Utilisation of eye health services and compliance with spectacles wear among community school adolescents: a mixed-methods study from Bagmati province of Nepal

Utilisation of eye care services

Our study showed that less than half (47.32%) went for further evaluation at a nearby referral centre after an abnormal vision screening at school. In a study in Kerala, India, among primary school students aged 4–12 years with symptoms in the past, 38% used the services of an ophthalmologist.27 The local health department records from Michigan, USA, showed that only 25% of school-aged children with abnormal vision screening completed follow-up examinations.15 In another state of the USA, Philadelphia, a similar proportion (25%) of children aged 5–13 years needing follow-up care completed referral eye examinations.16 Our study and other literature suggest that the utilisation of eye care among children is not satisfactory and requires urgent attention to minimise the multiple barriers to seeking care.

Our mixed-method study identified multiple reasons among adolescents for not going to eye care services, which are similar to other studies. Eye health facilities being far away was the primary reason for non-utilisation. The non-availability of an eye care facility nearby and the cost associated with reaching a facility farther from home were also shared as a reason for the non-utilisation of eye care services. The students also reported that their families could not afford eye check-ups, spectacles or medicines if required. Non-affordability and inaccessible reasons were also shared by parents of school students with ocular conditions from Kerala, India.27 The parents of preschool children with ocular morbidities from the USA also reported a lack of insurance coverage for eye examinations as reasons for not following up.28 A systematic review also determined non-availability, non-accessibility and non-affordability as the main barriers to accessing paediatric eye care services in Africa.29 There is little doubt that the interdependencies of availability, affordability and accessibility significantly limit the reach of any health programmes, including eye care services. Greater efforts are needed to make eye care available, affordable and accessible.

In our study, additional reasons related to non-utilisation were the roles and awareness of family members. They were either busy with their household or were not convinced their child needed eye care. A study in the USA among preschool children (3–5 years) with vision problems also showed that parents either ignored the issues in their child or waited for the problem to deteriorate or did not believe their child had vision issues.28 A telephone survey among parents of school-aged children with abnormal vision screening from Michigan, USA, also pointed out that parents did not suspect a problem and/or doubted the screening test’s accuracy.15 Meanwhile, a study in Australia among young children’s parents showed that concern about the child’s vision was a major reason for their child having an eye examination.30 Another reason shared for the non-utilisation of eye care among our study participants was their perception of eye health. Some believed their vision was good, and they did not need eye examination, while some did not want to go as they did not want to wear spectacles. A study among students aged 4–12 years in India also revealed that the majority did not feel any reason to consult the doctor despite having symptoms of eye diseases.27 Negative attitude or ignorance can exacerbate existing eye conditions. There is a need to raise awareness and educate students and their guardians to help them overcome concerns that hinder them from seeking timely care and saving the sight of children.

Another reason shared by our students for the non-utilisation of eye care services was the ongoing COVID-19 pandemic during the study period. The number of patients visiting for eye care during the pandemic decreased worldwide due to the fear of infection.31 32 This is obvious as staying safe from the infection was the priority over most other ailments during the period.

Our study showed that male students used eye care services more than female students, but the association was not statistically significant. In contrast, the Canadian Community Health Survey between 2007 and 2008 showed that males were 10% less likely than females to use services.33 A study from Taiwan showed that female children with ocular conditions had lower utilisation than their male counterparts.34 A hospital-based review in Nepal also showed that females consulted for eye care less commonly than males.35 Nepal is a patriarchal society, and earlier reports suggest that gender disparity was profound in the utilisation of eye care services and pervasive in all regions of Nepal.36 Promoting equity in eye care access contributes to gender equality by ensuring that females have the same opportunities as males to receive the care they need and can break down barriers and stereotypes related to gender roles and expectations.

In our study, there was no significant difference between young and older adolescents in the utilisation of eye care services. More younger students used eye care services than older adolescents in our study. A study among 4–12 years students in Ernakulam District of Kerala, India, showed that children of higher age groups used eye care services more.27 In our study, as described above, the initial vision screening was conducted by fellow students aged 14–17 years. The older adolescents, being the peers of the screeners, might not have believed in the vision screening capacity of students or were ignorant of their advice to go for check-ups.

The students whose parents had a high school education and above were 1.3 times more likely to use eye care services than parents who had just a school education or were literate. However, there was no statistically significant association between parents’ education and utilisation in our study. The Taiwan National Health Interview Survey showed that among children aged 3–12 years with ocular conditions, higher levels of mother’s and father’s education also had similar odds as our study of receiving subsequent eye care, and father’s education was significantly associated with utilisation.34 However, a study in urban Kerala showed that the parents’ education level did not influence utilisation of eye care services among children aged 4–12 years when they are inflicted with an eye disease.27 Parents with higher levels of education can have better access to information about the importance of eye care and are more likely to seek care.

The students whose parents had regular paid jobs like in services, teaching or business were likelier to use eye care services in our study than parents with other jobs like daily labour or were housemakers or farming. The students with mothers with regularly paid jobs were more likely to use eye care services in our study, and this association was statistically significant. The survey from Taiwan has also added evidence that children aged 3–12 years with ocular conditions living in families with higher family incomes were much more likely to receive eye care.34 A study from the USA also showed that family with higher income were likely to take their preschool-aged children with abnormal vision screening for follow-up care.28 A cohort study from Avon, in Southwest England, UK, showed that children from lower socioeconomic status groups were less likely to see an eye care specialist or to use screening services.37 The same cohort study also suggested that eye conditions were more prevalent among children in the lower social classes, suggesting they have a greater healthcare need but less access to services than those from higher socioeconomic groups.37 The differences between socioeconomic groups in using eye care services suggest inequitable access. If we are to tackle preventable sight loss and move along with eye health as an essential part of Sustainable Development Goals,38 ensuring equitable access to eye care is vital.

In our study, the students residing in urban areas were more than four times more likely to use eye care services, and the association was statistically significant. Similarly, in our study, the students residing within a half-an-hour walk to the nearest eye clinic were more likely to use eye care services than those who had to walk more than half-an-hour, and the association was statistically significant. In Nepal, there is a negligible number of eye care services by governmental health facilities, with 90% of eye health services primarily delivered by non-governmental organisations run eye hospitals, followed by private health facilities.7 39 Almost all eye care centres are in metropolises or district headquarters. Distance and poor accessibility have always influenced eye care service utilisation for children or other populations. An earlier study has shown that great distance from home to eye facilities, unavailability of eye health service providers in their locality, and inadequate eye care services in their local health facilities affected eye health services utilisation among people from Mustang, Nepal.40 The study among parents of school students also disclosed that poor accessibility was one of the major reasons for not taking students for follow-up care.27 Expanding access to affordable eye care services, particularly in underserved areas, can address disparities in the utilisation of eye care services.

Compliance with spectacles wear

Three to four months after the distribution of subsidised spectacles, in unannounced school visits, 59.31% of students were wearing spectacles in our study. This is higher than a previous study in Lumbini, Nepal, where 51% of students were wearing spectacles on similar visits.41 In South India, 57.8% of school children aged 7–15 years were found to be in compliance with spectacles wear during unannounced visits conducted after 3 months of providing spectacles free of cost.42 A study among Tanzanian students showed that 56% of students were wearing their spectacles or had them at school at the 3-month follow-up.43 A study among Botswanian school students aged 12–17 years showed 60.1% of children were compliant with spectacle wear at 3–4 months follow-up from spectacle distribution.22 In a study among 5–16 year old students from Chitwan, Nepal, only 28% were wearing spectacles after a year.25 Another study among rural secondary school children (8–16 years) in Western India showed that 29.5% were wearing spectacles after 6–12 months of providing free spectacles.44 A multicentre study in Southern Arizona, USA, among children aged 8–14 years showed only 33.2% were wearing spectacles after a year.45 These studies show that the compliance rate has decreased as days have passed by. All these studies from around the globe show that compliance with spectacles use is a major issue in eye care, even though the children get it for free or not.

Our study showed that relief of the symptoms after wearing the spectacles was one of the facilitators for compliance with spectacles wear. Many students reported vision being clearer and relief from eye pain and headaches after wearing spectacles in our study. The beneficial impact on their vision also influenced compliance with spectacles wear among Tanzanian students.43 The children from the USA who were wearing spectacles also reported that their distance vision was blurred without spectacles.45 In contrast, headaches after wearing spectacles or discomfort were also reasons for the non-wear of spectacles in our study. One common reason our study participants shared was difficulty in wearing masks and spectacles together as the study was conducted during COVID-19. Similar inconveniences like uncomfortable spectacles, headaches and their eyes watering were shared by 10–16 years old students from India for non-compliance with spectacles.46

The aesthetic aspect of the spectacles was also a facilitator for compliance with spectacles in our study. Liking how they looked in spectacles was also significantly associated with school children wearing spectacles in Southern Arizona.45 A study in Tanzania among early teenage students showed they seemed happy with the appearance of their spectacles.43 Some students from India complained that they did not like the frame, it was bad looking, or the colour of the frame was not to their liking as a reason for non-compliance to spectacles wear.46 The shape and colour of the frame, according to face shape, along with personal fashion, style and comfort, can enhance one’s overall appearance and boost one’s confidence. Hence, be it free or subsidised, students must be allowed to choose and try the frame so it fits them and use them.

The peers and family were facilitators and barriers in compliance with spectacles wear in our study. Few students reported that compliance with spectacles wear was support from peers and family or their peers and family members were wearing spectacles. Some students reported negative attitudes about wearing spectacles from peers and family, which also barred them from wearing spectacles. Peer pressure and parental concerns about the safety of spectacle wear were barriers to spectacles wear in a study in Tanzania.43 Students from Chitwan, Nepal, were also concerned about teasing and were not wearing spectacles.25 Some students refused to wear spectacles after being subjected to teasing, name-calling and harmless jokes to being bullied or discriminated against in Tanzania.43 A few students from the same cohort believed their families did not like them wearing spectacles.43 Similar reasons were also shared by students from India, where friends calling them names, teasing from relatives, parents not allowing them to wear spectacles and disliking spectacles themselves.46 In a study from Onitsha, Nigeria, students aged 5–15 years reported that parents’ disapproval about the wearing of spectacles, concerned or teased about appearances and children should not wear spectacles were a few reasons for non-compliance with spectacles.47 The most common cause of non-compliance in Lumbini, Nepal, was a lack of awareness among guardians about the need for distance spectacles for the children.41 Poor awareness about the usefulness of spectacles wear was found among our study participants also. Some of our study participants did not feel they needed spectacles and were not wearing them. The students from Nigeria also had similar attitudes and reported that they felt that they did not need to wear spectacles.47 Some students in our study did not wear spectacles because they thought that vision diminishes if one wears spectacles. Students from southern Nepal were also worried that spectacles would make their eyes weak.41 Some students from Tanzania also reported that they did not use spectacles because they cause headaches, and spectacles will sink into the eye sockets.47 Chinese adolescent students who held the attitude that ‘spectacles make the vision worse’ were less likely to wear spectacles.23 Besides selling or recommending spectacles, counselling related to the importance of compliance with spectacles wear needs to be given due emphasis to the students and their caretakers to bust myths and misconceptions about spectacles.

Two of the barriers to spectacles mentioned in our study were lost and broken spectacles. Similar reasons were cited by students aged 5–16 years from Chitwan, Nepal.25 A multicentre study from the USA also showed that the most common reasons among children aged 8–14 years children for non-wear were lost (44.9%) or broken (35.3%) spectacles, even though they were provided with two pairs the previous year.45 Lost and broken spectacles as reasons for the non-wear of spectacles were also shared by students from India.46 In addition, our study participants reported that the cost associated with buying new spectacles or even changing powers made them not wear spectacles even if they got them for free the first time. Students from Tanzania shared similar affordability issues.43 The future school eye health programme should focus on providing high-quality frames as well as educating students and parents about the importance of taking care of spectacles and keeping them safe to reduce the incidence of lost or broken spectacles.

Our study showed no significant difference between male and female students in compliance with spectacles wear. Though the proportion of males wearing spectacles is higher than females in our study as well as in the Chinese study,23 there was no significant sex difference, unlike in the study in Tanzania.43 A significantly higher proportion of 8–16 years males (73.7%) were not wearing their spectacles compared with females (67.5%) in Pune, India.44 A study among Chinese adolescents showed the prevalence of spectacles utilisation was 35.2% for females and 36.2% for males, with no significant difference.23 In the multicentre study from the USA, 64.6% of females and 35.4% were wearing spectacles, and females were 1.8 times more likely to wear spectacles, and the association was statistically significant.45 The study from students (12–17 years) of Botswana also showed that female children were 2.32 times more likely to wear spectacles than males.22 A study among school children aged 6–17 years of Oman also showed higher compliance among females (78.3%) than males (65.1%).48 A study from the Rupandehi district of Nepal also showed that spectacles wear compliance was higher in females (58%) than males (48%).41 These studies have shown that both sexes could be less compliant with spectacles wear. Both sexes can have RE, and it is important to emphasise that wearing spectacles is primarily related to RE correction and eye health and be made aware of it.

Older adolescents were nearly twice as likely to keep wearing spectacles than younger adolescents in our study, and this association was statistically significant in multivariate analysis. Among students aged 6–17 years of Dhakhiliya, Oman, higher compliance was observed among secondary than preparatory students, implying higher-aged students were wearing spectacles, and the association was statistically significant.48 Non-compliance was not significantly related to the age of the students, but older children were slightly more non-compliant in Pune, India.44 A study in Goodhope district, Botswana, among students aged 12–17 years, showed that the odds of spectacle wear decreased with age.22

In our study, the students with parents who were illiterate or only had a school education were likelier to wear spectacles than those with a high school education and above. However, in other studies from Nepal, compliance was better among students with higher education levels of parents.25 41 Spectacles non-compliance among secondary school students in Pune, India, was significantly related to lack of education of the father but not of the mother.44 Parental education levels were positively associated with spectacles utilisation among students from Mojian, southwestern China.23 Parents with lower levels of education can be proactive in supporting their children to continue to wear spectacles if they are counselled well about RE and keeping spectacles safe. Therefore, efforts to promote spectacle compliance should focus on education and awareness for all parents, regardless of educational background, to ensure that every child with RE continues wearing spectacles.

Students whose parents had regular paid jobs in services, teaching or business were more likely to wear spectacles in our study than parents with other jobs like daily labour, housemakers or farming. The students who had mothers with regularly paid jobs had more than twice the odds of spectacles compliance than those who did not, and this association was statistically significant in multivariate analysis. Non-compliance among Indian students was not significantly associated with the father’s occupation.44 In a study among Chinese adolescent students, students whose families had higher incomes were more likely to wear spectacles.23 Economic constraints can affect a family’s ability to replace lost or damaged spectacles or afford regular eye exams, impacting compliance. In addition, a mother with regular pay is usually empowered and caring enough to influence her child with spectacle compliance positively.

In our study, adolescents whose family members were wearing spectacles were more likely to be compliant with spectacles wear. Chinese adolescents whose parents had a higher rate of spectacle-wearing were also more likely to wear spectacles.23 Adolescents might have observed their family members’ positive experiences with spectacles, which could have encouraged them to wear spectacles as prescribed.

In our study, the students who had gone to eye care centres and were prescribed spectacles were more likely to wear spectacles than those who got spectacles at schools, and the association was statistically significant. Students liked the spectacles procured from the base hospitals much more than those given free by an organisation in a study in India.46 In our study, the students residing in urban areas had odds of nearly 2.5 times more likely to have compliance with spectacles than those from rural areas, and the association was statistically significant in multivariate analysis, too. This might be because eye care centres are in proximity to the students, mostly in urban areas. However, the students motivated to go for eye check-ups at clinics may also be motivated to wear them. In addition, going to an eye centre can help one choose a variety of frames than at school-based refraction with limited choices. The aesthetic aspect of spectacles was a major reason for spectacles compliance in our study and other studies.43 45 46

The major limitation of the study was that the study site was Bagmati Province, one of the most developed provinces with relatively greater access to eye care services in Nepal. Therefore, the results cannot be generalised to other parts of the country. The cross-sectional nature of the study precludes the analysis of behaviour over time or the long-term trends in compliance with spectacles wear among students. Furthermore, it is difficult to establish cause-and-effect relationships, such as the utilisation of eye care services among students with poor vision. Furthermore, during group discussions, there could be a presence of social desirability bias among study participants. Another limitation of this study is that the calculated sample size was not reached due to a low response rate from students.