Perceiving Beyond the Seizures: “A Study on Epilepsy Stigma in the General Population of Karachi”

Perceiving Beyond the Seizures: “A Study on Epilepsy Stigma in the General Population of Karachi” | 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 Perceiving Beyond the Seizures: “A Study on Epilepsy Stigma in the General Population of Karachi” Ubaid Ahmed Khan, Muhammad Hammad, Mawara Amin, Rumaisa Siddiqui, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7171592/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Epilepsy is commonly associated with significant stigma, which can be particularly pronounced among individuals at high risk due to frequent seizures or other related health challenges. The study aims to explore the clinical and socio-demographic factors contributing to the stigma experienced by people living with epilepsy. Methods: A prospective cross-sectional study was conducted from March 2024 to November 2024, enrolling 385 patients from Star general hospital and Muslim khatri hospital in Karachi. Participants, age 15-65 years, with a self-reported epilepsy diagnosis and at least one hemorrhagic event in the past six months, were included and individuals with chronic illnesses like cancer, kidney failure, dementia, pregnancy or mental instable excluded from study. Data were collected using a structured questionnaire, assessing socio-demographic characteristics, seizure severity, mental health comorbidities, self-efficacy, self-management, health literacy, depression symptoms, social support, and quality of life was analysis using STATA version 16. 1and SPSS version 26.0. Results: Stigma in people with epilepsy (PLWE) was strongly linked to more severe seizures, higher AED use and mental health issues, particularly depression. Factors like lower self-efficacy, poorer health literacy, and reduced quality if life were associated with higher stigma. Regression models showed that better self-efficacy, health literacy, and social support helped reduce stigma, while depression and poor quality of life increased it. Conclusion: Seizure severity, mental health issues, and self-management skills all influenced stigma in epilepsy. Reducing stigma and improving quality of life can be achieved by addressing these variables through social support, health literacy, self-management programs, and mental health screening. Quality of life social support self-management mental health comorbidity stigma epilepsy Introduction Over 50 million people worldwide suffer with epilepsy, a neurological condition that is frequently associated with severe stigma in the form of unfavorable social perceptions and misunderstandings. 1 More than half of those with epilepsy reported feeling stigmatized, according to a cross-cultural survey, underscoring how widespread this problem is. 2 Because of its negative impact on the psychological health of epileptic patients, the Institute of Medicine has designated stigma associated to epilepsy as a priority. Even with improvements in antiepileptic medication treatments and surgical procedures, stigma is still a major cause of psychological discomfort and a lower quality of life (QOL) for those who have epilepsy. 3 According to a systematic review, the first emotional responses of over half of individuals with epilepsy to receiving a new diagnosis were fear, despair, or rage, with a significant percentage voicing worries about social stigma. These anxieties were frequently exacerbated by the dread of other people's unfavorable reactions, which resulted in social withdrawal, loneliness, and feelings of shame. 4 Epilepsy stigma is caused by a variety of circumstances, including social, personal, and health-related ones. According to Berlin research, the main causes of stigma, especially interpersonal, internalized, and institutional forms, include educational attainment, personality qualities, understanding of epilepsy, family support, and the financial strain of hiring people with the condition. 5 Similarly, a cross-sectional study discovered a significant correlation between greater levels of stigma and the incidence and length of seizures. 6 Moreover, Lee SA et al., highlighted that more frequent seizures were strongly associated with worsened stigma perceptions. Behaviors associated with seizures, such as incontinence or tongue biting during a seizure, are also frequently viewed as socially unacceptable, exacerbating stigma. 7 A systematic review Fite RO et al., categorized predictors of stigma into three primary domains: demographic factors (e.g., country of origin, socioeconomic status, illness-related variables such as seizure type, severity, frequency, and history of epilepsy related injuries, and psychosocial factors e.g., impaired global quality of life, low social support, depression, anxiety, and poor access to epilepsy-related education. 4 Comorbid psychiatric conditions, such as depression, anxiety, and other mental health disorders, are frequently present in epileptic patients and can exacerbate feelings of stigma. These psychiatric comorbidities may contribute to maladaptive coping strategies, such as social retreat or secrecy, which in turn reinforce perceptions of stigmatization and further diminish quality of life. 8 According to research, both male and female patients with epilepsy frequently had mental comorbidity, highlighting the intertwined nature of neurological and psychiatric disorders. 9 Given the widespread underestimation of the impact of stigma by healthcare providers, it is critical to identify the specific factors that contribute to stigma in epileptic patients, particularly among those at high risk for poor health outcomes. Negative consequences of epilepsy-related stigma are far-reaching, affecting both the physical and mental health of individuals. Therefore, understanding these clinical, demographic, and psychosocial correlates of stigma is essential to developing targeted care approaches that can help mitigate the burden of epilepsy. The primary aim of this study was to explore the clinical and socio-demographic factors associated with increased stigma in a population considered at high risk due to recent experiences of frequent seizures and other negative health events and secondary objectives were to assess how these correlates independently contribute to experience stigma, providing deeper insights into the factors that shape the stigma experienced by this high-risk group. Methodology A prospective cross-sectional study was conducted over a period of six month from March 2024 to November 2024. Study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of Jinnah Sindh Medical University (Reference No: JSMU/IRB/2023/817). Data were collected from patients at two clinics in Karachi: Star General Hospital and Muslim Khatri Hospital. A non-probability convenience sampling method was used, and the estimated sample size was calculated to be 385, using OpenEpi based on 95% confidence interval, and an anticipated frequency 50% corresponding to the population size of 17,236,000 people in Karachi as per 2023 census survey of Pakistan. 10 Individuals of age between 15–65 years, who were mentally stable, capable of providing informed consent, a self-reported diagnosis of epilepsy, experienced at least one hemorrhagic event within 6 months prior to screening, and able to respond to the questionnaire were enrolled in the study. Whereas, participants that having chronic long-term illness such as stage 3 cancer, kidney failure, dementia, being pregnant and mentally unstable excluded from the study. Non-hemorrhagic event was defined as seizures, injuries (either traumatic or accidental), visits to emergency room or hospitalization and self-harm attempts. Data were collected through a structured questionnaire developed based on a comprehensive review of the literature on epilepsy stigma. Questionnaire was designed to gathered socio-demographic information (age, sex, marital status, education, employment status, and income) and clinical characteristics, such as epilepsy severity, seizure history, medication adherence, and comorbid mental health conditions. Participants and parents or legal guardian (below 16 years), were asked to signed informed consent forms after receiving detailed information about the study. Questionnaire was available in both Google forms and paper-based formats [Performa]. Responses were kept confidential, with data from Google forms downloaded directly for analysis, while paper responses were manually entered into a password protected computer system. Perceived stigma was assessed using Epilepsy Stigma Scale (ESS), a 10-item scale. 11 Non-health events (NHEs) were quantified by self -reported seizures, hospitalizations, self-harm attempts, and traumatic injuries in past 6 months. Seizure severity was evaluated using Liverpool Seizure Severity Scale 12 and medical history was assessed with Charlson comorbidity index. 13 Self-efficacy and self-management were measured using Epilepsy Self-Efficacy Scale (ESES) 14 and Epilepsy Self-Management Scale (ESMS) 15 respectively. Health Literacy was assessed with REALM-M. 16 Depression severity was assessed using PHQ-9 17 and MADRS. 18 Functional status was measured with the Short-Form Health Survey (SF-36), 19 Quality of life with QOLIE-10 20 and social support with MSPSS 21 . Internal consistency of the scales was assessed using Cronbach alpha test ((> 0.70 for all measures). Test-retest reliability conducted on the subset (n = 50) with the correlation coefficients > 0.80. Construct validity established through confirmatory factor analysis. Statistical analysis was performed using STATA version 16. 1and SPSS version 26.0. Descriptive statistics were calculated to summarize participants demographic characteristics (age, sex, education levels, marital status, education, employment status, and income) and clinical characteristics (seizure frequency, comorbidities, health literacy, quality of life). Mean, standard deviations and frequency distribution were calculated for continuous variables, while categorical variables were described using percentages. Relationship between continuous variables, including perceived stigma and factors such as self-efficacy, health literacy, and quality of life, was assessed using Pearson correlation. For binary variables (mental health comorbidities), point-biserial correlation was used. A multivariable linear regression was used to explore associations with ESS scores. A stepwise approach was applied, Model 1 including variables that showed a trend toward significance (p < 0.15) and Model 2 further evaluate specific impact of mental health conditions on stigma. Depression severity was assessed in Model 3 and 4, using both PHQ-9 and MADRS scales, respectively, to determine their influence on stigma. ANOVA was used to assess differences in stigma scores different categories of clinical and socio-demographic factors. The model assumptions, including multicollinearity, normality, and homoscedasticity, were checked through diagnostic tests, and variable inflation factor was used to assess multicollinearity. P value < 0.05 considered as significant. Results Correlations between various demographic and medical characteristics and the perceived stigma surrounding epilepsy showed in Table 1 . Age, for instance, shows a very weak negative correlation with stigma (r = -0.009, p = 0.043), indicating that older individuals tend to report slightly lower stigma levels. Educational status, income, and employment also revealed minor but notable associations with stigma, as lower levels of education (r = -0.07, p = 0.027) and income (r = -0.16, p = 0.03) correlated with higher stigma, while being employed (r = -0.23, p = 0.91) had a minimal association. Medical factors such as the number of antiepileptic drugs (r = 0.37, p = 0.01) and seizure severity (r = 0.17, p = 0.023) were moderately correlated with stigma, suggesting that more complex medical management and more severe seizures may contribute to higher stigma. Additionally, the presence of mental health diagnoses such as depression (r = 0.33, p < 0.0001), anxiety (r = 0.19, p = 0.005), and bipolar disorder (r = 0.31, p = 0.022) were strongly linked with increased stigma. Table 1 Results of correlation between basic characteristics and epilepsy stigma (n = 385) Characteristic Value Correlation (r or r pb) Age , years (n = 385) 38.63 ± 13.5 -0.009 (p = 0.043) Sex -0.23 (p = 0.91) Male 219 (56.88%) Female 166 (43.12%) Marital Status -0.17 (p = 0.18) Unmarried 87 (22.50%) Married 194 (50.49%) Divorce/window 104 (27.01%) Educational status -0.07 (p = 0.027) Employed 181 (47.01%) Unemployed 204 (52.99%) Income -0.16 (p = 0.03) < Rs 100000 201 (52.21%) ≥ Rs 100000 184 (47.79%) Medical history Disease duration, years 19.1 ± 11.2 (0–56) 0.17 (p = 0.31) Seizure type 0.025 (p = 0.08) Generalized seizure 228 (59.22%) Focal seizure 67 (17.40%) Unknown seizure 90 (23.38%) Number of antiepileptic drugs 1.89 ± 0.63 0.37 (p = 0.01) Seizure severity (LSSS score) 47.8 ± 15.7 0.17 (p = 0.023) No of negative health events during the previous months 19.4 ± 21.7 0.43 (p = 0.056) Seizures during previous 6 months (n = 385) 289 (75.06%) 0.023 (p = 0.05) Emergency room visit (n = 318) 198 (62.26%) -0.01 (p = 0.049) Accidents (n = 385) 42 (10.91%) -0.21 (p = 0.44) Hospitalization (n = 361) 65 (20.63%) 0.06 (p = 0.41) Physical comorbidity 121 (31.43%) 0.22 (p = 0.09) Any mental health diagnosis 96 (24.94%) 0.44 (p = 0.001) Attention deficit/hyperactivity disorder 41 (10.65%) 0.011 (p = 0.44) Anxiety 83 (21.56%) 0.19 (p = 0.005) Depression 137 (35.58%) 0.33 (p = 0.0001) Bipolar disorder 44 (11.43%) 0.31 (p = 0.022) Panic disorder 47 (12.21%) 0.017 (p = 0.044) Post-traumatic stress disorder 25 (6.49%) 0.07 (p = 0.047) Obsessive-compulsive disorder 9 (2.33%) 0.27 (p = 0.02) Schizophrenia 17 (4.41%) 0.15 (p = 0.041) Self-assessment scores Stigma (ESS score) 47.0 ± 16.5 NA Self-efficacy (ESES score) 268.4 ± 63.7 -0.57 (P = 0.005) Self- management (ESMS score) 120.9 ± 21.5 -0.33 (P = 0.047) Healthy literacy (REALM-R Score) 4.3 ± 1.4 -0.16 (P = 0.001) Social support (MSPSS score) 53.6 ± 19.8 -0.67 (P < 0.0001) Quality of life (QOLIE-10 score) 2.7 ± 1.1 0.44 (P = 0.009) Functional status (SF-36 score) Mental component (MCS score) 47.4 ± 12.7 -0.39 (p = 0.001) Physical component (PCS score) 55. 7 ± 9.3 -0.25 (p < 0.0001) Depression severity (PHQ-9 score) 13.1 ± 8.3 0.76 (p < 0.0001) Minimal depression (1–4) 79 (20.51%) Mild depression (5–9) 95 (24.68%) Moderate depression (10–14) 106 (27.54%) Moderately severe depression (15–19) 47 (12.20%) Severe depression (20–27) 58 (15.07%) Depression severity (MADRS score) 21.56 ± 13.7 0.44 (p < 0.0001) *Pearson correlation (r) or point biserial correlation ( r pb ) As for the multivariable regression analysis presented in Table 2 , factors such as self-efficacy, health literacy, and social support were significant predictors of stigma. Higher self-efficacy (β = -0.041, p = 0.007) and better health literacy (β = -1.98, p = 0.0001) were associated with lower stigma, highlighting the importance of empowering individuals with epilepsy through self-management and education. Social support also played a crucial role, with stronger social support correlating with reduced stigma (β = -0.37, p = 0.0058). Mental health factors, especially depression, were found to be significant contributors to stigma like, individuals with depression had a higher stigma score (β = 7.57, p = 0.0008) in the regression models. Results underscore complex relationship between epilepsy stigma, mental health, and social support, suggesting that addressing these areas may be key in reducing stigma in the general population. Table 2 Results of multivariable regression analysis with Epilepsy stigma scale score. Variables Model 1 Model 2 Model 3 Model 4 Self-efficacy (ESES score) -0.041 (-0.110 to -0.002), p = 0.007 -0.041 (-0.110 to -0.002), p = 0.007 -0.062 (-0.110 to -0.0011), p = 0.08 -0.039 (-0.112 to -0.002), p = 0.006 Health literacy (REALM-M -1.98 (-2.71 to -0.97), p = 0.0001 -1.99 (-2.89 to -1.01), p = 0.0017 -2.03 (-2.71 to -0.98), p = 0.0001 -2.12 (-3.11 to -1.18), p = 0.0058 Social Support (MSPSS score) -0.37 (-0.91 to -0.37), p = 0.0058 -0.31 (-0.71 to -0.29), p = 0.007 -0.26 (-0.51 to -0.13), p = 0.0031 -0.31 (-0.61 to -0.23), p = 0.0031 Quality of life (QOLIE-10 score) 5.48 (2.13 to 8.69), p = 0.0001 5.37 (2.04 to 9.12), p = 0.006 Mental health diagnosis 6.27 (3.09 to 10.81), p = 9.3×10 − 4 Depression (self-reported) 7.57 (0.81 to 9.98), p = 0.0008 PHQ-9 depression score 1.03 (0.29 to 1.57), p = 9.3×10 − 5 MADRS depression score 0.45 (0.33 to 0.89), p = 2.8×10 − 4 Δ R 2 0.501 0.501 0.471 0.498 ** β (95% confidence interval), p value. Discussion Study discovers factors influencing epilepsy stigma in Karachi population, particularly among individuals who have recently experienced epilepsy related complications. Our findings align with previous literature that highlights the significant role of individual, clinical and psychological factors in shaping perceptions of epilepsy. 4 It also identified a strong correlation between stigma and factors such as depression severity, self-efficacy, quality of life, health literacy, and social support and these findings are consistent with prior research that suggests individual with epilepsy (PLWE) experience heightened stigma, particularly when dealing with psychiatric comorbidities like depression and anxiety. 22 Mental health conditions, especially depression, were notably associated with higher stigma levels in our sample, corroborating findings from studies conducted in other populations where depression and epilepsy stigma are intertwined. Depression impact stigma is significant, as it not only affects patients’ emotional wellbeing but also complicates their ability to cope with societal prejudices. 23 The study contributes to existing literature by emphasizing the importance of psychosocial factors such as self-efficacy and social support in mitigating stigma. In several international studies it was observed stigma was negatively correlated with higher levels of self-efficacy and greater social support networks. This suggests that empowering people with epilepsy and promoting social ties can lessen stigma. 2 – 5 Study investigates the variables affecting the stigma associated with epilepsy in the Karachi community, especially among those who have recently dealt with issues linked to the condition. Our results are consistent with earlier research showing how individual, clinical, and psychological variables significantly influence how epilepsy is perceived. 11 In particular, the study found a robust relationship between stigma and social support, health literacy, quality of life, self-efficacy, and the severity of depression. These results are in line with other studies that indicate stigma is higher for people with epilepsy (PLWE), especially when they also have mental health conditions such anxiety and depression. 22 In our group, mental health conditions—particularly depression—were significantly linked to greater levels of stigma, which is consistent with research done in other communities where stigma around epilepsy and depression are linked. The stigma associated with depression is substantial since it not only impairs patients' emotional health but also makes it more difficult for them to deal with societal biases. 23 Moreover, by highlighting the significance of psychosocial elements like self-efficacy and social support in reducing stigma, our study adds to the body of current work. Higher levels of self-efficacy and stronger social support networks were inversely related to stigma, a pattern observed in several international studies, which suggests that empowering individuals with epilepsy and fostering social connections can reduce stigma. 13 – 14 However, our results support the growing body of evidence linking low health literacy with a higher stigma burden, as individuals with lower health literacy may struggle to understand their condition, leading to further marginalization. 24 Additionally, terms of clinical factors, we found that more severe seizures, higher numbers of antiepileptic drug (AEDs), and poorer seizures control were all associated with greater stigma. These findings align with previous studies which suggest that individuals with poorly controlled epilepsy or more frequent seizures may be viewed more negatively by the public, reinforcing the stigma surrounding the condition. 24 However, despite these correlations, demographic factors such as age, gender, marital status, and income showed minimal associations with stigma in our study, a finding consistent with some literature but differing from other studies that report a stronger relationship between stigma and certain demographic variables. 9 Study also highlights the need to address the mental health needs of individuals with epilepsy, particularly in regions where the stigma surrounding both epilepsy and mental health is high. Depression, anxiety, and other mental health issues were found to exacerbate the stigma burden, reinforcing the need for comprehensive care that addresses both the neurological and psychiatric aspects of epilepsy. These findings are in line with the work of Andersson K et al., who emphasized the importance of treating mental health comorbidities in PLWE to improve their quality of life and reduce stigma. Additionally, strong correlation between mental health diagnosis and stigma further underscores the need for integrated care approaches that simultaneously address both epilepsy and mental health disorders. 25 While our study contributes valuable insights into the relationship between epilepsy and stigma, there are several limitations that must be considered. The study only conducted in Karachi, limiting its generalizability to other populations outside Karachi. Self-reported nature of the data also introduces potential bias, particularly in identification of epilepsy and mental health conditions. Moreover, sample size, though relatively large, was not large enough to make strong claims about less common conditions such as post-traumatic stress disorder (PTSD) and panic disorder. Lastly the study did not include control group of individuals without epilepsy, which would have helped contextualize the observed stigma levels more accurately. Conclusion The study highlights that stigma associated with epilepsy is shaped by a mix of clinical, psychological, and social factors, with depression, limited health literacy, and weaker social support emerging as significant contributors. While the findings offer valuable insights, they should be interpreted with caution given the study’s cross-sectional nature and reliance on self-reported measures. Not all observed associations were strong, and some were only marginally significant, indicating the need for careful reflection rather than broad generalization. Moving forward, longitudinal research and targeted interventions especially those integrating mental health care and patient education could play a vital role in reducing stigma and improving quality of life for individuals with epilepsy, particularly in diverse urban settings like Karachi. Declarations Ethical approval: Study was approved by Jinnah Sindh Medical University (Reference no: JSMU/IRB/2023/817). The research was conducted in compliance with ethical standards, adhering to the Declaration of Helsinki (1975, revised in 2013) and relevant national regulations. All authors confirm that this study did not in volve animal subjects or tissue. Informed consent: Participants and parents or legal guardian (below 16 years), were asked to signed informed consent forms after receiving detailed information about the study. Human and animal rights: Consent was obtained or waived by all participants in this study. Consent for Publication All participants provided consent for the publication of anonymized data and findings derived from this study. Availability of Data and Materials The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing Interests The authors declare no competing interests related to this publication. Funding No external funding was received for this study. Authors’ Contributions UAK : Principal Investigator, Conception, and Critical Review MH : Study Design, Data Analysis, Interpretation, Supervision MA : Materials Provision RS : Data Collection and Processing RF, SA : Literature Search FA : Manuscript Writing Strobe Statement The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items. 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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-7171592","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506754824,"identity":"7baadb31-3b37-4c2a-b54a-c397d17ffc18","order_by":0,"name":"Ubaid Ahmed Khan","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ubaid","middleName":"Ahmed","lastName":"Khan","suffix":""},{"id":506754825,"identity":"9e6698d0-2662-43c2-8840-d7a6444ccc0f","order_by":1,"name":"Muhammad Hammad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDACCR4wxdjY3v/xAZDBw0e0luaeA8YGIC1sRGtpn5FgJgFiEdSiO7v34KebOXayvTMS0iq/5tjJsDEwP3x0A48WszvnkqVztyUbz+x5cOy27LZkoMPYjI1z8Gm5kWMA1MKcuLE9se225DZmoBYeNmkCWox/526rT9x/IJmtWHJbPVFazIC2HE5s7EhjY/y47TBxWqxztx03buw5wyzNuO04DxszYb8Y387dVi3b2N7D+PHntmp7fvbmh4/xaUEBzOA4YiZWOQgw/iBF9SgYBaNgFIwYAAAFjUwgg0trvwAAAABJRU5ErkJggg==","orcid":"","institution":"Riphah International University","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Hammad","suffix":""},{"id":506754826,"identity":"1afeeeda-4910-4649-ad05-4cf1a2af601d","order_by":2,"name":"Mawara Amin","email":"","orcid":"","institution":"Sindh Institute of Urology and Transplantation","correspondingAuthor":false,"prefix":"","firstName":"Mawara","middleName":"","lastName":"Amin","suffix":""},{"id":506754830,"identity":"d5070baf-1e92-41d4-8aa3-41af71c66f34","order_by":3,"name":"Rumaisa Siddiqui","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Rumaisa","middleName":"","lastName":"Siddiqui","suffix":""},{"id":506754832,"identity":"29f1e7ef-417b-4cf8-8f89-48629cd70ca4","order_by":4,"name":"Rabia Farid","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Rabia","middleName":"","lastName":"Farid","suffix":""},{"id":506754835,"identity":"6e55eb64-c708-4687-b6d9-52708cb27e44","order_by":5,"name":"Fabeha Afzal","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fabeha","middleName":"","lastName":"Afzal","suffix":""},{"id":506754837,"identity":"9b9c0b0d-2e59-4f87-8326-bd9b7ee5cd75","order_by":6,"name":"Saqib Ali","email":"","orcid":"","institution":"Jinnah Sindh Medical University","correspondingAuthor":false,"prefix":"","firstName":"Saqib","middleName":"","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2025-07-20 19:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7171592/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7171592/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90588396,"identity":"7e9493ee-d610-4bc8-9c53-36d18484e56d","added_by":"auto","created_at":"2025-09-04 11:55:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":786684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7171592/v1/e9a6a3e3-2ee2-46b6-8d37-f4d212bb8f37.pdf"},{"id":90587041,"identity":"e0b71c58-567e-4b41-8edf-6aa1def6fd40","added_by":"auto","created_at":"2025-09-04 11:39:20","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":36310,"visible":true,"origin":"","legend":"","description":"","filename":"Performa.docx","url":"https://assets-eu.researchsquare.com/files/rs-7171592/v1/0589f56358689b37c6401254.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceiving Beyond the Seizures: “A Study on Epilepsy Stigma in the General Population of Karachi”","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver 50\u0026nbsp;million people worldwide suffer with epilepsy, a neurological condition that is frequently associated with severe stigma in the form of unfavorable social perceptions and misunderstandings.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e More than half of those with epilepsy reported feeling stigmatized, according to a cross-cultural survey, underscoring how widespread this problem is.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Because of its negative impact on the psychological health of epileptic patients, the Institute of Medicine has designated stigma associated to epilepsy as a priority. Even with improvements in antiepileptic medication treatments and surgical procedures, stigma is still a major cause of psychological discomfort and a lower quality of life (QOL) for those who have epilepsy.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e According to a systematic review, the first emotional responses of over half of individuals with epilepsy to receiving a new diagnosis were fear, despair, or rage, with a significant percentage voicing worries about social stigma. These anxieties were frequently exacerbated by the dread of other people's unfavorable reactions, which resulted in social withdrawal, loneliness, and feelings of shame.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEpilepsy stigma is caused by a variety of circumstances, including social, personal, and health-related ones. According to Berlin research, the main causes of stigma, especially interpersonal, internalized, and institutional forms, include educational attainment, personality qualities, understanding of epilepsy, family support, and the financial strain of hiring people with the condition.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Similarly, a cross-sectional study discovered a significant correlation between greater levels of stigma and the incidence and length of seizures.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Moreover, Lee SA et al., highlighted that more frequent seizures were strongly associated with worsened stigma perceptions. Behaviors associated with seizures, such as incontinence or tongue biting during a seizure, are also frequently viewed as socially unacceptable, exacerbating stigma.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e A systematic review Fite RO et al., categorized predictors of stigma into three primary domains: demographic factors (e.g., country of origin, socioeconomic status, illness-related variables such as seizure type, severity, frequency, and history of epilepsy related injuries, and psychosocial factors e.g., impaired global quality of life, low social support, depression, anxiety, and poor access to epilepsy-related education.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Comorbid psychiatric conditions, such as depression, anxiety, and other mental health disorders, are frequently present in epileptic patients and can exacerbate feelings of stigma. These psychiatric comorbidities may contribute to maladaptive coping strategies, such as social retreat or secrecy, which in turn reinforce perceptions of stigmatization and further diminish quality of life.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e According to research, both male and female patients with epilepsy frequently had mental comorbidity, highlighting the intertwined nature of neurological and psychiatric disorders.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGiven the widespread underestimation of the impact of stigma by healthcare providers, it is critical to identify the specific factors that contribute to stigma in epileptic patients, particularly among those at high risk for poor health outcomes. Negative consequences of epilepsy-related stigma are far-reaching, affecting both the physical and mental health of individuals. Therefore, understanding these clinical, demographic, and psychosocial correlates of stigma is essential to developing targeted care approaches that can help mitigate the burden of epilepsy. The primary aim of this study was to explore the clinical and socio-demographic factors associated with increased stigma in a population considered at high risk due to recent experiences of frequent seizures and other negative health events and secondary objectives were to assess how these correlates independently contribute to experience stigma, providing deeper insights into the factors that shape the stigma experienced by this high-risk group.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eA prospective cross-sectional study was conducted over a period of six month from March 2024 to November 2024. Study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of Jinnah Sindh Medical University (Reference No: JSMU/IRB/2023/817). Data were collected from patients at two clinics in Karachi: Star General Hospital and Muslim Khatri Hospital. A non-probability convenience sampling method was used, and the estimated sample size was calculated to be 385, using OpenEpi based on 95% confidence interval, and an anticipated frequency 50% corresponding to the population size of 17,236,000 people in Karachi as per 2023 census survey of Pakistan.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIndividuals of age between 15\u0026ndash;65 years, who were mentally stable, capable of providing informed consent, a self-reported diagnosis of epilepsy, experienced at least one hemorrhagic event within 6 months prior to screening, and able to respond to the questionnaire were enrolled in the study. Whereas, participants that having chronic long-term illness such as stage 3 cancer, kidney failure, dementia, being pregnant and mentally unstable excluded from the study. Non-hemorrhagic event was defined as seizures, injuries (either traumatic or accidental), visits to emergency room or hospitalization and self-harm attempts. Data were collected through a structured questionnaire developed based on a comprehensive review of the literature on epilepsy stigma. Questionnaire was designed to gathered socio-demographic information (age, sex, marital status, education, employment status, and income) and clinical characteristics, such as epilepsy severity, seizure history, medication adherence, and comorbid mental health conditions. Participants and parents or legal guardian (below 16 years), were asked to signed informed consent forms after receiving detailed information about the study. Questionnaire was available in both Google forms and paper-based formats [Performa]. Responses were kept confidential, with data from Google forms downloaded directly for analysis, while paper responses were manually entered into a password protected computer system.\u003c/p\u003e\u003cp\u003ePerceived stigma was assessed using Epilepsy Stigma Scale (ESS), a 10-item scale.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Non-health events (NHEs) were quantified by self -reported seizures, hospitalizations, self-harm attempts, and traumatic injuries in past 6 months. Seizure severity was evaluated using Liverpool Seizure Severity Scale\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e and medical history was assessed with Charlson comorbidity index.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Self-efficacy and self-management were measured using Epilepsy Self-Efficacy Scale (ESES)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and Epilepsy Self-Management Scale (ESMS)\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e respectively. Health Literacy was assessed with REALM-M.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Depression severity was assessed using PHQ-9\u003csup\u003e17\u003c/sup\u003e and MADRS.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Functional status was measured with the Short-Form Health Survey (SF-36),\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Quality of life with QOLIE-10\u003csup\u003e20\u003c/sup\u003e and social support with MSPSS \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Internal consistency of the scales was assessed using Cronbach alpha test ((\u0026gt;\u0026thinsp;0.70 for all measures). Test-retest reliability conducted on the subset (n\u0026thinsp;=\u0026thinsp;50) with the correlation coefficients\u0026thinsp;\u0026gt;\u0026thinsp;0.80. Construct validity established through confirmatory factor analysis.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using STATA version 16. 1and SPSS version 26.0. Descriptive statistics were calculated to summarize participants demographic characteristics (age, sex, education levels, marital status, education, employment status, and income) and clinical characteristics (seizure frequency, comorbidities, health literacy, quality of life). Mean, standard deviations and frequency distribution were calculated for continuous variables, while categorical variables were described using percentages. Relationship between continuous variables, including perceived stigma and factors such as self-efficacy, health literacy, and quality of life, was assessed using Pearson correlation. For binary variables (mental health comorbidities), point-biserial correlation was used. A multivariable linear regression was used to explore associations with ESS scores. A stepwise approach was applied, Model 1 including variables that showed a trend toward significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.15) and Model 2 further evaluate specific impact of mental health conditions on stigma. Depression severity was assessed in Model 3 and 4, using both PHQ-9 and MADRS scales, respectively, to determine their influence on stigma. ANOVA was used to assess differences in stigma scores different categories of clinical and socio-demographic factors. The model assumptions, including multicollinearity, normality, and homoscedasticity, were checked through diagnostic tests, and variable inflation factor was used to assess multicollinearity. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered as significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCorrelations between various demographic and medical characteristics and the perceived stigma surrounding epilepsy showed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Age, for instance, shows a very weak negative correlation with stigma (r = -0.009, p\u0026thinsp;=\u0026thinsp;0.043), indicating that older individuals tend to report slightly lower stigma levels. Educational status, income, and employment also revealed minor but notable associations with stigma, as lower levels of education (r = -0.07, p\u0026thinsp;=\u0026thinsp;0.027) and income (r = -0.16, p\u0026thinsp;=\u0026thinsp;0.03) correlated with higher stigma, while being employed (r = -0.23, p\u0026thinsp;=\u0026thinsp;0.91) had a minimal association. Medical factors such as the number of antiepileptic drugs (r\u0026thinsp;=\u0026thinsp;0.37, p\u0026thinsp;=\u0026thinsp;0.01) and seizure severity (r\u0026thinsp;=\u0026thinsp;0.17, p\u0026thinsp;=\u0026thinsp;0.023) were moderately correlated with stigma, suggesting that more complex medical management and more severe seizures may contribute to higher stigma. Additionally, the presence of mental health diagnoses such as depression (r\u0026thinsp;=\u0026thinsp;0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), anxiety (r\u0026thinsp;=\u0026thinsp;0.19, p\u0026thinsp;=\u0026thinsp;0.005), and bipolar disorder (r\u0026thinsp;=\u0026thinsp;0.31, p\u0026thinsp;=\u0026thinsp;0.022) were strongly linked with increased stigma.\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\u003eResults of correlation between basic characteristics and epilepsy stigma (n\u0026thinsp;=\u0026thinsp;385)\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\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCorrelation (r or r\u003csub\u003epb)\u003c/sub\u003e\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\u003c/b\u003e, years (n\u0026thinsp;=\u0026thinsp;385)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.63\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.009 (p\u0026thinsp;=\u0026thinsp;0.043)\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\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e-0.23 (p\u0026thinsp;=\u0026thinsp;0.91)\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\u003e219 (56.88%)\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\u003e166 (43.12%)\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\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e-0.17 (p\u0026thinsp;=\u0026thinsp;0.18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87 (22.50%)\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\u003e194 (50.49%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorce/window\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104 (27.01%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational 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\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e-0.07 (p\u0026thinsp;=\u0026thinsp;0.027)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e181 (47.01%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e204 (52.99%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e-0.16 (p\u0026thinsp;=\u0026thinsp;0.03)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; Rs 100000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e201 (52.21%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; Rs 100000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184 (47.79%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedical history\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\u003eDisease duration, years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2 (0\u0026ndash;56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.17 (p\u0026thinsp;=\u0026thinsp;0.31)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeizure type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.025 (p\u0026thinsp;=\u0026thinsp;0.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneralized seizure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e228 (59.22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFocal seizure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67 (17.40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown seizure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (23.38%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of antiepileptic drugs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.37 (p\u0026thinsp;=\u0026thinsp;0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeizure severity (LSSS score)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.17 (p\u0026thinsp;=\u0026thinsp;0.023)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNo of negative health events during the previous months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.43 (p\u0026thinsp;=\u0026thinsp;0.056)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeizures during previous 6 months (n\u0026thinsp;=\u0026thinsp;385)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e289 (75.06%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.023 (p\u0026thinsp;=\u0026thinsp;0.05)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmergency room visit (n\u0026thinsp;=\u0026thinsp;318)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e198 (62.26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (p\u0026thinsp;=\u0026thinsp;0.049)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccidents (n\u0026thinsp;=\u0026thinsp;385)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (10.91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.21 (p\u0026thinsp;=\u0026thinsp;0.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHospitalization (n\u0026thinsp;=\u0026thinsp;361)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65 (20.63%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06 (p\u0026thinsp;=\u0026thinsp;0.41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical comorbidity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121 (31.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.22 (p\u0026thinsp;=\u0026thinsp;0.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny mental health diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96 (24.94%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44 (p\u0026thinsp;=\u0026thinsp;0.001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention deficit/hyperactivity disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (10.65%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.011 (p\u0026thinsp;=\u0026thinsp;0.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83 (21.56%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.19 (p\u0026thinsp;=\u0026thinsp;0.005)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e137 (35.58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.33 (p\u0026thinsp;=\u0026thinsp;0.0001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBipolar disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (11.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.31 (p\u0026thinsp;=\u0026thinsp;0.022)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePanic disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (12.21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.017 (p\u0026thinsp;=\u0026thinsp;0.044)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (6.49%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07 (p\u0026thinsp;=\u0026thinsp;0.047)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObsessive-compulsive disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (2.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.27 (p\u0026thinsp;=\u0026thinsp;0.02)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchizophrenia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (4.41%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.15 (p\u0026thinsp;=\u0026thinsp;0.041)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-assessment scores\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStigma (ESS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47.0\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-efficacy (ESES score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e268.4\u0026thinsp;\u0026plusmn;\u0026thinsp;63.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.57 (P\u0026thinsp;=\u0026thinsp;0.005)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf- management (ESMS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120.9\u0026thinsp;\u0026plusmn;\u0026thinsp;21.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.33 (P\u0026thinsp;=\u0026thinsp;0.047)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthy literacy (REALM-R Score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.16 (P\u0026thinsp;=\u0026thinsp;0.001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial support (MSPSS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.67 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of life (QOLIE-10 score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44 (P\u0026thinsp;=\u0026thinsp;0.009)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFunctional status (SF-36 score)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental component (MCS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.39 (p\u0026thinsp;=\u0026thinsp;0.001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical component (PCS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55. 7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.25 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression severity (PHQ-9 score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.76 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinimal depression (1\u0026ndash;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (20.51%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild depression (5\u0026ndash;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95 (24.68%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate depression (10\u0026ndash;14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106 (27.54%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerately severe depression (15\u0026ndash;19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (12.20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere depression (20\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (15.07%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression severity (MADRS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.56\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Pearson correlation (r) or point biserial correlation (\u003cb\u003er\u003c/b\u003e\u003csub\u003e\u003cb\u003epb\u003c/b\u003e\u003c/sub\u003e\u003cb\u003e)\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs for the multivariable regression analysis presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, factors such as self-efficacy, health literacy, and social support were significant predictors of stigma. Higher self-efficacy (β = -0.041, p\u0026thinsp;=\u0026thinsp;0.007) and better health literacy (β = -1.98, p\u0026thinsp;=\u0026thinsp;0.0001) were associated with lower stigma, highlighting the importance of empowering individuals with epilepsy through self-management and education. Social support also played a crucial role, with stronger social support correlating with reduced stigma (β = -0.37, p\u0026thinsp;=\u0026thinsp;0.0058). Mental health factors, especially depression, were found to be significant contributors to stigma like, individuals with depression had a higher stigma score (β\u0026thinsp;=\u0026thinsp;7.57, p\u0026thinsp;=\u0026thinsp;0.0008) in the regression models. Results underscore complex relationship between epilepsy stigma, mental health, and social support, suggesting that addressing these areas may be key in reducing stigma in the general population.\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\u003eResults of multivariable regression analysis with Epilepsy stigma scale score.\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\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModel 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModel 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModel 4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-efficacy (ESES score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.041 (-0.110 to -0.002), p\u0026thinsp;=\u0026thinsp;0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.041 (-0.110 to -0.002), p\u0026thinsp;=\u0026thinsp;0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.062 (-0.110 to -0.0011), p\u0026thinsp;=\u0026thinsp;0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.039 (-0.112 to -0.002), p\u0026thinsp;=\u0026thinsp;0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth literacy (REALM-M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.98 (-2.71 to -0.97), p\u0026thinsp;=\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.99 (-2.89 to -1.01), p\u0026thinsp;=\u0026thinsp;0.0017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.03 (-2.71 to -0.98), p\u0026thinsp;=\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.12 (-3.11 to -1.18), p\u0026thinsp;=\u0026thinsp;0.0058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Support (MSPSS score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.37 (-0.91 to -0.37), p\u0026thinsp;=\u0026thinsp;0.0058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.31 (-0.71 to -0.29), p\u0026thinsp;=\u0026thinsp;0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.26 (-0.51 to -0.13), p\u0026thinsp;=\u0026thinsp;0.0031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.31 (-0.61 to -0.23), p\u0026thinsp;=\u0026thinsp;0.0031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of life (QOLIE-10 score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.48 (2.13 to 8.69), p\u0026thinsp;=\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.37 (2.04 to 9.12), p\u0026thinsp;=\u0026thinsp;0.006\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\u003eMental health diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.27 (3.09 to 10.81), p\u0026thinsp;=\u0026thinsp;9.3\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;4\u003c/sup\u003e\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\u003eDepression (self-reported)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.57 (0.81 to 9.98), p\u0026thinsp;=\u0026thinsp;0.0008\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\u003ePHQ-9 depression score\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\u003cp\u003e1.03 (0.29 to 1.57), p\u0026thinsp;=\u0026thinsp;9.3\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;5\u003c/sup\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\u003eMADRS depression score\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\u003cp\u003e0.45 (0.33 to 0.89), p\u0026thinsp;=\u0026thinsp;2.8\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;4\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ R\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.471\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.498\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\u003e** β (95% confidence interval), p value.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eStudy discovers factors influencing epilepsy stigma in Karachi population, particularly among individuals who have recently experienced epilepsy related complications. Our findings align with previous literature that highlights the significant role of individual, clinical and psychological factors in shaping perceptions of epilepsy.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e It also identified a strong correlation between stigma and factors such as depression severity, self-efficacy, quality of life, health literacy, and social support and these findings are consistent with prior research that suggests individual with epilepsy (PLWE) experience heightened stigma, particularly when dealing with psychiatric comorbidities like depression and anxiety.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Mental health conditions, especially depression, were notably associated with higher stigma levels in our sample, corroborating findings from studies conducted in other populations where depression and epilepsy stigma are intertwined. Depression impact stigma is significant, as it not only affects patients\u0026rsquo; emotional wellbeing but also complicates their ability to cope with societal prejudices.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e The study contributes to existing literature by emphasizing the importance of psychosocial factors such as self-efficacy and social support in mitigating stigma. In several international studies it was observed stigma was negatively correlated with higher levels of self-efficacy and greater social support networks. This suggests that empowering people with epilepsy and promoting social ties can lessen stigma.\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Study investigates the variables affecting the stigma associated with epilepsy in the Karachi community, especially among those who have recently dealt with issues linked to the condition. Our results are consistent with earlier research showing how individual, clinical, and psychological variables significantly influence how epilepsy is perceived.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e In particular, the study found a robust relationship between stigma and social support, health literacy, quality of life, self-efficacy, and the severity of depression. These results are in line with other studies that indicate stigma is higher for people with epilepsy (PLWE), especially when they also have mental health conditions such anxiety and depression.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e In our group, mental health conditions\u0026mdash;particularly depression\u0026mdash;were significantly linked to greater levels of stigma, which is consistent with research done in other communities where stigma around epilepsy and depression are linked. The stigma associated with depression is substantial since it not only impairs patients' emotional health but also makes it more difficult for them to deal with societal biases.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMoreover, by highlighting the significance of psychosocial elements like self-efficacy and social support in reducing stigma, our study adds to the body of current work. Higher levels of self-efficacy and stronger social support networks were inversely related to stigma, a pattern observed in several international studies, which suggests that empowering individuals with epilepsy and fostering social connections can reduce stigma.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e However, our results support the growing body of evidence linking low health literacy with a higher stigma burden, as individuals with lower health literacy may struggle to understand their condition, leading to further marginalization.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAdditionally, terms of clinical factors, we found that more severe seizures, higher numbers of antiepileptic drug (AEDs), and poorer seizures control were all associated with greater stigma. These findings align with previous studies which suggest that individuals with poorly controlled epilepsy or more frequent seizures may be viewed more negatively by the public, reinforcing the stigma surrounding the condition.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e However, despite these correlations, demographic factors such as age, gender, marital status, and income showed minimal associations with stigma in our study, a finding consistent with some literature but differing from other studies that report a stronger relationship between stigma and certain demographic variables.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Study also highlights the need to address the mental health needs of individuals with epilepsy, particularly in regions where the stigma surrounding both epilepsy and mental health is high. Depression, anxiety, and other mental health issues were found to exacerbate the stigma burden, reinforcing the need for comprehensive care that addresses both the neurological and psychiatric aspects of epilepsy. These findings are in line with the work of Andersson K et al., who emphasized the importance of treating mental health comorbidities in PLWE to improve their quality of life and reduce stigma. Additionally, strong correlation between mental health diagnosis and stigma further underscores the need for integrated care approaches that simultaneously address both epilepsy and mental health disorders.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWhile our study contributes valuable insights into the relationship between epilepsy and stigma, there are several limitations that must be considered. The study only conducted in Karachi, limiting its generalizability to other populations outside Karachi. Self-reported nature of the data also introduces potential bias, particularly in identification of epilepsy and mental health conditions. Moreover, sample size, though relatively large, was not large enough to make strong claims about less common conditions such as post-traumatic stress disorder (PTSD) and panic disorder. Lastly the study did not include control group of individuals without epilepsy, which would have helped contextualize the observed stigma levels more accurately.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study highlights that stigma associated with epilepsy is shaped by a mix of clinical, psychological, and social factors, with depression, limited health literacy, and weaker social support emerging as significant contributors. While the findings offer valuable insights, they should be interpreted with caution given the study\u0026rsquo;s cross-sectional nature and reliance on self-reported measures. Not all observed associations were strong, and some were only marginally significant, indicating the need for careful reflection rather than broad generalization. Moving forward, longitudinal research and targeted interventions especially those integrating mental health care and patient education could play a vital role in reducing stigma and improving quality of life for individuals with epilepsy, particularly in diverse urban settings like Karachi.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e Study was approved by Jinnah Sindh Medical University (Reference no: JSMU/IRB/2023/817). The research was conducted in compliance with ethical standards, adhering to the Declaration of Helsinki (1975, revised in 2013) and relevant national regulations. All authors confirm that this study did not in volve animal subjects or tissue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e Participants and parents or legal guardian (below 16 years), were asked to signed informed consent forms after receiving detailed information about the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman and animal rights:\u003c/strong\u003e Consent was obtained or waived by all participants in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided consent for the publication of anonymized data and findings derived from this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests related to this publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eUAK\u003c/strong\u003e: Principal Investigator, Conception, and Critical Review\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMH\u003c/strong\u003e: Study Design, Data Analysis, Interpretation, Supervision\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMA\u003c/strong\u003e: Materials Provision\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRS\u003c/strong\u003e: Data Collection and Processing\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRF, SA\u003c/strong\u003e: Literature Search\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFA\u003c/strong\u003e: Manuscript Writing\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStrobe Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have read the STROBE Statement\u0026mdash;checklist of items, and the manuscript was prepared and revised according to the STROBE Statement\u0026mdash;checklist of items.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSajatovic M, Ghearing GR, Tyrrell M, Black J, Krehel-Montgomery J, McDermott G, Yala J, Barigye R, Adeniyi C, Briggs F. 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Epilepsia Open. 2022;7(4):792\u0026ndash;801. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/epi4.12661\u003c/span\u003e\u003cspan address=\"10.1002/epi4.12661\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHenning O, Buer C, Nakken KO, Lossius MI. People with epilepsy still feel stigmatized. Acta Neurol Scand. 2021;144(3):312\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ane.13449\u003c/span\u003e\u003cspan address=\"10.1111/ane.13449\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndersson K, Ozanne A, Zelano J, Malmgren K, Chaplin JE. Perceived stigma in adults with epilepsy in Sweden and associations with country of birth, socioeconomic status, and mental health. Epilepsy Behav. 2022;136:108886. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.yebeh.2022.108886\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2022.108886\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Quality of life, social support, self-management, mental health, comorbidity, stigma, epilepsy","lastPublishedDoi":"10.21203/rs.3.rs-7171592/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7171592/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eEpilepsy is commonly associated with significant stigma, which can be particularly pronounced among individuals at high risk due to frequent seizures or other related health challenges. The study aims to explore the clinical and socio-demographic factors contributing to the stigma experienced by people living with epilepsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA prospective cross-sectional\u003cstrong\u003e \u003c/strong\u003estudy was conducted from March 2024 to November 2024, enrolling 385 patients from Star general hospital and Muslim khatri hospital in Karachi. Participants, age 15-65 years, with a self-reported epilepsy diagnosis and at least one hemorrhagic event in the past six months, were included and individuals with chronic illnesses like cancer, kidney failure, dementia, pregnancy or mental instable excluded from study. Data were collected using a structured questionnaire, assessing socio-demographic characteristics, seizure severity, mental health comorbidities, self-efficacy, self-management, health literacy, depression symptoms, social support, and quality of life was analysis using STATA version 16. 1and SPSS version 26.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eStigma in people with epilepsy (PLWE) was strongly linked to more severe seizures, higher AED use and mental health issues, particularly depression. Factors like lower self-efficacy, poorer health literacy, and reduced quality if life were associated with higher stigma. Regression models showed that better self-efficacy, health literacy, and social support helped reduce stigma, while depression and poor quality of life increased it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Seizure severity, mental health issues, and self-management skills all influenced stigma in epilepsy. Reducing stigma and improving quality of life can be achieved by addressing these variables through social support, health literacy, self-management programs, and mental health screening.\u003c/p\u003e","manuscriptTitle":"Perceiving Beyond the Seizures: “A Study on Epilepsy Stigma in the General Population of Karachi”","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 11:39:16","doi":"10.21203/rs.3.rs-7171592/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-21T13:54:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T02:27:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133003290440157558705322191539234185932","date":"2025-09-13T12:13:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261963394849698751957025188221196621863","date":"2025-09-05T13:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T06:24:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-20T08:50:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-31T21:30:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-31T17:48:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-07-31T17:45:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"db584a48-79b8-4c43-aa51-2270be825459","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-04T11:39:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-04 11:39:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7171592","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7171592","identity":"rs-7171592","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}