Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol

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This study aims to implement and evaluate a culturally sensitive epilepsy education intervention in primary schools within Limpopo Province. Using a Community-Based Participatory Research (CBPR) design, the intervention will integrate epilepsy education into the Life Skills curriculum for Grades 5 to 7. The project involves conducting a needs assessment, co-developing the curriculum with stakeholders, training educators, and implementing the program in selected rural schools. Quantitative pre- and post-intervention surveys will measure changes in knowledge and attitudes, while qualitative methods will capture the experiences and perceptions of participants. The anticipated outcomes include improved knowledge of epilepsy, reduced stigma, increased educator confidence, and the creation of a more inclusive school environment. Additionally, the study aims to promote sustainability through a train-the-trainer model and advocate for the integration of epilepsy education into policy. This intervention seeks to bridge the gap between biomedical knowledge and traditional beliefs, ultimately contributing to long-term improvements in health literacy and social inclusion for individuals with epilepsy in under-resourced school settings." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-865/v2", "name": "Implementing and Assessing the Effectiveness of Epilepsy Education..." } } ] } Home Browse Implementing and Assessing the Effectiveness of Epilepsy Education... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Makhado TG and Makhado L. Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.12688/f1000research.169687.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Revised Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] Thendo Gertie Makhado https://orcid.org/0000-0001-5673-1644 1 , Lufuno Makhado https://orcid.org/0000-0003-1689-9308 2 Thendo Gertie Makhado https://orcid.org/0000-0001-5673-1644 1 , Lufuno Makhado https://orcid.org/0000-0003-1689-9308 2 PUBLISHED 25 Mar 2026 Author details Author details 1 Advanced Nursing Sciences, University of Venda, Thohoyandou, Limpopo, South Africa 2 Public Health, University of Venda, Thohoyandou, Limpopo, South Africa Thendo Gertie Makhado Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Lufuno Makhado Roles: Methodology, Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Epilepsy is a highly stigmatized neurological condition in rural South Africa, where it is often misunderstood and associated with cultural myths, such as witchcraft. This study aims to implement and evaluate a culturally sensitive epilepsy education intervention in primary schools within Limpopo Province. Using a Community-Based Participatory Research (CBPR) design, the intervention will integrate epilepsy education into the Life Skills curriculum for Grades 5 to 7. The project involves conducting a needs assessment, co-developing the curriculum with stakeholders, training educators, and implementing the program in selected rural schools. Quantitative pre- and post-intervention surveys will measure changes in knowledge and attitudes, while qualitative methods will capture the experiences and perceptions of participants. The anticipated outcomes include improved knowledge of epilepsy, reduced stigma, increased educator confidence, and the creation of a more inclusive school environment. Additionally, the study aims to promote sustainability through a train-the-trainer model and advocate for the integration of epilepsy education into policy. This intervention seeks to bridge the gap between biomedical knowledge and traditional beliefs, ultimately contributing to long-term improvements in health literacy and social inclusion for individuals with epilepsy in under-resourced school settings. READ ALL READ LESS Keywords Curriculum, Epilepsy, Effectiveness, Education, Intervention Corresponding Author(s) Thendo Gertie Makhado ( [email protected] ) Close Corresponding author: Thendo Gertie Makhado Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Makhado TG and Makhado L. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Makhado TG and Makhado L. Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.12688/f1000research.169687.2 ) First published: 03 Sep 2025, 14 :865 ( https://doi.org/10.12688/f1000research.169687.1 ) Latest published: 25 Mar 2026, 14 :865 ( https://doi.org/10.12688/f1000research.169687.2 ) Revised Amendments from Version 1 This updated version of the manuscript includes several revisions aimed at improving methodological clarity, transparency, and reproducibility following reviewer feedback. The study design has been refined to more clearly describe the quasi-experimental cluster approach and the allocation of participating schools. The description of outcome measures has been expanded, including clearer operational definitions for key constructs such as epilepsy knowledge, attitudes toward epilepsy, stigma, and inclusive school environments. Additional methodological detail has been provided regarding the evaluation instruments, including the structure of learner and teacher questionnaires, scoring procedures, and plans for reliability testing. The timing of outcome assessments has also been clarified, specifying baseline, immediate post-intervention, and follow-up assessments to evaluate both short-term learning gains and retention of intervention effects. The curriculum intervention has been described in greater detail, including lesson structure, content progression across Grades 5–7, educator training procedures, and fidelity monitoring mechanisms. A new section has been added outlining the cultural adaptation process used to ensure the intervention addresses locally relevant beliefs about epilepsy while maintaining biomedical accuracy. The data analysis plan has also been added on the revised version. Improvements have been made to the reporting of ethical considerations, confidentiality procedures, and data-sharing plans to enhance transparency and align the protocol with open science and ethical research standards. This updated version of the manuscript includes several revisions aimed at improving methodological clarity, transparency, and reproducibility following reviewer feedback. The study design has been refined to more clearly describe the quasi-experimental cluster approach and the allocation of participating schools. The description of outcome measures has been expanded, including clearer operational definitions for key constructs such as epilepsy knowledge, attitudes toward epilepsy, stigma, and inclusive school environments. Additional methodological detail has been provided regarding the evaluation instruments, including the structure of learner and teacher questionnaires, scoring procedures, and plans for reliability testing. The timing of outcome assessments has also been clarified, specifying baseline, immediate post-intervention, and follow-up assessments to evaluate both short-term learning gains and retention of intervention effects. The curriculum intervention has been described in greater detail, including lesson structure, content progression across Grades 5–7, educator training procedures, and fidelity monitoring mechanisms. A new section has been added outlining the cultural adaptation process used to ensure the intervention addresses locally relevant beliefs about epilepsy while maintaining biomedical accuracy. The data analysis plan has also been added on the revised version. Improvements have been made to the reporting of ethical considerations, confidentiality procedures, and data-sharing plans to enhance transparency and align the protocol with open science and ethical research standards. See the authors' detailed response to the review by Michael S. Petrides See the authors' detailed response to the review by yasemin sahin yildiz READ REVIEWER RESPONSES Introduction Epilepsy is a significant neurological condition that affects millions worldwide, with a particularly high prevalence in rural areas of South Africa, including in Limpopo province. Despite its medical classification, epilepsy continues to be misunderstood, often being associated with supernatural beliefs such as witchcraft and evil spirits. 1 – 3 Such misconceptions perpetuate stigma and discrimination, leading to social isolation, limited healthcare access, and adverse psychological impacts on affected individuals. 4 – 8 Prior research highlights the need for structured epilepsy education interventions within primary schools as an effective means of reducing stigma and misinformation. The previous study also developed guidelines aimed at incorporating epilepsy in life skills education. 9 , 10 Therefore, the current project seeks to leverage existing guidelines developed for epilepsy education in Mpumalanga and Limpopo primary schools to implement and evaluate a comprehensive epilepsy education program. The intervention will target Primary schools to ensure a broad impact on young learners, educators, and the community. Despite available clinical knowledge on epilepsy management, there remains a critical gap in translating this knowledge into school-based health literacy programs, especially in under-resourced rural schools. Studies have shown that although awareness campaigns exist, they are often ad hoc and lack systematic follow-up or integration into the educational curriculum. 2 , 3 , 9 As a result, epilepsy related misconceptions persist, particularly among school-aged children and their caregivers, many of whom rely on traditional or informal sources of information. 9 , 11 , 12 This gap underscores the urgent need for structured, evidence-based, and culturally sensitive interventions in schools to improve understanding and foster acceptance. 3 , 13 Moreover, existing research often focuses on epilepsy awareness in urban or clinical settings, leaving rural school contexts under-represented. 2 , 14 , 15 In South Africa, especially in Limpopo Province, little is known about how primary school learners perceive epilepsy or how teachers respond during seizure episodes. Several reports suggest that teachers feel ill-prepared or fearful when faced with such scenarios, potentially leading to further stigmatization and the exclusion of affected learners from classroom activities. 14 , 16 – 19 These contradictions between medically recommended epilepsy management and the lived realities of learners require urgent contextual and educational attention. Another critical gap lies in the lack of long-term evaluation of school-based epilepsy interventions. While some initiatives report short-term improvements in knowledge, few studies assess whether these gains translate into lasting attitude change or behavioral shifts. 2 , 3 , 16 , 20 The role of school curricula in normalizing discussions about epilepsy remains underexplored. Despite evidence suggesting that curriculum integration, such as embedding epilepsy education in Life Skills, may foster inclusive values and reduce stigma, this strategy is still underutilized in South Africa’s public education system. 9 , 10 , 16 , 20 , 21 Lastly, the potential of a Community-Based Participatory Research (CBPR) model in epilepsy education has not been fully realized. CBPR fosters collaboration between educators, healthcare providers, learners, families, and community leaders to co-create educational interventions that are both contextually and culturally relevant. 22 This participatory approach ensures that biomedical insights are merged with indigenous knowledge systems, allowing interventions to be educational and also socially resonant and sustainable. 8 , 23 Incorporating the voices and lived experiences of community stakeholders is crucial to bridging the disconnect between scientific understanding and traditional belief systems. Epilepsy stigma in South Africa remains a significant barrier to quality education and social integration. Studies have shown that many individuals with epilepsy experience exclusion, bullying, and academic challenges due to widespread myths about the condition. 2 , 3 Although previous interventions have attempted to raise awareness, the persistent misconceptions indicate a need for a structured, culturally relevant educational intervention. There is a critical gap in school-based, curriculum-integrated epilepsy education that is participatory, inclusive, and tailored to the lived experiences of rural communities. Without addressing these gaps, learners with epilepsy remain vulnerable to bullying, dropout, and limited academic progress. A structured, evidence-based intervention is needed to equip both learners and educators with the knowledge and tools to promote inclusion and reduce stigma in primary school settings. This project aims to address these issues by implementing and assessing the effectiveness of an epilepsy education intervention in primary schools of Limpopo Province. The study will evaluate the impact of this intervention on reducing stigma, improving knowledge, and fostering a supportive environment for individuals with epilepsy. Primary and secondary objectives • Primary objective The primary objective of this study is to evaluate the effectiveness of the epilepsy education intervention in reducing stigma associated with epilepsy among primary school learners in Grades 5–7 in selected rural schools in Limpopo Province. This objective aligns with the overarching aim of fostering a more inclusive and supportive school environment for learners with epilepsy. • Primary outcome The primary outcome will be the change in epilepsy-related stigma scores among learners, measured using a structured stigma scale administered at: a) Baseline (pre-intervention) b) Immediate post-intervention c) Follow-up at 4–6 weeks post-intervention Intervention success will be defined as a statistically significant reduction in mean stigma scores from baseline to post-intervention, with sustained reduction at follow-up. Effect sizes (Cohen’s d or standardized mean difference) will also be reported to quantify the magnitude of change. • Secondary objectives The secondary objectives, derived from the original study objectives, include: a) To improve epilepsy-related knowledge among learners and teachers. b) To improve attitudes toward individuals living with epilepsy. c) To increase educators’ confidence and preparedness in managing seizures and delivering epilepsy-related content. d) To implement and assess the feasibility of integrating epilepsy education into the Life Skills curriculum. e) To explore participants’ experiences, perceived inclusion, and cultural beliefs related to epilepsy through qualitative inquiry. • Secondary outcomes Secondary outcomes will include: a) Change in epilepsy knowledge scores b) Change in attitude scores c) Teacher self-efficacy scores related to seizure management d) Qualitative themes reflecting perceived inclusion, stigma reduction, and curriculum feasibility We hypothesize that participants exposed to the intervention will demonstrate statistically significant improvements in epilepsy-related knowledge, reductions in stigma, and increased confidence and skills in seizure management from baseline to post-intervention, with these effects sustained at follow-up. Research design and methods Study design This study will employ a quasi-experimental cluster design with matched comparison schools within a Community-Based Participatory Research (CBPR) framework. Eight rural primary schools will participate in the study. Four schools will receive the epilepsy education intervention (intervention group), and four demographically comparable schools will serve as comparison schools (control group). Schools will be matched based on key characteristics, including: • Geographic location (rural context) • School size • Socioeconomic profile • Grade structure (Grades 5–7 availability) Due to logistical and ethical constraints within the public education system, random school assignment will not be feasible. Instead, schools will be selected in consultation with the district education office and matched to ensure comparability. Comparison schools will continue with the standard Life Skills curriculum without the integrated epilepsy education module during the study period. To ensure ethical fairness, the epilepsy education intervention will be offered to comparison schools after completion of post-intervention and follow-up data collection (delayed intervention model). A cluster-based quasi-experimental design is appropriate because the intervention is delivered at the classroom/school level and contamination between learners within the same school would be unavoidable if individuals were randomized. The use of matched comparison schools strengthens internal validity by allowing between-group comparisons of change over time while maintaining feasibility within the rural educational context. Study flow and timeline The study will employ a comprehensive, structured approach to implement its intervention, which can be broken down into several clear stages: • Stage 1: Recruitment and School Allocation In this initial stage, we will engage with the local Department of Education and connect with school principals to establish a collaborative relationship. The objective is to carefully select and match eight rural primary schools based on specific criteria. These schools will then be divided into two groups: an intervention group of four schools and a comparison group of the remaining four schools. • Stage 2: Baseline Assessment (T0) Following the school allocation, we will distribute consent forms for parents and assent forms for learners to ensure ethical participation. This stage will also involve administering baseline surveys to evaluate knowledge, attitudes, and stigma related to epilepsy. Additionally, teachers will complete a baseline survey, and a qualitative needs assessment will be conducted to gather insights into the current school environment. • Stage 3: Educator Training Following baseline assessment, Life Skills educators in intervention schools will participate in a structured training workshop prior to curriculum delivery. Training prepares educators to implement the epilepsy education modules and manage seizure-related scenarios confidently. • Stage 4: Curriculum Delivery (6–8 Weeks) The epilepsy education curriculum will be delivered during scheduled Life Skills periods in intervention schools over a 6–8 week period. Implementation fidelity will be monitored throughout this phase. Comparison schools will continue standard Life Skills instruction during this time. • Stage 5: Immediate Post-Intervention Assessment (T1) After the curriculum delivery period, we will conduct immediate assessments by administering post-intervention surveys to measure any changes in knowledge and attitudes. Feedback from teachers will also be gathered, along with focus group discussions involving both learners and teachers to capture their experiences and insights. • Stage 6: Follow-Up Assessment (T2; 4–8 weeks post-intervention) To assess the long-term impact of the intervention, we will re-administer the outcome surveys 4 to 8 weeks after the initial post-intervention assessment. Selected participants will participate in follow-up qualitative interviews and focus groups to evaluate knowledge retention and any sustained reductions in stigma. • Stage 7: Delayed Intervention for Comparison Schools Finally, once the T2 data collection is complete, the epilepsy curriculum will be delivered to the comparison schools, providing them with the same educational opportunities as the intervention schools. This stage aims to ensure that all schools benefit from the knowledge and skills developed during the study. Evaluation design The study will employ a quasi-experimental cluster design with schools as the unit of allocation. Eight rural primary schools will participate. Four schools will be allocated to the intervention arm and four to a wait-list control arm. Allocation will be conducted in consultation with the district education office to minimize contamination between geographically proximate schools. Baseline assessments will be conducted in all schools prior to implementation. Intervention schools will receive the epilepsy curriculum over 6–8 weeks, while control schools will continue the usual Life Skills instruction. Post-intervention and six-week follow-up assessments will be conducted in both groups. Control schools will receive the intervention after follow-up data collection is complete. Study setting The study will be conducted in selected rural primary schools within the Limpopo Province, South Africa. These schools are representative of low-resource settings with limited access to health education on neurological conditions like epilepsy. Participants In this study, the primary participants will be primary school learners in Grades 5 to 7, who bring their unique perspectives and experiences. They are guided by Life Skills educators, who play a crucial role in imparting essential knowledge and skills. Additionally, curriculum advisors contribute their expertise, ensuring that the educational content is relevant and effective for the students. Together, these individuals create a collaborative environment that enhances young learners’ learning experience. Inclusion Criteria for the participants will be as follows: Learners • All learners enrolled in Grades 5 to 7 at selected schools in Vhembe District, including those with or without epilepsy. • Assent to participate (with parental/guardian consent provided). • Age range starting from 10 years and above (Grade 5–7 age group in South Africa). • Able to participate in standard Grade 5–7 Life Skills instruction. • Operationalization of the Comprehension Criterion All learners enrolled in Grades 5–7 at participating schools will be eligible to participate in the intervention, including learners with or without epilepsy, provided parental consent and learner assent are obtained. The intervention is delivered universally at the classroom level and does not require disclosure of medical status. No learner will be excluded on the basis of having epilepsy, and no learner will be required to disclose a diagnosis for participation. This approach ensures inclusivity and prevents unintended stigmatization. The eligibility criterion “ability to comprehend age-appropriate content” is operationalized using objective and contextually appropriate indicators. Eligibility is primarily determined by enrollment in Grades 5–7 within the standard Life Skills curriculum, as the intervention is aligned with this grade level. Learners must demonstrate functional participation in routine classroom instruction conducted in the school’s language of instruction (Xitsonga, Tshivenda, or English). Functional comprehension will be confirmed through consultation with the class teacher based on regular academic participation, rather than through formal cognitive screening. No additional standardized cognitive screening instrument will be administered for research eligibility purposes. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and educator consultation, may be excluded from survey-based outcome assessments to ensure the validity of questionnaire responses. However, such learners will not automatically be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Because lived experience with epilepsy may influence baseline knowledge, attitudes, and stigma dynamics, the potential presence of learners with epilepsy within classrooms will be acknowledged in the interpretation of findings. However, epilepsy status will not be systematically collected in survey instruments in order to protect confidentiality and avoid unintended disclosure. Teachers (Educators) • Must be Life Skills educators at selected primary schools in the Vhembe District. • Must be actively teaching Grades 5 to 7. • Willing and able to participate in training and intervention activities. • Provide informed consent. • Approximately 25–65 years. Curriculum advisors • Currently serving as curriculum advisors for Life Skills education and natural sciences in the selected circuits of Vhembe. • Actively involved in curriculum support or teacher development programs. • Provide informed consent. In estimating the sample sizes for our study, we anticipate a range of 400 to 480 learners. This calculation assumes two classes in each of the eight schools, with each class consisting of 25 to 30 students. Due to the quasi-experimental implementation nature of the study and the use of existing school populations, the sample size will be determined by the number of eligible learners in the participating schools rather than by a priori power calculation. All eligible learners in the selected schools will be invited to participate. Additionally, we expect 16 teachers to participate in the study, with 2 assigned per school across the 8 institutions. Moreover, we estimate that four to six curriculum advisors will participate in the project. Identification, selection, and recruitment of participants Engagement with educational authorities Following ethical clearance from the University of Venda Human and Clinical Trial Research Ethics Committee (HCTREC), formal permission will be sought from the Limpopo Department of Education and Vhembe District Education Office. Approval from circuit managers and school principals will be obtained to access schools and participants. Curriculum advisors A list of Life Skills curriculum advisors will be obtained from the district office. Using purposive sampling, 4–6 actively involved advisors will be invited via the Department of Education. Each will receive an invitation letter, information sheet, and consent form. Consenting advisors will join co-development workshops and training activities. Teachers From 8 selected primary schools, principals will help identify two Life Skills educators per school. These teachers will be invited via on-site briefing sessions. Informed consent will be obtained before participation in epilepsy education workshops. Learners Grade 5 to 7 classes from participating schools will be included. Parental consent forms and learner information sheets will be distributed by teachers. Upon receipt of written consent, learners will be briefed and asked for assent. Only those with both parental consent and learner assent will participate. Materials and resources The curriculum materials will consist of custom-designed modules focused on epilepsy education, which will be integrated into life skills education. This approach ensures that students receive comprehensive knowledge about epilepsy while developing essential life skills. To support educators in delivering this content effectively, a toolkit will be developed. This toolkit will include a variety of resources, such as training manuals that guide instructors on best practices, activity guides that outline engaging ways to teach the material, and first aid reference charts for quick access to important information. Additionally, digital multimedia resources will be available, including videos, animations, and infographics, which will enhance the learning experience and provide diverse methods of engagement for learners. Evaluation instruments This study employs a mixed-methods evaluation framework combining quantitative surveys and qualitative inquiry to assess changes in knowledge, attitudes, stigma, confidence, and perceived inclusivity. • Outcome Measurement and Instrument Specification Quantitative outcomes will be assessed using structured learner and teacher questionnaires specifically adapted for use in rural primary schools in Limpopo Province. Separate but complementary instruments will be administered at baseline (T0), immediately post-intervention (T1), and at 4–8-week follow-up (T2) to assess change over time. The learner questionnaire measures four domains: (1) epilepsy knowledge, (2) attitudes toward peers with epilepsy, (3) epilepsy-related stigma and misconceptions, and (4) seizure first-aid response knowledge. The knowledge domain includes items assessing understanding of epilepsy as a neurological condition, recognition of seizure signs, beliefs about curability, and contagion myths. Attitude items assess willingness to interact with and include peers with epilepsy in classroom and social activities. Stigma-related items assess endorsement of supernatural causation beliefs, fear responses, and tendencies toward social distancing. First-aid items assess recognition of appropriate seizure management steps and harmful practices to avoid. Learner knowledge and first-aid items are scored dichotomously (correct = 1; incorrect or “not sure” = 0). Attitude and stigma items are coded so that higher composite scores reflect more positive attitudes and lower stigma. Domain scores are calculated by summing relevant items, allowing for comparison across time points. The teacher questionnaire assesses knowledge of epilepsy, attitudes toward inclusion, beliefs about its causes, confidence in seizure management, and self-efficacy in delivering epilepsy education. Knowledge is assessed through structured and open-ended items. The attitude and self-efficacy domains use a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with negatively worded items reverse-scored. Composite scale scores will be computed for attitudes and self-efficacy domains. The instruments are adapted from previously validated epilepsy knowledge and stigma tools used in school and community-based research and were contextualized for rural South African primary school settings. To ensure cultural and linguistic appropriateness, the instruments will undergo expert panel review involving neurologists, public health specialists, and Life Skills educators to establish content validity. Where required, questionnaires will be translated into Tshivenda and Xitsonga using forward translation and independent back-translation procedures to ensure semantic equivalence. Cognitive interviewing and pilot testing with a small group of learners will be conducted to assess clarity, comprehension, and cultural relevance prior to full implementation. Internal consistency reliability will be evaluated using Cronbach’s alpha for multi-item domains (attitudes and stigma), with α ≥ 0.70 considered acceptable. Where sample size permits, exploratory factor analysis will be conducted to examine the underlying scale structure. These procedures ensure that outcome measures are culturally appropriate, psychometrically sound, and suitable for repeated measurement in this context. The full instruments are provided in the Supplementary Materials to enhance transparency and replicability. Operational definitions of key constructs To enhance clarity and reproducibility, the key study constructs are operationally defined as follows: Epilepsy knowledge refers to factual understanding of epilepsy as a medical condition and appropriate responses to seizures. It will be operationalized as a composite knowledge score derived from objective items assessing: (i) causes and nature of epilepsy, (ii) seizure recognition, (iii) seizure first-aid/response, (iv) treatment and prognosis, and (v) myths/misconceptions (including culturally rooted explanations). Knowledge will be measured primarily among learners and teachers using a structured questionnaire at baseline, immediately post-intervention, and at follow-up. Attitudes toward epilepsy refer to learners’ and teachers’ evaluative beliefs and willingness to interact with, include, and support individuals living with epilepsy in school contexts. Attitudes will be operationalized using a Likert-scale attitude index assessing: (i) comfort with social interaction, (ii) willingness to learn/play/work with a learner with epilepsy, (iii) perceived capabilities of people with epilepsy, and (iv) endorsement of inclusion in classroom and school activities. Attitudes will be measured among learners and teachers at baseline, immediate post-intervention, and follow-up. Epilepsy-related stigma refers to negative stereotypes, social distancing, fear, and discriminatory beliefs or behaviours directed toward individuals with epilepsy. Stigma will be operationalized using a stigma score/index derived from Likert-type items assessing: (i) social distancing intentions, (ii) shame/avoidance, (iii) perceived dangerousness or contagion beliefs, and (iv) discriminatory expectations (e.g., exclusion from activities). Stigma will be measured among learners and teachers at baseline, immediate post-intervention, and follow-up. An inclusive school environment is one in which learners with epilepsy are accepted, supported, and able to participate safely and meaningfully in classroom and school activities without discrimination. This construct will be operationalized using process and qualitative indicators, including: (i) teacher self-efficacy and preparedness in seizure management and inclusive pedagogy (survey items and teacher reflections), (ii) observed classroom practices and learner engagement (observation checklists), and (iii) perceived changes in peer behaviour, bullying/exclusion, and classroom participation described in focus groups and interviews. An inclusive environment will be explored through teachers, learners, and curriculum advisors, and triangulated across qualitative and observational data. Table 1. Construct-to-measure mapping Construct Operational domains/index Respondents Data source Timepoints Knowledge Composite knowledge score (causes, seizure recognition, first aid, treatment, myths) Learners, teachers Survey (objective items) Baseline, post, 4–6 week follow-up Attitudes Attitude index (interaction willingness, perceived capability, inclusion support) Learners, teachers Survey (Likert items) Baseline, post, follow-up Stigma Stigma index (social distance, fear/avoidance, stereotypes, discrimination) Learners, teachers Survey (Likert items) Baseline, post, follow-up Inclusive environment Teacher preparedness/self-efficacy + observed practices + perceived inclusion/bullying changes Learners, teachers, advisors Teacher logs, observation checklists, FGDs/interviews Throughout implementation + post, + follow-up reflections Procedure The study procedure is structured into six phases, each designed to systematically address the educational needs surrounding epilepsy in rural schools and to promote an inclusive learning environment for all students. Phase 1: Needs assessment To initiate the study, a comprehensive needs assessment is conducted. This involves baseline surveys and focus groups engaging learners, educators, and curriculum advisors. The aim is to evaluate the existing knowledge and beliefs about epilepsy within these communities. Critical factors such as perceived stigma, knowledge gaps, and contextual elements that influence health education in rural schools are systematically documented. This analysis of findings serves as the foundation for effective content development and stakeholder engagement strategies. Phase 2: Curriculum development Building on the insights gathered from the needs assessment, the next phase focuses on the collaborative development of a culturally relevant and age-appropriate curriculum on epilepsy. Input from health experts, including neurologists and psychologists, as well as educators and policymakers, ensures that the curriculum is scientifically sound and contextually appropriate. Interactive and inclusive teaching methodologies, such as role-playing, storytelling, and peer discussions, are integrated to promote engagement and understanding. Additionally, the curriculum is aligned with the national life skills education policy to enhance its scalability and legitimacy. • Cultural Adaptation and Contextualization Process The intervention is described as culturally sensitive because it explicitly addresses locally held beliefs, explanatory models, and social meanings associated with epilepsy within rural Limpopo communities. In this context, epilepsy is often attributed to supernatural causes such as witchcraft, ancestral displeasure, or spiritual possession. The curriculum, therefore, incorporates structured dialogue that acknowledges these beliefs while introducing biomedical explanations in a respectful, non-dismissive manner. • Content Addressing Cultural Beliefs The curriculum includes specific modules that: • Explore common community beliefs about epilepsy (e.g., witchcraft, contagion, curses). • Compare traditional explanatory models with biomedical explanations of epilepsy. • Address myths and misconceptions using interactive discussion and storytelling. • Emphasize respect for cultural beliefs while providing evidence-based medical information. • Promote empathy and inclusion rather than confrontation of belief systems. Teaching strategies such as role-playing, storytelling, and scenario-based discussions will be used to help learners critically reflect on prevailing beliefs and explore alternative perspectives in a safe, structured environment. • Cultural Adaptation Process During Co-Development Cultural adaptation will be conducted through a structured Community-Based Participatory Research (CBPR) approach, involving: a) Needs Assessment Findings Baseline surveys and focus groups will identify locally prevalent misconceptions and stigma patterns. b) Stakeholder Co-Development Workshops Curriculum advisors, Life Skills educators, community representatives, and health professionals will collaboratively review and adapt educational materials. c) Content Review Panels Neurologists and public health experts will ensure biomedical accuracy while maintaining contextual relevance. d) Cognitive Pre-Testing Draft materials will be piloted with small learner groups to assess clarity, cultural resonance, and acceptability. e) Iterative Revision Feedback from stakeholders will be systematically documented and incorporated into revised materials. • Documentation of Cultural Adaptation All stages of cultural adaptation will be documented through workshop minutes and stakeholder feedback summaries, version tracking of curriculum revisions, field notes from pilot testing and documentation of modifications made based on community input. This documentation will enhance transparency and allow replication or adaptation in other cultural settings. Phase 3: Training of educators and facilitators With the curriculum developed, the next step involves conducting structured workshops for educators and facilitators. These workshops cover essential topics, including the basics of epilepsy, seizure management, and first aid protocols. Emphasis is placed on inclusive pedagogy, equipping educators with classroom strategies to support learners with epilepsy effectively. To reinforce learning, simulation sessions and role plays are implemented. Participants receive a comprehensive training manual and access to digital support tools, while a peer-support network is established to foster ongoing mutual learning and sustainability among educators. Educator training will consist of a structured 8-hour workshop delivered in one full day. Training includes didactic instruction, interactive discussion, and practical seizure first-aid simulation. Educators must demonstrate correct first-aid procedures during simulation exercises prior to implementation to ensure competence in delivery. Phase 4: Curriculum implementation The epilepsy curriculum will be implemented in intervention schools during scheduled Life Skills periods, while comparison schools continue standard instruction. Delivery will follow the standardized facilitator manual. Engagement and adherence will be monitored using teacher logs and classroom observations. After completion of follow-up data collection, comparison schools will receive the curriculum (delayed intervention model). • Intervention Structure and Dose The epilepsy education intervention consists of six structured Life Skills lessons delivered over 6–8 consecutive weeks during scheduled class periods. Each lesson is 60 minutes, resulting in approximately 6 hours of learner exposure time. All sessions are delivered by trained Life Skills educators within their own classrooms. Prior to implementation, participating educators complete a standardized 8-hour in-person training workshop facilitated by the research team. The training covers epilepsy fundamentals, seizure recognition, first-aid simulation, inclusive pedagogy, and procedures for curriculum delivery. Educators must demonstrate competence in seizure first-aid simulation before delivering the lessons. • Grade-Level Content Overview The intervention uses a standardized facilitator manual with grade-sensitive adaptation in complexity. For Grade 5 , content focuses on basic understanding of the brain, defining epilepsy as a medical condition, recognizing common seizure signs, and identifying simple first-aid responses. For Grade 6, lessons emphasize causes of epilepsy, addressing myths and misconceptions (including cultural beliefs such as witchcraft), correcting contagion myths, and promoting peer inclusion. For Grade 7 , the content includes advanced seizure recognition, structured first-aid role-play simulations, stigma-reduction strategies, and leadership in inclusive classroom practices. Across all grades, interactive methods such as role-play, myth-versus-fact discussions, storytelling, and scenario-based learning are used to enhance engagement. • Materials and Delivery Standardized materials include a facilitator manual, slide presentations, myth–fact flashcards, seizure first-aid posters, structured role-play scenarios, and learner worksheets. All materials are delivered face-to-face within the school setting during regular Life Skills periods. Teacher training is delivered by the principal investigator and a trained public health team member. Learner sessions are delivered exclusively by trained Life Skills educators. Fidelity observations are conducted by a research team member not directly involved in classroom teaching. • Fidelity Monitoring Fidelity is assessed using structured classroom observation checklists and teacher reflection logs. A lesson is considered “delivered as intended” if at least 80% of predefined lesson objectives are completed, seizure first-aid steps are demonstrated accurately (protect head, turn to side, do not restrain, do not insert objects in mouth), and at least one interactive learning activity is implemented. At least one session per school will be directly observed by the research team. Any deviations from the manual will be documented to allow transparent reporting of implementation variability. Phase 5: Process and outcome evaluation Evaluation occurs on two levels: process and outcome. Process evaluation utilizes observation checklists to assess the fidelity of curriculum delivery and student engagement. Qualitative feedback is solicited from both teachers and learners through structured reflections and focus group discussions, highlighting implementation challenges and best practices via interviews with educators and school leaders. Outcome evaluation involves conducting pre- and post-intervention surveys among learners, teachers, and parents, focusing on key areas such as knowledge of epilepsy, seizure response capabilities, changes in attitudes, and stigma reduction. Further qualitative data is gathered through focus groups and interviews, exploring shifts in perception, inclusion, and behaviour. Where feasible, comparisons are drawn between outcomes in intervention schools and control schools to assess overall efficacy. • Timing of outcome assessments (retention and persistence of effects) To assess both short-term learning gains and the persistence of intervention effects, quantitative outcome assessments will be conducted at three timepoints: 1. Baseline (T0): Prior to implementation of the epilepsy education curriculum 2. Immediate post-intervention (T1): Within one week after completion of the final lesson/session 3. Follow-up (T2): 4–8 weeks post-intervention to assess knowledge retention and sustained changes in attitudes and stigma At each time point, learners and teachers will complete the same structured questionnaire assessing epilepsy knowledge, attitudes toward epilepsy, and epilepsy-related stigma. The follow-up assessment will be scheduled in collaboration with each participating school to minimise disruption to teaching time and will be administered during routine Life Skills periods where feasible. This addition allows comparison of immediate post-intervention changes (T0→T1) with retained effects over time (T0→T2) and potential attenuation or strengthening of effects between immediate and follow-up assessments (T1→T2). Where schools serve as comparison sites (if applicable), the same assessment schedule (T0, T1, T2) will be applied to both intervention and comparison schools. Phase 6: Sustainability and policy engagement To ensure the longevity of the project, a train-the-trainer model is developed. This empowers local educators to continue delivering the curriculum independently. Refreshments and mentorship workshops are scheduled to promote sustained learning. Additionally, findings from the study are shared with local education departments, health authorities, and policy stakeholders, advocating for the integration of epilepsy education into the national life skills curriculum. This approach not only enhances the educational framework but also aims to foster an enduring change in attitudes and practices surrounding epilepsy in rural schools. Through these phases, the study seeks to establish a robust educational model that addresses the complexities of teaching about epilepsy while promoting a supportive and inclusive learning environment. Data analysis • Quantitative Analysis Quantitative data from learner and teacher questionnaires will be entered into Statistical Package for Social Sciences (SPSS) and analyzed using a predefined statistical plan. Descriptive statistics will summarize demographic characteristics and baseline outcome measures. Continuous variables (e.g., knowledge, attitude, stigma scores) will be reported using means and standard deviations or medians and interquartile ranges, depending on distributional normality. Categorical variables will be summarized using frequencies and percentages. Given the clustered design (learners nested within schools), intervention effects will be evaluated using mixed-effects regression models with random effects for school to account for intra-cluster correlation. Fixed effects will include group (intervention vs comparison), time (baseline, immediate post-intervention, follow-up), and the group × time interaction term to assess differential change over time. Where appropriate, analyses will adjust for relevant covariates such as age, gender, and baseline score. If substantial intra-class correlation is observed at the classroom level, additional random effects for class will be considered where model convergence permits. Repeated measures analysis will be conducted to examine within-participant changes across time points. For comparisons between intervention and comparison schools, a difference-in-differences approach will be applied using the group × time interaction term. Assumptions of normality and homogeneity will be assessed prior to model selection. Where outcomes are not normally distributed, appropriate transformations or non-parametric alternatives will be considered. Missing data will first be examined to determine patterns (missing completely at random, missing at random, or not at random). If data are judged to be missing at random, multiple imputation techniques will be employed. Sensitivity analyses will compare complete-case and imputed results to assess robustness. Statistical significance will be set at p < 0.05. Internal consistency reliability of multi-item domains (e.g., attitudes, stigma, self-efficacy) will be assessed using Cronbach’s alpha. Where sample size permits, exploratory factor analysis may be conducted to examine scale structure. • Qualitative Analysis Qualitative data from focus group discussions, semi-structured interviews, teacher reflection logs, and classroom observations will be analyzed using reflexive thematic analysis as described by Braun and Clarke. The analytic process will follow six stages: 1. Familiarization – Transcripts will be read repeatedly to gain immersion in the data. 2. Initial Coding – Meaningful units of text will be coded inductively and deductively, guided by the study objectives (knowledge change, stigma reduction, inclusion, cultural beliefs, implementation feasibility). 3. Theme Development – Codes will be grouped into broader candidate themes. 4. Theme Review – Themes will be refined to ensure internal coherence and distinction from one another. 5. Theme Definition and Naming – Clear definitions will be developed for each theme. 6. Interpretation – Themes will be interpreted in relation to quantitative findings and relevant literature. Two members of the research team will independently code a subset of transcripts and discuss discrepancies to enhance credibility. An audit trail will be maintained to document analytic decisions. Triangulation will occur across data sources (learners, teachers, curriculum advisors, observations) to strengthen trustworthiness. Reflexive journaling will be used to acknowledge the researcher’s positionality. • Mixed-Methods Integration This study adopts a convergent parallel mixed-methods design, whereby quantitative and qualitative data are collected during the same intervention period, analyzed separately, and integrated during interpretation. Integration will occur at three levels: 1. Design Level – Both data strands are implemented concurrently to capture complementary dimensions of intervention impact. 2. Methods Level – Qualitative findings will help explain quantitative trends, including unexpected or heterogeneous effects. 3. Interpretation Level – Findings will be merged using joint display tables that present quantitative outcomes (e.g., changes in mean stigma scores) alongside related qualitative themes (e.g., narratives describing reduced bullying or increased empathy). Convergent findings will strengthen confidence in the intervention’s effectiveness, while divergent findings will be explored to identify contextual or cultural explanations. Ethical considerations Ethical approval was obtained from the University of Venda Human and Clinical Trial Research Ethics Committee (HCTREC) number FHS/25/PDC/09/1306. Written informed consent and assent will be obtained from all participants. Written Informed consent will be obtained from the parents or legal guardians of all participating minors before their involvement in the study. In addition, age-appropriate assent will be sought directly from the minors to ensure that their participation is voluntary and understood. The consent and assent process will follow ethical guidelines for research with children and will be overseen by the institutional research ethics committee. Participant confidentiality will be maintained using anonymized data, and digital data will be stored securely. Participants may withdraw at any time without consequence. Emotional risks will be minimized, and referral mechanisms to school-based psychosocial services will be in place. The study adopts an inclusive approach. Learners with epilepsy will participate alongside their peers without being singled out or identified. No disclosure of medical conditions will be required, and confidentiality will be strictly maintained. Confidentiality and classroom data collection procedures To protect confidentiality during survey administration, questionnaires will not collect names or identifiable health information. Each participant will be assigned a unique study code. Surveys will be completed individually during class time with seating arranged to reduce visibility of responses. Completed questionnaires will be placed in sealed envelopes and collected immediately by the research team. For focus group discussions, participation will be voluntary and conducted in small groups in a private setting within the school. Participants will be reminded not to disclose personal medical information and to respect the confidentiality of peers. Ground rules emphasizing privacy and respect will be established at the beginning of each session. Teachers will not have access to individual learner responses. Data will be stored in password-protected files accessible only to the research team. Reporting will use aggregated data to prevent identification of individual participants or schools. Expected results The school-based epilepsy education intervention in rural Limpopo primary schools is anticipated to yield significant improvements in knowledge, attitudes, and behaviours regarding epilepsy among both students and educators. Similar to the study conducted in Turkey, which reported positive attitudes towards epilepsy with an increase in knowledge regarding epilepsy. 24 Central to this initiative is the implementation of a culturally relevant, curriculum-integrated program grounded in the Community-Based Participatory Research (CBPR) model. This approach aims to effectively reduce epilepsy-related stigma and misconceptions, particularly those stemming from traditional beliefs, such as witchcraft. Expected outcomes include an enhanced understanding of epilepsy as a medical condition among students, while educators will develop increased confidence in teaching about epilepsy and managing seizures within the classroom setting. Furthermore, the intervention seeks to cultivate a more inclusive and supportive learning environment, thereby reducing the likelihood of marginalization or exclusion of children with epilepsy. To ensure long-term sustainability and maximize community impact, the program employs a train-the-trainer model along with community engagement strategies. Additionally, the initiative is poised to inform policy recommendations for the integration of epilepsy education into the national life skills curriculum. This provides a scalable model for future public health interventions in educational settings, promoting greater awareness and support for individuals with epilepsy within the community. Institutional review board statement The study will be conducted in accordance with the Declaration of Helsinki and was approved by the Human and Clinical Trial Research Ethics Committee (HCTREC) of the University of Venda (FHS/25/PDC/09/1306). Informed consent statement Written Informed consent will be obtained from all subjects involved in the study. Data availability statement This manuscript reports a study protocol; therefore, no dataset has yet been generated. Upon completion of data collection and analysis, de-identified quantitative datasets will be deposited in the project’s Open Science Framework (OSF) repository in accordance with journal and institutional policies. The shared materials will include: • De-identified raw quantitative data • A detailed data dictionary and codebook describing variable names, coding schemes, missing data codes, and clustering structure (school/class level) • Scoring algorithms for composite indices • Statistical analysis scripts (where applicable) • Final versions of intervention materials, facilitator manuals, and fidelity monitoring tools All datasets will be fully anonymized prior to sharing. Direct identifiers will be removed, and indirect identifiers (e.g., school names or small subgroup characteristics) will be aggregated or masked to minimize re-identification risk. Given that the study involves minors, access to certain datasets may be subject to controlled access procedures where required by the ethics committee or institutional data governance policies. A “readme” file will accompany the dataset, providing clear instructions for data use, variable definitions, clustering structure, and guidance for replication analyses. Extended data OSF: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary Schools in Limpopo Province: https://doi.org/10.17605/OSF.IO/MY87S (Makhado and Makhado, 2025) The project contains the following extended data: 1. Supplement 1: Questionnaire and Interview Guide 2. Supplement 2: Information Sheet and Consent Form Acknowledgments I want to thank the University of Venda for allowing us to conduct our research project. We also appreciate the University Staff Doctorate Programme (USDP) for providing us with financial support for the Epilepsy Research Project, which is an important part of our study. References 1. Chabangu Q, Maputle MS, Lebese RT, et al. : Indigenous Practices for Management of Epilepsy by Traditional Healers in South Africa. Epilepsy and Paroxysmal Conditions. 2022; 14 : 267–275. Publisher Full Text 2. Prudance Musekwa O, Makhado L, Maphula A: Public Perception of Epilepsy in Rural Limpopo and Mpumalanga Provinces: A Quantitative Study on Knowledge, Awareness, and Attitudes. Challenges (Basel). 2022; 13 : 65. Publisher Full Text 3. Prudance Musekwa O, Makhado L, Maphula A, et al. : How Much Do We Know? Assessing Public Knowledge, Awareness, Impact, and Awareness Guidelines for Epilepsy: A Systematic Review. The Open Public Health Journal. 2020; 13 : 794–807. Publisher Full Text 4. 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Epilepsy Behav. 2021; 121 : 108023. PubMed Abstract | Publisher Full Text 8. Makhado L, Maputle MS, Mashau NS, et al. : GladAfrica Epilepsy Research Project (GERP): Initiation, Launch and Community Interest Report. Africa Journal of Nursing and Midwifery. 2020; 22 . Publisher Full Text 9. Gertie Makhado T, Lebese RT, Sonto Maputle M: Incorporation of Epilepsy into Life Skills Education: Perceptions of Primary School Learners in Mpumalanga and Limpopo Province—A Qualitative Exploratory Study. Children (Basel). 2023; 10 : 569. PubMed Abstract | Publisher Full Text | Free Full Text 10. Makhado TG, Lebese RT, Maputle MS: Development and Validation of Epilepsy Life Skills Guidelines for Primary School Learners and Teachers in Limpopo and Mpumalanga Provinces. Multidisciplinary Digital Publishing Institute. 2023; 10 : 1194. Publisher Full Text 11. Keikelame MJ, Swartz L: Parents’ Understanding of the Causes and Management of Their Children’s Epilepsy in Khayelitsha, Cape Town. S. Afr. J. Psychol. 2007; 37 : 307–315. Publisher Full Text 12. Gertie Makhado T, Lebese TR, Sonto Maputle M, et al. : Epilepsy Life Skill Education Guidelines for Primary School Teachers and Learners in Limpopo and Mpumalanga Provinces, South Africa: Multiphase Mixed Methods Protocol. PLOS ONE. 2022; 17 . PubMed Abstract | Publisher Full Text | Free Full Text 13. Musekwa OP, Makhado L, Maphula A: Developing and Validating an Epilepsy Awareness and Education Program: Bridging Gaps in Knowledge and Support for People Living with Epilepsy and Their Families. Patient Prefer. Adherence. 2024; 18 : 2235–2248. PubMed Abstract | Publisher Full Text | Free Full Text 14. Makhado TG, Lebese RT, Maputle MS: Inclusion of Epilepsy in Life Skills Education of Primary School Learners: The Perceptions of Life Skills Advisors in Mpumalanga and Limpopo Provinces (South Africa). Epilepsia and Paroxysmal Conditions. 2023; 15 : 125–134. Publisher Full Text 15. Brook HA, Hiltz C, Kopplin VL, et al. : Increasing Epilepsy Awareness in Schools. J. Sch. Nurs. 2015; 31 : 246–252. Publisher Full Text 16. Makhado TG, Sepeng NV, Makhado L: A Systematic Review of the Effectiveness of Epilepsy Education Programs on Knowledge, Attitudes, and Skills among Primary School Learners. Front. Neurol. 2024; 15 . PubMed Abstract | Publisher Full Text | Free Full Text 17. Pitta S, Papadopoulos A, Tsiamaki E, et al. : Teachers’ and School Professionals’ Knowledge and Attitudes Towards Epilepsy in Greece: Misconceptions and Management Options for Affected Students—A Survey Study. Educ. Sci. 2025; 15 : 591. Publisher Full Text 18. Savarese G, Carpinelli L, D’Elia D, et al. : Teachers of Various School Grades and Representations of Epilepsy: Problems, Relational Aspects and Perspectives of Life Quality. Ital. J. Pediatr. 2015; 41 : 70. PubMed Abstract | Publisher Full Text | Free Full Text 19. Iannone LF, Roberti R, Arena G, et al. : Assessing Knowledge and Attitudes toward Epilepsy among Schoolteachers and Students: Implications for Inclusion and Safety in the Educational System. PloS one. 2021; 16 : e0249681. PubMed Abstract | Publisher Full Text | Free Full Text 20. Makhado TG, Lebese RT, Maputle MS: Perceptions of Teachers Regarding the Inclusion of Epilepsy Education in Life Skills for Primary Learners and Teachers in Limpopo and Mpumalanga Provinces (South Africa). Epilepsia and Paroxysmal Conditions. 2023; 14 : 334–343. Publisher Full Text 21. Altayyar S, Chengan D, Noormamode Y, et al. : Evaluating the Effect of an Educational Comic Book on the Knowledge, Attitudes and Practices Regarding Epilepsy among Public Schoolchildren in Mauritius. Seizure. 2025; 126 : 106–113. PubMed Abstract | Publisher Full Text 22. Prudance Musekwa O, Makhado L, Maphula A: Caregivers’ and Family Members’ Knowledge Attitudes and Practices (KAP) towards Epilepsy in Rural Limpopo and Mpumalanga, South Africa. Int. J. Environ. Res. Public Health. 2023; 20 : 5222. PubMed Abstract | Publisher Full Text | Free Full Text 23. Frank GC, Centinaje E, Gatdula N, et al. : Culturally Relevant Health Education: A Foundation for Building Cultural Competence of Health Professionals. Californian Journal of Health Promotion. 2021; 19 : 13–21. Publisher Full Text 24. Yıldız YŞ, Kasapoğlu ES, Dülger H: An evaluation of the knowledge and attitudes that Health Care Services department students have about epilepsy. Epilepsy Behav. 2022; 134 : 108840. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 Advanced Nursing Sciences, University of Venda, Thohoyandou, Limpopo, South Africa 2 Public Health, University of Venda, Thohoyandou, Limpopo, South Africa Thendo Gertie Makhado Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Lufuno Makhado Roles: Methodology, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 25 Mar 2026, 14:865 https://doi.org/10.12688/f1000research.169687.2 version 1 Published: 03 Sep 2025, 14:865 https://doi.org/10.12688/f1000research.169687.1 Copyright © 2026 Makhado TG and Makhado L. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Makhado TG and Makhado L. Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.12688/f1000research.169687.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 25 Mar 2026 Revised Views 0 Cite How to cite this report: yildiz ys. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.197516.r470538 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v2#referee-response-470538 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Mar 2026 yasemin sahin yildiz , Bartın University Vocational School of Health Services, Agdaci Campus, Turkey Approved VIEWS 0 https://doi.org/10.5256/f1000research.197516.r470538 The authors have satisfactorily addressed all previously raised concerns. The revisions ... Continue reading READ ALL The authors have satisfactorily addressed all previously raised concerns. The revisions have improved the clarity, methodological rigor, and overall quality of the manuscript. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Attitude, Epilepsy, Knowledge, Peer education, Seizure first aid. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT yildiz ys. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.197516.r470538 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v2#referee-response-470538 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 03 Sep 2025 Views 0 Cite How to cite this report: Petrides MS. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r432670 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-432670 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Feb 2026 Michael S. Petrides , University of Nicosia, Nicosia, Nicosia, Cyprus Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.187045.r432670 Summary of the article This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be ... Continue reading READ ALL Summary of the article This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Responses to the journal questions 1) Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . 2) Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). 3) Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. 4) Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Points that must be addressed to make the article scientifically sound Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Minor comments and polishing suggestions Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pharmacoepidemiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Petrides MS. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r432670 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-432670 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 25 Mar 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 25 Mar 2026 Author Response Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, ... Continue reading Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Comment 1 Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Response 1 We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes. Comment 2 Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Response: We thank the reviewer for this important suggestion. The manuscript has been revised to explicitly operationalize the core constructs, knowledge, attitudes, stigma, and inclusive school environment, by specifying the domains/indices used to represent each construct and identifying the respondent groups and data sources. A construct-to-measure mapping table has been added under the Evaluation Instruments section to improve clarity, transparency, and reproducibility of the evaluation framework. Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . Response 2 We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation. Comment 3 Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Response 3 We thank the reviewer for highlighting the need for clarification regarding the study design. We revised the study design and will now employ a quasi-experimental cluster design with matched comparison schools. Eight schools will participate, with four receiving the intervention and four serving as comparison schools matched on geographic and demographic characteristics. Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model). Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level. Comment 4 Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). Response 4 We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change. Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components. Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability. Comment 5 Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Response 5 We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist. Comment 6 Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Response 6 We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify: The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication. Comment 7 Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Response 7 We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines: The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation. Comment 8 Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Response 8 We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate. In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Comment 9 Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. Response 9 We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript. We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript. Comment 10 Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Response 10 It has been provided in the manuscript Comment 11 Points that must be addressed to make the article scientifically sound: Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Response 11 The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified. Comment 12 Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Response 12 The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints. Comment 13 Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Response 13 The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria. Comment 14 Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Response 14 A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design. Comment 15 Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Response 15 Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place. Comment 16 Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. Response 16 It was added in the manuscript but not as table Comment 17 In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Response 17 expected outcomes were framed as hypotheses Comment 18 Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Response 18 Consistency ensured throughout the document Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Comment 1 Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Response 1 We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes. Comment 2 Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Response: We thank the reviewer for this important suggestion. The manuscript has been revised to explicitly operationalize the core constructs, knowledge, attitudes, stigma, and inclusive school environment, by specifying the domains/indices used to represent each construct and identifying the respondent groups and data sources. A construct-to-measure mapping table has been added under the Evaluation Instruments section to improve clarity, transparency, and reproducibility of the evaluation framework. Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . Response 2 We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation. Comment 3 Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Response 3 We thank the reviewer for highlighting the need for clarification regarding the study design. We revised the study design and will now employ a quasi-experimental cluster design with matched comparison schools. Eight schools will participate, with four receiving the intervention and four serving as comparison schools matched on geographic and demographic characteristics. Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model). Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level. Comment 4 Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). Response 4 We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change. Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components. Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability. Comment 5 Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Response 5 We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist. Comment 6 Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Response 6 We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify: The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication. Comment 7 Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Response 7 We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines: The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation. Comment 8 Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Response 8 We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate. In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Comment 9 Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. Response 9 We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript. We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript. Comment 10 Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Response 10 It has been provided in the manuscript Comment 11 Points that must be addressed to make the article scientifically sound: Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Response 11 The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified. Comment 12 Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Response 12 The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints. Comment 13 Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Response 13 The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria. Comment 14 Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Response 14 A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design. Comment 15 Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Response 15 Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place. Comment 16 Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. Response 16 It was added in the manuscript but not as table Comment 17 In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Response 17 expected outcomes were framed as hypotheses Comment 18 Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Response 18 Consistency ensured throughout the document Competing Interests: No competing interest Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 25 Mar 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 25 Mar 2026 Author Response Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, ... Continue reading Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Comment 1 Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Response 1 We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes. Comment 2 Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Response: We thank the reviewer for this important suggestion. The manuscript has been revised to explicitly operationalize the core constructs, knowledge, attitudes, stigma, and inclusive school environment, by specifying the domains/indices used to represent each construct and identifying the respondent groups and data sources. A construct-to-measure mapping table has been added under the Evaluation Instruments section to improve clarity, transparency, and reproducibility of the evaluation framework. Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . Response 2 We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation. Comment 3 Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Response 3 We thank the reviewer for highlighting the need for clarification regarding the study design. We revised the study design and will now employ a quasi-experimental cluster design with matched comparison schools. Eight schools will participate, with four receiving the intervention and four serving as comparison schools matched on geographic and demographic characteristics. Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model). Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level. Comment 4 Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). Response 4 We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change. Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components. Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability. Comment 5 Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Response 5 We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist. Comment 6 Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Response 6 We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify: The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication. Comment 7 Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Response 7 We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines: The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation. Comment 8 Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Response 8 We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate. In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Comment 9 Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. Response 9 We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript. We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript. Comment 10 Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Response 10 It has been provided in the manuscript Comment 11 Points that must be addressed to make the article scientifically sound: Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Response 11 The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified. Comment 12 Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Response 12 The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints. Comment 13 Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Response 13 The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria. Comment 14 Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Response 14 A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design. Comment 15 Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Response 15 Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place. Comment 16 Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. Response 16 It was added in the manuscript but not as table Comment 17 In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Response 17 expected outcomes were framed as hypotheses Comment 18 Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Response 18 Consistency ensured throughout the document Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Comment 1 Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Response 1 We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes. Comment 2 Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Response: We thank the reviewer for this important suggestion. The manuscript has been revised to explicitly operationalize the core constructs, knowledge, attitudes, stigma, and inclusive school environment, by specifying the domains/indices used to represent each construct and identifying the respondent groups and data sources. A construct-to-measure mapping table has been added under the Evaluation Instruments section to improve clarity, transparency, and reproducibility of the evaluation framework. Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . Response 2 We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation. Comment 3 Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Response 3 We thank the reviewer for highlighting the need for clarification regarding the study design. We revised the study design and will now employ a quasi-experimental cluster design with matched comparison schools. Eight schools will participate, with four receiving the intervention and four serving as comparison schools matched on geographic and demographic characteristics. Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model). Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level. Comment 4 Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). Response 4 We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change. Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components. Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability. Comment 5 Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Response 5 We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist. Comment 6 Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Response 6 We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify: The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication. Comment 7 Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Response 7 We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines: The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation. Comment 8 Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Response 8 We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate. In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Comment 9 Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. Response 9 We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript. We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript. Comment 10 Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Response 10 It has been provided in the manuscript Comment 11 Points that must be addressed to make the article scientifically sound: Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Response 11 The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified. Comment 12 Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Response 12 The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints. Comment 13 Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Response 13 The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria. Comment 14 Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Response 14 A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design. Comment 15 Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Response 15 Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place. Comment 16 Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. Response 16 It was added in the manuscript but not as table Comment 17 In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Response 17 expected outcomes were framed as hypotheses Comment 18 Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Response 18 Consistency ensured throughout the document Competing Interests: No competing interest Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: yildiz ys. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r413146 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-413146 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Oct 2025 yasemin sahin yildiz , Bartın University Vocational School of Health Services, Agdaci Campus, Turkey Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.187045.r413146 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? ... Continue reading READ ALL I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact. Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Attitude, Epilepsy, Knowledge, Peer education, Seizure first aid. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT yildiz ys. Reviewer Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r413146 ) The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-413146 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 25 Mar 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 25 Mar 2026 Author Response Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The ... Continue reading Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? Response 1 We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment 2 - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response 2 We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment 3 - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response 3 We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment 4 However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response 4 Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey. Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? Response 1 We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment 2 - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response 2 We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment 3 - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response 3 We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment 4 However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response 4 Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey. Competing Interests: No competing interest Close Report a concern Author Response 21 Apr 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 21 Apr 2026 Author Response Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to ... Continue reading Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? RESPONSE We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? RESPONSE We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey Competing Interests: No conlict of interest Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 25 Mar 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 25 Mar 2026 Author Response Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The ... Continue reading Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? Response 1 We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment 2 - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response 2 We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment 3 - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response 3 We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment 4 However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response 4 Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey. Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? Response 1 We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment 2 - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response 2 We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment 3 - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response 3 We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment 4 However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response 4 Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey. Competing Interests: No competing interest Close Report a concern Author Response 21 Apr 2026 Thendo Gertie Makhado , Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa 21 Apr 2026 Author Response Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to ... Continue reading Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? RESPONSE We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? RESPONSE We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey Competing Interests: No conlict of interest Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Sep 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 25 Mar 26 read Version 1 03 Sep 25 read read yasemin sahin yildiz , Bartın University Vocational School of Health Services, Agdaci Campus, Turkey Michael S. Petrides , University of Nicosia, Nicosia, Cyprus Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 yildiz y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Mar 2026 | for Version 2 yasemin sahin yildiz , Bartın University Vocational School of Health Services, Agdaci Campus, Turkey 0 Views copyright © 2026 yildiz y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have satisfactorily addressed all previously raised concerns. The revisions have improved the clarity, methodological rigor, and overall quality of the manuscript. Competing Interests No competing interests were disclosed. Reviewer Expertise Attitude, Epilepsy, Knowledge, Peer education, Seizure first aid. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) yildiz ys. Peer Review Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.197516.r470538) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-865/v2#referee-response-470538 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Petrides M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Feb 2026 | for Version 1 Michael S. Petrides , University of Nicosia, Nicosia, Nicosia, Cyprus 0 Views copyright © 2026 Petrides M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Summary of the article This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Responses to the journal questions 1) Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . 2) Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). 3) Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. 4) Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Points that must be addressed to make the article scientifically sound Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Minor comments and polishing suggestions Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Pharmacoepidemiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (1) Author Response 25 Mar 2026 Thendo Gertie Makhado, Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa Reviewer 2 This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration. Comment 1 Is the rationale for, and objectives of, the study clearly described? Partly. What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation). What needs strengthening (must address for scientific soundness): Define the primary objective and primary outcome explicitly. The protocol lists multiple objectives but does not specify which is primary (e.g., stigma reduction vs knowledge gain) or how success will be judged. This is essential for a robust evaluation plan. Response 1 We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes. Comment 2 Operationalize key constructs. Terms like “stigma,” “knowledge,” “attitudes,” and “inclusive environment” are not operationally defined in the protocol (i.e., which domains/indices will represent them, and in whom—learners, teachers, parents). Response: We thank the reviewer for this important suggestion. The manuscript has been revised to explicitly operationalize the core constructs, knowledge, attitudes, stigma, and inclusive school environment, by specifying the domains/indices used to represent each construct and identifying the respondent groups and data sources. A construct-to-measure mapping table has been added under the Evaluation Instruments section to improve clarity, transparency, and reproducibility of the evaluation framework. Clarify the scope of the intervention being “culturally sensitive.” The protocol emphasizes bridging biomedical knowledge and traditional beliefs, but it does not specify what content addresses these beliefs and how cultural adaptation will be performed/documented during co-development. Constructive suggestions: Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table: construct → instrument/subscale → respondent group → timing . Response 2 We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation. Comment 3 Is the study design appropriate for the research question? Yes (with important clarifications needed). A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences). Key issues to address (some are “must address” because they affect internal validity): Intervention vs control/comparator is ambiguous. The protocol mentions comparisons with “control schools” where feasible but does not define whether a control group will exist, how it will be selected, or what it receives. Must address: State clearly whether this is (a) single-group pre/post, (b) quasi-experimental with matched controls, or (c) cluster trial/pilot with controls, and justify feasibility. The implementation plan conflicts with sampling. The protocol anticipates 8 schools (400–480 learners), but the implementation phase states piloting in 3–5 schools. Must address: Reconcile the number of schools and specify which schools contribute to evaluation data. Response 3 We thank the reviewer for highlighting the need for clarification regarding the study design. We revised the study design and will now employ a quasi-experimental cluster design with matched comparison schools. Eight schools will participate, with four receiving the intervention and four serving as comparison schools matched on geographic and demographic characteristics. Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model). Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level. Comment 4 Timing is incomplete for assessing persistence of effects. Only immediate pre-/post-assessment is described. For educational interventions, a follow-up assessment (e.g., 4–8 weeks post) is important to assess retention and sustained attitude change (and was also raised in the included open review). Strongly recommended: Add a follow-up timepoint and describe procedures. Constructive suggestions: Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination). Response 4 We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change. Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components. Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability. Comment 5 Are sufficient details of the methods provided to allow replication by others? Partly. The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments. Major replication gaps (must address for scientific soundness): Intervention specification is not detailed enough. The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify: the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”). Fix: Include a structured intervention description (e.g., TIDieR checklist style: why/what/materials/procedures/who/how/where/when/tailoring/fidelity). Response 5 We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist. Comment 6 Outcome measurement is underspecified. The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s). Fix: Name the questionnaire(s), specify domains (knowledge/attitudes/stigma/first-aid response), scoring rules, and planned validity steps (translation/back-translation, cognitive interviewing, internal consistency). Response 6 We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify: The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication. Comment 7 Analysis plan is missing. There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation). Fix: Add a dedicated “Data analysis” section for quantitative and qualitative components, including how mixed-methods integration will occur (convergent, explanatory sequential, etc.). Response 7 We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines: The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation. Comment 8 Eligibility criterion “able to comprehend age-appropriate content” is not operationalized. It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool). Fix: Define an objective method (e.g., standard grade enrollment plus language of instruction; or brief screening; or exclude only severe cognitive impairment as identified by school records—whichever is ethical and feasible). Response 8 We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate. In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons. Comment 9 Additional important clarifications (recommended): Inclusion/exclusion of learners with epilepsy is not explicitly stated; this can affect outcomes (baseline knowledge, lived experience, stigma dynamics). Consent logistics : the process is described generally; consider specifying how confidentiality is protected within classrooms and focus groups involving minors. Response 9 We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript. We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript. Comment 10 Are the datasets clearly presented in a useable and accessible format? Not applicable (as a protocol), but extended materials are available. The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion. It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency. Constructive suggestions (recommended for future data sharing quality): Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class). Response 10 It has been provided in the manuscript Comment 11 Points that must be addressed to make the article scientifically sound: Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot). Response 11 The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified. Comment 12 Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion). Response 12 The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints. Comment 13 Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity). Response 13 The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria. Comment 14 Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings. Response 14 A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design. Comment 15 Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion. Response 15 Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place. Comment 16 Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. Response 16 It was added in the manuscript but not as table Comment 17 In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Response 17 expected outcomes were framed as hypotheses Comment 18 Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability. Response 18 Consistency ensured throughout the document View more View less Competing Interests No competing interest reply Respond Report a concern Petrides MS. Peer Review Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r432670) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-432670 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 yildiz y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Oct 2025 | for Version 1 yasemin sahin yildiz , Bartın University Vocational School of Health Services, Agdaci Campus, Turkey 0 Views copyright © 2025 yildiz y. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact. Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Attitude, Epilepsy, Knowledge, Peer education, Seizure first aid. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 25 Mar 2026 Thendo Gertie Makhado, Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa Reviewer 1 I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. Comment 1 - The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? Response 1 We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment 2 - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response 2 We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment 3 - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response 3 We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment 4 However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response 4 Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey. View more View less Competing Interests No competing interest reply Respond Report a concern Author Response 21 Apr 2026 Thendo Gertie Makhado, Advanced Nursing Sciences, University of Venda, Thohoyandou, South Africa Reviewer 1 Comment I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research. The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? RESPONSE We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation. Comment Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. Response We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility. The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains: Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items). We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity. These revisions enhance scientific rigor, replicability, and clarity of outcome measurement. We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology. Comment - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. Response We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.” Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly. Comment However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study. Response Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey View more View less Competing Interests No conlict of interest reply Respond Report a concern yildiz ys. Peer Review Report For: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary schools in Limpopo province: A Protocol [version 2; peer review: 1 approved, 1 not approved] . F1000Research 2026, 14 :865 ( https://doi.org/10.5256/f1000research.187045.r413146) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-865/v1#referee-response-413146 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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