Pluralistic and singular causal attributions for epilepsy in Uganda Caleigh E. Smith a,1 , Mayanja Kajumba b , Samuel Bobholz c,2 , Patrick J. Smith d , Mark Kaddumukasa e , Angelina Kakooza-Mwesige f,g , Payal Chakraborty h,i,3 , Drishti D. Sinha a,4 , Martin N. Kaddumukasa e,j , Alex Gualtieri k,5 , Noeline Nakasujja l , Erica Onuoha a,6 , Juliet Nakku m , Christine Muhumuza h,n , Nadine Sanchez h,i , Anthony T. Fuller h,i,o , Michael M. Haglund h,i,o , Deborah C. Koltai h,p,d, ⁎ a Duke University Trinity College of Arts & Sciences, Durham, NC 27708, USA b Department of Mental Health and Community Psychology, Makerere University School of Psychology, P.O. Box 7062, Kampala, Uganda c University of Wisconsin - Madison, Department of Neurology, 1685 Highland Avenue, Madison, WI 53705-2281, USA d Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, DUMC Box 3119, Trent Drive, Durham, NC, USA e School of Medicine, College of Health Sciences, Makerere University. P.O. Box 7072, Kampala, Uganda f Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda g Department of Pediatrics and Child Health, Mulago National Referral Hospital, Pediatric Neurology Unit, Kampala, Uganda h Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Box 3807 Duke University Medical Center, Durham, NC 27705, USA i Duke Global Health Institute, 310 Trent Dr, Durham, NC 27710, USA j Department of Medicine, Mulago National Referral Hospital, Neurology Unit, Kampala, Uganda k Duke University Medical Center, Clinical Neuropsychology Service, Box 3333, Durham, NC, USA l Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda m Butabika National Referral Mental Hospital, P.O. Box 7017, Kampala, Uganda n Makerere University School of Public Health, Department of Epidemiology and Biostatistics, New Mulago complex, P.O. Box 7072, Kampala, Uganda o Duke University, School of Medicine, 3100 Tower Blvd, Durham, NC 27707, USA p Duke University, Department of Neurology, 3116 N Duke St, Durham, NC 27704, USA abstract article info Article history: Received 13 February 2020 Revised 24 June 2020 Accepted 28 June 2020 Available online xxxx Objective: In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions. Methods: In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then uti- lized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann–Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups. Results: Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a poten- tial cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the pat- terns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a bio- logical etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p b 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p b 0.01), and there were significant differences in income across specific groups (p b 0.01). Keywords: Epilepsy Causes Pluralism Uganda Epilepsy & Behavior xxx (xxxx) xxx ⁎ Corresponding author at: Clinical Neuropsychology Service, Box 3333, Duke University Medical Center, Durham, NC 27705, USA. E-mail address: koltai@duke.edu (D.C. Koltai). 1 Current address: Weill Cornell Medicine, Center for Global Health, New York, NY, USA. 2 Current address: Medical College of Wisconsin, Department of Biophysics, 8701 Watertown Plank Rd. Milwaukee, WI 53226, USA. 3 Current address: Division of Epidemiology, College of Public Health, The Ohio State University, Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA. 4 Current address: Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, USA. 5 Current address: Duke School of Nursing, 307 Trent Dr., Durham, NC 27710, USA. 6 Current address: Weill Cornell Medicine, Department of Healthcare Policy & Research, 425 East 61st St Suite 301, New York, NY 10065, USA. YEBEH-107334; No of Pages 6 https://doi.org/10.1016/j.yebeh.2020.107334 1525-5050/© 2020 Published by Elsevier Inc. Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh Please cite this article as: C.E. Smith, M. Kajumba, S. Bobholz, et al., Pluralistic and singular causal attributions for epilepsy in Uganda, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2020.107334