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PSYCHOLOGIA
An International Journal, Volume 9 No.1, 2001
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VOLUME NINE ISSN 1117-1421
NUMBER ONE MARCH 2001
Editorial i
Contents iii
C.HOF& Teenage Pregnancy-as an Issue of Human Rights
A. RlCHTERS , for Women: The Case of Zimbabwe
F.K. AMEDAHE 12 Combining Teacher Assessment Scores with
External Examination Scores for Certification: Comparative
Study of Four Statistical Models
A.S. JEGEDE, 35 Public Health in Nigeria: From Cure to Care
S.E.IDEMUDlA
S.N.MADU
J.H.NENTY 47 Tendency to Cheat during Mathematics
Examination and some Achievement-Related Behaviour
among Secondary School Students in Lesotho.
B.O.OLLEY 65 Perceived Stigma: Prevalence and Related Factors
AmongClinically Diagnosed Nigerian Individuals with
Epilepsy
J.A. ATHANASOU & 74 A Case' Study of Student Judgements of Interest in
O. ANEW ALEHINMI A Subject
A.J.mANGA 83 Aids Pandemic: Challenge for the
&A.ZAMANI Nigerian Psychologists
R.M. SCHROEDER 89 Stress and Copingamong Ghanaian School
C.S. AKOTlA & Teachers
A.K.APEKEY
M.G. FAJONYOMI 99 Relative Effectiveness of Three Modes of
Treatment on English Language Performance among
Secondary School Students in Maiduguri
F.A. KALGO 105 Sex and Age Trend of Field-
IndependentlDependent among Secondary School Student in
Sokoto State
B.O. EHIGIE & liS Psychological Strategies in Managing Television
N.A. SHENGE Commercial Efficacy
M.A.BANKAT 123 Traditional Forms of Psychotherapy of the Fer
People of Plateau State, Nigeria.
s.s. OMOTOSHO 128 Learning Disability Problems Prevalent Among
Elementary School Age Children in Ilorin Metropolis:
Implications for Special Education and Counselling
B.J.BILESANMIA-WODERU 134 The Relationship Between Nigerian High School Seniors'
Performance in Theory and Practical Biology
L.M. OLAYIWOLA 141 Infrastructural needs and Responses in Rural
Nigeria Between 1960-1990: A Planner's Viewpoint
,
UNIVERSITY OF IBADAN LIBRARY
PERCEI\"ED STIG:\IA: PRE\"ALE:\CE A:\D RELATED fACTORS .UIO:\G
CLI:\ICALL Y DIAG:\OSED :\IGERL\:\ I:\DI\"IDLUS WITH EPILEPSY
OLLEY; B.O
Department of Psychology.
Faculty of the Social Sciences.
University ofIbadan.
Ibadan Xigeria
Abstract
The theoretical model that epilepsy is globally stigmatizing \I'as tested llmong .\'igl'1'ian
adults. The model suggested relationships among several characteristics (seizure control. agt'
at onset of illness. duration 0/ epilepsy. seizure type) depression. neuroticism. social support
and perceived stigma. Subjects Irere 26-1 adults. 21 to 60 years old. clinically diagnosed
epilepsy.
Using both correlational analysis of variables and a hierarchical multiple regression
analysis. results of the study suggest that Nigerian individuals with epilepsy felt seriously
stigmatized by the illness.
Five variables: poor "seizure control. duration of epilepsy. depression. neuroticism and
social supports were related to stigma. However depression and social support best predicted
perception of stigma.
Introduction
The concept of stigma was formulated to explain the behavior. perceptions. beliefs. and
development of the social and psychological self of stigmatized persons. Stigmatized persons
can be broadly defined as individuals who possess an attribute that others see as negative.
unfavorable, or in some way unacceptable. Examples of such individuals may include those
with physical disabilities. facial deformities. facial deformities. mental retardation. and mental
illness. A contention among contemporary researchers about the social consequences of
epilepsy is that, it bears a universal and devastating stigma. From a modest beginning through
the work of Temkin (1971). researches and concern regarding the effects of stigma on
individuals with epilepsy have grown tremendously. All these studies have maintained that the
illness bears a lot of stigma (Bagley. 1973; Janzik. Schmitz. Geiger. & Mayort. 1978; Schneider
& Conrad, 1983; Awaritefe, 1985; Scambler & Hopkins 1980; Amston. Droge. Norton &
Murray 1986; Hermann, Whitman, Wyler. Anton & Vanderzwagg 1990; Westbrook. Silver
Coupey & Skinnar 1991; Westbrook. Bauman & Skinnar 1992; Westbrook 1995; Aziz. Akhatar
& Hasan 1997; Chaplin 1998 And Amir. Roziner, Knoll. & Neufeld. 1999). Dell. (1986)
documented that this stigma has resulted in the past a prohibition of mariage and adoption.
mandatory sterilization and institutionalization for individuals with epilepsy. They are often a
subject of prejudice and rejection (Bagley. 1973) and often less preferred compared to the
psychotics (Awaritefe, 1985).
These attribute. seemingly can result in various forms of psychosocial and psychiatric
complications, the relationships. which have attracted much studies among contemporary
researchers. For example Janzik et al (1978) reported a relationship between subjective feelings
of stigmatization in social interaction and tendency to conceal the presence of the disorder. It
was also reported that perception of stigma was related to direct exposure to rejection and
disapproval from others. (Schneider & Conrad. 1983) and that epileptic persons did not
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Ife Psychologia
disclose their disorder to their employer and majority of them thought their careers had been
inhibited (Scambler & Hopkins 1980). Amston et al (1986) found that perceived stigma was
correlated with perceived helplessness, depression, anxiety, somatic symptoms, and low self-
esteem. Similarly, Hermann et al (1990) found a significant association between feelings of
stigma and psychiatric symptoms and Westbrook et aI., (1991) found a significant difference
exist between adolescents with epilepsy and adolescents with other chronic illnesses in the way
they disclosed their conditions to others. Those with epilepsy told fewer teachers and fewer
friends about their disorders and found talking about their epilepsy more difficult. A
behavioural pattern that is consistent with what was described as selective disclosure Goffman
(1963) or the revealing of disease condition to only sympathetic others. Westbrook et al (1992)
tested a theoretical model that sought to explain the association of stigma to self- esteem among
adolescents (12-20 years old) . .They found using a hierarchical multiple regression analysis,
perceived stigma, seizure type, and seizure frequency as predictors of low self-esteem. In
Nigeria, there is a dearth of empirical studies about the perception of stigma in individuals with
epilepsy and its effects on their psychological well being. Apart from the study of Danesi
(1984) who documented evide~e of perceived non-acceptance in the sample of epileptics .he
studied, no other study has docpmented stigma from the perspective of the individuals with
epilepsy. Result from. Danesi (1984) study showed that individuals with epilepsy rated
themselves lower, than individuals without epilepsy with regard to employability and higher
with respect to emotional problems and tendencies toward violence. Two alternative model
have been postulated in literature as capable cause of stigma in individuals with epilepsy: the
first model assumes a direct influence of epilepsy on stigma, meaning that perception of stigma
will increase as seizure severity and lack of maintaining seizure control increases. The second
model, which is psychosocial, assumes that other individual characteristics are also important
and therefore have an explanatory role in the degree of stigma perceived by an individual with
epilepsy. This study hypothesized that epilepsy is not globally stigmatizing and that the
psychosocial factors are equally important in explaining_perception of stigma among individuals
with epilepsy. It foremost documents the prevalence of perceived stigma among a sample of
patients with epilepsy and examined the causal factors of this stigma using some predictable
variables·.
Methods
Subjects
The subjects were selected from among patients on follow-up management at the clinics
of two psychiatric facilities in Nigeria: the Neuro-psychiatric hospital Aro and the University
College Hospital Ibadan.
Most of the patients in these clinics are either self-referred or brought by relatives. Only
a few of the new patients at these clinics would have received any form of orthodox medical
care for their illness before presentation.
A total of 264 subjects were interviewed over a 4 month counseling sessions at each of
"the clinic days. This sample size was based on the 37% cases of psychiatric morbidity found in
a previous study Gureje (1991) among epileptics seen at the Neuro-psychiatric hospital Aro
Nigeria.
Criteria for inclusion were: (a) epilepsy diagnosed on clinical and EEG findings, (b)
adults epilepsy in the age range of 21-65 years, (c) absence of evidence of mental sub-normality
or other gross diagnosable neurological disorders, (d) attendance at follow-up at the clinics for
at least a period of three months prior to interview. This latter criterion is necessary so as to
guarantee all vital investigations prior to clinical diagnosis.
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Olley, B.: Perceived Stigma Among Nigerian Individuals with Epileps)'
Measures
Perceived Stigma
Due to the non-availability of an established culturally relevant instrument jo determine
perceived stigma among epileptics in Nigeria, it was imperative or the researcher to develop an
instrument, which will help in assessing the concept. This was accomplished by employing the
judgment of experts and learning directly from epileptic patients themselves Nunnally, (1978).
In order to achieve this, a focus group discussion (FGD) session was conducted separately with
a purposive sampling of 10 (5 'men and 5 women) of epileptic patients who were on follow-up
at the neurology clinic of the Neuro-psychiatric Hospital Aro, Abeokuta. The FGD was
instituted due to the nature of the concept and the relative lack of background information. It
was made to encourage patients to talk about what they perceived to be stigmatizing about their
illness and what they perceived as their limitations as patients with epilepsy. They were asked
questions on their general knowledge about their illness, the causes and the management of the
illness. The researcher who also served as the moderator jotted points. -A psychologist youth
corper served as an observer. The subsequent scripts were reviewed, and it was possible to
produce a list of 19 potential stigma items. Responses to the items were coded on a five point
Likert format scale, ranging from never (score of zero) to often (score of four). The 19-item
scale was pre-tested among 71 other epileptics who were also on follow-up at the same clinic.
The purpose of the pre-testing was to further establish validity as well as the reliability of
instrument. Internal consistency was established by obtaining a significant relationship between
each item and the total score. .
Correlation between each item and the total score ranged from +0.41 to +0.52 p<O.OOO
for all the items. Cronbach Alpha is +0.82 p<O.OOO. Split half reliability is +0.86 p<O.OOO.
Factor ananlysis of the responses of 71 epileptics using principal component analysis with
varimax rotation yielded a 6 factor, 7 items questionnaire, which made up the perceived stigma
scale used for this study (see table 1).
The 6 factors that were yielded from the factor analysis are as follows: friendship
domain, receptivity domain, fear of contamination domain, limitation domain, reproductive
domain, and discrimination domain.
These six factors accounted for 64% of the variance of the entire 19 items.
Predictor variables
Neuroticism
This was measured using the Crown-Crisp Experiential Index (CCEI) formerly the
Middlesex Hospital Questionnaire (HMQ) developed by Crown and Crisp (1966) as a self
reported questionnaire providing information usually generated by a formal psychiatric
consultation. It is used for research, screening for psychoneurotic with an overall score for
emotionality or neuroticism and with further sub-scores in six clinical subscales of eight items
respectively. The subscales are free-floating anxiety (A); Phobic anxiety (P), Obsessionality
(0), Somatic concomitants of anxiety (S), Depression (D) and Hysterical anxiety (H).
In this questionnaire, subjects were normally requested to state how frequently they
manifested the described symptoms. A score of 0, 1,2,3, and 4 were assigned to hte ranges of
these frequencies from "not at all" (score of zero), through. rarely (score of one), don't know
(score of two), sometimes (i.e. three to fouf times - score of three) and certainly (score of four).
Scoring was done in such a way that highest scores consistently indicated greater emotionality.
Depression
This was measured using the Becks Depression Inventory (BDI) (Beck;' Ward;
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Mendelson; Mock; & Erbough 1961), an instrument developed for the assessment of a stable-
trait-like property of depression. It is a self-rating inventory and can as well be administered by
interviewing. It measures severity of depression and therefore used as measure of treatment
outcome. It comprises 21 items describing a specific behavior manifestation of depression. The
inventory has been mainly used on psychiatric inpatients and outpatients with any diagnoses
like schizophrenia, epilepsy. Internal consistency was demonstrated by obtaining a significant
relationship between each item and total score. The split-half reliabi).ity is +0.78, Concurrent
validity' was assessed by comparing the total BDI scores with a 4-point clinical rating of the
severity of depression (none, mild, moderate and severe).
Social Support
This is a self developed index, for the measurement of the number of people in the entire
family knit (limited to nuclear family) that individual patients .can turn to in a variety of
situations such as finances and counseling and the degree of satisfaction derived from such
network.
Other variables
Other variables are included in the explanatory model of perceived stigma, include age,
gender, age at onset of illness, seizure type and duration of epilepsy.
Procedure
Data collection for this study extended through a period of 4 month. After the initial
contact with the management of the two health facilities used as the study setting, permission
was granted to create an Ad hoc Epilepsy Counseling Clinic which lasted through the duration
of the study. The clinic collaborated with the consultant in charge of patient on follow-up
treatment for the purpose of screening, assessing and counseling for the study.
All patients' case notes that were consecutively booked for appointment on a particular
clinic- day were screened tor eligibility based on the inclusion criteria. Each eligible patient
automatically qualified to be included as subjects for the study and none was excluded. They
were then approached at the time of their visit to the clinic for informed consent and
confidentiality was assured. No patient refused to participate. A Consultant Neurologist, blind
to .the psychological status of the subjects assessed the degree of seizure severity defined in
relation to the seizure type and the frequency of attack of the seizure type Rosemary Ryna et al
(1980). Both age at onset, and duration were included because of their theoretical relevance
with information obtained from case notes review and patient self-reports. Age and sex were
also included for their value in defining demographic characteristic of the patients.
All interviews were conducted with the translated Yoruba version of the questionnaire.
The English version was administered to subjects who did not understand Yoruba.
Subjects who neither spoke nor understand English and Yoruba were excluded. All
subjects had both version of the questionnaire read to them. The decision to read the
questionnaire to them was informed by the fact that many of the patients could neither read
English nor the Yoruba version; of the questionnaire. For consistency in the mode of
interviewing however, an audio-recorded version of the translated version was done and always
listened to by the researcher at the end of a particular clinic day.
A consultant neurologist who was blind to the subject's assessment status classified the
seizure type and also defined seizure control. The Kappa statistic for inter-diagnostician
reliability was calculated on 78 of the entire subjects. This was generally very good, ranging
from 62 for a few classifications to 1 for most.
The procedure was repeated during every clinic clays of the week and was done at the
two health facilities for the study until the desired number of subjects were seen.
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Olley. S.: Perceived Stigma Among Nigerian Individuals with Epilepsy
Data analysis
Two analytic procedures were utilized. First the Pearson Product Moment correlation
coefficients were computed between each of the nine prediction variables and perceived stigma.
The probability statistic of 5% or less was taken to indicate a significant result
Stepwise multiple· regressions were computed for perceived stigma using the nine
independent constructs. The assumptions underlying regression analysis (homogeneity of
variance, and independence and normally of error variance) were verified statistically. For this
analysis only variables, which reached the conventional level of statistical significance (P<0.05)
were taken to indicate a significant result.
Results
Descriptive D·ata
The mean age of the 264 subjects was 32.6 years (SD 10.2), and they had a mean of7.2
years of basic education (SD 5.0). The mean age at onset of their seizure disorder was 20.4
years (SD 10.9), and the mean duration of their seizure disorder was 14 years (SD 9.2). One
hundred and fifty-four, 58.6% were males while 110 (41.1%) were females. One hundred and
seventeen (44.3%) were diagnosed as. having primary generalized epilepsy, four (1.5%)
diagnosed as partial epilepsy with simple symptomatology, 13 (14.9%) diagnosed as partial
epilepsy with complex symptomatology, 19 subjects (7.2%) were diagnosed as epilepsy of the
undifferentiated type, while 111 (42.0%) received a diagnose of partial epilepsy with secondary
generalization.
Majority of the subjects were on a single drug treatment regimen. Forty (15.2%)
received Carbarmazepine only. One hundred and twenty-six (47.7%) received Phenobarbitone
only. Twenty-four (9.1%) received phenytoin only, while fifty-two (19.7%) received both drug
combination of phenobarbitone, Carbamazepine .and phenytoin. Twenty-two (8.3%) received
both in addition to their anticonvulsant drugs a prescription ofneuroleptics. Seventy-five (75%)
were of low socio-economic status. Most were employed as 166 (62.9%) indicated, 56 (21.2%)
were unemployed while 42 (15.9%) were never employed.
Further distributions of the data showed that most patients appeared stigmatized by their
epilepsy: 68% reported that it did affect whether people want to be friends with them, 61%
reported that the illness affects whether people like them or not. 70% indicated that due to their
epilepsy people around them do not want to eat with them for fear of contamination. 74%
however believed that people with epilepsy could have sexual intercourse just like ordinary
people. 54% believed that employers and teachers they have dealt with have treated them fairly
60% believed that most people they know are willing to be educated about epilepsy, while 38%
think that if they are nervous, it can bring on an attack.
Bivariate analyses
The seizure, psychological and socio-demographic fac.ors were compared against each
other and on the perceived stigma. Increased stigma was associated with poor seizure control
(r=0.31, p-0.004), duration of epilepsy (r=0.34, p=0.005), depression (r=0.43,
p=O.OOI),neuroticism (r=0.35, p=0.005) and social support (r=0.41, p=O.OOI). Age was
significantly associated with duration of epilepsy (r=0.60, p=O.OOO)and depression (r=0.50,
p=O.OOO). Gender was not related to age, duration of epilepsy; seizure type, age at onset of
illness and seizure control. Social support was related to depression (r=0.44, p=O.OOI),
neuroticism (r=0.34 p=0.003), duration of epilepsy, (r=0.40, p=0.003) and seizure control
(r=0.37, p=0.004).
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Ife PS) chologia
vtuhivariate Analyses
From these independent variables the five significant variables associated with increased
perceived stigma were entered into a stepwise multiple regression analysis, two variables
remained significant. The social support two (p=0.005) and depression P = 0.019.
Discussion
This study evaluated the extent to which persons with epilepsy in Nigeria felt
stigmatized by the disorder and also document the relative explanatory power of some specific
seizure. psychological and demographic factors on perceived stigma. In order to measure
stigma a scale was developed that quantitatively defined the concept and extent to which
individuals with epilepsy feel they are the victims of prejudice. The results of this study suggest
that Nigerian individuals with epilepsy feel globally stigmatized by the disorder. Among the.
subjects studied, the majorities felt that other people discriminated and act differently to them
because of their epilepsy. This finding run contrary to earlier findings by Aziz et al (1997) and
Westbrook et al (1'995) who found among their samples that epilepsy is not universally
stigmatizing. In this study Aziz et al (1997), which was investigated among individuals with
epilepsy in Pakistan. it was concluded that educational level, difficulties in daily living activities.
and 'decisions about marriage and children was related to stigma. Rosemary Ryan et al (1980)
on the order hand found that the relationship between the severity of seizure and the perception
of stigma was mediated by other psychosocial characteristics. Based on stigma theory, we
expected that attributes of a stigmatizing mark should be more among patients who could not
maintain good seizure control, are depressed, neurotic or had history of long duration of illness.
In line with this theoretical proposition, investigation of the association between seizure
controls, age at onset of epilepsy, duration of illness, depression, neuroticism, gender and age
on perceived stigma was done. It was found that individual adults with epilepsy who had higher
elevated scores on depression, neuroticism, and those who had poor seizure control longer
duration of illness and lack of social support, also reported more stigmas.
This confirm earlier report Rosemary Ryna (1980) who found that subjects with frequent
tonic-clonic seizures were more likely to report feeling of stigma by their epilepsy, it further
confirmed theinterest of Amston et al 1986 and Herman et al (1990) which found perceived
stigma to be related to depression, somatic symptom and general psychiatric distress of the
subject studies. Stigma theory in its current stage or development implies strong and direct
relationship between variables, However, the results of this study suggestthat such relatedness
may be more subtle and indirect. In comparison with more formally developed theories from
which testable model are readily derived, stigma theory is less explicit and may be more
challenging to translate into discrete hypothesis. Rather than prematurely abandon what could
be a useful theory for a broad range of research disciplines, it is recommended that further
clarification be sought in this endeavor. As each new hypothesis is modified with empirical
testing, it is believed that stigma theory will merit the continued attention of future researchers.
Several new hypotheses can be proposed for future analysis of a modified stigma model. First,
the 'attributes of a stigmatizing mark vis-a-vis visibility and unpleasantness may be mediated by
other characteristics of the individual, such as personality traits and general adjustment, and the
.particular social context of individual.
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Olley. B.: Perceived Stigma Among Nigeri~ Individuals with Epilepsy
TABLE 1: FACTOR ANALYSIS OF THE RESPONSES OF 71 ADULT EPILEPTICS
TO THE PERCEIVED STIGMA SCALE
Factor Factor Item Cases Raw Score S.D.
Loadings Mean
+0.92 I Do you think having epilepsy affects 71 2.41 1.20
whether people want to be friends with you
+0.56 I Do you think having epilepsy affects 71 2.32 1.19
'whether people like you or not
+0.97 2 Do you think' most people you know are 71 2.47 0.74
willing -tobe educated about epilepsy?
+0.93 :i Do you think people that know you have 71 1.95 1.23
epilepsy will not want to eat with you for
fear of conta-mination?.
+0.97 4 Do' you think that if you really get 71 2.07 0.88
nervous/tense I can bring on a seizure
+0.98 5 Do you think that people with epilepsy can 71 2.05 1.07
have sexual intercourse just like ordinary
people?
+0.98 .6 Do you think employers/teachers you have 71 2.91 1.24
dealt have jtreate.•tyou fairly .
-
.,
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TABLE 2: RE,~RESSION ANALYSIS OF PREDICTIONS OF STIGMA
Study Variables Adjusted R2 R2 Chanze Beta weizht
"
Seizure Faetors .30 .34* -0.32
Age at Onset of illness -0.21
Duration ef epilepsy \ -0.18
Seizure type + -0.04
Psychological Factors + .41 .10**
Depression 0,16
I
Neuroticism 0.12
Socie-demographic Factors .11 .03* -0.19
Age -0.19
Sex + .-0.15
Social Support 0.14
+ = Converted to Dummy variable in the regression analysis.
UNIVERSITY OF IBADAN LIBRARY
Olley. S.: Perceived Stigma Among Nigerian Individuals with Epilepsy
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