evans dewa - university of zimbabwe
TRANSCRIPT
i
NON-ATTENDANCE OF TREATMENT REVIEW VISITS AMONG EPILEPTIC
PATIENTS IN GOKWE SOUTH DISTRICT: MIDLANDS PROVINCE, ZIMBABWE
2012
By
Evans Dewa
Dissertation Submitted in partial fulfilment Of Masters in Public Health [Health
Promotion] Degree University of Zimbabwe
COLLEGE OF HEALTH SCIENCES
DEPARTMENT OF COMMUNITY MEDICINE
UNIVERSITY OF ZIMBABWE
HARARE
AUGUST 2012
ii
Declaration
This dissertation is the original work of Evans Dewa. It has been prepared in accordance with the
guidelines for MPH [Health Promotion] dissertations in the University of Zimbabwe. It has not
been submitted elsewhere for another degree at this or any other university.
1. Name of student: ________________________________________________
Signature: __________________ Date: ______________
2. Name of Supervisor: _____________________________________________
Signature____________________ Date: _______________
3. Chairman, Community Medicine, University of Zimbabwe Medical School.
Signature____________________ Date: ________________
iii
Abstract
Introduction
Epilepsy is the most common condition reported through the psychiatric returns surveillance
system in Gokwe South District. The condition is controllable with antiepileptic medication.
Review visits attendance is key to the successful control of seizures among epilepsy patients. A
high proportion of scheduled review visits are missed every month. This study sought to
establish the attendance pattern of epileptic patients, prevalence of non-attendance and the
associated factors.
Methods: The study was an analytic cross-sectional study. One hundred and ten (110)
respondents were selected randomly from the district’ epilepsy register. Interviewer-administered
pretested questionnaires were used to collect data. Epi info version 3.5.1 was used to create
frequencies and proportions were calculated as well as Odds ratios to determine associations.
Logistic regression analysis was done to identify independent risk factors and to control for
confounding variables.
Results: One hundred and ten (110) epileptic patients were included in the study. The epileptic
patients missed treatment review visits ranging from 1 to 11 of the expected 12 review visits
between June 2011 and June 2012. 70.9% missed at least 2 visits in a period of 12 months while
46.4%missed 2 or more consecutive visits. Knowledge of treatment duration [POR 0.24(95% CI
0.08-0.74)] and high risk perception [POR 0.14 (95% CI: 0.06-0.33) were associated with a
lower likeliness of missing review visits. Barriers such as shortage of drugs [POR 7.09 (95% CI:
3.00-16.72)] and long distances to health facilities [POR 6.63(95% CI: 2.63-16.76)] were
associated with high likeliness of missing two or more review visits consecutively. Shortage of
drugs [AOR 6.7336 (95% CI: 1.8538, 24.4581)]and higher risk perception [AOR 0.1948(95%
CI: 0.0625, 0.6071)] remained significant on logistic regression analysis.
Conclusion and Recommendations
A high number of epileptic patients miss their review visits mainly owing to shortage of drugs,
having no village health workers to assist patients in treatment process. The District Health
Executive must ensure constant supply of Antiepileptic drugs.
Key Words
Epilepsy, Review visits, Non-attendance, Gokwe South
iv
Acknowledgement
I would like to express my sincere gratitude to the Provincial Medical Director of Midlands
province Dr M Chemhuru and his staff for all the support rendered in this project. I would also
want to express my gratitude to my field supervisor Dr P T Mafaune for the guidance and
support throughout this project. I also want to acknowledge the Department of community
medicine for all the support rendered to me. My sincere gratitude also go to the District Medical
Officer for Gokwe South Dr A Mapanga, District nursing Officer Mr D.T. Matiyenga, the
District Environmental Officer Mr D Mkotsi, The district mental health coordinator Mr P
Tavengwa, Mr Musiiwa, and all the other Gokwe district health staff for their unwavering
support. Many thanks also to all the clinic nurses and EHTs for assisting me during the study and
guidance in their areas of jurisdiction. I would also want to thank all the study participants for
taking their time and agreeing to take part in this study. My uttermost gratitude goes to Mr J
January and Mrs J Maradzika for the guidance throughout the whole process of preparing this
project.
I also want to thank my wife Rutendo and my Daughter Gamuchirai for great understanding of
my tight schedule when i was carrying out this study.
Evans Dewa
University of Zimbabwe, August 2012
v
Table of Contents Abstract ........................................................................................................................................................ iii
Acknowledgement ....................................................................................................................................... iv
List of tables ............................................................................................................................................... viii
List of Figures ............................................................................................................................................ viii
Abbreviations ............................................................................................................................................... ix
CHAPTER 1: BACKGROUND ................................................................................................................... 1
1.1.1 Introduction ...................................................................................................................................... 1
1.1.2. Risk Factors for epilepsy ............................................................................................................. 1
1.1.3. Burden of Illness Due to Epilepsy .................................................................................................. 2
1.1.4 Epilepsy burden in Zimbabwe ......................................................................................................... 3
1.1.5. Epilepsy burden in Gokwe South .................................................................................................... 3
1.1.6. Psychosocial Impact of Epilepsy .................................................................................................... 4
1.1.7. Treatment of epilepsy ..................................................................................................................... 5
1.2. Problem Statement ................................................................................................................................. 6
1.2.1. Non-Attendance of epilepsy review visits among epileptic patients in Gokwe South. .............. 7
Chapter 2: Literature Review ....................................................................................................................... 8
2.1. Introduction ........................................................................................................................................ 8
2.2. Adherence .......................................................................................................................................... 8
2.2.1 Factors associated with non-adherence ............................................................................................ 8
2.3. Attendance of review visits ................................................................................................................ 9
2.3.1. Prevalence of Non-attendance ........................................................................................................ 9
2.3.2. Factors contributing to non-attendance ......................................................................................... 10
Conceptual framework ............................................................................................................................ 11
Justification ............................................................................................................................................. 13
Research Questions ................................................................................................................................. 14
Hypothesis .............................................................................................................................................. 14
Objectives of the Study ........................................................................................................................... 15
Chapter 3: Methods ..................................................................................................................................... 16
3.1. Study Type ....................................................................................................................................... 16
3.2. Study Setting .................................................................................................................................... 16
3.3. Study population .............................................................................................................................. 17
vi
3.4. Sampling Frame ............................................................................................................................... 17
3.5. Study Unit ........................................................................................................................................ 17
3.6. Sampling Technique ........................................................................................................................ 17
3.7. Sample Size ...................................................................................................................................... 18
3.8. Inclusion criteria .............................................................................................................................. 18
3.9. Exclusion criteria ............................................................................................................................. 18
3.10. Variables ........................................................................................................................................ 19
3.11. Data Collection .............................................................................................................................. 20
3.12. Pretesting........................................................................................................................................ 20
3.13. Data analysis .................................................................................................................................. 20
3.14. Permission to proceed with study .................................................................................................. 21
3.15. Ethical considerations .................................................................................................................... 21
Chapter 4: Results ....................................................................................................................................... 22
4.1.1. Demographic characteristics of respondents ................................................................................. 23
1.1.2. Services offered during epilepsy treatment review visits ............................................................. 24
4.2. Predisposing factors ......................................................................................................................... 25
4.2.1. Knowledge/Awareness ............................................................................................................. 25
4.2.2. Sources of information ............................................................................................................. 25
4.2.3. Reminders ................................................................................................................................. 26
4.2.4. Perceived susceptibility............................................................................................................. 27
4.2.5. Perceived severity of condition ................................................................................................. 27
4.2.6. Perceived benefits of attending review visits ............................................................................ 27
4.2.7. Behaviour intention ................................................................................................................... 27
4.3. Reinforcing factors ........................................................................................................................... 28
4.3.1. Social support ............................................................................................................................ 28
4.4. Enabling factors ............................................................................................................................... 30
4.4.1. Barriers to attendance................................................................................................................ 30
4.5. Review visits non-attendance pattern .............................................................................................. 31
4.6. Bivariate analysis ................................................................................................................................. 32
4.6.1. Predisposing factors ...................................................................................................................... 32
4.6.1.3. Perceptions ................................................................................................................................. 35
4.6.1.4. Behaviour intention .................................................................................................................... 37
vii
4.6.2. Enabling factors............................................................................................................................. 37
4.6.3. Reinforcing factors ........................................................................................................................ 38
4.6.4. Socio-demographic and condition-related variables ................................................................... 39
4.7. Logistic Regression Analysis ........................................................................................................... 41
4.8. Availability of Antiepileptic drugs and IEC material ...................................................................... 42
4.9. Challenges experienced in management of epilepsy ....................................................................... 42
Chapter 5: Discussion ................................................................................................................................. 44
Conclusions ............................................................................................................................................. 48
Recommendations ................................................................................................................................... 49
References ................................................................................................................................................... 50
ANNEX 1A: ENGLISH INFORMED CONSENT FORM ........................................................................ 52
ANNEX 1B: GWARO RECHITENDERANO .......................................................................................... 56
ANNEX 2A: ENGLISH CONSENT FORM FOR PARENTAL CONSENT ............................................ 59
ANNEX 2B: GWARO RECHITENDERANO NEMUBEREKI WEMWANA ........................................ 64
Annex 3: Questionnaire .............................................................................................................................. 68
Annex 3: PMD’s Approval letter ................................................................................................................ 78
Annex 5: Institutional Review Board approval ........................................................................................... 80
Annex 6: Medical Research Council Approval .......................................................................................... 81
viii
List of tables
Table 1: Epilepsy review non attendance Gokwe South, 2009-2011 ............................................. 7
Table 2: Variables ......................................................................................................................... 19
Table 3: Demographic variables ................................................................................................... 23
Table 4: Review visits non-attendance, Gokwe south 2012 ......................................................... 31
Table 5: Knowledge and awareness related factors ...................................................................... 33
Table 6: Sources of epilepsy related information associated with non-attendance of treatment
review visits .................................................................................................................................. 34
Table 7: Perceived susceptibility and non-attendance of treatment review visits ........................ 36
Table 8: Enabling factors associated with non-attendance of treatment review visits ................. 38
Table 9: Socio-demographic and condition related factors .......................................................... 40
Table 10: Logistic regression analysis .......................................................................................... 41
List of Figures
Figure 1: Epilepsy incidence, Gokwe South, 2005-2011 ............................................................... 4
Figure 2:Epilepsy treatment review visits Non-attendance: Midlands Province, 2010 .................. 7
Figure 3: Diagram of conceptual framework ................................................................................ 13
Figure 4: Services offered during treatment review visits ............................................................ 25
Figure 5: Sources of epilepsy-related information........................................................................ 26
Figure 6: Intended visits by Epileptic patients in a 12 months period, Gokwe south, 2012 ......... 28
Figure 7: Support offered to epileptic patients by their relatives and friends ............................... 29
Figure 8: Times when patients went to health facility when there were no AEDs ....................... 31
ix
Abbreviations
AED Anti-Epileptic Drugs
AFRO African Region Office
AOR Adjusted Odds Ratios
CI Confidence Interval
DALY Disability-Adjusted of Life Years
EHT Environmental Health Technician
DMO District Medical Officer
MOHCW Ministry of Health and Child Welfare
PEDCO Provincial Epidemiology and Disease Control Officer
PRECEDE Predisposing, Reinforcing, and Enabling Constructs in
Educational/Environmental Diagnosis and Evaluation
PROCEEDE Policy, Regulatory, and Organizational Constructs in
Educational and Environmental Development
PMD Provincial Medical Director
POR Prevalence Odds Ratio
VHWs Village Health Workers
WHO World Health Organization
YLL Years of Life Lost
1
CHAPTER 1: BACKGROUND
1.1.1 Introduction
Epilepsy is a chronic neuropsychiatric disorder characterized by recurrent seizures, which may
vary from a brief lapse of attention or muscle jerks, to severe and prolonged convulsions. The
seizures are caused by sudden, usually brief, excessive electrical discharges in a group of brain
cells (neurons). The condition is defined by two or more unprovoked seizures hence not all
seizures are defined as epilepsy1. Epileptic seizures are the clinical manifestations (signs and
symptoms) of excessive and/or hyper-synchronous, usually self-limited, abnormal activity of
neurons in the brain hence others see epilepsy as a symptom complex or a condition rather than a
disease on its own right. About 10% of the world population who live full length of their
expected lifespan will experience at least one epileptic seizure in their life1. Active epilepsy has
been defined as epilepsy that has caused two or more unprovoked seizures on different days in
the year prior to the assessment date2.
1.1.2. Risk Factors for epilepsy
Causation of epilepsy has always been difficult to establish due to the multiple causes of the
condition. The most common type of epilepsy accounting for 6 out of 10 cases is idiopathic
epilepsy and has no known cause3.
Secondary epilepsy is the one with known causes which range
from; brain damage from a loss of oxygen or trauma during birth, a severe blow to the head, a
stroke that starves the brain of oxygen, an infection of the brain such as meningitis, or a brain
tumour3. The major risk factor for epilepsy is cerebrovascular disease. Head trauma, central
nervous system infections and tumors are associated with secondary epilepsy. For the younger
2
population, perinatal complications, congenital, developmental and genetic conditions are
associated with epilepsy3. A family history of epilepsy also increases the influence of other risk
factors3.
1.1.3. Burden of Illness Due to Epilepsy
Epilepsy is the most common neuropsychiatric disorder in the general population globally
affecting an estimated 40 million people 4. The developing world; however is the one bearing the
major burden of the condition3. Approximately 85% of the people suffering from epilepsy are in
developing countries and the incidence rate is also higher in developing world compared to the
developed countries (estimated to be 100 new cases per 100 000 people per year in developing
countries compared to an estimated 50 per 100 000 people per year in the developed countries)3.
Studies carried out in Africa showed prevalence up to 58 cases per 1000 people2.
There were a total of about 40 million known epilepsy patients against a population of
approximately 6.4 Billion people globally and 7.7 million patients were from the WHO AFRO
region with a population of approximately 737.5 million people in 20044. This shows a
prevalence of about 10.4 cases per 1000 people for the WHO AFRO region and 6.2 cases per
1000 people globally. Carrying out similar calculations for all other WHO regions showed that
the African region has the greatest burden in the world with the least burden being in the
Western Pacific followed by the European regions (4.0 and 4.6 cases per 1000 people
respectively). The same study also revealed that epilepsy contributes 0.2% of deaths worldwide,
contributed 0.3% of years of potential life lost (YLL) and 0.5% of DALYs globally.
3
1.1.4 Epilepsy burden in Zimbabwe
Zimbabwe’s Ministry of Health and Child Welfare acknowledges that epilepsy is the most
prevalent neuropsychiatric condition in Zimbabwe as a whole, Midlands Province generally and
Gokwe South district specifically. It was highlighted in the Zimbabwe national health strategy
that epilepsy contributed 56% of all conditions reported through the mental health surveillance
system (psychiatric returns) in Zimbabwe in 2004 5. Levy et al estimated epilepsy prevalence to
be 7.4 per 1000 people in 1961 2
. A study done by the global campaign against epilepsy in 2003
showed a prevalence of 13.4 cases per 1000 people in rural Hwedza district of Zimbabwe6
which
is much higher than that reported by Levy earlier on in 1961 2
.
1.1.5. Epilepsy burden in Gokwe South
The district hospital and all the clinics offer epilepsy treatment. Currently the district has a total
of 209 patients in epilepsy register in Gokwe South district who are currently on follow-up. This
however, is contrary to the recorded incidences of epilepsy in the district. The district’s T5
system shows that 433 new epilepsy cases were recorded between 2005 and 2011. Figure 1
below shows the incidence of epilepsy between 2005 and 2011.
4
Figure 1: Epilepsy incidence: Gokwe South District: 2005-2011
Figure 1: Epilepsy incidence, Gokwe South, 2005-2011
Source: T5 system (2005, 2006, 2007, 2008, 2009 and 2011)
1.1.6. Psychosocial Impact of Epilepsy
Epileptic patients face a number of challenges in activities of daily living including; difficulties
in speed of thinking, difficulties in using public transport, difficulties in relationships with others,
sexual dysfunction, and difficulties in daily problem-solving. In Zimbabwe 67% of epileptic
patients attending epilepsy clinics were found to be facing challenges with solving daily
problems, 65% of epileptic patients in community support groups had difficulties with speed of
thinking, 67% of epileptic patients attending epilepsy clinics said sexual functioning is not
applicable to them despite being in the sexually-active age-group, 25% and 27% of epileptic
patients attending epilepsy clinics and those from community support groups face difficulties in
relationships with others, and overally more than 60% of epileptic patients have reduced
functioning7. There is usually stigma attached to epilepsy. The Hindu Marriage Act 1955 and
Special Marriage Act 1958 in India specified that a marriage under these acts can be solemnized
43
21
31
18
8
19
0
5
10
15
20
25
30
35
40
45
50
2005 2006 2007 2008 2009 2011
Inci
de
nce
pe
r 1
00
00
0 p
eo
ple
Year
5
if, at the time of marriage, neither party suffered from insanity or epilepsy8. A study carried out
among, student nurses and laboratory assistants in Cameroon showed that 15.3% believed that
epilepsy is a form of insanity, 10% thought that epilepsy is contagious, and about 33% and 52%
would, respectively, object to their children associating with and marrying people with epilepsy9.
1.1.7. Treatment of epilepsy
The goal of medication is to allow epileptic patients to live a better quality of life, free of
seizures. In Zimbabwe the commonly used drugs for epilepsy are Phenobarbital, Carbamazepine
and Phenytoin. After two to five years of successful treatment, drugs can be withdrawn in about
70% of children and 60% of adults without relapses of seizures 3.
A follow-up study done in Tanzania revealed that 52.4% of epileptic patients achieved complete
seizure suppression, 36% had reduced frequency of seizures and only 7.9% experienced no
change after 20 years of treatment10
. In rural Mali, 80% out of 96 patients treated with
Phenobarbital became seizure free within one year11
. Generally people believe that epilepsy can
be treated or controlled16
. Sureka found that treatment of epilepsy is easy since most of the
epileptic patients can be managed at rural centre without sophisticated investigations12
. A study
carried out in India revealed that poor adherence to prescribed medication is considered to be the
main cause of unsuccessful drug treatment for epilepsy13
.
6
1.2. Problem Statement
While it has been noted that epileptic seizures could be controlled with medications such as
Phenobarbital, Carbamazepine and Phenytoin in 70% of the patients3, effectiveness of all
medicines including anti-epilepsy Drugs (AEDs) however, depends on adherence to the whole
treatment process (which include, taking of medicines in the required quantities and timeously as
well as going for medical/health reviews as appointed). Attendance of scheduled medical
reviews (which is one of the measures of epilepsy treatment adherence) has been unacceptably
low in Gokwe South district. In 2010 only, 851 out of the appointed 1604 visits, which is about
53.1% visits for epileptic patients were missed. This is much higher than the provincial average
of 40.4% in the same year which is a skewed distribution towards Gokwe South district and it is
of great concern. Figure 2 below shows non-attendance of review visits across the whole of
Midlands Province (by district). Attendance of review visits is important in epilepsy treatment
since these are the days when progress of treatment is assessed and this is also when patients get
their usual supply of anti-epileptic medicine. This is thus important in ensuring that patients live
a seizure-free life or at least experience reduced frequency and severity of seizures. As a form of
non-adherence, those who do not attend review visits regularly are also expected to suffer higher
frequency of seizure. There is evidence which shows that non-adherence lead to increased
frequency of seizures 14
.
7
Figure 2:Epilepsy treatment review visits Non-attendance: Midlands Province, 2010
Source: Psychiatric Returns: Midlands Province, 2010
1.2.1. Non-Attendance of epilepsy review visits among epileptic patients in Gokwe South.
Non- attendance of epilepsy treatment review visits was more than 50% in Gokwe south District
in 2009 and 2010. Table 1 shows proportion of missed visits for 2009 and 2010.
Table 1: Epilepsy review non attendance Gokwe South, 2009-2011
Year Total Number of
Scheduled Visits
Total
Non-attendance
Percentage of non-
attendance (%)
2009 1383 715 51.7
2010 1604 851 53.1
2011 2506 1280 51.1
Information Extracted from District Psychiatric monthly returns
0
10
20
30
40
50
60
Pro
po
rtio
n (
%)
District
8
Chapter 2: Literature Review
2.1. Introduction
Adherence to treatment has been shown to be one of the great determinants of prognosis of any
condition including epilepsy 15
.
2.2. Adherence
The goal of treatment is to reduce the frequency and severity of seizures, however this mainly
fails due to failure to adhere to the drug regimen or when a less-than-adequate drug regimen is
prescribed. Good adherence to treatment and proper health education are fundamental to the
successful management of epilepsy. Non-adherent patients experience an increase in the number
and severity of seizures, which leads to more ambulance rides, emergency department visits and
hospitalizations16
. Non-adherence therefore results directly in an increase in health care costs,
and reduced quality of life16
. Different levels of adherence to antiepileptic medication have been
reportedly both nationally and in Zimbabwe. A study done by Manungo in Harare, Zimbabwe
revealed that drug compliance was around 67.4% for epileptic children attending paediatric
epilepsy clinic17
. In a study by Modi, Rausch and Glauser in The United States of America
(Cincinnati), near perfect adherence was found to be only 42%, with 20% severe non-
adherence18
.
2.2.1 Factors associated with non-adherence
Epileptic patients generally know that they are not supposed to miss a single dose of their
antiepileptic medication. A study Smi Choi-Kwon found that 72% of the patients attending
epileptic clinics actually know that they are not supposed to miss their antiepileptic medication20
.
Though knowledge is one of the major contributing factors to drug adherence, there are many
other factors that also influence drug adherence20
. In a study by Loiseau and Marchal , longer
9
time (10-20 years) durations with the condition was shown to be associated with non-adherence
19.
Even with high knowledge levels, patients may still miss their medication due to a number of
factors like perceived dangers of using antiepileptic drugs. In a study by Smi Choi-Kwon, these
perceived dangers of AEDs have been shown to be high among some patients and these include;
the belief that taking AEDs will impair memory (78.5%) and may also lead to kidney and liver
damage (73.4%) 20
.
A study done in Cincinnati, USA by Modi et al, found that low socioeconomic status was
associated with non-adherence among epileptic children18
. Experiencing low frequency of
seizures sometimes increase none adherence since most of the people who experience few
epileptic seizures may have low perceived susceptibility to seizure attacks. A study by Loiseau
and Marchal showed that experiencing low frequency of seizures was associated with non-
adherence among epileptic patients19
.
2.3. Attendance of review visits
Attendance of appointments has been identified as one indirect measures of adherence to
antiepileptic medication21
.
2.3.1. Prevalence of Non-attendance
Generally epileptic patients have been shown to miss more than half of their scheduled visits. A
study carried out in Uganda by Odaga et al showed that epileptic patients miss more than half of
their scheduled visits with 84.5% of epileptic patients missing at least one visit in a period of two
years22
. The same study showed that treatment review visits attendance is around 40% at any
given time22
. A follow-up study done by Tsai and Cheng in Taiwan showed that only 42% of
10
epileptic patients could adhere to the scheduled appointments and 14% would come to the
facility irregularly23
.
2.3.2. Factors contributing to non-attendance
Studies carried out nationally, regionally and globally have shown a number of factors
contributing to the patterns of epilepsy treatment review visits attendance.
Having epilepsy-related information is one of the important factors which may improve epilepsy
treatment review visits attendance. A number of methods and different types of media could be
used to disseminate information with varying impact. Information-dissemination among epileptic
patients through print media can significantly increase epilepsy review visits attendance. An
intervention study carried out in Zvimba district of Zimbabwe by Adamolekun et al has shown
significantly lower epilepsy defaulter rates of 22.3% among a group that was given epilepsy
pamphlets compared to the defaulter rate (56.3%) of those who were not given epilepsy
pamphlets (p=0.0001) 24
.
A study carried out by Berhanu in Ethiopia has shown that perceived drug-efficacy may lead to
preference for traditional remedies hence leading to more defaulting among epileptic patients 25
.
Memory of dates for review visits is also a key determinant to review visits attendance.
Forgetfulness was shown to significantly contribute to non-attendance of review visits among
children with epilepsy in Saudi Arabia in a study by Al-Faris et al26
.
Difficulties to travel to health centres is also a key hindrance to epilepsy review visits attendance
among epileptic patients as found in a study that was carried out in rural Ethiopia25
. These
difficulties may be due to long distances to health facilities especially for newly diagnosed
patients who usually will be experiencing fits more frequently. Odaga in a study carried out in
11
Uganda stated long distance (between 10 and 20 km) to be one of the most mentioned reasons
for defaulter mentioned by both health workers and patients22
. In a study by Tsai and Cheng,
environmental factors such as availability of time and transportation to clinic were the major
significant causes of epilepsy patients’ drop-out (12%) and irregular clinic appointment visits
(50%) (p<0.01) in Taiwan23
.
Direct support and community follow up by health workers is one factor that contributes
significantly to epilepsy patient recruitment and retainment. This is ensured when there is a
skilled and knowledgeable workforce. In a study by Adamolekun in Zvimba district of
Zimbabwe, it was shown that training of Primary Care Nurses and Environmental health
technicians on epilepsy management increased epilepsy patient recruitment by 74%, the bulk of
the increase being attributed to follow-ups being done by Environmental Health Technicians24
.
Having well informed and involved community leaders is also important in ensuring epilepsy
review visits attendance and reduce defaulting. A study carried out by Ball showed that
educating community leaders significantly (p=0.02) increase attendance of previously diagnosed
epileptic patients at clinics in Epworth in Zimbabwe27
.
Conceptual framework
A number of factors may be contributing to the phenomenon at individual, family, community
and health system levels. The Educational and Ecological Assessment of the PRECEDE -
PROCEED model was used to explain the variation in review visits attendance among epileptic
patients28
. The PRECEDE-PROCEED model is a logical planning model with 8 phases which
was developed in the 1970s29
. The acronym stands for Predisposing, Reinforcing, and Enabling
Constructs in Educational/Environmental Diagnosis and Evaluation. PROCEED was added in
1991 as a recognition of the role played by environmental factors as determinants of health. The
12
Acronym stands for (Policy, Regulatory, and Organizational Constructs in Educational and
Environmental Development). The Educational and Ecological assessment is Phase 3 of the
PRECEDE-PROCEED Model. This helps planners to identify antecedent and reinforcing factors
contributing to an identified and prioritized behaviour for intervention. The factors are divided
into Predisposing factors, Enabling factors and Reinforcing factors. Predisposing factors are
antecedents to behaviour that provide rationale or motivation for the behaviour, Reinforcing
factors are the factors following a behaviour that provide continuing reward or incentive for the
persistence or repetition of the behaviour, while enabling factors are antecedents to behavioural
or environmental change that allow a motivation or environmental policy to be realized28
.
Behaviour intention and subjective norms from the theory of planned behaviour30
and perceived
susceptibility and perceived severity from the Health belief model were incorporated into the
conceptual framework.
The Model suggests that behaviour is a product of Predisposing, Enabling and Reinforcing
factors. Cues to action and Constructs from the Theory of Planned Behaviour (Behaviour
intention, Subjective Norms and Attitudes towards Behaviour) were incorporated into the model.
Attendance of review visits among epileptic patients was proposed to be a product of these
factors as well as other demographic factors such as age, marital status, gender, occupation,
socio-economic status as well as religion. The factors are at 5 main levels namely; individual,
interpersonal, organizational, community and policy level. This study focused on individual,
interpersonal, community and organizational levels. Individual factors were mainly predisposing
factors, while the enabling factors were looked at organizational level, while the community and
interpersonal factors comprised mainly of reinforcing factors.
13
Justification
Epilepsy is controllable with medication (about 70% of epileptic patients will live a seizure-free
life if under treatment); however the effectiveness depends on adherence to the treatment
process. Attendance of scheduled monthly treatment reviews as one of the measures of
adherence has been shown to be low in Gokwe South district. The factors contributing to this
phenomenon have not been sufficiently explored in the district and Zimbabwe at large. This
study hence primarily, sought to establish individual, family, community and health system-
related factors associated with the high levels of non-attendance of scheduled review visits
among epileptic patients in Gokwe South district. Evidence gathered can mainly be used by
Adopted and modified from Green and Ottoson, 200631
Phase 3: Educational
and Ecological
Assessment
Predisposing
Knowledge
Attitudes
Perceptions (benefits
and Barriers)
Values
Self efficacy
Behaviour intention
Modifying variables;
Demographic,
Illness-related factors
(e.g. Time on treatment)
Enabling
Availability
Accessibility
Affordability of services
Skills
Epilepsy review visits
attendance (Behaviour)
Environment
Reinforcing
Influence from parents,
spouses, community
members etc.
Social support from
relatives and friends
Health
Education
Mass Media
Advocacy
Training
Policy,
Regulation and
Organization
Phase 4: Intervention
alignment Administrative and
policy Assessment
Figure 3: Diagram of conceptual framework
14
programme planners at district level and also be to inform policy makers on the implications of
health policies on epileptic patients in rural areas of Zimbabwe.
Most of the studies done in Zimbabwe did not take into consideration the effects of the social
environment and social support to review visits/appointment attendance among epileptic
patients. Other factors that were not sufficiently exploited are the physical and economic barriers
to care such as the cost of travelling to health facilities. There is a gap in the investigation of
personal perceptions regarding attending epilepsy review visits as appointed by health care
workers. Such factors include perceived vulnerability to epilepsy related complications, benefits
of attending review visits, and self-efficacy. Behaviour intention is one of the major close
determinants of behaviour which also need more investigation. Effects of availability or absence
(uninterruptedly) of resources such as medicines on review visits were also not sufficiently
explored especially in the Zimbabwean setting. Further-on, most of the studies were actually
more concerned with improving patient recruitment with little focus on retainment.
Research Questions
a) What is the prevalence of epilepsy review visits non-attendance in Gokwe South district?
b) What are the factors associated with epilepsy review visits non-attendance in Gokwe South
district?
Hypothesis
H0: There is no association between low knowledge levels, perceived low threat of non-
attendance, non-enabling environment or low interpersonal support and non-attendance of
treatment review visits among epileptic patients in Gokwe South district.
H1: At least one of the above-stated factors is associated with non-attendance of treatment
review visits among epileptic patients in Gokwe South district.
15
Objectives of the Study
Broad Objective: To determine the factors associated with non-attendance of epilepsy review
visits in Gokwe south district
Specific Objectives
- To determine the prevalence of epilepsy treatment review visits attendance in Gokwe
South district
- To establish predisposing factors associated with non-attendance of scheduled treatment
review visits among epileptic patients in Gokwe South District
- To determine enabling factors associated with non-attendance of scheduled treatment
review visits among epileptic patients in Gokwe South District
- To establish reinforcing factors associated with non-attendance of scheduled treatment
review visits among epileptic patients in Gokwe South District
- To establish condition-related factors associated with non-attendance of epilepsy
treatment review visits in Gokwe South
- To determine socio-demographic factors contributing to non-attendance epilepsy review
visits in Gokwe South district.
16
Chapter 3: Methods
3.1. Study Type
An analytical cross-sectional study was carried out where epileptic patients were drawn in the
study and their review visits attendance pattern was ascertained at the same time with
measurement of the determinants variables (predisposing, enabling, reinforcing factors, socio-
demographic factors and condition-related factors). This study design enabled the researcher to
establish the proportion of epileptic patients who miss some of their epilepsy treatment review
visits. This was done since the information available only showed the number of visits missed
each month without tracking individual patients and establish their attendance pattern. After this,
the patients were divided into attendees and non-attendees for further analysis (bivariate and
multivariate analysis). Non-attendees were further divided into 3 more categories (those who
missed only 1 visit, those who missed more than 1 visit and those who missed at least 2
consecutive visits).
3.2. Study Setting:
The study was carried out in Gokwe South District. Gokwe South District is one of the 8 districts
in Midlands province. The district population profile in the health information department shows
that Gokwe South has a projected total population of 321 446 people in 2012. The district has a
total of 31 health facilities of which, 30 are primary level health facilities while one is secondary
(Gokwe South District hospital). The district hospital and all the clinics offer epilepsy treatment
hence study participants were drawn from the district hospital and the clinics’ catchment areas.
Patients interviewed were from Gokwe District hospital, Cheziya Clinic, Krima clinic, Nyaje
17
clinic, Huchu clinic, Msita clinic, Svisvi clinic, Chemahororo clinic, Gwanika clinic, Kana
mission, Sasame clinic and njelele satellite clinic
3.3. Study population
The study population were all epileptic patients who were on treatment and residing in Gokwe
South district during the period of the study. The district epilepsy register has a total of 209
epileptic patients expected to attend treatment review visits on monthly basis.
3.4. Sampling Frame
A list of epileptic patients from the Gokwe South district epilepsy register was compiled and
participants were drawn from this list.
3.5. Study Unit
An epileptic patient from the epilepsy register of Gokwe South district
3.6. Sampling Technique
There were 209 patients in the whole of Gokwe South District’s epilepsy register. A list of
patients was prepared from the register and this was used as the sampling frame. All patients on
the list were allocated a number between 1 and 209. Microsoft excel Random function
[=RAND()*n] was used to pick study participants randomly from the sampling frame where ‘n’
was the total number on the sampling frame.
18
3.7. Sample Size
A sample size of 103 was calculated using from Wayne W. Daniel32
, however 110 participants
were included to cater for non-responses expecting a non-response rate of 6.4%. The following
formula was utilised:
where n is the sample size, N is the population of epileptic patients in Gokwe South district, p is
the proportion with the outcome of interest, d is the absolute precision and z is risk of type 1
error.
This sample size was calculated assuming that 15.5% of the epilepsy patients did not miss any
scheduled visit in Gokwe South in the previous 12 months (based on a study done in Uganda by
Odaga 22
). A study population of 209 was used since these are the confirmed number of epilepsy
patients in the district epilepsy treatment register.
Hence p = 15.5%, (1-p) = 84.5%, N=209, and d= 0.05
3.8. Inclusion criteria
Epileptic patients who are registered in Gokwe South, who were commenced on epilepsy
biomedical treatment at least 12 months before the study who consented or assented to
participate were included in the study.
3.9. Exclusion criteria
The study excluded patients who were on biomedical epilepsy treatment for less than 12 months
and those who did not consent or assent were excluded from the study.
n =
Nz2p(1-p)
d2(N-1) +z
2p(1-p)
19
3.10. Variables
Table 2: Variables
Variable How to measure Information source
DEPENDANT VARIABLE
Scheduled medical Reviews NON-
attendance
Scheduled Review visits missed Patients self reports/Epilepsy
Registers/Patients treatment cards
INDEPENDENT VARIABLES
1. Personal and demographic
characteristics
Patients’ self reports
a. Time suffering from epilepsy Years past Patients’ self reports
b. Preferred place for treatment Patients’ self reports
c. Time on Treatment Past Years since treatment begun Patient self reports and Patients’
treatment cards review.
d. Distances to nearest facility where
services are offered
2. Predisposing Factors
a. Knowledge/Awareness Knowledge on regimens for
treating epilepsy, patient’s own
drug schedule and patient’s own
review dates
Patient self reports and Patients’
treatment cards review.
b. Sources of Information/Cues To
action
Patient self reports
c. Attitudes Towards
Behaviour/Threats
Perceived effects of behaviour
Perceived outcome and severity
of the effects.
Patients’ self reports
d. Perceived Behavioural
control/Self-Efficacy
Ability to decide on place for
treatment, whether to be on or to
be not on treatment, when to
terminate treatment
Patients’ self reports
e. Intention Number of intended visits in a
year
Patients’ self reports
3. Enabling Factors
a. Availability of services Number of visits where services
were unavailable/Broken
appointments
Number of visits when Drugs
were out of stock
Patients’ self reports and patients’
treatment cards
b. Affordability of services Costs of consultations, Drugs
and Travelling
Patients self reports
c. Perceived/real Physical
barriers to accessing services
Presents of physical barriers like
poor roads/Terrain, Rivers
Patients’ self reports
4. Reinforcing Factors
a. Community and family
support/Reinforcement
Presents of support networks,
Community driven initiatives to
support epileptic patients
Self reports
20
3.11. Data Collection
An interviewer-administered questionnaire was used to collect data from the participants (See
Annex 3). The questionnaire was created based on the constructs of the conceptual framework
(the Educational and ecological diagnosis of the PRECEDE model). Questionnaire
administration was done in Shona. Attendance was measured from patients’ self reports and
verified by checking patients’ treatment cards. The district register had list of names of epileptic
patients and the respective clinics to which they report. A list of patients who were selected
together with their respective clinics was prepared and the researcher went to clinic level where
physical addresses of participants were obtained. Study participants were then followed-up
using addresses listed in the treatment registers. Availability of antiepileptic drugs was checked
at health facilities using a checklist. The data collection exercise was done in a period of one
month from 23 July to 21 August 2012.
3.12. Pretesting.
The data collection tool was pretested at Gweru district hospital and where necessary
adjustments were done.
3.13. Data analysis
Epi Info version 3.5.1 was used to enter, clean and analyse the data. Frequencies and proportions
were generated. Prevalence odds ratios (POR) were used to determine strength of associations
between the independent variables and the outcome of interest (non-attendance of review visits).
The outcome of interest was whether one missed 2 or more consecutive visits. 95% confidence
intervals for PORs were used to determine the significance of associations between independent
variables and the outcome of interest. Logistic regression analysis was performed to identify
independent risk factors for factors associated with non-attendance of review visits among
21
epileptic patients and to control for confounding variables. The logistic regression model initially
included all variables with a p-value of 0.25 or less.
3.14. Permission to proceed with study
Permission to carry out the study was granted by the Department of Community Medicine, The
Provincial medical director of Midlands province, and Gokwe South District Medical Officer.
3.15. Ethical considerations
Ethical approval for the protocol was sought from the Joint Research Ethics Committee and the
Medical Research Council of Zimbabwe and was granted (See Annex 5 and 6). The study
protocol was explained in full to all study participants in Shona (their local language). Written
informed consent was obtained from all study participants using a consent form (See Annex 1A
and 1B). Parental consent and study participant assent was sought for all participants below the
age of 18 years (See Annex 2A and 2B). No force, coercion or persuasion by any means was
used to recruit study participants. Study participants were allowed to terminate their participation
at any time they felt like doing so. The consent forms and filled questionnaires were stored
separately under lock and key by the Principal Investigator at the PMD’s office where analysis
was done by the Principal Investigator. Confidentiality was assured and maintained throughout
the study.
22
Chapter 4: Results
A total of 110 epileptic patients who were on epilepsy treatment for more than 12 months were
interviewed in Gokwe South district. Participants had suffered from epilepsy for periods ranging
from 1year to 50 years and had a median period of 12 years (Q1=7 years; Q3 = 20 years)
suffering from epilepsy. Their period on biomedical treatment ranged from 1 year to 40 years
with a median period of 10.5 years (Q1 = 6 years; Q3= 19 years). Treatment was first sought
from a health facility by 52 (47.3%) of the participants while the remaining 58 (52.7%) first
sought treatment from traditional healers, 27 (24.5%) and faith healers 31 (28.2%). Seventy-five
(75) (68.2%) of the epileptic patients are currently receiving treatment from health facilities only,
while 35 (31.8%) were on the time of study also getting treatment from either traditional healers
16 (14.5%) or faith healers 19 (17.3%).
23
4.1.1. Demographic characteristics of respondents
Table below 3 shows the socio demographic characteristics of the respondents
Table 3: Demographic variables
Variable Frequency (N=110) Proportion (%)
Sex
Males 67 60.9
Females 43 39.1
Age (Years)
Below 21 20 18.2
21-30 41 37.3
31-40 28 25.5
41-50 12 10.9
51 Yrs and above 9 8.2
Marital status
Married 38 34.5
Single 65 59.1
Widowed 4 3.6
Divorced 3 2.7
Religion
Apostolic 26 23.6
Pentecostal 31 28.2
Catholic 40 36.4
Traditional African 13 11.8
24
Variable Frequency (N=110) Proportion (%)
Distance to nearest health
facility
<5 KM 22 20.0
5-10 KM 41 37.3
> 10 KM 47 42.7
Time on Biomedical treatment
0-5 Years 24 21.8
6-10 Years 31 28.2
More than 10 Years 55 50.0
1.1.2. Services offered during epilepsy treatment review visits
The major mentioned service got by epileptic patients was AEDs refilling which was mentioned
by epileptic patients 86.4% of the respondents. This was followed by monitoring of treatment
progress with 41.8% whilst the lowly mentioned was general medical exam which was
mentioned by 25.5% of the study respondents. Figure 4 shows the services offered during
treatment review visits as mentioned by Respondents
25
Figure 4: Services offered during treatment review visits
4.2. Predisposing factors
4.2.1. Knowledge/Awareness
Knowledge was high for the drug-taking schedule, the treatment regimen, and the duration of
treatment with 99 (90%) knowing their drug taking schedule, 95 (86.4%) knowing the treatment
regimen they are on, 91 (82.7%) knew the duration of treatment and 83 (75.5%) knew the
expected number of visits in a year. Seventy-two, 72 (65.5%) of the participants could remember
their next review visit dates. Forty-four, 44 (40%) were verbally told their next review visit date
while 56 (50.9%) had their next review visit indicated on their treatment cards.
4.2.2. Sources of information
The major source of epilepsy-related information mentioned are health workers at health
facilities 65 (59.1%) followed by Health workers who give health education in communities,
(34.5%), village health workers; 14 (12.7%), posters 14 (12.7%), community gathering, 10
(9.1%) and Radio/TV 6 (5.5%) respectively. Thirty-three (33), (30%) of the participants stated
that they have no source of epilepsy-related information. Figure 5 shows sources of epilepsy
information as mentioned by the respondents.
38.2 41.8 29.1
86.4
25.5
0.0
20.0
40.0
60.0
80.0
100.0
checking AEDside effects
MonitoringTreatmentprogress
Checkingepilepsy relatedcomplications
AEDs refilling General medicalexamination
Pro
po
rtio
n (
%)
Services offered
Services offered to epileptic patients in Gokwe South, 2012
26
Figure 5: Sources of epilepsy-related information
4.2.3. Reminders
The most common reminders on review visits attendance was found to be an immediate family
member as shown by 99 (90%) of the respondents stating that a family member reminds them on
the attendance of the next review visit. Other people were also mentioned as reminders on next
review visit attendance with 24 (21.8%) mentioning other relatives, 25 (22.7%) mentioning
friends, 17 (15.5%) mentioning village health workers, and only 6 (5.5%) mentioning a
community member. Ten (9.1%) of the participants said that they had no one to remind them on
their next treatment review visits at home.
Fifty-six (56) (50.9%) of respondents had their next review visits written on their treatment
cards, 44 (40.%) had their review visits given verbally, 30 (27.3%) had their next review visit
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0P
rop
ort
ion
(%
)
Source
Sources of epilepsy-related information, Gokwe South, 2012
27
given both verbally and written on treatment cards while 40 (36.4%) said they had neither been
told their next review visit verbally nor had it written on their treatment cards.
4.2.4. Perceived susceptibility
Fifty-seven of the patients perceive themselves to be generally in danger of suffering severe
epileptic attacks, with 67 (60.9%) perceiving themselves to be greatly susceptible to more and
severe attacks when compared to other epileptic patients whom they knew. Seventy-one
representing 64.5% of the respondents felt that missing review visits will lead to frequent and
severe epileptic seizures.
4.2.5. Perceived severity of condition
One hundred and one (101) of the respondents agreed that suffering more frequent epileptic
attacks predisposes them to injuries, 88 (80%) agreed that suffering more frequent and severe
epileptic seizures affects them emotionally while 94 (85.5%) agreed that suffering more frequent
and severe epileptic attacks limits their day-to-day work.
4.2.6. Perceived benefits of attending review visits
The most mentioned benefit of attending treatment review visits was getting anti-epileptic
medicine which was mentioned by 96 (87.3%) of the respondents. This was followed by
monitoring of treatment progress which was mentioned by 68 (61.8%) of the respondents while
49 (44.5%) mentioned early detection of complications.
4.2.7. Behaviour intention
Sixty-eight (61.8%) of patients intended to attend all the 12 visits, 23 (20.9%) intended to attend
between 10 and 11 of their review visits, 14 (12.7%) intended to attend below 6 visits while 5
(4.5%) intended to attend from 6 to 9 of their treatment review visits. Figure 6 shows the
intended visits by epileptic patients in Gokwe South district.
28
Figure 6: Intended visits by Epileptic patients in a 12 months period, Gokwe south, 2012
4.3. Reinforcing factors
4.3.1. Social support
Epileptic patients stated having different forms of support from close relatives and friends to
varying levels. Fig 7 shows proportions of epileptic patients who had their close relatives and
friends checking the progress of their treatment and those with their close relatives looking after
their possessions when they go for routine treatment review visits. The support was at 5 levels
ranging from not at all to every time.
0
10
20
30
40
50
60
70
80
90
100
0-5 visits 6-9 visits 10-11 visits 12 visits
Pro
port
ion
(%
)
Intended number of visits in a 12 months period (highest is 12)
Intention to go for monthly epilepsy treatment review visits , Gokwe South: 2012
Percentage
29
Figure 7: Support offered to epileptic patients by their relatives and friends
There was however no epilepsy support groups across the whole district. Ninety-two (83.6%) of
respondents acknowledged that health-related issues are sometimes discussed at village meetings
but only 33 (30%) acknowledged that epilepsy-related issues are discussed as health issues at
community gatherings. Thirty (30), (27.3%) of participants stated that community-based health
workers sometimes visit them to assist them in the treatment process.
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
a few times everytime most of thetimes
not at all sometimes
Pro
po
rtio
n (
%)
Frequency of support
Support offered to epileptic patients by relatives and friends, Gokwe South 2012
check treatment progress
look after possession
support offered
30
4.4. Enabling factors
4.4.1. Barriers to attendance
Sixty (60) (54.5%) of the respondents mentioned shortage of drugs as a barrier to review visits
attendance, 34 (30.9%) mentioned long distances to health facilities, 28(25.5%) mentioned high
consultation fees, 9 (8.2%) mentioned physical barriers, 6 (5.5%) mentioned transport
unavailability, 6 (5.5%) mentioned high transport costs and 4 (3.6%) mentioned negative staff
attitudes.
4.4.2. Availability of Antiepileptic Drugs
The greater proportion of the epileptic patients failed to get their monthly supply of drugs in the
last 12 months period. Figure 8 shows the proportion of patients who did not get their monthly
drug supply on their review visits in a 12 months period (from June 2011-May 2012)
31
Figure 8: Times when patients went to health facility when there were no AEDs
4.5. Review visits non-attendance pattern
Fourteen (14) representing 12.7% of the epileptic patients did not miss any treatment review visit
during the previous 12 months period, 16.4% missed only once whilst 70.9% missed more than
one treatment review visit. Table 4 shows the pattern of treatment review visits non-attendance
among epileptic patients in Gokwe South district.
Table 4: Review visits non-attendance, Gokwe south 2012
Visits missed Frequency Proportion (%)
Non 14 12.7
Only one 18 16.4
2 or more 78 70.9
Total 110 100
2 or more consecutively 51 46.4
Visits missed ranged from 0-11; median of 3 visits (Q1=1; Q3=6)
0
10
20
30
40
50
60
70
80
90
100
None a few times Most of the times All the times
Pro
po
rtio
n (
%)
Times when AEDs were unavailable
Unavailability of antiepileptic drugs, Gokwe south, 2012
Proportion
32
4.6. Bivariate analysis
Bivariate analysis was done to determine factors that are associated with missing at least 2 visits
consecutively. The factors were divided into 4 main groups; Predisposing factors, Enabling
factors and reinforcing factors.
Factors associated with missing at least 2 consecutive visits
4.6.1. Predisposing factors
Knowledge
Knowledge of treatment duration was shown to be associated with a low likeliness of patient to
miss two or more visits consecutively with a POR of 0.24 (95% CI: 0.08-0.74) and the
association is statistically significant. Having knowledge of expected number of review visits
was shown to be associated with a high likeliness of missing two or more treatment review visits
with a POR of 1.35 (95% CI:0.56-3.26) , however this association is not statistically significant.
Being told the date of the next review visit was shown to be associated with low likeliness of
patients to miss two or more visits consecutively, however the association was not statistically
significant with an OR of 0.69 (95% CI:0.32-1.50). Epileptic patients who had their review visits
indicated on their treatment cards were less likely to miss two or more treatment review visits
consecutively with OR of 0.41 (95% CI: 0.19-0.89). Table 5 shows the factors associated with
non-attendance of at least 2 consecutive visits.
33
Table 5: Knowledge and awareness related factors
Factor Missed
N=51
Did not
miss
N= 59
POR
(95% Confidence
interval)
p- value
1. Knowledge
Date of next review visit
Yes 33 39 0.94 (0.43-2.07) 0.96
No 18 20
Treatment duration
Yes 37 54 0.24(0.08-0.74) 0.02*
No 14 5
AED regiment
Yes 42 53 0.53(0.17-1.60) 0.39
No 9 6
Expected number of visits per year
Yes 40 43 1.35 (0.56-3.26) 0.65
No 11 16
2. How review visit was given
a. verbally
Yes 18 26 0.69 (0.32-1.50) 0.46
No 33 33
b. written on card
Yes 20 36 0.41 (0.19-0.89) 0.04*
No 31 23
* Statistically significant
34
4.6.1.2 Sources of Epilepsy information
Patients who received epilepsy information through health education sessions by health workers
at health facilities were less likely to miss two or more of their treatment reviews consecutively
and this association is statistically significant [POR = 0.33 (95% CI: 0.15, 0.73), p = 0.01].
Epileptic patients who stated that they do not receive epilepsy information from any source were
four times more likely to miss at least 2 review visits consecutively [POR = 4.03 (95% CI: 1.68,
9.66), p = 0.003].
Table 6: Sources of epilepsy related information associated with non-attendance of
treatment review visits
Source of Information Missed
N=51
Did not
miss
N= 59
POR
(95% Confidence
interval)
p- value
Health Education by health workers at
health facilities
Yes 23 42 0.33 (0.15-0.73) 0.01*
No 28 17
Posters and Pamphlets
Yes 7 7 1.18 (0.38- 3.63) 0.996
No 44 32
Indicated No source
Yes 23 10 4.03 (1.68-9.66) 0.003*
No 28 49
* Statistically significant
35
4.6.1.3. Perceptions
Epileptic patients who perceived themselves to be in danger of suffering more epileptic seizures
were less likely to miss 2 or more consecutive scheduled review visits compared to those who
did not perceive themselves to be in danger with a POR of 0.14 (95% CI: 0.06-0.33) and this
association was statistically significant. Perceiving that missing review visits would lead to more
severe epileptic seizures was also significantly associated with low likeliness of missing at least
2 consecutive visits with a POR of 0.32 (95% CI: 0.14-0.73). Those who believe that attending
treatment review visits had a benefit of epilepsy treatment progress monitoring were also less
likely to miss their treatment review visits with a POR of 0.10 (95% CI: 0.04-0.24)
36
Table 7: Perceived susceptibility and non-attendance of treatment review visits
Factor Missed
N=51
Did not
miss
N= 59
POR
(95%
Confidence
interval)
p- value
Susceptible to more severe attacks
Yes 14 43 0.14 (0.06-0.33) 0.00*
No 37 16
Susceptible to more severe attacks
compared to other epileptics
Yes 27 40 0.53(0.25-1.16) 0.163
No 24 19
Susceptible to more severe attacks if
visits are missed
Yes 26 45 0.32 (0.14-0.73) 0.01*
No 24 14
Perceived benefits of attending
review visits
Monitoring of treatment progress 18 (26.5%)
50(73.5%) 0.10 (0.04-0.24) < 0.001*
Checking of epilepsy-related
complications
Yes 12 20 0.60 (0.26-0.39) 0.325
No 39 39
* Statistically significant
37
4.6.1.4. Behaviour intention
On analysis those who intended to attend all their visits were less likely to miss their treatment
review visits compared to those who intend to attend some of the visits 0.18 ( 95% CI: 0.08-
0.42).
4.6.2. Enabling factors
Significant factors included finding drugs out of stock during review visits, mentioning shortage
of drugs and long distances as barriers to review visits attendance. Those who found drugs out of
stock few times when they went for their monthly treatment review visits were less likely to miss
two or more consecutive visits in a 12 months period compared to those who found antiepileptic
drugs out of stock many times with POR of 0.22 (95% CI: 0.09-0.52). Epileptic patients who
indicated shortage of antiepileptic drugs were 7 times more likely to miss at least 2 review visits
consecutive compared to those who did not mention shortage of drugs 7.09 (95% CI: 3.00-
16.72). Those who indicated long distance as a barrier to review visits were also more likely to
miss review visits than those who did not with OR of 6.63(95% CI: 2.63-16.76). High
consultation fees was associated with an increased likeliness of missing review visits, however
this factor was not statistically significant with a POR of 1.47 (95% CI: 0.62-3.49). Table 8
shows the enabling factors.
38
Table 8: Enabling factors associated with non-attendance of treatment review visits
Factor Missed
N=51
Did not miss
N= 59
POR
(95% Confidence
interval)
p - value
Found no drugs at health
facility
Few times 10 31 0.22 (0.09-0.52) 0.001*
Many times 41 28
Barriers to attendance
long distance
Yes 26 8 6.63(2.63-16.76) <0.01*
No 51 25
shortage of drugs
Yes 40 20 7.09 (3.00-16.72) <0.01*
No 11 39
High consultation fees
Yes 15 13 1.47 (0.62-3.49) 0.505
No 36 40
* Statistically significant
4.6.3. Reinforcing factors
The only significant reinforcing factor was being assisted by village health workers in the
treatment process. Those who were assisted by village health workers in their epilepsy treatment
were less likely to miss their treatment review visits (POR=0.39, 95% CI: 0.16-0.94).
39
4.6.4. Socio-demographic and condition-related variables
Females were more likely to miss two or more consecutive visits compared to their male
counterparts with an Odds Ratio of 4.24 (95% CI: 1.87-9.59) and the association was statistically
significant. Another significant factor was distance from the nearest clinic where shorter distance
(0-5km) showed a protective effect with a POR of 0.31 (95% CI: 0.12-0.81). Other factors that
showed associations were more than 5 years on biomedical epilepsy treatment and ever being
burnt during an epileptic attack, however the associations were not statistically significant.
Epileptics who were on biomedical treatment for more than five years were more likely to miss
two or more consecutive visits in a 12 months period compared to those who were on treatment
for five years or less with POR of 1.28 (95% CI:0.51-3.19). Those who reported to have ever
been burnt during an epileptic seizure were more likely to miss at least two (2) consecutive
treatment review visits compared to those who have never been burnt during an epileptic seizure
with a POR of 1.59(95% CI: 0.72-3.53).
40
Table 9: Socio-demographic and condition related factors
Factor Missed
N=51
Did not miss
N= 59
POR
(95%
Confidence
interval)
p- value
Sex
Female 29 14 4.24 (1.87-9.59) 0.00079*
Male 22 45
Distance from nearest
health facility
0-5 Km 7 20 0.31(0.12-0.81) 0.026*
> 5 Km 44 39
Time on Biomedical
Treatment
> 5 Years 41 45 1.28 (0.51-3.19) 0.77
≤5 Years 10 14
Ever been burnt
during an epilepsy
attack
Yes 20 17 1.59(0.72-3.53) 0.34
No 31 42
Have on
* Statistically significant
41
4.7. Logistic Regression Analysis
Step wise multivariate analysis was carried out to estimate the measures of association while at
the same time controlling for a number of confounding variables. All the variables that were
significant at 0.25 level (P-value< 0.25 in the Bivariate analysis were included in the logistic
regression model.
The model was started off with a single variable. Other variables were added one by one.
Variables that were not significant were eliminated until all the variables that were significant at
0.05 level (95% CI) were added to the model. The adjusted odds ratios (AOR) and 95%
confidence intervals (95% CI) from the final model are presented in the Table 10 below:
Table 10: Logistic regression analysis
Term
Odds
Ratio
95% C.I. Coeff S. E.
Z-
Statistic
P-
Value
Intent to attend (Some/All) 4.2087 1.1292 - 15.6869 1.4372 0.6713 2.1410 0.0323
Mentioned Long distance
(Yes/No)
6.0874 1.6008 - 23.1480 1.8062 0.6815 2.6504 0.0080
N6Susceptible to frequent and
severe seizures (Yes/No)
0.1948 0.0625 - 0.6071 -1.6357 0.5799 -2.8206 0.0048
Shortage of AEDs (Yes/No) 6.7336 1.8538 - 24.4581 1.9071 0.6581 2.8979 0.0038
Will be monitored treatment
progress (Yes/No)
0.1225 0.0352 -0.4261 -2.0994 0.6359 -3.3018 0.0010
CONSTANT * * -0.3231 0.7488 -0.4315 0.6661
42
The results shows that behaviour intention to attend (some/all) of the treatment review visits
[AOR 4.21 (95% CI: 1.13,15.69) p= 0.0323], mentioning long distance as a barrier to treatment
review visits attendance [AOR 6.09 (95% CI: 1.60, 23.15) p= 0.0080], perceiving to be
susceptible to more frequent seizures [AOR 0.2 (95% CI: 0.16, 0.61) p=0.0048], mentioning
shortage of AEDs as a barrier to review visits attendance [AOR 6.73(95% CI: 1.85-24.46)
p=0.0038] and mentioning monitoring of treatment progress as a benefit of attending epilepsy
treatment review visits[AOR 0.12(95% CI: 0.04, 0.43) p=0.0010] were independent factors
associated with the likelihood of non-attendance of 2 or more consecutive review visits in
Gokwe South district. Those who intended to attend some visits were about 4 times more likely
to miss their review visits compared to those who intended to attend all their visits. Mentioning
long distance and shortage of drugs as barriers of review visits attendance were also associated
with higher likeliness of missing 2 or more visits. Perceiving self to be at risk of frequent and
severe seizures and perceiving monitoring of treatment progress as a benefit of attending
treatment review visits were protective against missing 2 or more treatment review visits in a 12
months period.
4.8. Availability of Antiepileptic drugs and IEC material
Most of the health facilities had no antiepileptic drugs during the times of this study and most of
the facilities had AEDs stock out for more than 2 months. All the health facilities had no IEC
material on epilepsy.
4.9. Challenges experienced in management of epilepsy
The major challenge cited is the constant AEDs stock outs. All the visited health facilities
mentioned that it was disheartening to have epileptic patients coming for reviews and find no
43
drugs for their conditions. Follow up of defaulters was also challenging since the major service
(AEDs monthly resupplies) will not be available.
44
Chapter 5: Discussion
This study sought to establish the prevalence of epilepsy review visits non-attendance and the
associated factors in the district. Only 12.7% of epileptic patients did not miss any review visit in
a 12 months period (June 2011 to June 2012) meaning that 87.3% missed at least once in a
similar period. This confirms that there is a problem of non-attendance of treatment review visits
in Gokwe South District. Furthermore 70.9% of the study participants missed more than one visit
while 46.4% missed at least 2 treatment review visits consecutively. Missing consecutive visits
worsen epilepsy treatment outcomes since it will be evident that the patient will be going for
longer period of time without taking the antiepileptic drugs hence this study went on to
determine the factors that contributed to the missing of two or more review visits. In a study by
Adamolekun in Zvimba district, people who missed two or more visits consecutively were
classified as treatment defaulters which then made this group more important24
.
Knowledge/memory of review dates was not significantly associated with review visits
attendance. This is contrary to the findings of Al-Faris et al who stated that memory of dates of
review visits was a significant factor in determing epilepsy treatment review visits in Saudi
Arabia26
. In The Zimbabwean situation, there might be more important factors such as drug
availability and overall accessibility of epilepsy treatment services that could rule out the
significance protective effect of memory of dates of review visits.
Knowledge of expected review visits. 75.5% knew that they were expected to go for their
treatment reviews once every month. There was however no statistically significant association
between knowing the expected number of visits and actual attendance.
45
Having review visits written on treatment card was significantly associated with a low likeliness
of missing at least 2 consecutive visits. This could be due to the fact that, the treatment card will
have a reminder on when one is expected to come back for the reviews. This may reduce the
problem of forgetting the review dates since one will always have somewhere to refer to and get
the correct date when one is needed. A study by Al-Faris et al has shown that forgetfulness
contributed to 22.5% of the reasons for children’s failure to attend epilepsy treatment review
visits in Saudi Arabia26
.
Having information through posters and pamphlets was not significantly associated with missing
at least 2 consecutive visits though. This is contrary to the findings of Adamolekun in Zvimba
district of Zimbabwe. The reason for this could be that in Adamolekun’s study there was use of
multiple methods that were used including the training of health staff such as EHTs who also did
patient follow ups. This shows that though information provided through print may be a constant
cue to action, it is not sufficient to ensure treatment review attendance. Health education and
advice at health facilities showed a significant association with review visits non-attendance,
where the health education sessions and health advice was protective against review visits non-
attendance. The health advice could play a major role since this includes a one-to-one interaction
between the health care provider and the patient where there could be a two way communication
where issues are also clarified. Those epileptic patients who would have gone for their review
visits may be a more receptive audience than those within communities. Information
dissemination however remains an important factor to treatment reviews attendance as shown in
this study that those who do not have any source of epilepsy treatment were more likely to miss
their review visits. There is still however need to utilize multiple methods of information
dissemination to improve review visits attendance among epileptics in Gokwe South.
46
Long distances were associated with high likeliness of missing 2 or more visits. Those who lived
within 5 km were shown to be less likely to miss treatment review visits compared to those who
live more than 5 km from their health facility. Perceiving the distance from the health facility to
be long was also shown in this study to be associated with higher odds of missing at least 2
consecutive visits. This also conforms to the findings of Odaga 22
who showed that the major
mentioned reasons for treatment review visits non-attendance was residing a long distance from
the nearest health facility. Living long distances from the health facility thus lowers accessibility
of health services even in situations where services are readily available.
Shortage of drugs was also one of the significant factors that negatively impact on review visits
attendance. This studies established that patients who went to the health facility and found AEDs
out of stock few times were less likely to miss their treatment review visits compared to those
who go to health facility and find no drugs many times. Services and resource availability
uninterruptedly contribute towards a health enabling health system environment. Availability of
drugs thus can impact much on attendance since it was also shown during this study that 87.3%
of the participants have indicated that the main benefit of attending monthly treatment review
visits is getting Antiepileptic medication hence when there constant AEDs stock outs, epileptic
patients will not see any benefit of attending the treatment review visits. AED refilling was the
mostly stated service (stated by 86.4% of the participants compared to the second most
mentioned monitoring of treatment progress which was mentioned by 41.8% of the respondents)
got during review visits and hence when drugs are not available there will be virtually no service
offered to them hence attendance of these review visits will be not seen as important unless the
patients heard that drugs are now available. Most of the health facilities had no antiepileptic
drugs during the time of the study which hence increases review visits non-attendance. There is
47
thus a need to relook into the priorities of the Ministry of Health to consider epilepsy as one of
the conditions which need resource allocation for management purposes. High perceived
susceptibility as measured by the question on whether one feels to be susceptible to frequent and
severe attack was shown to be among the most significant determinants of review visits
attendance. This factor remained significant during logistic regression analysis. This may be
because patients who perceive that they are at risk of experiencing more seizures will go to the
facility as many times even if they do not get their AEDs supply. The association between
mentioning of monitoring of treatment progress as a benefit of review visits and non-attendance
of review visits (which was protective) shows that a more comprehensive epilepsy management
package contributes towards treatment review visits attendance. Assessing the implication of
having epilepsy support groups was not possible since no one mentioned the presents of the
groups. These may still be important to allow sharing of information and peer motivation for
epilepsy review attendance and treatment adherence among epileptic patients. Support groups as
a way of community action groups may also successfully mobilize resources and lobby for
formulation of policies that make epilepsy services more accessible. These support groups may
also be the main place in community participation and may further on assist in identifying more
epileptic cases in communities and help in tracing and encouraging defaulters to go back on
biomedical treatment.
48
Conclusions
Even with high knowledge levels and intention, an enabling environment is required to improve
and ensure treatment review visits attendance among epileptic patients. This study has shown
that drug availability, and supporting structures such as village health workers at grass roots to
assisting epileptic patients improves treatment reviews attendance. High perceived risk of more
severe epileptic seizures also contributes towards treatment review visits attendance. The major
significant barriers to treatment review visits attendance were shortage of drugs and long
distances to health facilities.
49
Recommendations
- The District Health Executive through the pharmacy department must ensure
uninterrupted supply of antiepileptic drugs at all health facilities
- The Health executive through the District nursing officer must lobby for the training of
more village health workers to improve the coverage and must also empower these
Village health workers with knowledge on epilepsy
- The health Promotion department must ensure availability of epilepsy IEC material at all
health facilities
- The District Health Executive must train health committees on community resource
mobilization so that they can prioritize epilepsy, source and lobby for support at grass
roots level
- The health promotion officer must empower health staff with skills and knowledge so
that they improve epilepsy information dissemination utilizing community structures
- The District health executive must empower clinics (through their ward health
committees) to source AEDs
- There is need for further research on the effects of social support groups on epilepsy
treatment review visits attendance
50
References
1. Engel J. Epilepsy in the World today: the medical point of view. Epilepsia, Vol. 43 (suppl.
6), pp. 12–13. 2002
2. World Health Organization. Epilepsy in the WHO African region. 2004.
3. World Health Organization. Epilepsy Fact sheet N999. January 2009.
4. World Health Organization. The Global Burden of Disease: 2004 Update. 2008.
5. Ministry of Health and Child Welfare. The National Health Strategy For Zimbabwe,
2009 – 2013: Equity and Quality in Health-A People's Right.
6. Global Campaign Against Epilepsy. Demonstration Project on Epilepsy in
Zimbabwe.2003
7. Mielke JK. Sebit and Adamolekun B.The impact of epilepsy on thequality of life of
people with epilepsy in Zimbabwe. Seizure, Vol. 9. 2000
8. International Newsletter of the International Bureau for Epilepsy. Issue. 12010.
9. Njamnshi AK. et al. Knowledge, Attitudes and Practices with respect to epilepsy among
student nurses and laboratory assistants in the South West region of Cameroon. Epilepsy
and Behaviour, 17(3). 2010
10. Jilek-Aall L and Rwiza H T. Prognosis of epilepsy in a rural African community: a 30-
year follow-up of 164 patients in an outpatient clinic in rural Tanzania. Epilepsia, Vol.
33, pp. 645–650. 1992
11. Nimaga K. et al. Treatment with Phenobarbital and monitoring of epileptic patients in
rural Mali. Bulletin of the World Health Organization, Vol. 80. 532-537. 2002
12. Sureka RK. Clinical profile and spectrum of epilepsy in rural Rajasthan. Journal of the
association of Physician of India, Vol. 47. 608-610. 1999
13. Chandra RS. et al. Compliance monitoring in epileptic patients. Journal of the
Association of Physicians of India,, Vol. 41, pp. 431–432. 1993
14. Jones, R M. Adherence to treatment in patients with epilepsy: Associations with seizure
control and illness beliefs. Seizure: European Journal of Epilepsy, 15 (7). 504-508. 2006
15. Garnett WR. Antiepileptic drug treatment: outcomes and adherence. Pharmacotherapy,
Vol. 20, pp. 191s-199s. 2000
16. Leppik IE. How to get patients with epilepsy to take their medication: The problem of
non-compliance. Postgraduate medicine, Vol. 88, pp. 253-256. 1990
17. Manungo J. Childhood epilepsy in Zimbabwe. Trop Geogr Med, 45 (5). 246-247. 1993
18. Modi A C. Rausch J R and Glauser T A. Patterns of non-adherence Antiepileptic drug
therapy in children with newly diagnosed epilepsy. JAMA. 2011
19. Loiseau P and Marchal C. Determinants of compliance in epileptic patients
1988.Epilepsy Research . Supplement, Vol. 1, pp. 135-140. 1988
20. Smi Choi-Kwon. et al. Common Misconceptions in People With Epilepsy. Journal of
Clinical Neurology, Vol. 2, pp. 186-193. 2006
51
21. Paschal AM. et al. Measures of adherence to epilepsy treatment: Review of present
practices and recommendations for future directions. Epilepsia. 49 (7). 1115-1122. 2008
22. Odaga J. Cicciò and Maniple E.D. Overcoming barriers to anti-epileptic treatment:a life-
time sentence? UMU Press, 6 (1). 54-65. 2008
23. Tsai J J. and Cheng T J. Status of Follow-Up among Patients with Epilepsy in Epilepsy
Clinic., The Japanese Journal of Psychiatry and Neurology, Vol. 46 (2). 405-408. 1992
24. Adamolekun B. Mielke JK. and Ball DE. An evaluation of the impact of Health worker
and patient education on the care and compliance of patients with Epilepsy in Zimbabwe,
Epilepsia, 507-511. 1999
25. Berhanu S. Alemu S. Prevette M. and Perry EHO. Primary care treatment of epilepsy in
rural ethiopia; causes of default to follow-up. Seizure-European Journal of epilepsy, 18
(2). 100-103. 2009
26. Al-Faris EA. Abdulghani HM. Mahdi AH. Salih MA. and Al-Kordi AG. Compliance
with appointments and medications in a pediatric neurology clinic at a University
Hospital in Riyadh, Saudi Arabia. Saudi Med J, 23 (8), pp. 969-974. 2002
27. Ball DE. et al. Community Leader Education to Increase Epilepsy Attendance at Clinics
in Epworth, Zimbabwe. Epilepsia, 41(8). 1044-1045. 2000
28. Green L. W. and Kreuter M. W. Health Promotion Planning: An Educational and
Ecological Approach. 4th. New York : McGraw-Hill, 2005.
29. Green, L. W., Kreuter, M. W., Deeds, S. G., and Partridge, K. B,. Health Education
Planning: A Diagnostic Approach. Mountain View, Calif. : Mayfield, 1980.
30. Ajzen I. The theory of Planned Behaviour. 1991.
31. Green L W and Ottoson JM. A Framework for planning and evaluation: PRECED-
PROCEED, Evolution of application of the model. 2006.
32. Daniel.W W. Biostatistics: A foundation for analysis in the health science.8th
ed. John
Wiley & sons, inc. 2005
52
ANNEX 1A: ENGLISH INFORMED CONSENT FORM
UNIVERSITY OF ZIMBABWE
Non-attendance of review visits among Epileptic patients in Gokwe South District:
Midlands Province Zimbabwe:
2012
Principal Investigator: Dewa Evans (MPH trainee)
Phone number: 0775843562
Academic Supervisor: Mrs. J. Maradzika, Mr. J January
Field Supervisors: Dr. Mafaune (PEDCO)
Initials _________________
53
Introduction: My name is Evans Dewa. I am a Public Health student with the University of Zimbabwe
attached to Midlands Provincial Medical Director’s office. I am conducting a study on the factors
associated with non-attendance of epilepsy review visits among epileptic patients in Gokwe South district.
Before you decide to volunteer for this study, you must understand its purpose, how it may help you, the
risks to you and what is expected of you. This purpose is called informed consent
Purpose of the study: You are being asked to participate in a research study of the factors associated
with non-attendance of review visits among epileptic patients on treatment in Gokwe South district. The
purpose of the study is to establish the factors which may be causing epileptic patients to miss their
medical review visits. Treatment of epilepsy using anti-epileptic medicine has been shown in other
studies to reduce frequency and severity of seizures among epileptic patients with some living a seizure
free when treatment is adhered to. You were selected as a participant in this study because you are one of
those who have been on epilepsy treatment in the district. The results of this study could potentially
benefit epileptic patients in the district as the recommendations could be used to improve epilepsy
treatment services in Gokwe South district. This study will have a minimum of 103 participants in Gokwe
South district. The information obtained will be used on designing interventions on how to improve
epilepsy services, improve epilepsy review visits attendance among epileptic patients so as to improve
treatment outcomes.
Procedures and Duration: If you decide to participate in this study, you will undergo an
interview which may take 15 - 20 minutes to complete. You will be asked questions about
yourself and your pattern of epilepsy review visits attendance.
I will also require with your permission, to check your treatment card to verify attendance, and scheduled
dates as well as the regimen you are on. You are free to ask for clarification on any questions that you do
not understand at any point during the interview. If you have questions about the study, you may ask at
any time. You will also be given information on epilepsy at the end of this interview.
Initials _________
54
Risks and Discomforts: Some of the questions that you will be asked are of a personal
nature so you may feel embarrassed to respond to them. The answers you provide will be
kept private and confidential. If you feel very uncomfortable, you are free to decline
answering any question that you do not want to answer.
Benefits and / or Compensation: There are no direct benefits/compensation that will come from
participating in this study. You will get an opportunity to learn more about the importance of treatment of
epilepsy using antiepileptic drugs in reducing seizure and improve quality of life among epileptic patients.
Alternative Procedure or Treatments: there are no interventions or treatments that will be
done in this study.
Confidentiality: If you indicate your willingness to participate in this study, your
participation will be on a voluntary basis. You are free to withdraw from the study at any
point. Information collected about you and your responses will be treated with
confidentiality. The questionnaire to be used during the interview will be identified by a
coded number instead of your name. This consent form will be separated from the coded
questionnaires and stored in a secure place.
Additional Costs: You will not incur any expenses from participating in this study.
Offer to Answer Questions: If you have any questions on any aspects that are not clear to
you about this study, please feel free to ask me before you sign this form. You are free to take
as much time as you can to think about it.
Authorization: By signing this form, it means that you have read and understood the
information provided above, had all your questions answered, and decided to participate
voluntarily without being coerced and can choose to stop your participation at any time without loss of
any benefits entitled to you. You authorize myself , field and academic supervisors to
access the information that you will have provided. The information you provide will only be
used for the purpose of this study.
Initials __________
55
Signature of Client...................................................... Date.....................................
Client Name ……………………………………….
Signature of Researcher....................................................... Date.....................................
Witness Signature ………………………………………
For any further information pertaining to this study, please feel free to contact me at:
University of Zimbabwe,
College of Health Sciences
Department of community medicine
PO Box A178, Avondale,
Harare
Zimbabwe
YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP
If you have any questions concerning this study or consent form beyond those answered by
the investigator, including questions about the research, your rights as a research subject or
research-related injuries: or if you feel that you have been treated unfairly and would like to
talk to someone other than a member of the research team, please feel free to contact the
The Joint Research Ethics Committee on Telephone 04-708140
Initials ___________
56
ANNEX 1B: GWARO RECHITENDERANO
Kutanga: Ndinonzi Evans Dewa. Ndiri mudzidzi we Public Health pachikoro che University Of
Zimbabwe. Parizvino ndiri kuhofisi kwaProvincial Medical Director WeMidlands Province kwandiri
kuita ongororo inotsvaka zvikonzero zvinosakisa kuti varwere ve tsviyo vasaenda kukiriniki kana
kuchipatara kunoonekwa navanamukoti kana chiremba pamazuva avo akatarwa muno mudunhu reGokwe
South. Musati mazvisarudzira kupinda muongororo iyi munofanira kuziva chinangwa cheongororo,
zvamungabatsirika nazvo, njodzi dzingakuwirai nekuva muongoro ino pamwe nezvamunotarisirwa kuita
muongororo ino.
Chinangwa cheongororo: Murikukumbirwa kuti muve nhengo yeongororo yekutsvaka zvikonzero
zvinoita kuti varwere varikurapwa chirwere chetsviyo muzvipatara vasaenda kukiriniki pamazuva avo
akatarwa muno mudunhu reGokwe South .Nekudaro, Chinangwa chikuru cheongororo iyi ndichekuwana
zvikonzero zvinotadzisa varwere varikurapwa tsviyo muzvipatara kuuya kuchipatara kana kiriniki
pamazuva avakatarirwa. Zvakawonekwa mune dzimwe tsvakurudzo zhinji kuti kurapwa kwetsviyo
nemapiritsi emuzvipatara kunoderedza dambudziko rechirwere ichi muvanhu vanorwara nacho. Ongororo
iyi ichaitwa muvanhu vanosvika kana kupfuura Zana nevatatu (103) vanorwara nechirwere ichi muno
muGokwe South.
Zvichaitwa muongororo: Kana makasununguka kuva muongororo ino,ndichakubvunzai mibvunzo
inogona kutora nguva iripakati pemaminitsi gumi nemashanu kusvika makumi maviri kuti
tipedze.Ndichakubvunzai mibvunzo yakanangana nemi uye maererano nezvechirwere chetsviyo pamwe
nekurapwa kwenyu. Ndichatarisawo makadhi ekurapwa kwenyu kana mandipa mvumo kuti ndione
mazuva amakatarirwa, mapiritsi amunomwa pamwe nekuenda kwenyu kuchipatara pamazuva
amakatarirwa. Makasununguka kubvunza mibvunzo pamunenge musinganzwisise.Kana muinemimwe
mibvunzo pamusoro peongororo iyi, makasununguka kubvunza chero nguva.Kana tapedza hurukuro
yedu, tichapakurirana ruzivo nezvechirwere chetsviyo.
57
Initials _______
Njodzi dzamungasangana nadzo: Hapana njodzi yamungasangana nayo kuburikidza nekuva
muongororo ino. Asi dzimwe dzenguva munogona kuzonzwa muchinyara kupindura mimwe mibvunzo
yacho. Kana paine mibvunzo yamusina kusununguka kupindura, makasununguka kuregedza kupindura.
Zvakanakira kuva muongororo ino:Hapana muhoro wamuchawana kuburikidza nekuva muongororo
ino asi kuti muchawana mukana wokudzidza zvakawanda maererano nezvakanakira kurapiwa chirwere
chetsviyo kuchishandiswa mapiritsi muzvipatara uyewo kukosha kwekuenda kukiriniki kunoonekwa
nanamukoti pamazuva akatarwa.
Kurapwa
Hakuna Kurapwa kuchaitwa muongororo ino
Kuvimbika kwetsvakurudzo:Kuva kwenyu muongororo iyi hazvimanikidzwi, munoita nechido
chenyu.Hapana zvamunoitwa kana mukati hamuchada kuva muongororo ino nyangwe.Zvese
zvamuchazivisa pamusoro penyu hazvizoparadzirwa kune vamwe vanhu, zvinoperera pakati pedu. Bepa
richashandiswa pakubvunza mibvunzo richangozivikanwa nenhamba pasina zita renyu. Nhamba idzodzi
dzichachengeterwa pakasiyana negwaro rino ramuchazosayina kupa mvumo yokuti muve muongororo
ino.
Dzimwe mari dzikangodikanwa: Hapana mari inodikanwa kubva kwamuri kuti muve mutsvakiridzo
ino.
Kupindurwa kwemibvunzo: kana paine mibvunzo yamuchaona isina kujeka makasununguka
kundibvunza ikozvino, chero pane imwe nguva. Makasununguka kutora nguva yekuti mumbofunga.
Mvumo: Kusayina kwamuchaita panzvimbo inotevera zvinoratidza kubvuma kuti maziviswa maererano
neongororo iyi, hamuna kumanikidzwa kuva nechokuita nayo, uyezve kuti zvamaudzwa kana kuverenga
58
Initials___________
mugwaro rechitenderano iri zvaita kuti mugone kunyatsonzwisisa njodzi uye zvingakubatsirayi
zvamungawana mutsvakurudzo iyi zvekare kuti munokwanisa kusarudza kuti hamuchada kuenderera
mberi nekupindura mibvunzo pasina zvamungarasikirwa nazvo. Zvamunenge mazivisa patsvakiridzo ino
zvichabvumidza ini pamwe nevarairidzi vangu kuti tizvishandise muongororo ino bedzi.
Runyorwo rweMupinduri..................................................... Zuva....................................
Zita remupinduri ………………………………………………………
Runyorwo rweMuongorori................................................ Zuva....................................
Runyoro rwechapupu ……………………………………… Zuva …………………………
Kana paine zvamunoda kunzwisisa, ivai makasununguka kundinyorera pa kero inoti:
University of Zimbabwe
College of Health Sciences
Department of community medicine
PO Box A178, Avondale
Harare
Zimbabwe
MUCHAPIHWA RIMWE GWARO RECHITENDERANO KUTI MUGARE NARO
Kana muine imwe mibvunzo isina kupindurwa nemuongorori, kana mibvunzo yakanangana nekubatwa
kwamaitwa mutsvakurudzo iyi, kana kodzero dzenyu, kana kusabatwa zvakanaka kwamunenge maitwa
makasununguka Kutaura neveJoint Research Ethics Committee panhamba dzerunhare dzinoti:
04-708140
Initials _______
59
ANNEX 2A: ENGLISH CONSENT FORM FOR PARENTAL CONSENT
UNIVERSITY OF ZIMBABWE
Non-attendance of review visits among Epileptic patients in Gokwe South District:
Midlands Province Zimbabwe:
2012
Principal Investigator: Dewa Evans (MPH trainee)
Phone number: 0775843562
Academic Supervisor: Mrs. J. Maradzika, Mr J January
Field Supervisors: Dr.Mafaune (PEDCO)
60
Introduction: My name is Evans Dewa. I am a Public Health student with the University of Zimbabwe
attached to Midlands Provincial Medical Director’s office. I am conducting a study on the factors
associated with non-attendance of epilepsy review visits among epileptic patients in Gokwe South district.
Before you decide to allow your child to participate in this study, you must understand its purpose, how it
may help your child, the risks to your child and what is expected of your child in this study. This purpose
is called informed consent
Purpose of the study: You are being asked to allow your child to participate in a research study of the
factors associated with non-attendance of review visits among epileptic patients on treatment in Gokwe
South district. The purpose of the study is to establish the factors which may be causing epileptic patients
to miss their medical review visits. Treatment of epilepsy using anti-epileptic medicine has been shown in
other studies to reduce frequency and severity of seizures among epileptic patients with some living a
seizure free life when treatment is adhered to. The results may lead to recommendations that will be used
to improve the services in Gokwe South district. This study will have a minimum of 103 participants
Gokwe South district. The information obtained will be used on designing interventions on how to
improve epilepsy services, improve epilepsy review visits attendance among epileptic patients so as to
improve treatment outcomes.
Procedures and Duration: If you allow your child to participate in this study, he/she will undergo an
interview which may take 15 - 20 minutes to complete. He/she will be asked questions about him/ herself
and pattern of epilepsy review visits attendance. I will also require with your permission, to check his/her
treatment card to verify attendance, and scheduled dates as well as the regimen he/she is on. He/she will
be free to ask for clarification on any questions that may not be clear at any point during the interview. I
will also answer any questions that you may have now or after the study and I will also answer any
question that your child may have. Your child will also be given information on epilepsy at the end of this
interview.
Initials _________
61
Risks and Discomforts: Some of the questions that your child will be asked are of a personal
nature so he/she may feel embarrassed to respond to them. The answers that he/she provide will be kept
private and confidential. If he/she feel very uncomfortable, he/she will be free to decline
answering any question that he/she do not want to answer.
Benefits and / or Compensation: There are no direct benefits/compensation that will come from
participating in this study. Both you and him/her will get an opportunity to learn more about the
importance of treatment of epilepsy using antiepileptic drugs in reducing seizure and improve quality of
life among epileptic patients.
Alternative Procedure or Treatments: there are no interventions or treatments that will be
done in this study.
Confidentiality: If you indicate your willingness to let your child participate in this study, his/her
participation will be on a voluntary basis. He/she free to withdraw from the study at any
point .Information collected about him/her and his/her responses will be treated with
confidentiality. The questionnaire to be used during the interview will be identified by a
coded number instead of his/her name. This consent form will be separated from the coded
questionnaires and stored in a secure place.
Additional Costs: Neither you nor child will incur any expenses from his/her participation in this study.
Offer to Answer Questions: Before you sign this form, please ask any questions on any aspect of this
study that is unclear to you. You may take as much time as necessary to think it over.
Authorization: You are making a decision whether or not to allow your child to participate in this study.
Your signature indicates that you have read and understood the information provided above, have had all
your questions answered, and have decided to allow your child to participate voluntarily without being
coerced and can choose to stop his/her participation at any time without loss of any benefits entitled to
him/her.
Initials ______
62
You authorize myself , field and academic supervisors to access the information that your child will have
provided. The information your child provide will only be used for the purpose of this study.
Name of Parent (please print) ………………………………….. Date ………………
Signature of Parent or legally authorized representative ………………………….. Time ……..
Relationship to the Participant ………………………………………………..
Signature of Researcher....................................................... Date.....................................
Signature of witness ………………………………………………………... Date ……………………
For any further information pertaining to this study, please feel free to contact me at:
University of Zimbabwe
College of Health Sciences
Department of community medicine
PO Box A178, Avondale
Harare
Zimbabwe
YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP
If you have any questions concerning this study or consent form beyond those answered by
the investigator, including questions about the research, your child’s rights as a research subject or
research-related injuries: or if you feel that you have been treated unfairly and would like to
talk to someone other than a member of the research team, please feel free to contact the
Joint Research Ethics Committee on Telephone 04-708140
Initials ________
63
Child’s Assent
My participation in this research study is voluntary. I have read and understood the
above information, asked any questions which I may have and have agreed to participate.
I will be given a copy of this form to keep.
Name of Participant ............................................................. Date ................................................
Signature of Participant ......................................................... Date ..............................................
Initials ______
64
ANNEX 2B: GWARO RECHITENDERANO NEMUBEREKI WEMWANA
Kutanga: Ndinonzi Evans Dewa. Ndiri mudzidzi we Public Health pachikoro che University Of
Zimbabwe. Parizvino ndiri kuhofisi kwaProvincial Medical Director WeMidlands Province kwandiri
kuita ongororo inotsvaka zvikonzero zvinosakisa kuti varwere ve tsviyo vasaenda kukiriniki kana
kuchipatara kunoonekwa navanamukoti kana chiremba pamazuva avo akatarwa muno mudunhu reGokwe
South. Musati masarudza kuti mwana wenyu apinde muongororo iyi munofanira kuziva chinangwa
cheongororo, zvingabatsirika mwana wenyu nazvo, njodzi dzingawira mwana wenyu nekuva muongoro
ino pamwe nezvaanotarisirwa kuita muongororo ino.
Chinangwa cheongororo: Murikukumbirwa kuti mubvumire kuti mwana wenyu ave nhengo yeongororo
yekutsvaka zvikonzero zvinoita kuti varwere varikurapwa chirwere chetsviyo muzvipatara vasaenda
kukiriniki pamazuva avo akatarwa muno mudunhu reGokwe South. Nekudaro chinangwa chikuru
cheongororo iyi ndichekuwana zvikonzero zvinotadzisa varwere varikurapwa tsviyo muzvipatara kuuya
kuchipatara kana kiriniki pamazuva avakatarirwa. Zvakawonekwa mune dzimwe tsvakurudzo zhinji kuti
kurapwa kwetsviyo nemapiritsi emuzvipatara kunoderedza dambudziko rechirwere ichi muvanhu
vanorwara nacho. Ongororo iyi inoda vanhu vanosvika kana kupfuura Zana nevatatu (103) vanorwara
nechirwere ichi muno muGokwe South.
Zvichaitwa muongororo: Kana makasununguka kuti mwana wenyu ave muongororo
ino,ndichamubvunza mibvunzo inogona kutora nguva iripakati pemaminitsi gumi nemashanu kusvika
makumi maviri kuti tipedze. Ndichamubvunza mibvunzo yakanangana naye uye maererano
nezvechirwere chetsviyo pamwe nekurapwa kwake. Ndichatarisawo makadhi ekurapwa kwake kana
mandipa mvumo kuti ndione mazuva aakatarirwa kuuya kuchipatara, mapiritsi aanomwa pamwe
nekuenda kwake kuchipatara pamazuva aakatarirwa. Makasununguka kubvunza mibvunzo pamunenge
musinganzwisise ikozvino kana panopera hurukuro yangu naye.
Initials ______
65
Ndichapindurawo mimwe mibvunzo ingabvunzwa nemwana wenyu maererano nekurapiwa kwetsviyo
chero papi zvapo muhurukuro yandichaita naye. Kana muinemimwe mibvunzo pamusoro peongororo iyi,
makasununguka kubvunza cheronguva. Kana tapedza hurukuro yedu, tichapakurirana ruzivo
nezvechirwere chetsviyo.
Njodzi dzingasangana nemwana wenyu muongororo: Hapana njodzi ingasangana nemwana wenyu
kuburikidza nekuva muongororo ino. Asi dzimwe dzenguva anogona kunzwa kunyara kupindura mimwe
mibvunzo yacho. Kana paine mibvunzo yamaasina kusununguka kupindura, akasununguka kuregedza
kuipindura.
Zvakanakira kuva muongororo ino:Hapana muhoro wamuchawana kana kuwanikwa nemwana wenyu
kuburikidza nekuva kwake muongororo ino asi kuti achawana mukana wokudzidza zvakawanda
maererano nezvakanakira kurapiwa chirwere chetsviyo kuchishandiswa mapiritsi muzvipatara uyewo
kukosha kwekuenda kukiriniki kunoonekwa nanamukoti pamazuva akatarwa.
Kurapwa
Hakuna Kurapwa kuchaitwa muongororo ino
Kuvimbika kwetsvakurudzo:Kuva kwemwana wenyu muongororo iyi hazvimanikidzwi, munoita
nechido chenyu. Hapana zvamunoitwa kana zvinoitwa mwana wenyu kana mukati hamudi kuti mwana
wenyu ave muongororo iyi kana iye akati haachadi kuva muongororo ino nyangwe.Zvese zvaachazivisa
pamusoro pake hazvizoparadzirwa kune vamwe vanhu, zvinoperera pakati pedu. Bepa richashandiswa
pakubvunza mibvunzo richangozivikanwa nenhamba pasina zita rake. Bepa remibvunzo rine nhamba
idzodzi richachengeterwa pakasiyana negwaro rino ramuchazosayina kupa mvumo yokuti ave
muongororo ino.
Initials ______
66
Dzimwe mari dzikangodikanwa: Hapana mari inodikanwa kubva kwamuri kuti mwana wenyu ave
mutsvakiridzo ino.
Kupindurwa kwemibvunzo: kana paine mibvunzo yamuchaona isina kujeka makasununguka
kundibvunza ikozvino, chero pane imwe nguva. Makasununguka kutora nguva yekuti mumbofunga.
Mvumo: Kusayina kwamuchaita panzvimbo inotevera zvinoratidza kubvuma kuti maziviswa maererano
neongororo iyi, hamuna kumanikidzwa kuva nechokuita nayo, uyezve kuti zvamaudzwa kana kuverenga
zvaita kuti mugone kunyatsonzwisisa njodzi pamwe nezvingabatsira mwana wenyu zvaangawana
muongororo ino zvekari kuti mwana wenyu pamwe nemi munemvumo yekusarudza kubuda muongororo
ino panguva ipi zvayo pasina chamunorasikirwa nacho. Zvamunenge mazivisa patsvakiridzo ino
zvichabvumidza ini pamwe nevarairidzi vangu kuti tizvishandise muongororo ino bedzi.
Zita Remubereki..................................................... Zuva....................................
Runyorwo rweMubereki..................................................... Zuva....................................
Zita Remuongorori ..................................................... Zuva....................................
Runyorwo rweMuongorori................................................ Zuva....................................
Runyoro rwechapupu …………………………………….. Zuva …………………………
Kana paine zvamunoda kunzwisisa, ivai makasununguka kundinyorera pa kero inoti:
University of Zimbabwe
College of Health Sciences
Department of community medicine
PO Box A178, Avondale, Harare
Zimbabwe
Initials ______
67
MUCHAPIHWA RIMWE GWARO RECHITENDERANO KUTI MUGARE NARO
Kana muine imwe mibvunzo isina kupindurwa nemuongorori, kana mibvunzo yakanangana nekubatwa
kwamaitwa mutsvakurudzo iyi, kana kodzero dzenyu, kana kusabatwa zvakanaka kwamunenge maitwa
makasununguka kubata veJoint Research Ethics Committee panhamba dzerunhare dzinoti: 04-708140
Mvumo Yemwana
Ndaita sarudzo yekuva nhengo yeongororo iyi pasina kumanikidzwa kana kugondedzerwa. Ndaverenga
ndikanzwisisa zvese zvirimuchibvumirano ichi. Ndawanawo mukana wekubvunza mibvunzo kuti
ndinzwisise nezveongororo iyi. Ndichapiwa gwaro rechitenderano rekuti ndisare naro
Zita Remupinduri ........................................................ Zuva ................................................
Runyoro Rwemupinduri ......................................... Zuva .............................................
Initials ______
68
Annex 3: Questionnaire
Kutanga: Makadini? Ndinonzi Evans Dewa. Ndiri mudzidzi we Public Health pachikoro che
University Of Zimbabwe. Parizvino ndiri kuhofisi kwaProvincial Medical Director WeMidlands
Province kwandiri kuita ongororo inotsvaka zvikonzero zvinosakisa kuti varwere ve tsviyo
vasaenda kukiriniki kana kuchipatara kunoonekwa navanamukoti kana chiremba pamazuva avo
akatarwa muno mudunhu reGokwe South. Makasununguka kuita sarudzo yekuva nhengo kana
kusava nhengo yeongororo iyi. Makasunungukawo zvekare kusarudzo kubuda muongororo iyi
kana kubvunza mibvunzo panguva ipi zvayo. Zvose zvatinokurukura nemi paongororo iyi
zvichava pakati pangu nemi. Kana makasununguka kuva muongororo iyi mungandisainira here
pazasi apa:
Runyoro rwemupinduri ....................................... Zuva .............................................
Section A: Demographic characteristics
1. Sex M [ ] F [ ]
2. Age/Mune makore mangani ……………… Years
3. Marital Status Married Makaroorwa/ra here?
Married
Single
Divorced
Widowed
4. Level of education/Makafunda kusvika danho ripi
None
Primary
Secondary
Tertiary
5. Employment status/Munosevenza Here?
Not employed/Handisevenzi
Informal employment /Ndinozvisevenzera
Formally employed/Ndinosevenza zvekubhadharwa pamwedzi kana Pavhiki
6. Religion/Munotevedzera chitendero Chipi
Apostolic
Pentecostal
Catholic
Traditional African Religion
Other (Specify) .....................................................................................................
7. Ward/Munobva mu Whadhi ipi ......................................................................................................
8. Nearest Clinic/Kiriniki iri pedo memi
.....................................................................................................
69
9. Distance from the nearest Health Facility?/ Kiriniki iyi iri kure nemusha wenyu zvakadini
..................................................Km
Section B: Condition related questions/ Zvakanangana nechirwere chetsviyo
10. How long have you been suffering from epilepsy (since the first seizure). Mava nenguva yakareba
zvakadini muchirwara nechirwere chetsviyo? ...........Years?
11. Where did you first seek treatment for your epilepsy?Makatanga kunorapwa kuna ani?
Traditional healer
Faith healer
Health Facility
12. How long have you been on biomedical treatment (mave nenguva yakareba zvakadini muri kurapiwa
chirwere ichi kukiriniki/chipatara)...............................Years
13. Besides the Health facility, where else are you currently getting epilepsy treatment?/Kusiya
kwekuchipatara ndekupi zvekare kwamuri kurapiwa chirwere ichi parizvino?
Faith Healer/Kumuporofita
Traditional healer/Kun’anga
Nowhere else/Hapana
Other (Specify)
Kumwewo....................................................................................................
14. Have you ever been burnt by fire during an epilepsy attack. Pane pamakambotswa here nemoto
mabatwa netsviyo?
Yes/hongu
No/kwete
Section C: Predisposing factors
a. Knowledge/Awareness and cues to action Please give information on the following:
Munganditaurirawo zvinotevera Given correctly?
Yes/Hongu No/Kwete
15. Date of next scheduled Visit/Zuva ramakatarirwa kuzoenda zvekare
kuchipatara
16. drugs taking schedule/Mapiritsi anomwiwa sei/ kangani?
17. Anti-epileptic drugs regiment/Mapiritsi amunonwa?
18. Duration of treatment/ Mushonga unonwiwa nguva yakareba zvakadini?
19. Expected Number of Visits per year/ Makatarirwa kuuya kangani
kuchipatara pagore?
20. Have you been told your next review visit verbally Yes [ ] No [ ]
21. Is the next review date written on card (check from card) Yes [ ] No [ ]
70
22. What are the services offered at health facilities when you go for your epilepsy treatment monthly
review visits/ Ndezvipi zvamunowana kana kuitirwa pamunouya kuchipatara kana kiriniki pamazuva
amakatarirwa?
Antiepileptic drugs refilling/Kupiwa mapiritsi angu etsviyo
Checking for Side effects of AEDs/Kuonekwa zvimwe zvinganyuka nekunwa mapiritsi angu
Monitoring of progress of treatment/Kuonekwa kana ndirikurapika nemazvo
Checking for any development of any epilepsy related complications/Kuonekwa kana ndisina
zvimwe zvirwere zvinganyuka nekuda kwetsviyo
General medical examination (such as BP check)/Kuongororwawo zvimwe zveutano zvakaita se
BP
Others (Specify)/ Zvimwewo (Tsanangurai)...............................................................................
23. What are the side effects of Antiepileptic drugs?/Ndezvipi zvakaipa zvimungawana nekunwa
mishonga yetsviyo Mentioned?/Zvakadomwa
Yes/Hongu No/Kwete
Dizziness/Dzungu
Unsteadiness/Kusagadzikana
Speech/Language/Kunetseka pakutaura
Double vision/Kuona madzengerere
Headache/Kutemwa nemusoro
Sleepiness /Hope dzakanyanya
Forgetfulness /Kukanganwa kwakanyanya
24. What are the complications of uncontrolled epilepsy?/Ndedzipi njodzi dzingaunzwa nekusarapwa
zvakakwana kwetsviyo?
Status epilepticus (More frequent seizures)
Drowning/Kunyura mumvura
Emotional health problems/Kushungurudzika pfungwa
Burns/kutsva
Others (specify).............................................................................................................
25. Where do you get epilepsy-related information from?/Ndekupi kwamunowana ruzivo nezve tsviyo?
Mentioned? (Probe for responses)
Sources Yes No
Health education/advice by VHWs or other community health workers/
Kubva knaana mbuya kana sekuru utano
Health education sessions by health workers at health facilities/
Kudzisiswa kukiriniki kana chipatara
Health education sessions by health workers (Nurses or EHTs) in the
community/ Kudzidziswa navana Utsanana kana vakoti vanouya
munharaunda medu
71
Posters/Pamphlets at Health facilities/ Kubva muzvinyorwa zvatinowana
pakiriniki
Radio/TV/Kubva muma wairesi kana rerevhizheni
Community gatherings/Pamakungano emunharaunda medu
Non/Hapana
Other/Kumwewo tsanangurai
26. Who are the people who remind you on your epilepsy treatment and review visits attendance? /
Ndivanani vanokuyeuchidzayi kuenda kukiriniki mazuva amakatarirwa Mentioned
Sources Yes No
Family member
Other Relatives/Dzimwewo hama
Friends/Shamwari
Community Health workers/Vana sekuru kana vanambuya utano
Community members/Vanhu vemunharaunda
Community leaders/Vatungamiriri vemunharaunda
Non/Hapana
Other (specify)/Vamwewo (Tsanangurai)
b. Perceptions:
Yes/Hongu No/Kwete
27. Do you feel that you are generally susceptible to more frequent and
severe epileptic attacks/munoona muri munjodzi yekubatwa netsviyo
nguva zhinji.
28. Do you feel more susceptible to more frequent and severe epileptic
attacks compared to other epileptic patients whom you know? Munoona
muri panjodzi huru yekubatwa netsviyo dzakanyanya kakawanda kana
muchizvienzanisa nevamwe vane chirwere chetsviyo vamunoziva here?
29. Are you more likely to experience more frequent and severe epileptic
attacks if you miss your medical reviews / munoona muchipinda
panjodzi huru here yekubatwa netsviyo dzakanyanya nguva zhinji Kana
mukasaenda kunoonekwa navana mukoti / Chiremba pamazuva
akatarwa ?
30. Do you think experiencing more frequent and severe epileptic seizures
will make you have more injuries/ munofunga kuti Kuita tsviyo
dzakanyanya nguva zhinji kunokuisai panjodzi yekukuvara kwakanyanya
here?
31. Do you think experiencing more frequent and severe epileptic seizures
will affect you emotionally/ munofunga kuti kuita tsviyo dzakanyanya
kakawanda kunokushungurudzai here?
32. Do you think experiencing more frequent and severe epileptic seizures
will limit you from doing your usual work (i.e. going to the field, school,
fetch water etc)/Ko kuita tsviyo dzakanyanya nguva dzakawanda
72
kunokukonesai kuita mabasa enyu emazuva ese.here?
33. What are the benefits of attending your scheduled review visits? /Zvakanakirei kuenda kuchipatara
pamazuva enyu akatarwa?
Monitoring of progress of treatment
Early identification of complications/other arising conditions
Getting drugs supplies
Others (Specify)/Zvimwewo (Tsanangurai)..........................................................................
No benefits
34. What do you think is the most effective treatment of epilepsy? Munofunga kuti ndezvipi
zvinonyatsoshanda mukurapa kana kudzikisa dambudziko retsviyo
Antiepileptic drugs
Traditional remedies
concoction from faith healers
35. Do you think Antiepileptic drugs are effective in controlling seizures/Ko munofunga kuti mapiritsi
etsviyo anonyatsoshanda mukudzikisa dambudziko retsviyo here?
Yes
No
c. Self-efficacy questions
Pleases tell me how many times are you able to do the following things/munogona kuita zvinotevera
kazhinji zvakadini?
Not at
all/Hapana
A few
times/Nguva
shomana
Sometimes/
Dzimwe
nguva
Most of the
times/nguva
Zhinji
All the
times/Nguva
dzose
36. Going to the health facility on your
own (without company)/ Kuenda
kukiriniki/Chipatara mega pasina
anokuperekedzai.
37. Use public transport without much
problems/ Kufamba nemabhazi
73
kana motikari dzinotakura
veruzhinji.
38. deciding on your own on whether
to go for medical reviews or not/
Kuzviitira sarudzo yekuenda kana
kusaenda kukiriniki/chipatara
pamazuva akatarwa
39. Overcome opposition from family
members regarding going for
treatment review visits/ kuenda
kuchipatara pamazuva akatarwa
apo veukama vasingadi kuti
muende
D. Intention
40. In the next 12 months how many times are you likely to go for your scheduled review visits
/Mumwedzi gumi nemiviri inotevera munotarisira kuenda kuchipatara/kiriniki pamazuva mangani
akatarwa? ................times (0-12).
Section D: Reinforcing factors
a. Social support and feedback
How often do your close relatives and friends do the following things for you or with you to help you in
this condition and its treatment process? / Hama kana shamwari dzenyu dzepedyo dzinokuitirai
zvinotevera kangani?
Not at
all/Hapana
A few
times/Nguva
shomana
Sometimes/
Dzimwe
nguva
Most of the
times/nguva
Zhinji
All the
times/Nguva
dzose
41. Check on the progress of your
treatment/kungoona kuti muri kuita
zvamunotarisirwa maererano
nekurapwa kwenyu
42. Tell you that you have done well
when you go for your monthly
appointment?/Kukuudzai kuti
maita zvakanaka kana maenad
kukiriniki/chipatara pamazuva
enyu akatarwa
43. Tell you that you haven’t done
well if you miss your monthly
appointments?/Kukuudza kuti
hamuna kuita zvakanaka kana
musina kuenda
74
kukiriniki/chipatara pamazuva
enyu akatarwa
44. Maintain confidentiality on things
that you would have discussed/
Kuchengetedza tsindidzo pane
zvamunenge mataurina
nezvehurwere hwenyu
45. Clarify to you what they expect of
you in the treatment process/
Kukujekeserai zvavanotarisira kuti
muite maererano nekurapiwa
kwenyu.
46. Let you know that he/she will
always be around if you need
assistance/Kukuvimbisai kuti
vachange vachikutsigirai nguva
dzose
47. Look after a family member
/possessions when you go for your
epilepsy treatment review visits/
Kusara vakachengeta zvipfuyo,
midziyo kana vana venyu
pamunoenda kukiriniki pamazuva
enyu akatarwa.
48. Physically go with you to the
health facility for your scheduled
review visits/any other health visit/
Kuenda nemi kukiriniki kana
kuchipatara kunoonekwa
nanamukoti/chiremba pamazuva
enyu akatarwa
49. Provide you with some transport to
go to health facility or provide
money for transport purposes to
attend your epilepsy treatment/
Kukupai chifambiso kana mari
yekufambisa kuti muende
kukiriniki pamazuva enyu
akatarwa
50. Observe you taking drugs/ Kuona
muchimwa mapiritsi enyu
B. Social approval
75
The following people think that you should attend (Non, a few, some, most, all or Not applicable) of
you scheduled epilepsy review visits/Vanhu vanotevera vanotarisira kuti muende kukiriniki
pamazuva enyu akatarwa mangani?
Non/hapana few/Mashoma Some/Mamwe Most/Mazhinj All/ese
51. Family members
52. Other close
relatives/Dzimwewo
hama dzepedo
53. friend/Sahwira
54. Neighbours/Vavakidzani
55. Village heads/Sabhuku
56. Church leaders
(vafundisi)
57. Clinic/hospital Health
worker/Vanamukoti
kana vamwe vashandi
vepachiptara/kiriniki
58. Village health
workers/MaVillage
Health workers
59. Are there any epilepsy support groups/networks in your area? Munharaunda menyu mune mapoka
evanorwara netsviyo here?
Yes/Hongu
No/Kwete
60. If yes, Do you belong to any of the groups?/Ko imi muri umwe wemapoka aya here kana ariko?
Yes/Hongu
No /Kwete
61. Are Health issues discussed at local village level developmental meetings in your area? Ko zveutano
zvinombotaurwawo here pamisangano ye Village renyu ?
Yes/Hongu
No/kwete
62. If yes, are epilepsy related issues discussed at such meetings?/ko chirwere chetsviyo
chinombokurukurwa nezvacho here pamisangano yevillage renyu?
Never/Kwete
Sometimes/dzimwe nguva
Most of the times/ nguva zhinji
76
63. Do community-Based Health works such as Village Health workers visit you and assist you in the
treatment process? Ko vashandi vezveutano vemunharaunda (VHWs) vanombokushanyiraiwo here
kuzokubatsirai maererano nechirwere chenyu?
Yes /Hongu
No/Kwete
Section E: Enabling factors
a. Availability
64. In the past 12 months how many times did you come to the facility and failed to get services because
there were no antiepileptic medicine at the health facility/mumwedzi gumi nemiviri yapfuura (12
months) kangani kamakaenda kukiriniki pamazuva enyu akatarwa mukawana kuchipatara/kiriniki
kusina mapiritsi etsviyo?
Non
A few times
Many times
Almost all the times
65. In the past 12 months how many times did you come and fail to get services because there was no one
to offer you the services/Mumwedzi gumi nemiviri (12 months) yapfuura kangani kamakaenda
kukiriniki mukasabatsirwa nekuti pakanga pasina mukoti
Non
A few times
Many times
Almost all the times
b. Accessibility of services
66. What do you consider to be barriers that may affect your coming for the scheduled medical review
visits/ Ndezvipi zvamunoona sezvibingamupinyi zvingakanganisa kuenda kwenyu kuchipatara/kiriniki
kunoonekwa pamazuva akatatrwa?
Long distances to health facilities/kukiriniki kure
High consultation fees at health facilities/ kudhura kwemari dzekuonekwa
nachiremba/mukoti
High cost of drugs/ kudhura kwemishonga
Shortage of drugs/kushaikwa kwemishonga
Physical barriers (mountains big rivers between home and facility)/makomo kana nzizi
unavailability of transport/ Kushaikwa kwezvifambiso
High transport cost to Health facility/kudhura kwezvifambiso
Negative attitudes of health workers/ kusabatwa zvakanaka nevashandi veutano
67. What mode of transport do you use to go to your nearest Health facility/Munoshandisa zvifambiso
rudzii kuenda kuchipata kana kiriniki iri pedyo nemi?
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On foot/Tsoka
Scotch-cart/ Ngoro
Bicycle/ Bhasikoro
Motor vehicle/Motikari
Others (Specify)/Zvimwewo...........................................................................
Section F: Attendance of Scheduled visits
68. How many visits did you attend in the past 12 months (Confirm from card). Makaenda kukiriniki
kangani pamazuva enyu amakatarirwa kana tichitarisa mwedzi gumi nemiviri yapfuura
...........................................
69. How many visits did you miss in the past 12 months; Makakundikana kangani kuenda kukiriniki
pamazuva enyu amakatarirwa tichitarisa mwedzi gumi nemiviri yapfuura? .........................
70. Did you miss at least 2 consecutive review visits in the previous 12 months? Ko pane
pamakambokundikana kuenda kukiriniki kanosvika kana kupfuura kaviri kakatevedzana pamazuva
amakatarirwa mumwedzi gumi nemiviri yakapfuura?
Yes/Hongu
No/Kwete
71. If yes, which months did you consecutively missed two or more visits?/Kana mati hongu, mwedzi
ipi?
(Verify from treatment cards) ..................................................................................................................
Thank you / Tatenda
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Annex 4: checklist for epilepsy resources
Name of Health facility.....................................................................Date.............................
Availability of Antiepileptic Drugs
DRUG MINIMUM
STOCK
CURRENT STOCK STOCK OUT
LAST 6 MNTHS
Carbamazapine
Phenobarbitone
Phenotoin
Fees charged to Epilepsy patient $.........................................
Availability of epilepsy IEC materials Displayed Yes [ ] No [ ]
Challenges faced by health facilities in providing epilepsy services.......................
...........................................................................................................................................
............................................................................................................................................
...............................................................................................................................................
................................................................................................................................................
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Annex 5: PMD’s Approval letter
80
Annex 6: Institutional Review Board approval
81
Annex 7: Medical Research Council Approval