OBJECTIVE Epilepsy is a global public health concern, with the majority of cases occurring in lower- and middle-income countries where the treatment gap remains formidable. In this study, we simultaneously explore how beliefs about epilepsy causation, perceived barriers to care, seizure disorder characteristics, and demographics influence the initial choice of healthcare for epilepsy and its impact on attaining biomedical care (BMC). METHODS This study utilized the baseline sample (n = 626) from a prospective cohort study of people with epilepsy (PWE) attending three public hospitals in Uganda (Mulago National Referral Hospital, Butabika National Referral Mental Hospital, and Mbarara Regional Referral Hospital) for epilepsy care. Patient and household demographics, clinical seizure disorder characteristics, and sociocultural questionnaires were administered. Logistic regression and principal component analyses (PCA) were conducted to examine associations with the choice of primary seizure treatment. RESULTS The sample was 49% female, and 24% lived in rural settings. A biomedical health facility was the first point of care for 355 (56.7%) participants, while 229 (36.6%) first sought care from a traditional healer and 42 (6.7%) from a pastoral healer. Preliminary inspection of candidate predictors using relaxed criteria for significance (p < 0.20) identified several factors potentially associated with a greater odds of seeking BMC first. Demographic predictors included older caredriver (decision-maker for the participant) age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: [0.99, 1.02], p-value: 0.09), greater caredriver education level (OR = 1.21, 95% CI: [1.07, 1.37], p-value = 0.003), and lower ratio of sick to healthy family members (OR = 0.77 [0.56, 1.05], P = 0.097). For clinical predictors, none of the proposed predictors associated significantly with seeking BMC first. Self-report causation predictors associated with a greater odds of seeking BMC first included higher belief in biological causes of epilepsy (OR = 1.31 [0.92, 1.88], P = 0.133) and lower belief in socio-spiritual causes of epilepsy (OR = 0.68 [0.56, 0.84], P < 0.001). In the multivariate model, only higher caredriver education (OR = 1.19 [1.04, 1.36], P = 0.009) and lower belief in socio-spiritual causes of epilepsy (OR = 0.69 [0.56, 0.86], P < 0.01) remained as predictors of seeking BMC first. Additionally, PCA revealed a pattern which included high income with low beliefs in nonbiological causes of epilepsy as being associated with seeking BMC first (OR = 1.32 [1.12, 1.55], p = 0.001). Despite reaching some form of care faster, individuals seeking care from traditional or pastoral healers experienced a significant delay to eventual BMC (P < 0.001), with an average delay of more than two years (traditional healer: 2.53 years [1.98, 3.24]; pastoral care: 2.18 [1.21, 3.91]). CONCLUSIONS Coupled with low economic and educational status, belief in spiritual causation of epilepsy is a dominant determinant of opting for traditional or pastoral healing over BMC, regardless of concurrent belief in biological etiologies. There is a prolonged delay to eventual BMC for PWE who begin their treatment seeking with nonallopathic providers, and although nonallopathic healers provide PWE with benefits not provided by BMC, this notable delay likely prevents earlier administration of evidence-based care with known efficacy. Based on these findings, initiatives to increase public awareness of neurobiological causes of epilepsy and effectiveness of biomedical drug treatments may be effective in preventing delays to care, as would programs designed to facilitate cooperation and referral among traditional, faith-based, and biomedical providers. This article is part of the Special Issue "The intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

中文翻译：

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乌干达癫痫护理的社会文化决定因素和医疗保健利用模式

目标癫痫是一个全球性的公共卫生问题，大多数病例发生在治疗差距仍然巨大的低收入和中等收入国家。在这项研究中，我们同时探讨了关于癫痫因果关系、感知护理障碍、癫痫发作特征和人口统计学的信念如何影响癫痫医疗保健的初始选择及其对实现生物医学护理 (BMC) 的影响。方法 本研究利用来自乌干达三所公立医院（穆拉戈国家转诊医院、布塔比卡国家转诊精神病医院和姆巴拉拉地区转诊医院）癫痫患者 (PWE) 的前瞻性队列研究的基线样本 (n = 626)关心。患者和家庭人口统计、临床癫痫症特征、并进行了社会文化问卷调查。进行逻辑回归和主成分分析 (PCA) 以检查与主要癫痫治疗选择的关联。结果 样本中 49% 是女性，24% 生活在农村地区。生物医学医疗机构是 355 名 (56.7%) 参与者的第一个护理点，而 229 名 (36.6%) 最初寻求传统治疗师的护理，42 名 (6.7%) 则来自牧师治疗师。使用宽松的显着性标准 (p < 0.20) 对候选预测变量进行初步检查，确定了几个可能与首先寻求 BMC 的可能性相关的因素。人口统计学预测因素包括老年护理人员（参与者的决策者）年龄（优势比 [OR]：1.01，95% 置信区间 [CI]：[0.99, 1.02]，p 值：0.09），更高的护理驾驶员教育水平（OR = 1.21，95% CI：[1.07, 1.37]，p 值 = 0.003），以及更低的患病家庭成员与健康家庭成员的比率（OR = 0.77 [0.56, 1.05]，P = 0.097）。对于临床预测因子，没有一个提议的预测因子与首先寻求 BMC 显着相关。与首先寻求 BMC 的更大几率相关的自我报告因果预测因素包括对癫痫的生物学原因的更高信念（OR = 1.31 [0.92, 1.88]，P = 0.133）和对癫痫的社会精神原因的更低信念（OR = 0.68 [0.56, 0.84]，P < 0.001)。在多变量模型中，只有较高的护理驾驶员教育（OR = 1.19 [1.04, 1.36]，P = 0.009）和对癫痫的社会精神原因的较低信念（OR = 0.69 [0.56, 0.86]，P < 0.01）仍然作为预测因子首先寻求BMC。此外，PCA 揭示了一种模式，其中包括高收入和低信念的癫痫非生物学原因与首先寻求 BMC 相关（OR = 1.32 [1.12, 1.55]，p = 0.001）。尽管更快地获得某种形式的护理，但寻求传统或牧师治疗师护理的个人最终获得 BMC 的时间明显延迟（P < 0.001），平均延迟超过两年（传统治疗师：2.53 年 [1.98, 3.24]；教牧关怀：2.18 [1.21, 3.91]）。结论 再加上经济和教育状况低下，对癫痫的精神原因的信念是选择传统或田园疗法而不是 BMC 的主要决定因素，无论是否存在生物学病因。对于开始向非对抗疗法提供者寻求治疗的 PWE 的最终 BMC 有很长的延迟，虽然非对抗疗法治疗师为 PWE 提供了 BMC 没有提供的好处，但这种显着的延迟可能会阻止早期实施已知疗效的循证护理。基于这些发现，提高公众对癫痫神经生物学原因和生物医学药物治疗有效性的认识的举措可能有效防止延误护理，旨在促进传统、基于信仰和生物医学提供者之间的合作和转诊的计划也是如此。本文是特刊“文化、资源和疾病的交叉点：乌干达的癫痫护理”的一部分。旨在提高公众对癫痫的神经生物学原因和生物医学药物治疗有效性的认识的举措可能有效防止延误护理，旨在促进传统、基于信仰和生物医学提供者之间的合作和转诊的方案也是如此。本文是特刊“文化、资源和疾病的交叉点：乌干达的癫痫护理”的一部分。旨在提高公众对癫痫的神经生物学原因和生物医学药物治疗有效性的认识的举措可能有效防止延误护理，旨在促进传统、基于信仰和生物医学提供者之间的合作和转诊的方案也是如此。本文是特刊“文化、资源和疾病的交叉点：乌干达的癫痫护理”的一部分。