Epilepsy in Uganda: Neurocognition and Functional Outcomes

Abstract

Objective: Epilepsy is a prevalent neurological disease disproportionately affecting people in low- and middle-income countries (LMICs), where over 80% of affected individuals reside and up to 75% lack access to treatment. Despite its high prevalence in sub-Saharan Africa and Uganda, in particular, the neurocognitive and functional consequences of the disease remain poorly characterized in this population. For this reason, we aimed to characterize neurocognition, education and employment outcomes among people with epilepsy in Uganda. Methods: We employed a cross-sectional study design nested within a nationally representative epilepsy prevalence study conducted across all four administrative regions of Uganda between January 2023 and July 2024. Processing speed, verbal fluency, and memory neurocognitive domains were assessed using the Symbol Digit Modalities Test (SDMT), semantic verbal fluency test, and the WHO/UCLA Auditory Verbal Learning Test (AVLT), respectively. Functional outcomes measured included academic progression among participants age 7–19 (school-age) and years of formal education completed among adults, age ≥20 years. In addition, employment status, type, and occupation were assessed among adult participants. Descriptive statistics were used to characterize the sample. Multivariable regression models were used to examine case-control differences and within-case clinical predictors of outcomes.Results: PWE demonstrated significantly worse performance across all neurocognitive domains. 57% of PWE met criteria for impairment in at least one cognitive domain, with the highest rates in memory (Recall: 36.2%, Learning: 34.3%). Antiseizure medication (ASM) use was associated with worse processing speed, verbal fluency, and memory within the case group, and higher seizure frequency predicted worse learning outcomes. PWE demonstrated poorer educational outcomes than controls: school-age cases showed approximately 1.6 years greater academic delay, and working-age PWE completed 2.3 fewer years of formal education compared to healthy controls (p < 0.001). Over half of PWE reported seizure-related school discontinuation, most often during early adolescence (Mean age: 13.91 years). Memory was a cognitive predictor of both academic deviation and employment status among cases.Conclusion: These findings demonstrate that epilepsy in Uganda is associated with a multidomain cognitive burden and significant functional disadvantage across the lifespan. A critical divergence was identified between school-age and working-age outcomes: among children, the academic deviation gap between PWE and controls was eliminated when all cognitive domains were intact and seizures well-controlled, suggesting that preserving cognition, where possible, and achieving seizure control in childhood can normalize academic trajectories. In contrast, the adult educational attainment gap persisted even among PWE with fully intact cognition, implicating structural and sociocultural barriers, including stigma, as independent drivers of functional disadvantage. These results contribute novel population-level evidence of epilepsy’s multidimensional burden in Uganda, and establish an empirical case for early treatment initiation, routine cognitive screening, stigma reduction programming, and inclusive educational and employment policies for PWE in Uganda and comparable low-resource settings.