To date, the researchers of the current study assured that this review and meta-analysis on the average prevalence of perceived stigma and its associated factors in people living with epilepsy is the first of its kind in the context of Ethiopia. Therefore, the result obtained from this meta-analysis on the prevalence of perceived stigma in people living with epilepsy will be significant evidence to clinicians, future researchers, and any other interested bodies planning to design interventional as well as administrative policy in the field.
The average prevalence of perceived stigma in people living with epilepsy in Ethiopia was substantial (43.79%). This was lower than the prevalence of perceived stigma reported by a study that assessed more than 5,000 people living with epilepsy in 15 European countries where the reported prevalence of perceived stigma was 51% (14). The result of the present study was also lower than a study on systematic review and meta-analysis on the prevalence, associated factors, and impacts of personal stigma in patients with schizophrenia spectrum disorders whereby 64.5% of patients had perceived stigma (45). The long time difference between the present and earlier studies might be responsible for this. Besides, the loss of judgment and insight in most people with schizophrenia spectrum disorders might affect the higher prevalence of perceived stigma.
The average prevalence of perceived stigma in this study was however higher than the prevalence of perceived stigma in ten European countries where the overall prevalence of perceived stigma was 17% (14). Differences in cultural, economic, and associated attitudinal factors where the European countries are economically advanced and health care utilization in this setting might be high and reduces the perception of stigma.
The average prevalence of perceived stigma in people living with epilepsy varies according to the measurement tool used to assess' perceived stigma, the location of study, and year of publication.
A sub-group analysis of perceived stigma with measurement tool used to screen perceived stigma revealed that the average prevalence of perceived stigma in studies measured with modified FIS scale (20, 27) was significantly higher than the average prevalence of perceived stigma in studies measured with Kilifi stigma scale and three-item stigma scale.
The modified FIS scale is a WHO-approved tool for screening perceived stigma. Also, its Amharic version is validated in Ethiopia so that that it can sensitively detect epilepsy patients with perceived stigma but in most of the included studies that utilized Kilifi stigma scale (29–31, 33), the 66th percentile is used as the cut-off point that might not be as such sensitive to detect perceived stigma. Moreover, the small number of studies included in the sub-group of the FIS scale might result in an overestimation of the result and gives a higher prevalence of perceived stigma than studies assessed with the Kilifi stigma scale.
Furthermore, the average prevalence of perceived epilepsy stigma was significantly higher in studies from the Amhara region (27, 30) and Oromia region (20, 33, 34) than the pooled prevalence of perceived epilepsy stigma in Addis Ababa (28, 29, 32). The population living in Addis Ababa, the capital city of Ethiopia is relatively developed in terms of knowledge, social, and cultural views. Therefore they might have a better attitude regarding chronic illness in general and epilepsy, in particular that could probably reduce the average perceived stigma than the population in the Amhara and Oromia region. Further to this, both Amhara and Oromia regions are the two most populated regions in Ethiopia so that the health care coverage of these populous regions is still low which might contribute to the high average perceived stigma in the regions.
We also did a segmental analysis of the prevalence of perceived stigma on the ground of year of publication of the included studies and studies published before 2016 (20, 27, 29, 34) provide higher average perceived stigma (56.26%) than studies published in and after 2016 (26, 28, 30–33) (35.47%). This might be because increased awareness of people towards epilepsy is expected as the country's economic development is advancing through time that lowers the perceived stigma. Further to this the relatively few studies included in the sub-group of studies published before 2016 as compared to the sub-group of studies published in and after 2016 could minimize the precision and result in an overestimation of perceived stigma.
Relating to the factors associated with perceived stigma in people living with epilepsy, a narrative analysis revealed that being divorced/widowed, living in rural areas, low level of education, low-income level, age groups of 18 to 24 years, frequent seizure occurrence, contagion believe regarding epilepsy, seizure-related injury, duration of epilepsy from 1 to 10 years, depression and anxiety co-morbidity were the associated factors with perceived stigma in people with epilepsy in Ethiopia.
This was supported by earlier review studies abroad, whereby rural residence, lower-income, and educational status, being female, and single, not witnessing individuals having the disorder, contagious believe regarding epilepsy and mental illness co-morbidity were reported to be associated with perceived stigma in epilepsy (35, 36). However, a review of literature in Nigeria had shown that people with epilepsy are felt stigmatized due to the psychopathology associated with epilepsy (37).
The difference between studies included in the meta-analysis
This review and meta-analysis study was prejudiced by a great heterogeneity from the difference between analyzed studies. Therefore consideration of sub-group and sensitivity analysis was instigated. The analysis of the sub-group was done under the assessment instrument for perceived stigma, regional setting, and year of publication of studies. All the above three dimensions of subgroup provide subtle evidence from where was the difference between studies arise. Even though a sensitivity analysis was done, there was no implication of a single study outweighing the average prevalence of perceived stigma in people with epilepsy in Ethiopia.
In using the results of the present meta-analysis study, we should take into consideration its shortcomings. Primarily, a few numbers of studies have been pooled in the subgroup analysis based on measurement tool, study location, and publication years with the possibility of influence on estimate precision. Further to this, the occurrence of great heterogeneity in the pooled prevalence of perceived stigma was also a constraint to the plausibility of the study. Finally, a sole narrative analysis of the associated factors for perceived stigma in individuals living with epilepsy still requires further exploration of the average effect size of associated factors by future researchers. The shortage of earlier meta-analysis studies in people living with epilepsy has also made the comparison the results of the present study difficult and should be taken into consideration.