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. 2026 Apr 3;67(7):3346–3360. doi: 10.1002/epi.70232

Clinician knowledge gaps in epilepsy surgery: An international survey across 18 countries or regions in Asia–Oceania

Parthvi Ravat 1,2, Si‐Lei Fong 1,3, Jasmine Parihar 1,4,5, Vigneswaran Veeramuthu 1,6, Surabhi Garg 1,7,8, Yukako Nakagami 1,9, Shuli Liang 10,11, Jing Peng 12,13, Chen Chen 1,12,13, Muhammad Akil Yerilwan Putra 1,14, Atiwat Soontornpun 1,15, Katrina Bianca Mantos 1,16, Minh‐An Thuy Le 1,17, Chia‐Yen Lin 1,18, Mayur Thakkar 19, Ajay Asranna 1,20,✉, Naoto Kuroda 1,21,22,✉
PMCID: PMC13360989  PMID: 41931042

Abstract

Objective

This study was undertaken to assess clinicians' knowledge of epilepsy surgery across Asia–Oceania and identify individual‐ and country‐ or region‐level factors associated with this knowledge, to inform strategies addressing the epilepsy surgery treatment gap.

Methods

We conducted a multinational, cross‐sectional, web‐based survey of clinicians involved in epilepsy care across 18 countries or regions in Asia–Oceania (May–September 2024). The primary outcome was an epilepsy surgery knowledge score (range = 0–12), derived from 12 multiple‐choice items covering indications for surgery, referral timing, understanding of surgical procedures, misconceptions about antiseizure medication efficacy, and perceived contraindications (e.g., electroencephalographic/magnetic resonance imaging findings, eloquent cortex, memory risk, psychiatric comorbidity, and intellectual disability). Linear mixed‐effects models were used to identify individual‐level predictors of knowledge, with country or region modeled as a random intercept. Ancillary analyses examined correlations between country‐ or region‐level knowledge effects and academic activity related to epilepsy.

Results

A total of 809 clinicians were included, with respondents primarily from India (n = 204), China (n = 194), and Japan (n = 93). The mean knowledge score was 7.3 ± 2.9, with item‐level correct response rates ranging from 11.2% to 87.6%. Higher knowledge was independently associated with being an epileptologist or neurosurgeon, working at a center with an epilepsy surgery program, and higher epilepsy case volume. Lower knowledge was observed among clinicians outside core neurological specialties. Significant country‐ or region‐level variation persisted after adjustment and correlated with national academic activity in epilepsy surgery and epilepsy awareness.

Significance

Clinician knowledge of epilepsy surgery varies substantially across Asia–Oceania. Although targeted education is necessary, structural factors such as the availability of epilepsy surgery programs and national academic engagement also appear critical for translating knowledge into access. Multilevel strategies that integrate education with health‐system strengthening are needed to meaningfully reduce the epilepsy surgery knowledge and treatment gaps.

Keywords: Asia–Oceania, epilepsy surgery, health disparities, Intersectoral Global Action Plan (IGAP), WHO

An international survey assessing clinician knowledge of epilepsy surgery across 18 countries or regions in Asia–Oceania. A web‐based survey of 809 clinicians evaluated knowledge (score range: 0–12) across key domains including indications, referral timing, procedures, antiseizure medication misconceptions, and contraindications. The mean knowledge score was 7.3 ± 2.9, with substantial variability across items (11.2%–87.6% correct responses). Higher knowledge was associated with specialty training, presence of an epilepsy surgery program, and higher case volume, whereas lower knowledge was observed among clinicians outside core neurological specialties. Knowledge varied significantly across regions and correlated with national academic activity.

graphic file with name EPI-67-3346-g002.jpg

Key points.

  • Epilepsy surgery knowledge varied widely among 809 clinicians across 18 Asia–Oceania countries or regions.

  • Higher knowledge was associated with specialty training, epilepsy surgery programs, and higher case volume.

  • Knowledge was lower among clinicians outside core neurological specialties.

  • Country‐ or region‐level differences persisted after adjustment and correlated with national academic activity.

1. INTRODUCTION

Epilepsy is one of the most common neurological disorders, affecting more than 57 million people worldwide, with a lifetime prevalence estimated at 4–10 per 1000 population. 1 , 2 In addition to its health impact, epilepsy contributes substantially to social and economic burdens due to stigma, underdiagnosis, and lack of access to effective treatment. 1 , 3 In response to this global burden, the World Health Organization has adopted the Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders (IGAP) 2022–2031, which includes targets for improving access to effective epilepsy care worldwide. 4 The Asia–Oceania region, which encompasses highly diverse health care systems and more than half of the world's population, plays a particularly critical role in achieving these goals. However, large treatment gaps persist across many countries in this region, especially in rural and resource‐limited settings. 5 , 6 , 7

One of the key drivers of the treatment gap is the knowledge gap among health care providers, which hinders timely diagnosis, referral, and access to appropriate therapies. 8 , 9 , 10 , 11 Among individuals with drug‐resistant epilepsy, defined as failure of adequate trials of two or more tolerated and appropriately chosen antiseizure medications, epilepsy surgery is a highly effective treatment option. 12 , 13 , 14 However, epilepsy surgery remains underutilized worldwide, often due to delayed or absent referrals by clinicians. 15 , 16 Population‐based data from high‐income regions indicate that even where advanced epilepsy care is available, epilepsy surgery is still underused; for example, in northern Europe epilepsy surgery is performed at a rate of approximately .5 per 100 000 population per year, and in North America only 1%–2% of patients with medically intractable epilepsy undergo surgery within 2 years, with approximately 2000 procedures performed annually among approximately 100 000 potentially eligible patients. 17 , 18 , 19 , 20 This underutilization is especially concerning in Asia–Oceania, where a substantial number of patients could benefit from epilepsy surgery, yet surgical treatment remains insufficiently available or accessible. 17 , 21 , 22 , 23 Compared with high‐income regions such as North America and Europe, access to epilepsy surgery in the Asia–Oceania region is dramatically more limited. For example, in India more than 500 000 individuals were estimated to be potential surgical candidates, yet only approximately 200 surgeries were performed annually, corresponding to fewer than .1% of eligible patients. 24 Clinicians' knowledge of epilepsy surgery plays a central role in shaping referral practices and access to surgical treatment. However, this knowledge is not evenly distributed and may differ substantially according to individual clinician backgrounds as well as broader country‐ or region‐level health care contexts. Identifying the sources of such variability is essential for developing targeted educational and policy interventions, yet empirical data addressing these issues in the Asia–Oceania region remain limited.

To address this knowledge gap, we conducted a multinational survey of clinicians involved in epilepsy care across Asia–Oceania. Our objectives were to (1) assess clinicians' knowledge of epilepsy surgery, (2) identify individual‐ and country‐ or region‐level factors associated with that knowledge, and (3) inform educational and policy strategies that promote timely surgical referral and contribute to the IGAP goals.

2. MATERIALS AND METHODS

2.1. Survey design and data collection

In this cross‐sectional study, we developed a structured 27‐item questionnaire based on prior literature and expert consensus to assess clinicians' knowledge, attitudes, and practices regarding epilepsy surgery. 12 , 23 , 25 The questionnaire was administered in English, Chinese, and Japanese. Eligible participants were health care professionals currently managing at least one patient with epilepsy in countries or regions across the Asia–Oceania region. The survey was conducted from May 10 to September 10, 2024, and disseminated via multiple platforms and in‐person channels. Digital informed consent was obtained from all participants. Further details regarding questionnaire development, participant eligibility, and dissemination strategy are provided in Methods S1.

2.2. Survey content overview

The full questionnaire is provided in Methods S2. The survey comprised 27 items across three sections: respondent characteristics, knowledge of epilepsy surgery, and referral practices and perceived barriers. The knowledge section consisted of multiple‐choice items assessing familiarity with surgical indications, referral timing, and procedural aspects of epilepsy surgery, whereas the final section addressed referral practices and barriers using both structured and open‐ended items.

2.3. Explanatory variables

Respondents' background characteristics were collected in the first section of the survey. Specifically, the following variables were collected: age, gender, specialty, years of experience in epilepsy care, number of patients with epilepsy seen per month, practice setting, country or region of practice, and availability of an epilepsy surgery program at the respondent's institution.

2.4. Outcome definition and measurement

The main outcome variable of this study was the epilepsy surgery knowledge score, ranging from 0 to 12, derived from Section 2 of the questionnaire (Q13–Q25). The correct answers to these questions are shown in Methods S3. Each correct response was awarded 1 point, and incorrect responses received 0 points. The score was constructed based on 12 multiple‐choice items informed by prior literature identifying key misconceptions and knowledge gaps. 12 , 23 , 25 The items covered four conceptual domains: (1) general understanding of the need for epilepsy surgery and the definition of drug‐resistant epilepsy (Q13–Q14); (2) knowledge of surgical procedures and referral criteria (Q15, Q17); (3) misperceptions regarding the efficacy of antiseizure medications in focal epilepsy (Q18); and (4) beliefs about potential contraindications, including electroencephalographic/magnetic resonance imaging findings, eloquent cortex, memory, psychiatric comorbidities, and intellectual disability (Q19–Q25).

2.5. Statistical analysis

Statistical analyses were performed using SPSS version 27.0, and statistical significance was defined as a two‐sided p‐value < .05. We performed a linear mixed‐effects model analysis to identify factors associated with knowledge of epilepsy surgery. Descriptive statistics were used to summarize demographic and professional characteristics of respondents, including frequencies and proportions for categorical variables, and means (SD) or medians (range) for continuous variables. Fixed effects included 11 explanatory variables in addition to the fixed intercept, based on their potential relevance to the outcome: (1) age (years, continuous), (2) gender (binary variable: male vs. others [reference group: others, including female, nonbinary, and prefer not to disclose]), (3) being an epileptologist (yes/no), 26 (4) being an adult neurologist (yes/no), 26 , 27 (5) being a pediatric neurologist (yes/no), 26 , 27 (6) being a neurosurgeon (yes/no), 26 , 27 (7) being a psychiatrist (including neuropsychiatrist; yes/no), 27 (8) having a specialty outside the basic specialties listed above (i.e., adult neurology, pediatric neurology, neurosurgery, psychiatry, or neuropsychiatrist; yes/no), 26 (9) years of experience in managing patients with epilepsy (continuous), 26 , 28 (10) average number of patients with epilepsy seen per month (continuous), 29 and (11) availability of an epilepsy surgery program at the respondent's current institution (yes/no). 29 For gender, the reference category was “male.” For all other binary variables, the reference category was “no” unless otherwise specified. Country or region of practice was modeled as a random intercept to account for variability across countries and regions. Specifically, regions were categorized according to the International League Against Epilepsy (ILAE) regional chapter structure in Asia and Oceania (https://www.ilae.org/regions‐and‐countries/regions/ilae‐asia‐and‐oceania/chapters).

2.6. Ancillary analyses

Several ancillary analyses were conducted to examine the potential influence of national income level, academic activity, sampling density, missing data, and clinical exposure on the main results. The detailed methods are provided in Methods S4.

2.7. Standard protocol approvals, registrations, and patient consents

This cross‐sectional study followed the principles of the Declaration of Helsinki and was approved by the ethics committee of Seth G. S. Medical College and King Edward Memorial Hospital, Mumbai, India (IEC(III)/OUT/379/2024). This study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines and CROSS (Consensus‐Based Checklist for Reporting of Survey Studies).

3. RESULTS

3.1. Respondent characteristics and descriptive analysis

A total of 910 responses were received (572 from the English version, 94 from the Japanese version, and 244 from the Chinese version), representing 18 of the 21 ILAE chapters in the Asia‐Oceania region. One hundred one responses (10.9%) were excluded for the following reasons: 77 had at least one missing or invalid response (one missing or invalid response: 52; two missing responses: 23; three missing responses: 2); 23 were duplicate entries between the English and Chinese versions, identified via matching email addresses; and one respondent completed the survey but did not provide consent to participate. As a result, 809 responses were included in the final descriptive and statistical analyses. Due to the broad dissemination strategy, including public postings and open access distribution, an exact response rate could not be calculated. Metrics such as page views or unique visitors were not available due to the open distribution of the survey link.

Table 1 summarizes the demographic characteristics of the respondents. The participants' median age was 38 years (range = 18–80), and 465 (57.5%) were male. Approximately 40% of participants had less than 5 years of experience in epilepsy care, and 40% had more than 10 years of experience. The majority of respondents were adult neurologists (309/809, 38.2%), followed by neurosurgeons (125/809, 15.5%), epileptologists (108/809, 13.3%), pediatric neurologists (88/809, 10.9%), and psychiatrists (65/809, 8.0%). The proportion of other specialties, including neuropsychologists, general physicians, internal medicine specialists, postgraduate medical trainees, and alternative medicine practitioners, accounted for 23.6% (191/809). Figure 1 shows the geographic distribution of respondents by country or region. Most respondents were from India (204/809, 25.2%) and China (194/809, 24.0%), followed by Japan (93/809, 11.5%).

TABLE 1.

Demographic characteristics of the respondents.

Entity Respondents, N = 809
Median age 38 years (range = 18–80)
Gender
Male 465 (57.5%)
Female 343 (42.4%)
Nonbinary 0 (0%)
Prefer not to disclose 1 (.1%)
Current place of practice a
University teaching hospital 260 (32.1%)
Public hospital or clinic 347 (42.9%)
Private hospital or clinic 193 (23.9%)
Current position a
Epileptologist 108 (13.3%)
Adult neurologist 309 (38.2%)
Pediatric neurologist 88 (10.9%)
Neurosurgeon 125 (15.5%)
Psychiatrist or neuropsychiatrist 65 (8.0%)
Specialty outside the core specialties [i.e., adult neurology, pediatric neurology, neurosurgery, or psychiatry/neuropsychiatry] 191 (23.6%)
Respondents with epilepsy surgery programs at their place of work 439 (54.3%)
Median of the average number of epilepsy patients seen per month 15 (range = 0–800)
Median years in epilepsy practice 7 years (range = 0–45)
<5 years of practice 328 (40.5%)
5–10 years of practice 151 (18.7%)
>10 years of practice 330 (40.8%)
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a

Multiple choices allowed.

FIGURE 1.

FIGURE 1

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Countries or regions of respondents in the Asia–Oceania region. (A) Proportion of respondents from each country or region (N = 809). (B) Geographical distribution of respondents by country or region. Map created using https://www.mapchart.net/world‐pacific.html. The categorization of countries or regions in this analysis follows the International League Against Epilepsy Asia–Oceania Regional Chapter structure (https://www.ilae.org/regions‐and‐countries/regions/ilae‐asia‐and‐oceania/chapters).

3.2. Overall knowledge of epilepsy surgery among respondents

Figure 2 displays the proportion of respondents who answered each of the 12 knowledge questions correctly. The mean and SD of the total epilepsy surgery knowledge score were 7.3 ± 2.9 (of 12). Overall, 53.2% of respondents answered at least 60% of the questions correctly, and 28.4% achieved a score of 80% or higher. The mean and SD of correct response rate per item were 61.0% ± 20.8%, ranging from 11.2% (Q15) to 87.6% (Q17). The lowest performing items were primarily related to components of epilepsy surgery, whereas the highest performing items addressed the eligible age for epilepsy surgery. These findings indicate considerable heterogeneity in baseline knowledge of epilepsy surgery across specific domains.

FIGURE 2.

FIGURE 2

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Knowledge of epilepsy surgery among respondents. (A) Summary of the 12 question topics assessing knowledge of epilepsy surgery. Actual questions, answer options, and correct answers are provided in Methods S1. (B) Proportion of correct responses for each of the 12 questions. (C) Distribution of total scores based on the 12 questions (0–12). ASM, antiseizure medication; IQ, intelligence quotient; MRI, magnetic resonance imaging; MTLE, mesial temporal lobe epilepsy.

3.3. Individual‐level factors associated with knowledge of epilepsy surgery

Table 2 summarizes the fixed‐effect estimates from the linear mixed‐effects model identifying individual‐level factors associated with knowledge of epilepsy surgery. Being an epileptologist with specialized training (coefficient = 1.13, 95% confidence interval [CI] = .50–1.76, p < .001) or a neurosurgeon (coefficient = 1.34, 95% CI = .50–2.18, p = .002), seeing a higher average number of patients with epilepsy per month (coefficient = .002, 95% CI = .0004–.005, p = .021), and working at a center with an epilepsy surgery program (coefficient = 1.08, 95% CI = .67–1.48, p < .001) were independently associated with higher knowledge scores. In contrast, being a psychiatrist (coefficient = −1.14, 95% CI = −2.06 to −.22, p = .015) and having a specialty outside the basic disciplines (i.e., adult neurology, pediatric neurology, neurosurgery, or psychiatry/neuropsychiatry; coefficient = −1.60, 95% CI = −2.42 to −.77, p < .001) were independently associated with lower knowledge scores.

TABLE 2.

Fixed effect coefficients of the linear mixed model to identify factors associated with respondents' knowledge of epilepsy surgery.

Variables Coefficient SE t p 95% CI
Age (years) .002 .018 .088 .930 −.035 to .038
Gender (1: male; 0: others) .024 .197 .122 .903 −.362 to .410
Epileptologist status (1: yes; 0: no) 1.130 .323 3.505 <.001 .497 to 1.763
Specialty: adult neurologist (1: yes; 0: no) −.143 .366 −.392 .695 −.863 to .576
Specialty: pediatric neurologist (1: yes; 0: no) .739 .416 1.776 .076 −.078 to 1.555
Specialty: neurosurgeon (1: yes; 0: no) 1.337 .428 3.121 .002 .496 to 2.177
Specialty: psychiatrist (1: yes; 0: no) −1.138 .467 −2.436 .015 −2.055 to −.221
Specialty: outside 4 major specialties (1 = other; 0 = any of the 4) a −1.596 .422 −3.785 <.001 −2.423 to −.768
Experience in managing patients with epilepsy (years) −.019 .021 −.883 .377 −.060 to .023
Average number of patients with epilepsy seen per month (n/month) .002 .001 2.305 .021 .0004 to .005
Epilepsy surgery program (1: yes; 0: no) 1.078 .206 5.241 <.001 .674 to 1.481
Fixed‐effect intercept 6.685 .756 8.842 <.001 5.199 to 8.170
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Abbreviation: CI, confidence interval.

a

The four major specialties include adult neurology, pediatric neurology, neurosurgery, and psychiatry.

3.4. Country‐ or region‐level variation in knowledge of epilepsy surgery

Table 3 summarizes the estimates of the random intercepts from the linear mixed‐effects model, used to assess country‐ or region‐level variation in knowledge of epilepsy surgery. Figure 3 presents the geographic distribution of the random intercept effect sizes for each country or region. Countries or regions with positive random intercepts, indicating higher knowledge scores than the overall mean after adjusting for fixed effects, included Japan (random intercept = .830, 95% CI = .16–1.50) and Taiwan (random intercept = .783, 95% CI = .009–1.56). In contrast, countries or regions with negative random intercepts, indicating lower than average knowledge scores, were led by Indonesia (random intercept = −1.23, 95% CI = −1.97 to −.48). Among all 18 countries or regions included in the analysis, only Japan, Taiwan, and Indonesia had random intercepts with 95% CIs that did not include zero, indicating statistically significant deviations from the overall mean.

TABLE 3.

Random effect intercepts of the linear mixed model to identify factors associated with respondents' knowledge of epilepsy surgery.

Country or region of practice a Random effect intercepts SE p 95% CI
Australia (11) −.160 .518 .760 −1.243 to .923
Bangladesh (8) −.363 .552 .521 −1.535 to .810
Cambodia (3) .044 .625 .946 −1.350 to 1.438
China (194) .073 .293 .805 −.524 to .669
Hong Kong (6) .341 .578 .565 −.903 to 1.585
India (204) .335 .273 .231 −.227 to .897
Indonesia (49) −1.226 .367 .002 −1.971 to −.482
Japan (93) .830 .328 .016 .164 to 1.496
Malaysia (40) .035 .668 .959 −1.513 to 1.584
Myanmar (9) .007 .393 .987 −.792 to .805
Pakistan (14) .453 .540 .413 −.686 to 1.592
Philippines (45) −.696 .503 .181 −1.741 to .349
Singapore (1) −.023 .372 .950 −.778 to .731
South Korea (1) .094 .668 .891 −1.455 to 1.644
Taiwan (40) .783 .381 .047 .009 to 1.556
Thailand (45) .105 .372 .780 −.649 to .859
Timor Leste (1) .028 .668 .967 −1.521 to 1.577
Vietnam (45) −.659 .376 .088 −1.421 to .102
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Note: The categorization of countries or regions in this analysis follows the International League Against Epilepsy Asia–Oceania Regional Chapter structure (https://www.ilae.org/regions‐and‐countries/regions/ilae‐asia‐and‐oceania/chapters).

Abbreviation: CI, confidence interval.

a

Numbers in parentheses indicates the number of respondents included in the analysis.

FIGURE 3.

FIGURE 3

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Geographic distribution of country‐ or region‐level effects. The map showing the effect sizes of random intercepts estimated for each country or region is based on the linear mixed‐effects model. The map was created using https://www.mapchart.net/world‐pacific.html. The categorization of countries or regions in this analysis follows the International League Against Epilepsy Asia–Oceania Regional Chapter structure (https://www.ilae.org/regions‐and‐countries/regions/ilae‐asia‐and‐oceania/chapters).

3.5. Ancillary analyses

Ancillary analyses indicated that country‐ or region‐level differences in epilepsy surgery knowledge were partially associated with national income level and academic activity related to epilepsy surgery and awareness. In contrast, general epilepsy research output and the number of respondents per country or region were not meaningfully associated with knowledge estimates. Robustness analyses addressing missing data and minimal clinical exposure yielded results consistent with the main model. The detailed results are provided in Supplementary Results, Tables S1–S12, and Figure S1.

4. DISCUSSION

4.1. Summary

This international cross‐sectional study analyzed responses from 809 clinicians across 18 countries and regions in the Asia–Oceania region to identify factors associated with knowledge of epilepsy surgery. At the individual level, four factors were independently associated with higher knowledge: being an epileptologist or a neurosurgeon, seeing a higher number of patients with epilepsy per month, and working at a center with an epilepsy surgery program. In contrast, two factors were independently associated with lower knowledge: being a psychiatrist/neuropsychiatrist and having a specialty outside the basic disciplines (i.e., adult neurology, pediatric neurology, neurosurgery, or psychiatry/neuropsychiatry). In addition, we found substantial country‐ or region‐level variation in knowledge, which was positively correlated with academic activity related to epilepsy surgery and epilepsy awareness, but not with general epilepsy research output.

4.2. Interpretation of overall knowledge levels and domain‐specific gaps

Item‐level analysis revealed substantial heterogeneity across knowledge domains. Although most clinicians were familiar with basic eligibility criteria for epilepsy surgery, knowledge was poorest for items assessing which surgical procedures and operative approaches are considered part of epilepsy surgery. This pattern indicates that many clinicians may understand who can undergo surgery but not what actually constitutes epilepsy surgery, which may represent a critical barrier to appropriate referral and treatment selection. When placed in an international context, a similar pattern of domain‐specific knowledge gaps has been reported in surveys from Europe and North America. Prior studies among neurologists in Canada, the United States, and several European countries have consistently shown that clinicians tend to have greater familiarity with general concepts such as surgical candidacy or treatment resistance, whereas understanding of specific surgical procedures, presurgical evaluations, and operative strategies is more limited. 30 , 31 , 32 , 33 In these studies, incomplete procedural knowledge has been identified as a potential contributor to delayed or absent referral, even among clinicians who acknowledge the effectiveness and safety of epilepsy surgery. Taken together, these findings suggest that the knowledge assessed under the umbrella of “epilepsy surgery” is not uniform but varies substantially across domains, and that this domain‐level heterogeneity is observed internationally rather than being specific to the Asia–Oceania region.

4.3. Individual‐level and country‐ or region‐level differences in knowledge of epilepsy surgery

The identification of individual‐ and country‐ or region‐level factors associated with knowledge provides important insights for addressing the epilepsy surgery treatment gap and the broader knowledge gap in the Asia–Oceania region. Our finding that epileptologists had significantly greater knowledge supports ongoing initiatives to expand epilepsy‐specific training. Programs such as e‐learning, webinars, and regional workshops play a critical role in equipping clinicians with essential knowledge about epilepsy. 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 In addition, clinicians working at institutions with an epilepsy surgery program and those seeing a higher volume of epilepsy patients showed greater knowledge. This association underscores the value of direct clinical exposure and multidisciplinary collaboration in fostering provider familiarity with surgical treatment pathways. Although comprehensive epilepsy centers may not be feasible in all settings, emerging models such as virtual case conferences, tele‐education, or collaborations with epilepsy centers may offer scalable solutions for expanding access to surgical knowledge. 43 Another key finding was that clinicians' medical specialty was significantly associated with knowledge of epilepsy surgery. Neurosurgeons demonstrated relatively high knowledge levels, likely reflecting their direct involvement in surgical care and familiarity with operative decision‐making. 44 In contrast, psychiatrists showed significantly lower levels of knowledge. One possible explanation is that even among psychiatrists specializing in epilepsy, clinical responsibilities may focus on patients with psychiatric comorbidities, a group less likely to be considered for epilepsy surgery. 25 , 45 Prior research suggests that psychiatric comorbidities may negatively influence referral decisions, which may reduce psychiatrists' engagement with surgical care pathways and contribute to lower familiarity with epilepsy surgery. 27 Clinicians whose specialties did not include neurology, pediatric neurology, neurosurgery, or psychiatry also exhibited lower knowledge scores. These clinicians, such as general internists, family medicine practitioners, and other nonspecialists, may primarily manage patients with less severe or less frequent seizures and therefore encounter fewer surgical candidates. As a result, they may have limited exposure to surgical treatment options. Nonetheless, even general practitioners are likely to care for patients who could benefit from epilepsy surgery. Targeted outreach and education for nonspecialist clinicians are therefore essential to closing the knowledge gap and improving access to surgical care. 39 , 40

At the country or region level, the random intercepts from our mixed model analysis indicated substantial variation in baseline knowledge across countries and regions, independent of individual clinician factors. Although exceptions existed, knowledge tended to be higher in high‐income countries and lower in low‐ and middle‐income settings. Ancillary analysis further revealed that countries with more academic publications related to epilepsy surgery and awareness also showed higher average knowledge scores. These findings align with previous recommendations emphasizing regionally relevant research and suggest that fostering academic activity may indirectly support clinical knowledge dissemination. 7 , 46 Initiatives such as special issues on epilepsy surgery and awareness in scientific journals may be helpful in this regard. Nonetheless, we acknowledge that these findings are correlational and do not establish causality. Moreover, the use of “awareness” as a search term may include unrelated studies (e.g., on impaired awareness seizures), limiting interpretability.

Although our study focused on health care provider knowledge, it is important to recognize that knowledge gaps are not the sole contributor to the epilepsy surgery treatment gap. Prior studies have identified a range of additional barriers, including limited availability of surgical services, inadequate diagnostic infrastructure, financial constraints, and patient‐level factors such as fear or stigma. 8 , 28 , 47 , 48 , 49 Communication between clinicians and patients also plays a critical role in the referral process. Addressing the knowledge gap is therefore necessary but not sufficient; a comprehensive and multifaceted strategy is needed to meaningfully reduce disparities in access to epilepsy surgery.

4.4. Methodological considerations

A key strength of this study lies in its broad geographic coverage across 18 countries in the Asia–Oceania region and large sample size, encompassing responses from 809 clinicians. Moreover, the innovative integration of PubMed publication metrics as a proxy for national academic activity provided an objective and novel lens through which to interpret cross‐country or ‐region differences in knowledge. Collectively, these methodological strengths lend robustness to the conclusions and provide a valuable foundation for policy and educational interventions across the region.

However, this study has several limitations. First, selection and network biases may have influenced our findings. Recruitment relied on e‐platforms, mailing lists, and social media, with open‐access links broadly disseminated via professional networks. As a result, clinicians with internet access and a stronger interest or background in epilepsy surgery were more likely to participate. More than half of the respondents were affiliated with established epilepsy surgery programs, which may have inflated knowledge scores. In addition, although the survey was available in English, Chinese, and Japanese, the absence of translations in other major Asia–Oceania languages (e.g., Korean, Thai, Indonesian, Vietnamese, or Hindi) may have introduced language‐related selection bias, potentially contributing to the overrepresentation of respondents from China and Japan and the underrepresentation of clinicians from other countries. Furthermore, we could not calculate an exact response rate, limiting the ability to assess nonresponse bias. Accordingly, the present findings should be interpreted as reflecting the knowledge levels of clinicians who were reachable through professional networks and motivated to participate, rather than as population‐representative estimates of clinician knowledge at the national level. In line with this, country‐ or region‐level effects in the mixed models should be interpreted as reflecting relative differences observed within the study sample, rather than definitive national benchmarks, given heterogeneity in respondent composition across countries. Importantly, the inclusion of country or region as a random intercept was intended to account for unmeasured contextual heterogeneity and clustering within the sample, rather than to rank or characterize countries at the population level. Other forms of self‐selection bias also cannot be excluded, whereby clinicians with greater interest, expertise, or engagement in epilepsy surgery may have been more likely to participate. Despite these limitations, the large absolute number of respondents, and the wide geographic scope of the survey allow meaningful exploration of patterns and correlates of epilepsy surgery knowledge at the individual clinician level. When interpreted with appropriate caution regarding national‐level generalizability, these associations provide valuable insights into structural and contextual factors shaping clinician knowledge across diverse health care settings in the Asia–Oceania region. Second, important clinician‐ and system‐level variables that may influence epilepsy surgery knowledge were not captured. In particular, we did not collect information on whether respondents personally refer patients for epilepsy surgery, the frequency of such referrals, or whether they routinely follow patients after surgery. These factors may substantially shape knowledge and attitudes toward surgical treatment but could not be evaluated in the present study and should be addressed in future research. Third, although we incorporated country or region as a random effect, we were unable to directly account for important aspects of national epilepsy surgery capacity, such as the duration of program availability, the presence of formal epilepsy surgery or fellowship training programs, or the maturity of national surgical infrastructures. Consequently, the country‐level random effects in our models should be interpreted as capturing unmeasured structural and historical differences in epilepsy care ecosystems rather than specific, identifiable components of service provision. Fourth, although we modeled country or region as a random effect, we could not account for within‐country or within‐region disparities. Even within the same country or region, differences between urban and rural areas, or among the different types of facilities, are known to affect clinicians' knowledge. 50 However, disparities in urban versus rural location could not be quantified due to the lack of standardized, accessible measures or definitions. We also refrained from including facility type (e.g., university vs. nonuniversity) as a covariate due to concerns about multicollinearity with the availability of an epilepsy surgery program. Finally, our study is cross‐sectional in design and therefore cannot establish causality between clinician characteristics or national academic activity and knowledge levels.

4.5. Future perspectives

Several ongoing initiatives aim to bridge the epilepsy surgery treatment gap. These include educational programs for nonsurgeons or physicians having a specialty outside the basic disciplines (e.g., referral timing, presurgical evaluation), technical training for epilepsy surgeons, and public awareness campaigns. Notably, the ILAE has increasingly utilized virtual or e‐platforms since the COVID‐19 pandemic to expand educational access globally. 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 Free online webinars, including those focused on epilepsy surgery, provide opportunities for clinicians in resource‐limited settings to receive high‐quality training without the constraints of travel or funding (Table S13). As part of this study, after submission of survey response, we provided an infographic on epilepsy surgery to all respondents as an educational tool (Figure S2). Future rounds of this survey will allow us to evaluate the impact of this infographic by comparing knowledge and referral‐related responses before and after its dissemination. Looking forward, investment in scalable educational programs is essential. In parallel, strengthening surgical training through fellowships, short‐term visits, or outreach by experienced epilepsy surgeons can help expand capacity (https://www.ilae.org/regions‐and‐countries/regions/ilae‐asia‐and‐oceania). Public education campaigns to reduce stigma and misinformation may also promote acceptance of surgery among patients and communities.

Future research should include stratified sampling within each country or region to ensure representation from different city tiers, such as metro, urban, and rural areas, to better understand local differences in knowledge and referral practices. It will also be important to study how factors like treatment costs and the availability of insurance or reimbursement policies affect referral decisions. Finally, future studies should assess the impact of these interventions through longitudinal tracking of knowledge, referral behavior, and access to surgery in diverse health care settings. These efforts are likely critical to advancing the goals of the IGAP.

5. CONCLUSIONS

This international cross‐sectional study involving 809 clinicians across 18 countries and regions in the Asia–Oceania region identified both individual‐ and country‐ or region‐level factors associated with knowledge of epilepsy surgery. These findings highlight the relevance of multilevel educational strategies in supporting progress toward the epilepsy surgery targets outlined in the IGAP. Future efforts should focus on evaluating educational strategies while also addressing broader structural and patient‐level barriers to epilepsy surgery.

AUTHOR CONTRIBUTIONS

Parthvi Ravat: Conception; study design; IRB approval; survey development; distribution and data collection; conceptualization and graphic designing of the educational infographic; drafting and editing the manuscript. Si‐Lei Fong: Conception; study design; survey development; survey distribution and data collection; drafting and editing the manuscript. Jasmine Parihar: Conception; study design; survey development; distribution and data collection; manuscript editing. Vigneswaran Veeramuthu: Conception; study design; survey development; distribution and data collection; manuscript editing. Surabhi Garg: Conception; study design; survey development; survey distribution and data collection; manuscript editing. Yukako Nakagami: Survey translation (Japanese); distribution; data collection; critical review of the manuscript. Chen Chen: Survey translation (Chinese); survey distribution; data collection; critical review of the manuscript. Jing Peng: Survey distribution; data collection; critical review of the manuscript. Shuli Liang: Survey distribution; data collection; critical review of the manuscript. Muhammad Akil Yerilwan Putra: Conception; study design; survey development; distribution and data collection; manuscript editing. Atiwat Soontornpun: Conception; study design; survey development; distribution and data collection; manuscript editing. Katrina Bianca Mantos: Survey distribution; data collection; critical review of the manuscript. Minh‐An Thuy Le: Conception; study design; survey development; survey distribution and data collection; manuscript editing. Chia‐Yen Lin: Survey distribution; data collection; critical review of the manuscript. Mayur Thakkar: IRB approval and survey development. Ajay Asranna: Conception; study design; survey development; survey distribution and data collection; manuscript editing. Naoto Kuroda: Conception; study design; survey review; statistical analysis; drafting and editing the manuscript.

CONFLICT OF INTEREST STATEMENT

None of the authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

INFORMED CONSENT

All participants provided informed consent before participating in the study. As this was an anonymous web‐based survey, consent was obtained electronically by asking participants to click an “I agree to participate” button before accessing the questionnaire. Participation was voluntary. Email addresses were collected only for study administration purposes (e.g., preventing duplicate entries and optional follow‐up communication) and were stored separately from survey responses to maintain confidentiality.

Supporting information

Appendix S1.

EPI-67-3346-s001.docx (1MB, docx)

ACKNOWLEDGMENTS

We thank the core committee members of the Asian–Oceanian YES Collaborators in Epilepsy Research (ACE), Ching Soong Khoo, Divyani Garg, and Honor Coleman, for their efforts in managing and organizing ACE. We also thank Joyce S. W. Chow, MD (Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong) for her help in collecting the answers from clinicians.

Contributor Information

Ajay Asranna, Email: ajayasranna@gmail.com.

Naoto Kuroda, Email: naoto.kuroda@wayne.edu.

DATA AVAILABILITY STATEMENT

Anonymized data not published within this article will be made available by request from any qualified investigator.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1.

EPI-67-3346-s001.docx (1MB, docx)

Data Availability Statement

Anonymized data not published within this article will be made available by request from any qualified investigator.

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