Moderating effect of physical activity on stigma and psychological distress in children and adolescents with epilepsy: a multicenter cross-sectional study in China

doi:10.21203/rs.3.rs-4816834/v1

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Moderating effect of physical activity on stigma and psychological distress in children and adolescents with epilepsy: a multicenter cross-sectional study in China

https://doi.org/10.21203/rs.3.rs-4816834/v1

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Objective: Children and adolescents with epilepsy suffer from stigma. Stigma associated with epilepsy is closely related to poor physical activity (PA) and high levels of psychological distress. However, the internal relationships are not well understood in China. This study aims to investigate the mediating effect of PA to determine whether PA mediates the relationship between stigma and psychological distress among children and adolescents with epilepsy.

Methods: A multicenter cross-sectional design was used to study children and adolescents with epilepsy admitted to 9 tertiary hospitals in China. Data were collected using a questionnaire measuring the Kilifi Stigma Scale for Epilepsy, the Depression Anxiety and Stress Scale, and the Physical Activity Rating Scale. The PROCESS macro in SPSS was used to examine the mediation model.

Results: 226 children and adolescents with epilepsy participated in the study. Psychological distress increased considerably as stigma levels increased, while a decrease was observed with increasing levels of PA. The results showed PA mainly plays partial mediating roles in the relationship between stigma and depression (ab = 0.042, 95% CI: 0.016 to 0.068), anxiety (ab = 0.077, 95% CI: 0.054 to 0.099) and stress (ab = 0.092, 95% CI: 0.061 to 0.122) dimensions of psychological distress. Additionally, intensity (ab = 0.027, 95% CI: 0.007 to 0.048) and frequency (ab = 0.028, 95% CI: 0.010 to 0.049) respectively only intermediated the relationship between stigma and anxiety and stress; duration (ab = 0.023, 95% CI: 0.002 to 0.044; ab = 0.034, 95% CI: 0.015 to 0.055; ab = 0.037, 95% CI: 0.012 to 0.061) all mediated between stigma and the psychological distress dimensions.

Conclusion: Stigma could increase psychological distress by indirectly influencing PA and its components. Interventions to improve physical activity may prevent or reduce psychological distress among children and adolescents with epilepsy.

epilepsy

stigma

adolescents

children

physical activity

Epilepsy is a common chronic neurological disorder that affects about 70 million people globally, nearly 80% of these people living in low- and middle-income countries[1]. It is estimated that approximately 75% of epilepsy begins during childhood[2]. Epilepsy is characterized by chronic or recurrent seizures disorder. Seizures can lead to a range of involuntary physical responses, including vocalizations, loss of consciousness, salivation, incontinence, and involuntary defecation or urination. These manifestations can be frightening for those experiencing or witnessing them[3]. Children with epilepsy have 4.8 times more psychological difficulties than in healthy children[4]. These difficulties mainly include social isolation, stigma, or disability[5]. Although seizures and their control are the main focus of clinical care, stigmatization is a major contributor to the overall burden associated with the condition[6].

Epilepsy is commonly seen as a mental disorder rather than a neurological condition in China[7]. Studies in China during the 1980s has estimated that up to 90% of people with epilepsy and 75% of their family members experience stigma[8]. An ethnographic study in rural and urban China found that most informants had negative attitudes towards epilepsy and people with epilepsy[9]. In a community-based survey, a third of people with epilepsy of all ages identified stigma as the most difficult part of living with epilepsy[10]. It is also worth noting that stigma has a major impact on both the physical and mental health of people with epilepsy. Many evidence has shown that stigma can be an important risk factor for psychological distress[11, 12]. The presence of stigma among children and adolescents with epilepsy is associated with low self-esteem, retardation in neurocognitive development, psychological distress[12, 13], poor academic progress[14, 15], and increased mortality (mainly suicide)[16]. The negative consequences of stigma worsen health conditions, leading to a vicious cycle of social marginalization and deteriorating health[17].

Psychological distress is the most common psychiatric comorbidities in children and adolescents with epilepsy[5, 18]. The social aspects of stigma are significant determinants to the development of anxiety and depression in epilepsy. Suurmeijer et al.[19] in Netherlands have confirmed that the main factor influencing anxiety and depression was social aspects of stigma. In addition, previous systematic reviews have reported a positive association between stigma and depression, anxiety, low self-efficacy, and substance abuse[20]. Children and adolescents are much more likely to experience psychological distress than adults[21]. Around 19% and 14% of children and adolescents with epilepsy meet diagnostic criteria for anxiety and depressive disorders, respectively[22], 3 to 5 times higher than the overall rate of children and adolescents[23]. It is confirmed that psychological distress is related to an unfavorable outcome and a poor quality of life.

Physical activity (PA) may be an effective method of preventing or alleviating psychological distress and improving mental health of children and adolescents[24], however, children and adolescents with epilepsy tend to lead more sedentary lifestyles and engage in lower level of PA than the general population[25]. Tedrus et al.[26] suggest that lower levels of PA are associated with higher levels of stigma and lower quality of life in adults with epilepsy. The experience of stigma has a negative impact on motivation to engage in physical exercise. Students who report being teased because of epilepsy exhibit reduced confidence in being physically active and lower levels of physical fitness compared with their peers[27]. With the development of activity psychology[28], the positive effects of PA and exercise on the physical and mental health of children and young people have long been recognized[29]. Exercise could be encouraged as part of non-pharmacological treatment for children and adolescents[30]. Physical inactivity is a significant public health concern, but few studies have focused on the physical activity patterns of children and adolescents with epilepsy[29]. There is an imperative need to advocate for the creation and maintenance of an exercise routine in children and adolescents with epilepsy.

To date, most of the research on stigma in epilepsy has focused on adults or mixed adolescent/adult samples. Lack of research in children and adolescents with epilepsy. The stigma characteristics of children and adolescents with epilepsy are not well understood in China. Meanwhile, stigma may impose dual physical and psychological distress on individuals. Lack of PA have been shown to be a major risk factor for poor mental health. Therefore, PA may play a role in the relationship between stigma and psychological distress. To our knowledge, no studies have been conducted to investigate the relationship between the three. To remedy this gap, this study aims to investigate the relationships among stigma, PA, and psychological distress in Chinese children and adolescents with epilepsy. Additionally, the study will determine whether the association between stigma and psychological distress is mediated by PA, including activity intensity, duration, and frequency. A better understanding of the underlying mediating processes of PA may help to mitigate the adverse effects of stigma in children and adolescents with epilepsy, thereby facilitating the implementation of more effective mental health interventions.

This study proposed the following hypotheses:

In China, children and adolescents with epilepsy have a high prevalence of stigma and low levels of physical activity.
High levels of stigma are associated with higher levels of psychological distress in children and adolescents with epilepsy in China.
There is a correlation between stigma and poor physical activity in children and adolescents with epilepsy.
Physical activity, including intensity, duration, and frequency, partially mediates the relationship between stigma and psychological distress dimensions.

2.1 Study design and population

A multicenter cross-sectional study was conducted from October 2023 to March 2024. The questionnaire was sent to 9 tertiary children’s and comprehensive hospitals in different regions of China by sharing the link to the questionnaire online. These regions included eastern, central and western China. The managers of the neurology units in the survey gave their consent before the survey. 226 children and adolescents with epilepsy and their caregivers were recruited.

Participants were recruited using convenience sampling. The inclusion criteria comprised of: (1) children and adolescents ages ranging from 8 to 18 years and diagnosed with epilepsy by neurologists according the 2014 International League Against Epilepsy criteria for 2 months or longer[31]; (2) caregivers older than 18 years who provided care for children and adolescents with epilepsy, only one of the caregivers who was present with the child during the period of data collection was included in the study; (3) both child and caregiver were able to read and understand the questionnaire independently or with the help of the researcher; (4) willing to participate the survey. The exclusion criteria were: (1) children and adolescents with intellectual impairment, an IQ score lower than 80 on the Wechsler Intelligence Scale; (2) caregivers were diagnosed with severe medical conditions, cognitive impairment, or mental illness.

The sample size of this study was determined by the number of parameters tested. A minimum ratio of sample size to parameters of 10:1 was recommended. 17 parameters were observed in the study. Considering the invalid response rate of 15%, the required sample size was 196. In the end, a total of 226 patients were recruited.

2.2 Instrument

2.2.1 Sociodemographic characteristics

The self-designed questionnaire was used to collect basic sociodemographic characteristics of children and adolescents and their families. The data included age, gender, region of residence, whether it is a one-child family, average monthly household income, height and weight. These were mainly collected by the caregivers.

2.2.2 Disease-related characteristics

Disease-related characteristics involved age of seizure onset in years, disease duration, seizure type, whether it is drug-resistant epilepsy, frequency of seizures in recent 3 months, and comorbidities. These were mainly collected by medical records and self-report of caregivers.

2.2.3 Stigma

The Kilifi Stigma Scale for Epilepsy (KSSE) is a three-point Likert 15-item scoring scale[32], which was used to measure stigma. The Chinese version of KSSE were translated and validated by Song et al[33]. The translated version exhibits good reliability and validity (Cronbach's α=0.93). This scale is the only validated scale of stigma for epilepsy patients in China. The total score ranges from 0 to 30. A score above the 66th percentile of the total score indicates perceived stigma, while a score below the 66th percentile shows the absence of stigma.

2.2.4 Psychological distress

The Depression Anxiety and Stress Scale (DASS-21) is a shortened version of the full 42-item DASS developed by Lovibond and Lovibond[34], which is a common instrument for screening psychological distress symptoms during the past week. The Chinese version of the DASS-21 showed good reliability and validity in Chinese samples (The total Cronbach's α=0.91)[35, 36]. This scale comprises 21 items grouped into three subscales: depression, anxiety, and stress. Each item is rated on a 4-point Likert scale from 0 (not true) to 3 (very true). The scores are summed and a higher score indicates a higher level of psychological distress.

2.2.5 Physical Activity (PA)

The Physical Activity Rating Scale-3 (PARS-3), a three-question scale, was used to measure the level of physical activity of participants in terms of intensity, duration and frequency of physical activity[37]. Rating of each item on a scale of 1 to 5 and the total score for physical activity were computed using the following equation: intensity × (duration - 1) × frequency, with a range of 0-100, and was further classified into three levels according to the score: high (>42), moderate (20-42), and low (0-19) physical activity. The scale demonstrated strong reliability and validity in Chinese individuals (Cronbach's α=0.86)[28], with a excellent test-retest reliability (r = 0.82)[38].

2.3 Ethical Statement

Participation in this study was completely voluntary and anonymous. Researchers obtained participants and their caregivers informed consent before completing the questionnaire. This study was approved by the Medical Ethical Committee of Children’s Hospital of Chongqing Medical University (No.2023-370).

2.4 Data collection methods

A multicenter cross-sectional survey study was conducted from October 2023 to March 2024 in China. A total of 9 hospitals in 8 cities of 6 provinces were investigated (at least ten valid questionnaires in each hospitals were distributed) in China. The questionnaire was distributed to pediatric epilepsy specialist clinics and specialty wards. The participants were recruited using a convenient sampling method. The researchers were trained in advance and then provided participants with unified instructions, instructions for completing the questionnaire, and links to access the questionnaire. Researchers obtained their informed consent before completing the questionnaire in face-to-face interviews. For children and adolescents, consent was obtained from the child's caregiver. Questionnaires were completed separately by children and adolescents and their caregivers. If the questionnaire was incomplete, the respondent was asked to complete the missing items immediately. 239 children and adolescents with epilepsy and caregivers was selected. A total of 13 patients declined to participate due to lack of interest (five patients), time (four patients), or other unspecified reasons (four patients). In the end, 226 (94.6%) participants were recruited and completed the survey. There were no statistically significant differences in the distribution of age, gender, or seizure type between respondents and non-respondents.

2.5 Statistical analysis

The SPSS version 26 was used to analyze all data. Normally distributed measurement data were described by mean and standard deviation (SD), whereas non-normally distributed measurement data were described by median and quartile. The categorical variables were stated as the frequency and percentage. One-way ANOVA and the S-N-K test were used to assess continuous data, while the Chi-square test was used to assess categorical variables.

All analyses were adjusted for age, gender, one-child family, place of residence, average monthly household income, and seizure type. We used multivariate linear regression to determine the relationship among stigma, PA, and psychological distress. Andrew F Hayes’ PROCESS macro v.3.5 was used to develop the mediation model. Psychological distress (depression, anxiety, and stress) was the dependent variable (Y), PA (intensity, duration, and frequency) was separately the mediating variable (M), and stigma was the independent variable (X).

The combination of the direct and indirect effects of stigma on psychological distress was the total impact (path c). After adjusting for PA, the direct effect (path c’) was the effect of stigma on psychological distress. The indirect effect (path ab) mediated the relationship between stigma and psychological distress. In addition, the PA components were investigated independently as mediating variables. We used the PROCESS macro’s bootstrap approach. The bootstrap method produces 95% bias-corrected CI for these effects from 5000 re-sample of the data. CI that do not contain zero indicate a significant effect[39].

3.1 Characteristics of the participants

A total of 226 children and adolescents with epilepsy and their caregivers were included in the study. All participants’ sociodemographic and disease-related characteristics have been presented in Table 1. The mean age of children and adolescents with epilepsy was 12.28 ± 2.64 years (range: 8-18 years), 108 (47.8%) of them were female, and 55 (24.3%) families are one-child families. 75 (33.2%) participants live in cities. The mean duration of epilepsy since diagnosis was 3.77 ± 3.16 years. 115 (50.9%) of seizure type had focal onset. Seizure freedom during the recent three months was noted in 83 (36.7%) participants; Moreover, 16.8% of participants reported were drug-resistant epilepsy and 122 (54.0%) had comorbidities. The 66th percentile of the KSSE was 10. Thus, 83 participants (36.7%) reached the cutoff, which indicated the presence of stigma. In addition, 147 (65.0%) children and adolescents stated that they would kept epilepsy secret from others. Among the participants, 160 (70.8%) had PARS-3 scores ≤ 19, 57 (25.2%) scored 20-42, and 9 (4.0%) scored ≥ 43.

Table 1 Sociodemographic and disease-related characteristics of study participants (n=226).

Variables

Classification

Number (%) or mean ± SD

Age (years)

12.28 ± 2.64

8-11

12-14

15-18

102 (45.1%)

82 (36.3%)

42 (18.6%)

Gender

Male

Female

118 (52.2%)

108 (47.8%)

One-child family

Yes

55 (24.3%)

171 (75.7%)

Place of residence

City

Town

Rural

75 (33.2%)

76 (33.6%)

75 (33.2%)

Average monthly household income (yuan)

<3, 000

3, 000-5, 000

5, 001-10, 000

>10, 000

58 (25.7%)

82 (36.3%)

49 (21.7%)

27 (16.4%)

BMI (kg/m2)

19.95 ± 2.96

<18.5

18.5-23.9

≥24

73 (32.4%)

138 (61.3%)

14 (6.2%)

Epilepsy duration (year)

3.77 ± 3.16

<1 years

1-5 years

>5 years

45 (20.0%)

112 (49.8%)

68 (30.2%)

Seizure type

Focal onset

Generalized onset

Mixed

Unknown or unclassified

115 (50.9%)

68 (30.1%)

19 (8.4%)

24 (10.6%)

Seizure frequency in recent 3 months

1-3

4-12

>12

83 (36.7%)

100 (44.2%)

28 (12.4%)

15 (6.6%)

Drug-resistant epilepsy

Yes

38 (16.8%)

188 (83.2%)

Comorbidity

Yes

122 (54.0%)

104 (46.0%)

Note: BMI: body mass index.

3.2. Association between stigma and psychological distress

As shown in Figure 1, scores in all dimensions of psychological distress increased significantly (P<0.001) with increasing levels of stigma, while psychological distress decreased significantly (P<0.001) with increasing levels of PA. Table 2 shows the multivariate linear regression analysis of the associations of the continuous variables. Stigma was significantly associated with all dimensions of psychological distress after controlling for variables. PA was negatively associated with psychological distress on all dimensions. In addition, intensity and duration were negatively associated with the depression, anxiety, and stress dimensions, and frequency was negatively associated with the anxiety and stress dimensions.

Table 2 Multivariate linear regression analysis of associations between stigma, PA, and psychological distress.

Variables	Mean (SD)	Depression		Anxiety		Stress
Variables	Mean (SD)	β (95%Cl)	p	β (95%Cl)	p	β (95%Cl)	p
Stigma	9.761±6.916	0.316 (0.287 to 0.346)	<0.001	0.326 (0.298 to 0.355)	<0.001	0.452 (0.416 to 0.487)	<0.001
Physical activity	16.058±11.648	-0.146 (-0.169 to -0.124)	<0.001	-0.164 (-0.184 to -0.144)	<0.001	-0.221 (-0.249 to -0.194)	<0.001
Activity intensity	2.283±0.961	-0.415 (-0.678 to -0.151)	0.002	-0.601 (-0.842 to -0.361)	<0.001	-0.457 (-0.760 to -0.154)	0.003
Activity duration	2.289±1.001	-0.418 (-0.671 to -0.164)	<0.001	-0.626 (-0.857 to -0.395)	<0.001	-0.692 (0.983 to -0.400)	<0.001
Activity frequency	2.956±1.078	-0.190(-0.408 to 0.028)	0.087	-0.283 (-0.482 to -0.085)	0.005	-0.603 (-0.854 to -0.353)	<0.001

Note: Covariates: age, gender, one-child family, place of residence, average monthly household ,income, and seizure type. Significant effects are shown in bold.

3.3 Mediating effect of physical activity

According to the hypothesis 4 proposed in this study, we use SPSS PROCESS (3.4) to establish a simple mediating model. The mediating effect of PA on the relationship between stigma and different psychological distress is further depicted in Table 3 and Figure 2. PA mediates between stigma and three dimensions of psychological distress (ab = 0.042, 95%CI: 0.016 to 0.068; ab = 0.077, 95%CI: 0.054 to 0.099; ab = 0.092, 95%CI: 0.061 to 0.122).

Table 3 The general mediating effect of PA on the relationship between stigma and psychological distress.

Independent variable	Mediating variable	Dependent variable	Coefficient (bias− correctedbootstrap95% CI)
Stigma	PA	Psychological distress	Indirect effect (ab)	Total effect (c)	Direct effect (c’)
		¹Depression	0.042(0.016, 0.068)	0.316(0.282, 0.346)	0.274(0.263, 0.316)
		²Anxiety	0.077(0.054, 0.099)	0.324(0.298,0.355)	0.250(0.212, 0.288)
		³Stress	0.092(0.061, 0.122)	0.452(0.416, 0.487)	0.360(0.312, 0.408)

Note: Covariates: age, gender, one-child family, place of residence, average monthly household income, and seizure type. Significant effects are shown in bold. The superscript number is the mediation model number.

3.4 Mediating effects of physical activity components

A more detailed analysis of the mediating effects of the PA components is presented in Table 4 and Figure 3. Results showed the mediating effects of intensity, duration, and frequency on stigma and psychological distress dimensions. Intensity (ab = 0.027, 95%CI: 0.007 to 0.048) mediated the relationship between stigma and anxiety dimension. Duration (ab = 0.023, 95%CI: 0.002 to 0.044; ab = 0.034, 95%CI: 0.015 to 0.055;ab = 0.037, 95%CI: 0.012 to 0.061) mediated between stigma and all psychological distress dimensions. Moreover, frequency (ab = 0.028, 95%CI:0.010 to 0.049) only mediated the relationship between stigma and stress dimension.

TABLE 4 Summary of mediation analysis for stigma, PA components, and psychological distress.

Independent variable	Mediating variable	Dependent variable	Coefficient (bias− correctedbootstrap95% CI)
Stigma	PA	Psychological distress	Indirect effect (ab)	Total effect (c)	Direct effect (c’)
	Intensity
		¹Depression	0.019(0.000, 0.040)	0.316(0.229, 0.346)	0.298(0.262, 0.333)
		²Anxiety	0.027(0.007, 0.048)	0.324(0.298, 0.355)	0.300(0.266, 0.333)
		³Stress	0.005(-0.017, 0.031)	0.452(0.416, 0.487)	0.446(0.404, 0.489)
	Duration
		⁴Depression	0.023(0.002, 0.044)	0.316(0.787, 0.346)	0.294(0.258, 0.330)
		⁵Anxiety	0.034(0.015, 0.055)	0.326(0.298, 0.355)	0.292(0.259, 0.326)
		⁶Stress	0.037(0.012, 0.061)	0.452(0.416, 0.487)	0.415(0.373, 0.457)
	Frequency
		⁷Depression	0.002(-0.013, 0.017)	0.316(0.287, 0.346)	0.315(0.281, 0.348)
		⁸Anxiety	0.002(-0.011, 0.016)	0.326(0.298, 0.355)	0.324(0.292, 0.356)
		⁹Stress	0.028(0.010, 0.049)	0.452(0.416, 0.487)	0.423(0.385, 0.463)

The objective of this study was to analyse the mediating effect of physical activity (PA) between epilepsy-related stigma and psychological distress dimensions in children and adolescents. The results indicated that stigma had a positive relationship with all dimensions of psychological distress, and that PA had a mediating effect after controlling for variables. In addition, each of the PA components partially mediated the association between stigma and psychological distress. To the best of our knowledge, this was the first study to examine the effect of PA on the mediation of the relationship between stigma and psychological distress in Chinese children and adolescents with epilepsy.

This study found that the prevalence of stigma in children and adolescents with epilepsy was 36.7%, which is slightly higher than previous studies using the same scale in south-western Uganda (34%)[40], patients aged over 16 in China (34. 29%)[41], and 189 patients between the ages of 18-74 (32.27%)[42]. Moreover, Our study found that 65% of children with epilepsy did not tell others about their disease (which could be a symbol of stigma), which were also slightly higher than for other age groups[43]. The high prevalence of stigma might indicate the huge influence of epilepsy on social life in China. Further more studies are needed to determine the status of children’s stigma in China. In addition, physical activity in children and adolescents with epilepsy is insufficient and has not yet reached the recommended levels[44]. The low level of physical activity exhibited by 70.8% of participants in the current study is a cause for concern. This finding is in line with previous Meta-analysis that found people with epilepsy are less active than their peers for a variety of reasons including prejudice, stigma, fear, shame, lack of knowledge or medical advice[45]. As a result, hypothesis H1 holds true.

Children and adolescents with epilepsy often suffer from stigma and psychological distress. Our findings confirmed that the relationship between stigma and psychological distress, that is, children and adolescents who experienced more stigma were at greater risk of psychological distress, including depression, anxiety, and stress, with hypothesis H2 being valid. Previous research has highlighted the deleterious effects of stigma on psychosocial and behavioral health of adults with epilepsy[46]. A study of adults with epilepsy in India found that overall perceived stigma strongly contributes 32.9% to the variance on stress, anxiety, and depression[47]. Similarly, as noted in the Mar et al.[48] research found a significant positive relationship between perceived stigma and depression. Furthermore, other studies on executive function in patients with epilepsy have demonstrated that executive dysfunction is a significant predictor of stigma and quality of life[49, 50]. Zhao et al.[51] in China found depression mediated the relationship between perceived stigma and suicidal tendency. Together, these findings reveal a complex stigma-mental disorder mechanism. Future studies are needed to measure and analyze the relationship between variables in longitudinal analysis.

While the benefits of regular participation in physical activity for children and adolescents are clear, children with epilepsy are often excluded from physical exercise[52, 53]. Data analysis revealed that stigma was negatively correlated with physical activity. Children and adolescents with epilepsy may be reluctant to go outside due to concerns about the possibility of an involuntary loss of control in public places [3]. Moreover, Chinese culture and folk traditions may have diminished the status of people with epilepsy, considered by many a terrible and incurable disease[7]. The internalization of negative images about epilepsy may also dampen engagement in physical activities[30]. The mediation effect analysis revealed that the PA total score plays a partial mediating role between stigma and psychological distress dimensions. The analysis suggests that PA may act as a stress reliever, as it is known to produce endorphins and facilitate social connection[54]. Furthermore, animal models confirm a positive effect of PA on mood, cognition, and seizure control[55]. Experimental studies have also indicated that PA may provide mechanisms of neuronal protection, including the release of β-endorphins and steroids. Epileptic discharges may decrease or disappear during exercise[56]. A Brazilian study documented that physical inactivity is a risk factor for the development of depression and anxiety in people with epilepsy[57]. Therefore, it is important for PA to reduce the adverse effect of stigma on psychological distress. Several studies have demonstrated that PA can help reduce stigma and improve psychological distress in children and adults with epilepsy[58, 59], which is also in line with our results.

To gain a more comprehensive understanding of the moderating effect of physical activity, this study extended the concept to include activity intensity, duration, and frequency. Different PA components are mediated in different psychological distress dimensions. The duration of PA was found to exert a moderating effect on depression, anxiety, and stress; intensity and frequency only had moderating effects in the anxiety and stress dimensions, with hypothesis H3 and H4 being valid. Children and adolescents with epilepsy should prioritize increasing the duration of PA. In fact, the mechanisms underlying the effects of PA on psychological distress remain unclear. Likewise, studies of the relationship between intensity, duration, and frequency of physical activity and psychological distress are inconsistent[60]. Further research could consider the inclusion of activity frequency, intensity and duration variables to assess the specific needed of children and adolescents with epilepsy.

In general, appropriate education and advice about particular types of physical activity is fundamental to avoid perceived risk of adverse events. Of note and interest, current evidence suggests that few restrictions are needed for children with epilepsy, beyond water-related precautions and avoiding very risky activities[61, 62]. Thus, Schools should ensure that children and young people with epilepsy are included and supported to participate in physical activity and exercise without undue restriction. Meanwhile, clinicians should incorporate an assessment of physical activity into routine obtain medical history and provide physical activity recommendations and plans for families of children with epilepsy, further emphasizing the need to train health professionals to provide advice on physical activity[63]. Importantly, an individual medical advice is also needed to consider safety in specific sports and in those where seizures have not been well controlled. However, there remains a lack of evidence on the specific details of exercise prescription in epilepsy and future more work is needed[61].

Our results offer new insights into this research field. First, this study reaffirms the importance of interventions that enhance the physical activity of children and adolescents living with epilepsy. School-based programs may provide children and adolescents with epilepsy for social and physical activities. Second, previous studies have mostly focused on the influencing factors of stigma and psychological distress[26, 47], and seldom delve deeper into the internal relationships between variables, whereas the mediation effect allows to analyse direct and indirect effects between variables in a clear way. Our research provide theoretical basis and empirical support for reducing or delaying the occurrence of psychological distress. Physical exercise and psychoeducation can reduce the burden of epilepsy and improve the overall quality of life by reducing perceived stigma[54, 59]. Policymakers and practitioners can launch a range of public awareness campaigns to reduce stigma and stereotypes about epilepsy and raise awareness of mental health issues in epilepsy.

While this study has provided new insight into the potential mediating role of physical activity between stigma and psychological distress in children and adolescents with epilepsy, there are still limitations that need to be addressed in future studies. Firstly, the cross-sectional study could not analyze the causal relationship between variables, merely indicating correlations. In the future, longitudinal designs can be used to confirm the mediational models proposed in this study. Secondly, self-report measures of PA measures are prone to inaccuracies. PA as measured by wearable technology should be more reliable. Furthermore, more detailed information about physical activity is needed, including types of physical activity (e.g., aerobic, resistance, and flexibility), metabolic equivalents (METS), and other personal factors that may influence participation. Thirdly, although our sample size was national multicenter, it is not a large sample. Future robust studies are needed to address negative attitudes and discrimination against epilepsy. These interventions, which focus on reducing stigma, indirectly prevent or reduce psychological distress by increasing physical activity.

This study demonstrates the possible influencing mechanism of stigma on the psychological distress of children and adolescents with epilepsy. The stigmatization of epilepsy in children and adolescents is a significant factor contributing to psychological distress, exerting both direct and indirect effects through physical activity as a mediator. Furthermore, duration exerts a more profound moderating influence than intensity and frequency. The findings indicate that promoting higher levels of physical activity, including increasing the duration of exercise, may be an effective intervention for improving the mental health of children and adolescents with epilepsy.

Ethics statement

The studies involving human participants were reviewed and approved by Children’s Hospital of Chongqing Medical University. All of the participants provided oral consent and expressed their willingness to complete the study. Additionally, participants’ legal guardians/next of kin were provided their written informed consent to participate in this study.

Declaration of competing interest

All authors certify that we have no conflict of interest to declare.

Funding

This work was supported by the Hospital of Chongqing Medical University Nursing hospital-level key project (CHCQMU2023.02), and the China Association Against Epilepsy (CAAE) Epilepsy Care - Kang Zhe Foundation (CK-2024-053).

Author Contribution

JZ and SL conceived of and designed the study. JZ contributed to data collection, performed data analysis, and wrote the original draft. SL contributed to subject recruitment, funding acquisition, oversight, and revision of the manuscript. NZ contributed to the drafting and final version of the paper. JZ and YX mainly responsible for the analysis and interpretation of data. TW and QX contributed to data collection. All authors contributed to the article and approved the submitted version.

Acknowledgments

The authors are particularly grateful to the Pediatric Neurology Care Professional Committee of the Chinese Pediatric Nursing Union and all nursing managers for their support of this study. The authors thank all participants for their valuable contributions.

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Moderating effect of physical activity on stigma and psychological distress in children and adolescents with epilepsy: a multicenter cross-sectional study in China

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Introduction

Materials and Methods

2.1 Study design and population

3. Results

3.1 Characteristics of the participants

3.2. Association between stigma and psychological distress

4. Discussion

5. Conclusion

Declarations

Ethics statement

Declaration of competing interest

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Author Contribution

Acknowledgments

References

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