**7.1 Health related stigma**

Stigma is a major social determinant of health, attributing to disease morbidity, mortality and to the successfulness of healthcare services [18].

Elements that articulate the complex process of health conditions related stigma include illness nature, it's course, and characteristics that represent origins of stigma; population related elements; treatment modalities and healthcare providers sought for consultation; reactions as well as coping mechanisms of stigmatized individuals to social acts of discrimination that may take a toll on their identity, social life, and economic thriving [17, 19, 20].

What is not so clearly defined however, is the relationship between stigma and healthcare outcomes, attributing to stigma being an entity that while having similar grounds in most health related conditions, its effects can be as illness specific as exclusive features of that illness, often referred to as the hidden burden of an illness, and this is an area that is deficient in research data [21, 22].

#### **7.2 Manifestation of stigma in high income vs. low-income countries**

Health related stigma, can be visualized more clearly in communities where compensation of one's health condition related disability is lacking. These compensations aim towards minimizing the gap between individuals with disabling health conditions and their peers in community. Communities where efforts to minimize this gap are lacking are mostly those of low-income economical index [20].

Stigma adversely affects individual health outcomes as well as related life chances, including educational opportunities, employment, housing, and social relationships. It has also been shown to negatively affect help- and treatmentseeking behaviors, compromising the ability to treat and prevent stigmatized health conditions. Masking of research on illness specific stigma under the generalization of its nature has limited the ability to understand the overall impact of stigma on individual wellbeing and the overall disease burden, restricting the ability to develop interventions addressing stigma, and this masking is amplified especially in low-income countries, because of the lacking resources available to healthcare research and services in general [20, 23].

Stigma affects caregivers of individuals being stigmatized, be it their families, relatives or close companions. Caregivers of patients in low-income countries suffer a heavier burden due to lacking national health agencies support, which widens the gap between illness-limited individuals and their peers in society, further enforcing stigma as well as worsening the financial burden. All these elements associated with stigma in low income countries develop a synergistic effect, in which each element contributes to the vicious cycle of further reducing the quality of life of stigmatized individuals [23].

#### **7.3 Stigma of epilepsy in low-income countries**

The weight and burden associated with epilepsy in terms of stigma manifests with variable intensities and forms across different age groups and communities [6, 24].

Developmental aspects of one's life including physical, mental and social development, and their bases of parenting by one's family, education and an uninterrupted

social learning experience, are affected differently with various onset age groups of epilepsy. For example, having a child with epilepsy puts tremendous pressure on the family and caregivers, especially in a low-income country where taking care of an illness free child can be troublesome. This leads to stressful parenting, creating many obstacles for a child who has epilepsy to develop at a normal rate. A child with epilepsy has a higher chance of academic underachievement, which would setback building of self-esteem and eventually in conjunction with other epilepsy related elements leads to enforcement of stigma and further disability and unsuccessful treatment, in contrast to adolescence onset of epilepsy which would have a different impact on their quality of life and would manifest in different aspects like social withdrawal despite being in a functional social and economic status. Adulthood onset of epilepsy and the manifestation of stigma associated with it could be less severe than childhood and adolescence onset and would affect one's ability to be involved in certain elements of society, but could also be devastating in certain low-income regions with plummeting education and awareness levels, for example not being able to have a spouse in a low-income community where having epilepsy is thought to be of demonic possession [1, 6, 24].
