Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the  Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfill our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free more...


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Pai and Kankonkar: Factors affecting non-compliance to spectacle wear in children aged six years and below with refractive errors: A hospital based cross-sectional study in India


Introduction

Uncorrected refractive errors (RE) are the most common cause of preventable Visual Impairment (VI) in children, which if untreated can lead to amblyopia.1 Spectacles remain the most popular and effective method for correction of RE.1 VI in early childhood interferes with their overall development affecting their future opportunities in life.2, 3 Children unlike adults, often don’t understand the need for wearing spectacles, thus prescribing spectacles in children becomes difficult.

There are limited studies done on non-compliance to spectacle wear in children belonging to the age group of six years and below. “Eye Health for All” and prevention of VI through provision of comprehensive universal eye-care services and quality service delivery, is one of the main objective of National Programme for Control of Blindness. Keeping this in mind, we conducted this study to find out proportion of spectacle wear non-compliance in children aged six years and below and identify factors associated with it in order to give suitable recommendation for achieving maximum compliance to spectacle wear and preventing VI.

Materials and Methods

A hospital-based cross-sectional study was conducted in 115 children aged six years and below with refractive errors who were prescribed spectacle correction. After obtaining approval from Institutional Ethics Committee, the study was conducted in Ophthalmology Out Patient Department (OPD) of a Government Medical College of India for a period of 12 weeks, starting from May 2018 to July 2018.

A list of eligible children registering at Ophthalmology OPD was prepared during OPD days (i.e. twice a week) for a period of 12 weeks (i.e. total 24 OPD days). Due to time constraint, each OPD day, five study participants were selected by Simple Random Sampling using lottery method (Figure 1 ). Study participants comprised of children aged six years and below with refractive errors who were prescribed spectacle correction. Those parents who refused participation were excluded.

Figure 1

Flowchart depicting selection of study participants

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/fc986079-b5db-4a8c-9fee-d09e18e28bb8/image/180109db-5130-44cf-a6ee-7a729fefdc0d-uimage.png

Sample size of 105 was calculated using the formula

n = [(z² × p × q) + d²] ÷ d²

where z = 1.96 (constant for 95% confidence level),

p = 0.074 (proportion of spectacle wear non-compliance)4

q = (1 – p) = 0.926 and

d = 0.05 (precision)

Anticipating a dropout rate of ten percent, an effective sample size of 115 was obtained.

Data collection

A semi-structured questionnaire was developed based on previous studies and was used to collect data.4, 5 Questionnaire was pilot tested on a sample of participants to check for comprehensibility and based on the feedback obtained, questionnaire was revised accordingly. After obtaining consent from the parent of the child, data was collected by interviewing the parent of the child. Confidentiality and anonymity of participants was maintained, participation was voluntary and there were no monetary benefits.

Spectacle wear non-compliance was considered as child wearing spectacle for less than six hours per day as obtained from the history given by participant. Demographic details such as age, sex, place of residence and mother’s education were included. Other variables under study were astigmatism, anisometropia, myopia, hypermetropia, squint, intolerance to glasses, glasses lost, glasses broken, concerned teasing and cost issues.

Statistical analysis

The data obtained was entered in Microsoft Excel 2016 and analysed using Epi Info android mobile app version 1.4.3 and IBM Statistical Package of the Social Science (SPSS) Statistics version 14. Categorical variables were expressed as frequencies and percentages. Fisher’s exact test was used to determine association between categorical variables. In univariate analysis, each variable was tested against the dependent variable (spectacle wear non-compliance) and crude odds ratio (OR), respective 95% confidence interval (95%CI) and P values were estimated. All variables with a P < 0.5 were selected for multivariate logistic regression. Adjusted Odds Ratio (AOR), respective (95%CI) and P values were estimated. The statistical level of significance was set at P ≤ 0.05.

Results

Out of 115 children, 58 (49.6%) were males and 57 (49.4%) were females. Majority (i.e. 64.3%) of the children were residing in urban area and mothers of most (i.e. 64.3%) of them had schooling of higher than primary (Table 1).

Factors associated with spectacle wear non-compliance.

The proportion of spectacle wear non-compliance was 53.04%. Most common reasons given for non-compliance to spectacle wear in study participants was intolerance to glasses (42.6%) (Table 2). Statistically significant association was observed between spectacle wear non-compliance and other independent variables such as age of the child (P = 0.002), mother’s education (P = 0.01), anisometropia (P < 0.001), astigmatism (P = 0.03), manifest squint (P = 0.025), Intolerance to glasses (P < 0.001), Glasses Lost (P = 0.001), Glasses Broken (P < 0.001), Concerned teasing (P < 0.001) and Cost issues (P < 0.001) (Table 3).

Table 1

Demographic characteristic of study participants

Variables

Frequency (n=115)

Percentage (%)

Age

< 2

30

26.1

2 - 4

46

40.0

4 - 6

39

33.9

Sex

Males

58

49.6

Females

57

49.4

Mothers education

Illiterate

8

7.0

Up to primary

33

28.7

Higher than primary

74

64.3

Residency type

Rural

41

35.7

Urban

74

64.3

Table 2

Reasons for non-compliance to spectacle wear in study participants

Reasons

Frequency (n=115)

Percentage (%)

Intolerance to glasses

Yes

49

42.6

No

66

57.4

Glasses Lost

Yes

14

12.2

No

101

87.8

Glasses Broke

Yes

35

30.4

No

80

69.6

Concerned teasing

Yes

24

20.9

No

91

79.1

Cost issues

Yes

42

36.5

No

73

63.5

Table 3

Factors associated with non-compliance to spectacle wear in study participants

Variables

Category

Non-compliant (n=61) No. (%)

Compliant (n=54) No. (%)

P value

Age (years)

< 2

23 (37.7%)

7 (13.0%)

0.002*‡ (ꭓ² = 12.84)

2 - 4

25 (41.0%)

21 (38.9%)

4 - 6

13 (21.3%)

26 (48.1%)

Sex

Males

31 (50.8%)

27 (50.0%)

1.000

Females

30 (49.2%)

27 (50.0%)

Mothers education

Illiterate

7 (11.5%)

1 (1.9%)

0.010*‡ (ꭓ² = 9.13)

Up to primary

22 (36.0%)

11 (20.4%)

Higher than primary

32 (52.5%)

42 (77.7%)

Residency type

Rural

25 (41.0%)

16 (29.6%)

0.240

Urban

36 (59.0%)

38 (70.4%)

Anisometropia

Present

31 (50.8%)

9 (16.7%)

<0.001*

Absent

30 (49.2%)

45 (83.3%)

Astigmatism

Present

36 (59.0%)

20 (37.0%)

0.020*

Absent

25 (41.0%)

34 (63.0%)

Hypermetropia

Present

26 (42.6%)

27 (50.0%)

0.460

Absent

35 (57.4%)

27 (50.0%)

Myopia

Present

27 (44.3%)

22 (40.7%)

0.710

Absent

34 (55.7%)

32 (59.3%)

Manifest squint

Present

16 (26.2%)

26 (48.1%)

0.020*

Absent

45 (73.8%)

28 (51.9%)

Intolerance to glasses

Yes

49 (80.3%)

0 (0.0%)

<0.001*

No

12 (19.7%)

54 (100.0%)

Glasses Lost

Yes

14 (23.0%)

0 (0.0%)

<0.001*

No

47 (77.0%)

54 (100.0%)

Glasses Broke

Yes

35 (57.4%)

0 (0.0%)

<0.001*

No

26 (42.6%)

54 (100.0%)

Concerned teasing

Yes

24 (39.3%)

0 (0.0%)

<0.001*

No

37 (60.7%)

54 (100.0%)

Cost issues

Yes

42 (68.9%)

0 (0.0%)

<0.001*

No

19 (31.1%)

54 (100.0%)

[i] * Statistically significant, † Fisher Exact Test, ‡ Pearson Chi-square with Yates correction

Table 4

Multivariate analysis of factors associated with non-compliance to spectacle wear in study participants

Variables

Unadjusted OR (95%CI)

P value

Adjusted OR (95%CI)

P value

Age of child (years)

< 2

6.57 (2.24 - 19.29)

< 0.001*

8.86 (2.13-36.80)

0.003*

2 - 4

2.97 (0.98 - 5.76)

0.085

4.26 (1.27-14.28)

0.019*

4 - 6

1 (Reference)

-

-

-

Mothers education

Illiterate

9.19 (1.08 - 78.50)

0.045*

9.76 (0.87-110.12)

0.065

Up to primary

3.50 (0.38 - 32.12)

0.470

3.69 (1.17-11.66)

0.026*

Higher than primary

1 (Reference)

-

-

-

Residency type

Rural

1.65 (0.76-3.58)

0.280

1.29 (0.48-3.50)

0.620

Urban

1 (Reference)

-

-

-

Anisometropia

Present

5.17 (2.16 - 12.38)

<0.001*

11.11 (3.36-36.73)

<0.001*

Absent

1 (Reference)

-

-

-

Astigmatism

Present

2.45 (1.15-5.19)

0.030*

2.23 (0.82-6.09)

0.120

Absent

1 (Reference)

-

-

-

Manifest squint

Absent

2.61 (1.20 - 5.70)

0.025*

3.83 (1.30-11.27)

0.015*

Present

1 (Reference)

-

-

-

[i] * Statistically significant, † OR – Odds Ratio, ‡ 95%CI – 95% Confidence Interval

There was no statistically significant association between spectacle wear non-compliance and other variables such as sex of the child, place of residence, hypermetropia and myopia.

Independent factors associated with spectacle wear non-compliance (Multivariate Logistic Regression).

In the multivariate analysis (Table 4), it was found that children with spectacle wear non-compliance were more likely to belong to the age group of two to four years (AOR = 4.3; 95% CI: 1.3-14.3), less than two years (AOR = 8.9; 95% CI: 2.1-36.8) as compared to four to six years of age. Likelihood of spectacle wear non-compliance was also found in following situations: mothers with up-to primary school education (AOR = 3.7; 95% CI: 1.2-11.7) compared to those having higher than primary school education; in children without manifest squint (AOR = 3.8; 95% CI: 1.3-11.3) as compared to those with manifest squint; in children with anisometropia (AOR = 11.1; 95% CI: 3.4-36.7) as compared to those who did not have anisometropia. The above finding were statistically significant at P ≤ 0.05.

Discussion

In our study, we observed that, more than half (53.04%) of the children were not compliant to spectacle wear, which was similar to the non-compliance observed by Bruce et al.6 (53.0%), whereas a lower non-compliance of 46.1% was observed among five to seven years old children in Aligarh, Uttar Pradesh.5

Odds of being non-compliant to spectacle wear was more if mothers had attended school up to primary as compared to those whose mothers had higher than primary school education. Similar results were observed by Bhandari et al.2 where children of parents with lower educational qualification were more non-compliant to spectacle wear than children born to parents with a higher educational status. These findings can be attributed to lack of awareness in less educated parents, about consequences of uncorrected refractive errors.

We also observed that, younger children (less than four years of age) were more likely to be non-compliant to spectacle wear than older children (four to six years of age). Similar findings were observed in Aligarh, Uttar Pradesh.5 On contrary, a study done in Rohtak, Haryana, observed that older children were more non-compliant to spectacle wear than younger children.7

Children with anisometropia were more likely to be non-compliant to spectacle wear as compared to children without anisometropia. This can be due to ineffective correction of anisometropia, leading to double vision and hence non-compliance to spectacle wear. Similarly, odds of being non-compliant to spectacle wear was more in children without manifest squint as compared to the children with manifest squint.

Statistically significant association was observed between spectacle wear non-compliance and other variables such as astigmatism, Intolerance to glasses, Glasses Lost, Glasses Broken, Concerned teasing and Cost issues. Mehnaz et al.5 observed statistically significant association between spectacle wear non-compliance and concerned teasing.

We did not find any statistically significant association between sex of child and non-compliant to spectacle wear, whereas Bhandari et al.2 observed that boys were more non-compliant to spectacle wear than girls.

Holguin et al.8 found that odds of spectacle wear non-compliance were significantly higher among urban children as compared to rural children. However, we did not observe any statistically significant association between spectacle wear non-compliance and type of residency.

We did not observe any statistically significant association between spectacle wear non-compliance and other variables such as hypermetropia and myopia. Whereas statistically significant association was observed between spectacle wear compliance and hypermetropia and myopia by Von-Bischhoffshausen et al.9

Most common reason for spectacle wear non-compliance was intolerance to glasses followed by high cost of spectacle. Whereas the most common reasons observed by Messer et al.10 for not wearing spectacle was lost spectacles (44.9%) and broken spectacles (35.3%). Similar observations were observed by Gogate et al.4

Conclusion

Children with spectacle wear non-compliance were more likely to: belong to the age group of two to four years (AOR = 4.3; 95% CI: 1.3-14.3); have mother with up-to primary school education (AOR = 3.7; 95%CI: 1.2-11.7); have anisometropia (AOR = 11.1; 95% CI: 3.4-36.7) and those without manifest squint (AOR = 3.8; 95%CI: 1.3-11.3).

Recommendations

Children of illiterate mothers or those with up-to primary school education should be given special attention and their parents should be informed about the possible consequences that may occur due to spectacle wear non-compliance. This is only possible if parent’s educational status is included in history taking at OPD level.

Multi-specialty approach (involving ophthalmologist, paediatrician and optician) can be used to tackle spectacle wear non-compliance in children aged four years and below.

Limitations

A Focus Group Discussion should have been conducted among parents of children aged six years and below in order to understand their perceptions, attitudes, beliefs, opinions and ideas on spectacle wear in children.

Father’s educational history should have been assessed to find out its association with non-compliance to spectacle wear.

Source of Funding

None.

Conflict of Interest

None.

References

1 

P Sharma N Gaur How do we tackle a child’s spectacle?Indian J Ophthalmol201856512

2 

G Bhandari S Pradhan M Shrestha K Bassett Eye glasses compliance among children undergoing school visual acuity screening in NepalAdv Ophthalmol Vis Syst2016528690

3 

O Sushil B Meenu J Vaibhav S Brijesh S Singh Pattern of refractive error in paediatric patients coming to rural tertiary care hospital of Central IndiaIndian J Clin and Exp Ophthalmol20162725

4 

P Gogate D Mukhopadhyaya A Mahadik TJ Naduvilath S Sane A Shinde Spectacle compliance amongst rural secondary school children in Pune district, IndiaIndian J Ophthalmol201361812

5 

S Mehnaz Z Siddiqui AJ Abedi MA Ansari Spectacle wear and factors associated with non-compliance among children of 5-15 yearsIndian J Comm Health2020328790

6 

A Bruce B Kelly B Chambers BT Barrett M Bloj J Bradbury The effect of adherence to spectacle wear on early developing literacy: a longitudinal study based in a large multiethnic cityBMJ Open20188e02127710.1136/bmjopen-2017-021277

7 

NK Bhatt M Rathi CS Dhull S Sachdeva J Phogat Spectacle compliance amongst school children of RohtakInt J Community Med Public Health201747347

8 

Amc Holguin N Congdon N Patel A Ratcliffe P Esteso S T Flores Factors Associated with Spectacle-Wear Compliance in School-Aged Mexican Children. Invest Ophthalmol Vis Sci200647925953

9 

FB Von-Bischhoffshausen B Muñoz A Riquelme MJ Ormeño JC Silva Spectacle-Wear Compliance in School Children in Concepción ChileOphthal Epidemiol2014213629

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DH Messer GL Mitchell JD Twelker M Crescioni Spectacle Wear in Children Given Spectacles Through a School-Based ProgramOptom Vis Sci2012891926



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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

503-508


Authors Details

Sharvani Pai, Prajoth Kankonkar*


Article History

Received : 11-03-2021

Accepted : 22-04-2021

Available online : 30-09-2021


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