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Objectives The prevalence of all epilepsies (both convulsive and non-convulsive seizures) in Low- and Middle-Income Countries (LMIC), particularly sub-Saharan Africa is unknown. Under estimation of non-convulsive epilepsies in data from these countries may lead to inadequate and sub-optimal allocation of resources to control and prevent epilepsy. We determined the prevalence of all types of epilepsies and compared the mortality between convulsive seizures and non-convulsive seizures in a resource limited rural area in Kenya. Methods Trained clinicians identified cases of epilepsy in a randomly selected sample of 4,441 residents in the Kilifi Health and Demographic Surveillance System site using a cross-sectional survey design. Seizure types were classified by epileptologists using the current guidelines of the International League Against Epilepsy (ILAE). We estimated prevalence for epilepsy with convulsive seizures and non-convulsive seizures and for epilepsy with non-convulsive seizures only and compared premature mortality between these groups of seizures. Results Of the 4441 people visited, 141 had lifetime epilepsy and 96 active epilepsy, which is a crude prevalence of 31.7/1,000 persons (95% CI: 26.6-36.9) and 21.6/1,000 (95% CI: 17.3-25.9), respectively. Both convulsive and non-convulsive seizures occurred in 7% people with epilepsy (PWE), only convulsive seizures in 52% and only non-convulsive seizures in 35% PWE; there was insufficient information to classify epilepsy in the remainder 6%. The age- and sex-adjusted prevalence of lifetime people was 23.5/1,000 (95% CI: 11.0-36.0), with the adjusted prevalence of epilepsy with non-convulsive seizures only estimated at 8.2/1,000 (95%CI:3.9-12.6). The mortality rate in PWE was 6.3/1,000 (95%CI: 3.4-11.8), compared to 2.8/1,000 (2.3-3.3) in those without epilepsy; hazard ratio (HR) =2.31 (1.22-4.39; p=0.011). The annual mortality rate was 11.2/1,000 (95%CI: 5.3-23.4) in PWE with convulsive and non-convulsive seizures and none died in PWE with non-convulsive seizures alone. Conclusions Our study shows that epilepsy with non-convulsive seizures is common and adds to the prevalence of previously reported estimates of active convulsive epilepsy. Both epilepsy with convulsive seizures and that with non-convulsive seizures should be identified for optimising treatment and for planning resource allocation.

Objective We determined the reliability of The Kiddie-Schedule for Affective Disorders and Schizophrenia for School- Age Children–Present and Lifetime (K-SADS-PL) for screening and diagnosing ADHD in children. Method K-SADS-PL was administered to 2,074 children in the community. Psychometric properties, factorial structure, and clinical validity of K-SADS-PL in screening or diagnosis of ADHD were examined. Results Internal consistency was excellent for items in the screening interview (Macdonald’s Omega [ω] = 0.89; 95% confidence interval [CI] [0.87, 0.94]) and diagnostic supplement (ω = 0.95; 95% CI [0.92, 0.99]). The standardized coefficients for items in the screening interview were acceptable (0.59-0.85), while fit indices for single factorial structure reached acceptable levels. Screening items were associated with high sensitivity (97.8%; 95% CI [97.2, 98.5%]) and specificity (94.0%; 95% CI [93.0, 95.0%]) for diagnosis of ADHD in the supplement. The test-retest and interinformant reliability as measured by intraclass correlation coefficient was good for most of the items. Conclusion This large study shows that K-SADS-PL can be reliably used to screen and diagnose ADHD in children in Kenya.

Objective To determine the prevalence of active convulsive epilepsy (ACE) and describe the clinical characteristics and associated factors among a rural Ugandan population. Methods The entire population in Iganga/Mayuge Health Demographic Surveillance Site (IM-HDSS) was screened using two questions about seizures during a door-to-door census exercise. Those who screened positive were assessed by a clinician to confirm diagnosis of epilepsy. A case control study with the patients diagnosed with ACE as the cases and age/sex-matched controls in a ratio of 1:1 was conducted. Results A total of 64,172 (92.8%) IM-HDSS residents, with a median age of 15.0 years (interquartile range [IQR]: 8.0–29.0), were screened for epilepsy. There were 152 confirmed ACE cases, with a prevalence of 10.3/1,000 (95% confidence interval [CI]: 9.5– 11.1) adjusted for nonresponse and screening sensitivity. Prevalence declined with age, with the highest prevalence in the 0–5 years age group. In an analysis of n = 241 that included cases not identified in the survey, nearly 70% were unaware of their diagnosis. Seizures were mostly of focal onset in 193 (80%), with poor electroencephalogram (EEG) agreement with seizure semiology. Antiepileptic drug use was rare, noted in 21.2% (95% CI: 16.5–25.8), and 119 (49.3%) reported using traditional medicines. History of an abnormal antenatal period (adjusted odds ratio [aOR] 10.28; 95%CI 1.26– 83.45; p = 0.029) and difficulties in feeding, crying, breathing in the perinatal period (aOR 10.07; 95%CI 1.24–81.97; p = 0.031) were associated with ACE in children. In adults a family history of epilepsy (aOR 4.38 95%CI 1.77–10.81; p = 0.001) was the only factor associated with ACE. Significance There is a considerable burden of epilepsy, low awareness, and a large treatment gap in this population of rural sub-Saharan Africa. The identification of adverse perinatal events as a risk factor for developing epilepsy in children suggests that epilepsy burden may be decreased by improving obstetric and postnatal care.

Why was the cohort set up?In many resource-constrained settings, availability of reli-able vital statistics and health information is limited bylack of proper system for civil registration and health infor-mation. This is further limited by the fact that the majorityof population health events, such as births, morbidity andmortality, occur outside the reach of these systems. In par-ticular, obtaining credible data from rural and remote ge-ographies can be even more constrained. The developmentof population-based surveillance systems in resource-constrained countries to monitor demographic and healthevents in these countries has as its basis the limited capac-ity of civil registration and health information systems.Locally rooted surveillance systems that are embedded inthe nexus of existing community structures and localhealth systems can serve to address this gap.

Background Acute symptomatic seizures and febrile seizures are common in children admitted to hospitals in Africa and may be markers of brain dysfunction. They may be associated with behavioural and emotional problems, but there are no published community-based studies in Africa. Methods We screened 7047 children aged 1–6 years (randomly sampled from 50,000 in the community) for seizures (using seven questions) and invited those who screened positive and a proportion of negatives for a clinical assessment. Risk factors were identified using a parental questionnaire. Behavioural and emotional problems were examined using the Child Behaviour Checklist (CBCL) in 3273 children randomly selected from 7047. Generalised linear models with appropriate link functions were used to determine risk factors and associations between behavioural or emotional problems and acute seizures. Sobel–Goodman mediation tests were used to investigate if the association between acute seizures and CBCL scores was mediated by co-diagnosis of epilepsy. Results Acute seizures were identified in 429 (6.1%) preschool children: 3.2% (95% confidence interval CI: 2.9–3.5%) for symptomatic seizures, and 2.9% (95% CI: 2.6–3.3%) for febrile seizures. Risk factors for acute seizures included family history of febrile seizures (odds ratio OR = 3.19; 95% CI: 2.03–5.01) and previous hospitalisation (OR = 6.65; 95% CI: 4.60–9.63). Total CBCL problems occurred more frequently in children with acute seizures (27%; 95% CI: 21–34%) than for those without seizures (11%; 95% CI: 11–12%; chi-squared p ≤ 0.001). Acute seizures were associated with total CBCL problems (adjusted risk ratio (aRR) = 1.92; 95% CI: 1.34–2.77), externalising problems (aRR = 1.82; 95% CI: 1.21–2.75) and internalising problems (aRR = 1.57; 95% CI: 1.22–2.02), with the proportion of the comorbidity mediated by a co-diagnosis of epilepsy being small (15.3%; 95% CI: 4.5–34.9%). Risk factors for this comorbidity included family history of febrile seizures (risk ratio (RR) = 3.36; 95% CI: 1.34–8.41), repetitive acute seizures (β = 0.36; 95% CI: 0.15–0.57) and focal acute seizures (RR = 1.80; 95% CI: 1.05–3.08). Conclusions Acute seizures are common in preschool children in this area and are associated with behavioural and emotional problems. Both conditions should be assessed and addressed in children. Electronic supplementary material The online version of this article (10.1186/s12916-018-1021-y) contains supplementary material, which is available to authorized users.

Epilepsy is a common neurologic disorder directly affecting about 70 million people in the world, with about 90% residing in lower‐and middle‐income countries.1 The treatment gap for epilepsy is large (up to 90%) in these areas, and this is in part due to negative attitudes toward biomedical services, cost of accessing diagnosis and treatment, and traditional beliefs about the cause of epilepsy.2, 3 People with epilepsy (PWE) are thought to have more hospital admissions than those with other chronic neurologic disorders,4 and is the third most common after stroke and spinal cord injuries in sub‐Saharan Africa (SSA).5 Epilepsy‐related hospital admissions are increasing in high‐income countries; for example, the rate of hospital use increased from 66 to 68/100,000 persons/year over 10 years in England and Wales,4 and by 27% over 12 years in the United States.6 In the American study, epilepsy accounted for more than half of all hospital stays among admissions of PWE, with respiratory‐related complications being the most common causes for admission.6 The hospital admission rates would be expected to be higher in SSA compared to the West because of the higher prevalence of epilepsy7 and the larger treatment gap.3 In addition, epilepsy in Africa is associated with increased complications such as status epilepticus, burns, and head injuries,8 which often require treatment at the hospital. Nevertheless, there are few published studies that document the burden, causes, and duration of hospitalization in PWE in SSA, where epilepsy may add a considerable burden on the health system. In Zambia PWE had a poorer socioeconomic status compared to their peers with other medical conditions,9 but the focus of this study was not to examine the burden of hospitalization due to epilepsy. This study estimates the incidence of admissions with epilepsy, the associated disability‐adjusted life years (DALYs) and determines the important causes and risk factors of admission to a rural hospital among PWE. We further examined the risk factors associated with the major outcomes (duration of hospitalization and mortality) among PWE.

Background In Africa, where access to specialist medical services is often limited, telemedicine, the use of information and communication technologies for the provision of healthcare at a distance, can contribute towards enhancing access to healthcare. Informed consent is considered the cornerstone of ethical practice, especially when technology and techniques are considered new and or unproven. It is advised that informed consent should be gained in the patient’s mother tongue. However, many African languages have not kept pace with technology and lack the words and terms needed to describe computing and technical terms. Additionally, even when present, patients may not understand these words and terms. This affects the validity of informed consent given. Methods Forty relevant computer terms and words used when explaining telemedicine during the consent process were selected and translated into Kiswahili. Patients at the outpatient department of the Kilifi County Hospital in Kenya participated. The study consisted of two phases. In the first, 50 people were asked whether they understood the translated words and terms and were able to explain their meaning. In the second (n = 42) they were asked to explain the meaning of the translated word, the original English word, and those words that could not be translated. Results Of the 40 terms, 14 could not be translated (35%). A total of 92 people attending the Kilifi County Hospital participated. Their average age was 31.2 ± 10.6 y, 70.7% were female and 55.4% were from rural areas. More than half of the respondents did not understand videoconference, store and forward, digital photograph, wireless, World Wide Web, antivirus or email in either language. No-one understood the words telemedicine, firewall, encryption, decryption and tele-diagnosis. Conclusions Currently it is unlikely that valid informed consent can be obtained for a telemedicine encounter in Kiswahili. Innovative solutions are required to overcome the barrier of languages failing to keep pace with technology and their effect on consent.

Background Despite bearing the largest HIV-related burden, little is known of the Health-Related Quality of Life (HRQoL) among people living with HIV in sub-Saharan Africa. One of the factors contributing to this gap in knowledge is the lack of culturally adapted and validated measures of HRQoL that are relevant for this setting. Aims We set out to adapt the Functional Assessment of HIV Infection (FAHI) Questionnaire, an HIV-specific measure of HRQoL, and evaluate its internal consistency and validity. Methods The three phase mixed-methods study took place in a rural setting at the Kenyan Coast. Phase one involved a scoping review to describe the evidence base of the reliability and validity of FAHI as well as the geographical contexts in which it has been administered. Phase two involved in-depth interviews (n = 38) to explore the content validity, and initial piloting for face validation of the adapted FAHI. Phase three was quantitative (n = 103) and evaluated the internal consistency, convergent and construct validities of the adapted interviewer-administered questionnaire. Results In the first phase of the study, we identified 16 studies that have used the FAHI. Most (82%) were conducted in North America. Only seven (44%) of the reviewed studies reported on the psychometric properties of the FAHI. In the second phase, most of the participants (37 out of 38) reported satisfaction with word clarity and content coverage whereas 34 (89%) reported satisfaction with relevance of the items, confirming the face validity of the adapted questionnaire during initial piloting. Our participants indicated that HIV impacted on their physical, functional, emotional, and social wellbeing. Their responses overlapped with items in four of the five subscales of the FAHI Questionnaire establishing its content validity. In the third phase, the internal consistency of the scale was found to be satisfactory with subscale Cronbach’s α ranging from 0.55 to 0.78. The construct and convergent validity of the tool were supported by acceptable factor loadings for most of the items on the respective sub-scales and confirmation of expected significant correlations of the FAHI subscale scores with scores of a measure of common mental disorders. Conclusions The adapted interviewer-administered Swahili version of FAHI questionnaire showed initial strong evidence of good psychometric properties with satisfactory internal consistency and acceptable validity (content, face, and convergent validity). It gives impetus for further validation work, especially construct validity, in similar settings before it can be used for research and clinical purposes in the entire East African region.

Background Three-quarters of the burden of mental health problems occurs in low-and-middle-income countries, but few epidemiological studies of these problems in preschool children from sub-Saharan Africa have been published. Behavioural and emotional problems often start in early childhood, and this might be particularly important in Africa, where the incidence of perinatal and early risk factors is high. We therefore aimed to estimate the prevalence and risk factors of behavioural and emotional problems in young children in a rural area on the Kenyan coast. Methods We did a population-based epidemiological study to assess the burden of behavioural and emotional problems in preschool children and comorbidities in the Kilifi Health and Demographic Surveillance System (KHDSS, a database formed of the population under routine surveillance linked to admissions to Kilifi County Hospital). We used the Child Behaviour Checklist (CBCL) to assess behavioural and emotional problems. We then determined risk factors and medical comorbidities associated with behavioural and emotional problems. The strength of associations between the risk factors and the behavioural and emotional problems was estimated using generalised linear models, with appropriate distribution and link functions. Findings 3539 families were randomly selected from the KHDSS. Of these, 3273 children were assessed with CBCL. The prevalence of total behavioural and emotional problems was 13% (95% CI 12–14), for externalising problems was 10% (9–11), and for internalising problems was 22% (21–24). The most common CBCL syndrome was somatic problems (21%, 20–23), whereas the most common DSM-IV-oriented scale was anxiety problems (13%, 12–14). Factors associated with total problems included consumption of cassava (risk ratio 5·68, 95% CI 3·22–10·03), perinatal complications (4·34, 3·21–5·81), seizure disorders (2·90, 2·24–3·77), and house status (0·11, 0·08–0·14). Seizure disorders, burn marks, and respiratory problems were important comorbidities of behavioural and emotional problems. Interpretation Behavioural and emotional problems are common in preschool children in this Kenyan rural area and are associated with preventable risk factors. Behavioural and emotional problems and associated comorbidities should be identifi ed and addressed in young children.

Background: The prevalence of epilepsy in sub-Saharan Africa seems to be higher than in other parts of the world, but estimates vary substantially for unknown reasons. We assessed the prevalence and risk factors of active convulsive epilepsy across five centres in this region. Methods: We did large population-based cross-sectional and case-control studies in five Health and Demographic Surveillance System centres: Kilifi, Kenya (Dec 3, 2007-July 31, 2008); Agincourt, South Africa (Aug 4, 2008-Feb 27, 2009); Iganga-Mayuge, Uganda (Feb 2, 2009-Oct 30, 2009); Ifakara, Tanzania (May 4, 2009-Dec 31, 2009); and Kintampo, Ghana (Aug 2, 2010-April 29, 2011). We used a three-stage screening process to identify people with active convulsive epilepsy. Prevalence was estimated as the ratio of confirmed cases to the population screened and was adjusted for sensitivity and attrition between stages. For each case, an age-matched control individual was randomly selected from the relevant centre's census database. Fieldworkers masked to the status of the person they were interviewing administered questionnaires to individuals with active convulsive epilepsy and control individuals to assess sociodemographic variables and historical risk factors (perinatal events, head injuries, and diet). Blood samples were taken from a randomly selected subgroup of 300 participants with epilepsy and 300 control individuals from each centre and were screened for antibodies to Toxocara canis, Toxoplasma gondii, Onchocerca volvulus, Plasmodium falciparum, Taenia solium, and HIV. We estimated odds ratios (ORs) with logistic regression, adjusted for age, sex, education, employment, and marital status. Results: 586 607 residents in the study areas were screened in stage one, of whom 1711 were diagnosed as having active convulsive epilepsy. Prevalence adjusted for attrition and sensitivity varied between sites: 7·8 per 1000 people (95% CI 7·5-8·2) in Kilifi, 7·0 (6·2-7·4) in Agincourt, 10·3 (9·5-11·1) in Iganga-Mayuge, 14·8 (13·8-15·4) in Ifakara, and 10·1 (9·5-10·7) in Kintampo. The 1711 individuals with the disorder and 2032 control individuals were given questionnaires. In children (aged