Epilepsy & Behavior 20 (2011) 428–434

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Epilepsy & Behavior

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Review

Multicultural challenges in epilepsy

Emanuele Bartolini a,b, Gail S. Bell a, Josemir W. Sander a,c,⁎a Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, and the National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UKb Department of Neuroscience, University of Pisa, Pisa, Italyc SEIN – Epilepsy Institute in the Netherlands Foundation, Achterweg 5, 2103 SW Heemstede, The Netherlands

⁎ Corresponding author. Department of Clinical and EHospital for Neurology and Neurosurgery, Queen SquFax: +44 20 3108 0115.

E-mail address: l.sander@ion.ucl.ac.uk (J.W. Sander)

1525-5050/$ – see front matter © 2011 Elsevier Inc. Aldoi:10.1016/j.yebeh.2010.12.045

a b s t r a c t

a r t i c l e i n f o

Article history:Received 8 December 2010Revised 24 December 2010Accepted 27 December 2010Available online 18 February 2011

Keywords:EpilepsyMulticulturalPrognosisTreatment gapTraditional beliefs

Epilepsy is a common neurological condition throughout the world. Its care involves medical expertise, butmay also bring different cultural challenges. We discuss clinical, social and psychological outcomes indifferent cultural settings. We point out differences and similarities in epilepsy epidemiology (etiology andrisk factors, prognosis, and natural history), disparities in care and health services, and cultural influences andtraditional beliefs, with special respect to practical issues and possible transcultural misunderstandings. Wealso discuss the relevance of multicultural issues to clinicians working in developed countries.

xperimental Epilepsy, Nationalare, London WC1N 3BG, UK.

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l rights reserved.

© 2011 Elsevier Inc. All rights reserved.

1. Introduction

It is likely that more than 60 million people worldwide haveepilepsy [1]. The World Health Organization (WHO) estimated thatnearly 80% of the burden of epilepsy worldwide is borne by resource-poor countries [2]. Low- and middle-income countries (LAMIC) sharesome factors that hinder epilepsy care: poverty, social and politicalinstability, widespread stigma,myths andmisconceptions, inadequatehealth care facilities, and a severe shortage of epilepsy specialists [3].

Throughout the world, neurologists regularly advise people withepilepsy whose ethnic, linguistic, and social backgrounds are differentfrom their own and who may have different cultural beliefs abouttheir condition. The risk factors for their epilepsy may be different,and they may have had different levels of care previously. Patchyknowledge and lack of comprehension of these cultural andgeographic aspects may result in misunderstanding and inadequatecare.

2. Methods

Three main issues are considered important background informa-tion in this review: epidemiology (including risk factors and etiology,prognosis, and natural history), disparities in care and health services,and cultural influences and traditional beliefs. We discuss the rele-vance of this information to everyday practice. Our aim is to raise

awareness of the importance of sociocultural knowledge in epilepsy,to improve care and health provision.

We searched PubMed with the algorithm ([epilepsy OR seizures],[epilepsy AND (etiology OR epidemiology OR treatment OR stigma)],[epilepsy AND (Africa OR Asia OR Latin America OR world]) and alsoexplored professional websites about epilepsy. Other articles werefound by manual searching and review of the archives of the authors.

3. Background

3.1. Epidemiology

3.1.1. PrevalenceThe prevalence of active epilepsy has usually been estimated as

between 4 and 10/1000 people in many different countries [4–12].Most large-scale studies in LAMIC have reported the prevalence ofactive epilepsy to be between 6 and 10/1000 [4,11,13,14], with higherrates usually found in rural areas than in urban areas [11,13–15].Lifetime prevalence is higher than the prevalence of active epilepsy,and it is generally agreed that up to 5% of a population will experienceat least one nonfebrile seizure at some point in life [4,16]; this findingapplies to both industrialized countries and LAMIC.

3.1.2. IncidenceIn high-income countries the annual incidenceusually lies between

40 and 70/100,000 [14,16]. The incidence is usually higher in resource-poor countries, where it is often reported as greater than 100/100,000[11,14,16]. Annual incidence in Asia (29–60/100,000) is similar to thatin Western countries, but the reported incidence is much higher in

Table 2Examples of cultural differences in dissociative seizures.

Turkey: Dissociative seizures are seldom reported by men, as culturally they areconsidered a sign of weakness [144].

United Arab Emirates: Conversion symptoms may be the best way of attractingsympathy for women living under many restrictions. In Arab society, men havemore advantages and thus do not need to adopt a sick role [145,146].

India: Dissociative seizures affect predominantly housewives and female students,coming from rural areas, with low socioeconomic conditions and pooreducational background [147].

South Africa: Dissociative seizures may be concomitant with epilepsy inneurocysticercosis. The clinical differentiation is difficult if long-term video/EEG monitoring techniques are not available [148].

Argentina: Long-term video/EEG monitoring has been available only since 1990.Economic problems may limit the implementation of adequate diagnostictechniques [149].

429E. Bartolini et al. / Epilepsy & Behavior 20 (2011) 428–434

sub-Saharan Africa (63–158/100,000) and Latin America (78–190/100,000) [17–19] (Table 1).

3.1.3. Incidence, prevalence, and ethnicityAssociations between ethnicity and epilepsy remain largely un-

known. Studies from the United States suggest higher incidence andlifetime prevalence in African-Americans than in Caucasian Americans[20–22]. Lower standards of perinatal care might be relevant, but thisneeds to be formally assessed in these settings. People who are sociallyand economically deprivedmay bemore liable to develop epilepsy [23],and it is likely that African-Americans in these settings are in moredeprived strata of society. A lower prevalence has been reported inSouth Asian populations living in the United States and the UnitedKingdom [24,25]; this has not been confirmed in second-generationimmigrants [13] and may reflect differential migration as people withepilepsymay be less likely to migrate. Age and gender distributionmayalso differ between people coming from LAMIC and those from high-income countries. In many ethnic groups, such as people from Asia orsub-Saharan Africa, the peak of incidence in the older age groupsobserved inWestern countriesmay not be seen, probably because of thedifferent demographic makeup of the populations [16,18,19]. In sub-SaharanAfrica a higher prevalence of epilepsy inmales is reported, but ithas been suggested that young women and their families may hideepilepsy so that they couldmarry [19]. A door-to-door prevalence studyfrom Sicily also suggested that teenage girls, and others, may concealtheir epilepsy [26]. A high index of suspicion for epilepsy should alwaysbe kept inmind. The differential diagnosis of seizuresmust consider andexclude nonepileptic phenomena of a psychological nature (e.g.,psychogenic seizures or dissociative seizures). Information on this isscarce, but there are some suggestions that dissociative seizures couldbe culture bound and difficult to assess, particularly where diagnosticfacilities are poor (see Table 2).

3.1.4. Risk factors and etiologiesThe range of risk factors in the epilepsies varies according to

geographic location [16]. These differences may be due to environ-mental factors or genetic susceptibility. In general, most population-based studies from North America, Europe, and Africa have reportedan identified cause in 14–39% of all cases; in the majority of casesthere is no identifiable cause [27] (Table 3). In high-income countries,in people in whom the probable etiology is identified, epilepsy iscaused mainly by cerebrovascular accidents, head trauma, braintumors, congenital problems, and genetic abnormalities [28,29].These factors may, of course, also be responsible for epilepsy inpeople from LAMIC, but other risk factors, often not seen in high-income countries, must also be considered. Infections and infestationsof the central nervous system are frequent in LAMIC andmay be partlyresponsible for the higher incidence of epilepsy seen in some areas ofthese countries. The clinician may need to ask specifically about visitsor periods of residence abroad in people with a new onset of seizures.

3.1.4.1. Neurocysticercosis. Neurocysticercosis, caused by brain infes-tation with Taenia solium, the pork tapeworm, is considered the main

Table 1Incidence of recurrent unprovoked seizures in population-based studies in differentcountries.

Region Reference Incidence (per 100,000)

United States Zarrelli et al. [138] 52United Kingdom Cockerell et al. [139] 23Italy Granieri et al. [140] 33Ecuador Placencia et al. [11] 122Chile Lavados et al. [141] 113China Wang et al. [142] 29Tanzania Rwiza et al. [12] 73Uganda Kaiser et al. [143] 156

cause of acquired epilepsy in many parts of LAMIC [30]. Cysticercosisis often present in areas where hogs are raised, but it may also occuroutside such areas. Pigs are the usual intermediate host for T. solium,whereas humans are the definitive host. Humans may become theintermediate host by ingesting foodstuff or water contaminated withhuman feces containing eggs from T. solium; thus, poor sanitationfacilitates transmission of T. solium. The parasite may then becomeestablished in subcutaneous tissue, muscle, or brain (causingneurocysticercosis) [31]. Neurocysticercosis is widespread in Asia(e.g., India, Nepal, Bali, Papua and Sulawesi in Indonesia, parts ofVietnam and China) [18], Africa (apart from the Muslim areas)[19,31,32], and Latin America (e.g., Peru, Ecuador, Mexico) [33–36]. Inendemic countries, cysticercosis is prevalent in urban and middle-class areas as well as in rural areas. Seizures are the most frequentsymptom of neurocysticercosis, especially in those with parenchymalcysts [37]. Symptoms usually result from a host inflammatoryresponse after parasite death. Solitary enhancing CT lesions are acommon manifestation, and the definitive diagnosis is often formedon the basis of resolution or calcification over months withconservative treatment. Neoplasms such as glioblastoma multiformemay present with clinical and radiological signs similar to those ofneurocysticercosis [38]. Clinical history and origin in or recent travelto endemic areas may be the clue to an early diagnosis. There is noclear evidence that cysticidal treatment offers reliable benefit [39].Conservative treatment is frequently effective, as antiepilepticmonotherapy often leads to seizure freedom [30]. Although it iscrucial to consider the diagnosis of cysticercosis in people whooriginated from, or have traveled to, areas where neurocysticercosis isendemic, it is also important to consider the possibility that thediagnosis may, indeed, be an alternative, including neoplasms.

3.1.4.2. Malaria.Malaria is one of themost commonparasitic infectionsin the world. It is caused by the protozoan Plasmodium sp. The highestlevels of endemicity are in tropical regions, especially sub-SaharanAfrica, possibly parts of South and Southeast Asia (e.g., India, Burma,Indonesia, Pakistan, Cambodia, Papua New Guinea, Bangladesh), andSouth America [40,41]. The parasite is transmitted by the bite of thefemalemosquito of the genus Anophele. Plasmodium falciparum causesthe most severe form of malaria (after 6–20 days of incubation), ofteninvolving the central nervous system. Seizures are common manifes-tations of the acute stage of infection and can occur in the context of

Table 3Etiology of epilepsy in population-based studies in different countries.

Region Reference Symptomatic (%) Unknown (%)

United States Hauser et al. [150] 24 76Italy Granieri et al. [140] 40 60Chile Lavados et al. [141] 30 70India Bharucha et al. [151] 23 77Tanzania Rwiza et al. [12] 11 88

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cerebral malaria, with fever and impairment of consciousness. Aseizure in a person with a febrile disease, recently coming from atropical endemic region, calls for the suspicion of malaria. The risk ofmortality or neurological sequelae, including epilepsy, is very high[42–45].

3.1.4.3. Human immunodeficiency virus. Human immunodeficiencyvirus infection is a risk factor for epilepsy. Seizures in people with HIVinfection can occur through direct invasion of the central nervoussystem or as a result of opportunistic infections (e.g., cryptococcosis,herpes simplex virus, toxoplasmosis, tuberculosis) [30]. AIDS affectssub-Saharan Africa more than any other part of the world.Management of antiepileptic therapy can be troublesome. Peoplewith epilepsy from LAMIC frequently take enzyme-inducing AEDs;these can reduce the half-life of antiretroviral drugs such asnevirapine, a component of Triomune, one of the few multidrugregimens for HIV available in sub-Saharan Africa [46]. By contrast, HIVprevalence in high-income countries is lower and non-enzyme-inducing AEDs are more readily available [47,48]. Knowledge of theorigin of the individual and understanding of the social and culturalbackgroundmay ease AEDmanagement and choice, particularly if theperson is likely to return to a resource-poor setting.

3.1.4.4. Other infections. Clinicians should also consider more rare riskfactors for seizures such as Japanese encephalitis, schistosomiasis,toxoplasmosis, toxocariasis, African trypanosomiasis, and paragoni-miasis [48–53]. The Japanese encephalitis flavivirus is endemic inmost of China, Southeast Asia, and the Indian subcontinent; 65% ofpeople with Japanese encephalitis have acute symptomatic seizuresand 13% develop chronic epilepsy [48,49]. Schistosoma japonicum,endemic in Southeast Asia, may cause seizures as a symptom of acutecerebral schistosomiasis or as a consequence of chronic schistosomi-asis [49]. Toxoplasmosis may be an opportunistic infection and maycause seizures, with a relevant causal impact where AIDS is endemic[49]. Human toxocariasis is caused by larval stages of Toxocara canis,the common roundworm of dogs, and although there is no directevidence that central nervous system invasion by the larvae causesepilepsy, a strong association between seropositivity and focalepilepsy has been observed [52,54,55]. Trypanosoma brucei is endemicin many countries of sub-Saharan Africa; chronic trypanosomiasis ischaracterized by progressive neurological involvement, includinggeneralized and focal seizures [49]. Paragonimus westermani isprevalent in the Far East, Southeast Asia, some parts of Africa, andSouth America; cerebral paragonimiasis is often associated with focalseizures [49].

3.1.4.5. Noninfectious risk factors. Other risk factors are important inthe development of epilepsy in resource-poor settings. Perinatalinjuries cause a serious burden in LAMIC; in sub-Saharan Africa it hasbeen estimated that perinatal causes, such as obstetric injuries,neonatal hypoxia, and watershed cerebral ischemia, account for morethan a third of seizures [19]. Multiparity, prematurity, and maternalinfections aggravate the situation where home births withoutprofessional aid are frequent [53]. Perinatal stroke seems morefrequent in LAMIC and is sometimes associated with epilepsy; themain risk factors for perinatal stroke are maternal disorders (e.g.,preeclampsia, coagulation disorders); placental disorders (e.g., pla-cental abruption, placental thrombosis); blood disorders (e.g., factor VLeiden mutation, protein S deficiency, protein C deficiency); andinfectious disorders (meningitis, systemic infections) [56].

Genetic factors should also be considered in people coming fromLAMIC, as familial aggregation has been observed in India [57,58], Laos[59], China [60], and sub-Saharan Africa [19], and consanguinity iscommon in many African communities and in certain Asian cultures[53,61]. Roma/Gypsy communities constitute cultural and frequentlyinbred genetic isolates. Different phenotypes of idiopathic generalized

epilepsy, focal epilepsy, and mosaicism SCN1A/Dravet syndrome witha familial inheritance have been described in Roma/Gypsy families[62–64].

3.1.5. Prognosis and natural historyResource-poor countries are important in understanding the

natural history of epilepsy, particularly with respect to treatment.Recurrence rates after a first unprovoked seizure and after AEDwithdrawal are similar in low- and high-income countries [65,66].Studies in Ecuador have reported a substantial proportion of people inlong-term remission without treatment, and data from China seem tosuggest a similar trend [67,68].

Despite an overall good prognosis, epilepsymay be associatedwithsevere consequences. Where health resources are lacking, as in sub-Saharan Africa, people with epilepsy may experience frequent,uncontrolled seizures in an unsafe physical environment, leading tosevere burns, drowning, and fractures [69,70]. Status epilepticus is notrare in LAMIC and is often associated with abrupt drug withdrawal inpeople with epilepsy [71]. There are shortcomings in knowledgeabout overall epilepsy mortality in resource-poor countries. Ifmortality is high, this could explain the gap between the highincidence and relatively low prevalence of active epilepsy. Although inthe United Kingdom standardized mortality ratios (SMRs) between2.6 and 3.0 have been reported in people with epilepsy [72,73], arecent study found a SMR of 3.9 among 2455 people with epilepsy atthe primary health care level in rural China [74]. High mortality rateshave also been reported in other resource-poor regions of the world:28.9 per 1000 person-years in a rural area of Cameroon [75] and 31.6per 1000 person-years in rural central Ethiopia [76].

3.2. Disparities in care and health services

Neurology provision varies from one or two neurologists per 20,000to one per 100,000 people inWestern countries, whereasmany parts ofAsia, Latin America, and Africa have no neurologists at all [77]. This isparticularly the case in rural areas, where nearly two-thirds of people inresource-poor countries reside [78]. The median number of hospitalbeds for epilepsy care per 100,000 population in LAMIC is low (0.05 inSoutheast Asia, 0.46 in the Western Pacific area, 0.55 in Africa)compared with Europe (1.65) [79]. People with epilepsy have accessto specialist care in 89% of high-income countries, but only 56% of low-income countries, where diagnostic instruments are also scarce. EEGservices are available in three-quarters of LAMIC, but not unusuallysetups are managed and run by personnel with no formal training. MRIis available in only 21% of African countries, 48% of Western Pacificcountries, and 56% of Southeast Asian countries [80]. There is asubstantial treatment gap, as an important proportion of people withepilepsy in resource-poor countries never receive appropriate treat-ment. The treatment gap is defined as the number of peoplewith activeepilepsy not on treatment or on inadequate treatment, expressed as apercentage of the total number with active epilepsy [81,82]. A recentmeta-analysis found an overall treatment gap of 56% in resource-poorcountries; the treatment gap was high in Asia (64%), Latin America(55%), and Africa (49%), with higher rates in rural (73%) than in urban(47%) populations [83]. Most AEDs are available in Asia, but second-generation AEDs are often prohibitively expensive [18]. In Africa, AEDavailability depends also on cultural heritage; in French-speaking areasphenobarbital is prescribed for 65–85% of people with treated epilepsy;in English-speaking countries, phenytoin is the most prescribed AEDand carbamazepine is prescribed for 5–20% of those treated [82]. Asurgical treatment gap also exists; in 2006, epilepsy surgery wasavailable in only 13% of LAMIC, compared with 66% of high–incomecountries [80].

It may be appropriate to consider further diagnostic workup in aperson whose original diagnosis was made in a low- or middle-income country, as more refined investigations may facilitate an

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accurate diagnosis. Similarly, if seizures are not well controlled onAEDs prescribed in LAMIC, the clinician could consider other AEDs,always taking into consideration whether the individual is likely toreturn to another country and the availability and affordability of theAEDs there.

3.3. Cultural influences and traditional beliefs

Traditional, non-biomedical views are considered to have a stronginfluence on the differences observed in epilepsy care [82]. Ethnicminorities residing in Western countries may keep traditional viewsintermixed with scientific conceptions. Physicians must consider thisin establishing a therapeutic alliance with the person. Religious beliefscan exert positive influences on health by acting as a source ofinspiration, or negative influences when they are linked with guilt orresult in a sense of fatalism. A fatalist attitude considering epilepsy asa divine curse has been described in some South Asian communities inthe United Kingdom [84]. Some cultures, as in the Voodoo religion orin the rural Indian subcontinent, may believe people with epilepsy arepossessed by spirits [84,85]. Hinduism and Sikhism endorse the beliefthat illness is usually a punishment for misdeeds perpetrated inprevious lives [84]. Religious prescriptions may also translate intopractical issues on therapeutic adherence and drug management.During Ramadan, the ninth month of the Islamic lunar calendar, adultMuslims should not take oral drugs, nor food or water, between dawnand sunset. Ramadan can occur in any of the four seasons; thus, thefasting period may vary from 11 to 18 hours. People with chronicdiseases often fast even though they are permitted not to by Islamicconvention. Adjusting the drug intake to the life rhythm of Ramadan isoften not practical [86]. This is a particular problem for medicationswith a narrow therapeutic index such as some AEDs, which should betaken at regular intervals to maintain constant blood levels. Changesin circadian rhythms, drug regimen, pharmacokinetics, and pharma-codynamics of AEDs may lead to an overall increase in seizurefrequency [87].

Traditional beliefs are sometimes the source of discriminatoryattitudes. A widespread prejudice considers epilepsy as an infectiousdisease or as a mental illness, and people with epilepsy may be leftalone to avoid contagion. This has been reported in many African andAsian countries [88–92]. Unconventional treatments are often mixedwith conventional medicine, and people with epilepsy may considereach as effective as the other. The Indian official health systemincludes some of the elements of the Muslim-derived Unani system ofmedicine; this includes use of purgatives, venesection, cleansingagents (Jadwar-Ood-E-Salaib and Khamir-E-Abresham), inducedsneezing, hot oil massage with Roghan-E-Surkh or E-Baboona, andbrain tonics such as Itherifal-Usta-Khudoos, Dawa-Ul-Misk, andMuatidil Jawahar Wali [93]. In Sub-Saharan Africa concoctions,scarifications, witch hunting, incantations, rituals, and ingestion ofhot herbal liquids can be considered useful remedies [91,94,95]. Iftreatment fails, many traditional healers refer the person to a hospital[91]. Co-operation with traditional healers may ease access to medicaltreatment for people with epilepsy in LAMIC [96]. In Tibet nearly 60%of individuals take traditional medicine [97]. People of South Asianorigin living in the United Kingdom have been reported to believe inWestern medicine, but also to consult with gurus (Hindus and Sikhs)or pirs (Muslims) visiting from the Indian subcontinent. Pirs mayadvise wearing amulets (taweez) containing verses from the Koran,usually around the neck or the arm, drinking blessedwater, or recitingfrom holy texts. Conventional medicine is deemed first choice, butpeople may also seek help from herbal practitioners (hakims), usuallyduring trips to visit relatives in Southeast Asia [84]. In China, Westernand traditional medicine are now practiced together, consideringAEDs as useful for treating seizures specifically, while Chinesemedicine is used as regulator of the person's constitution betweenseizures [98–101]. There is no evidence in favor of acupuncture

effectiveness, but this is seen as a means of “restraining the nerve,”and acupressure is seen as stopping seizures when they occur[98,102]. According to the WHO, integrating Western and traditionalmodels in the treatment of epilepsy can be useful [103].

Common lay terminology for epilepsy and seizures can suggestclues to the psychological background of people with epilepsy. InChina, particularly in rural areas, epilepsy is yang jiao feng (meaning“making a noise like a sheep”). In Vietnam it is described as dong kinh(“unstable nerve epilepsy”), phong giat (“wind-bitten seizure”), andkinh phong cap (“acute neurological wind-bitten”) [98]. In Arabiccountries and in Turkey epilepsy is often referred to as Saraa (“beingknocked down”) [104]. In Urdu it is calledMirgi (“small death”) [105].The Tzeltal Mayas, from Chapas, Mexico, call epilepsy tub tub ik'al(“person that breathes anxiously or shocking”) [106].

4. Discussion: How this should influence the Western neurologist

When assessing any person with epilepsy, it is always paramountto consider the whole person; for many people, of whatever culture,this may involve cultural and ethnic matters.

As seen above [23], the incidence of epilepsy seems to be higher inmore deprived populations. The reasons for this are not entirely clearbut the causes are likely to be multifactorial. People in poorer areasmay have inadequate or delayed access to medical services anddiagnostic facilities [23], and those of lower socioeconomic status maybe less likely to adhere to treatment regimens [103]. In the UnitedKingdom, AEDs are provided free of charge for people with epilepsy,but difficulties in accessing neurologists and pharmacies may hinderaccess to good care.

In some cultures it is thought shameful to have a family memberwith epilepsy [107]. In other cultures, epilepsy is seen as apunishment and not amenable to medical treatment [108]. Thus,treatment may be delayed, and individuals may already have sufferedthe consequences of uncontrolled seizures. We can hypothesize thatthe attempt to hide epilepsy to marry may involve stopping AEDs,with negative consequences. The clinicianmay need to emphasize theimportance of adherence to the treatment regimen and the possibleconsequences of not doing so.

The differential diagnosis of epilepsy may be complicated inpeople of different backgrounds. For example, malaria as a risk factorshould always be considered in someone presenting with seizureswho has been to a malarial area, particularly those areas endemic forPlasmodia falciparum. Treating the cause of the seizures, in this case, isparamount. If someone who has been in areas endemic forcysticercosis presents with the symptoms and signs of an enhancinglesion, all alternative diagnoses must also be considered unless theevidence for the diagnosis of neurocysticercosis is overwhelming.Noninfectious causes may also have different etiologies in peoplefrom LAMIC. It is therefore important that the diagnostic workup ofpeople with acute symptomatic seizures or epilepsy takes intoaccount the person's origins and travel to avoid misdiagnosis.

The possibility of a genetic origin should be considered, particu-larly in people from ethnic groups in which consanguinity is common.Investigators conducting genetic research in people coming fromresource-poor countries should, however, be wary lest the addition ofthe dimension of familial transmission of the disease could lead tofurther ostracism [58].

Possibly one of the most difficult areas is treatment with AEDs.People from most cultures may use alternative or complementaryremedies, and interactions have been identified between herbs andsome AEDs [109]. In addition, many people do not consider herbs orcomplementary remedies to be “drugs” and may not volunteer theinformation that they have taken them when asked about theirmedication intake [110]. Thus it is important always to ask individualswhether they take unconventional medicines when a medical historyis taken [111]. In people who are likely to return to another area of the

Table 4Epilepsy management during Ramadan.

•Both the Qur'an (holy book of Islam) and Hadith (Practices & Sayings of Holy ProphetMohammed) exempt Muslims from fasting during any illness if there is a risk toindividual health.

•People with epilepsy willing to fast need careful follow up.•Maintain regularity of drug intake (e.g., do not modify times of doses, number ofdoses, time span between doses, total daily dosage).

•Avoid sleep deprivation.•Keep fluid intake as constant as possible.•Injection or intravenous administration that is solely medical is allowed.

432 E. Bartolini et al. / Epilepsy & Behavior 20 (2011) 428–434

world where AEDs are less widely available, this should be consideredwhen prescribing.

Devout Muslims may wish to fast during Ramadan, even thoughconvention allows them not to do so. It is important to ask whether ornot people intend to fast, and to try to find some agreement that willnot jeopardize AED intake (see Table 4).

Few data are available on the transcultural aspects of dissociativeseizures, but there seem to be differences related to local culturalcontexts (Table 2).

5. Conclusions

Epilepsy is still a highly stigmatizing condition, especially inresource-poor countries [103,104]. In such settings epilepsy repre-sents a major public health and social problem, characterized by lackof prioritization and infrastructure support and by a treatment gap.Consideration must be given to the many preventable causes such asparasitic infections [7,104]. Adequate drug supplies must be providedfor the success of any epilepsy management program, but simplydelivering AEDs to resource-poor countries will not necessarilyreduce the treatment gap [112]. Epilepsy care can be addressed bytargeting preventable causes (e.g., parasitic infections) and througheducational interventions for health providers (including traditionalhealers), people with epilepsy, and the wider community [113–123].Pragmatic models of health delivery integrated into existing serviceshave been set up in several countries, leading to reduction of thetreatment gap [116,118,124–129].

Cultural aspects deeply influence health-seeking strategies. Super-natural beliefs may encourage people with epilepsy and their familiesto seek help from traditional healers [130,131]. This can delay access toWestern medicine by several years [131]. Stigma may hamper correctapproaches to coping with epilepsy. The acknowledgment of culturaland geographic differences is important to promote better de-stigmatization campaigns [132–135]. Seeking support from the familyis a common coping strategy, but is difficult when the family feelsshame for having a relative with epilepsy [98,136]. Emotions are oftenimportant for people with epilepsy, and they may express dissatisfac-tion if the medical team emphasizes medications rather thaneducation and comprehension [136,137]. Every intervention shouldbe based on the local perceptions and should consider socialconditions. Epilepsy imposes many challenges in a multiculturalsociety where people from different communities live together. Cross-cultural communication and understanding of different backgroundsof peoplewith epilepsy have become cornerstones of epilepsy care in amulticultural society.

Conflict of interest statement

None of the authors has any conflicts of interest in relation to thiswork to disclose.

Acknowledgements

This work was supported by the Epilepsy Society. It was partlyundertaken at UCLH/UCL, which receives a proportion of funding fromthe Department of Health's NIHR Biomedical Research Centre'sfunding scheme. J.W.S is supported by the Dr. Marvin Weil EpilepsyResearch Fund.

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