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The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies |
Mbuba CK, Ngugi AK, Newton CR, Carter JA |
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CRD summary This review assessed the interventions used for addressing the epilepsy treatment gap in developing countries and concluded that some causes of the treatment gap can be addressed through educational interventions and supply of anti-epileptic drugs. Inadequate reporting of results, coupled with a lack of randomised trial evidence, means the authors' conclusions should be interpreted with caution. Authors' objectives To investigate the magnitude and causes of the epilepsy treatment gap in developing countries, and to determine the effectiveness of intervention strategies to improve outcomes. This abstract was primarily concerned with the intervention strategies. Searching MEDLINE, EMBASE, and PsycINFO were searched for studies in any language from inception to 2007; search terms were reported. Reference lists of key papers were also searched. Studies reported as editorials, letters, or reports were excluded. Study selection Prospective cohort, randomised controlled, or pre-post studies were eligible for inclusion if they focused on either education or supply of drugs as interventions to address some of the causes of the epilepsy treatment gap in developing countries. Included studies were conducted in Africa or Asia, and assessed educational interventions (verbal workshops) targeted at people with epilepsy and health professionals, anti-epileptic drugs, or both. Participant ages (where stated) ranged from one to 75 years.
The authors did not state how the papers were selected for the review, nor how many reviewers performed the selection. Assessment of study quality Two independent reviewers assessed study quality based on response rates, adequacy of follow-up, and descriptions of the study populations, interventions, and sampling procedures. Studies were then rated as being good, average, or poor. Data extraction Data was extracted by one reviewer, with a second reviewer re-extracting data from a sample of half the studies. Methods of synthesis A narrative synthesis was presented. Results of the review Seven studies (three prospective cohort, three pre-post, and one with both these designs, n=1,606 patients with epilepsy) were included in the review, and were generally of good or average quality. Studies ran for between two months and three years.
The education interventions (pre-post studies) led to increased knowledge among patients with epilepsy and health professionals (four studies), and increased patient recruitment (three studies). Information pamphlets improved knowledge and default rates, but had no effect on adherence (two studies), while verbal education and drug supply did improve adherence (four studies). One study reported decreased levels of depression and neurotic disorders in patients receiving education. Authors' conclusions Some causes of the treatment gap in developing countries could be addressed through educational interventions and supply of anti-epileptic drugs. CRD commentary This review addressed a clear question and was supported by appropriate inclusion criteria. Attempts to identify relevant studies in any language were undertaken by searching three electronic databases and by checking references. No attempt appears to have been made to identify unpublished studies, which leaves the review open to the possibility of publication bias. Methods were employed to minimise or reduce the risks of reviewer error and bias in the processes of data extraction and assessment of study quality. The authors did not report whether such methods were used to select studies for inclusion. Although study quality was assessed, the results of the assessment were not used in the interpretation of the results of the review. Sufficient study details were provided and a narrative synthesis of the data was undertaken. Information on whether results were statistically significant was only provided for two studies, with no values reported, and only percentages, or no numbers at all, were provided for the other studies.
In the light of these issues, and bearing in mind the absence of randomised trial evidence, the authors conclusions should be interpreted with caution. Implications of the review for practice and research Practice: The authors stated that interventions should be tailored to the needs of each target group (i.e. health providers or patients) and should include psychosocial aspects of epilepsy.
Research: The authors stated the need for future research to focus on well-planned and coordinated medical, developmental and psychosocial interventions, which involve health system personnel and traditional healers. Funding Wellcome Trust-UK, and Kenya Medical Research Institute. Bibliographic details Mbuba CK, Ngugi AK, Newton CR, Carter JA. The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies. Epilepsia 2008; 49(9): 1491-1503 Indexing Status Subject indexing assigned by NLM MeSH Anticonvulsants /therapeutic use; Developing Countries /statistics & Epilepsy /epidemiology /etiology /therapy; Humans; Patient Compliance; numerical data AccessionNumber 12008106282 Date bibliographic record published 23/12/2008 Date abstract record published 20/01/2010 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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