Epilepsy is a neurological condition characterized by recurrent seizures. A seizure is a transient disturbance of cerebral function secondary to abnormal paroxysms in the brain, resulting in sudden and excessive disorderly discharge of the cerebral neurons. People with epilepsy have an increased risk of developing a variety of psychological problems, including depression, anxiety, and psychosis [1]. Most cases of epilepsy are idiopathic; however, some cases may result from brain injury, stroke, brain tumour, or drugs/alcohol abuse. In addition, some cases of epilepsy have been shown to arise from specific genetic mutations [2].

In contrast to seizures and epilepsy in adults, generalised tonic-clonic seizures in children may have various origins and a different natural history. Children may also be more sensitive to the effects of drugs. The doctor must consider the likelihood of future seizures as well as any potential repercussions when deciding whether or not to treat a child who has only had one or a few seizures. Signs and symptoms can range from mild to severe and vary depending on seizure type. Seizure signs and symptoms may include (a) temporary confusion; (b) staring spells; (c) uncontrollable jerking movements of the arms and legs; (d) loss of consciousness or awareness; and (e) cognitive or emotional symptoms such as fear, anxiety, or déjà vu [3].

The worldwide prevalence of epilepsy in children has been reported to be 6.38 per 1,000 persons [4], while in the Kingdom of Saudi Arabia, the prevalence has been reported to be 6.54 per 1,000 persons [5]. A recent study in the Qassim region of Saudi Arabia indicated that public knowledge about epilepsy is insufficient [6, 7]. In Riyadh, it has been reported that both the general public and schoolteachers require improvement in epilepsy-related knowledge [8, 9]. Another study conducted among schoolteachers showed that their knowledge regarding both epilepsy and first aid is insufficient [10].

Although epilepsy is one of the most prevalent and severe neurologic disorders, our knowledge of its intricate pathophysiology and, consequently, the rationale for much of its therapy and management is still limited. Caregivers of children with epilepsy must have an adequate awareness of the disease in order to provide sufficient care. To the best of our knowledge, this study is the first to investigate caregivers' general knowledge and first-aid practice of epilepsy management and the effectiveness of education on those parameters in the Kingdom of Saudi Arabia.

We enrolled 586 caregivers from different regions of Saudi Arabia and administered questionnaires to assess their knowledge and first-aid practices. Table 1 presents the sociodemographic characteristics of the sample. The age range was 17 to 74 years (mean age, 38.7 years). Middle adults (31–40 years) were the most common age group (38.1%). More than half (52.4%) of the sample comprised males, and the most common region of residence was the southern region (39.1%). A majority of respondents reported achieving either a university degree (45.4%) or a high school (32.4%) level of education. As for employment status, 49.8% were employed, 44.9% were unemployed, and 5.3% were students.

Table 2 presents the relationship between caregivers and the patients and the caregivers’ pre-intervention knowledge about seizures and first aid practices. The proportion of caregivers who reported having knowledge about epilepsy and first aid was 42.7% and 39.8%, respectively. About one-third (33.1%) of the caregivers were mothers, and 24.4% reported that other persons who were close to the patient were taking care of the patient.

Fig. (1) depicts the information sources regarding seizures. It was found that the commonest source of information was the patient’s doctor (18.4%), followed by the internet (14.3%). Family and friends were the least common source of information (2.6%). Fig. (2) depicts the most frequently reported sources of information regarding first aid. The most commonly reported source of information was the patient’s doctor (21.8%), followed by the internet (9.6%) and courses attended (3.9%). As with the information about seizures, family and friends were the least commonly used source (1.9%).

Fig. (1) presents percentage of patients who reported using doctors, the internet, courses, family and friends, or others as their primary source of information about seizures.

Fig. (2) presents percentage of patients who reported using doctors, the internet, courses, family and friends, or other as their primary source of information about seizure-related first aid practices.

Table 3 shows the results of the knowledge assessment regarding epilepsy before and after education. The top 3 items where caregivers exemplified good understanding were; “Ictus: Sweating, blackouts, jerking movements, twitching, chewing or lip-smacking, unable to move, repeated blinking of eyes”, for which 85.5% of caregivers demonstrated pre-education knowledge and 96.4% of caregivers demonstrated post-education knowledge; “Treatment for epilepsy are anticonvulsants while surgery is indicated in some cases”, for which 73.9% of caregivers demonstrated pre-education knowledge and 85.8% of caregivers demonstrated post-education knowledge, and “CNS disorder”, for which 63.5% of caregivers demonstrated pre-education knowledge and 85.5% of caregivers demonstrated post-education knowledge. Overall, the t-value between pre and post-intervention was -2.94, with a statistically significant p-value of 0.006, indicating an improvement in knowledge following the educational intervention.

Fig. (1). Sources of information about seizures.

Fig. (2). Sources of information about seizure-related first aid.

Table 4 shows the results of the questionnaire on first-aid practices both before and after caregiver education. Prior to education, caregivers showed the best first-aid practices for the items: “call 911 if needed” (57.8%), “stay with the patients until awake” (49.1%), and “stay with the patient and start timing the seizure” (42.2%). After education, caregivers showed improved first-aid practices for the items: “Turn the patient on his/her side” (90.4%), “Call 911 if needed” (87.5%), and “Keep the patient safe and remove or guide away from harmful objects” (83.3%). Overall, the t-value between pre and post-intervention is -4.4265, with a statistically significant p-value of 0.0002, indicating an improvement in first-aid practices following the educational intervention.

Table 5 shows the mean questionnaire scores and a summary of the levels of caregiver knowledge about seizures and seizure-related first-aid practices before and after education. For our sample, the mean knowledge score was 3.96 (SD 1.69) before education and 5.58 (SD 1.63) after education. Approximately 60% of caregivers demonstrated poor seizure-related knowledge prior to education, but this number was reduced to 23.2% after education. For the first-aid practices questionnaire, the mean score was 3.08 (SD 2.19) before education and 6.32 (SD 2.08) after education. Before education, a strong majority (84%) of caregivers exhibited poor knowledge of proper first-aid practices, but after education, this number was reduced to 32.4%.

This study assessed the effectiveness of education in improving knowledge of epilepsy and first-aid practices of caregivers in Saudi Arabia. The findings of the current study may be useful to improve knowledge of patients' caregivers and the outcomes for patients with seizures. A disease-oriented caregiver is most likely to provide safe first-aid treatment to a child having a seizure episode. After educational intervention, a good knowledge level was attained among a majority of the participants.

Al Harbi et al. [9] reported that primary school female teachers showed slightly better overall knowledge, with approximately 80% of their sample demonstrating above-average knowledge about epilepsy, than what the current study reports. Consistent with our findings, several studies have reported significant improvements in knowledge of seizures among caregivers of children [3, 11-15] after interventions. However, Abbasi Kangevari et al. [16] reported a low level of knowledge in a sample taken from the general population of Iran.

In this study, several factors influenced epilepsy knowledge level. In particular, higher levels of education were associated with good knowledge levels, while older age and living in the western regions of Saudi Arabia were associated with poor knowledge levels. These findings were consistent with studies by Teferi and Shewangizaw [1] and Eze et al. [3]. Furthermore, respondents with previous knowledge about seizures showed significantly better knowledge prior to education. Still, following the educational sessions, the difference between those who did or did not have previous knowledge was not statistically significant, even though both groups exhibited an improvement in knowledge. Similar to the current study, Teferi and Shewangizaw [1] observed a difference in knowledge between respondents based on prior knowledge about epilepsy. They also reported various other factors as being associated with knowledge, including having heard about epilepsy, distance to health facility from the place of residence, having witnessed an epileptic seizure, having an age range from 46 to 55 years, occupational history of being self-employed or a laborer, and having a history of epilepsy or a history of epilepsy in family members. A study in Nigeria reported that a multivariate regression model identified marital status and department of study as possible predictors of knowledge in a sample of trainee teachers [3].

In order to provide urgent and safe care in response to seizures, it is necessary for caregivers of patients with epilepsy to have adequate practical knowledge of effective first-aid techniques. In the current study, a majority of caregivers (84%) performed poorly in first-aid practices, with only 16% of respondents achieving good scores. However, after education, the percentage of caregivers with poor levels of practice decreased to 32.4%, while 67.6% showed good practices. These results are similar to improvements following education reported in Nigeria [1], Iran [14], and India [15]. Other papers have reported overall good practices toward first aid management. For example, Teferi and Shewangizaw [1] reported that 33.5% of respondents adopted safe practices related to epilepsy, while Abbasi Kangevari et al. [16] reported that 45.4% of their respondents showed good and 42.5% showed very good levels of practical techniques. In contrast, Al-Harbi et al. [9] indicated that the overall practices were poor in the Kingdom of Saudi Arabia, with only 31.8% of female teachers reporting an ability to provide first-aid care to epileptic students.

Additionally, we observed that showing a good understanding of first-aid practices was significantly dependent on knowledge level, while having a poor understanding was significantly associated with caregivers' residence originating from the western regions of the Kingdom of Saudi Arabia. We also observed that the age group was not significantly associated with first-aid practices before the educational intervention; however, after the sessions, the oldest age group (>50 years) showed significantly lower practice scores. Another important finding was that gender was not significantly associated with first-aid practices before education, but after education, females showed significantly higher practice scores than males. In contrast, previous knowledge about seizures and first aid did not significantly improve the scores after education.

Finally, caregivers who were close to patients and had a diseased-oriented relationship did not show a significant difference from relative caregivers in pre-education first-aid practice scores, but after education caregiver type was significantly associated with first-aid practices. Few studies have evaluated the factors associated with first-aid practices before and after education. However, a study in Ethiopia reported that several factors were observed to be related to practical knowledge, including living alone, living in rural areas, years of formal education, age, and prior knowledge about epilepsy [1]. The results of that study conflicted with those of a study conducted in Nigeria [3], which reported observing no relationships between first-aid management and general characteristics in a sample of trainee teachers.

In the present study, the correlations between and among pre-education knowledge, post-educational knowledge, pre-education first-aid practices, and post-education first-aid practices were positive and significant. That is, pre-education knowledge was positively and strongly correlated with post-education knowledge, pre-education first-aid practices, and post-education first-aid practices. Similarly, post-education knowledge was positively correlated with both pre- and post-education first-aid practices, and the correlation between pre-education first-aid practices and post-education first-aid practices was also significant. This indicates that as pre-education knowledge increases, all domains are likely to increase for both pre-and post-education.

Knowledge of information sources is necessary to address gaps in both knowledge and use of first-aid practices. In this study, our results revealed that the source of information for knowledge about seizures and for practical knowledge about first aid were strikingly similar in nature. Caregivers reported that doctors, the internet, and courses were the most commonly used sources to obtain information about seizures and first aid. This result is consistent with the results of Neyaz et al. [2], who reported that teachers listed doctors and the internet as their main sources of information regarding first aid. Other studies have reported conflicting results. For instance, several studies have reported that participants are more likely to rely on information from media [3-15], while others have reported that participants rely on relatives, family, and friends for information [16].

The limitations of the research must be acknowledged. The study was constrained by the lack of a control group given the nature of the pre- and post-test intervention design; as a result, it was underpowered to determine the magnitude of the associations between variables and improvement in both knowledge and practice. It is important to consider the time of the post-test intervention assessment as it could have caused recollection bias among the caregivers.

Prior to education, caregivers' knowledge about seizures and seizure-related first aid practices was suboptimal, but these were markedly improved following education. Our results suggested that having a university degree was positively associated with seizure-related knowledge and first-aid practices. A collective effort is therefore needed in order to increase both caregiver general knowledge and practical knowledge related to first-aid. Government institutions play a vital role in addressing the education gaps among caregivers. An awareness campaign might aid in effectively delivering education through community-based programs or print ads. These targeted educational health promotions could bring awareness to those with lower levels of education and older caregivers living in particularly the Western regions of Saudi Arabia.