The compliance to spectacle wear was only 29.5% amongst the rural secondary school children and compared with 19.5% compliance from rural central India,[12
] 13.4% from Mexico,[9
] 30% from Baltimore USA[15
] and 37.7% from rural China.[6
] The compliance may have been low due to the surprise check as only those actually wearing the spectacles at the time of the visit were termed compliant. Therefore, this accurately gauged non-compliance. But, the free spectacles provided by ZP and DBCS were not used by most children.
The study has some limitations. Only ZP's program in 1 rural district was studied. The study excluded children who were out of formal schools and those in unaided and private schools. Hyperopia may have been underestimated as cycloplegic refraction, was not done on all children. The causes for non-wear were reported by the students who were around 10 to 12 years of age. We had to believe the child's word when they reported that they had the spectacles at home and also when they reported that they lost them.
We found boys to be more non-compliant in wearing spectacles, similar to observations from Mexico,[9
] and China.[6
] Perhaps it could be that the spectacles make the face look more studious and made the child stand out in the class, which may be more acceptable to girls. Or perhaps boys were engaged in more outdoor sports in rural areas. 15 children had their spectacles in the school bag, therefore, there was some parental pressure to use the pair of spectacles, but the children were not enamored about wearing them. 15.2% children not wearing the spectacles at the time of the visit, nonetheless, reported using them sometimes. This was akin to results from rural China where more than half the students reported that they used the spectacles occasionally or for special occasion.[6
These spectacles had been distributed 1 year ago, a shorter duration after dispensing may have shown a higher figure of compliance, but nearly half of the children who were not wearing the spectacles did not use them for more than 6 months. In most villages, the children and their parents had no access to refractive correction services; in case the child lost or broke his spectacles, it would be very difficult to get a replacement.
A Tanzanian study demonstrated that spectacles dispensed free of cost, as it under SSA, were used less as compared to those in which the recipients paid for them.[17
] A study from Mexico observed that older children were less likely to be complaint than younger ones as it was in this study, but the difference was not statistically significant.[9
] This was in variance with results from rural China where older children were less likely to be non-compliant to spectacle wear.[6
Children with less educated parents were more likely to be non-compliant to spectacle wear. Surprisingly, the effect of father's education was more pronounced than that of the maternal parent. This may be due to a patriarchal society or educated women having equal or more educated husbands. Children who were non-compliant with spectacles had an average academic score lesser than their compliant peers. But, there could be confounders for this, like more inclination and aptitude for studies amongst the compliant students, or even some studies have co-related myopia with higher measured IQ. Complaint students were also more highly myopic.
Children from larger villages or small towns were more non-compliant than those from smaller villages. Cosmetics may be less of an issue in small villages, or the teachers may have more authority, and there would not be any other refractive service available. In larger villages and small towns, children could be choosier about their spectacles.
A Mexican study also found the chief causes of non-wear to be lost/broken spectacles (14.0%), teased about spectacles (16.6%), forgot spectacles at home (16.6%) and used occasionally for special occasions (14.2%) like this study.[9
Another reason for non-compliance may be because no choice given to child while dispensing the spectacles. A one size fit all strategy was used. Children spectacle frames are not just miniature of adult frames, their esthetics (color, size, design) and needs are different, and do matter to even rural children. Also, something that was given free, like spectacles, was perceived as having very less value. The round ‘Harry Potter’ style frames may be popular in urban areas but were associated with ‘Gandhiji style’ spectacles in rural areas. They may be associated with old age and ancient things and were thus unfashionable amongst the students. The children were not happy about the quality of spectacles provided, they were certainly ‘ordinary’. The fitting and centration could have been better, which may have contributed to the complaints of discomfort and headache.
The children wearing spectacles were likely to be teased by peers as was seen in the Avon longitudinal study of parents and children in UK.[18
] The study found that more than a third (37%) of children wearing glasses reported that they had been subjected to verbal and some even to physical abuse. In this study, ‘teased by other children’ was the single most common cause of non-wear, similar to results from Mexico and Tanzania though it was reported by only 1/5th
of the children.[8
Small refractive errors (< 1.0D) might not be corrected as the children have reasonable uncorrected visual acuity and do not use the spectacles as much though 25% in the –0.50D to –1.9D category were compliant, and their myopia is very likely to increase.[19
] A balance has to be struck between unnecessarily concerning parents and the child feelings of guilt for not wearing spectacles, cost and the benefits of getting used to spectacles as a vision aid – a need that will certainly increase in such children. However, some program managers dispense more spectacles as they consider it a sign of success, with budgets spent and targets over-achieved. The program managers should also educate teachers, parents and even children, wherever possible, about the benefits of spectacle wear as that would improve compliance of wear.
In conclusion, while the free spectacle program within the rural districts of Pune ensured the accessibility to spectacle correction to school children, the compliance to wear was poor. The effectiveness of this program can be improved by providing a greater choice of spectacle frames, educating the benefits of correction to students and their parents and involving the teachers to improve compliance. Success of such programs should account for compliance and not just the delivery of spectacles only. 40% children were not compliant because they were teased about, did not like, or were not comfortable in their spectacles – all societal issues that could and should be addressed.