Study design and study period
Institutional based cross sectional study was conducted from May 15 to June 30, 2016.
Study area
An institution based study was conducted at AMSH, AA - Ethiopia. The hospital has different teams. Neuro Epileptic Case Team (NEP) is one of health service team in the hospital. There are about 34,210 PWE who have regular follow up in a year at hospital’s NEP clinics. Among them 11,634 (34%) are females [11]. Averages of 1900 cases are seen monthly (AMSH, Central statistic bureau). The area is selected because of high patient flow which has good opportunities to trace patients who can be representative for the study population.
Population
Source population
Our source populations were all PWE who present for follow up visit at AMSH, NEP clinics.
Study population
Our study populations were PWE in the age group 18 and above who were presented for follow-up visit at AMSH NEP clinics in the study period.
Eligibility criteria
PWE age 18 and above, who had sexual experience for six or above months were included in this study.
PWE who is on ectal or post-ectal phase were not included in this study.
Sample size & sampling procedure
Sample size
The minimum number of sample required for this study determined by using power population proportion formula considering the following assumptions;
95% confidence level, 50% sexual dysfunction and 5% margin of error
$$ n=\frac{{\left(\frac{Z\alpha}{2}\right)}^2p\left(1-P\right)}{d^2} $$
(1)
$$ n=\frac{(1.96)^20.5\left(1-0.5\right)}{(0.05)^2}=384 $$
In Ethiopian culture, openly discussing on issues related with sexuality is taboo and not common. By considering such conditions and other studies non respondent rate this study was used a maximum non respondent rate; 15%. Thus; the total sample size calculated with single population proportion to study prevalence of sexual dysfunction among PWE.
$$ 384+\left(384\ast 15\%(384)\right)=442. $$
(2)
To address associated factors, final sample size was calculated by using power population proportion as:
$$ 608+\left(608\ast 15\%\left(\ 608\right)\right)=608+91.2=699.2\approx 700 $$
(3)
Sampling procedure
Our study participants were select from AMSH, NEP OPDs through stratified systematic random sampling technique. Sample size was allocated proportionally for each sex categories (66% for male and 34% for female participants). Sampling interval was determined by dividing total study population; 2850 PWEs [11]; who had follow up during six weeks data collection period by total sample size (700). The sampling fraction was: 2850/700 = 4.07. Approximately five was taken not to miss respondents in the sampling fraction above four (0.07). The first respondent was selected by lottery method from the first five study population for each strata, and the next respondent was chosen at regular intervals of every 5th cases in each sex categories.
Instruments used for data collection and data collection procedures
Instruments used for data collection
In this study, to assess Socio-demographic information, clinical data, quality of sexual functioning and factors associated with sexual dysfunction; We mainly used Couples Satisfaction Index (CSI) scales to assess participant’s satisfaction on their relationship, Daily Stress Full Life Events Measurement Scale (DSLEMS) to assess presence of Stressful Life Events and to obtain socio-demographic and clinical data a detailed self-designed semi structured questionnaire was administered to study participant.
Sexual response was measured by using Changes in Sexual Functioning Questionnaires (CSFQ-14-) which have separate forms for female (CSFQ - Female Clinical Version) and male (CSFQ - Male Clinical Version) data. CSFQ has 14 items on a single sheet and it is used to assess the existence of sexual problems in study participants. All the 14 items should be answered on a five point (Likert type) scale to assess global sexual dysfunction. Eleven of the items from “Never”, through “Rarely”, “Sometimes”, and “Often”, to “Every day”; the rest three of the items which has reverse scored from No”, through “Little”, “Some”, and “much”, to “Great”. In addition other CSFQ domains; Sexual Desire, Pleasure, arousal/excitement and Orgasm/Completion can be obtain and represent as a profile. The CSFQ-14- has chosen because it is standard, have a brief, valid, reliable, relatively unobstructive, available and gender-specific questionnaire to monitor sexual functioning. Also it has Cronbach’s α 0.91 and 0.93 for the male and female scales, respectively [12].
The English version of instruments was translated to Amharic language and retranslate to English by accepted psychiatric professionals. For participants in different languages, translators were assisting data collectors.
Data collection procedures
Data collectors got brief orientation on the data collection procedure and data collection protocol before they engage into actual data collection activities. Three health officers and three BSC nurses (four males and two females) were recruited to collect data. Amharic Version of structured and semi structured interviewer administered questionnaire was used. It has six parts: The 1st part contains socio-demographic characteristics of participants; the 2nd part contains “Changes in Sexual Functioning Questionnaires (CSFQ)”; the 3rd and the 4th parts were containing Relationship Assessment Scale (RAS) and Self-esteem scale respectively, Daily Stressful Life Events Measurement Scale (DSLEMS) was the 5th tool used to assess Stressful Life Event/s and the last part contains clinical data of participants. This tools were administered to 700 eligible clients at AMSH; NEP clinics during the study period. Privacy of participants was given special consideration before the beginning of data collection. To make the communication easy female data collectors were expected to contact female subjects and the same procedure were performing for male subjects. Two separate OPDs (NEP OPD-3rd for males and MCH OPD for females) were used to obtain data from each sex categories.
Definition of variables
Sexual Dysfunction was dependent variable and independent variables were Psychosocial factors (quality of relationship, stressful life event/s, self-esteem), Demographic factors (age, sex, education, occupation, relationship status), Clinical factors (comorbid conditions, medication for comorbidities, obesity), Illness related factors (type of AEDs, seizure experience (uncontrolled/ controlled), age onset of epilepsy, medication regimen, type of epilepsy], Behavioral factor (alcohol use, khat use or/and cigarette use).
Sexual dysfunction: it is explained by total scores below the cutoff points from all 14 CSFQ elements; below 41 and 47 for female and male participants respectively [12].
Sexual dissatisfaction: it is explained by scoring less than 5 from CSFQ-14- (item one).
Sexual desire problem: it is explained by scoring less than 16 for females and less than 20 for males from the sum of CSFQ-14- (items 2 through 6).
Arousal/excitement dysfunction: it is explained by scoring less than 13 for females and less than 14 for males from the sum of CSFQ-14- (items 7 through 9).
Anorgasmia: it is explained by scoring less than 12 for females and less than 14 for males from the sum of CSFQ-14- (items 11 through 13).
Dyspareunia: it is explained by scoring less than 5 for both sex categories from the CSFQ − 14- (item teen).
Quality of relationship: it is explained by score above 15 from the summation of Relationship Assessment Scale called the more satisfied with his/her relationship [8, 13] .
Poor self-esteem: is defined as score below 15 on Rosenberg self-esteem scale.
Khat: is a flowering plant native to the Horn of Africa and the Arabian Peninsula. It contains the alkaloid cathinone, a stimulant, which is said to cause excitement, loss of appetite and euphoria [14].
Comorbid illness: is defined as presence of additional illness among PWE; which includes previously confirmed psychosis, depression, hypertension, diabetic mellitus, and asthma.
Stressful Life Event: experiencing one or more from listed ten items within the past six months from time of data collection.
Poly therapy: taking two or more than two types of AEDs.
Underweight: BMI less than 18.5 Kg/m2.
Normal weight: BMI in the range 18.5 to 24.99 Kg/m2.
Overweight: BMI in the rages of 25 to 29.99 Kg/m2.