Utilization and Therapeutic Choices after a First Seizure: A Mixed- Methods Analysis of Determinants in a Malian Cohort

Utilization and Therapeutic Choices after a First Seizure: A Mixed- Methods Analysis of Determinants in a Malian Cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Utilization and Therapeutic Choices after a First Seizure: A Mixed- Methods Analysis of Determinants in a Malian Cohort Youssoufa MAIGA, Leon Samuel Moskatel, Seybou Hassane Diallo, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8958943/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background The therapeutic pathway options of people living with epilepsy (PWE) in Sub-Saharan Africa (SSA), especially in Mali are influenced by sociocultural, anthropological, and economic factors. Our study aimed to analyze the determinants of healthcare-seeking behavior and therapeutic choices after an inaugural epileptic seizure. Methods We focused on analyzing the choice of care pathway after an inaugural epileptic seizure in an environment characterized by the coexistence of conventional medicine (CM) and traditional medicine (TM). We hypothesized that a mixed approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches, would allow for a deeper understanding of the issue. This study was conducted in urban and rural referral centers for the management of PWE. Patients with clinically and EEG-confirmed epilepsy were consecutively enrolled in outpatient consultations at the two sites during the study period, and data were collected through direct and semi-structured interviews. Descriptive statistics and linear regressions were used to analyze the generated data. Results A total of 87 patients met the inclusion criteria and participated in the interviews (patients or caregivers). The mean age was 20 ± 14 years, and were predominantly men (50/87, 57%). Epilepsy was mainly symptomatic, linked to complications from abnormal childbirth, head trauma, stroke, and cerebral malaria. Following the inaugural seizure, patients consulted conventional healthcare facilities (48%), traditional practitioners (49%) and pastor (2%). The high cost of antiepileptic drugs in conventional medicine emerged as a limiting factor. The multivariate model showed that male sex and higher levels of education were associated with significantly more robust odds ratios for consulting a physician. Conversely, a greater distance from a healthcare facility was associated with a significantly lower likelihood of consulting a physician. Conclusion The diagnosis and treatment of epilepsy remain major public health challenges in sub-Saharan Africa, particularly in Mali. This study highlights the central role of traditional medicine as a primary therapeutic option following an inaugural seizure, often favored due to the high cost of medication and, significantly, the challenges surrounding the accessibility and availability of conventional healthcare facilities. In this context, the implementation of the Universal Health Insurance Plan (RAMU) is essential to mitigate the prohibitive cost of anti-seizure medications and ensure financial accessibility for the most vulnerable populations. Researchers and policymakers must implement innovative strategies aimed at: (1) improving access to healthcare facilities, especially in rural areas; (2) promoting collaboration between traditional and conventional medicines; and (3) developing information and education campaigns to foster positive behavioral changes. Our work represents an initial step toward adapting epilepsy care to local sociocultural and economic realities—a prerequisite for reducing the burden of this pathology in Mali and throughout sub-Saharan Africa. Figures Figure 1 1. Introduction Epileptic seizures affect approximately 10% of the population, ultimately leading to epilepsy in 1–2% of people worldwide [1]. In 2021, about 51.7 million people were living with epilepsy (PWE), 80% of whom lived in low- and middle-income countries (LMIC), where significant treatment gaps have emerged [2,3]. In these regions, it is estimated that only one in four people with epilepsy has access to appropriate care [3]. The World Health Organization (WHO) has declared epilepsy a public health imperative and developed the Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders 2022–2031, adopted by the World Health Assembly in May 2022 [4,5]. In Mali, the prevalence of epilepsy is estimated at 15.6 per 1,000 in rural areas and 14.6 per 1,000 in urban settings [6]. Many factors, particularly in rural areas, render the management of epilepsy challenging in Sub-Saharan Africa, including shortages of qualified healthcare personnel and limited access to diagnostic resources. In addition, lack of acceptance of the disease, poor adherence to treatment by patients and their families due to deeply held beliefs, the high cost of medications, their relative unavailability, and the lack of universal health coverage mechanisms all contribute to suboptimal care for PWE [7]. Beliefs, perceptions, and fears also vary from one country to another and influence individual and collective strategies regarding healthcare-seeking behavior [8–11]. Epilepsy can also be associated with significant stigma, prejudice, and discriminatory practices that negatively affect daily life and hinder evidence-based diagnosis and management [12,13]. These factors may partly explain the higher prevalence of active epilepsy and lifetime epilepsy observed in developing countries overall, and in SSA in particular [14]. This is especially important as epilepsy is one of the few severe and disabling neurological diseases that can be effectively managed with low-cost interventions. In this context, utilization of traditional medicine (TM) is high, as it remains the first line of care for many PWE in SSA [15]. For example, in Guinea (West Africa), the average duration of care with a traditional healer before consulting conventional medicine (CM) was reported to be 39 months, a period during which patients were not receiving effective anti-seizure medications [16]. While the treatment gap for established epilepsy is well-documented, the specific period immediately following the first seizure is a critical window that often dictates the long-term therapeutic trajectory. Within Africa more broadly, this practice resembles the subtle competition between traditional and conventional medicine in the management of neurological disorders, particularly epilepsy [17]. Careful assessment of the underlying factors that motivate people with epilepsy to seek traditional medicine immediately after an inaugural seizure becomes crucial, as optimal management of this initial phase can greatly affect disease outcomes. Furthermore, analyzing the determinants and sociodemographic parameters of healthcare-seeking behavior will best inform effective epilepsy control programs tailored to local beliefs and practices. This study aimed to examine the determinants of healthcare utilization and therapeutic choices following a first epileptic seizure in Mali using a mixed-methods approach. 2. Materials and Methods Study Hypotheses This study focused on analyzing human behavior, specifically, the choice of healthcare pathway in the event of an unusual and critical situation, such as an inaugural epileptic seizure, within a complex environment marked by the coexistence of conventional medicine (CM) and traditional medicine (TM). We hypothesized that a mixed-methods approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches, would allow a deeper and more nuanced understanding of the issue [19,20]. 2.1. Conventional healthcare system in Mali The health system in Mali is organized in a pyramidal structure, reflecting a hierarchical model of service delivery. At the base of the pyramid are the community and primary healthcare facilities, including health posts and community health centers, which provide basic preventive and curative services, maternal and child health care, and health education. The intermediate level comprises district and regional hospitals, which offer more specialized care, laboratory services, and management of complex cases referred from primary facilities. At the top of the pyramid are the national referral hospitals and specialized centers, responsible for advanced diagnostics, specialized treatments, research, and training of healthcare professionals. This structure is intended to ensure progressive access to care, with patients ideally moving from lower to higher levels of care based on the complexity of their health needs. However, disparities in infrastructure, workforce distribution, and accessibility often challenge the optimal functioning of this pyramidal system in Mali. Study Sites 2.2. Study Sites This was a cohort study conducted among outpatients followed up at two referral centers for the management of people with epilepsy in Mali. Importantly, the two health centers work in close collaboration within an urban-rural healthcare network. All patients had a unique identification number to avoid registering the same patient at both sites, given the porosity between the two structures. 2.2.1. Study Site 1: Polyclinique Pasteur It is an urban health facility at the intermediate level in the health pyramid located in Bamako, the capital city of Mali. It benefits from the full range of resources available in a major African city. It employs several neurologists with formal training in epileptology. In terms of technical facilities, it is equipped with an EEG system, a 16-slice computed tomography (CT) scanner, and a 1.5 Tesla magnetic resonance imaging (MRI) unit. The medical biology laboratory is relatively well-equipped. 2.2.2. Study Site 2: Dinandougou Medical Clinic It is a rural health facility at the intermediate level in the health pyramid located in Markacoungo, 85 km from Bamako. The rural clinic was selected because of its strong involvement and recognized expertise in the management of PWE in Mali. It has served as the site for several epilepsy-related research projects in the country [19–22] and is also identified by the Faculty of Medicine and Odonto-Stomatology of Bamako as a training site for students undertaking rural medical practice. Furthermore, it is one of the few rural facilities equipped with an electroencephalography (EEG) machine capable of performing standard wakefulness and sleep EEG recordings. 2.3. Study Period The study followed a sequential exploratory mixed-methods design, implemented in two distinct phases: Qualitative Phase (August 1st – November 23, 2023): We conducted semi-structured interviews to explore healthcare pathways and the underlying logic of therapeutic choices (traditional vs. biomedical) within the population. Constructive Step The thematic analysis of these qualitative findings served as a conceptual framework for developing the quantitative survey instrument. This step ensured that the variables were culturally adapted and grounded in the patients' lived experiences. Quantitative Phase (December 1st, 2023 – February 28, 2024): The resulting structured questionnaire was administered to the cohort to statistically assess the determinants of healthcare utilization following a first seizure." 2.4. Study Population 2.4.1. Inclusion Criteria Participants were eligible for inclusion if they met all of the following criteria: Patients of any sex, aged ≥ 1 year, who presented to either Polyclinique Pasteur (Bamako) or Dinandougou Medical Clinic (Markacoungo) Patients with confirmed epilepsy (clinically/EEG), with complete and usable medical records. Availability of the patient or a primary caregiver capable of providing reliable information on healthcare-seeking behavior and therapeutic choices Provision of written or verbal informed consent by the patient or, for minors, by a parent or legal guardian 2.4.2. Exclusion Criteria Participants were excluded if they met any of the following criteria: Seizures clearly attributable to acute symptomatic causes (e.g., hypoglycemia, acute intoxication, high fever without neurological involvement) with complete resolution and no recurrence risk Patients with an uncertain diagnosis of epilepsy Patients with severe cognitive impairment or altered consciousness preventing reliable data collection, in the absence of a caregiver Refusal or inability to provide informed consent Incomplete clinical records or insufficient information regarding care pathways after the first seizure 2.4.3. Sampling Consecutive sampling was used, with patients included according to the eligibility criteria until the desired sample size was reached. The minimum sample size was calculated using the Daniel Schwartz formula, with a desired statistical power of 95% and a precision set at 10%. Based on a study by Maïga Y et al. conducted in Mali [8], which reported that 63% of parents of children with epilepsy sought care from a traditional healer as the first line of treatment, the minimum required sample size was estimated at 89 PWE 2.5. Study Design We conducted a mixed method approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches. A mixed method was likely to allow a deeper and more nuanced understanding of the issue in the context of dual use of conventional and traditional medicine in Mali [19,20]. All patients living with clinically and electroencephalographically confirmed epilepsy who were consecutively followed in outpatient consultation in any of the two sites during the study period were included. Informed consent was required from patients or legal guardians before participating in the study. All included patients had complete medical records. Patient medical records included sociodemographic data, disease history, personal and family medical history (including a family history of epilepsy, consanguinity, pregnancy and childbirth context, infectious diseases, and head trauma), standard EEG findings, and neuroimaging data (CT and/or MRI). Biological investigations were guided by the clinical presentation and included complete blood count, blood glucose, renal function tests, serum electrolytes, liver function tests, inflammatory markers, HIV serology, hemoglobin electrophoresis, malaria testing, and, for selected patients, cerebrospinal fluid analysis. The compilation of medical records, clinical examination, and patient interviews allowed for syndromic and etiological classification in accordance with International League Against Epilepsy (ILAE) criteria [2,21–24]. This classification framework considers local realities, particularly the difficulty in investigating certain etiologies (inflammatory, metabolic, and genetic). Finally, we adopted the following etiological classification: (i) Infectious causes (cerebral malaria, meningitis, neuro-meningeal tuberculosis, HIV, neurocysticercosis, and other infectious diseases with cerebral complications); (ii) Structural causes (sequelae related to pregnancy and/or difficult childbirth, sequelae of head trauma, stroke, malformations, inflammatory lesions of the central nervous system, and other potentially epileptogenic lesions incidentally discovered on CT or MRI); (iii) Epilepsies occurring in the context of developmental encephalopathies; (iv) Well-defined idiopathic generalized epilepsy syndromes, including childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy; (v) Unknown causes, referring to patients with epilepsy in whom no specific cause or syndrome could be identified. For the qualitative component, we conducted interviews using an interview guide. For the quantitative component, adult PWE, as well as parents or guardians of minors or patients with limited cognitive capacity, were administered a questionnaire containing both closed- and open-ended questions. 2.6. Study Variables Sociodemographic characteristics, included age, sex, marital status, level of education, and occupation. Other variables included information on participants’ perceptions of epilepsy and healthcare-seeking pathways and therapeutic choices following the inaugural seizure. 2.7. Data Collection and Analysis Data were collected through direct and semi-structured interviews with patients or their legal guardians. An individual data collection form was used, after which the data were entered and cleaned using Microsoft Excel 2013 to identify and correct outliers and inconsistencies. Descriptive statistics, including percentages, means, and standard deviations, were calculated. The data were then imported to Stata (StataCorp, College Station, TX, 2015) for additional statistical analysis. Linear, for continuous variables, and logistic, for categorical variables, univariable and multivariable regressions were used for the analysis of factors associated with utilization of seeking care, respectively. Confidence intervals (CI) were set at 95%. The factors found to be statistically significant in the univariable regressions were then used in the multivariable regression. 2.8. Ethical Considerations This study was conducted in accordance with the principles of the Declaration of Helsinki. Authorization to collect data was obtained from the administrative authorities of Polyclinique Pasteur and the Dinandougou Medical Clinic in Markacoungo. All participants provided free and informed consent. Patients and their parents or guardians were informed that declining participation would in no way affect the quality of care they received. Interviews were conducted in quiet, private settings. Participant anonymity and confidentiality were fully ensured, and no identifying information was collected. The data were used exclusively for scientific purposes. Our protocol received approval from the ethics committee of the Faculty of Medicine, Pharmacy, and OdontoStomatology (FMOS) of Bamako under the number 2024/45/CE/USTTB. 3. Results A total of 87 patients met the inclusion criteria and completed the interview. The mean age of the participants was 20 ± 14 years, and the majority were male (50/87; 57%). Most participants were Muslim (83/87; 95%), with notable diversity in ethnic background and geographic origin. Detailed sociodemographic characteristics are presented in Table 1 . Table 1 Demographics of included patients Total patients 87 Age (years), Mean ± SD 20 ± 14 Sex n (%) Female 37 (43%) Male 50 (57%) Religion Christian 4 (5%) Muslim 83 (95%) Region Bamako 36 (41%) Koulikoro 28 (32%) Kayes 3 (3%) Kita 2 (2%) Markacoungo 2 (2%) Mopti 4 (5%) Ségou 6 (7%) Sikasso 6 (7%) Education Level No schooling 35 (40%) Koranic School 15 (17%) Primary 21 (24%) Secondary 9 (10%) Higher Education 7 (8%) Marital Status Single 27 (31%) Child 33 (38%) Married 22 (25%) Widow 3 (3%) Divorced 2 (2%) All patients underwent at least one standard awake EEG, and the majority (78/87, 90%) had more than two recordings performed at different stages of follow-up. Regarding imaging, 71 of the 87 (82%) patients underwent a head CT scan, and 12 of these also received an additional brain MRI.Etiological classification revealed that: (1) structural causes were identified in 25/87 patients (29%), predominantly involving children with sequelae of complicated childbirth and head trauma; this group also included five cases of vascular epilepsy related to sickle cell disease; (2) infectious causes were found in 23/87 patients (26%), with cerebral malaria sequelae being the most frequent, along with two cases of neurocysticercosis; (3) epileptic encephalopathies accounted for 11/87 patients (12%); (4) idiopathic generalized epilepsies were observed in 7/87 patients (8%); and (5) epilepsy of unknown etiology was noted in 21/87 patients (24%). Table 2 summarizes the syndromic and etiological distribution. Table 2 Etiology and Syndromes Etiologies Frequency (n = 87) Percentage (% Structural causes 25 29 Sequelaie of childbirth 9 36 Head trauma 7 28 Vascular epilepsy 5 20 Other structural causes 4 16 Infectious causes 23 26 Sequelae of cerebral malaria 11 48 Sequelae of meningitis 6 26 Neurocysticercosis 2 9 Other infections 4 17 Neurodevelopmental disorders 11 13 Cerebral palsy 5 45 Autism spectrum disorder 4 36 Attention deficit disorder with or without hyperactivity 2 18 Idiopathic generalized epilepsy 7 8 Absence epilepsy 4 57 Myoclonic epilepsy 3 43 Epilepsy of unknown etiology 21 24 Most participants perceived epilepsy as a brain disorder (75/87, 86%), considered it more serious than other diseases (54/87, 62%), and believed it to be curable (84/87, 97%) through medical therapy (75/87, 86%) (Table 3 ). Table 3 Participants' perceptions of epilepsy Perceptions and Beliefs n (%) Survey information source Parent 50 (57%) Patient 37 (43%) What do you think about epilepsy? Disorder of the brain 75 (86%) Natural disorder 7 (8%) Witchcraft 5 (6%) For you, is this an illness like any other? No 66 (76%) It's a less serious disease 12 (18%) It's a more serious disease 54 (82%) Yes 21 (24%) Is this a curable disease? No 2 (2%) The treatment calms the disease 2 (100%) Yes 84 (97%) No opinion 1 (1%) What is the appropriate treatment? Medical 75 (86%) Traditional 2 (2%) Mixed 10 (11%) Regarding the first seizure, the age of onset was most commonly between 10 and 19 years (36%), and 78% of patients experienced their first onset before the age of 30. Tonic-clonic seizures were the most common phenotype, occurring in 66% of patients (Table 4 ). Table 4 Participants’ characteristics of the first seizure Total patients 87 Age at first attack (year) n (%) 1 to 9 19 (22%) 10–19 31 (36%) 20 to 29 17 (20%) 30 to 39 11 (13%) 40 to 49 4 (5%) 50 to 60 3 (3%) More than 60 2 (2%) First seizure type Tonic-clonic 57 (66%) Clonic 8 (9%) Tonic 7 (8%) Absence 3 (3%) Other 12 (14%) The majority (93%) of patients who sought care after their first seizure did so immediately (Table 5 ). Beyond the first consultation, 62/87 (71%) also pursued a second consultation. For the initial consultation, there was a near-even split between those seeking a doctor (48%) and those seeking a traditional practitioner (49%). However, a significant shift occurred for the second consultation, as all patients (62/62, 100%) consulted a physician. Most participants chose their provider based on reputation ("had heard about them"), both for the first (62%) and second (81%) consultations. Table 5 Characteristics of the first and second consultations for seizure Characteristics First Consultation Second Consultation Healthcare Provider, n (%) Total Patients 87 62 Did you consult anyone after the first attack? n (%) n (%) Yes 81 (93%) -- Immediately 81 (100%) -- No 6 (7%) -- It was not serious 6 (100%) -- Have you consulted another person(s)? Yes 62 (71%) -- No 25 (29%) -- Who was your consultation with? Doctor 42 (48%) 62 (100%) Pastor 2 (2%) 0 (0%) Traditional practitioner 43 (49%) 0 (0%) What was the reason for this choice? We told you about them 54 (62%) 50 (81%) You had confidence in them 22 (25%) 8 (13%) You knew them by reputation 6 (7%) 4 (6%) You didn't know who to see 5 (6%) 0 (0%) Where was the consultation place located? Village 56 (64%) 38 (61%) City 31 (36%) 23 (37%) Other region 0 (0%) 1 (2%) What did the person you consulted tell you about what was happening to you? Severity Severe 53 (61%) 3 (5%) Very Severe 12 (14%) 0 (0%) Nothing 22 (25%) 59 (95%) Contagious? Yes (by saliva) 1 (1%) 0 (0%) No 38 (44%) 62 (100%) Nothing 48 (55%) 0 (0%) Curability Curable 61 (70%) 0 (0%) Slow to cure 26 (30%) 61 (98%) Rapdly curable 0 (0%) 1 (2%) How did they suggest to treat your seizures? Plants 42 (48%) 0 (0%) Medications 42 (48%) 62 (100%) Prayers 3 (3%) 0 (0%) When will you use these treatments? Outside of the seizures 85 (98%) 62 (100%) During the seizures 2 (2%) 0 (0%) Pre- and post-consultation thoughts Before the consultation, did you think that this (these) other person(s) I thought they could cure me 25 (29%) 14 (23%) I thought they could help me 1 (1%) 2 (3%) I thought they couldn't do much 4 (5%) 0 (0%) No opinion 57 (66%) 46 (74%) Before this other consultation, how did you think you could be cured? Plants 7 (8%) 2 (3%) Medications 16 (18%) 9 (15%) No opinion 61 (70%) 51 (82%) After consultation, do you estimate the necessary means probably? Very expensive 16 (18%) 23 (37%) Reasonable 26 (30%) 37 (60%) Cheap 41 (47%) 2 (3%) No opinion 4 (5%) 0 (0%) Initial treatment suggestions were evenly divided between herbal remedies and conventional medications (48% each) but shifted exclusively to medications (100%) during second consultations. Perceptions of curability also changed: while the first consultant often suggested the disease was quickly curable (70%), second consultants (physicians) overwhelmingly described it as "slow to cure" (98%). Similarly, the perception of cost increased significantly; the proportion of patients who viewed treatment as "cheap" dropped from 47% at the first consultation to only 3% at the second, with reciprocal increases in the "reasonable" (30% to 60%) and "very expensive" (18% to 37%) categories. To evaluate the factors associated with the choice of care, we performed a regression analysis (Table 6 ). In the univariable model, male sex (OR 2.55; 95% CI 1.06–6.13, p = 0.037), primary schooling (OR 4.0; 95% CI 1.29–12.78, p = 0.017), and higher education (OR 15.00; 95% CI 1.60–140.96, p = 0.018) were associated with a higher likelihood of consulting a physician. Conversely, residing in the Koulikoro (OR 0.15; p = 0.001) or Sikasso (OR 0.09; p = 0.018) regions was associated with a significantly lower likelihood. These factors remained independent predictor s in the multivariable model, maintaining their respective associations with the choice of healthcare provider. Table 6 Univariable and multivariable regression results for factors affecting the utilization of physicians for initial consultation after the first seizure. Univariable Multivariable Coefficient p-value Coefficient p-value Age 0.0061 (-0.02 to 0.036) 0.689 OR (95% CI) p-value OR (95% CI) p-value Sex Female Ref Ref Male 2.55 (1.06 to 6.13) 0.037 3.89 (1.15 to 13.17) 0.029 Religion Christian Ref Muslim 0.30 (0.03 to 2.96) 0.3 Region Bamako Ref Ref Kayes 0.22 (0.02 to 2.69) 0.236 0.08 (0.004 to 1.68) 0.105 Koulikoro 0.15 (0.05 to 0.45) 0.001 0.13 (0.035 to 0.47) 0.002 Marka coungo 0.44 (0.03 to 7.70) 0.574 2.18 (0.11 to 44.85) 0.614 Mopti 0.44 (0.05 to 3.54) 0.44 0.21 (0.02 to 2.35) 0.208 Ségou 2.2 (0.23 to 21.1) 0.494 2.95 (0.25 to 34.52) 0.389 Sikasso 0.09 (0.01 to 0.84) 0.035 0.07 (0.01 to 0.86) 0.038 Kita N/A Schooling No schooling Ref Ref Koranic School 2.86 (0.82 to 10.0) 0.1 3.02 (0.61 to 14.99) 0.175 Primary 4.06 (1.29 to 12.78) 0.017 4.84 (1.19 to 19.62) 0.027 Secondary 3.13 (0.59 to 14.08) 0.138 1.70 (0.27 to 10.60) 0.57 Higher Education 15.00 (1.60 to 140.96) 0.018 33.47 (2.00 to 561.0) 0.015 Marital Status Single Ref Divorced 1.25 (0.07 to 22.13) 0.879 -- -- Child 1.5 (0.54 to 4.17) 0.437 -- -- Married 0.87 (0.28 to 2.70) 0.804 -- -- Widow 2.50 (0.20 to 31.00) 0.476 -- -- What do you think about epilepsy? Disorder of the brain Ref Natural disorder 6.86 (0.79 to 59.76) 0.081 -- -- Witchcraft 0.29 (0.03 to 2.68) 0.273 -- -- For you, is this an illness like any other? No Ref -- -- Yes 0.58 (0.21 to 1.58) 0.287 -- -- Is this a curable disease? No Ref Yes 0.95 (0.06 to 15.8) 0.973 What is the appropriate treatment? Medical Ref Traditional N/A Mixed 4.82 (0.960 to 24.2) 0.056 Regarding ongoing care, 97% of patients who sought a second consultation found it more helpful than the first. Patients reported an average of 1.9 ± 0.6 consultations over the past six months. Carbamazepine was the most frequently prescribed anti-seizure medication (51%). Reassuringly, 85% of patients achieved seizure freedom with treatment 4. Discussion Epilepsy research in sub-Saharan Africa (SSA) has largely focused on epidemiological aspects and sociocultural representations, often to the detriment of therapeutic considerations. To our knowledge, this study is among the few to rigorously analyze the determinants of healthcare-seeking behavior and therapeutic choices following a first epileptic seizure. The therapeutic pathway of people living with epilepsy (PWE) in SSA, especially in Mali, is complex and shaped sociocultural, anthropological, and economic factors [25]. It is estimated that only about 20% of PWE in SSA receive appropriate anti-seizure medications [26]. This treatment gap is largely inherent to the healthcare systems in Africa which dually utilizes conventional medicine (CM) and traditional medicine (TM). In most African settings, TM is the first point of care for PWE [27]. However, despite this, existing data do not fully capture all the factors influencing the choice of therapeutic pathways toward TM versus CM. Our work directly addresses this key question of which type of practitioner is sought following an inaugural epileptic seizure. All included patients were had complete documentation and had a confirmed diagnosis of epilepsy, thereby reducing bias and strengthening our study as complementary diagnostic investigations in SSA are often limited but lack of records and vetted diagnoses. [28]. An original methodological approach Considering the complexity of studying human behavior, we opted for an original mixed-methods approach that combines classical qualitative and quantitative methods with constructivist perspectives. To explore the behavior of PWE and their relatives when faced with the choice of therapeutic pathway after an inaugural epileptic seizure, this mixed approach appeared particularly well-suited. Our aim to understand population behavior in the context of de novo epilepsy within a complex environment where TM and CM coexist, led us to consider this mixed approach as the most appropriate, consistent with previous work [29]. Such approaches are recommended when situations are complex and poorly documented, as is the case previously for our studied scenario. Our work also draws inspiration from several studies that have adopted similar methodological frameworks to investigate behavior and attitudes in the management of PWE [30,31]. Implications for our understanding of illness From both anthropological and medical perspectives, explanatory models of disease in SSA differ from those in Western societies. In many African communities, illness is not perceived solely as the result of natural causes but may also be attributed to supernatural forces. Treatment is therefore bidirectional, addressing the organic disorder through plant-based remedies while simultaneously restoring balance among vital forces through prayers and rituals. Within this explanatory framework, CM is often disqualified [17]. In this context, available data suggest that an epilepsy diagnosis in Africa is frequently delayed or inaccurate, exposing individuals to recurrent seizures with significant consequences. Factors contributing to delayed diagnosis include late recognition of seizure symptoms by patients, parents, and witnesses, cultural, geographic, and financial barriers to accessing healthcare, as well as lack of accurate and timely diagnoses by non-specialist healthcare providers [32]. This African reality contrasts sharply with the situation in Western countries, where recent technological advances, such as smartphone video recordings, genetic testing, advances in electrophysiology, and artificial intelligence, have improved diagnostic algorithms for epilepsy and, consequently, care for patients with epilepsy [33,34]. Unfortunately, these diagnostic and therapeutic technological advances have yet to benefit patients in LMIC, particularly those living in rural areas of Africa, where an epilepsy diagnosis remains problematic for most patients who remain outside the conventional healthcare system [35]. Sociodemographic and clinical characteristics of the study population This cohort showed a slight male predominance. In the context, this overrepresentation may be partly due to the underreporting of epilepsy among women [36]. For this study, we adopted a classification that aligns with ILAE standards while also accounting for our limited ability to investigate certain etiologies due to constraints in technical capacity, particularly in genetics, immunology, and metabolism. Similarly, we isolated the group of idiopathic generalized epilepsies (IGEs), which are clinically and electrographically accessible, as identifying these syndromes carries important prognostic and therapeutic implications [22]. Symptomatic epilepsies are the predominant causes Structural causes were the most common etiologies in this cohort, accounting for 28.73% (25/87). In this group, epilepsy was most often caused by sequelae of complicated childbirth. In SSA, perinatal causes are estimated to account for between 2% and 65% of epilepsy cases [37]. Birth trauma, often resulting from complicated pregnancies or deliveries, can lead to epilepsy, with hypoxia and hypoglycemia frequently cited as underlying mechanisms of neonatal distress [37]. Traditional beliefs and long distances to maternity facilities often result in home deliveries without medical assistance [38]. A case–control study demonstrated a strong association (OR 10.2, 95% CI 1.1–93.4) between adverse perinatal events and epilepsy [39]. This situation suggests that most childhood epilepsies in SSA could be preventable through improved prenatal and perinatal care [40,41]. In addition to childbirth-related sequelae, this study included five cases of vascular epilepsy related to sickle cell disease (SCD). This hemoglobinopathy is the most common monogenic disorder worldwide, with most affected individuals living in SSA [42]. Current data indicate that epilepsy is two to three times more frequent among people with SCD than in the general population, with higher mortality across all genotypes [43,44]. These findings confirm the importance of this widespread genetic condition in SSA in general and in Mali in particular, where consanguineous marriages are common. It is therefore essential to integrate messages about SCD into epilepsy awareness and control campaigns in SSA. Infectious causes remain significant In this cohort, epilepsy was attributed to infectious causes in 26.43% (23/87). In SSA, infections of the nervous system, parasitic, viral, and bacterial, are suspected to be responsible for epilepsy in approximately 9% to 26% of cases, with cerebral malaria being the most common cause [45,46]. Febrile seizures associated with cerebral malaria are described as severe and recurrent among African children and have been implicated as a cause of epilepsy in up to 71% of epileptic children in Tanzania [47]. Studies conducted in Mali and Kenya further support a strong association between cerebral malaria and epilepsy [48,49]. One notable and somewhat unusual finding in our cohort was the low prevalence of neurocysticercosis, which is commonly described as a frequent cause of epilepsy in SSA [50]. In Mali, this can be explained by dietary habits, as pork consumption is uncommon due to the predominance of Islam, practiced by more than 90% of the population [51]. Overall, these findings support previous data on factors associated with epilepsy in Mali. A recent case-control study involving 1,506 epilepsy cases across six health districts in Mali identified a history of cerebral malaria, meningitis, and dystocic childbirth as key risk factors for epilepsy in the country [52]. Characteristics and level of healthcare utilization after the first seizure Among the participants, the age at onset of the first seizure was most commonly between 10 and 19 years (36%), and 78% of patients experienced their first seizure before the age of 30. This corroborates existing literature, as most studies report an early onset of epilepsy in SSA, with more than 60% of cases beginning before the age of 20 [53]. Regarding healthcare utilization, patients were almost evenly divided between those who consulted a physician in a conventional healthcare facility (48%) and those who consulted a traditional practitioner (49%) ( Fig. 1 ). The photograph shows a traditional amulet ("gris-gris") and medicinal substances on the scalp of a 27-year-old patient. This illustrates the therapeutic duality and sequential healthcare-seeking pathways (traditional medicine as first-line) frequently observed in the Malian epilepsy cohort. It is noteworthy that this tendency toward TM appears to be shifting in favor of CM. A decade earlier, a pediatric study on the attitudes and behaviors of families of children with epilepsy reported that 63% of parents initially sought care from a traditional healer [8]. Our study, in line with the literature, confirms the strategic position of traditional medicine in the management of neurological disorders in general and epilepsy in particular [17,53]. In neighboring Guinea, which shares similar sociocultural realities with Mali, a study showed that 79% of patients with epilepsy first consulted a traditional healer before turning to conventional medicine [17]. What determines the choice of the first point of care? The high cost of medications in CM emerges as a major barrier, particularly in rural areas where PWE are often poor and vulnerable. Similar findings have been previously reported by other authors [64]. Improving the availability and accessibility of anti-seizure medications could help reduce this obstacle. Some authors advocate for strengthening epilepsy care services in rural areas, with an emphasis on regular, uninterrupted, and free provision of anti-seizure medications [54]. Beyond cost, the relatively long-term nature of the treatment in CM also represents a barrier, as African cultural beliefs often do not incorporate the concept of prolonged therapy [17]. The multivariable analysis showed that male sex and having received formal education were associated with robust and significantly higher odds of consulting a physician. The influence of male sex likely reflects sociocultural and economic considerations, as poverty may lead some families to prioritize boys over girls. This finding may also be explained by underreporting of epilepsy among girls at the age of marriage, a phenomenon documented in the literature [55]. The positive influence of education on choosing CM over TM is also well described in Africa and other LMIC [56–58]. Conversely, this study shows that living in remote areas away from major urban centers is associated with a significantly lower likelihood of consulting a physician. These results are consistent with a study from Kenya involving 673 PWE, which found that living more than 30 km from healthcare facilities, high costs of anti-epileptic drugs, and low education levels were associated with lower utilization of conventional medical care [59]. How to shift the trend in favor of conventional medicine ? The position of TM as the first point of care for PWE in SSA is widely reported [8,16,60,61]. This tendency delays the initiation of anti-seizure medications and negatively affects the natural course of the disease [17,62]. It is therefore crucial to reverse this trend in favor of CM, particularly in cases of de novo epilepsy. Based on our findings and existing literature, we propose several strategies to promote favorable behavioral change. (1) Improve access to healthcare facilities, especially in rural areas In SSA, reliance on TM is largely due to the shortage of physicians in general and neurologists in particular. Data on neurology services in SSA show that 35 of the 53 African countries have few or no trained neurologists [63]. This shortage is compounded by the scarcity of neurology units outside urban areas. Moreover, the limited number of neurologists in major cities often divides their time between teaching at medical schools and private practice. As a result, patients living outside large cities must travel long distances to consult a neurologist [64,65]. Addressing this deficit requires urgent strategies to strengthen medical coverage in rural areas. Given the socioeconomic constraints of many African countries, alternative approaches are needed, including training frontline healthcare workers in epilepsy management. In line with this strategy, we conducted a study to assess the performance of community health workers (CHWs) trained in epilepsy case management in community health centers across six health districts in Mali. This work demonstrated that providing clear, concise clinical guidelines to CHWs, non-physician frontline providers, significantly improved epilepsy care, leading to better diagnosis and treatment of PWE [66]. We believe that this approach should be widely promoted and implemented across low-income countries in Africa. (2) Promote collaboration between traditional medicines Epilepsy control campaigns in SSA should take inspiration from successful models proven from other disease areas. In Gambia and Tanzania, trained and supervised traditional healers have contributed to tuberculosis and HIV control efforts by participating in screening and referring patients to conventional healthcare facilities [67]. In this model, trained traditional practitioners can provide psychosocial support and, crucially, facilitate patient referral to CM facilities staffed by qualified neurologists [68]. In Cameroon, this approach has proven essential for improving epilepsy treatment [69]. These ideas are already being implemented in Burkina Faso, where a study found that 69.5% of patients with epilepsy reported using TM alongside CM during their therapeutic journey [70]. Formalizing this relationship represents the next logical step toward shifting care-seeking behavior in favor of CM and ensuring better epilepsy management. Strengths and limitations of the study This study aimed to analyze the determinants of therapeutic choice following an initial epileptic seizure in Mali, which inherently involves examining the behavior and attitudes of PWE and their families within a complex environment where TM and CM coexist. A key limitation is the retrospective nature of the data, relying on patient and caregiver recall, which is potentially subject to recall bias or voluntary and involuntary modifications of narratives. It is well understood that one of the greatest challenges in behavioral research is that human subjects are aware of being studied and may consciously or unconsciously alter their responses; this must be considered when interpreting these findings. To tackle these potential limitations, we adopted a methodological approach tailored to complex situations. Within this mixed-methods framework, the objective was not to identify the “right” decision made by patients, but rather to understand the factors and the internal logic that guided their choices. Another important limitation is the relatively small sample size (n = 87), which may limit the statistical power of our quantitative analysis. Furthermore, we did not exhaustively examine the influence of broader societal factors, such as family dynamics, ethnicity, social status, and specific customs, on treatment choices. Further studies with larger cohorts will be needed to explore these aspects, as they might have a significant level of influence on patient choices. We also recognize a potential selection bias, as our study population included patients who voluntarily visited our two healthcare facilities. Those who never accessed these centers and services were not part of the study and may display different behaviors, which could limit the generalizability of our findings. Nonetheless, our data offer valuable insights that can help develop programs, such as the Universal Health Insurance Plan (RAMU), to reduce the burden of epilepsy in sub-Saharan Africa. Finally, the lack of validated questionnaires designed for such complex environments was a challenge, as using standardized instruments would have improved the validity of the data collected. However, we believe this limitation was partly offset by the development of a context-specific questionnaire and, most importantly, by our mixed-methods approach, which increased the overall robustness of the study Conclusion The diagnosis and treatment of epilepsy remain major public health challenges in sub-Saharan Africa, particularly in Mali. This study highlights the central role of traditional medicine as a primary therapeutic option following an inaugural seizure, often favored due to the high cost of medication and, significantly, the challenges surrounding the accessibility and availability of conventional healthcare facilities. In this context, the implementation of the Universal Health Insurance Plan (RAMU) is essential to mitigate the prohibitive cost of anti-seizure medications and ensure financial accessibility for the most vulnerable populations. Researchers and policymakers must implement innovative strategies aimed at: (1) improving access to healthcare facilities, especially in rural areas; (2) promoting collaboration between traditional and conventional medicines; and (3) developing information and education campaigns to foster positive behavioral changes. Our work represents an initial step toward adapting epilepsy care to local sociocultural and economic realities—a prerequisite for reducing the burden of this pathology in Mali and throughout sub-Saharan Africa. Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Authorization to collect data was obtained from the administrative authorities of Polyclinique Pasteur and the Dinandougou Medical Clinic in Markacoungo. All participants provided free and informed consent. Patients and their parents or guardians were informed that declining participation would in no way affect the quality of care they received. Interviews were conducted in quiet, private settings. Participant anonymity and confidentiality were fully ensured, and no identifying information was collected. Written or verbal informed consent was obtained from all adult participants and from parents or legal guardians for participants under the age of 18. The data were used exclusively for scientific purposes. Our protocol received approval from the ethics committee of the Faculty of Medicine, Pharmacy, and OdontoStomatology (FMOS) of Bamako under the number 2024/45/CE/USTTB. Clinical trial number Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and the accompanying image (Figure 1). Although the patient’s face is not visible, she was informed that complete anonymity cannot be guaranteed. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions related to patient medical records but are available from the corresponding author [Prof. Dr Youssoufa MAIGA] on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions Conceptualization: Youssoufa MAIGA. Data curation: Youssoufa Maiga, Salimata Diallo, Awa Coulibaly, Ibrahim Nimaga , Seybou H Diallo; Moussa Doumba; Cheick Oumar Tounkara; Souleymane dit Papa Coulibaly, Bakary Danthioko; Investigation: Youssoufa Maiga, Seybou H Diallo, Salimata Diallo, Awa Coulibaly, Mariam Daou, Adama Sissoko, Mohamed Albakaye, Zoumana Traoré, Souleymane dit papa Coulibaly ; Methodology: Youssoufa MAIGA; Leon Samuel Moskatel, Abou Sogodogo; Abdoulaye Yalcoué, Modibo Sangaré; Analysis: Youssoufa MAIGA, Leon Samuel Moskatel, Modibo Sangaré; Abou Sogodogo; Supervision: Youssoufa MAIGA, Julien Nizard, Robert Cowan; Writing – original draft: Youssoufa MAIGA; Writing – review & editing : Youssoufa MAIGA, Leon Samuel Moskatel, Modibo Sangaré. Acknowledgements The authors would like to thank the staff of Polyclinique Pasteur and Dinandougou Medical Clinic, as well as all the patients and their families who participated in this study. References Falco-Walter J. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8958943","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":616828568,"identity":"b329c703-4c4e-47d8-b976-95680b570161","order_by":0,"name":"Youssoufa 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Bamako","correspondingAuthor":false,"prefix":"","firstName":"Abdoulaye","middleName":"","lastName":"Yalcoué","suffix":""},{"id":616828575,"identity":"bf88f7f8-6e49-4ab8-848b-3fa068a9ce58","order_by":5,"name":"Cheick Oumar Tounkara","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cheick","middleName":"Oumar","lastName":"Tounkara","suffix":""},{"id":616828576,"identity":"f91fdf76-dd07-4a1e-960d-5acca013757e","order_by":6,"name":"Salimata Diallo","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Salimata","middleName":"","lastName":"Diallo","suffix":""},{"id":616828577,"identity":"a2510898-16f0-46de-903a-162f2814ab45","order_by":7,"name":"Awa Coulibaly","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Awa","middleName":"","lastName":"Coulibaly","suffix":""},{"id":616828578,"identity":"7f355896-a819-4cd4-a771-46d28853070c","order_by":8,"name":"Mariam Daou","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mariam","middleName":"","lastName":"Daou","suffix":""},{"id":616828579,"identity":"98b67a06-45ce-466b-b3b1-032c072fce90","order_by":9,"name":"Bakary Danthioko","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bakary","middleName":"","lastName":"Danthioko","suffix":""},{"id":616828580,"identity":"abbb61af-1d6f-497a-a848-7f45a81a53f6","order_by":10,"name":"Moussa Doumbia","email":"","orcid":"","institution":"Medical Clinic “Dinandougou”","correspondingAuthor":false,"prefix":"","firstName":"Moussa","middleName":"","lastName":"Doumbia","suffix":""},{"id":616828582,"identity":"296dd653-d65c-4145-9a36-a1591d7d0df4","order_by":11,"name":"Ibrahim Nimaga","email":"","orcid":"","institution":"Medical Clinic “Dinandougou”","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Nimaga","suffix":""},{"id":616828584,"identity":"ad0793f6-3e94-437c-a77f-55a64304dce5","order_by":12,"name":"Adama Sissoko","email":"","orcid":"","institution":"University of Sciences, Techniques and Technologies of Bamako","correspondingAuthor":false,"prefix":"","firstName":"Adama","middleName":"","lastName":"Sissoko","suffix":""},{"id":616828589,"identity":"b621058d-5763-43e2-98b1-bd724b1e53ff","order_by":13,"name":"Souleymane Papa Coulibaly","email":"","orcid":"","institution":"Faculty of Medicine and Odontostomatology (FMOS)","correspondingAuthor":false,"prefix":"","firstName":"Souleymane","middleName":"Papa","lastName":"Coulibaly","suffix":""},{"id":616828590,"identity":"2565ade0-053f-4f05-b292-746149e22d43","order_by":14,"name":"Mohamed Albakaye","email":"","orcid":"","institution":"Gabriel Toure Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Albakaye","suffix":""},{"id":616828591,"identity":"bc568049-5c04-4a8c-86fb-045ea2fe1670","order_by":15,"name":"Zoumana Traoré","email":"","orcid":"","institution":"Neuroscience and Medical Genetics Research and Training Center","correspondingAuthor":false,"prefix":"","firstName":"Zoumana","middleName":"","lastName":"Traoré","suffix":""},{"id":616828592,"identity":"276a50d3-3c9f-4bb1-9ba3-1f963a863d89","order_by":16,"name":"Julien Nizard","email":"","orcid":"","institution":"University of Nantes","correspondingAuthor":false,"prefix":"","firstName":"Julien","middleName":"","lastName":"Nizard","suffix":""},{"id":616828593,"identity":"3c1995be-eab1-48a2-9ffe-7f91810eef00","order_by":17,"name":"Robert Cowan","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Cowan","suffix":""}],"badges":[],"createdAt":"2026-02-24 15:09:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8958943/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8958943/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106189868,"identity":"b30c3b40-2f9e-4106-aede-e553c5ba8f0d","added_by":"auto","created_at":"2026-04-05 17:11:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":695919,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical evidence of medical pluralism during an EEG recording.\u003cbr\u003e\nThe photograph shows a traditional amulet (\"gris-gris\") and medicinal substances on the scalp of a 27-year-old patient. This illustrates the therapeutic duality and sequential healthcare-seeking pathways (traditional medicine as first-line) frequently observed in the Malian epilepsy cohort.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8958943/v1/d87615881c3235199e7a7a1f.png"},{"id":106405892,"identity":"478c19ab-117b-4ba8-8221-a5dfcf8d077f","added_by":"auto","created_at":"2026-04-08 09:28:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3161034,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8958943/v1/4184adaa-3549-4562-87c8-5708aadeeec7.pdf"},{"id":106402857,"identity":"558dd4fd-c3da-4332-adfc-cd44f938550e","added_by":"auto","created_at":"2026-04-08 09:13:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26463,"visible":true,"origin":"","legend":"","description":"","filename":"DatadictionaryANGYM.docx","url":"https://assets-eu.researchsquare.com/files/rs-8958943/v1/7b30a6cf2c31240fa1c67126.docx"},{"id":106189870,"identity":"9909bc87-3216-4f6c-92e8-ec48507ec105","added_by":"auto","created_at":"2026-04-05 17:11:36","extension":"xls","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":80896,"visible":true,"origin":"","legend":"","description":"","filename":"DataBase.xls","url":"https://assets-eu.researchsquare.com/files/rs-8958943/v1/5eeab8b3f9858ebda9a9d77b.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilization and Therapeutic Choices after a First Seizure: A Mixed- Methods Analysis of Determinants in a Malian Cohort","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEpileptic seizures affect approximately 10% of the population, ultimately leading to epilepsy in 1\u0026ndash;2% of people worldwide [1]. In 2021, about 51.7\u0026nbsp;million people were living with epilepsy (PWE), 80% of whom lived in low- and middle-income countries (LMIC), where significant treatment gaps have emerged [2,3]. In these regions, it is estimated that only one in four people with epilepsy has access to appropriate care [3]. The World Health Organization (WHO) has declared epilepsy a public health imperative and developed the Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders 2022\u0026ndash;2031, adopted by the World Health Assembly in May 2022 [4,5]. In Mali, the prevalence of epilepsy is estimated at 15.6 per 1,000 in rural areas and 14.6 per 1,000 in urban settings [6].\u003c/p\u003e \u003cp\u003eMany factors, particularly in rural areas, render the management of epilepsy challenging in Sub-Saharan Africa, including shortages of qualified healthcare personnel and limited access to diagnostic resources. In addition, lack of acceptance of the disease, poor adherence to treatment by patients and their families due to deeply held beliefs, the high cost of medications, their relative unavailability, and the lack of universal health coverage mechanisms all contribute to suboptimal care for PWE [7]. Beliefs, perceptions, and fears also vary from one country to another and influence individual and collective strategies regarding healthcare-seeking behavior [8\u0026ndash;11]. Epilepsy can also be associated with significant stigma, prejudice, and discriminatory practices that negatively affect daily life and hinder evidence-based diagnosis and management [12,13]. These factors may partly explain the higher prevalence of active epilepsy and lifetime epilepsy observed in developing countries overall, and in SSA in particular [14]. This is especially important as epilepsy is one of the few severe and disabling neurological diseases that can be effectively managed with low-cost interventions.\u003c/p\u003e \u003cp\u003eIn this context, utilization of traditional medicine (TM) is high, as it remains the first line of care for many PWE in SSA [15]. For example, in Guinea (West Africa), the average duration of care with a traditional healer before consulting conventional medicine (CM) was reported to be 39 months, a period during which patients were not receiving effective anti-seizure medications [16]. While the treatment gap for established epilepsy is well-documented, the specific period immediately following the first seizure is a critical window that often dictates the long-term therapeutic trajectory.\u003c/p\u003e \u003cp\u003eWithin Africa more broadly, this practice resembles the subtle competition between traditional and conventional medicine in the management of neurological disorders, particularly epilepsy [17]. Careful assessment of the underlying factors that motivate people with epilepsy to seek traditional medicine immediately after an inaugural seizure becomes crucial, as optimal management of this initial phase can greatly affect disease outcomes. Furthermore, analyzing the determinants and sociodemographic parameters of healthcare-seeking behavior will best inform effective epilepsy control programs tailored to local beliefs and practices. This study aimed to examine the determinants of healthcare utilization and therapeutic choices following a first epileptic seizure in Mali using a mixed-methods approach.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e \u003cb\u003eStudy Hypotheses\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study focused on analyzing human behavior, specifically, the choice of healthcare pathway in the event of an unusual and critical situation, such as an inaugural epileptic seizure, within a complex environment marked by the coexistence of conventional medicine (CM) and traditional medicine (TM). We hypothesized that a mixed-methods approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches, would allow a deeper and more nuanced understanding of the issue [19,20].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Conventional healthcare system in Mali\u003c/h2\u003e \u003cp\u003eThe health system in Mali is organized in a pyramidal structure, reflecting a hierarchical model of service delivery. At the base of the pyramid are the community and primary healthcare facilities, including health posts and community health centers, which provide basic preventive and curative services, maternal and child health care, and health education. The intermediate level comprises district and regional hospitals, which offer more specialized care, laboratory services, and management of complex cases referred from primary facilities. At the top of the pyramid are the national referral hospitals and specialized centers, responsible for advanced diagnostics, specialized treatments, research, and training of healthcare professionals. This structure is intended to ensure progressive access to care, with patients ideally moving from lower to higher levels of care based on the complexity of their health needs. However, disparities in infrastructure, workforce distribution, and accessibility often challenge the optimal functioning of this pyramidal system in Mali.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy Sites\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study Sites\u003c/h2\u003e \u003cp\u003eThis was a cohort study conducted among outpatients followed up at two referral centers for the management of people with epilepsy in Mali. Importantly, the two health centers work in close collaboration within an urban-rural healthcare network. All patients had a unique identification number to avoid registering the same patient at both sites, given the porosity between the two structures.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1. Study Site 1: Polyclinique Pasteur\u003c/h2\u003e \u003cp\u003eIt is an urban health facility at the intermediate level in the health pyramid located in Bamako, the capital city of Mali. It benefits from the full range of resources available in a major African city. It employs several neurologists with formal training in epileptology. In terms of technical facilities, it is equipped with an EEG system, a 16-slice computed tomography (CT) scanner, and a 1.5 Tesla magnetic resonance imaging (MRI) unit. The medical biology laboratory is relatively well-equipped.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2. Study Site 2: Dinandougou Medical Clinic\u003c/h2\u003e \u003cp\u003eIt is a rural health facility at the intermediate level in the health pyramid located in Markacoungo, 85 km from Bamako. The rural clinic was selected because of its strong involvement and recognized expertise in the management of PWE in Mali. It has served as the site for several epilepsy-related research projects in the country [19\u0026ndash;22] and is also identified by the Faculty of Medicine and Odonto-Stomatology of Bamako as a training site for students undertaking rural medical practice. Furthermore, it is one of the few rural facilities equipped with an electroencephalography (EEG) machine capable of performing standard wakefulness and sleep EEG recordings.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Study Period\u003c/h2\u003e \u003cp\u003eThe study followed a sequential exploratory mixed-methods design, implemented in two distinct phases:\u003c/p\u003e \u003cp\u003e \u003cb\u003eQualitative Phase\u003c/b\u003e (August 1st \u0026ndash; November 23, 2023): We conducted semi-structured interviews to explore healthcare pathways and the underlying logic of therapeutic choices (traditional vs. biomedical) within the population.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConstructive Step\u003c/strong\u003e \u003cp\u003eThe thematic analysis of these qualitative findings served as a conceptual framework for developing the quantitative survey instrument. This step ensured that the variables were culturally adapted and grounded in the patients' lived experiences.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eQuantitative Phase\u003c/b\u003e (December 1st, 2023 \u0026ndash; February 28, 2024): The resulting structured questionnaire was administered to the cohort to statistically assess the determinants of healthcare utilization following a first seizure.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Study Population\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1. Inclusion Criteria\u003c/h2\u003e \u003cp\u003eParticipants were eligible for inclusion if they met all of the following criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients of any sex, aged\u0026thinsp;\u0026ge;\u0026thinsp;1 year, who presented to either Polyclinique Pasteur (Bamako) or Dinandougou Medical Clinic (Markacoungo)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients with confirmed epilepsy (clinically/EEG), with complete and usable medical records.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAvailability of the patient or a primary caregiver capable of providing reliable information on healthcare-seeking behavior and therapeutic choices\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProvision of written or verbal informed consent by the patient or, for minors, by a parent or legal guardian\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2. Exclusion Criteria\u003c/h2\u003e \u003cp\u003eParticipants were excluded if they met any of the following criteria:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSeizures clearly attributable to acute symptomatic causes (e.g., hypoglycemia, acute intoxication, high fever without neurological involvement) with complete resolution and no recurrence risk\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients with an uncertain diagnosis of epilepsy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePatients with severe cognitive impairment or altered consciousness preventing reliable data collection, in the absence of a caregiver\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRefusal or inability to provide informed consent\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIncomplete clinical records or insufficient information regarding care pathways after the first seizure\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.4.3. Sampling\u003c/h2\u003e \u003cp\u003e Consecutive sampling was used, with patients included according to the eligibility criteria until the desired sample size was reached. The minimum sample size was calculated using the Daniel Schwartz formula, with a desired statistical power of 95% and a precision set at 10%. Based on a study by Ma\u0026iuml;ga Y et al. conducted in Mali [8], which reported that 63% of parents of children with epilepsy sought care from a traditional healer as the first line of treatment, the minimum required sample size was estimated at 89 PWE\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Study Design\u003c/h2\u003e \u003cp\u003eWe conducted a mixed method approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches. A mixed method was likely to allow a deeper and more nuanced understanding of the issue in the context of dual use of conventional and traditional medicine in Mali [19,20]. All patients living with clinically and electroencephalographically confirmed epilepsy who were consecutively followed in outpatient consultation in any of the two sites during the study period were included. Informed consent was required from patients or legal guardians before participating in the study. All included patients had complete medical records. Patient medical records included sociodemographic data, disease history, personal and family medical history (including a family history of epilepsy, consanguinity, pregnancy and childbirth context, infectious diseases, and head trauma), standard EEG findings, and neuroimaging data (CT and/or MRI). Biological investigations were guided by the clinical presentation and included complete blood count, blood glucose, renal function tests, serum electrolytes, liver function tests, inflammatory markers, HIV serology, hemoglobin electrophoresis, malaria testing, and, for selected patients, cerebrospinal fluid analysis. The compilation of medical records, clinical examination, and patient interviews allowed for syndromic and etiological classification in accordance with International League Against Epilepsy (ILAE) criteria [2,21\u0026ndash;24]. This classification framework considers local realities, particularly the difficulty in investigating certain etiologies (inflammatory, metabolic, and genetic).\u003c/p\u003e \u003cp\u003eFinally, we adopted the following etiological classification: (i) Infectious causes (cerebral malaria, meningitis, neuro-meningeal tuberculosis, HIV, neurocysticercosis, and other infectious diseases with cerebral complications); (ii) Structural causes (sequelae related to pregnancy and/or difficult childbirth, sequelae of head trauma, stroke, malformations, inflammatory lesions of the central nervous system, and other potentially epileptogenic lesions incidentally discovered on CT or MRI); (iii) Epilepsies occurring in the context of developmental encephalopathies; (iv) Well-defined idiopathic generalized epilepsy syndromes, including childhood absence epilepsy, juvenile absence epilepsy, and juvenile myoclonic epilepsy; (v) Unknown causes, referring to patients with epilepsy in whom no specific cause or syndrome could be identified.\u003c/p\u003e \u003cp\u003eFor the qualitative component, we conducted interviews using an interview guide. For the quantitative component, adult PWE, as well as parents or guardians of minors or patients with limited cognitive capacity, were administered a questionnaire containing both closed- and open-ended questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Study Variables\u003c/h2\u003e \u003cp\u003eSociodemographic characteristics, included age, sex, marital status, level of education, and occupation. Other variables included information on participants\u0026rsquo; perceptions of epilepsy and healthcare-seeking pathways and therapeutic choices following the inaugural seizure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Data Collection and Analysis\u003c/h2\u003e \u003cp\u003eData were collected through direct and semi-structured interviews with patients or their legal guardians. An individual data collection form was used, after which the data were entered and cleaned using Microsoft Excel 2013 to identify and correct outliers and inconsistencies. Descriptive statistics, including percentages, means, and standard deviations, were calculated. The data were then imported to Stata (StataCorp, College Station, TX, 2015) for additional statistical analysis. Linear, for continuous variables, and logistic, for categorical variables, univariable and multivariable regressions were used for the analysis of factors associated with utilization of seeking care, respectively. Confidence intervals (CI) were set at 95%. The factors found to be statistically significant in the univariable regressions were then used in the multivariable regression.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.8. Ethical Considerations\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the principles of the Declaration of Helsinki. Authorization to collect data was obtained from the administrative authorities of Polyclinique Pasteur and the Dinandougou Medical Clinic in Markacoungo. All participants provided free and informed consent. Patients and their parents or guardians were informed that declining participation would in no way affect the quality of care they received. Interviews were conducted in quiet, private settings. Participant anonymity and confidentiality were fully ensured, and no identifying information was collected. The data were used exclusively for scientific purposes. Our protocol received approval from the ethics committee of the Faculty of Medicine, Pharmacy, and OdontoStomatology (FMOS) of Bamako under the number 2024/45/CE/USTTB.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 87 patients met the inclusion criteria and completed the interview. The mean age of the participants was 20\u0026thinsp;\u0026plusmn;\u0026thinsp;14 years, and the majority were male (50/87; 57%). Most participants were Muslim (83/87; 95%), with notable diversity in ethnic background and geographic origin. Detailed sociodemographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of included patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (95%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBamako\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoulikoro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKayes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKita\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarkacoungo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMopti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS\u0026eacute;gou\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSikasso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoranic School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll patients underwent at least one standard awake EEG, and the majority (78/87, 90%) had more than two recordings performed at different stages of follow-up. Regarding imaging, 71 of the 87 (82%) patients underwent a head CT scan, and 12 of these also received an additional brain MRI.Etiological classification revealed that: (1) structural causes were identified in 25/87 patients (29%), predominantly involving children with sequelae of complicated childbirth and head trauma; this group also included five cases of vascular epilepsy related to sickle cell disease; (2) infectious causes were found in 23/87 patients (26%), with cerebral malaria sequelae being the most frequent, along with two cases of neurocysticercosis; (3) epileptic encephalopathies accounted for 11/87 patients (12%); (4) idiopathic generalized epilepsies were observed in 7/87 patients (8%); and (5) epilepsy of unknown etiology was noted in 21/87 patients (24%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the syndromic and etiological distribution.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEtiology and Syndromes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiologies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructural causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSequelaie of childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular epilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther structural causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfectious causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSequelae of cerebral malaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSequelae of meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurocysticercosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurodevelopmental disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutism spectrum disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention deficit disorder with or without hyperactivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIdiopathic generalized epilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsence epilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyoclonic epilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpilepsy of unknown etiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost participants perceived epilepsy as a brain disorder (75/87, 86%), considered it more serious than other diseases (54/87, 62%), and believed it to be curable (84/87, 97%) through medical therapy (75/87, 86%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants' perceptions of epilepsy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions and Beliefs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvey information source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat do you think about epilepsy?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisorder of the brain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNatural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWitchcraft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFor you, is this an illness like any other?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIt's a less serious disease\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e12 (18%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIt's a more serious disease\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e54 (82%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIs this a curable disease?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eThe treatment calms the disease\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e2 (100%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (97%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat is the appropriate treatment?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the first seizure, the age of onset was most commonly between 10 and 19 years (36%), and 78% of patients experienced their first onset before the age of 30. Tonic-clonic seizures were the most common phenotype, occurring in 66% of patients (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; characteristics of the first seizure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at first attack (year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20 to 29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 to 39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40 to 49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 to 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFirst seizure type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTonic-clonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe majority (93%) of patients who sought care after their first seizure did so immediately (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Beyond the first consultation, 62/87 (71%) also pursued a second consultation. For the initial consultation, there was a near-even split between those seeking a doctor (48%) and those seeking a traditional practitioner (49%). However, a significant shift occurred for the second consultation, as all patients (62/62, 100%) consulted a physician. Most participants chose their provider based on reputation (\"had heard about them\"), both for the first (62%) and second (81%) consultations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the first and second consultations for seizure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst Consultation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecond Consultation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare Provider, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you consult anyone after the first attack?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt was not serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you consulted another person(s)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWho was your consultation with?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePastor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat was the reason for this choice?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWe told you about them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (81%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYou had confidence in them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYou knew them by reputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYou didn't know who to see\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhere was the consultation place located?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVillage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat did the person you consulted tell you about what was happening to you?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeverity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNothing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (95%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eContagious?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes (by saliva)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNothing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlow to cure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (98%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRapdly curable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow did they suggest to treat your seizures?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrayers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhen will you use these treatments?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutside of the seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuring the seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre- and post-consultation thoughts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore the consultation, did you think that this (these) other person(s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI thought they could cure me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI thought they could help me\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI thought they couldn't do much\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (74%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBefore this other consultation, how did you think you could be cured?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (70%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAfter consultation, do you estimate the necessary means probably?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery expensive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReasonable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCheap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInitial treatment suggestions were evenly divided between herbal remedies and conventional medications (48% each) but shifted exclusively to medications (100%) during second consultations. Perceptions of curability also changed: while the first consultant often suggested the disease was quickly curable (70%), second consultants (physicians) overwhelmingly described it as \"slow to cure\" (98%). Similarly, the perception of cost increased significantly; the proportion of patients who viewed treatment as \"cheap\" dropped from 47% at the first consultation to only 3% at the second, with reciprocal increases in the \"reasonable\" (30% to 60%) and \"very expensive\" (18% to 37%) categories.\u003c/p\u003e \u003cp\u003eTo evaluate the factors associated with the choice of care, we performed a regression analysis (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). In the univariable model, male sex (OR 2.55; 95% CI 1.06\u0026ndash;6.13, p\u0026thinsp;=\u0026thinsp;0.037), primary schooling (OR 4.0; 95% CI 1.29\u0026ndash;12.78, p\u0026thinsp;=\u0026thinsp;0.017), and higher education (OR 15.00; 95% CI 1.60\u0026ndash;140.96, p\u0026thinsp;=\u0026thinsp;0.018) were associated with a higher likelihood of consulting a physician. Conversely, residing in the Koulikoro (OR 0.15; p\u0026thinsp;=\u0026thinsp;0.001) or Sikasso (OR 0.09; p\u0026thinsp;=\u0026thinsp;0.018) regions was associated with a significantly lower likelihood. These factors remained independent predictor\u003cb\u003es\u003c/b\u003e in the multivariable model, maintaining their respective associations with the choice of healthcare provider.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariable and multivariable regression results for factors affecting the utilization of physicians for initial consultation after the first seizure.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.0061 (-0.02 to 0.036)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eRef\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.55 (1.06 to 6.13)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.037\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.89 (1.15 to 13.17)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.30 (0.03 to 2.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBamako\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKayes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22 (0.02 to 2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08 (0.004 to 1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoulikoro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.15 (0.05 to 0.45)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.13 (0.035 to 0.47)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarka coungo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44 (0.03 to 7.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.18 (0.11 to 44.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMopti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44 (0.05 to 3.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21 (0.02 to 2.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS\u0026eacute;gou\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 (0.23 to 21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.95 (0.25 to 34.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSikasso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.09 (0.01 to 0.84)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.07 (0.01 to 0.86)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKita\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchooling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo schooling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKoranic School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.86 (0.82 to 10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.02 (0.61 to 14.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4.06 (1.29 to 12.78)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e4.84 (1.19 to 19.62)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.027\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.13 (0.59 to 14.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.70 (0.27 to 10.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e15.00 (1.60 to 140.96)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e33.47 (2.00 to 561.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25 (0.07 to 22.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (0.54 to 4.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87 (0.28 to 2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.804\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.50 (0.20 to 31.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat do you think about epilepsy?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisorder of the brain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNatural disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.86 (0.79 to 59.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWitchcraft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.29 (0.03 to 2.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFor you, is this an illness like any other?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.58 (0.21 to 1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIs this a curable disease?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.06 to 15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat is the appropriate treatment?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.82 (0.960 to 24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding ongoing care, 97% of patients who sought a second consultation found it more helpful than the first. Patients reported an average of 1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 consultations over the past six months. Carbamazepine was the most frequently prescribed anti-seizure medication (51%). Reassuringly, 85% of patients achieved seizure freedom with treatment\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eEpilepsy research in sub-Saharan Africa (SSA) has largely focused on epidemiological aspects and sociocultural representations, often to the detriment of therapeutic considerations. To our knowledge, this study is among the few to rigorously analyze the determinants of healthcare-seeking behavior and therapeutic choices following a first epileptic seizure.\u003c/p\u003e \u003cp\u003eThe therapeutic pathway of people living with epilepsy (PWE) in SSA, especially in Mali, is complex and shaped sociocultural, anthropological, and economic factors [25]. It is estimated that only about 20% of PWE in SSA receive appropriate anti-seizure medications [26]. This treatment gap is largely inherent to the healthcare systems in Africa which dually utilizes conventional medicine (CM) and traditional medicine (TM). In most African settings, TM is the first point of care for PWE [27]. However, despite this, existing data do not fully capture all the factors influencing the choice of therapeutic pathways toward TM versus CM.\u003c/p\u003e \u003cp\u003eOur work directly addresses this key question of which type of practitioner is sought following an inaugural epileptic seizure. All included patients were had complete documentation and had a confirmed diagnosis of epilepsy, thereby reducing bias and strengthening our study as complementary diagnostic investigations in SSA are often limited but lack of records and vetted diagnoses. [28].\u003c/p\u003e \u003cp\u003e \u003cb\u003eAn original methodological approach\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConsidering the complexity of studying human behavior, we opted for an original mixed-methods approach that combines classical qualitative and quantitative methods with constructivist perspectives. To explore the behavior of PWE and their relatives when faced with the choice of therapeutic pathway after an inaugural epileptic seizure, this mixed approach appeared particularly well-suited. Our aim to understand population behavior in the context of \u003cem\u003ede novo\u003c/em\u003e epilepsy within a complex environment where TM and CM coexist, led us to consider this mixed approach as the most appropriate, consistent with previous work [29]. Such approaches are recommended when situations are complex and poorly documented, as is the case previously for our studied scenario. Our work also draws inspiration from several studies that have adopted similar methodological frameworks to investigate behavior and attitudes in the management of PWE [30,31].\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplications for our understanding of illness\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFrom both anthropological and medical perspectives, explanatory models of disease in SSA differ from those in Western societies. In many African communities, illness is not perceived solely as the result of natural causes but may also be attributed to supernatural forces. Treatment is therefore bidirectional, addressing the organic disorder through plant-based remedies while simultaneously restoring balance among vital forces through prayers and rituals. Within this explanatory framework, CM is often disqualified [17].\u003c/p\u003e \u003cp\u003eIn this context, available data suggest that an epilepsy diagnosis in Africa is frequently delayed or inaccurate, exposing individuals to recurrent seizures with significant consequences. Factors contributing to delayed diagnosis include late recognition of seizure symptoms by patients, parents, and witnesses, cultural, geographic, and financial barriers to accessing healthcare, as well as lack of accurate and timely diagnoses by non-specialist healthcare providers [32].\u003c/p\u003e \u003cp\u003eThis African reality contrasts sharply with the situation in Western countries, where recent technological advances, such as smartphone video recordings, genetic testing, advances in electrophysiology, and artificial intelligence, have improved diagnostic algorithms for epilepsy and, consequently, care for patients with epilepsy [33,34].\u003c/p\u003e \u003cp\u003eUnfortunately, these diagnostic and therapeutic technological advances have yet to benefit patients in LMIC, particularly those living in rural areas of Africa, where an epilepsy diagnosis remains problematic for most patients who remain outside the conventional healthcare system [35].\u003c/p\u003e \u003cp\u003e \u003cb\u003eSociodemographic and clinical characteristics of the study population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis cohort showed a slight male predominance. In the context, this overrepresentation may be partly due to the underreporting of epilepsy among women [36]. For this study, we adopted a classification that aligns with ILAE standards while also accounting for our limited ability to investigate certain etiologies due to constraints in technical capacity, particularly in genetics, immunology, and metabolism. Similarly, we isolated the group of idiopathic generalized epilepsies (IGEs), which are clinically and electrographically accessible, as identifying these syndromes carries important prognostic and therapeutic implications [22].\u003c/p\u003e \u003cp\u003e \u003cb\u003eSymptomatic epilepsies are the predominant causes\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStructural causes were the most common etiologies in this cohort, accounting for 28.73% (25/87). In this group, epilepsy was most often caused by sequelae of complicated childbirth. In SSA, perinatal causes are estimated to account for between 2% and 65% of epilepsy cases [37]. Birth trauma, often resulting from complicated pregnancies or deliveries, can lead to epilepsy, with hypoxia and hypoglycemia frequently cited as underlying mechanisms of neonatal distress [37]. Traditional beliefs and long distances to maternity facilities often result in home deliveries without medical assistance [38]. A case\u0026ndash;control study demonstrated a strong association (OR 10.2, 95% CI 1.1\u0026ndash;93.4) between adverse perinatal events and epilepsy [39]. This situation suggests that most childhood epilepsies in SSA could be preventable through improved prenatal and perinatal care [40,41].\u003c/p\u003e \u003cp\u003eIn addition to childbirth-related sequelae, this study included five cases of vascular epilepsy related to sickle cell disease (SCD). This hemoglobinopathy is the most common monogenic disorder worldwide, with most affected individuals living in SSA [42]. Current data indicate that epilepsy is two to three times more frequent among people with SCD than in the general population, with higher mortality across all genotypes [43,44]. These findings confirm the importance of this widespread genetic condition in SSA in general and in Mali in particular, where consanguineous marriages are common. It is therefore essential to integrate messages about SCD into epilepsy awareness and control campaigns in SSA.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInfectious causes remain significant\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn this cohort, epilepsy was attributed to infectious causes in 26.43% (23/87). In SSA, infections of the nervous system, parasitic, viral, and bacterial, are suspected to be responsible for epilepsy in approximately 9% to 26% of cases, with cerebral malaria being the most common cause [45,46]. Febrile seizures associated with cerebral malaria are described as severe and recurrent among African children and have been implicated as a cause of epilepsy in up to 71% of epileptic children in Tanzania [47]. Studies conducted in Mali and Kenya further support a strong association between cerebral malaria and epilepsy [48,49]. One notable and somewhat unusual finding in our cohort was the low prevalence of neurocysticercosis, which is commonly described as a frequent cause of epilepsy in SSA [50]. In Mali, this can be explained by dietary habits, as pork consumption is uncommon due to the predominance of Islam, practiced by more than 90% of the population [51].\u003c/p\u003e \u003cp\u003eOverall, these findings support previous data on factors associated with epilepsy in Mali. A recent case-control study involving 1,506 epilepsy cases across six health districts in Mali identified a history of cerebral malaria, meningitis, and dystocic childbirth as key risk factors for epilepsy in the country [52].\u003c/p\u003e \u003cp\u003e \u003cb\u003eCharacteristics and level of healthcare utilization after the first seizure\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong the participants, the age at onset of the first seizure was most commonly between 10 and 19 years (36%), and 78% of patients experienced their first seizure before the age of 30. This corroborates existing literature, as most studies report an early onset of epilepsy in SSA, with more than 60% of cases beginning before the age of 20 [53]. Regarding healthcare utilization, patients were almost evenly divided between those who consulted a physician in a conventional healthcare facility (48%) and those who consulted a traditional practitioner (49%) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe photograph shows a traditional amulet (\"gris-gris\") and medicinal substances on the scalp of a 27-year-old patient. This illustrates the therapeutic duality and sequential healthcare-seeking pathways (traditional medicine as first-line) frequently observed in the Malian epilepsy cohort.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIt is noteworthy that this tendency toward TM appears to be shifting in favor of CM. A decade earlier, a pediatric study on the attitudes and behaviors of families of children with epilepsy reported that 63% of parents initially sought care from a traditional healer [8]. Our study, in line with the literature, confirms the strategic position of traditional medicine in the management of neurological disorders in general and epilepsy in particular [17,53]. In neighboring Guinea, which shares similar sociocultural realities with Mali, a study showed that 79% of patients with epilepsy first consulted a traditional healer before turning to conventional medicine [17].\u003c/p\u003e \u003cp\u003e \u003cb\u003eWhat determines the choice of the first point of care?\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe high cost of medications in CM emerges as a major barrier, particularly in rural areas where PWE are often poor and vulnerable. Similar findings have been previously reported by other authors [64]. Improving the availability and accessibility of anti-seizure medications could help reduce this obstacle. Some authors advocate for strengthening epilepsy care services in rural areas, with an emphasis on regular, uninterrupted, and free provision of anti-seizure medications [54]. Beyond cost, the relatively long-term nature of the treatment in CM also represents a barrier, as African cultural beliefs often do not incorporate the concept of prolonged therapy [17].\u003c/p\u003e \u003cp\u003eThe multivariable analysis showed that male sex and having received formal education were associated with robust and significantly higher odds of consulting a physician. The influence of male sex likely reflects sociocultural and economic considerations, as poverty may lead some families to prioritize boys over girls. This finding may also be explained by underreporting of epilepsy among girls at the age of marriage, a phenomenon documented in the literature [55]. The positive influence of education on choosing CM over TM is also well described in Africa and other LMIC [56\u0026ndash;58]. Conversely, this study shows that living in remote areas away from major urban centers is associated with a significantly lower likelihood of consulting a physician. These results are consistent with a study from Kenya involving 673 PWE, which found that living more than 30 km from healthcare facilities, high costs of anti-epileptic drugs, and low education levels were associated with lower utilization of conventional medical care [59].\u003c/p\u003e \u003cp\u003e \u003cb\u003eHow to shift the trend in favor of conventional medicine\u003c/b\u003e?\u003c/p\u003e \u003cp\u003eThe position of TM as the first point of care for PWE in SSA is widely reported [8,16,60,61]. This tendency delays the initiation of anti-seizure medications and negatively affects the natural course of the disease [17,62]. It is therefore crucial to reverse this trend in favor of CM, particularly in cases of \u003cem\u003ede novo\u003c/em\u003e epilepsy. Based on our findings and existing literature, we propose several strategies to promote favorable behavioral change.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(1) Improve access to healthcare facilities, especially in rural areas\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn SSA, reliance on TM is largely due to the shortage of physicians in general and neurologists in particular. Data on neurology services in SSA show that 35 of the 53 African countries have few or no trained neurologists [63]. This shortage is compounded by the scarcity of neurology units outside urban areas. Moreover, the limited number of neurologists in major cities often divides their time between teaching at medical schools and private practice. As a result, patients living outside large cities must travel long distances to consult a neurologist [64,65]. Addressing this deficit requires urgent strategies to strengthen medical coverage in rural areas. Given the socioeconomic constraints of many African countries, alternative approaches are needed, including training frontline healthcare workers in epilepsy management.\u003c/p\u003e \u003cp\u003eIn line with this strategy, we conducted a study to assess the performance of community health workers (CHWs) trained in epilepsy case management in community health centers across six health districts in Mali. This work demonstrated that providing clear, concise clinical guidelines to CHWs, non-physician frontline providers, significantly improved epilepsy care, leading to better diagnosis and treatment of PWE [66]. We believe that this approach should be widely promoted and implemented across low-income countries in Africa.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(2) Promote collaboration between traditional medicines\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEpilepsy control campaigns in SSA should take inspiration from successful models proven from other disease areas. In Gambia and Tanzania, trained and supervised traditional healers have contributed to tuberculosis and HIV control efforts by participating in screening and referring patients to conventional healthcare facilities [67]. In this model, trained traditional practitioners can provide psychosocial support and, crucially, facilitate patient referral to CM facilities staffed by qualified neurologists [68]. In Cameroon, this approach has proven essential for improving epilepsy treatment [69]. These ideas are already being implemented in Burkina Faso, where a study found that 69.5% of patients with epilepsy reported using TM alongside CM during their therapeutic journey [70]. Formalizing this relationship represents the next logical step toward shifting care-seeking behavior in favor of CM and ensuring better epilepsy management.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations of the study\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study aimed to analyze the determinants of therapeutic choice following an initial epileptic seizure in Mali, which inherently involves examining the behavior and attitudes of PWE and their families within a complex environment where TM and CM coexist. A key limitation is the retrospective nature of the data, relying on patient and caregiver recall, which is potentially subject to recall bias or voluntary and involuntary modifications of narratives. It is well understood that one of the greatest challenges in behavioral research is that human subjects are aware of being studied and may consciously or unconsciously alter their responses; this must be considered when interpreting these findings.\u003c/p\u003e \u003cp\u003eTo tackle these potential limitations, we adopted a methodological approach tailored to complex situations. Within this mixed-methods framework, the objective was not to identify the \u0026ldquo;right\u0026rdquo; decision made by patients, but rather to understand the factors and the internal logic that guided their choices. Another important limitation is the relatively small sample size (n\u0026thinsp;=\u0026thinsp;87), which may limit the statistical power of our quantitative analysis. Furthermore, we did not exhaustively examine the influence of broader societal factors, such as family dynamics, ethnicity, social status, and specific customs, on treatment choices. Further studies with larger cohorts will be needed to explore these aspects, as they might have a significant level of influence on patient choices.\u003c/p\u003e \u003cp\u003eWe also recognize a potential selection bias, as our study population included patients who voluntarily visited our two healthcare facilities. Those who never accessed these centers and services were not part of the study and may display different behaviors, which could limit the generalizability of our findings. Nonetheless, our data offer valuable insights that can help develop programs, such as the Universal Health Insurance Plan (RAMU), to reduce the burden of epilepsy in sub-Saharan Africa.\u003c/p\u003e \u003cp\u003eFinally, the lack of validated questionnaires designed for such complex environments was a challenge, as using standardized instruments would have improved the validity of the data collected. However, we believe this limitation was partly offset by the development of a context-specific questionnaire and, most importantly, by our mixed-methods approach, which increased the overall robustness of the study\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe diagnosis and treatment of epilepsy remain major public health challenges in sub-Saharan Africa, particularly in Mali. This study highlights the central role of traditional medicine as a primary therapeutic option following an inaugural seizure, often favored due to the high cost of medication and, significantly, the challenges surrounding the accessibility and availability of conventional healthcare facilities. In this context, the implementation of the Universal Health Insurance Plan (RAMU) is essential to mitigate the prohibitive cost of anti-seizure medications and ensure financial accessibility for the most vulnerable populations. Researchers and policymakers must implement innovative strategies aimed at: (1) improving access to healthcare facilities, especially in rural areas; (2) promoting collaboration between traditional and conventional medicines; and (3) developing information and education campaigns to foster positive behavioral changes. Our work represents an initial step toward adapting epilepsy care to local sociocultural and economic realities\u0026mdash;a prerequisite for reducing the burden of this pathology in Mali and throughout sub-Saharan Africa.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Authorization to collect data was obtained from the administrative authorities of Polyclinique Pasteur and the Dinandougou Medical Clinic in Markacoungo. All participants provided free and informed consent. Patients and their parents or guardians were informed that declining participation would in no way affect the quality of care they received. Interviews were conducted in quiet, private settings. Participant anonymity and confidentiality were fully ensured, and no identifying information was collected. Written or verbal informed consent was obtained from all adult participants and from parents or legal guardians for participants under the age of 18. The data were used exclusively for scientific purposes. Our protocol received approval from the ethics committee of the Faculty of Medicine, Pharmacy, and OdontoStomatology (FMOS) of Bamako under the number 2024/45/CE/USTTB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and the accompanying image (Figure 1). Although the patient’s face is not visible, she was informed that complete anonymity cannot be guaranteed. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions related to patient medical records but are available from the corresponding author [Prof. Dr Youssoufa MAIGA] on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e\u0026nbsp;Youssoufa MAIGA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData curation:\u003c/strong\u003e\u0026nbsp;Youssoufa Maiga, Salimata Diallo, Awa Coulibaly, Ibrahim Nimaga , Seybou H Diallo; Moussa Doumba; Cheick Oumar Tounkara; Souleymane dit Papa Coulibaly,\u0026nbsp;Bakary Danthioko; \u003cstrong\u003eInvestigation:\u003c/strong\u003e Youssoufa Maiga, Seybou H Diallo, Salimata Diallo, Awa Coulibaly, Mariam Daou, Adama Sissoko, Mohamed Albakaye, Zoumana Traoré, Souleymane dit papa Coulibaly ; \u003cstrong\u003eMethodology:\u003c/strong\u003e Youssoufa MAIGA; Leon Samuel Moskatel, Abou Sogodogo; Abdoulaye Yalcoué, Modibo Sangaré; \u003cstrong\u003eAnalysis:\u003c/strong\u003e Youssoufa MAIGA, Leon Samuel Moskatel, Modibo Sangaré; Abou Sogodogo; \u003cstrong\u003eSupervision:\u003c/strong\u003e Youssoufa MAIGA, Julien Nizard, Robert Cowan; \u003cstrong\u003eWriting – original draft:\u003c/strong\u003e Youssoufa MAIGA; \u003cstrong\u003eWriting – review \u0026amp; editing\u003c/strong\u003e: Youssoufa MAIGA, Leon Samuel Moskatel, Modibo Sangaré.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors would like to thank the staff of Polyclinique Pasteur and Dinandougou Medical Clinic, as well as all the patients and their families who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Falco-Walter J. 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Acta Neurol Scand. avr 2004;109(4):250‑4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8958943/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8958943/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe therapeutic pathway options of people living with epilepsy (PWE) in Sub-Saharan Africa (SSA), especially in Mali are influenced by sociocultural, anthropological, and economic factors. Our study aimed to analyze the determinants of healthcare-seeking behavior and therapeutic choices after an inaugural epileptic seizure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe focused on analyzing the choice of care pathway after an inaugural epileptic seizure in an environment characterized by the coexistence of conventional medicine (CM) and traditional medicine (TM). We hypothesized that a mixed approach, combining classical biomedical methods (qualitative and quantitative) with constructivist approaches, would allow for a deeper understanding of the issue. This study was conducted in urban and rural referral centers for the management of PWE. Patients with clinically and EEG-confirmed epilepsy were consecutively enrolled in outpatient consultations at the two sites during the study period, and data were collected through direct and semi-structured interviews. Descriptive statistics and linear regressions were used to analyze the generated data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 87 patients met the inclusion criteria and participated in the interviews (patients or caregivers). The mean age was 20 ± 14 years, and were predominantly men (50/87, 57%). Epilepsy was mainly symptomatic, linked to complications from abnormal childbirth, head trauma, stroke, and cerebral malaria. Following the inaugural seizure, patients consulted conventional healthcare facilities (48%), traditional practitioners (49%) and pastor (2%). The high cost of antiepileptic drugs in conventional medicine emerged as a limiting factor. The multivariate model showed that male sex and higher levels of education were associated with significantly more robust odds ratios for consulting a physician. Conversely, a greater distance from a healthcare facility was associated with a significantly lower likelihood of consulting a physician.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diagnosis and treatment of epilepsy remain major public health challenges in sub-Saharan Africa, particularly in Mali. This study highlights the central role of traditional medicine as a primary therapeutic option following an inaugural seizure, often favored due to the high cost of medication and, significantly, the challenges surrounding the accessibility and availability of conventional healthcare facilities. In this context, the implementation of the Universal Health Insurance Plan (RAMU) is essential to mitigate the prohibitive cost of anti-seizure medications and ensure financial accessibility for the most vulnerable populations. Researchers and policymakers must implement innovative strategies aimed at: (1) improving access to healthcare facilities, especially in rural areas; (2) promoting collaboration between traditional and conventional medicines; and (3) developing information and education campaigns to foster positive behavioral changes. Our work represents an initial step toward adapting epilepsy care to local sociocultural and economic realities—a prerequisite for reducing the burden of this pathology in Mali and throughout sub-Saharan Africa.\u003c/p\u003e","manuscriptTitle":"Utilization and Therapeutic Choices after a First Seizure: A Mixed- Methods Analysis of Determinants in a Malian Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-05 17:11:32","doi":"10.21203/rs.3.rs-8958943/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"130119746296756928575588336834618499335","date":"2026-04-16T22:49:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-08T15:31:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66791556963117164612341276464742348049","date":"2026-04-02T20:42:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-31T10:39:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-13T06:18:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T02:15:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-25T02:15:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2026-02-24T14:56:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d94486d-1bf7-44d9-bbc2-bdf0ecd18a8c","owner":[],"postedDate":"April 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-05T17:11:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-05 17:11:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8958943","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8958943","identity":"rs-8958943","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}