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Print version ISSN 1676-2649
J. epilepsy clin. neurophysiol. vol.16 no.2 Porto Alegre 2010
CLINICAL, PSYCHOSOCIAL AND SCIENTIFIC NOTE
IBE Promising Strategies Program 2008: "Epilepsy at School: Teaching the Teachers" - educational plan of the "Associação Brasileira de Epilepsia" with teachers of elementary school
Programa IBE Promising Strategies 2008: "Epilepsia nas Escolas: Ensinando os Professores" - plano educacional da Associação Brasileira de Epilepsia com professores de educação básica
Laura GuilhotoI; Heloise MartinsI; Marcos Vidal-DouradoI; Erika AlmeidaI; Sueli MesquitaI; Carlos TavaresI; Katia LinI; Veriano Alexandre Jr.I; Alzira CastroI; Alice MasukoI; Adriana MendonçaII; Maria Helena MartinsII; Marcos GalvezII; Marluce CamarinhoII; Natalina MateusII; Rose JurjuckII; Elza Márcia YacubianI
IAssociação Brasileira de Epilepsia (ABE), Oficial Brazilian Chapter of the International Bureau for Epilepsy
IISecretaria Estadual da Educação do Estado de São Paulo, Brazil
INTRODUCTION: The aim of this study is to evaluate trough questionnaires the knowledge about epilepsy of Elementary School teachers obtained in the "Promising Strategies Program 2008" from International Bureau for Epilepsy entitled "Epilepsy at School. Teaching the Teachers." performed by the official Brazilian branch "Associação Brasileira de Epilepsia" (ABE).
METHODS: A questionnaire was developed by ABE and it is composed by 35 objective questions concerning the following areas: concepts and definition of epilepsy and its causes (10); treatment and adverse effects of antiepileptic medication (10); popular stigma about epilepsy (5); activities of people with epilepsy (PWE) (5); and finally, first-aid during and after an epileptic seizure (5). The questionnaire was presented in phase (ph) 1 to teachers before the lecture "Epilepsy: Causes, symptoms and treatment" given by a health professional from ABE trough classical live class (CC) or by video-conference (VC) on "Rede do Saber's site" (http://www.rededosaber.sp.gov.br/portais/NotíciasConteúdo/tabid/369/language/pt-BR/IDNoticia/851/Default.aspx) and afterwards in ph 2. The results were compared to a control group of 66 teachers that did not attend any lecture.
RESULTS: Classical class was given in four different cities of Brazil and VC was performed in the state of Sao Paulo and was transmitted to 74 different cities, including Sao Paulo city, this latter with 12 sites; 1,153 teachers were instructed either by CC 25% (288) or VC 75% (865). Most (78.5%) were female, aged between 18 to 68 years (mean 41.4); 76.6% attended University and 21.1%, graduate studies; 50% affirmed to know a PWE. The mean of right answers in ph 1 in CC was 78.4% (±10.1) and VC, 79.8% (±8.6) and in ph 2 in CC, 86.5% (±6.4) and VC, 86.8% (±7.1), reflecting increased knowledge in ph 2 (p<0.001) in the 2 strategies (control group: ph 1, 78.2%±7.4; ph 2, 79.6%±8.6; p>0.05). Comparison of variability of the combined action (CC+VC) between ph 1 (79.5%±8.6) and 2 (86.8%±6.8) was 9.9%±13.9 (p<0.001) (control group 2.3%±10.2; p<0.001, compared to CC+VC). The topics "popular stigma" and "first aid during seizures" had the lowest correct scores in ph 1 (CC+VC), 74.6% and 72.8%, respectively (control group 78.8±10.2 and 67.9±17.5). The highest gain (35.6%) in ph 2 was observed in "first aid" (control group 0.8±27.2, p<0.001) and the lowest (0.1%), in "popular stigma" (control group 1.7±26.4, p>0.05). There was a significant variation in the topic "first aid" in CC, 41.1% compared to VC, 33.3% (p=0.009).
CONCLUSION: The educational plan of the "Associação Brasileira de Epilepsia" revealed good performance of the teachers of Elementary School without significant differences between the types of presentation (CC/VC), although CC was more efficient to teach first aid during epileptic seizures. The topic "Popular stigma about epilepsy knowledge" has not improved after the lectures and this subject still needs further research and efforts for better understanding and action planning.
Keywords: Education; epilepsy; survey; teacher; school.
OBJETIVOS: Avaliar através de questionários o conhecimento obtido pela ação educativa com professores de Educação Básica intitulada "Epilepsia nas Escolas: Ensinando os Professores" no programa "Promising Strategies 2008" do International Bureau for Epilepsy realizado pelo capítulo oficial brasileiro, a Associação Brasileira de Epilepsia (ABE).
MÉTODOS: Questionário foi desenvolvido pela ABE com 35 questões objetivas abrangendo os tópicos: conceitos e definições da epilepsia (10); tratamento e reações adversas de medicações antiepilépticas (10); atividades físicas e profissionais da pessoa com epilepsia (PCE) (5); conhecimento popular estigmatizante (5); cuidados básicos durante e após a crise (5). O questionário foi aplicado antes (Fase 1) e depois (Fase 2) da palestra "Epilepsia: Causas, Sintomas e Conduta" por aula presencial (AP) e videoconferência (VC) na "Rede do Saber" (http://www.rededosaber.sp.gov.br/portais/NotíciasConteúdo/tabid/369/language/pt-BR/IDNoticia/851/Default.aspx). Os resultados foram comparados a um grupo controle de 66 professores que não assistiram à aula sobre epilepsia.
RESULTADOS: Aula presencial foi ministrada em quatro cidades brasileiras e VC foi transmitida a 74 cidades do estado de São Paulo, incluindo a capital, esta última com 12 sítios de transmissão. Foram instruídos 1.153 educadores por AP 25% (288) e VC 75% (865). A maioria (78,5%) era do sexo feminino, com idades de 18 a 68 anos (média 41,4); 76,6% cursaram ensino superior e 21,1%, pós-graduação; 50% afirmou conhecer PCE. A média de acertos na fase 1 em AP foi de 78,4% (±10,1) e VC, 79,8% (±8,6) e na fase 2 em AP 86,5% (±6,4) e VC, 86,8% (±7,1), refletindo aumento do conhecimento na fase 2 (p<0,001) nas 2 estratégias (grupo controle: fase 1, 78,2%±7.4; fase 2, 79,6%±8.6; p>0,05). A comparação da variação da ação conjunta (AP+VC) entre fase 1 (79,5%,±8,6) e 2 (86,8%,±6,8) foi de 9,9%±13,9 (p<0,001) (grupo controle 2.3%±10.2; p<0,001, comparado a CC+VC). Os tópicos "conhecimento estigmatizante" e "cuidados básicos" tiveram menor índice de acerto na fase 1 (AP+VC), 74,6% e 72,8%, respectivamente (grupo controle 78,8±10,2 e 67,9±17,5). No entanto, o maior ganho (35,6%) na fase 2 se deu em "cuidados básicos" (grupo controle 0,8±27,2, p<0,001) e o menor (0,1%), em "conhecimento estigmatizante" (grupo controle 1,7±26,4, p>0,05). Houve significante variação do tópico "cuidados básicos" em AP 41,1% comparada à VC 33,3% (p=0,009).
CONCLUSÃO: A ação educativa da ABE mostrou bom aproveitamento dos educadores sem diferenças significativas entre os modos de divulgação (AP/VC), porém AP foi mais eficiente em ensinar cuidados básicos na crise epiléptica. O tópico "Conhecimento Popular Estigmatizante sobre Epilepsia" não mostrou aumento após a aula, sendo necessários esforços conjuntos em pesquisa e planejamento estratégico nessa área.
Unitermos: Educação; epilepsia; questionário; professores; escola.
It is well known that children with epilepsy suffer prejudice at school and this fact is responsible for much of the stigma in adult life. Teacher's knowledge about epilepsy can have a direct impact on students regarding school and social achievements and consequently, employment and networking links in adult life. Despite this important role of the educator, little research is done in this field in the whole world, especially with intervention programs. Most of the studies from different countries refer insufficient training of the teachers about epilepsy, as well as, potentially prejudice concepts about the condition.1-9
Teachers play a fundamental role in order to accept diversity and to fight against discrimination, and as they are not well informed and trained regarding epilepsy, Associação Brasileira de Epilepsy (ABE) proposed an intervention program in elementary schools in Sao Paulo state, called "Epilepsy at School: Teaching the Teachers" that was one of the programs selected for the Promising Strategies Program of the International Bureau for Epilepsy in 2008.10
This program is composed by a lecture with simple didactic visual resources concerning the following infor- mation about epilepsy: 1) basic aspects of brain anatomy; 2) definition; 3) causes; 4) epidemiology; 5) diagnosis; 6) treatment; 7) first-aid during a seizure; 8) psychological and social consequences; 9) wrong mythos in epilepsy; 10) world-wide International League Against Epilepsy campaign "Epilepsy Out of the Shadows".
The aim of this study is to evaluate the efficacy of the lecture "Epilepsy at school. Teaching the teachers." given by ABE to teachers of elementary schools by measuring the impact in knowledge trough questionnaires about epilepsy comparing two methods of presentation, classical live class and video-conference.
A pilot questionnaire regarding experience, and comfort with epilepsy with 23 questions was developed by ABE and it was presented to one public school in a poor suburb of Sao Paulo city.11 Afterwards it was developed a new questionnaire by ABE experts composed by 35 questions concerning the following topics: A - Concepts and Definition of Epilepsy and its Causes (10); B - Treatment and Adverse Effects of Antiepileptic Medication (10); C - Popular Stigma about Epilepsy (5); D - Activities of People with Epilepsy (PWE) (5); E - First Aid during and after an Epileptic Seizure (5).12 Respondents had to indicate if the statements were right or wrong. The questionnaire and its topics are presented in Table 1.
The questionnaire was presented in phase 1 to teachers before the lecture "Epilepsy: Causes, Symptoms and Treatment" given by a health professional from ABE and afterwards in phase 2. The lecture was given either trough classical live class (CC) or video-conference (VC). Video-conference was broadcast in an educational site (Rede do Saber) held by the Educational Authorities of Sao Paulo state which promotes divulgation of their programs (http://www.rededosaber.sp.gov.br/portais/NotíciasConteúdo/tabid/369/language/pt-BR/IDNoticia/851/Default.aspx).
This prospective study was performed with the lecture group (n=1,153) and a control group (n=66). Both groups were assessed twice: the lecture group before and after it; the control group answered the questionnaire before and after a lecture about other topic, and afterwards an Epilepsy lecture was available only for educative purposes and not with the aim of measuring its efficacy.
Primary outcome measure was increase in knowledge about epilepsy using the questionnaire and the main hypothesis was that greater increase of knowledge in the lecture group compared to control group. Statistical analysis consisted of Fisher exact test and t-Student test for independent samples for categorical and continuous variables, respectively; comparisons before and after the lecture were performed using McNemar chi-square test and Paired T test for categorical and continuous variables, respectively. Influence of variables in the topics of the questionnaire was analyzed by ANOVA. Level of statistical significance was set at p < 0.05 in all tests.
Classical class was given in four different cities of Brazil and VC was performed in the state of Sao Paulo and was transmitted to 74 different cities, including Sao Paulo city, this latter with 12 sites; 1,153 teachers were instructed either by CC 25% (288) or VC 75% (865).
Most teachers (78.5%) were female, aged between 18 to 68 years (mean 41.4) and 50% affirmed to know a PWE. They had at least 12 years of education; 76.6% attended University and 21.1%, graduate studies. Mean time of teaching experience was 13.1 years (SD 8.8) and 75% of the surveyed teachers had at least 5 years of experience. The demographic data is shown in Table 2.
The mean of right answers in phase 1 in CC was 78.4% (±10.1) and VC, 79.8% (±8.6) and in phase 2 in CC, 86.5% (±6.4) and VC, 86.8% (±7.1), reflecting increased knowledge in phase 2 (p<0.001) in the 2 strategies (control group: phase 1, 78.2%±7.4; phase 2, 79.6%±8.6; p>0.05). Comparison of variability of the combined action (CC+VC) between phase 1 (79.5%±8.6) and 2 (86.8%±6.8) was 9.9%±13.9 (p<0.001) (control group 2.3%±10.2; p<0.001, compared to CC+VC). Graph 1 shows the comparison between phases 1 and 2.
The areas in which there was a greater improvement in knowledge of the surveyed teachers between phases 1 and 2 were, "First-aid during an Epileptic Seizure" (mean variation 35.6%, p<0.001; compared to controls p<0.001), followed by "Activities of PWE" (mean variation 19.9%, p<0.001; compared to controls p=0.327), and finally "Concepts and Definition of Epilepsy and its Causes" (mean variation 15.9%, p<0.001; compared to controls p=0.024) and "Treatment and Adverse Effects of Antiepileptic Medication" (mean variation 7.4%, p<0.001; compared to controls p=0.001). In the topic "Popular Stigma about Epilepsy" there was a decrease in the number of correct answers after the lecture (mean variation 0.1%, p=0.007; compared to controls p=0.001). Graph 2 shows the variation before and after the lecture in the several surveyed topics.
The topics "Popular Stigma" and "First Aid during Seizures" had the lowest correct scores in phase 1 (CC+VC), 74.6% and 72.8%, respectively (control group 78.8±10.2 and 67.9±17.5). The highest gain (35.6%) in phase 2 was observed in "First Aid" (compared to control group 0.8±27.2, p<0.001) and the lowest (0.1%), in "Popular Stigma" (compared to control group 1.7±26.4, p>0.05). There was a significant variation in the topic "First Aid" in CC, 41.1% compared to VC, 33.3% (p=0.009).
Previous studies, including developing and developed countries, have reported insufficient knowledge about epilepsy among teachers and their willing in improving this situation trough specific material about the subject, including lectures or public awareness campaigns.13-16
In our study there was an overall improvement in knowledge among the teachers after the lecture about epilepsy. This finding was similar in the study done by Appolone et al. in 1979 with non medical professionals, including teachers, which demonstrated that those who attended a workshop about epilepsy improved significantly more than the two control groups in their knowledge of and comfort with the condition.17 A long term effect was also noticed in schools in Japan by Miyake et al. in 1991 with a public awareness campaign about epilepsy.18
The area most impacted was "First Aid during an Epileptic Seizure" which rose from 71.1 to 89% of correct answers between phase 1 and 2. This fact probably reflects the low knowledge of first-aid care in the general population probably superposed to the stigma of the epileptic seizure. Several studies have reported the lack of knowledge of teachers regarding the first measures during a seizure.19-22 Another area of great impact was "Activities of PWE", which got 88.7% of correct answers in phase 2 (mean variation 19.9%), although it was statistically non significant compared to the control group (p=0.327). Probably in these two areas the information was easier to the teachers to learn because the principles were transmitted as true "rules" and they were based either in scientific or legal aspects.
The topics "Concepts and Definition of Epilepsy and its Causes" and "Treatment and Adverse Effects of Anti- epileptic Medication" showed good improvement (mean variation 15.9% and 7.4%; compared to controls p=0.024 and p=0.001, respectively) but somewhat inferior to the previous mentioned areas. This probably reflects the broad range of definitions and treatment options in the field of epilepsy with several syndromic presentations.
The poor results in phase 2 observed in the topic "Popular Stigma about Epilepsy" may be caused by three factors: 1) inadequate questions; 2) difficulties of health professionals to transmit this information in a simple and direct way to lay people; 3) specific nosological problems in this area of medicine. Regarding the questions, we noticed that there are difficulties in understanding the difference between the terms "to cause" and "to predispose" the occurrence of an epileptic seizure. Problems in communication between Health and School personnel were also referred by other authors that have found better tolerance and greater knowledge among higher educated teachers.23-24 Another fact to contribute to these nosological problems in this area of medicine is the fact that epilepsy is included in the area of Mental Health by the World Health Organization.25
We observed that teachers of these surveyed Elementary Schools in Brazil, had basic knowledge about epilepsy, which could be increased after the specific lecture given by the "Associação Brasileira de Epilepsia". There were no significant differences between the types of presentation (CC/VC), although CC was more efficient to teach first aid during epileptic seizures. Popular stigma about epilepsy knowledge has not improved after the lectures and this subject still needs further research and efforts for better understanding and action planning.
We acknowledge the help of Patricia Guilhem de Almeida Ramos for statistical analysis.
International Bureau for Epilepsy (Promising Strategies Program 2008); Companhia de Seguros Aliança do Brasil; Secretaria da Educação do Estado de São Paulo, Brazil for support.
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Received May 25, 2010; accepted June 11, 2010.