Compliance with spectacle use is an important aspect in eye health of children. This systematic review and meta-analysis was conducted with a purpose of detecting the overall compliance rate with spectacle use in children prescribed spectacles and to identify the reasons for non-compliance. Twenty-three studies were selected after thorough literature search and of these 20 studies were included in the quantitative analysis (meta-analysis). The overall pooled estimate shows that the compliance with spectacle use is considerably low among children 40.14% (95% CI- 32.78–47.50) as assessed from 20 studies, though the studies were heterogeneous. The most commonly reported reasons for non-compliance were broken glasses, lost spectacles, forgetfulness and parental disapproval complaints of visual disturbances and headache.
Majority of the studies were from South East Asia Region (SEAR) and lower middle-income countries. There was a dearth of studies from low-income countries, which could have altered the results and improved representativeness. The estimated compliance rate with spectacle was less than half (40.14%). Sub optimal compliance is a point of concern and can lead to progression of refractive errors. Negative, non significant correlation of percentage compliance with per capita GDP and percentage expenditure on health, suggests that apart from pecuniary factors, psychosocial factors may be a contributor to compliance. It was observed that the setting (screening vs clinical care) and the method of assessing compliance (interview vs observation) did not have significant effect on the compliance. Although, pooled compliance in the clinical care setting where problem was identified by the child or family compared to vision screening setting provided at school was not significant, but the results point to of better compliance in clinical care setting, thus indicating that they are more likely to be aware and are motivated to use the spectacles. Personal, behavioral and cultural factors influence children’s compliance with spectacle use. The rate was less than half for most countries except a few which showed extremes on the lower and higher side. Compliance rate was overlapping between almost all studies except for two studies which reported a very high compliance23,25 and two that reported low compliance16,24. In the study by Khandekar et al23 (2008), the compliance may be high for two reasons. First, the sample size was small (77), that may have been a contributor to the difference in the compliance value from other studies. Second, the cut off for spectacle compliance was >0.75D error, hence free glasses were given to children with higher refractive error, which itself is a factor for good compliance. In the study by Khandekar et al25(2002), the students were being assessed for compliance at regular intervals, thus improving the compliance rate. On the other hand, the reasons reported by Megbeylian et al16 (2013) for poor compliance were lack of affordability and deep-rooted customs /traditions. In Nigeria, the expenditure on health as percentage of GDP and the HDI are low, which may be other contributory factors to affordability. The prescription cut offs for spectacle compliance assessment also varied across studies, though most studies did not report specific cut offs, a few showed that the compliance was poorer in children who had lower refractive errors as compared to children with higher refractive errors. Increased severity of refractive error warrants a stricter compliance to spectacle use as it hinders daily activities due to poor visibility. Some studies 14,16,19,24,27 reported better compliance in myopia as compared to hypermetropia. Recent study by Mc Cormick I et al (2018)35 also reported better compliance with higher refractive error in their study on determinants of compliance to spectacle use. Due to different definitions and cut offs we could not find an effect of these factors on the compliance as some studies have mentioned the prescription cut offs in terms of diopters while others have measured it in terms of visual acuity In addition the available data was also not uniform to be pooled together.
Identifying reasons for non-compliance with spectacle use is important for understanding the social determinants for intervention. The most commonly reported reasons for non-compliance were broken glasses9–12,14,15,17–20,23,24,27, forgetfulness9–11,14,15,17–19,24,27, loss of spectacles9–12,14,15,17–20,24,27 and parental disapproval8,9,11,12,15,16,18,23,24,34.(Fig. 4 a- 4d) Addressing these issues by generating awareness is imperative.. The outcomes indicate more of socio cultural factors as major contributors to poor compliance, that are commonly seen in Upper middle income countries. Any habit, if inculcated in the early years of life is bound to show results in adulthood. Most of the reasons identified for poor compliance are modifiable and are due to carelessness and poor encouragement of children. Breakage, loss and forgetfulness are intervention points that can bring substantial difference in the compliance rate. Parental disapproval is a significant contributor to child behavior. Parents usually stop their children from wearing spectacles, as they are concerned with the societal opinions. In many low and middle income countries, spectacles are considered a sign of weakness and their use hinders the process of finding a suitable match for the children when they reach adulthood. Many parents are seeking LASIK as a procedure for permanent removal of eyeglasses by surgical correction. Factors related to visual problems and headache can be addressed by modification of the prescription glasses and appropriate correction till comfort is achieved.
Compliance with spectacle use in children is an often-neglected issue. Unless social and perceptual barriers are overcome, the families will not access the financial and logistical assistance available to seek eye care for school-aged children. Behavior change communication (BCC) targeted at education and behavior change of parents, so they encourage children to use spectacles, is advocated. Another point of action could be school health programs, which should focus on incorporating the component of ensuring compliance through follow-up, apart from screening of children for refractive errors. Some potential actions that we think may address the poor compliance found in our study include provision of spectacles to children at zero cost, promotion of school vision screening programs by government, involvement of teachers in the process of identifying children not compliant and ensuring remedial actions. Parental education and support are key pillars to strengthen the interventions. It is unlikely that uni-dimensional intervention approaches to increase follow up and spectacle adherence in the context of refractive errors (e.g., free spectacles) will be adequate to achieve sustained improvement in treatment outcomes among school children. Positive reinforcement is essential at both the school and household levels. Generating awareness and glamourizing spectacles by using lightweight, unbreakable and trendy frames will promote their acceptance, especially in adolescent age groups. Lastly, the role of eye care practitioners is imperative in early identification, diagnosis and treatment of refractive errors among children, so as to curb the problem at a very nascent stage.
There are a number of strengths of this study. First, the present review is a first systematic review on spectacle compliance in children. No systematic review or meta-analysis has been conducted previously on this topic. Efforts have been made to include all the available studies on the topic. Secondly, no time restriction was imposed and we have obtained studies for all years. There are a few limitations of the study as well. Despite all our efforts to extract maximum number of studies, we may have missed relevant studies in unpublished literature (publication bias). Also, the number of studies obtained was mostly from middle-income countries and a clearer picture of influential factors from high income and low-income countries would not be made very clear.