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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 11
| Issue : 2 | Page : 91-96 |
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Parent's eyecare seeking behavior for young children in Saudi Arabia
Ashwaq Mohammed Almalki1, Lina Hassan Raffa2, Ayat Mohammed Aldosari1, Roaya Ayed Alsulami3
1 Department of Ophthalmology, King Abdulaziz Medical City, Jeddah, Saudi Arabia
2 Department of Ophthalmology, King Abdulaziz University Hospital; Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3 Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| Date of Submission | 14-Mar-2022 |
| Date of Decision | 15-Jun-2022 |
| Date of Acceptance | 19-Jul-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Lina Hassan Raffa
Department of Ophthalmology, King Abdulaziz University Hospital, Prince Majid Road, Al Sulaymaniyah, P. O. Box: 80215, Jeddah 21589
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_35_22
Background: In Saudi Arabia, school health services lack adequate vision screening. To date, limited data on access to eye care in young children in Saudi Arabia exist. Aim: This study aims to evaluate whether parents who reside in Saudi Arabia know how to access eye care for their young children, and what barriers might exist to prevent them from seeking care. Materials and Methods: A cross-sectional study among parents of children 14 years or younger who reside in Saudi Arabia was conducted using an online questionnaire. Results: A total of 1023 completed questionnaires were analyzed. Of all responses, the majority 57.9% (n = 592) of parents reported that vision screening did not take place in their children's schools. Over half of the parents (n = 522, 58.9%) reported that their children had never undergone an eye examination before. Most common reason to seek eye care would be for concerns over poor vision reported in 59.5% (n = 609). The most common barrier to accessing eye care was not knowing how to access an eye test in 33.9% (n = 347) followed by a quarter of parents citing other reasons (n = 258, 25.2%) such as having no concerns and no clear reason to have their child's eyes examined. Conclusion: Parents in Saudi Arabia have some concerns and challenges in seeking eye care for their young children. Planned awareness programs to educate parents and help them overcome the barriers that hinder them from seeking eye care for their children are recommended.
Keywords: Amblyopia, child, knowledge, refractive errors, vision screening
How to cite this article:
Almalki AM, Raffa LH, Aldosari AM, Alsulami RA. Parent's eyecare seeking behavior for young children in Saudi Arabia. Saudi J Health Sci 2022;11:91-6 |
| Introduction | |  |
It is estimated that 1.4 million of childhood blindness are in developing countries.[1] The prevalence of blindness in developing countries is 10–40 times higher than in developed countries and close to three-quarters of the world's blindness. Reported causes are either curable or preventable.[2] Different studies postulated the prevalence of childhood blindness to be 1.5% in Saudi Arabia[2],[3] with school-age children constituting 20%–30% of this population.[1] Large population-based studies indicate the majority of cases of significant visual disorder in childhood are those of refractive error or strabismus, both of which often result in amblyopia.[4] The goal of vision screening is to detect amblyopia or risk factors that threaten visual development and manage it in a timely manner to yield the highest benefit.[5] In a reported recent population-based studies conducted in Saudi Arabia, the postulated prevalence of amblyopia was higher than in most countries probably attributed to the lack of implementation of visual screening programs in Saudi Arabia to date.[6],[7],[8 ] It has been argued that untreated amblyopia may impact the child's education and behavior and have long-term negative visual consequences.[4]
Parents' knowledge and misconception toward childhood eye care as well as their eye care seeking behavior have an influence on the prevalence of childhood poor vision and blindness. In a recent study conducted, the authors suggested that the knowledge of parents whose children attended public schools toward eye care in Saudi Arabia was considered below average.[9]
To date, limited data exist regarding access to eye care among young children in Saudi Arabia.[9] Therefore, the present study sought to evaluate if parents know how to access eye care for their young children, what may prompt them to do so and what possible barriers might exist to prevent them from seeking an eye care.
| Methodology | | |
Study design and subjects
The study is a descriptive quantitative cross-sectional that targeted parents of children aged 14 years or less residing in different regions of Saudi Arabia. It included Saudi and non-Saudi parents and excluded those who resided outside of Saudi Arabia.
The used survey was adapted from Donaldson et al.[4] and adjusted based on the cultural differences. Permission from the primary author of the original paper was obtained.[4] Translation to Arabic and back to English by two separate bilingual ophthalmologists. The results of the pilot study were used to slightly refine the questions and make them more applicable to our region. Both Arabic and English questionnaire versions were piloted on a sample of 20 parents and were not included in the final data.
The survey was divided into four main sections: demographics, parental beliefs, possible barriers to seeking eye care, and parental knowledge. Parents' awareness of a routine vision screening program in their child's school, presence of visual concerns, and family history of an eye condition, as well as whether their child received any eye examination were investigated. Reasons they would consider to seek an eye examination for their child and possible barriers that may prevent them were also noted. The section on existing parental knowledge involved parents agreeing or disagreeing with five statements on eye care.
Data were collected through an online distributed prestructured survey during 2019. A total of 1023 online surveys were distributed through different social media platforms including Twitter, WhatsApp, Snapchat, Facebook, and Telegram.
Statistical analysis
The sample size was computed using Epi Info TM version 7.2 software (https://www.cdc.gov/epiinfo/). The inputs were a population size of 8.4 million children under the age of 14 years based on the last Saudi population census reported in 2019, an expected frequency of 50%, with a 95% confidence interval. The estimated overall sample size was recorded (n = 1000). Investigators of this study promoted the survey over a year to recruit a sufficient number of participants that adequately represented the population in each cluster.
This study was analyzed using IBM SPSS version 23 (IBM Corp., Armonk, NY, USA). A simple descriptive statistics was used to define the characteristics of the study. Domains are calculated during the analysis, by a simple additive method. The questions under the “knowledge” are converted first to correct and incorrect answer before the calculation. Where incorrect is equivalent to 0 and correct is equivalent to 1.
Ethical approval
The study was approved by the Research Ethics Committee of King Abdulaziz University (No. 313-19) and followed the tenets of the Declaration of Helsinki. Informed consent was electronically obtained from all participants.
| Results | | |
Characteristics of the study sample
[Table 1] represents the demographics of the surveyed sample. All respondents reported being comfortable conversing in their chosen language preference either English or Arabic.
Vision screening status
In regard to the parent's awareness of a routine vision screening program in school, considering only the children ages 3 years and above, majority of parents were unaware of these services at 65.5% (n = 581). Of those who were aware (7.2%), the majority underwent vision screening in their Grade 1 primary school (n = 28, 45.2%) while students who had their vision screening done during preprimary school (n = 28, 32.3%) cited kindergarten (n = 11, 68.8%) as the specific grade level.
Majority of the participants had no experience of being rejected in availing an eye examination (n = 906, 88.6%). However, a quarter (n = 4, 25%) of those who were rejected cited the lack of specialization or equipment and having a very young examinee as the reason.
Of the surveyed population, majority (53.4%) were concerned about their child's vision, while (41.1%) had no concerns. Although half of the surveyed parents were concerned about their children's vision, 52% did not know how to access the appropriate eye test for their child. Moreover, (68%, n = 696) had a first-degree family member who was suffering from an eye condition, whether it was eyeglass wear, having a lazy eye (amblyopia) or an eye turn.
Among the 1023 children of the participants, majority (n = 522, 58.9%) have not taken any form of eye or vision test. Of those who did (n = 340), it was carried out at preprimary grade (n = 167), and at primary grade school (n = 168) and (n = 20) were not sure of the time.
Interestingly, the level of parents' educational attainment significantly determined whether or not their child has had an eye examination (P = 0.005). A large disparity was found in the eye-testing experience of children whose parents have the least educational background (tested = 33.3% vs. not tested = 66.7%).
Existing parental knowledge and awareness
The assessment of the parent's knowledge about eye care revealed that out of the 5 questions, only 1 question, pertaining to the child's necessity to know the letters to undergo a vision test, was answered correctly by the majority (n = 605, 59.1%) of the participants. Specifically, participants are misinformed about the services offered at local hospitals and primary care centers (37.5%), vision improvement with the use of spectacles (43.6%), need to seek advice even for occasional eye turn (48.3%), and lack of testing for all eye problems by school vision screening (43.0%).
One significant correlation found was that parents are more informed about eye health when their child is female. In addition, there is a significant difference in relating the gender of the child and having undergone eye examination. In addition, there is greater percentage of male children (63.9%) who are unexamined compared to female (57.3%, P = 0.048).
Parental knowledge about eye health is correlated to the current educational level of the child (P < 0.001). Multiple comparison test results show that there is a significant difference in parental knowledge when the child does not attend primary school as compared to when enrolled in preprimary and primary (all P < 0.001) school. Furthermore, the current educational level of a child significantly determines whether or not the child has experienced eye examination (P < 0.001). There is an apparent decrease in percentage of untested children from nearly three-fourths (72%) to only about half (51.3%) as the educational level of the child increases. Whereas, the percentage of tested children almost increased by a double from those who are enrolled in preprimary school (24%) to those enrolled in primary school (46.3%).
The parents' highest educational attainment appears to be significantly correlated to having higher knowledge on eye health (P < 0.001). Specifically, post hoc tests revealed that holders of PhD degrees have better knowledge on eye care compared to those with a Master's degree (P < 0.001), Diplomas (P < 0.001), and Bachelor's degree (P < 0.001).
Existing beliefs
In considering a vision test, participants cite concerns about poor vision (n = 609, n = 59.5%) as the most probable reason for seeking an examination [Figure 1].
In terms of the parents' beliefs regarding eye health, the participants' educational attainment was found to be statistically correlated. A significant trend toward increase in children undergoing vision screening with increase in educational attainment was observed (P < 0.001) [Figure 2]. | Figure 2: Effect of parental educational attainment on obtaining vision tests for their children
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Eye health beliefs were also found have a significant association with the city of the participants (P = 0.015) where the belief system in Central City had the highest average score of 3.09 ± 2.2. Nevertheless, it should be noted that residents from other cities were underrepresented in this study where, Northern (3.5%), Eastern (5.8%), and Southern (3.9%) residing participants combined barely surpassed one-tenth of the population.
The history of wearing of spectacles and the presence of amblyopia or esotropia (eye turn) in first-degree family members is significantly associated with both the parents' concern for their child's eye vision (P < 0.001) and the child having received a vision test (P < 0.001) [Figure 3]. There is an observed increase in parental concern and the number of children tested from nearly a quarter (23.6% and 24.3%, respectively) when there is no family history of vision problems to three-fourths (75.3% and 75.7%, respectively) in the presence of family member with a history of vision problems. | Figure 3: Effect of positive family history of vision problems on parental eye care seeking behavior
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With respect to the age of the children, there was a significant mean difference (P < 0.001) found when the response of the parents who reported to have concern with their child's eyes was compared to the response of those parents who were not concerned.
Possible barriers
The most apparent barrier to obtaining an eye examination is the parent's lack of information on how to and where to arrange an appointment for an eye test [Figure 4].
The current educational level of the child is correlated to barriers from seeking eye test (P < 0.001). Furthermore, children who do not attend primary school are significantly more hindered in availing eye examinations as compared to students in the preprimary (P = 0.027) and primary (P < 0.001) school level with the lowest barrier mean (1.47 ± 0.9) at the highest educational level of primary school. The educational level attained by the parents is also found to be significantly and inversely correlated to the barriers in seeking eye test (P < 0.001).
| Discussion | | |
This study highlights parents' conception, concerns and challenges in seeking eye care for their young children. We found the majority 57.9% of parents reported that vision screening did not take place in their children's schools. Just over half of the parents reported that their children had never undergone an eye examination before. The most common reason to seek eye care would be for concerns over poor vision. The most common barrier to accessing eye care was not knowing how to access an eye test for their child.
Among the 1023 children of the participants, majority (60.9%) have not taken any form of eye or vision test. Closely similar to this result, an Indian research on parent's perception and awareness of children's eye care revealed that greater than half of the parents did not exhibit eye care-seeking behavior for their children.[10] Likewise, a descriptive study from Swaziland, Africa, reported that the majority (60.1%) of participating parents have not taken their offspring to any form of eye examination.[11] In Saudi Arabia, a study on amblyopia awareness also showed majority (n = 989, 60%) of the respondents have not taken their child for a comprehensive eye examination.[8] Meanwhile, one study reported a different result with (52.6%) of parents claiming to have taken their child to an eye test as opposed to the 34.0% who did not.[9]
In regard to the parent's awareness of a routine vision screening program in school, majority (65.6%) of parents whose child are 3-year-old and above were unaware of these services. Similar cases of unaware parents were reported in London where only 15% of 249 reported knowledge of the vision screening taking place for school entry.[4] In Qassim Province of Saudi Arabia, more than three-fourths (86.7%) of participating parents were also uninformed of the vision screening programs in their child's respective school health units.[12]
The majority of children ages 3 years and above underwent vision screening in their Grade 1 primary school (n = 28, 45.2%) while students who had their first vision screening done during preprimary school (n = 28, 32.3%) cited kindergarten (n = 11, 68.8%) as the specific grade level. This is in agreement with a study from Mississippi, the USA, stating from 3 to 6 years of age where the child would be in preprimary and early primary grade level as the year the student had their first eye examination.[13]
Majority of the participants had no experience of being rejected in availing an eye examination (n = 906, 88.6%). However, a quarter (n = 4, 25%) of those who were rejected cites the lack of specialization or equipment and having a very young patient as the reason. Donaldson et al.[4] also mentioned a previous study citing 50% examination rejection rate for eye patients that are 1-year-old presumably due to the parents' unfamiliarity with where to avail of the services of an accredited pediatric eye specialist.
In considering a vision test, participants cite concerns about poor vision as the most probable reason for seeking an examination. The 72 (7%) participants who chose “others” specified child complaint and long exposure to electronic devices as the reasons for seeking eye examination. A study involving young children in London also reports more than two-thirds (67%) of parents' concern about poor vision as the rationale to seek eye care.[4] Meanwhile, two African studies mention that most parents seek eye care only when there is an apparent problem or a child complaint[14] and that poor vision is a common effect of watching television.[11]
In our study, the most apparent barrier in obtaining an eye examination is the parent's lack of information on how to and where to arrange an appointment for an eye test. One study from the United Kingdom contradicts this reporting 62% of the participants experiencing no hindrances in obtaining eye care.[4] However, compliant to the results of this study, not seeing the need for a vision examination is one of the top reasons preventing parents. For instance, in Nigeria,[15] almost 60% of both fathers and mothers report not taking their child to have an eye examination because it was not necessary. In an Indian study,[16] half (50.9%) of parents mentioned their child having no eye problem and sees no need to seek an eye examination. A study by Baashar et al.[9] in Saudi Arabia supports these claims with data showing that parents find eye examination as unnecessary (61.9%), are unaware that their child may need an examination (52.6%) and are uninformed of where to find eye care clinics (15.5%).[9] Specifically, participants are misinformed about the services offered at local hospitals and primary care centers (37.5%), use of spectacles (43.6%), occurrence of eye turn (48.3%), and school vision screening tests (43.0%). The lack of knowledge about eye care is prevalent in the global setup where in Africa,[11] majority of parents admitted to being unfamiliar about childhood eye conditions. In India,[16] only 24.9% of the participants in a study possessed adequate knowledge and in a research from Saudi Arabia[9] a mean score of 2.03 ± 1.69 out of a maximum of 7 was obtained for parent's understanding of children eye care. Correlations between parental knowledge, parental beliefs, and access barriers and the demographic characteristics of both the child and the parent were evaluated. Similar to our study, Londin and Puerto Rico indicated 50% and 40%, respectively, of child's eye care attendance failure was due to the patient being too young.[4],[17]
There is an apparent doubling in percentage of tested children from those who are enrolled in preprimary school to those enrolled in primary school. A similar increase in number of examined children has been observed in Saudi Arabia, primarily due to the mandatory eye screening on enrollment.[12]
This result is shared in the study of Sukati et al.[11] in South Africa, and Baashar et al.[9] in Saudi Arabia stating that there is no significant difference in knowledge of different levels of parent's education. Interestingly, in our study, the level of parents' educational attainment significantly determines whether or not their child has had an eye examination. A large disparity was found in the eye-testing experience of children whose parents have the least educational background (tested = 33.3% vs. not tested = 66.7%). This result differs from studies done in Africa where the parent's educational status has no significant effect on the attitude of having eye tests.[11],[15]
Parents having less than high school educational achievement are significantly more likely to face hindrances in seeking eye care. A multiple study review done by Ntsoane and Oduntan[14] presumes that parents' educational achievement is linked to the socioeconomic class of the family. This implies that parents with low educational level are members of lower socioeconomic class and are less likely to seek eye care.
The majority of both concerned and unconcerned parents and of both tested and untested children reported having a family history of vision defects. There is an observed increase in parental concern and number of children tested from nearly a quarter when there is no history of vision problems to three-fourths when there is a history of vision problems. Sukati et al., had a similar report stating that there is an increased likelihood of being tested when there is an immediate family member wearing glasses.[11] With respect to the age of the children, there was a significant mean difference (P < 0.001) found when the response of the parents who reported to have concern with their child's eyes was compared to the response of those parents who were not concerned.
A potential limitation in our present study is the random sampling potentially leading to selection bias. However, this study includes a large representative sample from different regions of Saudi Arabia, good response rate, and is one of few studies that shed light on the possible barriers encountered by caregivers in our region. Knowledge of these barriers can help service providers plan strategies to improve childhood eye care provision and access.
| Conclusion | | |
This study has provided evidence on the lack of awareness of importance of eye care and barriers to access in Saudi Arabia. Efforts should be made to address the barriers faced by the families. Public-based campaigns targeting caregivers and schools to educate the parents and education providers are needed. It should also be made mandatory by the ministry of health that all children submit to a vision check before school enrollment.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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