Compliance to spectacle use in children with refractive errors- a systematic review and meta-analysis

Methodological quality of the review: High confidence

Author: Nonita Dhirar, Sankalp Dudeja, Mona Duggal, Parul Chawla Gupta, Nishant Jaiswal, Meenu Singh and Jagat Ram

Region: India, Pakistan, Nepal, Iraq, Chile, Saudi Arabia, Nigeria, Romania, USA, Tanzania, Mexico, Oman, UK

Sector: Refractive error

Subsector: Compliance to spectacle use in children

Equity focus: No

Study population: Children

Type of programme: Community based

Review type: Other review

Quantitative synthesis method: Systematic review and meta-analysis

Qualitative synthesis method: Not applicable

Background: Uncorrected refractive errors are a major cause of morbidity globally. Children suffering from refractive errors viz., myopia, amblyogenic hyperopia, astigmatism and anisometropia require appropriate treatment at the earliest opportunity. Uncorrected refractive errors in children lead to poor academic growth, injuries, reduced social participation and functional impairment. Correction of visual impairment with spectacles is the most cost-effective intervention for improving eye care and thus the productivity and functionality of children. Compliance remained low even when the spectacles were provided for free, and poorer rates were observed in older children and children residing in rural areas. Poor follow-up after school-based screenings, broken spectacles, loss, forgetfulness, parental and children’s perceptions, peer pressure, safety concerns and the patient’s self-esteem are a few of the reasons cited for poor compliance.

Objectives: to measure compliance with spectacle use in children with refractive errors. The secondary objective was to understand the reasons for non-compliance.

Main findings: In total, 23 articles were included in this review. All the 23 studies included were cross-sectional in nature. The studies are geographically diverse and covered 14 countries. The greatest number of (39.1%) of studies were from lower to middle income country (LMIC) groups. The per capita GDP of the countries ranged from 835 USD for Nepal to 59,532 USD for USA. The total number of children studied was 7,859. The children enrolled were from all age groups ranging from preschool to end of school. The period of follow-up ranged from ‘no follow-up’ to follow-up of 18 months. Close to half (43.5%) of the studies were of good quality, while nine studies (39.1%) were of satisfactory quality, and four studies (17.4%) were poor quality with the score <30%. The overall compliance with spectacle use was 40.14% (95% CI=32.78-47.50) for 20 studies. The compliance varied from 9.84% (95% CI=2.36-17.31) to 78.57% (95% CI=68.96-88.18). The compliance across almost all income groups was poor. The correlation coefficient for relationship between per capita GDP and percentage compliance was −0.051, indicating a decrease in compliance with an increase in per capita income. However, this was not statistically significant (P=0.830). The Galbraith plot has shown that the studies had significant heterogeneity. The heterogeneity could be attributed to varying sample sizes and prescription cut offs (degree of refractive errors). The most commonly cited reasons for non-compliance with spectacle use in the studies were broken/lost spectacles, forgetfulness and parental disapproval. These were followed by headache, teasing by peers and dislike for spectacles. The reasons for non-compliance were pooled for different studies, and is as shown in the forest plots. The reasons were broadly classified into personal factors, social factors, visual problems and breakage/loss/forgetfulness. The non-compliance due to personal factors was 25.78%, for social factors it was 13.18%, visual problems/headache it was 5.47% and for breakage/loss/forgetfulness it was 23.34% of the total. The results clearly show that personal factors and breakage/loss/forgetfulness were the most commonly cited reasons for non-compliance.

Authors note that appropriate remedial measures, such as health education and strengthening vision care services will be required to address poor compliance with spectacle use among children.

Methodology: Observational and experimental study designs were included in the systematic review. These included cross sectional, case control and cohort study designs. Experimental study designs were also explored. Studies assessing compliance with spectacle use in children with REs, published in English language, with one or more of the key words in the title or abstract were included in the review. Compliance was defined as regular use of glasses prescribed for refractive errors including myopia, hypermetropia and astigmatism, assessed either by observation or by interviewing the children.

The searches were performed on 28 May 2017, and were updated on 31 March 2018 on the following databases: Ovid, Embase, CINAHL and PubMed. A thorough search of title and abstracts using the key words, was performed. Reference lists of articles retrieved in the initial step were screened for pertinent studies. Efforts were made to contact authors for articles, which could not be obtained. We also searched additional platforms, like Google Search, for non-indexed studies. The studies were independently reviewed by two researchers (N.D, S.D), who performed a thorough search of the databases and screened titles and abstracts based on the research question, and population and outcome in terms of compliance with spectacle use. After extraction, all related data was entered into Microsoft Excel for compilation. The data was analysed with STATA MP 12 v11.

Applicability/external validity: Regarding external validity, the authors reported that this meta-analysis is the first systematic review on spectacle compliance in children. Also, many studies from LMIC were included and every effort has been made to include all available publications.

Geographic focus: the authors reported that most studies obtained were from middle income countries, and a clearer picture of influential factors from high income and low income countries would not be very clear.

Summary of quality assessment: Overall, there is high confidence in findings of this meta-analysis. The authors used a reliable methodology to identify studies for inclusion, screen studies and data extraction of included studies.