Abstract
Context:
Epileptic seizures and the unpredictable falls resulting from epileptic seizures predispose the people living with epilepsy (PLWE) to various physical injuries as well as postictal cognitive and behavioral changes.
Aims:
The aim of the study was to determine the frequency and patterns of seizure-related physical injuries, postictal cognitive impairments, and behavioral changes.
Settings and Design:
This was a cross-sectional descriptive study in a Southeast Nigeria local government area.
Subjects and Methods:
PLWE identified during a two-phase door-to-door survey and their caregivers were interviewed using a semi-structured questionnaire.
Statistical Analysis Used:
The Statistical Package for the Social Sciences version 22.0 was used.
Results:
There were 56 cases of active convulsive seizures comprising 33 (58.9%) males and 23 (41.1%) females, with a mean age of 32.9 ± 14.2. The lifetime prevalence of seizure-related physical injuries, postictal behavioral changes, and postictal cognitive impairments was 9.8 per 1000 (95% confidence interval [CI]: 9.1–10.0), 8.4 per 1000 (95% CI: 7.2–9.2), and 6.3 per 1000 (95% CI: 4.9–7.5), respectively. Skin/soft-tissue injuries and tongue laceration were the most frequent physical injuries found in 66.1% (n = 37/56) and 60.7% (n = 34/56) of cases, respectively. The frequency of soft-tissue injuries was significantly higher (χ2 = 5.038; P = 0.0248) in the females 78.3% (n = 18/23) than the males 48.5% (n = 16/33). About a third of the females 39.1% had burn injuries compared to 18.1% of the males.
Conclusions:
Seizure-related injuries are common and have the tendency to increase the burden of epilepsy and epilepsy-related stigma from deformities and the chronic disfiguring scars resulting from such injuries.
Keywords: Behavioral changes, cognitive impairment, postictal, seizure-related injuries
Résumé
Contexte:
Les crises d’épilepsie et les chutes imprévisibles résultant des crises d’épilepsie prédisposent les personnes vivant avec l’épilepsie (PLWE) à diverses blessures physiques ainsi que des changements cognitifs et comportementaux post-critiques.
Objectifs:
Le but de l’étude était de déterminer la fréquence et les caractéristiques des blessures physiques liées aux crises, des déficiences cognitives post-critiques et des changements de comportement.
Paramètres et conception:
il s’agissait d’une étude descriptive transversale dans une zone de gouvernement local du sud-est du Nigeria.
Sujets et méthodes:
PLWE identifiées lors d’une enquête porte-à-porte en deux phases et leurs soignants ont été interrogés à l’aide d’un questionnaire semi-structuré. Analyse statistique utilisée: Le progiciel statistique pour les sciences sociales version 22.0 a été utilisé.
Résultats:
Il y a eu 56 cas de crises convulsives actives comprenant 33 (58,9 %) hommes et 23 (41,1 %) femmes, avec un âge moyen de 32,9 ± 14,2 ans. La prévalence au cours de la vie des blessures physiques, des changements de comportement post-critiques et des troubles cognitifs post-critiques liés aux crises était de 9,8 pour 1 000 (95 % intervalle de confiance [IC]: 9,1 à 10,0), 8,4 pour 1 000 (IC à 95 %: 7,2 à 9,2) et 6,3 pour 1 000 (IC à 95 %: 4,9 à 7,5), respectivement. Blessures de la peau/des tissus mous et les lacérations de la langue étaient les blessures physiques les plus fréquentes trouvées dans 66,1 % (n = 37/56) et 60,7 % (n = 34/56) des cas, respectivement. La fréquence de les blessures des tissus mous étaient significativement plus élevées (χ2 = 5,038; P = 0,0248) chez les femmes 78,3 % (n = 18/23) que chez les hommes 48,5 % (n = 16/33). Environ un tiers Parmi les femmes, 39,1 % avaient des brûlures, contre 18,1 % des hommes.
Conclusions:
Les blessures liées aux convulsions sont fréquentes et ont tendance à accroître le fardeau de l’épilepsie et de la stigmatisation liée à l’épilepsie due aux malformations et aux cicatrices défigurantes chroniques résultant de telles blessures.
Mots-clés: Changements comportementaux, troubles cognitifs, post-critiques, blessures liées aux crises
INTRODUCTION
People living with epilepsy (PLWE) are particularly prone to physical injuries and accident resulting from the sudden and unpredictable nature of epileptic seizures.[1] Falls following seizures expose PLWE to various degrees of bodily injuries such as bruises, burns, fracture/dislocation among others.[1,2,3] Besides the injuries, the chronic scarification and deformities resulting from such injuries have the tendency to increase epilepsy-related stigma.[4]
The frequency of seizure-related injuries can range from as low as 5% to as high as 98.9% depending on the population surveyed.[2,5,6,7] Potential risk factors for seizure-related injuries include the seizure frequency, lack of a prolonged seizure-free interval, number of antiepileptic drugs the patient is taking, and a history of generalized seizures.[3,8] Others include comorbid attention-deficit disorder as well as the presence of cognitive handicap that can complicate the seizure event.[8]
Population-based data which are believed to provide more accurate data than hospital-based studies on the prevalence of seizure-related injuries are sparse, especially in developing nations.[3] This study therefore aimed to determine the frequency and pattern of seizure-related injuries and postictal cognitive and behavioral changes seen among PLWE dwelling in the six communities of Dunukofia Local Government Area (LGA) of Anambra State, Nigeria.
SUBJECTS AND METHODS
Study design and study area
This was a cross-sectional descriptive study of the frequency and patterns of seizure-related injuries and complications found among PLWE during a door-to-door community study in the six communities that make up the Dunukofia LGA of Anambra State, Southeast Nigeria.
Dunukofia LGA covers a land area of approximately 64 km2 and shares boundaries with Awka North, Idemili North, Njikoka, and Oyi LGAs. The population of Dunukofia LGA is about 95,517, and it has 20,708 households by ownership status of dwelling units according to the 2006 National Population Census data.[9]
Dunukofia LGA is inhabited predominantly by the Igbo-speaking people who are the major ethnic group inhabiting the southeastern part of the country. Subsistence farming is the primary economic activity of the people of Dunukofia with a fewer population working as civil servants under the state/local government employment and artisans. Christianity is the major religion with a few adherents of African traditional religions.
The survey
This study was conducted among PLWE found in a two-phase community-based survey over a 4-month period, from May 6, 2019, to September 20, 2019. The first phase was a door-to-door survey during which a team of trained research assistants interviewed every member of all households in the selected enumeration areas who were above the age of 10 years using a validated questionnaire adapted from the modified World Health Organization questionnaire for detecting neurological diseases.[10] The estimated minimum sample size for the study was 7905 and was calculated using the formula: n = DZ1−α/22 P (1−P)/d2 where D = design effect =2, Z1−α/2= standard normal deviate corresponding to 5% level of significance (two-sided test) =1.96, P = prevalence =4.3 per 1000[11] =0.0043, and d = absolute precision =0.00215.[12,13]
Dunukofia LGA has a population of 95,517 according to the 2006 Population Census, but this population is expected to have increased.[9] To select an adequate representative sample, we estimated the population to be studied using national data stating that each census enumeration area has an average of 47 households and that the average household size in the nation is 5.0 persons per household.[14] Dunukofia has 471 census enumeration areas: Ukwulu (127), Ifitedunu (112), Ukpo (88), Umunachi (55), Umudioka (54), and Nawgu (35). These were identified and listed, and using computer-generated random numbers, one out of every cluster of seven (approximately 15%) of the enumeration areas was selected for the survey. A total of 67 enumeration areas with an estimated population of 15,980 were therefore selected as follows: Ukwulu, 18; Ifitedunu, 16; Ukpo, 12; Umunachi and Umudioka, 8 each; and Nawgu, 5 enumeration areas. Persons <10 years old, which accounted for 30.9% of the Nigerian population, were excluded from the study, and the estimated population to be surveyed was 11,043 persons.[14] Since the calculated minimum sample size was 7905, everyone 10 years and above in all the households in the selected enumeration areas who consented were surveyed to make room for the expected increase in the population and improve the power of the study.
The aim of this first stage was to identify those with possible active convulsive epilepsy. The adapted questionnaire was translated to Igbo language and back translated to English by two bilingual Igbo West African Examinations Council examiners. Furthermore, the translated version was considered by an expert panel consisting of translators, researchers versed in Igbo language, and some laypersons to consider the instrument within the Igbo context and culture, and a number of changes were made to come up with the harmonized Igbo version. The harmonized Igbo version was evaluated before the actual study, and a local validation of the instrument at the Neurology Clinic of Nnamdi Azikiwe University Teaching Hospital yielded a sensitivity of 100% and specificity of 65%.
In the second stage of the study, all those identified as possibly having active epilepsy during the first stage of the study were interviewed by the team of neurologists and senior residents in neurology. Active epilepsy was defined as the occurrence of two or more unprovoked seizures on different days in the previous year or currently on anti-seizure medication.[11,15] A semi-structured epilepsy-specific questionnaire, a modification of an epilepsy questionnaire developed for tropical countries, was used for the interview at the second stage of the study with the aim of making a diagnosis of active convulsive epilepsy and detecting seizure-related complications.[16] The seizure-related complications investigated were (1) seizure-related physical injuries defined as any bodily injury resulting from the seizures, namely tongue laceration (including tongue biting and orolingual injuries), skin/soft-tissue injuries (bruises or skin abrasion), burns, fracture, head injury different from dental injury, etc.; (2) postictal cognitive impairments defined as either confusion, loss of speech, walking, or talking without purpose manifesting immediately after a seizure attack; and (3) postictal behavioral changes defined as anxiety, depression, aggression, rage, or anger that manifest immediately after seizures without prior history of psychiatric illness. The questionnaire also contained other essential sociodemographic data of participants. The clinical profile of epilepsy for those confirmed as having active convulsive seizures were also obtained.
Ethical approval for the study was obtained from the Ethics Committee of the institution while informed consent was obtained from the traditional rulers of the six communities and the heads of the households surveyed. Verbal consent was also obtained from the adult subjects as well as parents or close family relatives of children. All the subjects gave their consent. Parents or close family members confirmed the accounts given by grown-up children in some cases, but in some others, they acted as a proxy for children and persons unable to understand and respond to the questions.
Statistical analysis
Data collected were analyzed using the Statistical Package for the Social Sciences (SPSS™) version 22.0 (SPSS Inc., Illinois, USA).[17] Relevant percentages, frequencies, means, and standard deviation were calculated. The sex difference in the frequency of seizure-related injuries were determined using the Chi-squared test and the Fisher’s exact test. The limit of statistical significance was set at P < 0.05.
RESULTS
A total of 9000 persons comprising 5038 (56.0%) males and 3962 (44.0%) females were surveyed in the first phase of the study. Those identified as possibly having active convulsive seizures in the first phase were 141 and were all screened in the second phase of the study. Those with active convulsive epilepsy found were 56 comprising 33 (58.9%) males and 23 (41.1%) females, with a mean age of 32.9 ± 14.2 and an age range of 11–65 years. Table 1 shows the demographic data of those with active convulsive epilepsy.
Table 1.
Demographics of persons with epilepsy
| Characteristics | Number of subjects (%) |
|---|---|
| Age groups | |
| 10–19 | 11 (19.6) |
| 20–29 | 14 (25.0) |
| 30–39 | 14 (25.0) |
| 40–49 | 10 (17.9) |
| 50–59 | 3 (5.4) |
| 60–69 | 4 (7.1) |
| Age range | 11–65 years |
| Mean age | 32.9±14.2 |
| Gender | |
| Male | 33 (58.9) |
| Female | 23 (41.1) |
| Marital status | |
| Single | 41 (73.2) |
| Married | 9 (16.0) |
| Divorced | 2 (3.6) |
| Separated | 2 (3.6) |
| Widow/widower | 2 (3.6) |
| HELA | |
| Primary | 23 (41.1) |
| Secondary | 27 (48.2) |
| Tertiary | 2 (3.6) |
| No formal | 4 (7.1) |
| Occupation | |
| Artisan | 19 (33.9) |
| Student | 11 (19.6) |
| Farming | 10 (17.9) |
| Dependent | 8 (14.3) |
| Trading | 5 (8.9) |
| Civil servant | 3 (5.4) |
HELA=Highest educational level attained
Table 2 shows the profile of seizure-related injuries and postictal cognitive impairments and behavioral changes. Seizure-related physical injuries were found in 98.2% of the cases (prevalence rate of 9.8 per 1000 [95% confidence interval (CI): 9.1–10.0]), postictal behavioral changes in 83.9% of cases (prevalence rate of 8.4 per 1000 [95% CI: 7.2–9.3]), and postictal cognitive impairments in 62.5% of cases (prevalence rate of 6.3 per 1000 [95% CI: 4.9–7.5]). The frequency of seizure-related physical injuries and postictal behavioral changes was higher in males 100% and 84.8%, respectively, than in females 95.7% and 82.6%, respectively. On the other hand, the frequency of postictal cognitive impairment was higher in females (73.9%) compared to males (54.5%). However, these observed differences were not statistically significant.
Table 2.
Profile of seizure-related injuries and postictal events (cognitive impairment and behavioral changes)
| Lifetime prevalence of seizure-related injuries and postictal events | |||||
|---|---|---|---|---|---|
| Characteristics | Frequency (%) | Prevalence | 95% CI | ||
| Postictal cognitive impairment | 35 (62.5) | 6.2 per 1000 | 4.9–7.5 | ||
| Postictal behavioral changes | 47 (83.9) | 8.4 per 1000 | 7.2–9.3 | ||
| Physical injuries | 55 (98.2) | 9.8 per 1000 | 9.1–10.0 | ||
|
Sex difference in the frequency of seizure-related complications | |||||
| Characteristics | Yes, n (%) | No, n (%) | Total, n (%) | P* | |
|
| |||||
| Postictal cognitive impairment | |||||
| Male | 18 (54.5) | 15 (45.5) | 33 (100.0) | 0.14080 | |
| Female | 17 (73.9) | 6 (26.1) | 23 (100.0) | ||
| Postictal behavioral changes | |||||
| Male | 28 (84.8) | 5 (15.3) | 33 (100.0) | 1.00000† | |
| Female | 19 (82.6) | 4 (17.4) | 23 (100.0) | ||
| Physical injuries | |||||
| Male | 33 (100) | 0 | 33 (100.0) | 0.41070† | |
| Female | 22 (95.7) | 1 (4.3) | 23 (100.0) | ||
|
Lifetime history of seizure-related hospital/health center admissions | |||||
| Frequency (%) | |||||
|
| |||||
| Yes, n (%) | 39 (69.6) | ||||
| No, n (%) | 17 (30.4) | ||||
| Total, n (%) | 56 (100.0) | ||||
|
Frequency of seizures in the last 12 months | |||||
| Number of seizures | Frequency (%) | ||||
|
| |||||
| 1–3 | 23 (41.1) | ||||
| 4–6 | 21 (37.5) | ||||
| >6 | 12 (21.4) | ||||
| Total | 56 (100) | ||||
*Chi-square test, †Fisher’s exact test. CI = Confidence interval
A seizure frequency of more than 6 seizure episodes in the past 1 year was reported by 21.4% (n = 12/56) of the cases while 37.5% (n = 21/56) reported a frequency of 4–6 episodes. The remaining 41.1% (n = 23/56) of the cases reported a frequency of 1–3 episodes. A significant proportion (69.6%) of PLWE had been admitted to the hospital/health center in the past.
Table 3 shows the patterns of seizure-related physical injuries. Tongue laceration which was reported by 66.1% (n = 37/56) of PLWE was the most common physical injury, followed by skin/soft-tissue injury reported by 60.7% (n = 34/56). A higher proportion of the females 78.3% (n = 18/23) in this study had soft-tissue injury compared to the males 48.5% (n = 16/33), and this difference was statistically significant χ2 = 5.038; P = 0.0248. Similarly, the proportion of females with burns was 39.1% (n = 9/23) compared to 18.1% (n = 6/33) found in the males, but this difference was not statistically significant χ2 = 3.033; P = 0.0816. Only one person, 1.8% (1/56), did not report any injury while 25% (14/56) reported multiple injuries.
Table 3.
Number and types of seizure-related physical injuries
| Type of physical injury | ||||
|---|---|---|---|---|
| Characteristics | Male, n* (%) | Female, n* (%) | Total, n* (%) | P |
| Tongue laceration | 20 (60.6) | 17 (73.9) | 37 (66.1) | 0.3008† |
| Skin/soft-tissue injury | 16 (48.5) | 18 (78.3) | 34 (60.7) | 0.0248† |
| Burns | 6 (18.1) | 9 (39.1) | 15 (26.8) | 0.0816† |
| Dental injury | 6 (18.1) | 3 (13.0) | 9 (16.1) | 0.7226‡ |
| Head injury | 5 (15.2) | 3 (13.0) | 8 (14.3) | 1.000‡ |
| Motor vehicle accident | 2 (6.1) | 0 | 2 (3.6) | 0.5071‡ |
| Fracture | 1 (3.0) | 0 | 1 (1.8) | 1.000‡ |
| None | 0 | 1 (4.3) | 1 (1.8) | 0.4107‡ |
|
Number of physical injuries | ||||
| Number of injuries | Frequency (%) | |||
|
| ||||
| None | 1 (1.8) | |||
| Single | 41 (73.2) | |||
| Multiple | 14 (25.0) | |||
| Total | 56 (100.0) | |||
*Multiple responses recorded, †Chi-square test, ‡Fisher’s exact test. n=Number of cases
DISCUSSION
We report a high prevalence of seizure-related physical injuries among the community-dwelling PLWE in the six communities that make up a Southeastern Nigeria local government district. Seizure-related physical injuries were found in 98% (55/56) of the PLWE found in the present study. Currently, there is no community-based study on the prevalence of seizure-related injuries in Nigeria to directly compare with the findings in the present study. However, the obtained frequency of 98% is comparable to 98.9% reported by Ezeala-Adikaibe et al.[2] among adult PLWE attending epilepsy clinics in two tertiary hospitals in Enugu also in Southeast Nigeria. The authors of Enugu study did not give any reason for the high frequency of seizure-related injuries found in their study; however, the high frequency of seizure-related injuries found in the present study may not be unrelated to poor seizure management as evidenced by the high seizure frequency reported among PLWE in the communities of this local government. Both studies highlight the need for more robust approach to epilepsy care in this region that will be applicable both in the cities and mixed-rural and semi-urban communities. A lower prevalence of seizure-related injuries (45.6% [57/125]) was reported by Lagunju et al.[18] in a hospital-based study among children in Ibadan.[18] This lower prevalence of seizure-related injuries reported in Ibadan when compared with findings in this present study and the study in Enugu by Ezeala-Adikaibe et al.[2] can be explained by the better seizure control among the participants in Ibadan study. Moreover, the difference in the study population (protected children vs. more active adults) might have also contributed to the finding.
A quarter (25%) of those with active convulsive epilepsy in the present study reported multiple injuries. This is not different from 24.8% (31/125) found among children in Ibadan but is lower than 34% reported by Lawn et al.[7] in America.[7,18] When seizure-related injuries are multiple, the prognosis and outcome are poorer and the cost of management higher.
Seizure frequency was high among the patients seen in this index study as evidenced by the occurrence of ≥4 seizure episodes in the preceding 12 months in more than half (58.9%) of the population. Seizure frequency is a potential risk factor for seizure-related injuries.[3] PLWE with high seizure frequencies are at increased risk for seizure-related injury. It has also been reported that PLWE have a higher incidence of home, street, and work accidents, even without obvious clinical seizure probably due to interictal electroencephalogram epileptiform discharges occurring in the absence of obvious clinical seizure activity.[19,20,21]
Postictal cognitive impairment and behavioral changes both have the tendency to increase the frequency of seizure-related injuries. PLWE have been physically assaulted in the past during behavioral change associated with seizure episodes.[2] In this index study, a significant proportion 62.5% (35/56) of those with active convulsive epilepsy reported having experienced postictal cognitive effects following a seizure while 83.9% (47/56) reported behavioral changes following seizures. A greater proportion of females 73.9% (17/23) had postictal cognitive impairment compared to males 54.5% (18/33), but this difference was not statistically significant (χ2 = 2.1692; P = 0.14). Postictal seizure-related cognitive effect is a less researched area and is therefore difficult to make direct comparisons between findings in this index study and other available studies. Seizure-related postictal cognitive impairments and behavioral changes may be part of ongoing seizure and are usually transient and reversible unlike the interictal cognitive changes that may be permanent.[22] Postulated mechanisms for these postictal events include neuronal exhaustion after recurrent seizures due to the depletion of neurotransmitters and glucose levels after seizures.[22] Others include the disruption of the blood–brain barrier after seizures as well as other newer mechanisms like active inhibition of neuronal activity by hyperpolarization and neurovascular decoupling.[22]
Recurrent hospital admissions among PLWE are common occurrence although sometimes the admissions may not be seizure-related. Lifetime seizure-related hospital admissions were seen in a significant proportion of PLWE 69.6% (39/56) in this index study. Globally, admission rates ranging from as low as 6.9% to as high as 73.6% have been reported depending on the population studied, the study methodology and definition of terms such as degree of injuries and the period surveyed (lifetime versus last 12 months).[2,3,7,23,24] Studies that focused only on physical injuries or excluded tongue lacerations as injuries and those that covered only a 12-month period reported lower rates of hospital admissions.[7,18,25] It is worth noting that hospital admission in the context of the present study includes admission to private hospitals and local government health centers who do not have qualified personnel to effectively manage epilepsy. The enormity of the challenge of epilepsy care in these mixed rural and semi-urban local government communities cannot be overemphasized and should be the priority of policymakers and government to address.
Tongue laceration and skin/soft-tissue injuries were among the top-listed seizure-related physical injuries seen in this index study. Tongue laceration was reported by 66.1% (37/56) while soft-tissue injury was reported by 60.7% (34/56) of the patients with active convulsive seizure. Lower rates were reported in Ibadan and Guinea among hospital patients.[18,26] Lagunju et al.[18] reported a rate of 19.2% and 26.4% for tongue laceration and soft-tissue injury respectively in Ibadan, while in Guinea Kariuki et al.[26] reported a rate of 31% for skin/soft-tissue injuries. These lower rates could be explained by the minor nature of some of these tongue lacerations and soft-tissue injuries that the patients do not present to the hospitals with them for treatment.[26]
The proportion of female patients with burn injury in the present study was higher than that of the male counterpart as in some other African studies.[20,26] This sex difference has been attributed to the roles of women in the African families and society.[20,26] It is the family and societal responsibilities of women to cook in the African culture, thus exposing to burns injury if they have seizure attacks during such periods. Similarly, head injuries and fractures were more in men than women in this present study. This is likely due to the difference in the social and physical behaviors as well as recreational behaviors seen among men that exposes them to high-risk traumatic injuries such as head injuries and fractures. This pattern has also been reported in other African studies.[20,26] Although only one case of fracture was reported in the present study, fracture is said to be a common injury in PLWE due to several reasons. These include the sudden and unpredictable nature of epileptic seizures that make it difficult for PLWE to activate protective reflexes resulting in falls and subsequent fracture. Furthermore, the muscular contraction occurring during seizures can increase the load on the skeleton and lead to a crush fracture of the spine.[3] However, reports from studies on the risk of fracture in PLWE compared to the general population are still conflicting, and it remains to be determined if PLWE are at a higher risk of fracture than the general population.[3]
Motor vehicle accident was reported by 3.6% (2/56) of the PLWE in the present study a finding comparable to findings in other previous studies.[7,23,24,26] Driving is an issue with the management of epilepsy and driving regulations and rules differs from place to place. Seizure occurring while driving puts the patient and the general public at considerable risk. Although some studies have shown that the rate of fatal crashes in the general population is 2.6 times greater than for those with epilepsy, there is a need for caution because having a seizure disorder increases the likelihood that a person will have an accident while driving.[3,27,28]
Dental injury was reported by 16.1% (9/56) of the persons with active convulsive epilepsy in this index study. This is higher than 10.3% (9/28) reported among hospital patients surveyed in Enugu by Ezeala-Adikaibe et al.,[2] and dental injuries in that study were among the severe injuries reported by the participants in that survey. Beyond the cost of management of these injuries, the chronic disfiguring effects of skin/soft-tissue and dental injuries tend to worsen the burden to stigma in epilepsy.[29]
Limitations
Although the present study has attempted to provide the long-awaited population-based survey on the frequency and patterns of seizure-related injuries in the region, there are multiple limitations to the study. The small number of PLWE found during the survey and were interviewed makes a general application of the findings to the wider population difficult. The challenge of recall bias likely also existed, especially for those parameters that require recalling lifelong events or events in the preceding 12 months like hospital admissions due to seizure-related injuries. Since recall of specific reasons for the admissions will be difficult, all hospital admissions relating to the seizure disorder rather were recorded.
CONCLUSIONS
Seizure-related injuries as well as postictal behavioral changes and postictal cognitive impairments are common and have the tendency to increase the burden and stigma of epilepsy.
Financial support and sponsorship
This study was financially supported by the neuroepidemiology program of NAU (Nnamdi Azikiwe University).
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors wish to acknowledge the traditional leaders and union leaders of the six Dunukofia communities for their consent and for providing logistics for seamless access to the people. The authors are grateful to the research assistants, the staff of the health centers, and the ward development councils in the six communities for their contributions to the successes of the fieldwork.
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