Spectacle utilisation rate and reasons for non-compliance with wearing of spect acles amongst primary school children in Onitsha , Anambra state , Nigeria

Recent data suggest that many people are visually impaired because of refractive error (RE), as they are not using appropriate refractive compensation.1 Refractive error is the main cause of visual impairment (VI) in the world, and its correction has been reported to significantly improve visual functioning and quality of life.2 Refractive errors if left uncorrected in children can lead to amblyopia, which negatively affects their educational, psychological and social well-being.3 Early assessment of vision in school children facilitates timely correction of RE, if present, which can help improve academic performance and prevent a major proportion of visual disorders, including binocular vision anomalies.4


Introduction
http://www.avehjournal.org Open Access settings: 60% in rural China, 8 50% in suburban Chile 9 and 49% in native Americans in the western United States of America. 10 The provision of spectacles is currently a challenge in many developing countries because of issues related to availability and affordability. 6 Studies 1,8,10,11 have shown that globally only one-third or less of children with VI because of RE wear corrective spectacles. Correction of REs is a priority of Vision 2020, but if spectacles are not worn, the efforts to correct REs will not be effective. Hence, every effort should be made to remove obstacles in the availability of spectacles and their use. 12 Cost, ignorance of refractive status and lack of awareness of a possible solution for reduced vision are identified as reasons for the non-acceptance of recommended corrective spectacles in Nigeria. 13 This is largely attributable to inadequate, in some cases non-existent, eye care services in some parts of Nigeria. 13 In Nigeria, the situation is exacerbated by cultural beliefs that consider use of spectacles by children or young people unacceptable. 14 In spite of the low rates of compliance with spectacle use globally, few studies have been undertaken to investigate the factors that influence wearing of spectacles in children. 15 Available studies on this subject have mainly focussed on amblyopic children and adults after cataract surgery, 16 which are not representative of the population at large. Few studies 17,18 have examined spectacles utilisation and risk factors for non-compliance in children, with most being conducted outside Africa. There is a need for local studies to ascertain the use of spectacles and reasons for non-compliance with wearing spectacles in children in each community, as this varies from one locality to another for a variety of reasons. These include tribal, ethnical, geographical, religious and cultural factors. This study set out to determine spectacle utilisation rate and reasons for non-compliance to spectacle usage amongst primary school children in Onitsha, Anambra state, Nigeria.

Methods
Information documents were given to the participants, their parents and the various school heads explaining the purpose of the study and the procedures to be followed. Written assent was obtained from every child once their parents had provided written consent. Anonymity was ensured by providing individual codes to all participants before and during the study. The children were informed about the purpose of the study, importance, benefits of the study and their right to decline from participating if they choose to do so. Participants with ocular pathologies were referred to the nearest eye clinic for further assessment and management.
The study adhered to the tenets of the Declaration of Helsinki involving human subjects. This was part of a larger study on RE, VI (Refractive Error Study in Children [RESC]) and utilisation of spectacles amongst primary school children in Onitsha, and a detailed methodology has been described elsewhere. 19 In summary, a stratified random cluster sampling procedure was used to select children aged [5][6][7][8][9][10][11][12][13][14][15]  Myopia was defined as RE of at least −0.50 diopter (D), hyperopia as +2.00 D or more and astigmatism as −0.50 D or more using subjective refraction, whilst utilisation of spectacles was defined as wearing spectacles at the time of examination.
Utilisation rate of spectacles was determined based on the number of children wearing their spectacles at the time of examination. The researcher noted down all primary school children who wore spectacles at the time of examination. If a child had spectacles but was not wearing them, he/she was considered as 'non-compliant'. Children not wearing spectacles were asked whether they had spectacles with them and to identify from a questionnaire different reasons (one out of eight) for non-compliance. Most of the reasons were formulated following a thorough review of existing literature 1,8,9,10,14,17,18 on the subject. Others were included after the pilot study had identified reasons that were not listed. The children not wearing spectacles at the time of this study were counselled alongside their parents and teachers.

Data analysis
Data were analysed using SPSS Statistical Package for Social Sciences, version 24. Descriptive statistics and Chi-square tests were used to investigate relationships between age, gender and type of RE with spectacle utilisation; p < 0.05 was considered statistically significant.

Ethical consideration
The study was approved by the Biomedical Research and Ethics Committee (BREC) of the University of KwaZulu-Natal (BE620/16). Permission to conduct the study in primary schools was obtained from the Department of Education and Training, and the heads of the identified schools in Onitsha, Nigeria. Informed written consent was obtained from parents before examination.

Results
Of the 998 children examined in the RESC in Onitsha, uncorrected VA of 20/32 or better in the better eye was found in 901 (90.3%) children; 97 (9.7%) children had uncorrected VA of 20/40 or worse in the better eye (Table 1)  Of the 97 children with RE, 41 (42.3%) had previously tested their eyes and were prescribed spectacle corrections but only 20 (48.8%) wore them at the time of examination; the spectacle utilisation rate was therefore 20.6% (20/97). Eleven (55%) of those wearing spectacles were girls, 13 (65%) were myopic and children aged 8-10 years had the highest number (10, 50%) of those wearing spectacles. A statistically significant association was found between age, gender, type of RE and use of spectacles (all p-values < 0.05; Table 3). Amongst those not wearing their spectacles, the majority (28.6%) reported that their parents disapproved the use of spectacles. Other reasons for noncompliance with spectacles wearing are presented in Table 4.

Discussion
The present study showed that spectacle utilisation rate amongst children in Onitsha was 20.6%. This could be because of poor awareness about the use of corrective spectacles for RE and low uptake of RE services in Onitsha. It is worth noting that 95.7% of children with RE in this study had improved vision after refraction and provision of spectacles. Interestingly, none of the 1707 children examined in a study conducted in Ile-Ife in south-west of Nigeria 20 had previously had an eye examination. This could be because Ile-Ife is a semi-urban area with few eye care service providers and people are of lower socio-economic status. Muma et al. 21 also found only one child wearing spectacles in their study in the rural area of Kenya. This result could be explained by inaccessibility and the high cost of eye care services as well as the social stigma associated with wearing spectacles. A recent study 22 conducted in Nigeria showed utilisation of spectacles to be highest in the north-west region.    Megbalayin, 22 in a study to determine barriers to spectacle utilisation amongst undergraduates in Akwa-Ibom state, Nigeria, found that only six (9.8%) out of 81 students with RE were wearing spectacles at the time of examination. The author further revealed that students with headaches, tearing and with both parents wearing spectacles were more likely to use spectacles. Similar findings were reported by Faderin and Aijeyeoba 23 in Lagos, Nigeria. The authors reported that poor awareness of eye problems and benefits of spectacles usage amongst parents not wearing spectacles could account for parental disapproval of spectacles usage in their children.
Variations in the findings could be attributed to the fact that Onitsha is a relatively affluent area with easy access to eye care services and people are of a higher socio-economic status than those in Ile-Ife.
However, the spectacle utilisation rate of 20.6% found in the current study is lower than 35.8%, 42.3% and 93% recorded in China, 24 Egypt, 25 and India, 12 respectively. However, it is considerably higher than what was reported in other studies carried out in Iran, 26,27 Chile, 28 Kenya 21 and South Africa 29 (Table 5). Variations in spectacle utilisation rates in these studies could be attributed to racial/ethnical differences, targeted population, access to eye care services, type of RE prevalent in that area, cultural beliefs regarding use of spectacles and the cost of spectacles. For example, the low utilisation rates recorded in Chile 28 and Iran 26,27 could be because of high cost of spectacles in those countries, whilst poor access to eye care services and cultural beliefs could be responsible for the lower utilisation rate in Kenya. In addition, the spectacle utilisation rate of 93% reported in India 12 could be because the community mobilisers employed in the study were working very close with the community and might have given some prior information to the community about the study, resulting in a very high compliance rate. In addition, the study did not find any evidence of parental disapproval or stigma associated with wearing spectacles, although it was evident that liking or disliking spectacles and the style of spectacles were more important for children than adults. The study further suggested that communication campaigns involving popular images and role models are important in influencing children's behaviour and compliance in wearing spectacles.
Use of spectacles was found to be significantly associated with boys aged 5-7 years and those with myopia (all p-values < 0.05; Table 3). A study conducted in Akwa-Ibom, Nigeria, found that all the students wearing spectacles were males; 22 this is contrary to the findings of Alex et al., 30 who found that females had a greater tendency to wear spectacles than their male counterparts. Marmamula et al. 31 also reported that spectacles wearing rate was higher in women than in men (35% vs. 24%). Adefule-Ositelu 32 noted that women aged 15-18 years wore spectacles for fashion, whilst men wore them based on the severity of RE, and not because of fashion. Fotouhi et al. 26 and Hashemi et al. 27 reported in their studies carried out in Iran that utilisation of spectacles is associated with age and gender. Variations in the findings reported could be because of differences in culture, geographical locations, race and socio-economic factors. Moreover, the current study was a school-based study and had a sample size of 998 examined children, whilst those completed in Tehran 26 and two underserved rural areas of Iran 27 were population-based research with sample sizes of 4353 and 3314, respectively.
A study conducted in Nigeria showed that factors affecting spectacles wearing were complex. 22 In this study, 20 (20.6%) children wore spectacles at the time of examination, although 21 (21.6%) others reported being prescribed spectacles but were not wearing them. Our study found that parents disapproved wearing spectacles in their children, which was the major reason reported for non-compliance with spectacles wearing. Similar findings were recorded in Saudi Arabia, 4 the United States of America, 33 India 34 and Tanzania. 35 The findings of our study also showed that children did not comply with spectacles wearing because of being teased about their appearance by fellow students, forgetting spectacles at home or that spectacles cause headaches. Concern over appearance or being teased in the class was reported as the main reason for non-compliance with spectacles wearing in the studies conducted in Mexico, 18 the United States of America, 33 Iran, 26,27 South Africa, 29 Ghana, 36 Oman, 37 Saudi Arabia, 4 China 38 and India 39 . This observation could be because of the stigma attached with wearing spectacles and the belief that their use eventually leads to blindness. 40 Some children in the current study reported that spectacles should not be worn by children and, if necessary, they should be used occasionally or for special occasion because of fear of spectacles sinking their eyes. Nwosu 41 reported claims of the deleterious effects of spectacles on eyes, such as sunken eye sockets and ocular discomfort (headaches), with the use of corrective lenses as a major reason given by respondents for not wearing prescribed spectacles in his study carried out in Nigeria. Castanon Holguin et al. 18 stated that about one-quarter (16%) of children forget their spectacles at home and use them occasionally. Measures to improve wearing of spectacles for refractive correction in children should be carried out effectively through educational and awareness campaigns. Parents should also be involved in these programmes, and schools should conduct follow-up visits after school screening programmes.
Fotouhi et al. 26 and Hashemi et al. 27 found that age, gender, and type of RE influenced non-compliance with wearing of spectacles. Castanon Holguin et al. 18 in Mexico also found that non-compliance with wearing of spectacles was higher amongst older children and those in urban areas. The authors reported that older urban-based children were more likely to list concerns about their appearance after wearing spectacles and being teased than their younger and rural counterparts. This could be related to our study, as only one child (5%) aged 14-15 years was wearing spectacles. Thirteen (65%) children who wore spectacles in our study were myopic, indicating that myopic children were more likely to comply with spectacles wearing than those with astigmatism or hyperopia. This could be because myopes wear spectacles to correct their distance vision unlike hyperopes, who still manage to see at a distance without corrective spectacles because of their accommodative ability. This is similar to the findings reported by Hashemi et al. 27 in Tehran, where 74.5% of those wearing spectacles were found to be myopic. Although children with hyperopia are less likely to comply with spectacles wearing, they are more at risk of developing strabismus and amblyopia. Strategic measures should be devised to reduce non-compliance with wearing of spectacles in school children.
The results of this study must be considered within the context of certain limitations. For example, a major limitation of this study was the small non-probability sample which precluded the use of higher-order statistical analysis. The study involved only children in the city of Onitsha, and therefore the findings cannot be generalised to the entire population of children in Nigeria. Another limitation was that the measure of compliance was based only on whether the participants presented wearing spectacles on the day of eye examination, and the reasons for non-compliance with spectacles wearing were obtained from participants' self-report. A further limitation is that the study did not investigate cultural attitudes and the role of teachers regarding spectacles wearing. In addition, children who were absent from school were excluded from the study.

Conclusion
Spectacle utilisation rate was relatively low (20.6%), and parental disapproval of the use of spectacles was the major reason for non-compliance in this study. These highlight the need for awareness programmes about the use of corrective spectacles in school health and education programmes. These would help to prevent the negative impact of RE and VI on children's education and development. Compliance with spectacles wearing could be improved by educating the parents and their children about the importance of wearing spectacles.