**3. Results**

#### *3.1. Intergroup Comparisons*

In the first step of the conducted analysis, levels of weekly physical activity of the subjects were compared. Results are shown in Table 2.

**Table 2.** Comparison of physical activity levels of women and men.

Markings: *n*—count, *%*—percent, *x*2—c2 test value, *p*—significance level, *V*—effect size expressed by Crammer's *V* coefficient, \*—levels of weekly physical activity were distinguished based on results expressed in MET units.

Nearly three-quarters of the women surveyed showed a sufficient level of weekly physical activity. A high level of activity characterized 15.0% of female respondents, and a low level of activity characterized more than one-tenth of female respondents.

In the group of men, more than three-quarters of the study participants were characterized by a high level of weekly physical activity. The activity of nearly one-fifth of the respondents was sufficient, while the lowest percentage of men showed insufficient weekly physical activity.

The analysis resulted in a strong statistically significant gender effect for weekly physical activity.

Women, compared to men, less often revealed a high level of physical activity, while more often, their weekly activity was classified as sufficient and insufficient.

In the second step of the analysis, the level of physical activity, mental health, cognitive processes and the quality of social functioning of the surveyed women and men were assessed. The results of the comparative analysis are presented in Table 3.

**Table 3.** Comparison of physical activity, mental health, cognitive processes and social functioning of women and men.

Markings: *M*—mean, *SD*—standard deviation, *t*—value of Student's *t*-test for independent data, *p*—significance level, *d*—measure of Cohen's *d* effect size, \*—results expressed in MET units, \*\*—raw results, \*\*\*—results expressed in sten.

The weekly physical activity of the surveyed women was classified as sufficient. However, in the male population it reached a high level. Regardless of gender, the respondents spent the most time on walks, then on intense physical activity, and the least on training with a moderate level of vigorous activity and passive rest (sitting, lying down).

The general mental health of the study participants was within the upper limit of the average results, which also suggests that in the analyzed population of women, in the event of the occurrence of adverse factors generating severe and chronic stress, there may be a risk of developing symptoms characteristic of mental health disorders. In women, somatic symptoms were most severely intensified, followed by anxiety and insomnia, symptoms of depression and symptoms typical of disorders in everyday functioning. In the group of men, the overall mental health condition was moderate. The respondents were dominated by a sense of anxiety and insomnia, while functional disorders, somatic symptoms and symptoms of depression were less severe.

The functioning of the cognitive processes of the studied populations was classified as moderate. In the female population, the most pronounced difficulties related to perceptual work, followed by perception deficits and attention deficits. The highest intensity of perception deficits was observed in men, while the problems with perceptual work and attention deficits were at a slightly lower level.

Social functioning of the analyzed groups was in the area of moderate results. Women did best in family relationships and among acquaintances and friends, and the worst

in professional interactions. Men showed the highest level of coping skills in interpersonal relationships, then in family relationships, and the poorest quality of interactions in professional relationships.

As a result of the comparative analysis, a strong gender effect was noted for moderate activity; moderate gender effects for weekly activity, somatic symptoms, cognitive functioning, perceptual work, attention deficits and professional relationships; and weak gender effects for walking, vigorous activity, mental disorders, functional disorders, depressive symptoms and family relationships.

Compared to men, women showed a lower level of weekly physical activity, walking, moderate physical activity and vigorous physical activity, as well as a lower quality of family relationships. Moreover, more severe mental disorders, somatic symptoms, functional disorders, depressive symptoms, cognitive disorders, perceptual work disorders, attention deficits and a higher quality of relationships in the area of professional life were more often noted in the female population than in men. On the other hand, sitting and lying down, anxiety and insomnia, perception deficits, social relationship and interpersonal relationships were at a comparable level in the analyzed groups.

#### *3.2. Estimation of Measurement Models*

Prior to estimation of the complete interactive structural model presenting the relationships between physical activity, mental health, cognitive disorders and social functioning, its four measurement parts were estimated. Model specifications were carried out in the group of women and men.

In the first measurement model, physical activity is a latent variable, while its partial indicators are walking, moderate activity and vigorous activity. Figure 1 shows the results of verification of the constructed model of physical activity measurement in the group of women, and Figure 2 illustrates the measurement model of physical activity in the group of men.

As a result of the estimation, the following measures were obtained: CMIN/DF = 1.75; GFI = 0.99; AGFI = 0.99; NFI = 0.99; RFI = 0.95; IFI = 0.99; TLI = 0.99; CFI = 0.99; RM-SEA = 0.001(0.001; 0.05); PCLOSE = 0.92; *N* HOELTER(1269; 1561), which confirm that the model reflects the nature of the relationships between the analyzed variablesvery well. The standardized values of factor loadings and the percentages of variances explained in each of the analyzed groups show that the constructed model of physical activity measurement is acceptable.

**Figure 1.** Standardized effects of the model of physical activity measurement in the group of women.

**Figure 2.** Standardized effects of the model of physical activity measurement in the group of men.

In the second measurement model, the presence of mental health disorders is an unobservable variable, and its partial indicators are somatic symptoms, anxiety and insomnia, functional disorders and the symptoms of depression. The results of the verification of the constructed model for measuring mental health disorders in the group of women are shown in Figures 3 and 4 illustrates the measurement model of mental health disorders in the group of men.

**Figure 3.** Standardized effects of the mental health disorder measurement model in the group of women.

**Figure 4.** Standardized effects of the mental health disorder measurement model in the group of men.

The following measures were obtained during the verification of the model: CMIN/DF = 1.75; GFI = 0.99; AGFI = 0.99; NFI = 0.99; RFI = 0.95; IFI = 0.99; TLI = 0.99; CFI = 0.99; RMSEA = 0.001(0.001; 0.05); PCLOSE = 0.92; *N* HOELTER(1116; 1442), which confirm that it is correctly fitted to the data, and the standardized values of factor loadings and the percentages of variances explained in the group of women and men allow for recognizing the constructed model of mental health disorders measurement as acceptable.

In the third measurement model, the presence of cognitive disorders is an unobservable variable, and its partial indicators are perceptual work, perception deficits and attention deficits. The results of the verification of the constructed model for measuring cognitive disorders in the group of women are shown in Figures 5 and 6 illustrates the measurement model of cognitive disorders in the group of men.

**Figure 5.** Standardized effects of the measurement model of cognitive disorders in the group of women.

**Figure 6.** Standardized effects of the measurement model of cognitive disorders in the group of men.

As a result of the estimation, the following measures were obtained: CMIN/DF = 1.75; GFI = 0.99; AGFI = 0.99; NFI = 0.99; RFI = 0.95; IFI = 0.99; TLI = 0.99; CFI = 0.99; RMSEA = 0.001(0.001; 0.05); PCLOSE = 0.92; *N* HOELTER(1317; 1596), which confirm that the model reflects the nature of the relationships between the analyzed variablesvery well. The standardized values of factor loadings and the percentages of variances explained in each of the analyzed groups show that the constructed model of cognitive disorders measurement is acceptable.

In the fourth measurement model, social functioning is an unobservable variable, and its partial indicators are support received from family members, friends, colleagues and medical professionals. The results of the estimation of the social support functioning model in the group of women are presented in Figures 7 and 8 illustrates the measurement model of social functioning in the group of men.

**Figure 7.** Standardized effects of the measurement model of social functioning in the group of women.

**Figure 8.** Standardized effects of the measurement model of social functioning in the group of men.

The following measures were obtained: CMIN/DF = 1.75; GFI = 0.99; AGFI = 0.99; NFI = 0.99; RFI = 0.95; IFI = 0.99; TLI = 0.99; CFI = 0.99; RMSEA = 0.001(0.001; 0.05); PCLOSE = 0.92; *N* HOELTER(1335; 1428), which confirm its compliance with the data. The standardized values of factor loadings and the percentages of variances explained in the groups analyzed indicate that the constructed model of social functioning measurement is acceptable.

#### *3.3. Structural Model Estimation*

The estimation and acceptance of the constructed measurement models allows for the estimation of the full interactive structural model, which was developed on the basis of the theoretical frameworks. As in the case of measurement models, its specification was carried out in the group of women and men. Figure 9 shows the construction and detailed standardized parameters of the interactive model of the relationship between physical activity, mental health, cognitive disorders and social functioning in the group of women, and Figure 10 depicts the results obtained in the group of men.

The accuracy of the interactive structural model was positively verified based on the following measures of goodness of fit: CMIN/DF = 1.38; GFI = 0.99; AGFI = 0.97; NFI = 0.98; RFI = 0.96; IFI = 0.99; TLI = 0.99; CFI = 0.99; RMSEA = 0.019 (0.008; 0.28); PCLOSE = 1.00; *N* HOELTER(1008; 1120).

In the group of women, the constructed model explained 51.0% of social functioning, which reflects the quality of tolerable family, interpersonal and professional relationships, and in the population of men, 41.0% of the variance of the analyzed variable was explained. In the group of women, there was a strong, directly proportional correlation between mental health disorders and cognitive disorders (*p* = 0.001), as well as a weak negative relationship of physical activity with mental health disorders (*p* = 0.001) and with cognitive disorders (*p* = 0.001). There was also a moderate, inversely proportional relationship between mental health disorders (*p* = 0.001) and social functioning, as well as a weak relationship between cognitive impairment and social functioning (*p* = 0.002).

In the group of men, there was a strong, directly proportional correlation between mental health disorders and cognitive disorders (*p* = 0.001), as well as a moderate negative relationship of physical activity with mental health disorders (*p* = 0.001) and with cognitive disorders (*p* = 0.001). There was also a moderate, inversely proportional relationship between mental health disorders (*p* = 0.001), cognitive disorders (*p* = 0.001) and social functioning.

**Figure 9.** Standardized effects of the structural model of the relationship between physical activity and psychosocial functioning in a group of women.

**Figure 10.** Standardized effects of the structural model of the relationship between physical activity and psychosocial functioning in a group of men.

The model shows that the consequences of the COVID-19 epidemic in Eastern Poland expressed in the form of mental health disorders and symptoms typical of cognitive disorders were moderated by physical activity from various sources. The more often the respondents engaged in physical activity by going for walks and training moderately and vigorously, the lower the risk was of developing mental disorders, manifested in the form of somatic symptoms, anxiety and insomnia, functional disorders and the symptoms of depression, as well as the occurrence of cognitive disorders, such as perceptual work disorders, perception deficits and attention deficits. Moreover, physical activity weakened the relationship between mental health disorders and disorders of cognitive processes and social functioning in family, interpersonal and professional relationships of the studied groups.

It should also be added that the comparisons of the values of parameters within and between groups showed that the relationship between mental health disorders and cognitive disorders was comparable in each group and stronger than the correlations between physical activity and mental health disorders and cognitive disorders. Moreover, in the case of women, the leading factor associated with the quality of social interactions was the state of mental health, which was less dependent on the level of physical activity than on the functioning of cognitive processes moderated by physical effort, while the quality of male social interactions depended on the relationship between the state of mental health and the cognitive functioning that is impaired by physical activity. In the population of women, compared to men, physical activity was less important for mental health and the functioning of cognitive processes, and the occurrence of symptoms typical of mental health disorders was more strongly associated with the quality of social interactions of women than men. It has also been shown that disorders of cognitive processes correlate more weakly with the social functioning of women than men.

## **4. Discussion**

The outbreak of the COVID-19 pandemic caused severe and long-lasting stress in many people from different countries of the world, the relatively common consequences of which were mental health problems associated with deterioration of cognitive and social functioning [6,53,54]. Despite many published empirical studies devoted to the discussed issue, the role of physical activity in the prevention of psychosocial functioning of the inhabitants of Eastern Poland has not been analyzed so far [53,55,56].

Therefore, research was carried out to assess the level of physical activity, mental health, cognitive processes and social functioning, as well as the interactions and relationships between them, in the population of Eastern Poland, depending on gender.

With regard to the above goals, two hypotheses were formulated. The first of them assumed that during the COVID-19 pandemic, in the inhabitants of Eastern Poland, the level of physical activity and the severity of symptoms characteristic of mental health disorders, cognitive disorders and the quality of social functioning differed depending on gender.

The conducted analysis allowed us to positively verify the adopted assumption in terms of statistically significant gender differences regarding levels and severity of weekly activity, as well as the severity of vigorous activity, moderate activity, walking, mental disorders, somatic symptoms, functional disorders, depressive symptoms, cognitive disorders, perceptual work, attention deficits, family relationships and professional relationships. It has been shown that women were less likely than men to show a high level of physical activity, but more often their weekly activity ranked at sufficient and insufficient levels. It was also noted that surveyed men showed higher than average physical activity, walking, moderate physical activity and vigorous physical activity than women, and they functioned more efficiently in family relationships, but had more difficulty finding their way in professional interactions. Moreover, men showed a lower severity of mental disorders, somatic symptoms, functional disorders, depressive symptoms, cognitive disorders, perceptual work disorders and attention deficits as compared to women.

The men had a moderate state of mental health and cognitive processes, while women's scores in mental disorders and perceptual work disorders were approaching the edge of the elevated area. The average weekly physical activity of men was high, and that of women was at a sufficient level, with the activity of more than three-quarters of the men surveyed being high, at nearly one-fifth sufficient, and 5.8% insufficient. In contrast, the women's group reported markedly different results. Almost three-fourths of the female respondents showed a sufficient level of activity, while high and low activity levels were reported by 15.0% and 13.7% of the respondents, respectively.

Comparing the data obtained with the results of surveys conducted in other regions of Poland and the world, one can see significant discrepancies. The research already mentioned in the theoretical introduction proves that both men and women from the northeastern part of Poland manifest an insufficient and significantly understated level of physical activity in comparison to residents of other regions of this country and European

countries. At the same time, men engaged in moderate physical activity and rode a bicycle more frequently than women [33].

Another empirical study also observed that women reported lower moderate physical activity than men, but were more likely to engage in light physical activity. It is worth noting, however, that because the study was conducted in a population of patients with a diagnosis of peripheral artery disease, vigorous activity was not analyzed in the study [57].

In contrast, a Canadian study, similar to our own, reported that women were less physically active than men during the COVID-19 pandemic, a result that was statistically significant [58]. Analogous observations have also come from the general population of Beirut [59]. In addition, women reported more barriers to engaging in systematic physical activity and reported significantly weaker mental fitness than the opposite sex [58,59]. A key observation appears to be that, among women, the most severe adverse mental health symptoms occurred in subjects whose physical activity was very low [58].

Thus, both the results of our own study and the conclusions of the work of other researchers suggest that, especially in the group of women, in the event of the occurrence or intensification of the impact of existing stressors, there may be a risk of developing undesirable symptoms in the state of mental health and cognitive processes [60]. This observation seems to be particularly important in the situation of a prolonged health crisis, because the effectiveness of coping, under the influence of chronic distress, may show a downward trend, and this directly implies an increased risk of undesirable symptoms in the field of mental health [61].

This effect was observed by Di Maio's team. On the basis of the conducted moderation analysis, he noted that the belief in the possessed remedial abilities was directly related to physical activity in a situation where the encountered challenges were relatively low. On the other hand, when these challenges were high, the relationship between physical effort and faith in one's abilities did not reach the level of statistical significance. The observed dependencies confirm the need to monitor not only direct but also long-term consequences in terms of the mental health of people affected by the COVID-19 pandemic [62].

The need to conduct this type of longitudinal research is also indicated by other researchers who, while forecasting the upcoming increase in the number of patients with depressive and anxiety disorders resulting from the current health crisis, as well as from the current problems of the mental health care system, point to the important role of physical activity in preventive interventions [7,63]. Systematic endurance training, by activating the HPA axis, stimulates the release of dopamine, which is responsible for self-regulation and mood [64,65]. The results of the meta-analysis, which included the data of 40,550 adults, show that the respondents who undertook systematic physical activity, compared to women and men with moderate and low activity, were less likely to develop mental disorders. The highest risk group was those who led a sedentary lifestyle [66], while the level of physical activity, physical fitness, mental health, cognitive processes and the quality of functioning in social interactions were higher in men than in women [67–70].

In this context, it should be noted, however, that the relationships between the aforementioned variables in the interactive and multidimensional approach have not been analyzed so far [71,72]. Taking into account the above premises, the second hypothesis assumed that during the COVID-19 pandemic in the inhabitants of Eastern Poland, depending on gender, the following are different: the importance of interactions between physical activity, mental health and cognitive disorders for social functioning.

The constructed structural model of the relationship between physical activity and selected aspects of psychosocial functioning allowed for a positive verification of the assumption. As a result of its estimation, in the group of women and men, the existence of interactions between physical activity, disorders of mental health and cognitive processes was confirmed, and their association with the social functioning of the analyzed groups was verified. Systematic physical activity, including intense and moderate endurance training and walking, was negatively associated with symptoms characteristic of mental health disorders, which include symptoms of depression, functional disorders, anxiety and insomnia and somatization, as well as cognitive disorders manifesting as weakened speed of perception and deficits in perceptiveness and attention to social functioning of the respondents.

In the case of women, the leading factor related to the quality of social interactions was the state of mental health, which was less dependent on the level of physical activity than on the functioning of cognitive processes, while the quality of men's social interactions was most dependent on the relationship between the state of mental health and the functioning of cognitive processes. Moreover, in the group of women, compared to men, physical activity was more weakly linked to the state of mental health and the functioning of cognitive processes, and the occurrence of symptoms typical of mental health disorders had correlated more strongly with the quality of women's social interactions than men's. In turn, cognitive disorders were more weakly linked to the social functioning of women than men.

Relating the observed regularities to the conclusions of the empirical works of other researchers, it can be seen that they are to some extent similar [67,73]. In a sample of 5856 adults aged 26–70 years, it was noted that in the male population, physical activity was more negatively associated with problems in the sphere of mental functioning than in the group of women [67].

Another empirical study positively verified and moderated the role of gender in relation to physical activity, health-related quality of life and perceived social support. It was shown that people with the lowest assessments of mental health status had a 1.8 times lower probability of obtaining social support than respondents who showed high and average assessments of mental condition, while the participants with the lowest results in terms of physical health were twice as likely to be deprived of the help of their relatives than women and men who perceived their somatic health as very good or average. Moreover, men with low physical activity compared to women more often reported poor mental and somatic health and a lower overall quality of life than women. It should be added, however, that the discussed model did not take into account the symptoms characteristic of cognitive disorders [73].

Summing up the discussion, it is worth emphasizing that the results of our own research seem promising in the context of preventing the psychosocial functioning of adult inhabitants of Eastern Poland who have been affected by the COVID-19 epidemic. Nevertheless, due to the existing limitations, the observed effects require further empirical verification.

The aforementioned limitations include the fact that, in order to minimize the risk of SARS-CoV-2 infection and taking into account the epidemic restrictions in the country, the study was conducted online, which might not have been fully comfortable for the participants. In addition, the study sample consisted of volunteers, who had access and the ability to use a computer, which, despite a relatively large number of observations and controlling for a number of side variables, could have affected the results. Consequently, the data may not fully reflect the psychosocial situation in the Eastern region of Poland. In addition, the study population was made up exclusively of people who were employed and those in marriages and partnerships. This suggests, therefore, that the research results obtained should be generalized, with some caution, only to the population of healthy, economically active residents of Eastern Poland with life partners.

It should also be added that there were no people infected with the SARS-CoV-2 coronavirus and COVID-19 patients among the participants, so in the subsequent studies, it would be worth verifying whether this factor differentiates mental health disorders, cognitive disorders and social functioning. Another area requiring exploration is the determination of the level of physical activity and these parameters and the relationships between them in the population of medical staff, especially those who specialize in COVID-19 treatment. Due to the specificity of their work, the indicators of physical activity, mental health and cognitive problems as well as social functioning may be higher in this group than in the general population. It is also important to mention that the region of Eastern

Poland is characterized by a relatively low transmission of the SARS-CoV-2 coronavirus; therefore, the psychosocial consequences of the epidemic may be lower in the inhabitants of this part of the country than in those affected by a higher epidemic risk.

Another aspect that should be mentioned in the context of discussing the limitations of the presented results is that due to the cross-sectional nature of the research and the lack of data from before the outbreak of the pandemic, the conducted analysis showed only the current intensity of individual parameters and the strength of the relationships between them; however, the dynamics of changes under the influence of SARS-CoV-2 transmission were not estimated. For this reason, it is not possible to precisely determine to what extent the current pandemic situation has influenced the change in the intensity of the analyzed variables and the strength of their relationships.

It is also worth mentioning that the measurement of physical activity was carried out using the short form of the questionnaire (*IPAQ-SF*), which may have made it slightly less reliable than the full version (*IPAQ*) [25,50]. However, the decision to choose the *IPAQ-SF* was based on the suggestions of the authors of the Polish adaptation of the test, who, based on the conclusions of a number of empirical studies, recommend the use of the abbreviated Polish version of the tool for research conducted both within one country and conducted internationally. They point out that the full version of the *IPAQ*—due to its detail—requires much greater involvement of the subjects, and this in turn directly implies impatience, a tendency to give random answers, skip questions or drop out of the survey [50]. Researchers from other regions of the world have also encountered similar problems with the full version of the test [25]. Given that in our study, in addition to the test used to measure physical activity, four other questionnaires were used, the aforementioned risks were reduced by using the *IPAQ-SF* [25–50].

Nevertheless, the presented study is the first and largest project focused on the analysis of the psychosocial functioning of the inhabitants of Eastern Poland during the COVID-19 epidemic, in which diagnostic tools with high psychometric properties and advanced statistical methods were used. This allowed for the visualization of the structure of mutual and multifaceted relationships between particular variables in the group of women and men.

Moreover, the discoveries are of great cognitive and practical importance. Determining the current level of psychosocial functioning of the inhabitants of Eastern Poland during the pandemic, in terms of the level of physical activity, mental health, cognitive processes and the quality of social functioning, as well as verifying the occurrence and significance of interactions and relationships depending on gender, not only enriches knowledge about the mechanisms shaping the responses of adults to the current health crisis, but it is above all the basic element that allows for taking effective preventive actions. Confirmation that various forms of physical activity are a factor protecting against negative effects on mental health, cognitive processes and social functioning may constitute the basis for developing gender-individualized, interdisciplinary psychopreventive interventions aimed at strengthening the intrapsychic and interpersonal spheres of women and men at risk of the negative consequences of SARS-CoV-2 transmission.


**5. Conclusions**

In this study, the battery behaviors under 13 different aging conditions are investigated experimentally, based on which, an aging-conscious battery model is proposed for energy management application. The optimal control strategy is then proposed for PHEVs energy management against the impact of battery aging. The presented control strategy can achieve the optimal control performance over the entire battery lifespan based on the PSO algorithm. The quantitative impact of battery aging on the energy consumption has been revealed, indicating that the capacity and internal resistance are the main factors that cause the extra energy cost. The presented energy management strategy is evaluated and analyzed by a simulation study under two typical driving cycles. The results indicate that the energy cost of PHEV can be increased by up to 15.19% due to the battery aging. The aging-conscious energy management can balance out some of the harmful effects that battery aging can have on energy efficiency. Compared with the strategy without considering the battery aging, the presented strategy can reduce the aging-induced energy consumption by up to 2.24% at certain driving condition.

**Author Contributions:** Conceptualization and methodology are provided by Z.C. and J.L.; software and data analysis are conducted by B.L.; validation is presented by N.Z. and S.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by "the National Natural Science Foundation of China, grant number 51977029, 51607030" and "the Fundamental Research Funds for the Central Universities, grant number N2003002".

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.


2.3.2. Thermal Resistance

The boiling-induced nanoparticle deposition onto the interface of the solid and liquid phases seriously affects the interfacial thermal resistance (ITR) or Kapitsa resistance. The ITR can be modified by the wettability and morphology of the interface. For instance, the thermal conductance of different wettability interfaces functionalized with a self-assembled monolayer (SAM) has already been determined by the time-domain thermo-reflectance technique [59]. The authors reported that the ITR of a hydrophobic interface was near three-fold greater than that of a hydrophilic interface. Moreover, in the work performed by [5], the layer of carbon nanoparticles deposited onto the solid and liquid phases interface influenced the density of the working fluid, the heat transfer near the interface, and the ITR. The researchers numerically evaluated the ITR with changes in the intermolecular interactions between the fluid and the nanoparticles and those between the fluid and the surface. The researchers arrived at the following conclusions: (i) The nanoparticle layer deposited onto the solid–liquid interface decreased the ITR, which might become lower that the typical ITR value of a smooth heating surface, especially in the cases where the nanoparticles exhibit hydrophilicity. Additionally, it was common in the fullerene and amorphous nanoparticles. (ii) The considerable ITR decrease caused by the deposition layer enhanced the heat transfer from the heating surface to the nanoparticles, and, consequently, augmented the heat transfer of the nanoparticles. The key condition for the decrement in the ITR was the extraction, storing, and transport of the heat from the solid interface by the nanoparticles to the neighboring fluid outside the deposition layer. In addition to the heat flux increment, the temperature difference at the interface of the solid and liquid phases was decreased by the deposition of the nanoparticles. These alterations contributed to the ITR reduction. (iii) The deposit of nanoparticles onto the interface did not induce an appreciably extra thermal resistance as compared with the corresponding fluid layer, independently of the morphology of the nanoparticles. This was caused by the fact that the single layer of the nanoparticles was of such reduced dimensions that it could not be enough for producing the additional thermal resistance at the interface, although the thermal resistance of the used fullerene was high. (iv) The nanoparticle deposition changed

the density of the thermal fluid and the temperature gradient at the interface. The ITR decreased with increasing fluid density in the deposition layer. The changes in the fluid density in the interface nearby region and in its temperature gradient by the nanoparticle deposition were two major conditions affecting the ITR.


Perspective Chapter: How Can We Provide Lifelong Support for People with Epilepsy to Reduce Their Self-Stigma?

*Izumi Kuramochi, Takayuki Iwayama and Sakie Shimotsu*

#### **Abstract**

Self-stigma denotes the internalization of negative societal attitudes, and it is commonly referred in patients with epilepsy (PWE). Higher levels of self-stigma have been linked to lower self-esteem. According to the author's research, there is no significant correlation between knowledge level and self-stigma among PWE, and short-term treatment to control seizures alone proves inadequate for reducing self-stigma. These findings provide insights into the enduring nature of self-stigmatization, which appears to be influenced by cultural background, environmental factors, and personal experiences. Firstly, rectifying misinformation is crucial, as it promotes critical thinking and challenges cultural shame rather than accepting it. Secondly, cognitive approaches can be beneficial in helping individuals identify and overcome self-stigmatizing attitudes and beliefs. Recognizing the presence of social stigma and self-stigma are instrumental in reducing self-stigma. Lastly, facilitating individuals fostering a sense of agency in their lives can be accomplished through decision-making and empowerment strategies. Assisting clients in identifying their strengths and enabling them to make autonomous life choices can foster improved self-esteem and decrease self-stigma. While the primary goal of epilepsy treatment is the reduction of seizures, it is crucial for all stakeholders to acknowledge the persistent nature of self-stigma throughout the lifelong treatment trajectory of PWE.

**Keywords:** epilepsy, prejudice, self-stigma, quality of life, epilepsy self-stigma scale

#### **1. Introduction**

When considering "epilepsy," individuals often form mental associations or stereotypes about this medical condition. Stereotypes are constructed and established based on the prevailing social characteristics of the majority within a specific society, generally accepted as factual by most individuals in that society [1]. When individuals endorse negative stereotypes, it develops negative emotions and emotional responses, commonly known as "prejudice." For instance, someone who believes that people

with epilepsy (PWE) pose a danger may experience fear toward individuals with this condition. The issue received significant attention in Japan following the media's extensive coverage of traffic accidents involving individuals with epilepsy in 2011. As a result, the association between the public image of epilepsy and the concept of danger became more pronounced in 2013 [2].

These emotional reactions can manifest as discrimination, the behavioral response of harboring negative thoughts and feelings toward stigmatized groups. Due to fear (prejudice) and the acceptance of the associated stereotype, the general public may opt to maintain a physical and emotional distance from individuals with epilepsy. Epilepsy-related stigma is prevalent in numerous cultures [3, 4] and is widely recognized as one of the most significant factors negatively impacting the lives of PWE and their families [5–8].

Among those who feel "stigmatized" by society and live within that society are PWE themselves. Some PWE has stereotypes and self-stigmas about themselves. These include acceptance of self-stereotypes (e.g., "I am a danger to myself with epileptic seizures."), prejudice (e.g., "I am afraid of myself"), and the accompanying selfdiscrimination (e.g., social isolation due to self-blame). Internalizing negative stereotypes can trigger adverse emotional reactions, such as low self-esteem and diminished self-efficacy. Self-discrimination, particularly self-isolation, has detrimental effects, including reduced healthcare utilization, poorer health outcomes, and decreased quality of life [9]. Low self-efficacy and self-esteem have also been associated with missed opportunities for employment and independent living [10, 11]. Link et al. referred to this as the modified labeling theory, highlighting that individuals who internalize the stigma of mental illness worsen their condition due to the harm caused by internalized experiences [12, 13]. Self-stigmatization entails a reduction in self-worth and a detrimental impact on one's aspirations toward personal goals. Consequently, self-stigma emerges as an intrapersonal phenomenon that leads to adverse health outcomes and diminishes the quality of life experienced by individuals diagnosed with epilepsy (PWE) [9, 14].

#### **2. Efforts to reduce the stigma of epilepsy**

Epilepsy has been documented as far back as 4000 B.C. and has had severe physical, mental, and social effects on patients for centuries, with no difference in age, race, country, or geographical location [15]. In response to the history of prejudice due to lack of knowledge, preconceptions, and discrimination against epilepsy, in 1997, the International Epilepsy Congress and the WHO, in collaboration with the International League Against Epilepsy (ILAE) and the International Bureau of Epilepsy (IBE), launched an international campaign called "Out of the (Shadows [16]).

The Intersectoral Global Action Plan (IGAP) on epilepsy and other neurological disorders aims to enhance accessibility to care and treatment for people with neurological disorders while concurrently preventing new cases and advocating brain health and development throughout the lifespan [17]. This comprehensive initiative spans 10 years, from 2022 to 2031. Its approval by 193 states on 27 May during the 75th World Health Assembly [17] signifies a decade-long commitment to prioritizing brain health by bolstering policy focus and governance; facilitating effective and timely diagnosis, treatment, and care; implementing strategies for promotion and prevention; fostering research and innovation; and fortifying information systems, as well as enhancing the public health approach to epilepsy [18]. However, to mitigate the societal stigma associated with epilepsy, continued efforts will be necessary to sustain the campaign's impact. *Perspective Chapter: How Can We Provide Lifelong Support for People with Epilepsy to Reduce... DOI: http://dx.doi.org/10.5772/intechopen.112136*

#### **3. Lifelong support for epilepsy patients to reduce self-stigma**

What approaches help reduce self-stigma among people with epilepsy? To adequately facilitate the reduction of self-stigma, it is imperative to comprehend the intricacies involved in the formation of self-stigma within distinct cultural contexts. The authors have investigated the actual status of self-stigma in epilepsy patients in Japan, developed a measurement scale, and conducted group psychoeducation programs [19–21]. This paper therefore introduces the studies conducted by the authors and discusses the direction of clinical practice and future research aimed at reducing self-stigma in Japan.

#### **3.1 Self-stigma among epilepsy patients (results of qualitative analysis study)**

The authors used semi-structured interviews and their qualitative analysis to analyze elements of self-stigma among Japanese PWE [19]. For historical reasons, epilepsy in Japan is treated by neurology, neurosurgery, and neuropsychiatry. In Japan's administrative classification, epilepsy is classified as a psychiatric disorder, necessitating the involvement of psychiatrists due to its distinctive features. Analysis of 206 verbatim data obtained from epilepsy patients attending outpatient clinics in Japan resulted in the extraction of 74 codes. Qualitative analysis of these codes identified 22 subcategories of epilepsy-related self-stigma and three major categories: self-stigma, perceived social stigma, and actual distress/troubles. The subsequent paragraphs provide a detailed description of the self-stigma categories derived from the qualitative analysis.

Concerning self-stigma among PWE, negative beliefs are not only negative cognitions about the disease and diagnosis of epilepsy, such as "I am not capable" and "I am a weak person," but also "I have an image that epileptic seizures are something that makes me foam and fall" and "I will be a burden to others if I have an epileptic seizure." It was found that these included negative perceptions about epileptic seizures, such as "I will be a burden to others" and "People will feel uncomfortable if they figure out I have epileptic seizures."

The findings additionally revealed the presence of "negative feelings about epileptic seizures," exemplified by expressions such as "I do not want to have an epileptic seizure because I will burst into a bubble and collapse" and "It is painful to be seen having an epileptic seizure." Furthermore, sentiments such as "It is embarrassing to be seen having an epileptic seizure," "I hate going to a psychiatrist," and "I have an aversion to seeing a psychiatrist" were also expressed within the dataset. Influenced by these adverse emotional experiences, the patients conveyed challenges encompassing various aspects of the disclosure, including "difficulties in revealing my epilepsy diagnosis to others," "challenges in disclosing my condition to my family," "obstacles in informing my teachers about my epilepsy," "struggles in divulging my epilepsy diagnosis to my workplace," and "difficulties in communicating my condition to doctors from other medical departments," among others. The respondents admitted to behavioral changes such as "difficulty in telling my family that I have epilepsy," "wanting to hide the fact that I have epilepsy," "not wanting to take my medication in public," and "wanting to hide the fact that I have epilepsy and have to go to the hospital for treatment."

The behavioral manifestations of these negative changes were identified to be more prominently evident within the cognitive component, characterized by a "negative evaluation of my life so far," as opposed to the emotional component, which featured a "decreased general self-confidence." Additionally, the negative behavioral changes, precisely the "abandonment of various activities due to the presence of epilepsy," exhibited a lesser degree of recognition compared to the cognitive component.

These findings specifically examine the stigma of epilepsy in Japan, and it is crucial to note that not all of the identified factors may be applicable to other countries or cultures. In particular, the pronounced association with psychiatry may be influenced by the distinctive medical context of Japan. However, those individuals involved in epilepsy care need to acknowledge that patients with epilepsy may experience and endure these self-stigmas associated with the condition.

#### **3.2 Creation of the epilepsy self-stigma scale**

The Epilepsy Self-Stigma Scale (ESSS) [21] (**Table 1**) was developed to measure self-stigma explicitly pertaining to "epilepsy" and to provide a convenient assessment scale suitable for use in a short consultation time. The development of the ESSS involved the utilization of results from qualitative analysis in Japan. Subsequently, the questionnaire was formulated based on the results of a qualitative analysis, and an exploratory factor analysis was conducted based on data obtained from 100 epilepsy patients attending outpatient clinics at multiple medical institutions. As a result, a final questionnaire comprising three factors (Internalization of stigma, Societal incomprehension, and Confidentiality) and eight items was derived. The ESSS items are rated on a four-point Likert-type scale: 1: Strongly Disagree, 2: Slightly agree, 3: Agree, 4: Strongly Agree. Total scores range from 8 to 32. The higher the total score, the greater is the extent of the selfstigma toward epilepsy. The calculation of scores for each factor enables a comprehensive assessment of the relative significance of different dimensions of self-stigma. In addition, high internal consistency has been obtained across the entire scale and all subscales, and high retest reliability and adequate construct validity concerning depressive symptoms

*This questionnaire will ask you about what you think about having epilepsy.*

*For each question, please choose the most appropriate number from the scale to the right of each sentence.*

#### **Table 1.**

*Epilepsy self-stigma scale (eight items) [21].*

#### *Perspective Chapter: How Can We Provide Lifelong Support for People with Epilepsy to Reduce... DOI: http://dx.doi.org/10.5772/intechopen.112136*

and self-esteem. Cronbach's α for the total scale and each factor demonstrated good internal consistency (α = 0.76–0.87). The ESSS has undergone a prolonged development process, and its utilization in various studies has been relatively limited, resulting in a scarcity of comprehensive information. However, it is noteworthy that no significant correlation was observed between external criteria, such as an objective assessment of self-stigma conducted by the subject's physician, and the total score on the ESSS, which contrasts with findings from comparable scales. This finding aligns with the conceptualization of self-stigma as internalized stigma and highlights the challenge of accurately assessing a patient's self-stigma solely within the consultation setting.

#### **3.3 Efforts to reduce self-stigma in people with epilepsy**

#### *3.3.1 Educational needs, psychosocial education programs*

The first step in reducing self-stigma is to provide accurate information about PWE and its supporters. Education and awareness can reduce misconceptions and prejudices about epilepsy and promote public understanding and empathy. Education should be targeted not only to PWE and others affected by the disease but also to the general public, teachers, and healthcare professionals. People with epilepsy must understand their condition and learn about appropriate treatment and daily living precautions.

Psychosocial education programs on epilepsy have been conducted in various countries, and their usefulness has been reported [22]. Although psychosocial and educational programs took many forms depending on the country and context in which they were implemented, most interventions improved subjects' knowledge about epilepsy. For example, the authors conducted the "Epi-school" program in Japan, which yielded notable outcomes [20]. Furthermore, other programs, such as MOSES [23], The Seizures and Epilepsy Education (SEE) Program [24, 25], FLIP & FLAP [26], Be Seizure Smart [27], Children's (Epilepsy Program [28]), ACINDES [29], and A psychosocial self-management program for epilepsy [30], among others, have also showcased commendable effectiveness in this regard. The PEPE [31] and Ogata's program in Japan [32] showed significant improvement in knowledge based on subjects' subjective ratings. The FAMOSES [33, 34] program for young PWE is being implemented in Germany. It is a psychosocial educational program for children with epilepsy and their families. It is imperative to teach PWE of young origin to know about epilepsy with a view to the future in order to support epilepsy treatment throughout their lives.

The authors implemented a program named "Epi-school," which targeted individuals diagnosed with epilepsy (PWE) aged 16 years and older and their supporters within the outpatient psychiatry department of a university hospital. The program dealt with the epidemiology and fundamental knowledge of epilepsy, diagnosis and treatment of epilepsy, self-control and prognosis of epilepsy, and psychosocial aspects. The program was managed by two fixed trainers (an epilepsy specialist and a psychiatric nurse specialist) and a multidisciplinary team, including a pharmacist, a psychologist, and a mental health worker, depending on the content of each session. In addition to significant increases in knowledge about epilepsy for patients and relatives before and after the program, positive changes were observed in overall life satisfaction and psychological acceptance of epilepsy as an optimistic illness. In addition to enhancing disease-related knowledge and coping mechanisms, numerous participants also expressed observations regarding alterations in the psychological aspects of the disease. Further research is warranted to examine the changes in the self-stigmatization levels of PWE before and after the psychosocial education program.

#### *3.3.2 Psychological support*

Epileptic seizures may cause emotional distress and social isolation in PWE. Psychological support is essential to reduce self-stigma, and psychotherapy and counseling, in particular, may promote patients' mental health and reduce selfstigma. Psychological support includes counseling, acceptance and commitment therapy (ACT) [35, 36], cognitive behavioral therapy (CBT), relaxation methods, mindfulness, and motivational interviewing. Some psychosocial education programs mentioned in the previous section also offer psychosocial and psychological support.

Psychological support may be provided within psychosocial education programs, but individual psychotherapy and psychotherapy may benefit PWE who experience self-stigma, even in settings where dedicated psychosocial programs are unavailable.

#### *3.3.3 Support groups, self-help groups*

Support and self-help groups are places where people with the same illness can share information and experiences. For PWE, support and self-help groups can reduce feelings of isolation and anxiety by letting them know that others are going through similar experiences. Patients can increase their self-acceptance and reduce self-stigma by participating in support groups. In the context of self-help groups dedicated to epilepsy worldwide, enormous organizations have been established in various countries, including notable examples such as the Japan Epilepsy Association [37], the Epilepsy Foundation [38] in the United States, Epilepsy Action [39] in the United Kingdom, and Epilepsy Action Australia [40] in Australia. These organizations offer a range of information, consultation services and support activities pertaining to epilepsy. However, it is worth noting that the number of organizations operating on a global scale remains limited.

From the authors' survey, in Japan, the use of psychosocial support, that is, participating in epilepsy self-help groups and educational programs, was 5.8% [41]. As a reason for not participating in self-help groups, PWE in Japan worry that they might be discriminated against by society for participating in such groups. In order to effectively address and mitigate self-stigmatization experienced by PWE throughout their lifespans, it is vital to create an environment where PWE feel at ease engaging in self-help groups and study groups. Thus, constant efforts must be directed toward reducing the societal stigma associated with epilepsy and preventing the emergence of new self-stigmatizing beliefs among PWE.

#### **4. Conclusion**

This paper introduces the present situation regarding the stigma of epilepsy in Japan and attempts to reduce it, inspired by the authors' research findings. Healthcare professionals involved in epilepsy care must take positive action to prevent the continuation of inadequate knowledge, superstition, and prejudice. Research on self-stigmatization in relation to epilepsy remains limited, underscoring the necessity to develop assessment tools and intervention strategies informed by cross-national findings while accounting for cultural nuances and the specific circumstances surrounding the management of epilepsy in individual countries.

It is imperative to acknowledge that Goffman, the pioneer of the stigma concept, emphasized the significance of understanding stigma as a "relationship" rather than a mere attribute of an individual. This perspective holds spectacular importance in

*Perspective Chapter: How Can We Provide Lifelong Support for People with Epilepsy to Reduce... DOI: http://dx.doi.org/10.5772/intechopen.112136*

epilepsy, as it is insufficient to perceive epilepsy stigma solely as a characteristic of the individual with epilepsy. Consistent with Goffman's original proposition, it is crucial to conduct research that delves into the process of stigma formation within the psychosocial context of interactions between individuals with epilepsy and their immediate environment and the broader society.

We hope that developing the Epilepsy Self-Stigma Scale (ESSS) and psychosocial education programs presented here will assist this effort and further expand research activities to reduce self-stigma in PWE.

#### **Acknowledgements**

We appreciate Dr. Lester Luo's invaluable assistance in editing this manuscript in English.

#### **Funding**

This work was supported by the 31st Ochiai Memorial Award Research Grant (2020) and JSPS KAKENHI (No. 21 K13709) and the Maruki Memorial Special Award Research Grant (2022, No.22-1A-01). The funding source was not involved in the design of this study, the writing of this report, and the decision to submit the manuscript for publication.

#### **Declaration of competing interests**

None.

#### **Author details**

Izumi Kuramochi1 \*, Takayuki Iwayama1,2 and Sakie Shimotsu3

1 Department of Psychiatry, Saitama Medical Center, Saitama Medical University, Japan

2 Department of Psychology, Showa Women's University, Japan

3 Faculty of Human Development and Education, Kyoto Women's University, Japan

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Corrigan PW, Rao D. On the self-stigma of mental illness: Stages, disclosure, and strategies for change. Canadian Journal of Psychiatry. 2012;**57**(8):464-469. DOI: 10.1177/070674371205700804

[2] Kuramochi I, Iwayama T, Oga K, Shiganami T, Umemura T, Kobayashi S, et al. Internet survey on knowledge and perceptions of epilepsy among the general public in Japan. Heliyon. 2022;**8**(12):e12254. DOI: 10.1016/j.heliyon.2022.e12254 eCollection 2022 Dec

[3] Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Simon & Schuster; 1963

[4] Jacoby A, Snape D, Baker GA. Epilepsy and social identity: The stigma of a chronic neurological disorder. Lancet Neurology. 2005;**4**:171-178

[5] Baker GA. The psychosocial burden of epilepsy. Epilepsia. 2002;**43**:26-30

[6] Jacoby A. Epilepsy and the quality of everyday life. Findings from a study of people with well-controlled epilepsy. Social Science & Medicine. 1992;**34**:657-666

[7] Mclin WM, de Boer HM. Public perceptions about epilepsy. Epilepsia. 1995;**36**:957-959

[8] Morrel MJ. Stigma and epilepsy. Epilepsy & Behavior. 2002;**3**:21-25

[9] Watson AC, Corrigan PW, Larson JE, Sells M. Self-stigma in people with mental illness. Schizophrenia Bulletin. 2007;**33**:1312-1318

[10] Sirey JA, Bruce ML, Alexopoulos GS, et al. Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services. 2001;**52**(12):1615-1620

[11] Sirey JA, Bruce ML, Alexopoulos GS, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry. 2001;**158**(3):479-481

[12] Link B. Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review. 1987;**52**:96-112

[13] Link B, Cullen F, Struening E, et al. A modified labeling theory approach to mental disorders: An empirical assessment. American Sociological Review. 1989;**54**(3):400-423

[14] Corrigan PW, Watson A, Barr L. The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social & Clinical Psychology. 2006;**25**(9):875-884

[15] World Health Organization (WHO). Epilepsy: A public health imperative. 2019. Available from: https://www. who.int/publications/i/item/epilepsya-public-health-imperative [accessed 2021-11-30]

[16] Reis R, Meinardi H. ILAE/WHO "Out of the Shadows Campaign" Stigma: Does the flag identify the cargo? Epilepsy & Behavior. 2002;**3**(6S2):33-37

[17] World Health Organization (WHO). Intersectoral global action plan on epilepsy and other neurological disorders 2022-2031. Available

*Perspective Chapter: How Can We Provide Lifelong Support for People with Epilepsy to Reduce... DOI: http://dx.doi.org/10.5772/intechopen.112136*

from: https://www.who.int/news/ item/28-04-2022-draft-intersectoralglobal-action-plan-on-epilepsy-andother-neurological-disorders-2022-2031 [accessed 2022-11-3]

[18] World Health Organization (WHO). Improving the lives of people with epilepsy –technical brief. 2022. Available from: https://www.who.int/ news/item/12-12-2022-new-who-briefsets-out-actions-needed-to-improvelives-of-people-with-epilepsyt/news/ item/12-12-2022-new-who-brief-sets-out actions-needed-to-improve-lives-ofpeople-with-epilepsy

[19] Kuramochi I, Horikawa N, Shimotsu S, et al. The self-stigma of patients with epilepsy in Japan: A qualitative approach. Epilepsy & Behavior. 2020;**109**:106994

[20] Kuramochi I, Oga K, Iwayama T, et al. Pilot trial of "Epi-school" group psychosocial education program for patients with epilepsy and their relatives in Japan. Epilepsy & Behavior. 2020;**113**:107545

[21] Kuramochi I, Iwayama T, Horikawa N, et al. Development and validation of the epilepsy self-stigma scale. Epilepsia Open. 2021;**6**(4):748-756

[22] Mittan RJ. Psychosocial treatment programs in epilepsy: A review. Epilepsy & Behavior. 2009;**16**(3):371-380

[23] May TW, Pfafflin M. The efficacy of educational treatment program for patients with epilepsy (MOSES): Results of a controlled, randomized study. Epilepsia. 2002;**43**:539-549

[24] Helgeson DC, Mittan R, Tan SY, Chayasirisobhon S. Sepulveda Epilepsy education: the efficacy of a psychoeducational treatment program in treating medical and psychosocial

aspects of epilepsy. Epilepsia. 1990;**31**:75-82

[25] Shore CP, Perkins SM, Austin JK. The seizures and epilepsy education (SEE) program for families of children with epilepsy: A preliminary study. Epilepsy & Behavior. 2008;**12**:157-164

[26] Jantzen S, Muller-Godeffroy E, Hallfahrt-Krisl T, et al. FLIP&FLAP: A training programme for children and adolescents with epilepsy, and their parents. Seizure. Sep 2009;**18**(7):478- 486. DOI: 10.1016/j.seizure.2009.04.007

[27] Austin JK, McNelis AM, Shore CP, Dunn DW, Musick B. A feasibility study of a family seizure management program: "Be Seizure Smart". Journal of Neuroscience Nursing. 2002;**34**:30-37

[28] Lewis MA, Salas I, de la Sota A, Chiofalo N, Leake B. Randomized trial of a program to enhance the competencies of children with epilepsy. Epilepsia. 1990;**31**:101-109

[29] Tieffenberg JA, Wood EI, Alonso A, Tossutti MS, Vicente MF. A randomized field trial of ACINDES: A childcentered training model for children with chronic illnesses (asthma and epilepsy). Journal of Urban Health. 2000;**77**:280-297

[30] Pramuka M, Hendrickson R, Zinski A, Van Cott AC. A psychosocial self-management program for epilepsy: A randomized pilot study in adults. Epilepsy & Behavior. 2007;**11**(4):533-545

[31] Huber B, Seidel M. PEPE: A psychoeducative programme for people with epilepsy and learning disabilities. In: Pfafflin M, Frasier RT, Specht U, Thorbeck R, editors. Comprehensive Care for People with Epilepsy. France: John Libbey Eurotext; 2001. pp. 155-162 [32] Ogata A, Amano K. A psychosocial approach to epileptic patients. Epilepsia. 2000;**41**(Suppl. 9):36-38

[33] Wohlrab GC, Rinnert S, Bettendorf U, Fischbach H, Heinen G, Klein P, et al. Famoses Project Group. famoses: A modular educational program for children with epilepsy and their parents. Epilepsy & Behavior. 2007;**10**(1):44-48. DOI: 10.1016/j. yebeh.2006.10.005 Epub 2006 Nov 27

[34] Hagemann A, Pfäfflin M, Nussbeck FW, May TW. The efficacy of an educational program for parents of children with epilepsy (FAMOSES): Results of a controlled multicenter evaluation study. Epilepsy & Behavior. 2016;**64**(Pt A):143-151. DOI: 10.1016/j. yebeh.2016.09.027 Epub 2016 Oct 13

[35] Lundgren T, Dahl J, Yardi N, Melin L. Commitment therapy and yoga for drugrefractory epilepsy: A randomized controlled trial. Epilepsy & Behavior. 2008;**13**:102-108

[36] Lundgren T, Dahl J, Melin L, Kies B. Evaluation of acceptance and commitment therapy for drug refractory epilepsy: A randomized controlled trial in South Africa—a pilot study. Epilepsia. 2006;**47**:2173-2179

[37] The Japan Epilepsy Association. Available from: https://jes-jp.org/en/ [accessed 2023-5-17]

[38] The Epilepsy Foundation. Available from: https://www.jea-net.jp/ [accessed 2023-5-17]

[39] Epilepsy Action. Available from: https://www.epilepsy.com/ [accessed 2023-5-17]

[40] Epilepsy Action Australia. Available from: https://www.epilepsy.org.au/ [accessed 2023-5-17]

[41] Kuramochi I, Iwayama T, Oga K, Shiganami T, Umemura T, Kobayashi S, et al. A study of factors influencing self-stigma in people with epilepsy: A nationwide online questionnaire survey in Japan. Epilepsia Open. 2022;**7**(4):792- 801. DOI: 10.1002/epi4.12661 Epub 2022 Oct 25

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