The first step in a situational assessment is to determine what you need to inform planning decisions. I used Public Health Ontario's (2015) template with three broad questions and sub-questions below to shape the direction of the situational assessment and develop an outline for my situational assessment related to my health promotion project in epilepsy self-management.
1. What is the situation?
What impact does the current situation have on health outcomes, quality of life and other societal costs, such as noise, air pollution or increased healthcare spending?
Poorly controlled epilepsy has significant detrimental health outcomes including increased seizure frequency, worsened seizure severity, cognitive impairment (including memory problems and challenges with daily tasks), physical injuries (such as head injuries related to falls), psychological effects (including anxiety, depression, stigmatization, and social isolation), medication side effects (such as dizziness and fatigue), increased risk of death (such as Sudden Unexpected Death in Epilepsy or accidental deaths like drowning), and reduced quality of life including impacts on driving, working, and participating in life fully related to unpredictable seizures (Josephson et al., 2017; Laxer et al., 2014). Moreover, healthcare spending increases when epilepsy is not well managed because people with uncontrolled epilepsy will require more emergency room visits and hospitalizations for medical intervention (Szaflarski, 2014).
Which groups of people are at higher risk of health problems and poorer quality of life?
People at higher risk for epilepsy include those with a family history of epilepsy, infants and children with developmental challenges (e.g., structural brain abnormalities or perinatal injuries), aging adults (due to higher incidence of co-morbidities such as stroke and dementia), people that abuse drugs or alcohol (since this lowers the seizure threshold), and people with injuries or conditions impacting the brain (e.g., brain tumours, brain infections, Parkinson’s disease, brain aneurysms, and tuberous sclerosis), with poorer management related to lower socioeconomic status and poor health literacy (Duke et al., 2021; Gaitatzis et al., 2004; Tian et al., 2018). Women are also at higher risk of health problems related to epilepsy due to potential teratogenic effects of anti-epileptic drugs (AEDS), reproductive health issues, complications with pregnancy, and impacts of AEDs on bone density (BC Epilepsy Society, n.d.; Szaflarski, 2014)
People at higher risk for poor quality of life related to epilepsy include those that conceal their epilepsy due to fear of reactions of others or embarrassment (Mlinar et al., 2016). Also, those with less social ties that are unemployed and feel they are not independent are more likely to experience poorer quality of life (Lewinski et al., 2020). People that cannot easily access necessary resources (e.g., live in a region without epileptologists or a Seizure Investigation Unit) may struggle with epilepsy management and experience worse quality of life (Bethea et al., 2012).
Which settings or situations are high risk, or pose a unique opportunity for intervention?
The Seizure Investigation Unit at Vancouver General Hospital is a unique setting for intervention as patients are admitted for typically 1-3 weeks for spells characterization and have opportunities to ask questions and receive education. Remote and rural regions of British Columbia face the disadvantage of not having epilepsy specialists near their home making virtual care solutions an increasingly popular choice.
How do local stakeholders perceive the situation? What is their capacity to act? What are their interests, mandates, current activities? What are the needs, perceptions and supported directions of key influential community members, and the community-at-large?
Healthcare professionals: Primary care physicians perceive uncontrolled epilepsy as a threat to patient wellbeing that interferes with treatments of other medical conditions. Referrals to neurologists and epileptologists allows for better guidance related to epilepsy. Epileptologists perceive uncontrolled epilepsy as unsafe and requiring specialized care including finding the appropriate AEDs and exploring advanced interventions such as surgery. Neurophysiology Technologists, nurses, and other allied health professionals, help with diagnostic tests, providing education, and addressing psychosocial aspects of epilepsy. Healthcare professionals need more time in their busy schedule to dedicate towards implementing epilepsy education programs.
People with epilepsy: Patients perceive uncontrolled epilepsy as a hindrance to good quality of life since the unpredictable nature of seizures creates fear, anxiety, and frustration. Patients need to understand their seizure triggers and maintain a lifestyle that limits the occurrence of seizures. Patients need education about health promoting behaviours in epilepsy.
Caregivers: Family members, friends, and those providing care to people with epilepsy perceive uncontrolled epilepsy as a detriment to their loved ones life and their own quality of life. They need to understand the role of a caregiver and learn how to minimize risks in the environment and advocate for better services.
Support Organizations: Groups like the BC Epilepsy Society perceive uncontrolled epilepsy as an unfair consequence of poor public awareness, access to care, and funding for epilepsy (including research). Support organizations provide resources, education, and social cohesion to people with epilepsy and their caregivers. These organizations need more donations to continue their work and play a larger advocacy role.
Community: The general public has a distorted view of epilepsy based on media portrayals of the neurological condition. Perceptions of uncontrolled epilepsy vary depending on the amount of awareness and stigma (WHO, 2019). Some communities favour traditional/indigenous medicine over Western medicine or attribute epilepsy to non-scientific causes such as evil spirits (Mutanana, 2020). Campaigns that describe first aid in epilepsy and provide background knowledge about seizure triggers and health promoting behaviours are needed.
Government and Public Health Agencies: Decision-makers view uncontrolled epilepsy as a burden on the individual, community, and healthcare system. Policymakers are concerned with public health initiatives that ensure adequate prevention and management of epilepsy that uses an equity lens.
2. What influences are making the situation better and worse?
What high-risk or negative health behaviours by various groups of people are affecting the situation?
The negative health behaviours that may act as seizure triggers include sleep deprivation, alcohol or drug misuse, missing anti-epileptic medication doses, excessive screen time, or viewing bright flashing lights (Luedke et al., 2019; Tian et al., 2018).
Which underlying causes or conditions are driving these behaviours (e.g. individual, community, organizational or system-level causes)? Are there protective factors that can help avoid or alleviate the situation (such as ensuring walkable communities or encouraging strong parent-child relationships)?
Living in a technological era where we use digital devices for a good portion of our work (e.g., writing emails) and leisure time (e.g., video games) makes it challenging to limit screen time. Bright flashing lights can occur in the environment in many ways such as sunlight passing through trees at a fast frequency while driving, from police sirens, or from strobe lights in entertainment (making flashing lights warning beneficial). Sleep deprivation could be related to a work schedule (e.g., working the graveyard shift) or poor time management due to other responsibilities like family life. Alcohol or drug misuse can be linked to traumatic experiences or a particular community’s/group’s norms and culture. Designing communities that support active lifestyles and make healthy choices easier options will improve epilepsy management. People with epilepsy require good public transit systems if they have driving restrictions and need to attend medical appointments, social gatherings, political events, sporting activities, and other functions (Lewinski et al, 2020). Interpersonal connections support epilepsy management because it decreases stigma and increases inclusion.
Which strengths and weaknesses present in your organization may affect your course of action? Which opportunities and threats in your environment may affect your course of action?
In my organization, a key strength is our multidisciplinary team. Input from various perspectives and involvement with health professionals with various expertise helps ensure that the different aspects of epilepsy management is addressed. A specialized team is beneficial because it helps ensure accurate diagnosis, tailored and comprehensive treatment plans, psychological support, medication management, innovation, education, and empowerment. The staff in the Seizure Investigation Unit (SIU) communicate daily during rounds and can coordinate care through the newly implemented electronic health records system. A threat to our environment is staff turnover as this negatively impacts continuity of care and requires additional in-house training to ensure appropriate on-boarding and orientation to the SIU. Staffing shortages puts a strain on workers’ morale and ability to complete tasks.
3. What possible actions can you take to address the situation?
What are other organizations doing, or what have they done in the past, to address this situation? Specifically, what local policies, programs and environmental supports are being developed or implemented within the community? What evaluation data are available for these activities?
Non-profit organizations (e.g., BC Epilepsy Society): Raising awareness, providing education and resources, creating support groups, advocating for improved services.
Seizure Investigation Unit: Providing video-electroencephalography monitoring of patients with epilepsy to determine appropriate treatment plans, characterize spells and events, and determine if the patient is a candidate for surgery.
Telemedicine: Virtual care solutions by discussing symptoms and changes with specialists over digital platforms instead of the burden of travelling to a larger city.
Recent events/campaigns/dates of interest (Canadian Epilepsy Alliance, 2023):
- Epilepsy awareness month (March 26th)
- I am 1 in 100 campaign (March 2020)
- Purple Lights (monuments in Canada like CN Tower, Niagra Falls, Signal Hill, and BC Place, light up in purple to increase awareness of epilepsy) - Sail for Epilepsy (August 2023)
- Charity bike ride to raise funds for BC Epilepsy Society (June 2022)
- World Epilepsy Day (February 2nd)
What is the best available evidence that exists to support various courses of action?
Successful epilepsy management involves (Luedke et al., 2019; Tian et al., 2018):
1) Using self-monitoring tools: Keep a seizure diary that describes physical and mental changes (before, during, and after a seizure), seizure duration, and possible triggers. Journal about emotional states and bodily sensations. Collect data (e.g., heart rate and rhythmical movements of limbs) using a wearable device). Share self-monitoring information with a healthcare provider to guide treatment plans.
2) Discovering protective factors: Examine the various levels of influence within a socioecological framework to understand ways in which risks can be mitigated and benefits can be enhanced through our choices such as accessing healthcare resources.
3) Avoiding seizure triggers: Learn how our actions are influenced by risk perception and engage in health promoting behaviours (e.g., follow a medication regime, practice stress reduction techniques, and sleep better).
4) Connecting with community resources and advocacy organizations: Build a support network that bridges the knowledge gap and reduces stigma.
5) Receiving education: Educate the patient, caregivers, healthcare professionals, researchers, policymakers, and public about epilepsy to increase awareness, tolerance and funding while applying pressure to advocate for positive change.
Template adapted from: Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2015). Focus on: six strategic steps for situational assessment. Queen's Printer for Ontario; Toronto, ON. https://www.publichealthontario.ca/-/media/documents/f/2015/focus-on-situational-assessment.pdf?la=en
BC Epilepsy Society (n.d.). Women in mind. BC Epilepsy Society. Retrieved Sept. 24, 2023 from http://bcepilepsy.com/programs/women-in-mind
Bethea, T.N., Lopez, R.P., Cozier, Y.C., White, L.F. & McClean, M.D. (2012). The relationship between rural status, individual characteristics, and self-rated health in the Behavioral Risk Factor Surveillance System. Journal of Rural Health, 28, 327-338. https://doi.org/10.1111/j.1748-0361.2012.00414.x
Canadian Epilepsy Alliance (2023). March epilepsy awareness month 2023 campaign. Epilepsy awareness month. Retrieved Sept. 23, 2023 from
https://www.canadianepilepsyalliance.org/march-epilepsy-awareness-month-2023- campaign/#:~:text=Every%20March%2026th%2C %20people%20around,events%20to%20support%20epilepsy%20awareness.
Duke, S.M., Gonzalez Otarula, K.A., Canales, T., Lu, E., Stout, A., Ghearing, G.R. & Sajatovic, M. (2021). A systematic literature review of health disparities among rural people with epilepsy (PWE) in the United States and Canada. Epilepsy & Behavior, 122, 1-6. https://doi.org/10.1016/j.yebeh.2021.108181
Gaitatzis, A., Carroll, K., Majeed, A. & Sander, J.W. (2004). The epidemiology of the comorbidity of epilepsy in the general population. Epilepsia, 45, 1613-1622.
Josephson, C.B., Patten, S.B., Bulloch, A., Williams, J.V.A., Lavorato, D. & Fiest, K.M. (2017). The impact of seizures on epilepsy outcomes: A national, community- based survey. Epilepsia, 58, 764-771.
Laxer, K.D., Trinka, E., Hirsch, L.J., Cendes, F., Langfitt, J. & Delanty, N. (2014). The consequences of refractory epilepsy and its treatment. Epilepsy & Behavior, 37, 59-70.
Lewinski, A.A., Shapiro, A., Gierisch, J.M., Goldstein, K.M., Blalock, D.V., Luedke, M.W., Gordon, A.M., Bosworth, H.B., Drake, C., Lewis, J.D., Sinha, S.R., Husain, A.M., Tran, T.T., Van Noord, M.G. & Williams, J.W. (2020). Barriers and facilitators to implementation of epilepsy self-management programs: A systematic review using qualitative evidence synthesis methods. Systematic Reviews, 9, 92-109. https://doi.org/10.1186/s13643-020-01322-9.
Luedke, M.W., Blalock, D.V., Lewinski, A.A., Shapiro, A., Drake, C., Lewis, J.D., Goldstein, K.M., Husain, A.M., Gierisch, J.M., Sinha, S.R., Tran, T.T., Gordon, A.M., Kosinski, A.S., Bosworth, H.B., Van Noord, M. & Williams, J.W. (2019). Self-management of Epilepsy: A Systematic Review. Evidence Synthesis Program. Retrieved Sept. 24, 2023 from https://www.ncbi.nlm.nih.gov/books/ NBK544549/pdf/Bookshelf_NBK544549.pdf
Mlinar, S., Petek, D. Cotic, Z, Ceplak, M.M. & Zaletel, M. (2016). Persons with epilepsy: Between social inclusion and marginalization. Behavioural Neurology,1, 1-12. https://doi.org/10.1155/2016/2-185-0
Mutanana, N., Tshababa, M., Senderayi, P, Nyathi, C. (2020). Health promotion and disease prevention: Theories and models influencing epilepsy management. Journal of Research and Innovation in Social Science, 4(9), 1-5.
Szaflarski, M. (2014). Social determinants of health in epilepsy. Epilepsy & Behavior, 41, 283-289. https://doi.org/10.1016/j.yebeh.2014.06.013
Tian, N., Boring, M. & Kobau, R. (2018). Active epilepsy and seizure control in adults: United States, 2013 and 2015. MMWR Morb Mortal Wkly Rep., 67(15), 437-442.
World Health Organization (WHO) (2019). Epilepsy: A public health imperative. World Health Organization. Retrieved Sept. 24, 2023 from https://www.who.int/publications/i/item/epilepsy-a-public-health-imperative
Comments