clinic. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people. About 50% indicated that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there. Conclusion: The results revealed an inadequate level of knowledge and negative attitudes toward epilepsy among dental students at the University of Jordan. There is an urgent need to educate dental students about epilepsy. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a neurological disorder characterized by an enduring predisposition to generate seizures [1]. It is one of the most prevalent brain disorders, with an estimated worldwide prevalence of four to ten per thousand population [2]. Social acceptance of people with epilepsy is largely dependent on several population ideas and often represents a considerable problem for patients and their families. People with epilepsy are still socially discriminated against on the grounds of widespread negative public attitudes, misunderstandings, and defensive behavior [3,4]. Negative attitudes toward patients with epilepsy among health-care workers is particularly important because it can affect the provision of health services for this patient population. In fact, previous studies indicated that there are disparities in the provision of health services including dental care for patients with epilepsy compared with the general population [5]. Studies about attitudes of health-care workers have demonstrated that dental care professionals have a generally negative attitude toward ⁎ Corresponding author at: Department of Oral Surgery, Oral Medicine and Periodontology, Faculty of Dentistry, The University of Jordan, P.O. Box: 11942, Amman, Jordan. Tel.: +962 786220538. E-mail address: [email protected] (Y.M. Hassona).
http://dx.doi.org/10.1016/j.yebeh.2014.04.008 1525-5050/© 2014 Elsevier Inc. All rights reserved.
patients with epilepsy [6,7]. This is generally attributed to social and cultural beliefs. However, the contribution of knowledge and experience acquired during undergraduate training on the attitude of dental professionals toward patients with epilepsy is unknown. Assessing the knowledge and attitudes of dental students toward epilepsy is vital because they represent the future workforce in the field of dentistry. Therefore, the purpose of the present study was to assess the knowledge, attitudes, and practice of dental students toward patients with epilepsy in Jordan. The findings of the present study will help in identifying deficiencies in knowledge about epilepsy among dental students and factors that might influence their attitude toward patients with epilepsy. 2. Materials and methods This study was conducted at the Faculty of Dentistry at the University of Jordan, Amman. The Faculty of Dentistry Research Ethics Committee reviewed and approved the study. All dental students in the clinical years (4th year and 5th year) were eligible to participate in the study. A questionnaire developed by Aragon et al. [6] was slightly modified and employed in the present study. The questionnaires were distributed near the end of the academic year to all 4th- and 5th-year students at their clinical sessions and were returned once completed. Incompletely filled questionnaires were excluded. The questionnaire elicited information about demographics (3 items), personal experience with
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
epilepsy (2 items), knowledge about epilepsy (4 items), social tolerance (4 items), current practice (3 items), and willingness to care for patients with epilepsy (5 items). Responses to knowledge questions were assessed as correct or incorrect, and knowledge scores were calculated for each respondent. A score of 10 indicated that the student answered all the factual questions about epilepsy correctly, and a score of zero indicated that the student did not answer any question correctly. Statistical analysis was performed using SPSS for Windows release 17.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were generated. Student's t-test was used to examine differences between groups. Results were considered significant if P-values were less than 0.05. 3. Results 3.1. Demographic characteristics and personal experience with epilepsy Of the 214 dental students registered in the 4th and the 5th year level during the academic year 2012–2013, 171 returned completely filled questionnaires and were included in the study (response rate: 79.9%). The mean age of the survey respondents was 22.1 ± 0.81 years (range: 22–24 years), with 66.1% being female. Only 38% of the respondents knew someone with epilepsy, and 33.3% had witnessed epileptic seizures (Table 1). 3.2. Knowledge about epilepsy (Table 2) About one-third of the respondents attributed the cause of epilepsy to brain tumors (39.8%) and insanity (38%) followed by accidents (31.6%), inherited disease (29.8%), birth defects (29.2%), and stroke (25.1%). Nearly 39.8% attributed epilepsy to all the above mentioned causes, and 9.9% did not know the cause of epilepsy. Although convulsion or shaking is the most familiar recognizable feature of epilepsy, only 45% of the dental students were able to identify it as a sign of epilepsy. Very few of the respondents were aware that loss of consciousness (24.6%), behavioral change (18.7%), and period of memory disturbance (17.5%) are features of epilepsy. Most dental students (71.9%) agreed that medical history and physical examination cannot identify all patients with epilepsy. In answers to questions about treatment of epilepsy, the majority of students (87.7%) believed that medications can effectively control epileptic seizures. However, only 18.1% of the students did know that antiepileptic drugs can occasionally produce malformations in babies of mothers with epilepsy, and 19.9% were aware of the fact that antiepileptic drugs have advanced significantly over the past 10 years. In case of epileptic seizures in the dental clinic, 56.7% would move patients to an area where they cannot hurt themselves, and 54.4% would call for emergency help if the seizure lasted more than 3 min. Disappointingly, 25.7% of the students thought that they should put something in the patient's
3
Table 2 Dental students' responses to multiple choice questions about their knowledge of epilepsy. Questions and responses
Number of respondents who answered yes for each choice (%)
Cause of epilepsy Inherited diseasea Accidenta Insanity Brain tumorsa Birth defectsa Strokea All of the above Don't know
51 (29.8) 54 (31.6) 65 (38) 68 (39.8) 50 (29.2) 43 (25.1) 68 (39.8) 17 (9.9)
An epileptic attack is A convulsion or shaking A loss of consciousness An episode of behavioral change A period of memory disturbance Any of the abovea Don't know
77 (45) 42 (24.6) 32 (18.7) 30 (17.5) 97 (56.7) 8 (4.7)
Drug therapy in epilepsy Is seldom effective in controlling seizures Is best given as two or more drugs that work together Has advanced significantly over the past 10 yearsa Occasionally produces malformations in babies of mothersa with epilepsy Can be stopped abruptly after seizures are controlled for a year All of the above Don't know Epileptic seizure in the dental chair Put something in the patient's mouth to prevent him/her from choking with his/her tongue Hold the patient tight so the patient stops shaking Put the patient in the Trendelenburg position Administer oxygen Call emergency immediately Time it, and if it exceeds 3 min, call emergencya Move the patient to an area where he/she cannot hurt him/herself while having the seizurea a
21 (12.3) 44 (25.7) 34 (19.9) 31 (18.1) 16 (9.4) 47 (27.5) 50 (29.2)
44 (25.7) 19 (11.1) 32 (18.7) 18 (10.5) 39 (22.8) 93 (53.4) 97 (56.7)
Indicates the correct answers.
mouth to prevent him/her from choking with his/her tongue, and 11.1% thought that they should hold the patient tight to stop him/her from shaking. Students' knowledge about epilepsy was much less than adequate. The mean knowledge score was 3.61 out of 10 (±2.12). There was no significant association between the students' gender and year of study and their knowledge about epilepsy (P N 0.05) (Table 3). 3.3. Social tolerance toward people with epilepsy
Table 1 Demographic data of dental students and their personal experience with epilepsy. Factor Gender Male Female Year of study 4th year 5th year
Number of respondents (%) 58 (33.9) 113 (66.1)
91 (53.2) 80 (46.8)
Do you know or have ever known anyone with epilepsy Yes No
65 (38) 106 (26)
Have you ever seen anyone having epileptic seizure Yes No
57 (33.3) 114 (66.7)
About one-third of the students would object to their children having an association with persons with epilepsy or their relatives getting married with a person with a history of epilepsy. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people (Table 4). 3.4. Students' clinical experience and attitude toward providing dental treatment to patients with epilepsy Only 13 (7.6%) students treated patients with epilepsy during their clinical course. Although more than 95% of the respondents assumed that they have an ethical responsibility to treat patients with epilepsy, 11.7% refused providing dental treatment to patients with epilepsy. When asked about the reasons for refusal, 88.3% of the students reported that they were afraid of epileptic seizures during dental treatment
4
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
Table 3 Effect of gender and year of study on dental students' knowledge about epilepsy. Knowledge score was calculated for each student by adding the number of correct answers. The minimum score was zero, and the maximum score was 10. Variable Gender Male (no = 85) Female (no = 113) Year of study 4th (no = 91) 5th (no = 80)
Mean knowledge score (±sd)
P value 0.98
3.64 (±2.15) 3.61 (±2.13) 0.87 3.62 (±2.14) 3.58 (±2.15)
and were unsure about their ability to manage this emergency. Nearly half of the respondents indicated that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there (Table 5). 4. Discussion Epilepsy is one of the most common chronic neurological disorders. It affects nearly 50 million people in the world, with 85% living in developing countries [8]. The exact prevalence of epilepsy in Jordan is unknown; however, it has been estimated that about three quarter million people with epilepsy live in the Arab world [9]. This figure is probably a serious underestimate given that the Arab world has a population of more than 350 million people [10]. Possible reasons are the lack of large scale epidemiological studies in the Arab region and people's reluctance to disclose epilepsy because of social stigma. Previous research has indicated that there might be disparities in the provision of dental care for patients with epilepsy [5]. One possible reason is that dental professionals might have a lack of knowledge about epilepsy and negative attitudes toward patients with epilepsy. Dental students are the workforce of the future; therefore, assessing their knowledge and attitudes toward patients with epilepsy is vital. To the best of our knowledge, this is the first study to examine the knowledge and attitudes toward epilepsy among dental students. In the present study, we surveyed clinical dental students (4th- and 5th-year students) at the University of Jordan to determine their knowledge and attitudes toward epilepsy and their willingness to provide dental care for people with epilepsy. In addition, we wanted to evaluate the adequacy of the clinical training program in providing dental students with the necessary knowledge and experience to deal with patients who have epilepsy. Only 4th- and 5th-year dental students were included in the present study because 1st-, 2nd-, and 3rd-year students are enrolled in a preclinical training program and do not have any contact with patients [11]. The result of our study indicates that the level of students' knowledge about epilepsy was far from adequate. Our students lacked knowledge about the causes of the disease and the teratogenicity of antiepileptic drugs. More than one-third of the students believed that
Table 4 Dental students' response to questions about their social tolerance toward patients with epilepsy. Question
Number of respondents (%)
Would you object to your children associating with somebody with epilepsy? Would you object to your relatives marrying somebody with epilepsy? Do you think that people with epilepsy should have children? Do you think that people with epilepsy can be employed anywhere?
Yes No Yes No Yes No Yes No
66 (38.6) 105 (61.4) 65 (38) 106 (62) 95 (55.6) 76 (44.4) 66 (38.6) 105 (61.4)
epilepsy is due to insanity or mental illness. In addition, only 45% were able to identify convulsion or shaking as a sign of epilepsy. Of concern is the finding that more than one-third of the students did not know how to act in case of an epileptic seizure in the dental clinic. One quarter of the students would place something in the patient's mouth, 18.7% would put the patient in the Trendelenburg position, and 11.1% would hold the patient tight, actions that are not recommended for patients having a seizure [12]. The lack of knowledge about epilepsy among our students could be attributed to their limited clinical exposure to patients with epilepsy. In fact, almost all students (88.3%) felt that they do not have enough knowledge and training to provide dental treatment for patients with epilepsy. The current method for teaching medicine to dental students is based upon theoretical didactic lectures, a method that might not be the most appropriate for to dental students. It has been suggested that problem-based learning (PBL) enhances the ability of students in applying their knowledge to clinical situations without negatively influencing the acquisition of factual knowledge [13]. Therefore, adopting the PBL method to teach topics such as systemic diseases such as epilepsy to dental students might help in overcoming the gap in students' knowledge. Further studies, however, are needed to test this hypothesis. The lack of knowledge about epilepsy might adversely affect the provision of dental care for this patient population. In fact, 11.7% of our students reported that they have refused providing dental treatment to patients with epilepsy mainly due to lack of knowledge. Therefore, taking actions to improve students' knowledge about epilepsy and the management of epileptic seizures is important. In addition, the results of our survey indicate that dental students at the University of Jordan have limited experience in providing dental care for patients with epilepsy; only 7.6% of the students treated patients with epilepsy during their clinical training. This figure, however, might be an underestimate as many patients might be reluctant to disclose epilepsy because of social stigma and fear of rejection [14]. Unfortunately, there are no other studies that have examined the knowledge of dental students about epilepsy; therefore, it might be difficult to compare our results. Further studies from other institutions are encouraged. In general, attitudes toward people with epilepsy were negative. About one-third of the students would object to their children having an association with persons with epilepsy or their relatives getting married with a person with a history of epilepsy. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people. Studies among Canadian and Indian dentists demonstrated higher levels of social acceptance and positive attitudes toward patients with epilepsy [6,7]. The reasons behind these differences are unknown, but social, cultural, and family factors might be important. In fact, nearly 50% of the students reported that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there. The attitudes of our dental students were similar to the general public attitude toward epilepsy in Jordan. Daoud et al. reported that the overall attitude of Jordanian public toward epilepsy was negative and that the Jordanian community compares with the Asian communities but lags behind the western countries regarding knowledge and attitudes toward epilepsy [15]. The negative attitudes of dental students toward patients with epilepsy are likely to continue during their professional life; therefore, dental schools and health authorities need to take actions to raise the awareness about epilepsy and the social acceptance of patients with epilepsy. The present study possesses certain limitations. It did not examine social factors such as the social class, income, education of parents, and area of residence. These factors might influence students' attitudes toward patients with epilepsy; therefore, future studies are encouraged
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
5
Table 5 Responses related to students' clinical experience and willingness to treat patients with epilepsy. Response
Number of responses (%) Strongly agree
Medical history and physical examinations cannot identify all patients with epilepsy I feel that I have enough knowledge and training in providing dental treatments for epileptic patients in my future dental practice My family would be concerned if I treated patients with epilepsy If I treat patients with epilepsy, other patients may be reluctant to continue in my care As a dentist I have an ethical responsibility to treat patients with epilepsy
to take these factors into consideration. In addition, future studies are encouraged to replicate this study among dental students of other dental schools and among other health-care workers. It will be also interesting to examine the effect of changing the current teaching method on students' knowledge and attitudes toward patients with epilepsy.
5. Conclusion Despite its limitations, the present study has demonstrated that dental students at the University of Jordan have less than adequate knowledge about epilepsy and generally negative attitudes toward patients with epilepsy. Inadequate knowledge among dental students can adversely affect their willingness to provide dental treatment to patients with epilepsy in their future practice. Improving dental students' knowledge about epilepsy is, therefore, urgently needed. Adopting an alternative teaching method such as PBL might help in overcoming the gap in students' knowledge. In addition, raising public and professional awareness about epilepsy is needed to reduce the limitations encountered by people with epilepsy and their families. The ministries of health and education have important roles to play in this challenging task.
Conflict of interest None declared.
Agree
Disagree
Strongly disagree
47 (27.5) 4 (2.3)
76 (44.4) 16 (9.4)
40 (23.4) 64 (37.4)
8 (4.7) 87 (50.9)
25 (14.6) 8 (4.7) 106 (62)
71 (41.5) 47 (27.5) 57 (33.3)
45 (26.3) 78 (45.6) 5 (2.9)
30 (17.5) 38 (22.2) 3 (1.8)
References [1] Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005;46:470–2. [2] Scott RA, Lhatoo SD, Sander JWAS. The treatment of epilepsy in developing countries. Where do we go from here? Bull WHO 2001;79:344–51. [3] Mirnics Z, Czikora G, Závecz T, Halász P. Changes in public attitudes toward epilepsy in Hungary: results of surveys conducted in 1994 and 2000. Epilepsia 2001;42:86–93. [4] Young GB, Derry P, Hutchinson I, et al. An epilepsy questionnaire study of knowledge and attitudes in Canadian college students. Epilepsia 2002;43:652–8. [5] Károlyházy K, Kovács E, Kivovics P, Fejérdy P, Arányi Z. Dental status and oral health of patients with epilepsy: an epidemiologic study. Epilepsia 2003;44:1103–8. [6] Aragon CE, Hess T, Burneo JG. Knowledge and attitudes about epilepsy: a survey of dentists in London, Ontario. J Can Dent Assoc 2009;75:450. [7] Doshi D, Reddy BS, Kulkarni S, Karunakar P. N A. Dentists' knowledge, attitudes and practices toward patients with epilepsy in Hyderabad City, India. Epilepsy Behav 2012;23:447–50. [8] World Health Organization. Atlas: epilepsy care in the world. Available: www.who. int/mental_health/neurology/Epilepsy_ph_aspects2_rev1.pdf; 2005. [9] Benamer HT, Grosset DG. A systematic review of the epidemiology of epilepsy in Arab countries. Epilepsia 2009;50:2301–4. [10] World Health Organization. Epilepsy in the WHO Eastern Mediterranean region: bridging the gap. Retrieved from www.emro.who.int/dsaf/dsa1039.pdf; 2010. [11] Ryalat ST, Sawair FA, Shayyab MH, Amin WM. The knowledge and attitude about HIV/AIDS among Jordanian dental students: (clinical versus pre clinical students) at the University of Jordan. BMC Res Notes 2011;15(4):191. [12] Aragon CE, Burneo JG. Understanding the patient with epilepsy and seizures in the dental practice. J Can Dent Assoc 2007;73:71–6. [13] Bassir SH, Sadr-Eshkevari P, Amirikhorheh S, Karimbux NY. Problem-based learning in dental education: a systematic review of the literature. J Dent Educ 2014;78:98–109. [14] Thomas SV, Nair A. Confronting the stigma of epilepsy. Ann Indian Acad Neurol 2009;14:158–63. [15] Daoud A, Al-Safi S, Otoom S, Wahba L, Alkofahi A. Public knowledge and attitudes towards epilepsy in Jordan. Seizure 2007;16:521–6.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Dental students' knowledge and attitudes toward patients with epilepsy Yazan M. Hassona a,⁎, Ahmad Abd Al-Aziz Mahmoud b, Soukaina M. Ryalat a, Faleh A. Sawair a a b
Department of Oral Surgery, Oral Medicine and Periodontology, Faculty of Dentistry, University of Jordan, Amman, Jordan Department of Prosthodontics, Faculty of Dentistry, The University of Jordan, Amman, Jordan
a r t i c l e
i n f o
Article history: Received 22 February 2014 Revised 27 March 2014 Accepted 12 April 2014 Available online xxxx Keywords: Epilepsy Problem-based learning Systemic diseases in dentistry Jordan
a b s t r a c t Background: Inadequate knowledge and negative attitudes toward epilepsy can affect the provision of health services for patients with epilepsy. Aim: The aim of the present study was to assess the knowledge and attitudes toward epilepsy among clinical dental students in Jordan. Method: The study was conducted using a 21-item questionnaire to assess professional experience with epilepsy, knowledge about epilepsy, social tolerance, and willingness to care for patients with epilepsy among dental students at the University of Jordan. Results: More than one-third of dental students believed that epilepsy is due to insanity or mental illness. Only 45% were able to identify convulsion or shaking as a sign of epilepsy, and more than one-third did not know how to act in case of an epileptic seizure in the dental clinic. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people. About 50% indicated that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there. Conclusion: The results revealed an inadequate level of knowledge and negative attitudes toward epilepsy among dental students at the University of Jordan. There is an urgent need to educate dental students about epilepsy. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Epilepsy is a neurological disorder characterized by an enduring predisposition to generate seizures [1]. It is one of the most prevalent brain disorders, with an estimated worldwide prevalence of four to ten per thousand population [2]. Social acceptance of people with epilepsy is largely dependent on several population ideas and often represents a considerable problem for patients and their families. People with epilepsy are still socially discriminated against on the grounds of widespread negative public attitudes, misunderstandings, and defensive behavior [3,4]. Negative attitudes toward patients with epilepsy among health-care workers is particularly important because it can affect the provision of health services for this patient population. In fact, previous studies indicated that there are disparities in the provision of health services including dental care for patients with epilepsy compared with the general population [5]. Studies about attitudes of health-care workers have demonstrated that dental care professionals have a generally negative attitude toward ⁎ Corresponding author at: Department of Oral Surgery, Oral Medicine and Periodontology, Faculty of Dentistry, The University of Jordan, P.O. Box: 11942, Amman, Jordan. Tel.: +962 786220538. E-mail address: [email protected] (Y.M. Hassona).
http://dx.doi.org/10.1016/j.yebeh.2014.04.008 1525-5050/© 2014 Elsevier Inc. All rights reserved.
patients with epilepsy [6,7]. This is generally attributed to social and cultural beliefs. However, the contribution of knowledge and experience acquired during undergraduate training on the attitude of dental professionals toward patients with epilepsy is unknown. Assessing the knowledge and attitudes of dental students toward epilepsy is vital because they represent the future workforce in the field of dentistry. Therefore, the purpose of the present study was to assess the knowledge, attitudes, and practice of dental students toward patients with epilepsy in Jordan. The findings of the present study will help in identifying deficiencies in knowledge about epilepsy among dental students and factors that might influence their attitude toward patients with epilepsy. 2. Materials and methods This study was conducted at the Faculty of Dentistry at the University of Jordan, Amman. The Faculty of Dentistry Research Ethics Committee reviewed and approved the study. All dental students in the clinical years (4th year and 5th year) were eligible to participate in the study. A questionnaire developed by Aragon et al. [6] was slightly modified and employed in the present study. The questionnaires were distributed near the end of the academic year to all 4th- and 5th-year students at their clinical sessions and were returned once completed. Incompletely filled questionnaires were excluded. The questionnaire elicited information about demographics (3 items), personal experience with
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
epilepsy (2 items), knowledge about epilepsy (4 items), social tolerance (4 items), current practice (3 items), and willingness to care for patients with epilepsy (5 items). Responses to knowledge questions were assessed as correct or incorrect, and knowledge scores were calculated for each respondent. A score of 10 indicated that the student answered all the factual questions about epilepsy correctly, and a score of zero indicated that the student did not answer any question correctly. Statistical analysis was performed using SPSS for Windows release 17.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were generated. Student's t-test was used to examine differences between groups. Results were considered significant if P-values were less than 0.05. 3. Results 3.1. Demographic characteristics and personal experience with epilepsy Of the 214 dental students registered in the 4th and the 5th year level during the academic year 2012–2013, 171 returned completely filled questionnaires and were included in the study (response rate: 79.9%). The mean age of the survey respondents was 22.1 ± 0.81 years (range: 22–24 years), with 66.1% being female. Only 38% of the respondents knew someone with epilepsy, and 33.3% had witnessed epileptic seizures (Table 1). 3.2. Knowledge about epilepsy (Table 2) About one-third of the respondents attributed the cause of epilepsy to brain tumors (39.8%) and insanity (38%) followed by accidents (31.6%), inherited disease (29.8%), birth defects (29.2%), and stroke (25.1%). Nearly 39.8% attributed epilepsy to all the above mentioned causes, and 9.9% did not know the cause of epilepsy. Although convulsion or shaking is the most familiar recognizable feature of epilepsy, only 45% of the dental students were able to identify it as a sign of epilepsy. Very few of the respondents were aware that loss of consciousness (24.6%), behavioral change (18.7%), and period of memory disturbance (17.5%) are features of epilepsy. Most dental students (71.9%) agreed that medical history and physical examination cannot identify all patients with epilepsy. In answers to questions about treatment of epilepsy, the majority of students (87.7%) believed that medications can effectively control epileptic seizures. However, only 18.1% of the students did know that antiepileptic drugs can occasionally produce malformations in babies of mothers with epilepsy, and 19.9% were aware of the fact that antiepileptic drugs have advanced significantly over the past 10 years. In case of epileptic seizures in the dental clinic, 56.7% would move patients to an area where they cannot hurt themselves, and 54.4% would call for emergency help if the seizure lasted more than 3 min. Disappointingly, 25.7% of the students thought that they should put something in the patient's
3
Table 2 Dental students' responses to multiple choice questions about their knowledge of epilepsy. Questions and responses
Number of respondents who answered yes for each choice (%)
Cause of epilepsy Inherited diseasea Accidenta Insanity Brain tumorsa Birth defectsa Strokea All of the above Don't know
51 (29.8) 54 (31.6) 65 (38) 68 (39.8) 50 (29.2) 43 (25.1) 68 (39.8) 17 (9.9)
An epileptic attack is A convulsion or shaking A loss of consciousness An episode of behavioral change A period of memory disturbance Any of the abovea Don't know
77 (45) 42 (24.6) 32 (18.7) 30 (17.5) 97 (56.7) 8 (4.7)
Drug therapy in epilepsy Is seldom effective in controlling seizures Is best given as two or more drugs that work together Has advanced significantly over the past 10 yearsa Occasionally produces malformations in babies of mothersa with epilepsy Can be stopped abruptly after seizures are controlled for a year All of the above Don't know Epileptic seizure in the dental chair Put something in the patient's mouth to prevent him/her from choking with his/her tongue Hold the patient tight so the patient stops shaking Put the patient in the Trendelenburg position Administer oxygen Call emergency immediately Time it, and if it exceeds 3 min, call emergencya Move the patient to an area where he/she cannot hurt him/herself while having the seizurea a
21 (12.3) 44 (25.7) 34 (19.9) 31 (18.1) 16 (9.4) 47 (27.5) 50 (29.2)
44 (25.7) 19 (11.1) 32 (18.7) 18 (10.5) 39 (22.8) 93 (53.4) 97 (56.7)
Indicates the correct answers.
mouth to prevent him/her from choking with his/her tongue, and 11.1% thought that they should hold the patient tight to stop him/her from shaking. Students' knowledge about epilepsy was much less than adequate. The mean knowledge score was 3.61 out of 10 (±2.12). There was no significant association between the students' gender and year of study and their knowledge about epilepsy (P N 0.05) (Table 3). 3.3. Social tolerance toward people with epilepsy
Table 1 Demographic data of dental students and their personal experience with epilepsy. Factor Gender Male Female Year of study 4th year 5th year
Number of respondents (%) 58 (33.9) 113 (66.1)
91 (53.2) 80 (46.8)
Do you know or have ever known anyone with epilepsy Yes No
65 (38) 106 (26)
Have you ever seen anyone having epileptic seizure Yes No
57 (33.3) 114 (66.7)
About one-third of the students would object to their children having an association with persons with epilepsy or their relatives getting married with a person with a history of epilepsy. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people (Table 4). 3.4. Students' clinical experience and attitude toward providing dental treatment to patients with epilepsy Only 13 (7.6%) students treated patients with epilepsy during their clinical course. Although more than 95% of the respondents assumed that they have an ethical responsibility to treat patients with epilepsy, 11.7% refused providing dental treatment to patients with epilepsy. When asked about the reasons for refusal, 88.3% of the students reported that they were afraid of epileptic seizures during dental treatment
4
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
Table 3 Effect of gender and year of study on dental students' knowledge about epilepsy. Knowledge score was calculated for each student by adding the number of correct answers. The minimum score was zero, and the maximum score was 10. Variable Gender Male (no = 85) Female (no = 113) Year of study 4th (no = 91) 5th (no = 80)
Mean knowledge score (±sd)
P value 0.98
3.64 (±2.15) 3.61 (±2.13) 0.87 3.62 (±2.14) 3.58 (±2.15)
and were unsure about their ability to manage this emergency. Nearly half of the respondents indicated that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there (Table 5). 4. Discussion Epilepsy is one of the most common chronic neurological disorders. It affects nearly 50 million people in the world, with 85% living in developing countries [8]. The exact prevalence of epilepsy in Jordan is unknown; however, it has been estimated that about three quarter million people with epilepsy live in the Arab world [9]. This figure is probably a serious underestimate given that the Arab world has a population of more than 350 million people [10]. Possible reasons are the lack of large scale epidemiological studies in the Arab region and people's reluctance to disclose epilepsy because of social stigma. Previous research has indicated that there might be disparities in the provision of dental care for patients with epilepsy [5]. One possible reason is that dental professionals might have a lack of knowledge about epilepsy and negative attitudes toward patients with epilepsy. Dental students are the workforce of the future; therefore, assessing their knowledge and attitudes toward patients with epilepsy is vital. To the best of our knowledge, this is the first study to examine the knowledge and attitudes toward epilepsy among dental students. In the present study, we surveyed clinical dental students (4th- and 5th-year students) at the University of Jordan to determine their knowledge and attitudes toward epilepsy and their willingness to provide dental care for people with epilepsy. In addition, we wanted to evaluate the adequacy of the clinical training program in providing dental students with the necessary knowledge and experience to deal with patients who have epilepsy. Only 4th- and 5th-year dental students were included in the present study because 1st-, 2nd-, and 3rd-year students are enrolled in a preclinical training program and do not have any contact with patients [11]. The result of our study indicates that the level of students' knowledge about epilepsy was far from adequate. Our students lacked knowledge about the causes of the disease and the teratogenicity of antiepileptic drugs. More than one-third of the students believed that
Table 4 Dental students' response to questions about their social tolerance toward patients with epilepsy. Question
Number of respondents (%)
Would you object to your children associating with somebody with epilepsy? Would you object to your relatives marrying somebody with epilepsy? Do you think that people with epilepsy should have children? Do you think that people with epilepsy can be employed anywhere?
Yes No Yes No Yes No Yes No
66 (38.6) 105 (61.4) 65 (38) 106 (62) 95 (55.6) 76 (44.4) 66 (38.6) 105 (61.4)
epilepsy is due to insanity or mental illness. In addition, only 45% were able to identify convulsion or shaking as a sign of epilepsy. Of concern is the finding that more than one-third of the students did not know how to act in case of an epileptic seizure in the dental clinic. One quarter of the students would place something in the patient's mouth, 18.7% would put the patient in the Trendelenburg position, and 11.1% would hold the patient tight, actions that are not recommended for patients having a seizure [12]. The lack of knowledge about epilepsy among our students could be attributed to their limited clinical exposure to patients with epilepsy. In fact, almost all students (88.3%) felt that they do not have enough knowledge and training to provide dental treatment for patients with epilepsy. The current method for teaching medicine to dental students is based upon theoretical didactic lectures, a method that might not be the most appropriate for to dental students. It has been suggested that problem-based learning (PBL) enhances the ability of students in applying their knowledge to clinical situations without negatively influencing the acquisition of factual knowledge [13]. Therefore, adopting the PBL method to teach topics such as systemic diseases such as epilepsy to dental students might help in overcoming the gap in students' knowledge. Further studies, however, are needed to test this hypothesis. The lack of knowledge about epilepsy might adversely affect the provision of dental care for this patient population. In fact, 11.7% of our students reported that they have refused providing dental treatment to patients with epilepsy mainly due to lack of knowledge. Therefore, taking actions to improve students' knowledge about epilepsy and the management of epileptic seizures is important. In addition, the results of our survey indicate that dental students at the University of Jordan have limited experience in providing dental care for patients with epilepsy; only 7.6% of the students treated patients with epilepsy during their clinical training. This figure, however, might be an underestimate as many patients might be reluctant to disclose epilepsy because of social stigma and fear of rejection [14]. Unfortunately, there are no other studies that have examined the knowledge of dental students about epilepsy; therefore, it might be difficult to compare our results. Further studies from other institutions are encouraged. In general, attitudes toward people with epilepsy were negative. About one-third of the students would object to their children having an association with persons with epilepsy or their relatives getting married with a person with a history of epilepsy. Disappointingly, 43.4% of the respondents were of the opinion that people with epilepsy should not have children, and only 38.6% thought that people with epilepsy should be employed at the same jobs as other people. Studies among Canadian and Indian dentists demonstrated higher levels of social acceptance and positive attitudes toward patients with epilepsy [6,7]. The reasons behind these differences are unknown, but social, cultural, and family factors might be important. In fact, nearly 50% of the students reported that their families would be concerned about them treating patients with epilepsy, and 30% believed that knowing that patients with epilepsy were treated in their clinic might make other patients reluctant to continue their treatment there. The attitudes of our dental students were similar to the general public attitude toward epilepsy in Jordan. Daoud et al. reported that the overall attitude of Jordanian public toward epilepsy was negative and that the Jordanian community compares with the Asian communities but lags behind the western countries regarding knowledge and attitudes toward epilepsy [15]. The negative attitudes of dental students toward patients with epilepsy are likely to continue during their professional life; therefore, dental schools and health authorities need to take actions to raise the awareness about epilepsy and the social acceptance of patients with epilepsy. The present study possesses certain limitations. It did not examine social factors such as the social class, income, education of parents, and area of residence. These factors might influence students' attitudes toward patients with epilepsy; therefore, future studies are encouraged
Y.M. Hassona et al. / Epilepsy & Behavior 36 (2014) 2–5
5
Table 5 Responses related to students' clinical experience and willingness to treat patients with epilepsy. Response
Number of responses (%) Strongly agree
Medical history and physical examinations cannot identify all patients with epilepsy I feel that I have enough knowledge and training in providing dental treatments for epileptic patients in my future dental practice My family would be concerned if I treated patients with epilepsy If I treat patients with epilepsy, other patients may be reluctant to continue in my care As a dentist I have an ethical responsibility to treat patients with epilepsy
to take these factors into consideration. In addition, future studies are encouraged to replicate this study among dental students of other dental schools and among other health-care workers. It will be also interesting to examine the effect of changing the current teaching method on students' knowledge and attitudes toward patients with epilepsy.
5. Conclusion Despite its limitations, the present study has demonstrated that dental students at the University of Jordan have less than adequate knowledge about epilepsy and generally negative attitudes toward patients with epilepsy. Inadequate knowledge among dental students can adversely affect their willingness to provide dental treatment to patients with epilepsy in their future practice. Improving dental students' knowledge about epilepsy is, therefore, urgently needed. Adopting an alternative teaching method such as PBL might help in overcoming the gap in students' knowledge. In addition, raising public and professional awareness about epilepsy is needed to reduce the limitations encountered by people with epilepsy and their families. The ministries of health and education have important roles to play in this challenging task.
Conflict of interest None declared.
Agree
Disagree
Strongly disagree
47 (27.5) 4 (2.3)
76 (44.4) 16 (9.4)
40 (23.4) 64 (37.4)
8 (4.7) 87 (50.9)
25 (14.6) 8 (4.7) 106 (62)
71 (41.5) 47 (27.5) 57 (33.3)
45 (26.3) 78 (45.6) 5 (2.9)
30 (17.5) 38 (22.2) 3 (1.8)
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