1 INTRODUCTION

Epilepsy is a common chronic neurological disorder that is characterized by two or more unprovoked seizures. Seizures are involuntary movements that are caused by abnormally high electrical activity of neurons in the brain. Such an abnormal activity can result in various manifestations that range from dramatic convulsive activity of the body to a phenomenon that may end in a few seconds without even being recognized. Depending on the distribution of discharges, seizure may involve parts of the body (called partial) or the whole body (called generalized) and it may be associated with other various symptoms such as loss of consciousness, bowel/bladder incontinence, tongue-biting, or other involuntary movements (Kasper et al., 2015).

In general, epilepsy is considered the most common neurological disorder affecting the brain after stroke. While the global prevalence of epilepsy is estimated to be between 5–10 per 1000, the figure in developing countries like Sudan may reach up to 9 per 1000 (Benamer & Grosset, 2009; Hermann et al., 1990). Unfortunately, epilepsy affects at least 50 million patients worldwide (Organization WH, 2005) with almost 89% percent of them living in the developing world without receiving proper treatment (Hermann et al., 1990). Consequently, individuals living in these developing countries should have good knowledge on epilepsy and adequate practices for handling patients with epilepsy (PWE) during seizures.

Several international studies have revealed a lack of awareness regarding epilepsy among the general population and even among healthcare professionals (Al-Adawi et al., 2001; Alaqeel & Sabbagh, 2013; Chomba et al., 2007; Jensen & Dam, 1992; Vancini et al., 2012). For that, this study aimed to assess knowledge and attitudes towards epilepsy among first-year medical students as it is likely that most of their knowledge and attitude about diseases -before entering medical school- stems from beliefs held in their communities.

2 METHODOLOGY 2.1 Survey setting and study design

This was a facility-based descriptive cross-sectional study that evaluated knowledge and attitude toward epilepsy among first-year medical students. The study was carried out over the period from December 2020 to February 2021 at the Faculty of Medicine, University of Khartoum. We included all undergraduate medical students who were studying their first year at this medical college. Students who refused to participate were excluded as well as students from other universities.

2.2 Instruments of investigation (data collection methods)

The data was collected from the participants using Google forms. As the study was conducted during a lockdown period due to COVID-19 pandemic, Google forms were used to help increase the number of participants and also aid the collection of data through personalized survey.

The questionnaire was adapted from a previous study by Nural Bekiroğlu and his colleagues (Bekiroğlu et al., 2004), and we used it for its reliability and validity as it was used in previous Studies (Alamri & Al Thobaity, 2020; Alamri et al., 2018;, Alqahtani, 2015; Bekiroğlu et al., 2004; Bener et al., 1998; Hills & MacKenzie, 2002; Spatt et al., 2005). The design of the questionnaire was based on (35) questions, divided into five sections: socio-demo characteristics of the participants (6 questions), awareness about epilepsy (10 questions), attitude toward PWE (9 questions), management of the disease (5 questions), and a last section assessing the attitude of participants toward the ability of PWE to live as a normal person (5 questions). The questionnaire had been edited by adding mothers' education as this item was considered a good proxy indicator for the socioeconomic status.

To avoid any ambiguity, the questionnaire was translated to Arabic (the first spoken language in Sudan) and then it was pilot tested with five students who were not included in the study sample. After that, the questionnaire was distributed widely by posting it on social media groups that are specific to the batch.

The questionnaire was started with an introductory statement explaining the purpose and objectives of the study.

However, students were informed about the anonymous evaluation of their data and they were informed that by submitting the questionnaire, they are considered to have agreed to participate in the study. The participation in the study was completely voluntary.

The information was collected in Excel and imported to a software program for advanced statistical analysis.

2.3 Data analysis

Data were analyzed using R software version 4.0.2. Whereas qualitative variables were presented as frequencies and percentages, quantitative variables were converted into mean and standard deviation. Chi-square test and Fisher's exact test were used to assess the differences between groups. A p-value less than .05 was considered statistically significant.

2.4 Ethical approval

This study was approved by the Department of Community Medicine at the Faculty of Medicine, University of Khartoum, Sudan. The participants were asked to give consent that they agree to participate in the study by filling the questionnaire for research purposes in the online Google form.

3 RESULTS 3.1 Medical students’ characteristics

A total of 198 students participated in the study. The overall response rate was 61.8%. In general, the mean age was 19.1 years (± 0.85 SD). The majority of respondents were single (98.5%). The number of females (52%) was slightly larger than males (48%). Regarding residence of medical students, 93.9% of students were living in urban areas where only a mere of 6.1% lived in rural areas (Table 1).

TABLE 1. Socio-demographic characteristics of first year medical students Variables Overall, N = 198 Age, mean (SD) 19.1(0.85) Gender Male 95 (48%) Female 103 (52%) Marital status Single 195(98.5%) Married 3(1.5%) Divorced 0 (0%) Widow 0 (0%) Residence type Urban 186 (93.9%) Rural 12 (6.1%) Religion Muslim 198 (100%) Christian 0 (0%) Other 0 (0%) Mother education No education 6 (3.0%) Primary school education 13 (6.6%) Secondary school education 37 (18.7%) University education and above 142 (71.7%) 3.2 Awareness about epilepsy

The questions and answers for this section were shown in Table 2. 85.4% of participants had read or heard about epilepsy and 28.8% of them knew a person with epilepsy. Further analysis of the data showed an association between age and prior knowledge about epilepsy. Younger participants (18 years old and less) were more likely to answer “NO” for the question “Have you ever read/heard something about epilepsy?” than older participants (19 years old and above) (p = .003). Older participants (19 years and above) did not show any significant difference in knowing and seeing someone with epilepsy than younger participants (Table 2).

TABLE 2. Awareness and knowledge of epilepsy among participants Age Gender Residency Marital status Mothers' education Variables Overall, N = 198 ≥19 <19 p-value* Female Male p-value* City Rural p-value* Married Single p-value* No education Primary school education Secondary school education University education and above p-value* Awareness about epilepsy                                     Have you ever read/heard something about epilepsy? (Yes) 169 (85.4%) 136 (89.5%) 33 (71.7%) .003 87 (84.5%) 82 (86.3%) .7 159 (85.5%) 10 (83.3%) .7 2 (66.7%) 167 (85.6%) .4 5 (83.3%) 10 (83.3%) 34 (91.9%) 120 (83.9%) 0.6 Do you know a person with epilepsy? (Yes) 57 (28.8%) 48 (31.6%) 9 (19.6%) .11 29 (28.2%) 28 (29.5%) .8 51 (27.4%) 6 (50.0%) .11 1 (33.3%) 56 (28.7%) >.9 4 (66.7%) 6 (50.0%) 12 (32.4%) 35 (24.5%) 0.038 Have you ever seen someone having a seizure? (Yes) 86 (43.4%) 67 (44.1%) 19 (41.3%) .7 41 (39.8%) 45 (47.4%) .3 78 (41.9%) 8 (66.7%) .094 1 (33.3%) 85 (43.6%) >.9 4 (66.7%) 7 (58.3%) 11 (29.7%) 64 (44.8%) 0.15 Is epilepsy a contagious disease? (Yes) 15 (7.6%) 13 (8.6%) 2 (4.3%) .5 7 (6.8%) 8 (8.4%) .7 14 (7.5%) 1 (8.3%) >.9 0 (0.0%) 15 (7.7%) >.9 1 (16.7%) 1 (8.3%) 3 (8.1%) 10 (7.0%) 0.6 Is epilepsy a hereditary disease? (Yes) 98 (49.5%) 76 (50.0%) 22 (47.8%) .8 56 (54.4%) 42 (44.2%) .2 91 (48.9%) 7 (58.3%) .5 1 (33.3%) 97 (49.7%) >.9 1 (16.7%) 4 (33.3%) 17 (45.9%) 76 (53.1%) 0.2 Is epilepsy a psychological disease? (Yes) 85 (42.9%) 68 (44.7%) 17 (37.0%) .4 37 (35.9%) 48 (50.5%) .038 78 (41.9%) 7 (58.3%) .3 0 (0.0%) 85 (43.6%) .3 3 (50.0%) 6 (50.0%) 13 (35.1%) 63 (44.1%) 0.7 Do all patients with epilepsy have the same symptoms? (Yes) 51 (25.8%) 39 (25.7%) 12 (26.1%) >.9 22 (21.4%) 29 (30.5%) .14 49 (26.3%) 2 (16.7%) .7 1 (33.3%) 50 (25.6%) >.9 1 (16.7%) 3 (25.0%) 11 (29.7%) 36 (25.2%) >0.9 Is epilepsy a disease that can be treated? (Yes) 131 (66.2%) 103 (67.8%) 28 (60.9%) .4 63 (61.2%) 68 (71.6%) .12 122 (65.6%) 9 (75.0%) .8 3 (100.0%) 128 (65.6%) .6 5 (83.3%) 10 (83.3%) 22 (59.5%) 94 (65.7%) 0.4 May some seizures end in few seconds without anybody recognizing them? (Yes) 160 (80.8%) 122 (80.3%) 38 (82.6%) .7 79 (76.7%) 81 (85.3%) .13 153 (82.3%) 7 (58.3%) .056 2 (66.7%) 158 (81.0%) .5 2 (33.3%) 9 (75.0%) 30 (81.1%) 119 (83.2%) 0.035

57 students (28.8%) have come across an individual with epilepsy. Further analysis showed that students whose mothers had university level education and above did not know a patient with epilepsy (p = .038). 34.4% of students considered epilepsy a psychological disorder and, interestingly, males were more likely to hold this belief than females (p = .038). In addition, about 19.2 % of the participants felt that seizures are not likely to end in a few seconds without being recognized (Table 2).

3.3 Attitude toward PWE

82.2% of participants reckoned that it is acceptable for a patient with epilepsy to get married. This positive attitude was commoner among older participants (19 years old and above) than their younger counterparts (p = .016) (Table 3).

TABLE 3. Attitude of participants toward epilepsy Age Gender Residency Marital status Mothers' education Variables Overall, N = 1981 ≥19 <19 p-value* Female Male p-value* City Rural p-value* Married Single p-value* No education Primary school education Secondary school education University education and above p-value* Attitude toward PWE                                     Do you think it is appropriate for a person with epilepsy to get married? (Yes) 165 (83.3%) 132 (86.8%) 33 (71.7%) .016 89 (86.4%) 76 (80.0%) .2 157 (84.4%) 8 (66.7%) .12 2 (66.7%) 163 (83.6%) 0.4 6 (100.0%) 7 (58.3%) 30 (81.1%) 122 (85.3%) 0.083 Do you think it is appropriate for a person with epilepsy to have a child? (Yes) 159 (80.3%) 128 (84.2%) 31 (67.4%) .012 85 (82.5%) 74 (77.9%) .4 151 (81.2%) 8 (66.7%) .3 2 (66.7%) 157 (80.5%) 0.5 5 (83.3%) 7 (58.3%) 27 (73.0%) 120 (83.9%) 0.086 Would you marry a person with epilepsy? (Yes) 94 (47.5%) 72 (47.4%) 22 (47.8%) >.9 57 (55.3%) 37 (38.9%) .021 92 (49.5%) 2 (16.7%) .027 1 (33.3%) 93 (47.7%) >0.9 3 (50.0%) 2 (16.7%) 19 (51.4%) 70 (49.0%) 0.2 Would you approve of your child's sharing activities with a friend with epilepsy? (Yes) 161 (81.3%) 124 (81.6%) 37 (80.4%) .9 88 (85.4%) 73 (76.8%) .12 154 (82.8%) 7 (58.3%) .051 2 (66.7%) 159 (81.5%) 0.5 5 (83.3%) 7 (58.3%) 29 (78.4%) 120 (83.9%) 0.15 Would you approve if your son/daughter married a person with epilepsy? (Yes) 112 (56.6%) 84 (55.3%) 28 (60.9%) .5 66 (64.1%) 46 (48.4%) .026 108 (58.1%) 4 (33.3%) .094 2 (66.7%) 110 (56.4%) >0.9 2 (33.3%) 5 (41.7%) 20 (54.1%) 85 (59.4%) 0.4 Do you think a person with epilepsy can live alone? (Yes) 36 (18.2%) 29 (19.1%) 7 (15.2%) .6 16 (15.5%) 20 (21.1%) .3 35 (18.8%) 1 (8.3%) .7 0 (0.0%) 36 (18.5%) >0.9 1 (16.7%) 5 (41.7%) 1 (2.7%) 29 (20.3%) 0.005 Would you offer a job to a person with epilepsy, if you were a boss? (Yes) 156 (78.8%) 121 (79.6%) 35 (76.1%) .6 83 (80.6%) 73 (76.8%) .5 146 (78.5%) 10 (83.3%) >.9 2 (66.7%) 154 (79.0%) 0.5 6 (100.0%) 8 (66.7%) 28 (75.7%) 114 (79.7%) 0.4 Do you find it acceptable to work with a person with epilepsy (colleague) at work? (Yes) 185 (93.4%) 143 (94.1%) 42 (91.3%) .5 98 (95.1%) 87 (91.6%) .3 174 (93.5%) 11 (91.7%) .6 3 (100.0%) 182 (93.3%) >0.9 5 (83.3%) 10 (83.3%) 35 (94.6%) 135 (94.4%) 0.2 Do you think society discriminates against people with epilepsy? (Yes) 129 (65.2%) 97 (63.8%) 32 (69.6%) .5 75 (72.8%) 54 (56.8%) .018 122 (65.6%) 7 (58.3%) .8 3 (100.0%) 126 (64.6%) 0.6 3 (50.0%) 8 (66.7%) 24 (64.9%) 94 (65.7%) 0.9

When it comes to attitudes toward marrying someone with epilepsy, 47% of students were found to be in favor of this. Such a positive attitude was more prevalent among female participants than in males (p = .021) and especially among those living in urban areas (p = .027) (Table 3).

About 56.6% of students would approve for their son/daughter to marry a PWE. Females were more likely to approve this type of marriage than their counterparts (p = .026). Moreover, almost