See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/359437168

Awareness and knowledge about refractive errors and strabismus in South

Indian population

Article in International Journal of Community Medicine and Public Health · March 2022

CITATIONS READS

0 81

4 authors, including:

Srinivasa Pallerla Rohit C Khanna

Andhra Pradesh Right To Sight Society L V Prasad Eye Institute
4 PUBLICATIONS 0 CITATIONS 165 PUBLICATIONS 6,858 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

LVPEI-GLEAMS View project

Methodology to investigate the impact of blindness control activities in the southern Indian population View project

All content following this page was uploaded by Srinivasa Pallerla on 24 March 2022.

The user has requested enhancement of the downloaded file.

International Journal of Community Medicine and Public Health
Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317
http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20220688
Original Research Article

Awareness and knowledge about refractive errors and strabismus in

South Indian population
Srinivasa Reddy Pallerla1*, Rohit C. Khanna2, S. Krishnaiah2, Jill Keeffe2

1
Andhra Pradesh Right to Sight Society, Hyderabad, India
2
LV Prasad Eye Institute, Hyderabad, India

Received: 09 November 2021

Accepted: 18 December 2021

*Correspondence:
Dr. Srinivasa Reddy Pallerla,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: To assess the awareness, knowledge about refractive errors and strabismus among the general public in
southern Indian states of Andhra Pradesh and Telangana.
Methods: A cross sectional population-based survey used a semi structured questionnaire on awareness, knowledge
on refractive errors and strabismus done as part of knowledge, attitude and practices study (KAP). Stratified
multistage cluster random sampling method was used with a sample size of 867 adults- ≥16 years. Having heard of
refractive error and strabismus was defined as awareness and having knowledge of the type of error for which
spectacles were worn, was considered as knowledge. A pilot study was conducted to validate the questions used in the
main study. Statistical package SPSS (version 19) was used for analysis to calculate logistic regression and odds
ratios for gender, age, education and urban-rural areas.
Results: A total of 782/867 (90.1%) subjects participated in the survey with females 47.4%. 581 subjects (74.3%)
were aware of refractive error. 690 subjects (88.2%) were aware of squint. With multiple logistic regression about
awareness of refractive error to various variables, subjects who were educated 11 th class to degree had a higher
awareness (OR: 2.40; CI: 1.25-4.60). With multiple logistic regression about awareness of squint to various variables,
females had a higher awareness of squint (OR: 1.98; CI: 1.19-3.31).
Conclusions: Awareness of squint and refractive error was high among the general public, but the knowledge of it
was limited.

Keywords: Awareness, Knowledge, Refractive errors, Squint, General public

INTRODUCTION availability and non-affordability of the pediatric eye care

services, and the cultural disincentives to compriance.4
Awareness and knowledge of common eye diseases play Uncorrected RE’s can result in amblyopia and strabismus.
an important role in encouraging people to seek treatment It can restrict progress in education, limit career
for eye problems.1 Global estimates indicate that more opportunities and restrict access to information. 5 Hence it
than 2.3 billion people in the world were suffering from is essential to understand the awareness levels in the
poor vision due to refractive error (RE). 2 RE’s are the community to plan effective eye care programs to deal
most common forms of eye disorders that result in poor with the problem. A RE can simply be diagnosed, and
vision and have several social and economic implications treated with aid of optical corrective approaches and
if uncorrected.3 Uncorrected RE’s is one of the major devices such as spectacles, contact lenses or refractive
causes of avoidable blindness and low vision. A number surgical procedures.6 Despite this, an estimated 670
of factors are responsible for uncorrected RE’s. They are million people worldwide do not have spectacles or have
the lack of awareness of the problem, inability to inadequate correction. Current data suggests that more
recognize the problem at personal and family level, non- than 90% of people with uncorrected RE, worldwide,

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1312
 Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317

reside in rural and low income countries7. In the past a respond to the questions narrated by the investigator in
series of studies using a survey methodology referred to the local language. Having heard of refractive error and
as refractive error study in children (RESC), were strabismus (squint) was taken as ‘awareness’ and having
performed in populations with different ethnic origins and understanding of its effect on vision as ‘knowledge’.
cultural settings: a rural district in Eastern Nepal; a semi-
rural country outside of Beijing, China; an urban area of A pilot study was conducted before the main study. The
Santiago, Chile; an urban and semi-rural area of Cronbach’s Alpha for the questions on awareness,
Kwazulu-Natal, South Africa; a rural district near knowledge refractive error and strabismus was 0.14 (95%
Hyderabad India; and urban area of New Delhi India. 8-11 CI; 0.0, 0.40). With the experience garnered in pilot
These studies have confirmed that the need for RE study, questions were modified so that they were easily
correction is higher for children. Result shown in the understood in the local language without losing the
studies indicates that RE in children causes upto 77% of meaning. The data were entered in excel and statistical
blindness and severe visual impairment (<6/60 in better package SPSS version 19.0 was used for data analysis.
eye) in India, 75% in China, and 62.5% in Chile. RE is The multiple logistic regression was used to ascertain the
the cause of visual impairment (<6/12 in the better eye) in association between awareness and knowledge to
83% of children in urban India, 70% in rural India, 93% individual characteristics-age, gender, education level,
in China, 55.1% in Nepal, 55% in Chile, and 63.6% in urban and rural, and occupation. All p values are reported
South Africa.8-11 Of these cases 86% of children in rural and significance level was p<0.05.
India presented without correction for RE, 92% in Nepal,
58% in China, 46% in Chile, and 71% in South Africa. RESULTS
Lack of awareness of RE’s was one of the barriers for
uncorrected refractive errors and presbyopia lack of A total of 782/867 (90.1%) subjects participated in the
awareness and recognition of RE’s as correctable cause of survey with females 47.4% (Table 1). Out of 782 subjects
vision impairment was one the important barriers for participated 581 (74.3%) were aware of refractive error.
correction of RE.12,13 Among 581 subjects 277 (47.6%) were females (Table 2).
Among the 581 who were aware of RE 267 (45.9%) were
METHODS wearing glasses, 201 who were not aware of RE 54
(26.8%) were wearing glasses (Table 5). With multiple
The detailed methodology followed was published earlier logistic regression about awareness of refractive error to
Pallerla et al.14 The study was approved by the ethics various variables, subjects who were educated 11 th class
committee of LV Prasad eye institute as part of KAP on to degree had higher awareness (OR: 2.40; CI: 1.25-4.60)
eye health and diseases among general public in the South (Table 3).
Indian states of Andhra Pradesh and Telangana and was
conducted in accordance with the principles of Out of 782 subjects participated 696 (89.0%) were aware
Declaration of Helsinki. Briefly the survey was based on of strabismus. Out of 696 subjects 341 (48.9%) were
stratified multistage, cluster sampling strategy. This was a females (Table 2). Among 696 subjects who were aware
cross sectional study of people from one urban and three of strabismus, 294 (42.2%) were wearing glasses. 86
rural areas of the both the states of Andhra Pradesh and subjects who were not aware of strabismus, 29 (33.7%)
Telangana with the aim of having study sample were wearing glasses (Table 5). With multiple logistic
representation of urban and rural districts of both the regression about awareness of squint to various variables
states of Andhra Pradesh and Telangana. females had a higher awareness of squint (OR: 1.98; CI:
1.19-3.31) (Table 4).
The study was conducted on adult population of > 16
years of age. A structured questionnaire was designed in Of the 777 subjects responded to the question whether
order to get information related to awareness and they wearing glasses or not, 325 (41.8%) were wearing
knowledge of refractive error and strabismus. The glasses, out of which 133 were wearing for distance, 82
Questionnaire had two sections. The first section for, near, 98 for both distance and near vision and 12
contained questions on Awareness of eye diseases subjects reported they didn’t know what for they were
including refractive errors and strabismus. The second wearing glasses. Among the spectacle wearers highest
section had questions on the demographic profile of the percentage of age group was seen in >70 years of age
subjects. The subjects were given the questionnaire to fill (68.2%) followed by 40-69 age group (42.8%) and 16-39
in and if the subject was illiterate, he or she was asked to age group (38.7%).
Table 1: Demographic profile of study participants, (n=782).*

Variables Agriculture Business Student Employee Labourer Housewife Others Total

Age group (Years)
16-39 80 15 103 60 124 24 1 407
40-59 72 4 0 51 98 24 0 249
>60 48 1 1 7 60 5 2 124
Continued.

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1313
 Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317

Variables Agriculture Business Student Employee Labourer Housewife Others Total

Gender
Male 107 19 70 91 120 0 3 410
Female 93 1 34 27 162 53 0 370
Education
Illiterate 80 0 0 5 124 10 0 219
1-10th class 117 4 6 19 140 31 1 318
>11th class 3 16 98 94 18 12 2 243
Location
Urban 2 19 70 82 5 37 2 217
Rural 198 1 34 36 277 16 1 563
*Data from two participants missing

Table 2: Awareness of the refractive error and squint, (n=768).

Variables Total responses Awareness of refractive error/squint (%)

Age group (Years)
16-29 219 180 (82.2) 202 (92.7)
30-39 180 134 (74.4) 167 (89.8)
40-49 139 103 (74.1) 122 (87.8)
50-59 105 80 (76.2) 97 (91.5)
60-69 83 58 (69.9) 72 (87.8)
> 70 42 26 (61.9) 36 (83.7)
Gender
Male 405 304 (75.1) 355 (87.4)
Female 363 277 (76.3) 341 (92.7)
Education
Illiterate 212 149 (70.3) 195 (90.3)
1st to 5th 104 77 (74.0) 92 (86.8)
6th to 10th 209 143 (68.4) 186 (88.6)
11th to degree 216 187 (86.6) 197 (92.1)
Masters and above 25 23 (92.0) 24 (92.3)
Area
Urban 216 182 (84.3) 195 (90.3)
Rural 552 399 (72.3) 501 (89.8)
*number of subjects responded for awareness of refractive error and squint
Table 3: Multiple logistic regression showing association between awareness of refractive error and various
variables, (n=782*).

No. of aware of Odds ratio for being aware of

Total responses for
Variables refractive error (% refractive error multiple logistic P value
refractive error
in parenthesis) regression; 95% CI
Age group (years)
16-29 219 180 (82.2) 1.00/1.00
30-39 180 134 (74.4) 0.86; 0.51-1.45 0.59
40-49 139 103 (74.1) 0.87; 0.50-1.51 0.62
50-59 105 80 (76.6) 1.04; 0.56-1.94 0.88
60-69 83 58 (69.9) 0.77; 0.40-1.46 0.42
> 70 42 26 (61.9) 0.56; 0.26-1.22 0.14
Sex
Men 405 304 (75.1) 1.00/1.00
Women 363 277 (76.3) 1.31; 0.92-1.86 0.12
Education
Illiterate 212 149 (70.3) 1.00/1.00
1st to 5th class 104 77 (74.0) 1.18; 0.69-2.01 0.53
6th to 10th class 209 143 (68.4) 0.87; 0.56-1.34 0.54
11th to degree 216 187 (86.6) 2.40; 1.25-4.60 0.008
≥Masters 25 23 (92.0) 4.21; 0.91-19.41 0.06
Continued.

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1314
 Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317

No. of aware of Odds ratio for being aware of

Total responses for
Variables refractive error (% refractive error multiple logistic P value
refractive error
in parenthesis) regression; 95% CI
Area
Urban 216 182 (84.3) 1.00/1.00
Rural 552 399 (72.3) 1.18; 0.70-2.00 0.52
(Hosmar Lemeshow goodness of fit test=0.94), *14 subjects non respondents.

Table 4: Multiple logistic regression showing association between awareness of squint and various variables,
(n=782*).

No. of aware of Odds ratio for being aware

Total responses for
Variables squint (percentage in of squint multiple logistic P value
squint
parenthesis) (%) regression; 95% CI
Age group (years)
16-29 218 202 (92.7) 1.00/1.00
30-39 186 167 (89.8) 0.77; 0.36-1.62 0.49
40-49 139 122 (87.8) 0.66; 0.30-1.42 0.28
50-59 106 97 (91.5) 1.06; 0.42-2.68 0.89
60-69 82 72 (87.8) 0.63; 0.25-1.58 0.32
>70 43 36 (83.7) 0.52; 0.18-1.45 0.21
Sex
Men 406 355 (87.4) 1.00/1.00
Women 368 341 (92.7) 1.98; 1.19-3.31 0.008
Education
Illiterate 216 195 (90.3) 1.00 / 1.00
1st to 5th class 106 92 (86.8) 0.66; 0.32-1.38 0.28
6th to 10th class 210 186 (88.6) 0.83; 0.44-1.59 0.59
11th to degree 214 197 (62.1) 1.54; 0.61-3.83 0.35
≥ masters 26 24 (92.3) 1.60; 0.31-8.12 0.57
Area
Urban 216 195 (90.3) 1.00/ 1.00
Rural 558 501 (89.8) 0.75; 0.37-1.54 0.44
Hosmar Lemeshow goodness of fit test=0.60, * Totals may not add to as some subjects didn’t respond.

Table 5: Association of awareness of refractive error and squint to wearing of glasses and eye examination, (n=782).

Awareness of refractive error Awareness of squint

Variables
Yes (n=581*) No Yes (n=696*) No
Wearing of glasses
Yes 267 54 294 29
No 312 132 401 48
Eye examination in the last 2 years
Yes 270 64 305 31
No 287 111 357 46
* The total does not add as some subject did not respond.

DISCUSSION strabismus. People with higher education had a higher

awareness of both refractive errors and strabismus. There
This study examined the awareness and knowledge of was no difference in the awareness levels of location of
adults in urban and rural areas. The study was undertaken the participants either urban and rural.
as part of KAP study to identify information that could
help in formulating strategies to increase the awareness The awareness levels (74.3%) of RE in the present study
levels of refractive error, strabismus and amblyopia. The is comparable to the study done by Chew et al (75.3%),
results of this study show that the majority of participants and Aldebasi.1,15 There should be emphasis on public
were aware of refractive error and strabismus. education on awareness and significance of early
detection of refractive errors. The awareness levels of
In this study it was found that younger people and strabismus is high in the present study. Females had a
females were more aware of the refractive errors and higher awareness of strabismus in the present study

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1315
 Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317

similar to the other studies done elsewhere.16 In a study 3. Bourne RR, Dineen BP, Huq DM, Ali SM, Johnson
done by Hegde et al the awareness of squint was 90% GJ. Correction of refractive error in the adult
among the patients attending the eye camps in rural population of Bangladesh: meeting the unmet need.
India.17 This will help in early detection and treatment of Invest Ophthalmol Vis Sci. 2004;45:410-17.
RE, strabismus and amblyopia thereby reducing the 4. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP.
prevalence of strabismus and amblyopia in children and Global magnitude of visual impairment caused by
consequently improve the educational opportunities and uncorrected refractive errors in 2004. Bull World
their quality of life. There are limitations to this study that Health Organ. 2008;86:63-70.
need to be considered when interpreting the results. Self- 5. Shrestha GS, Digen Sujakhu, Joshi P. Refractive
reporting of the data can be influenced by recall bias. For error among school children in Jhapa, Nepal. J
those participants who were illiterate the interpreter Optom. 2011;4:49-55.
marked the responses. This may also can influence the 6. Kempen JH, Mitchell P, Lee KE, Tielsch JM,
information. Notwithstanding these limitations the results Broman AT. The prevalence of refractive errors
indicate that the study population had a high level of among adults in the United States, Western Europe,
awareness of refractive errors and strabismus, but their and Australia. Arch Ophthalmol. 2004;122:495-505.
knowledge was still limited. 7. World Health Organization. Director-General's
Office. Communications Office. Sight test and
One of the pre-requisites of health seeking behavior is glasses could dramatically improve the lives of 150
knowledge of disease and their symptoms which seems to million people with poor vision. Geneva: World
be lacking in parents of children.18 Hence the programs to Health Organization. 2006;2.
increase awareness of causative factors, spectacle wearing 8. Zhao J, Pan X, Sui R, Munoz SR, Sperduto RD.
and the harmful effects of squint should be conducted. Refractive Error Study in Children: results from
The lack of knowledge and awareness of refractive errors Shunyi District, China. Am J Ophthalmol.
are important risk factors for under corrected refractive 2000;129:427-35.
error in an urban Singapore population.19 A study done by 9. Naidoo KS, Raghunandan A, Mashige KP, Govender
Ranjbar et al studied at major deficiencies in the public P, Holden BA. Refractive error and visual
awareness about the role of ophthalmologists as well as impairment in African children in South Africa.
refractive error correction methods in Iran.20 Invest Ophthalmol Vis Sci. 2003;44:3764-70.
10. Dandona R, Dandona L, Srinivas M, Sahare P,
CONCLUSION Narsaiah S. Refractive error in children in a rural
population in India. Invest Ophthalmol Vis Sci.
Awareness of squint and refractive error was high among 2002;43:615-22.
the general public, but the knowledge of it was limited. 11. Murthy GV, Gupta SK, Ellwein LB, Munoz SR,
Pokharel GP. Refractive error in children in an urban
ACKNOWLEDGEMENTS population in New Delhi. Invest Ophthalmol Vis Sci.
2002;43:623-31.
Author would like to thanks to support from the midlevel 12. Marmamula S, Khanna RC, Shekhar K, Rao GN. A
ophthalmic personnel, Asha workers (female health population-based cross-sectional study of barriers to
assistants) working in the ministry of health and family uptake of eye care services in South India: the Rapid
welfare, government of Andhra Pradesh and Telangana in Assessment of Visual Impairment (RAVI) project.
helping to carry out the study in remote rural areas of BMJ Open. 2014;4:e005125.
both the states. 13. Yasmin S, Minto H. Community Perceptions of
refractive errors in Pakistan. Comm Eye Health.
Funding: Funding sources by Andhra Pradesh Right to 2007;20:52-3.
Sight Society and Government of Andhra Pradesh 14. Pallerla SR, Khanna RC, Sannapaneni K, Keeffe J.
Conflict of interest: None declared Public knowledge, attitudes and practices related to
Ethical approval: The study was approved by the eye diseases in Southern Indian population. Int J
Institutional Ethics Committee Community Med Public Health. 2020;7:4993.
15. Aldebasi Y. Young Public's Awareness to Refractive
REFERENCES Error Deficiency. Int J Health Sci (Qassim).
2011;5:9-15.
1. Chew YK, Reddy SC, Karina R. Awareness and 16. Isawumi MA, Ulaikere M, Adejumo OO, Adebayo
knowledge of common eye diseases among the M, Kekunnaya R. Awareness, perceptions and
academic staff (non-medical faculties) of University knowledge of strabismus among patients visiting a
of Malaya. Med J Malaysia. 2004;59:305-11. tertiary eye clinic in Southwest Nigeria. Int
2. Thulasiraj RD, Aravind S, Pradhan K. Spectacles for Ophthalmol. 2014;34:1037-42.
the Millions Addressing a priority of "VISION 2020 17. Hegde S, Mendonce N, Kamath BS, Vinay PG.
-The Right to Sight". Community Ophthalmol. Assessment of awareness and phychosocial impact of
2003;3:19-21. strabismus in rural India. IJBR. 2014;05:744-7.

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1316
 Pallerla SR et al. Int J Community Med Public Health. 2022 Mar;9(3):1312-1317

18. Senthilkumar D, Balasubramaniam SM, Kumaran Methods: A Population Based Study in Mashhad.
SE, Ramani KK. Parents' awareness and perception Patient Saf Qual Impro. 2013;1:23-9.
of children's eye diseases in Chennai, India. Optom
Vis Sci. 2013;90:1462-6. Cite this article as: Pallerla SR, Khanna RC,
19. Rosman M, Wong TY, Wong W, Wong ML, Saw Krishnaiah S, Keeffe J. Awareness and knowledge
SM. Knowledge and beliefs associated with about refractive errors and strabismus in South Indian
refractive errors and undercorrection: the Singapore population. Int J Community Med Public Health
Malay Eye Study. Br J Ophthalmol. 2009;93:4-10. 2022;9:1312-7.
20. Ranjbar AKSM, Pourmazar R, Gohary I. Awareness
and Attitude toward Refractive Error Correction

International Journal of Community Medicine and Public Health | March 2022 | Vol 9 | Issue 3 Page 1317

View publication stats