Pal, Deb Kumar; (1998) Control of childhood epilepsy in rural India: Evaluation of a community based intervention. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Childhood epilepsy is an important, largely unrecognised public health problem with pervasive economic and psychosocial impact in developing countries. Controversy over the side-effects of phenobarbitone, the challenges of case-finding for a stigmatising disorder, attrition from treatment, and lack of meaningful evaluation are major obstacles to achieving control. This study assessed the acceptability and relative efficacy of phenobarbitone in rural India and evaluated the effectiveness of an intervention within a community-based rehabilitation programme, using broad measures of outcome. A population of 117,000 in rural West Bengal was screened for childhood epilepsy, by key informant and survey methods, compared for cost, sensitivity and acceptability. Efficacy and side effects of phenobarbitone and phenytoin were compared in a randomised controlled trial of 94 untreated children. Parental adjustment, behavioural problems and social integration were blindly assessed at 12 months. Reasons for dropout were investigated. The survey was four times more sensitive but less acceptable to the community. There was no evidence of a difference in efficacy between phenobarbitone and phenytoin (hazard ratio 0.97; 95% CI: 0.32-2.78). There was no evidence of excess behavioural problems with phenobarbitone in parental reports (p=0.72), or by objective rating (odds ratio 0.51; 95% Cl: 0.16-1.60). Social integration was greatly impaired at baseline (p<0.01), intervention was associated with improvements, especially for girls. Parental adjustment was independently associated with low severity of impairment (p=0.01). Both child behavioural problems (p=0.03) and parental adjustment (p=0.06) were independently predicted by maternal satisfaction with social support. Ascertainment cost $8-$11 per case, and programme costs were $1 per child per month. Access and symptom resolution accounted for half the dropouts. Phenobarbitone is an acceptable first-line drug for childhood epilepsy in India. Ascertainment by key informants is more appropriate in community-based rehabilitation, itself an appropriate framework for intervention which resulted in important psychosocial changes, and at feasible cost.

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