Models of community-based primary care for epilepsy in low- and middle-income countries.

Objective: To review systematically community-based primary care interventions for epilepsy in low- and middle-income countries to rationalize approaches and outcome measures in relation to epilepsy care in these countries.

Methods: A systematic search of PubMed, EMBASE, Global Index Medicus, CINAHL, and Web of Science was undertaken to identify trials and implementation of provision of antiseizure medications, adherence reinforcement, and/or health care provider or community education in community-based samples of epilepsy. Data on populations addressed, interventions, and outcomes were extracted from eligible articles.

Results: The 24 reports identified comprise mostly care programs addressing active convulsive epilepsy. Phenobarbital has been used most frequently, although other conventional antiseizure medications (ASMs) have also been used, but none of the newer. Tolerability rates in these studies are high, but overall attrition is considerable. Other approaches include updating primary health care providers, reinforcing treatment adherence in clinics, and raising community awareness. In these programs, the coverage of existing treatment gap in the community, epilepsy-related mortality, and comorbidity burden are only fleetingly addressed. None, however, explicitly describe sustainability plans.

Conclusions: Cost-free provision, mostly of phenobarbital, has resulted in short-term seizure freedom in roughly half of the people with epilepsy in low- and middle-income countries. Future programs should include a range of ASMs. These should cover apart from seizure control and treatment adherence, primary health care provider education, community awareness, and referral protocols for specialist care. Programs should incorporate impact assessment at the local level. Sustainability in the long term as much as resilience and scalability should be addressed in future initiatives.