In 1924, Hans Berger first recorded the electrical activity from the human brain through an intact skull in Germany and called it an encephalogram. This work he published in 1929   . Electroencephalography has been described as “one of the most surprising, remarkable, and momentous developments in the history of clinical neurology”  . By 1938, the EEG had become an established neuro-diagnostic tool in much of Europe and America  .
Established indications for electroencephalography are well known (box)  .
There is paucity of literature write-ups on studies concerning the knowledge, attitude or perceptions and practice of the use of EEG among health practitioners. However literature review concerning the knowledge and practice of doctors towards epilepsy shows that, although most doctors in their lifetime will provide care for patients with epilepsy  , most of them do not receive further training in epilepsy  and therefore are not confident in managing such patients. As a matter of fact, some doctors consider their training in epilepsy care to be inadequate  and therefore may not be to make correct diagnosis or request for the appropriate investigations  of which electroencephalography is their chief.
The utilization of EEG has been suboptimal in Africa despite the huge burden of neurological disease. According to data from the World Health Organization, there is a very low physician to patient ratio for the neurosciences in Africa: 1 neurologist to 1 - 2.8 million population (versus 4/100,000 in Europe); 1 psychiatrist to 900,000 population (versus 9/100,000 in Europe) and 1 neurosurgeon to 2 - 6 million population (versus 1/100,000 in Europe). Similarly by 2004, it was estimated that there were only 79 EEG machines in Sub-Saharan Africa (excluding South Africa)  .
Nigeria is the most populous country in the African continent and the most populous black nation in the world. Yet there is no published data from the country on how knowledgeable medical doctors (specialists and general practitioners) are concerning EEG or how they utilize the EEG in their routine clinical practices. This study, set in Enugu, the major city in the South East region of Nigeria, determined the perception and practice in a cohort of physicians who live and practice in the vicinity.
2. Materials and Methods
2.1. Study Area
This descriptive study was carried out in Enugu, the major city of the South East region of Nigeria which is principally a rain forest environment with the population engaged principally in agriculture, public/civil service and commerce/trading.
2.2. Study Population
This comprised medical doctors with their practice in Enugu and adjoining communities attending a mandatory meeting of the state branch of the Nigeria Medical Association. Both general practitioners and specialists in medical/surgical disciplines were in attendance. Informed consent was obtained from all.
2.3. Study Period
This study was carried out in August 2018.
2.4. Sampling Technique
Total sampling was utilized in recruiting study participants.
A structured questionnaire, designed and pre-tested for clarity and adequacy, was utilized to obtain socio-demographic data as well as assess perception and practice towards electroencephalography in the respondents. The questionnaire was designed by OIO, EB and ECS. The result of pre-test for clarity and adequacy was 98.2% and 98% respectively. Section 1 of the questionnaire asked sociodemographic such as age, gender, number of years of practice, area of specialization. Section 11 tested the knowledge of the doctors about EEG, while section 111 studied the attitude of the doctors toward EEG. Section IV asked questions that will help to evaluate their practice of EEG.
2.6. Statistical Analysis
Analysis was done using IBM Statistical Package for the Social Sciences version 21 (Chicago, Illinois, USA). Descriptive statistics were used to compute means and standard deviations for numerical variables as well as frequencies for nominal and ordinal variables. The relationship between categorical responses and explanatory variables were evaluated using chi-square test. In all statistical tests, a value of p < 0.05 was considered significant.
A total of 520 questionnaires were deployed and 486 were satisfactorily enrolled for analysis (response rate 93.5%). There were 335 male and 151 female doctors (M/F = 2.2) with a mean age of 46.7 ± 9.6 years, of which 345 (71%) were specialists while 141 (29%) were of non-specialist cadre (general practitioners and intern house officers).
The distribution of the types of medical practice of the doctors is shown in Table 1. Only 141 (29%) were of non-specialist cadre.
As shown in Table 2, despite most doctors being aware of the EEG (479, 98.6%), there was varying degrees of knowledge of its clinical utility across the cadres with doctors in Internal Medicine/Pathology according most importance to it (46.5%/60%) while those in the surgical specialties had the lowest opinion on clinical utility of EEG with dental surgeons being the worst affected (100%). Interestingly up to 82.1% of newly qualified intern doctors (House Officers) felt the EEG was not useful. Across all the cadres of doctors, the neurologist was accepted as best suited to interpret EEG recordings.
Less than 40% of doctors certainly had EEG available as a service in their hospitals of practice. This knowledge was highest for doctors in Internal Medicine (>74%) but surprisingly lowest for psychiatrists (21.7%). Though the vast majority of doctors (89.5%) indicated interest in their centres of practice having an EEG machine, just 45.7% of respondents viewed this as necessity. Table 3 provides more details.
Table 1. Distribution of types of medical practice of respondents.
Table 2. Knowledge and perception about EEG in clinical use across the cadres.
Table 3. Exploring availability and need for EEG service.
Reviewing individual physician experience with EEG, about one in three doctors (34%) have ever witnessed an EEG recording in progress while about 60% of the doctors have seen an EEG report for a patient. Internal Medicine physicians performed best in this category. Table 4 illustrates these findings across the cadre.
As demonstrated in Table 5, less than half (40.5%) of all responding doctors had requested for EEG as part of diagnostic workup of their patients in the prior 1 year with a similar proportion (43.5%) having never made a request for more than half a decade. Subgroup analysis shows that pediatricians had the most recent requests for EEG (84.2%).
Most of the doctors (339, 85.2%) correctly named seizures/epilepsy as an indication for EEG while an array of other suitable and unsuitable medical conditions were listed too as shown in Table 6.
Table 4. Assessing physicians’ personal experiences with EEG.
Table 5. Time of physician’s last request for an EEG.
*84 participants did not answer the question.
Table 6. Physician- given indications for requesting EEG.
*88 participants did not respond to this question.
Despite the advent of high resolution anatomic imaging modalities such as the magnetic resonance imaging (MRI), computed tomography (CT) scan and positron emission tomography (PET), the EEG continues to be a valid tool for research and diagnosis. It is one of the few mobile techniques available and offers millisecond range temporal resolution, a property that is not possible with MRI, CT and (PET)  . From the EEG can be derived evoked potentials (EP) and event-related potentials (ERPs) which are techniques that are used in neurology and other neuroscience fields   .
There is a dearth of literature on the knowledge, attitude and practice of physicians towards the EEG especially in Africa, probably explained by the fact that though the EEG’s place in medical practice has been established for decades in much of the developed world, its role in the continent and indeed much of the developing countries has been severely hampered by both lack of equipment and extremely few neurologists in those areas   .
This study is the first one in the South East region of Nigeria to evaluate medical doctors and the contribution of electroencephalography as a diagnostic tool. The cohort assessed comprised a broad range of both specialist and non-specialist cadres of physicians (71% vs 29% respectively) with surgical consultants (surgery, ophthalmology, obstetrics/gynaecology, dentistry and anesthesia) making up nearly half of the specialists surveyed (48.6%).
Most physicians interviewed (85.2%), correctly identified seizures/epilepsy as indications for EEG. This proportion is important considering the high incidence of epilepsy in the African region   . It however sharply contrasts with the findings from Laos PDR where only 38.8% of physicians regarded EEG as relevant in epilepsy management  . However in terms of this knowledge being transferred to practice, there was a disparity as only 42% of all doctors have had cause to refer for EEG in the last 1 - 10 years. It could be that this is a reflection of the type of practice as most Pediatricians (84.5%) and Psychiatrists (81%) were more conversant with routine referrals, perhaps reflecting the doctors who experience greater exposure to EEG requiring patients including those with epilepsy/seizures.
Physicians generally had poor exposure to EEG with only 34% ever having witnessed a recording even as medical students. For decades there was a paucity of neurologists in the region and only one institution had an EEG machine. This could explain the rather unsatisfactory level of exposure. Of recent there has been a slight increase in the number of neurologists and greater efforts in medical education at both undergraduate and postgraduate levels in neurology are being made which should hopefully change the narrative over time. The drawback to these efforts are mainly institutional as evidenced by the fact that most hospitals lack access to EEG (61.7%) and surprisingly nearly half of the physicians (46.7%) did not believe EEG was needed in their centres.
Interestingly despite this low level of exposure, most doctors have seen a patient’s EEG report (60%) and nearly all doctors (87.4%) believe only the neurologist is competent to interpret the EEG. There appears to be a consistent line of disparity in the appreciation of the EEG across the cadres with general practitioners performing worse than specialists in all assessments regarding utility of the EEG, while the surgical specialists (surgery, ophthalmology, obstetrics/gynaecology, dentistry etc.) are out-performed by their medical specialist counterparts (internal medicine physicians, pediatricians, psychiatrists etc.) in knowledge, attitude and practice towards the EEG.
Currently, electroencephalography (EEG) is the most effective diagnostic tool for non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE) in intensive care units (ICUs) and emergency departments   . Meanwhile, it was estimated that less than two percent of the critically ill patients in ICUs and EDs undergo EEG  . Despite this established fact, an uncomfortable majority of anesthetists surveyed here (75%) were of the opinion that EEG was irrelevant in their routine practice. This finding should be a matter of concern for hospital administrators as anesthetists (as intensivists) are usually the personnel who oversee ICUs in hospitals across the region.
The under-adoption or decreased utilization of EEG originates from challenges to accommodate EEG into established practice protocols. General practitioners had been reported to have less awareness and more negative attitudes towards epilepsy  and this could well be the case in this region where epilepsy remains the commonest indicator for EEG. In communities in Nigeria, most patients with EEG requiring conditions are more likely to be attended to at the initial visit to a hospital or health centre by general practitioners.
One of the limitations of this study is the limited number of study participants. Not all the medical practitioners in Enugu state could be reached at the time of the study. Only those who attended the meeting of the state chapter of the Nigerian Medical and Dental Association participated in the study, and even then only those that gave their consent were recruited.
Secondly, there are no previous similar studies on the topic of this manuscript done locally, in Africa and generally on the international platform. Therefore literature search on EEG studies did not yield much to form a basis for comparison, hence the scanty literature review of this paper.
This study has demonstrated that electroencephalography is an under-appreciated investigative modality amongst physicians in Enugu, despite the high burden of neurological diseases in the population. More and continuous educational activities on the utility of EEG are needed for medical students and doctors to reverse the trend.
The authors are grateful to Dr. Maxwell Nnamdi who assisted with the logistics of data collection.
OIO and ECS conceived and designed the study as well as supervised the data collection. Data analysis was by EB and OIO. OIO and MNC wrote the manuscript. All the authors approved the final draft. Funding was provided by OIO, ECS, OCJ, MNC and EB. OIO is the guarantor of the manuscript.
 Vancini, R., Benedito-Silva, A.A., Sousa, B.S., Gomes da Silva, S., Ma-Souza-Vancini, M.I. and Vancini-Campanharo, C.R. (2012) Knowledge about Epilepsy among Health Professionals: A Cross-Sectional Survey in Sao Paulo, Brazil. British Medical Journal Open, 2, e000919.
 Harimanana, A., Chivorakul, P., Souvong, V., Preux, P.M. and Barennes, B. (2013) Is Insufficient Knowledge of Epilepsy the Reason for Low Levels of Healthcare in the Lao PDR? BioMed Central Health Services Research, 13, 41.
 Hämäläinen, M., Hari, R., Ilmoniemi, R.J., Knuutila, J. and Lounasmaa, O.V. (1993) Magnetoencephalography—Theory, Instrumentation, and Applications to Noninvasive Studies of the Working Human Brain. Reviews of Modern Physics, 65, 413-497.
 Yang, H., Ang, K.K., Wang, C., Phua, K.S. and Guan, C. (2016) Neural and Cortical Analysis of Swallowing and Detection of Motor Imagery of Swallow for Dysphagia Rehabilitation—A Review. Progress Brain Research, 228, 185-219.
 Jestrović, I., Coyle, J.L. and Sejdić, E. (2015) Decoding Human Swallowing via Electroencephalography: A State-of-the-Art Review. Journal Neural Engineering, 12, Article ID: 051001.
 Elliott, J. and Shneker, B. (2008) Patient, Caregiver, and Health Care Practitioner Knowledge of, Beliefs about, and Attitudes toward Epilepsy. Epilepsy and Behavior, 12, 547-556.