Dr. Sucheta Parija, S09161
Dr. Sucheta Parija (S0-9161)
Refractive errors are the most common cause of visual impairment among children and are under the disease control priority of Vision 2020-The Right to Sight.Refractive errors in children can be corrected by regular use of spectacles. India has a large population of school going children.The Govt. of India under the Sarva Siksha Abhiyamm (SSA) and through the District Blindness Control Society (DBCS) has made effort to provide spectacles free of cost and made it assessableto all children in rural areas.Yet many children do notwear the spectacles provided to them. Hence, every effort should be made to removethe obstacles to spectacle availability and wear.
The proportion of children who could benefit from spectacle correction and do not yet own or wearglasses has been found to be high in many studies conducted in Mexico, Tanzania, suburban Chile and China,however few such data is available for India and also little published research has focused on barriers to spectacle use in this age group in India.
Our study has been under taken to look at spectacle-wear compliance among children who receivedspectacles free of cost in a school based program and also to analyse the factors determining non-compliance of spectacle-wear.
Material and Methods
This study was approved by the ethical committee of All India Institute of Medical Sciences,Bhubaneswar.A randomised selection of few schools where students were provided free spectacles through DBCS under school screening programme in Tangi block of Khurdha district of Odisha in year 2014-2015 were recruited for this study.A closed-ended questionnaire was prepared with details on demographic data, visual examination and students’ perception of spectacles. The questionnaire was first piloted in a rural school in Tangi block before completing the format in 12 different schools from August-October 2015.
The initial visual acuity screening was carried out using Snellen’sIlliterate “E” chart in a well-illuminated class room chosen in eachschool. Children with poor vision (acuity < 6/12) were listed andexamined by the Ophthalmic Assistant. Objective refraction was performedwith a streak retinoscope.Therefractive state of the student’s eye was measured. This was followedby subjective refraction with trial of lenses. All hypermetropes and fewothers for whom best corrected visual acuity could not be achievedunderwent cycloplegic refraction.
Children with myopia of more than or equal to –0.5 spherical equivalent dioptres in one or both eyes, hypermetropia ≥ +1.00 spherical equivalent dioptres in one or both eyes and astigmatism≥1.00 D were provided with corrective spectacles at a later date free of cost.Children and their class teachers were briefed about the importanceof wearing spectacles regularly. Children were instructed to wearspectacle in the school and also at home when studying and watchingtelevision.
An unannounced follow-up visit to the schools to assess spectaclewearcompliance was conducted six months after the students receivedtheir spectacles. Direct inspection was done to see if the children were using spectacles regularly. Children not wearing spectacles were asked the reasons for not wearing. Compliance to spectacle usage was recorded in a binaryformat. Compliance rate was reported as percentages. Factors associated with compliance were analyzed initially using Chi-square test, and those found to be significant were included in a multiple logistic regression.
Result
556 students from 12 schools of Tangi block were recruited for this study from a sample size of 1328.Among them 185 were found to have refractive error and advised to wear spectacles during the school screening programme. Only158 students were located and interviewed regarding the use of spectacles after six months. The rate of compliance with wearing spectacles in rural students was 33.5% .Among the 105(66.5%) students not wearing their spectacles at the time of the visit, 4 (3.8%) had the glasses in their bags, 33(29.5%) had left it at their home while 19(18.1%) had broken glasses and frames while 12(11.4%)reported not requiring them at all.(Table1)
Table-1. Reasons for not wearing spectacles
|
Reasons for not wearing Spectacles |
Number of Children |
Percentage |
| Spectacles broken | 19 | 18.1 |
| Spectacle lost | 14 | 13.3 |
| Spectacle at home | 31 | 29.5 |
| Spectacle not required for me | 9 | 8.6 |
| Spectacle cause headache | 6 | 6.7 |
| Spectacle is used for sometime | 12 | 11.4 |
| Teasing by friends | 8 | 7.6 |
| Spectacle in bag | 4 | 3.8 |
| Parental disapproval | 2 | 1.9 |
Demographic factors associated with non-compliance are described in Table 2. Spectacles non-compliance was significantly related to lack of education in the father (P = 0.016) but not in the mother (P = 0.08) nor with father’s occupation (P= 0.232). Non-compliance was related to age of the students (P = 0.001), with older children being slightly more non-compliant.
Table-2: Demographic factors associated with non-compliance of spectacle wear
|
Compliant |
Non-compliant |
Total |
p-value |
|
| Gender
Male Female |
21 32 |
56 49 |
77 81 |
0.682 |
| Age
5-7yr 8-10yr 11-13 14-16 |
4 21 16 12 |
6 15 39 45 |
10 31 60 57 |
0.001 |
| Parent Education
(Father) Illiterate School pass Graduate
|
12 17 24 |
24 49 32 |
36 66 56 |
0.016 |
| Father Occupation
Service Business Farmer
|
13 12 28 |
29 41 35 |
42 53 63 |
0.232 |
The greater the refractive error, the greater was the spectacle compliance (P < 0.001) amongst the 42 (79.2%) myopes [Table 3].
Table 3: Distribution of compliance among children with myopia
| Vision
|
Non-compliant | Compliant | p-value | |
| Visual acuity
(unaided)
|
6/6-6/9
6/12-6/18 6/24-6/60 <6/60 |
9
4 1 1 |
2
8 14 3 |
<0.001 |
| Spherical equivalent
|
-0.5 t0-0.1
-1.0 to-2.0 -2.0to -3.0 -3.5 and above |
9
4 1 1 |
1
7 12 7 |
<0.001 |
| Academic Performance | 35.7% | 64.2% | <0.001 |
Similarly, compliance was higher with worse visual acuity in myopes (P < 0.001) as shown in Table 3. Children who had unaided visual acuity ≥ 6/18 were less likely to wear their spectacles while those with vision ≤ 6/60 were more likely to use them. 2 (13.3%) of those tested who were noncompliant (15) had visual acuity of 6/24 or less in their better eye. Children who were compliant to spectacles had a better academic performance.
In univariate model it was seen that children in the age group of 8-10 years were 2.3 times more likely to show compliance to spectacle-wear and 14-16 year-old children were less likely to be compliant. Girls were 2.1 times more compliant then boys .Children having father with higher level of education were found to show better compliance than children whose fathers were illiterate.
But in the multivariate model of logistic regression though females, children in younger age group showed better compliance, though the association was not statistically significant. Whereas statistical significant association was seen between the children of fathers with lower level of education and non-compliance.
Discussion
The compliance to spectacle wear was only 33.5% amongst the rural secondary school children and compared with 29.5% compliance from rural western India, 13.4% from Mexico,30% from Baltimore USA and 37.7% from rural China. The compliance may have been low due to the surprise check as only those actually wearing the spectacles at the time of the visit were termed compliant.
The boys were more non-compliant in wearing spectacles than girls similar with the studies from China, Oman and other parts of India. The study reported by Gogate et al. observed that spectacles noncompliance was significantly related to lack of education in the father (P =0.016), this finding is consistent with our study. We found that children having parents with higher level of education were found to be better compliant (OR = 5.8) than children whose parents were illiterate. Whereas parental education level was not significantly associated with spectacle wear in children in other studies that have looked at this factor.
The Avon longitudinal study of parents and children in UK reported that more than a third (37%) of children wearing glasses reported that they had been subjected to verbal and some even to physical abuse and teased by peers .The most common cause of non-wear in our study was, forgetting the spectacles at home which was different from the results from above study. Studies from Mexico and Tanzania also reported teasing by 1/5th of the children.
Spectacle design, quality of frame and lens and centration and fit are also few other factors that contributed to non compliance. Free of cost provision of spectacles, late supply and no facilities to look after broken frames or glasses also were other issues that were observed in this study which were also causes for spectacle non compliance in rural children. A study from Tanzania showed that children used the spectacles more often which was paid for than the spectacles provided free of cost. Messer et al found that 80% of American children were not using spectacles because of breakage or loss even though they were provided with two pairs of free spectacles. Ethan et al and Yabumoto et al. from Brazil found that scratched lenses, breakage and lost spectacles were the main reasons for not wearing spectacles.
The major reason for using spectacles among children was poor vision and high refractive errors. In our study, children with power more than -2.0 D or more had a better compliance with spectacles than children with -0.5D or less. This was comparable with the finding of Castanon Holguin et al who also found that 2% of children with refractive error of more than -0.1DS were actually using spectacles regularly. However studies by Li et al, Congdon et al found that the degree of refractive error was not a predicator of compliance with spectacle wear.
There are various limitations with this study. The study excluded children who were out of formal schools and those in unaided and private schools. Hyperopia may have been underestimated as cycloplegic refraction, was not done on all children.
Conclusion
The school screening programme carried out in various districts of Odisha under the DBCS was providing free spectacles but this study highlights the spectacle-wear compliance among the rural children of Khurdha district of Odisha to be poor. The effectiveness of this program can be strengthened by educating parents and teachers about the importance of spectacle use, provision for good quality frames and lenses , facilities for accessible and prompt spectacle repair and finally addressing the psychosocial factors like peer pressure and parental disapproval for spectacle use.
References:
1.Dandona R, Dandona L, Srinivas M, Sahare P, Narsaiah S, Muñoz SR, et al. Refractive error in children in a rural population in India.Invest Ophthalm Visc sci 2002;43:623-31.
2.Gogate P, Mukhopadhyaya D, Mahadik A, NaduvilathTJ, Sane S, Shinde A, et al. Spectacle compliance amongst rural secondaryschool children in Pune district, India. Indian J Ophthalmol 2013; 61:8-12.
3.Zhao J, Pan X, Sui R, Munoz SR, Sperduto RD, Ellwein LB, et al.Refractive error study in children: Results from Shunyi District, China. Am J Ophthalmol 2000; 129:427-35.
4.Maul E, Barpsso S, Munoz SR, Sperduto RD, Ellwein LB. Refractive error study in children: Results from La Florida, Chile. Am J Opbthalmol 2000;129:445-54.
5.Congdon N, Zheng M, Sharma A, Choi K, Song Y, Zhang M, et al. Prevalence and determinants of spectacle non-wear among rural Chinese secondary school children. The Xichang Pediatric Refractive Error Study Report 3. Arch Ophthalmol 2008; 126:1717-23.
6.He M, Patel N, Esteso P, Webber F, Msithini RB, Ratcliffe A, et al. Need and challenges of refractive correction in urban Chinese school children. Optom Vis Sci 2000; 82:229-34.
7.Odera N, Wedner S, Shigongo ZS, Nyalali K, Gilbert C. Barriers to spectacle use in Tanzanian secondary school students. Ophthalm Epidemiol 2008;15:410-7.
8.. Castanon Holguin AM, Congdon N, Patel N, Esteso P, Toledo Flores S, et al. Factors associated with spectacle-wear compliance in school-aged Mexican Children. Invest Ophthalmol Vis Sci 2006;47:925-8.
9.Preslan MN, Novak A. Baltimore vision screening project. Phase 2. Ophthalmology 1998;105:150-3.