[version 1; peer review: 1 approved with reservations, 1 not approved]
No competing interests were disclosed.
Epilepsy is a highly stigmatized neurological condition in rural South Africa, where it is often misunderstood and associated with cultural myths, such as witchcraft. This study aims to implement and evaluate a culturally sensitive epilepsy education intervention in primary schools within Limpopo Province. Using a Community-Based Participatory Research (CBPR) design, the intervention will integrate epilepsy education into the Life Skills curriculum for Grades 5 to 7. The project involves conducting a needs assessment, co-developing the curriculum with stakeholders, training educators, and implementing the program in selected rural schools. Quantitative pre- and post-intervention surveys will measure changes in knowledge and attitudes, while qualitative methods will capture the experiences and perceptions of participants. The anticipated outcomes include improved knowledge of epilepsy, reduced stigma, increased educator confidence, and the creation of a more inclusive school environment. Additionally, the study aims to promote sustainability through a train-the-trainer model and advocate for the integration of epilepsy education into policy. This intervention seeks to bridge the gap between biomedical knowledge and traditional beliefs, ultimately contributing to long-term improvements in health literacy and social inclusion for individuals with epilepsy in under-resourced school settings.
Epilepsy is a significant neurological condition that affects millions worldwide, with a particularly high prevalence in rural areas of South Africa, including in Limpopo province. Despite its medical classification, epilepsy continues to be misunderstood, often being associated with supernatural beliefs such as witchcraft and evil spirits.
Prior research highlights the need for structured epilepsy education interventions within primary schools as an effective means of reducing stigma and misinformation. The previous study also developed guidelines aimed at incorporating epilepsy in life skills education.
Despite available clinical knowledge on epilepsy management, there remains a critical gap in translating this knowledge into school-based health literacy programs, especially in under-resourced rural schools. Studies have shown that although awareness campaigns exist, they are often ad hoc and lack systematic follow-up or integration into the educational curriculum.
Moreover, existing research often focuses on epilepsy awareness in urban or clinical settings, leaving rural school contexts under-represented.
Another critical gap lies in the lack of long-term evaluation of school-based epilepsy interventions. While some initiatives report short-term improvements in knowledge, few studies assess whether these gains translate into lasting attitude change or behavioral shifts.
Lastly, the potential of a Community-Based Participatory Research (CBPR) model in epilepsy education has not been fully realized. CBPR fosters collaboration between educators, healthcare providers, learners, families, and community leaders to co-create educational interventions that are both contextually and culturally relevant.
Epilepsy stigma in South Africa remains a significant barrier to quality education and social integration. Studies have shown that many individuals with epilepsy experience exclusion, bullying, and academic challenges due to widespread myths about the condition.
There is a critical gap in school-based, curriculum-integrated epilepsy education that is participatory, inclusive, and tailored to the lived experiences of rural communities. Without addressing these gaps, learners with epilepsy remain vulnerable to bullying, dropout, and limited academic progress. A structured, evidence-based intervention is needed to equip both learners and educators with the knowledge and tools to promote inclusion and reduce stigma in primary school settings.
This project aims to address these issues by implementing and assessing the effectiveness of an epilepsy education intervention in primary schools of Limpopo Province. The study will evaluate the impact of this intervention on reducing stigma, improving knowledge, and fostering a supportive environment for individuals with epilepsy.
This study aims to implement and assess the effectiveness of an epilepsy education intervention in Primary Schools to improve epilepsy knowledge, reduce stigma, and create an inclusive educational environment.
This project will incorporate the following objectives:
Develop a comprehensive curriculum integrating epilepsy into the life skills subjects taught in primary schools. Train educators and facilitators to deliver the curriculum to teachers and learners. Implement the epilepsy life skills curriculum in selected rural schools. Evaluate the effectiveness of the intervention on the knowledge and attitudes of teachers and learners towards epilepsy. Identify gaps and areas of improvement for future interventions.
This study will employ a Community-Based Participatory Research (CBPR) design, which emphasizes collaborative partnership and co-learning between researchers, primary school stakeholders, and community members. The CBPR model supports shared decision-making across all phases, needs assessment, curriculum co-development, educator training, curriculum implementation, and evaluation.
The study will be conducted in selected rural primary schools within the Limpopo Province, South Africa. These schools are representative of low-resource settings with limited access to health education on neurological conditions like epilepsy.
In this initiative, the primary participants are composed of primary school learners from Grades 5 to 7, who bring their unique perspectives and experiences. They are guided by life skills educators, who play a crucial role in imparting essential knowledge and skills. Additionally, curriculum advisors contribute their expertise, ensuring that the educational content is relevant and effective for the students. Together, these individuals form a collaborative environment aimed at enhancing the learning experience for young learners.
Inclusion Criteria for the participants will be as follows:
Enrolled in Grade 5 to 7 at selected schools in Vhembe. Able to comprehend age-appropriate epilepsy education content. Assent to participate (with parental/guardian consent provided). Age range starts from 10 and above (Grade 5–7 age group in South Africa).
Must be Life Skills educators at selected primary schools in the Vhembe District. Must be actively teaching Grades 5 to 7. Willing and able to participate in training and intervention activities. Provide informed consent. Approximately 25–65 years.
Currently serving as curriculum advisors for Life Skills education in the selected circuits of Vhembe. Actively involved in curriculum support or teacher development programs. Provide informed consent.
In estimating the sample sizes for our study, we anticipate a range of 400 to 480 learners. This calculation is based on having two classes in each of the eight schools, with each class consisting of 25 to 30 students. Additionally, we expect to have 16 teachers involved in the study, with two teachers assigned per school across the eight institutions. Moreover, we estimate that there will be between four to six curriculum advisors participating in the project.
Following ethical clearance from the University of Venda Human and Clinical Trial Research Ethics Committee (HCTREC), formal permission will be sought from the Limpopo Department of Education and Vhembe District Education Office. Approval from circuit managers and school principals will be obtained to access schools and participants.
A list of Life Skills curriculum advisors will be obtained from the district office. Using purposive sampling, 4–6 actively involved advisors will be invited via the Department of Education. Each will receive an invitation letter, information sheet, and consent form. Consenting advisors will join co-development workshops and training activities.
From 8 selected primary schools, principals will help identify two Life Skills educators per school. These teachers will be invited via on-site briefing sessions. Informed consent will be obtained before participation in epilepsy education workshops.
Grade 5 to 7 classes from participating schools will be included. Parental consent forms and learner information sheets will be distributed by teachers. Upon receipt of written consent, learners will be briefed and asked for assent. Only those with both parental consent and learner assent will participate.
The curriculum materials consist of custom-designed modules focused on epilepsy education, which are integrated into life skills education. This approach ensures that students receive comprehensive knowledge about epilepsy while developing essential life skills. To support educators in delivering this content effectively, a toolkit has been developed. This toolkit includes a variety of resources, such as training manuals that guide instructors on best practices, activity guides that outline engaging ways to teach the material, and first aid reference charts for quick access to important information. Additionally, digital multimedia resources are available, including videos, animations, and infographics, which enhance the learning experience and provide diverse methods of engagement for students.
The research will employ a mixed-methods approach, incorporating both quantitative and qualitative components. To assess epilepsy knowledge, attitudes, and stigma among participants, pre- and post-intervention surveys will be conducted. This quantitative aspect aims to provide measurable data on changes in understanding and perceptions following the intervention.
In addition to the quantitative surveys, the qualitative component will gather in-depth insights through various methods. Focus group discussions will be guided by carefully designed prompts to facilitate open conversations. Interview protocols will be developed to conduct individual interviews, while teacher reflection logs and observation checklists will serve to document and analyze participants’ experiences and interactions during the intervention.
Furthermore, the logistical aspects of the training will require specific resources. Workshop supplies will be essential for conducting the sessions effectively. Simulation kits will be utilized for first-aid practice, offering participants hands-on experience. Additionally, ICT equipment will be necessary to enhance multimedia delivery, ensuring that training materials are engaging and accessible for all participants.
The study procedure is structured into six phases, each designed to systematically address the educational needs surrounding epilepsy in rural schools and to promote an inclusive learning environment for all students.
To initiate the study, a comprehensive needs assessment is conducted. This involves baseline surveys and focus groups engaging learners, educators, and curriculum advisors. The aim is to evaluate the existing knowledge and beliefs about epilepsy within these communities. Critical factors such as perceived stigma, knowledge gaps, and contextual elements that influence health education in rural schools are systematically documented. This analysis of findings serves as the foundation for effective content development and stakeholder engagement strategies.
Building on the insights gathered from the needs assessment, the next phase focuses on the collaborative development of a culturally relevant and age-appropriate curriculum on epilepsy. Input from health experts, including neurologists and psychologists, as well as educators and policymakers, ensures that the curriculum is scientifically sound and contextually appropriate. Interactive and inclusive teaching methodologies, such as role-playing, storytelling, and peer discussions, are integrated to promote engagement and understanding. Additionally, the curriculum is aligned with the national life skills education policy to enhance its scalability and legitimacy.
With the curriculum developed, the next step involves conducting structured workshops for educators and facilitators. These workshops cover essential topics, including the basics of epilepsy, seizure management, and first aid protocols. Emphasis is placed on inclusive pedagogy, equipping educators with classroom strategies to support learners with epilepsy effectively. To reinforce learning, simulation sessions and role plays are implemented. Participants receive a comprehensive training manual and access to digital support tools, while a peer-support network is established to foster ongoing mutual learning and sustainability among educators.
The curriculum is then piloted in a selection of 3 to 5 rural schools, allowing for real-world testing and refinement of teaching methods and content. Over the course of 6 to 8 weeks, the curriculum is implemented during regular life skills periods, incorporating supplementary materials such as interactive visuals and community engagement sessions. Family outreach initiatives are also included to extend the benefits beyond the classroom. Throughout this phase, engagement is closely monitored via teacher logs, student attendance records, and feedback reports, ensuring responsiveness and adaptability.
Evaluation occurs on two levels: process and outcome. Process evaluation utilizes observation checklists to assess the fidelity of curriculum delivery and student engagement. Qualitative feedback is solicited from both teachers and learners through structured reflections and focus group discussions, highlighting implementation challenges and best practices via interviews with educators and school leaders.
Outcome evaluation involves conducting pre- and post-intervention surveys among learners, teachers, and parents, focusing on key areas such as knowledge of epilepsy, seizure response capabilities, changes in attitudes, and stigma reduction. Further qualitative data is gathered through focus groups and interviews, exploring shifts in perception, inclusion, and behaviour. Where feasible, comparisons are drawn between outcomes in intervention schools and control schools to assess overall efficacy.
To ensure the longevity of the project, a train-the-trainer model is developed. This empowers local educators to continue delivering the curriculum independently. Refreshments and mentorship workshops are scheduled to promote sustained learning. Additionally, findings from the study are shared with local education departments, health authorities, and policy stakeholders, advocating for the integration of epilepsy education into the national life skills curriculum. This approach not only enhances the educational framework but also aims to foster an enduring change in attitudes and practices surrounding epilepsy in rural schools.
Through these phases, the study seeks to establish a robust educational model that addresses the complexities of teaching about epilepsy while promoting a supportive and inclusive learning environment.
Ethical approval was obtained from the University of Venda Human and Clinical Trial Research Ethics Committee (HCTREC) number FHS/25/PDC/09/1306. Written informed consent and assent will be obtained from all participants. Written Informed consent will be obtained from the parents or legal guardians of all participating minors before their involvement in the study. In addition, age-appropriate assent will be sought directly from the minors to ensure that their participation is voluntary and understood. The consent and assent process will follow ethical guidelines for research with children and will be overseen by the institutional research ethics committee. Participant confidentiality will be maintained using anonymized data, and digital data will be stored securely. Participants may withdraw at any time without consequence. Emotional risks will be minimized, and referral mechanisms to school-based psychosocial services will be in place.
The school-based epilepsy education intervention in rural Limpopo primary schools is anticipated to yield significant improvements in knowledge, attitudes, and behaviours regarding epilepsy among both students and educators. Central to this initiative is the implementation of a culturally relevant, curriculum-integrated program grounded in the Community-Based Participatory Research (CBPR) model. This approach aims to effectively reduce epilepsy-related stigma and misconceptions, particularly those stemming from traditional beliefs, such as witchcraft.
Expected outcomes include an enhanced understanding of epilepsy as a medical condition among students, while educators will develop increased confidence in teaching about epilepsy and managing seizures within the classroom setting. Furthermore, the intervention seeks to cultivate a more inclusive and supportive learning environment, thereby reducing the likelihood of marginalization or exclusion of children with epilepsy.
To ensure long-term sustainability and maximize community impact, the program employs a train-the-trainer model along with community engagement strategies. Additionally, the initiative is poised to inform policy recommendations for the integration of epilepsy education into the national life skills curriculum. This provides a scalable model for future public health interventions in educational settings, promoting greater awareness and support for individuals with epilepsy within the community.
The study will be conducted in accordance with the Declaration of Helsinki and was approved by the Human and Clinical Trial Research Ethics Committee (HCTREC) of the University of Venda (FHS/25/PDC/09/1306).
Written Informed consent will be obtained from all subjects involved in the study.
This is a study protocol. No dataset has been generated at this stage. Upon completion of the study and data collection, the dataset will be deposited in an open-access repository (OSF), and a citation with the permanent link will be provided in accordance with the journal’s guidelines.
OSF: Implementing and Assessing the Effectiveness of Epilepsy Education Intervention in Primary Schools in Limpopo Province:
The project contains the following extended data:
Supplement 1: Questionnaire and Interview Guide Supplement 2: Information Sheet and Consent Form
I want to thank the University of Venda for allowing us to conduct our research project. We also appreciate the University Staff Doctorate Programme (USDP) for providing us with financial support for the Epilepsy Research Project, which is an important part of our study.
This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration.
What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation).
Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table:
A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences).
Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination).
The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments.
the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”).
The protocol notes modules, toolkits, multimedia, role-play, etc., but does not specify:
The protocol says “surveys” but does not name instruments, provide sample items/domains, scoring, psychometrics, or whether tools are adapted/validated for this context/language(s).
There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation).
It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool).
The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion.
It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency.
Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors. Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class).
Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints. In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement). Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Partly
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Reviewer Expertise:
Pharmacoepidemiology
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
This protocol describes a Community-Based Participatory Research (CBPR) mixed-methods study to implement and evaluate a culturally sensitive epilepsy education intervention in rural primary schools in Limpopo Province, South Africa. The intervention is intended to be integrated into the Life Skills curriculum for Grades 5–7, and includes (i) a needs assessment, (ii) co-development of curriculum content with stakeholders, (iii) training of educators, (iv) implementation over 6–8 weeks, and (v) process and outcome evaluation using quantitative pre-/post-surveys and qualitative methods (focus groups, interviews, teacher logs, observation checklists). The protocol also proposes sustainability via a train-the-trainer approach and policy engagement to support curriculum integration.
What is clear: The introduction provides a coherent rationale: epilepsy-related stigma and misconceptions (including supernatural attributions) remain common in rural South Africa; schools are an underused setting for structured, curriculum-integrated education; and CBPR may improve cultural relevance and sustainability. The objectives are stated as a bullet list and align broadly with the rationale (curriculum development, educator training, implementation, evaluation).
We thank the reviewer for this important observation. We have revised the manuscript to clearly distinguish between primary and secondary objectives while retaining the key objectives originally outlined in the protocol. The primary objective is now explicitly defined as evaluating the effectiveness of the intervention in reducing epilepsy-related stigma among learners. The primary outcome is change in stigma scores measured at baseline, immediately post-intervention, and at the 4–6 week follow-up. The remaining objectives (knowledge improvement, attitude change, teacher preparedness, and curriculum feasibility) are now clearly defined as secondary objectives with corresponding secondary outcomes.
Add a short “Primary objective and hypotheses” subsection with 1–2 primary outcomes and a small number of secondary outcomes. Provide brief conceptual definitions and a mapping table:
We thank the reviewer for these constructive suggestions. In response, we have introduced a clearly defined “Primary and Secondary Objectives” subsection that includes explicit hypotheses and predefined primary and secondary outcomes. This clarification strengthens the study’s evaluation framework and ensures alignment between objectives, measurement tools, and statistical analysis. Additionally, we have operationalised the key constructs (knowledge, attitudes, stigma, and inclusive environment) by providing conceptual definitions and a construct-to-measure mapping table specifying the instrument/subscale, respondent group, and timing of assessment. This enhancement improves methodological transparency, reduces ambiguity, and strengthens internal validity and reproducibility of the intervention evaluation.
A CBPR framework is well matched to a culturally embedded stigma/health literacy problem, and the proposed mixed-methods evaluation is appropriate for capturing both measured changes (surveys) and contextual mechanisms (qualitative experiences).
We thank the reviewer for highlighting the need for clarification regarding the study design.
We revised the study design and will now employ a
Comparison schools will continue the standard Life Skills curriculum during the study period and will receive the epilepsy education intervention after completion of follow-up data collection (delayed intervention model).
Random allocation is not feasible due to logistical and administrative constraints within the public education system; however, the matched cluster design strengthens internal validity while maintaining feasibility and ethical fairness. The statistical analysis plan has been updated to include group-by-time interaction models that account for clustering at the school level.
Provide a design diagram (CONSORT-style flow for cluster/pilot studies or a clear timeline figure) showing: recruitment → baseline → training → delivery → post-test → follow-up → qualitative components. Pre-specify feasibility outcomes if this is a pilot (e.g., fidelity, acceptability, reach, retention, contamination).
We thank the reviewer for this important recommendation. We have revised the manuscript to include a follow-up outcome assessment to evaluate persistence of effects. Outcome measures will now be collected at three time points: baseline (pre-intervention), immediate post-intervention (within 1 week of completion), and follow-up at 4–8 weeks post-intervention. The Methods section has been updated to describe follow-up procedures, and the analysis plan has been aligned to assess both short-term gains and longer-term knowledge retention and sustained attitude/stigma change.
Furthermore, the manuscript has been revised to include a structured study flow and timeline outlining recruitment, baseline assessment, educator training, curriculum delivery, post-intervention testing, follow-up assessment, and qualitative components.
Additionally, a new subsection titled “Feasibility and Implementation Outcomes” has been added. This section pre-specifies key feasibility indicators, including fidelity, reach, acceptability, retention, and contamination. These indicators will inform the interpretation of effectiveness findings and assess the intervention's scalability.
The protocol outlines phases and participant categories well, but does not provide enough procedural detail for replication, particularly for the intervention content and measurement instruments.
the intervention dose (i.e. number of sessions/lessons, duration per session, total exposure time, and who delivers each session) lesson topics and learning objectives (by grade) who delivers each component (teacher vs facilitator), and required training hours fidelity monitoring criteria (what counts as “delivered as intended”).
We thank the reviewer for this valuable and methodologically important suggestion. We agree that clearer intervention specification enhances reproducibility, transparency, and rigor. In response, we have substantially revised the manuscript to include a structured intervention description aligned with the Template for Intervention Description and Replication (TIDieR) checklist.
We thank the reviewer for highlighting the need for greater clarity regarding outcome measurement. In response, we have substantially revised the manuscript to explicitly specify:
The names and structure of the learner and teacher questionnaires The outcome domains assessed (knowledge, attitudes, stigma, seizure first-aid response, and teacher self-efficacy) Example item types and response formats Scoring procedures and composite index construction Translation and back-translation procedures Cognitive interviewing procedures Planned psychometric evaluation, including internal consistency reliability We now clearly describe the adaptation process, including expert review and cultural contextualization. The full instruments are provided in Supplementary Material 1 for transparency and replication.
There is no statistical analysis plan (tests/models, clustering by school/class, handling missing data) and no qualitative analysis approach (e.g., thematic analysis steps, coding framework, triangulation).
We thank the reviewer for identifying the need for a clearer and more explicit analysis plan. In response, we have added a dedicated Data Analysis section that outlines:
The quantitative statistical analysis plan, including descriptive statistics, mixed-effects regression models to account for clustering at the school level, repeated measures analysis, and difference-in-differences comparisons. Procedures for handling missing data, including assessment of missingness patterns and use of multiple imputation where appropriate. A detailed qualitative analysis approach using reflexive thematic analysis, including coding procedures, theme development, triangulation, and strategies to enhance trustworthiness. A clear description of the mixed-methods design (convergent parallel design) and the strategy for integrating quantitative and qualitative findings using joint displays and triangulation during interpretation.
It is unclear how comprehension will be assessed, and who decides (teacher judgement vs screening tool).
We thank the reviewer for highlighting the need for clearer operationalization of this eligibility criterion. We agree that eligibility procedures must be transparent, objective, and ethically appropriate.
In response, we have revised the manuscript to clarify that comprehension will be operationalized primarily through (1) enrolment in Grades 5–7 within the standard Life Skills curriculum, and (2) functional proficiency in the school’s language of instruction (Xitsonga, Tshivenda, or English), as confirmed by routine classroom participation. No formal cognitive screening tool will be used. Learners with documented severe cognitive impairments that substantially limit participation in standard classroom instruction, as identified through school records and consultation with educators, may be excluded from survey-based outcome assessments for methodological reasons. However, such learners will not be excluded from receiving the educational intervention unless advised by school authorities for pedagogical or ethical reasons.
We thank the reviewer for this important clarification. The intervention is universal and classroom-based; therefore, learners diagnosed with epilepsy will not be excluded. We have clarified that participation does not require disclosure of medical status, and individual health conditions will not be recorded. As the unit of analysis is the group (school/class level), and no individual-level health data will be collected, the inclusion of learners with epilepsy is not expected to bias outcome assessment. This has now been explicitly stated in the manuscript.
We appreciate the reviewer’s concern regarding confidentiality safeguards in classroom and focus group settings involving minors. We have expanded the ethical procedures section to specify how survey administration will protect privacy (e.g., anonymous coding, sealed submission), and how focus group guidelines will emphasize voluntary participation, non-disclosure of personal medical information, and confidentiality agreements. These procedures have now been detailed in the manuscript.
The protocol appropriately states that no dataset exists yet, and indicates intent to deposit data on OSF after completion.
It also provides an OSF location containing extended data (questionnaire/interview guide; information sheet/consent forms), which is helpful for transparency.
Predefine what will be shared (de-identified raw data, codebook, analysis scripts, intervention materials, fidelity tools) and any access restrictions needed for safeguarding minors.
Commit to a clear data dictionary and “readme” describing variable coding, missingness codes, and clustering structure (school/class).
It has been provided in the manuscript
Clarify the evaluation design (comparator/control vs single-group pre/post) and reconcile the number of schools (8 planned vs 3–5 pilot).
The study design is now explicitly described as a quasi-experimental cluster design involving eight rural primary schools (four intervention and four matched comparison schools). The comparator group and delayed intervention model are clearly specified.
Specify primary outcome(s) and primary objective(s), and operationalize core constructs (knowledge/attitudes/stigma/inclusion).
The primary objective (reduction in epilepsy-related stigma) and primary outcome (change in mean stigma scores across three time points) are clearly defined. Key constructs (knowledge, attitudes, stigma, inclusive school environment) are operationalized with explicit measurement domains and timepoints.
Provide sufficient intervention detail for replication (dose, session structure, content, delivery, training duration, fidelity).
The intervention now includes detailed information on dose (six 60-minute sessions), delivery structure, grade-specific content, training duration (an 8-hour educator workshop), materials, and fidelity-monitoring criteria.
Provide a quantitative and qualitative analysis plan, including clustering considerations and missing data approach, plus the method for integrating mixed-methods findings.
A dedicated Data Analysis section outlines the quantitative statistical plan (mixed-effects regression accounting for school-level clustering, handling of missing data, effect size reporting), qualitative thematic analysis procedures, and mixed-methods integration using a convergent parallel design.
Fully specify measurement instruments (survey domains, scoring, adaptation/validation, languages) and operationalize the comprehension eligibility criterion.
Survey instruments are clearly specified, including domains, scoring procedures, adaptation and validation steps (expert review, translation/back-translation, cognitive interviewing), and reliability assessment. Full instruments are provided in the Supplementary Materials.The comprehension eligibility criterion is now objectively defined using grade enrolment and functional classroom participation, without requiring formal cognitive screening. Inclusion of learners with epilepsy is explicitly stated, with confidentiality safeguards in place.
Consider adding a brief table summarizing: participants, sample size targets, recruitment method, outcomes, and timepoints.
It was added in the manuscript but not as table
In “Expected results,” keep outcomes framed as hypotheses rather than assured effects (to avoid overstatement).
expected outcomes were framed as hypotheses
Ensure consistency in terminology (“life skills” vs “Life Skills,” “Primary schools” capitalization) for readability.
Consistency ensured throughout the document
I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research.
- The criterion of ‘ability to comprehend age-appropriate epilepsy education content’. How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process? - Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified. - It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention. The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact. Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section. However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Yes
Reviewer Expertise:
Attitude, Epilepsy, Knowledge, Peer education, Seizure first aid.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research.
- The criterion of ‘ability to comprehend age-appropriate epilepsy education content’.
How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process?
We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation.
- Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified.
We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility.
The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains:
Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items).
We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity.
These revisions enhance scientific rigor, replicability, and clarity of outcome measurement.
We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology.
- It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention.
The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section.
We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.”
Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly.
However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study.
Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings.
However, it was only included to show that the expected results are similar to what was found in Turkey.
I am pleased to review this study protocol as it aligns with my expertise in physiology, health education, and behavioural health research.
The criterion of ‘ability to comprehend age-appropriate epilepsy education content’.
How will this comprehension be assessed? Will it be determined by teacher evaluation, a pre-test, or during the teaching process?
RESPONSE
We appreciate the reviewer's methodological clarification. The inclusion criterion “ability to comprehend age-appropriate epilepsy education content” is now explicitly defined. Eligibility is based on enrollment in Grades 5–7, ensuring alignment with the national Life Skills curriculum. Learners must demonstrate understanding through routine classroom participation and a brief baseline questionnaire. This method enhances fairness and transparency, allowing learners with severe cognitive impairments to receive the intervention without exclusion from evaluation.
Comment
Surveys aimed at assessing knowledge, attitudes, and stigma regarding epilepsy should be clearly defined and specified.
Response
We thank the reviewer for this important observation. We agree that a clearer specification of the quantitative instruments strengthens methodological transparency and reproducibility.
The “Evaluation Instruments” section of the Methods has been revised to explicitly define the survey domains, item structure, scoring procedures, and validation processes. The questionnaire will now be structured into three clearly defined domains:
Epilepsy knowledge (15–20 objective items), Attitudes toward epilepsy (10–15 Likert-scale items), Epilepsy-related stigma (8–12 Likert-scale items).
We have specified scoring procedures, composite score calculation, and internal consistency assessment using Cronbach’s alpha. Additionally, procedures for cultural adaptation, translation, expert review, and cognitive testing have been added to ensure contextual validity.
These revisions enhance scientific rigor, replicability, and clarity of outcome measurement.
We have expanded the qualitative component to clearly specify sampling strategy, data collection procedures, analytic framework (thematic analysis), and strategies to enhance credibility and trustworthiness. This revision strengthens transparency and reproducibility of the qualitative methodology.
Comment
- It is not explicitly stated whether students diagnosed with epilepsy will be included in the study. This omission is significant, as the inclusion or exclusion of such students could substantially affect the outcomes of the educational intervention. To comprehensively evaluate the effectiveness of the educational intervention, it is important that post-tests are not limited to measuring only the short-term learning outcomes immediately following the intervention.
The persistence of knowledge and understanding over time, i.e. the long-term effect, is a critical indicator of the overall success of the educational programme. Therefore, it is recommended that the study include both a final test immediately after the intervention and a follow-up final test at a predetermined interval (e.g. 4-6 weeks). This approach will allow for a comparison between short-term gains and long-term knowledge retention, enabling a more reliable assessment of the intervention's sustainable impact.Additionally, to ensure reproducibility and scientific rigour, the timing and procedure of the follow-up test should be clearly outlined in the methodology section.
Response
We thank the reviewer for this important and constructive comment. The manuscript has been revised to explicitly state that learners diagnosed with epilepsy will not be excluded from participation. As the intervention is designed as a universal classroom-based educational programme, the inclusion of learners with epilepsy reflects real-world school settings and supports the study’s objective of promoting inclusion and reducing stigma. This clarification has been added under “Participants – Inclusion Criteria for Learners.”
Additionally, we agree that assessing only immediate post-intervention outcomes may not adequately capture sustained impact. The protocol has therefore been revised to include a follow-up assessment at 4–6 weeks post-intervention. Outcome measures will now be collected at baseline, immediate post-intervention, and follow-up, allowing evaluation of both short-term gains and long-term knowledge retention and attitude change. The statistical analysis plan has been updated accordingly.
Comment
However, the inclusion of studies conducted in Turkey could contribute to an understanding of regional differences and cultural contexts. Referencing relevant research from Turkey would increase the scope and global value of the study.
Response
Thank you for this valuable suggestion. I acknowledge that including studies conducted in Turkey could enrich the discussion by providing insights into regional differences and cultural contexts related to epilepsy awareness among teachers. While the current document represents the protocol stage of the study, relevant international literature, including studies from Turkey, will be considered and incorporated as the research progresses and during the development of the full literature review and final manuscript. Such studies can provide important comparative perspectives, particularly when discussing teachers’ knowledge, attitudes, and practices in different educational and cultural settings. However, it was only included to show that the expected results are similar to what was found in Turkey