1. Introduction
Epilepsy is a chronic neurological disorder characterized by persistent seizures described as “sudden occurrences of transient signs and symptoms caused by abnormal and excessive or synchronous neuronal activity in the brain” [
1]. Around 65 million people worldwide are considered to be affected. The disease causes a significant burden to the patients as it is linked with various somatic and psychiatric comorbidities, social issues caused by stigmatization, impaired quality of life, and increased mortality [
2,
3,
4,
5,
6].
Patients with epilepsy have been misunderstood, discriminated against, and socially stigmatized for centuries. This, unfortunately, continues today and significantly affects the daily lives of patients [
5,
7]. Stigma is determined not only by the objective characteristics of the disease but also by social stereotypes created due to lack of information and unfounded fears [
8]. Misconceptions and insufficient knowledge about epilepsy cause the development of negative attitudes toward patients with epilepsy and increase the stigmatization and psychosocial problems of patients [
9]. An epileptic seizure is traumatic both for the patient and for those who witness it. It can be difficult for patients to face the reactions of others. Patients are afraid that a seizure in public will lead to condemnation and avoidance by other people. Therefore, epilepsy is not just a seizure. For the patient, the severity of the disease is determined not only by the severity of the disease symptoms but also by the numerous negative opinions about patients with epilepsy attributed to these patients by the members of society [
9]. Stigma and discrimination negatively affect the quality of life and can often affect the patient less favorably than the seizures themselves [
4,
10]. Stigma stems from ignorance and misconceptions about epilepsy. Several studies have shown that more positive attitudes towards people with epilepsy were associated with a higher level of knowledge about epilepsy. Hence, strategies to combat social stigma include better education and marketing campaigns targeting the general population [
11,
12,
13]. Patients who do not have enough knowledge about epilepsy have difficulties adjusting to and understanding their disease and, therefore, may stigmatize themselves, which, in addition to facing social stigma, adversely affects their lives [
9,
13]. Their fear of the reaction of their peers leads to social anxiety and isolation, which could worsen existing psychological distress [
3,
4,
5,
14]. Therefore, it was no surprise that epilepsy was linked to an increased suicide risk [
2,
15].
Previous studies have shown that knowledge and attitudes toward epilepsy in the general population are insufficient, as well as among teachers who were expected to be more educated and able to provide first aid [
16,
17]. Improving knowledge about epilepsy and their attitudes towards those affected could be beneficial as it could raise social awareness and increase social support for the patients [
18]. Universities represent an environment that provides great opportunities for developing knowledge and building attitudes and beliefs based on scientific evidence, which could help young people create positive attitudes and correct behavior toward patients with epilepsy [
19]. As students represent an educated group of society, it is important they have the right knowledge and attitudes about health issues [
20]. Furthermore, it is especially important to evaluate the knowledge and attitudes of biomedical students as future medical workers who will directly work with epilepsy patients in the near future [
21]. Misconceptions, prejudice, negative attitudes, and gaps in knowledge could influence the quality of the care the future healthcare workers will provide for their patients [
22,
23]. One multicentric study conducted on university health students in the United States, Portugal, South Africa, Argentina, and Brazil showed that an alarming percentage of biomedical students still have mistaken ideas about epilepsy. A third of the included participants thought epilepsy was a mental disorder, and almost half did not know the pathophysiology of the disease [
20].
Epilepsy prevalence in Croatia has been previously determined to lie between 4.8–5.5/1000, with 53% of Croatian patients reporting feeling stigmatized [
24,
25]. A recent study showed that this prevalence might be underestimated, especially in less developed countries. Additionally, those poorer areas, with higher unemployment and lower education levels, might prove a further challenge for the patients, with more negative effects on their quality of life [
26]. Furthermore, no studies assessing Croatian university students’ knowledge and attitudes have ever been published.
For the aforementioned reasons, we conducted a survey-based cross-sectional study to determine the Croatian students’ knowledge and attitudes towards epilepsy, with special emphasis on the biomedical students who were compared with the general student population to analyze how their education affected their results.
2. Materials and Methods
This cross-sectional survey-based study was conducted in July and August 2021. Participants were Croatian students enrolled in the academic year 2020/2021. The survey was conducted online as a Google Forms document, and participants from multiple universities in Croatia were able to participate. The survey was distributed through the official students’ administration offices of the faculties and through student representatives in Croatian student organizations. The study was approved by the University of Split School of Medicine Ethics Committee (approval number: 2181-198-03-04-21-0069), and participants had to give informed consent before accessing the survey questionnaire.
The questionnaire was developed by Mewes et al. [
22], with additional items added from surveys by Alhalaiqa et al. [
19] and Akça et al. [
27]. It was adapted for Croatian students by first translating the adapted questionnaire into Croatian and then translating it back to English using native English speakers. The survey consisted of three parts and had a total of 26 items (
Supplementary Materials). The first part gathered demographic data, such as enrolled study program, study year, age, and gender. It consisted of 11 items and included questions about personal and family history of epilepsy and personal experience with epilepsy. The second part consisted of 7 items and measured the knowledge about epilepsy. It included questions about epilepsy prevalence, symptoms, first aid measures, and activities that might pose a danger to people with epilepsy. The final part gathered the participants’ attitudes towards people with epilepsy and consisted of 6 items that measured the attitudes on a Likert scale (Definitely yes, Probably yes, Maybe, Probably no, and Definitely no) and 2 items where the choices were Yes/No/I do not know.
According to the Croatian Bureau of Statistics, 155,627 students were enrolled in the academic year 2020/2021 [
28]. The sample size was calculated using the total number of students enrolled that year at all Croatian universities. With a confidence level set as 0.95 and a 5% margin of error, the necessary sample size was calculated and determined to be 384 participants.
Participants were grouped as either biomedical students or other. The biomedical field of studies was defined as one including the basic and clinical medical sciences, public health, veterinary medicine, dental medicine, and pharmacy, as defined by the National Council for Science, Higher Education and Technological Development, the government expert body that takes care of the development and quality of the scientific activity and the system of science, higher education, and technological development in the Republic of Croatia [
29]. Data were presented as overall number and proportion (%), mean and 95% confidence interval (CI) or median and interquartile range (IQR), where applicable. Data were analyzed using the Chi-square test and Mann–Whitney U test. Each participant was assigned an attitude score based on their answers to questions regarding attitudes toward patients with epilepsy. The total score was a sum of answers, with the answer ‘Definitely yes’ being assigned five points, the answer on the opposite side of the Likert scale ‘Definitely no’ assigned one point, and answers in between assigned four, three, or two points. Higher scores indicated more favorable views towards people with epilepsy, and scores ranged from a minimum of six to a maximum of thirty points. Linear regression analysis determined the factors associated with more positive attitudes. Univariate analysis was performed for each variable, with the attitude score serving as a dependent variable. Multivariate regression analysis was further conducted by including factors significantly associated with attitude score in univariate analysis. Results were considered statistically significant for
p < 0.05. Statistical analysis was conducted using SPSS (version 16.0, IBM Corporation, Chicago, IL, USA).