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Knowledge towards Strabismus and Associated Factors among Adults in Gondar Town, Northwest Ethiopia.

1. Introduction

Eyes are well aligned, so the foveae (corresponding retinal focus point) are aimed at the same visual target; this is termed as orthophoria. Due to different factors, eyes are deviated from its normal position, alternatively termed as strabismus, squint, oblique eye, or heterotropia. These terms come from the fact that strabismic patients often squint one eye to block out one of the two images that they see. Therefore, strabismus is an ocular misalignment in a different direction of gaze, or the eyes are not properly aligned with each other, whether caused by abnormalities in binocular vision or by anomalies of neuromuscular control of ocular motility [1-4].

Globally, the prevalence ranges from 2 to 6% [5-7]. The prevalence of strabismus was found to be 3.3% in whites, 2.1% in African American children [8], 1-4% in African [9-12], 2.4% in UK, [7] 2% in south East Iran [13], 3.1% in Sweden, [7] 5% in Saudi Arabia [14], 2.8% in Australia [7], 5.9% in Tanzania [10], 2.8% in Sudan [11], and 1.53% in Ethiopia [12].

Strabismus can develop at any age but usually develops during childhood, before 6 years of age; the peak age of onset is around 3 years. Strabismus in adulthood frequently occurs secondary to either systemic disease or mechanical damage such as trauma or brain tumor [15, 16].

The risk factors of strabismus are uncorrected refractive error, maternal health, premature birth, low birth weight, developmental delay, syndromes (a group of disease), genetic factors, systemic illnesses, and mechanical agents [16, 17].

Strabismus can be managed with eyeglasses, prisms, surgery, eye exercises, and medicines [16]. If left untreated, it results in abnormal fixation, double vision, abnormal head posture, and lazy eye (amblyopia). Untreated strabismus can also cause psychosocial effects, low performance in school, loss of confidence and self-esteem, and inability in employments and social stigma [18, 19].

In order to tackle such problems, parents/guardians should have good knowledge of the nature of strabismus/ squint because most of them do not know the appropriate and effectiveness of the treatment [9, 20].

Studies conducted in different regions of the world showed that there is a knowledge gap about strabismus. In India, 94.7% of participants had knew the consequence of strabismus [21], in Jeddah, 75% of participants knew etiologies [22], in Nigeria, 50% of participants did not know strabismus [23], and in Ethiopia, only 37.2% knew the cause of strabismus [9].

There were studies conducted on the prevalence and psychological effects of strabismus. Knowledge among adults towards strabismus is critical for children's health because it is important for early prevention of visual impairments, to decrease psychological trauma, to lessen the economic burden, to avoid social stigma, and to minimize poor school performance and unemployment. Despite all these uses, little is known about strabismus in Ethiopia in general and in the study area specifically. So, this study can give baseline information on strabismus and associated factors.

2. Materials and Methods

2.1. Study Design and Period. A community-based cross-sectional study was conducted from April 17 to May 01, 2019.

2.2. Study Setting. The study was conducted in Gondar town. Gondar town is located in Northwest Ethiopia. It is located 748 km from the capital, Addis Ababa, and 182 km from Bahir Dar, the capital of Amhara National Regional State. According to Gondar town statistics agency, 2016/17 projection has a population size of 351,675, out of which 168,993 are males and 182,682 are females. According to North Gondar information and statistics agency, the town is subdivided into 6 subcities and 24 city kebeles, holding approximately 53,725 households. The health coverage was 30% in 2007 [24]. There is one government hospital, University of Gondar Tertiary Eye Care and Training Centre (UoGTETC), which provides different specialty eye care services and give training for ophthalmologists, optometrists, and ophthalmic nurses. In the town, there are three private eye care clinics.

2.3. Sample Size and Sampling Technique. A total of 593 samples was determined using single population proportion formula by assuming 95% confidence level, 5% margin of error, 10% nonresponse rate, design effect 1.5, and the proportion of good knowledge from a similar study conducted in central Ethiopia, Cheha district (37.2%) [9].

A multistage sampling technique was employed. Six kebeles were selected from 24 kebeles by a simple random sampling technique. In selected kebeles, there were 189, 675 adult populations and 12,952 households. Proportion allocation was used to determine the sample size in each kebele. Households in each kebele were selected by a systematic random sampling method using a sampling fraction (K) of 22. One adult was selected using a lottery method from one household if there were two or more adults per household to obtain a final sample. All adults aged [greater than or equal to] 18 years had an equal likely chance to participate in this survey. Nevertheless, those adults who had a mental illness and unable to speak were excluded.

2.4. Data Collection Tool and Procedure. Data were collected through face-to-face interviews, using a pretested structured hard copy questionnaire. It has questions for sociodemographic characteristics, past ocular history-related factors, source of information socioeconomic factors, and knowledge-related questions such as definition, risk factor, treatment, and consequence of strabismus after reviewing the related literature.

The original questionnaire was translated from English to Amharic version and then translated back to English by two independent local language translators to maintain its consistency and accuracy. The interview was conducted by 8 BSc nurses.

2.5. Operational Definitions

2.5.1. Knowledge. The knowledge of respondents was assessed through different dimensions of strabismus, including definitions, causes, treatment, and consequences that scale up 28 points. Each correct response scored as 1 and the incorrect one was coded as 0 (zero).

(1) Good Knowledge. Respondents who answered greater than or equal to the median score of knowledge-related questions were said to have good knowledge, otherwise, poor knowledge.

(2) Adults. Individuals with age of 18 years and older [25].

(3) Role in the Community. Those participants having responsibility and in position in a local area such as kebele leader and religious leader.

2.6. Data Quality Control. The training was given for data collectors before the beginning of data collection. The questionnaire was pretested on 5% of the sample size outside the study area. Also, data clean up, checking for data completeness, outliers, and missing values, and supervision were carried out.

2.7. Data Processing and Analysis. Data from the entire questionnaire were coded, entered into Epi info version 7, and exported to SPSS version 20 for processing and analysis. Frequency, statistical summary, and cross-tabulations were used for the descriptive analysis of the entered data. Binary logistic regression was used to identify factors associated with knowledge about strabismus. All the variables were entered into multivariable logistic regression, and P value <0.05 was taken as statistically significant. The model fitness was checked according to Hosmer and Lemeshow goodness of fit. Finally, the analyzed result was presented using tables and charts.

2.8. Ethical Consideration. Ethical clearance was obtained from University of Gondar College of Medicine and Health Sciences, School of Medicine, ethical review committee. After informing about the objective of the study, verbal informed consent was obtained from each study participant. The questionnaires did not require the identifiers of the participants. Confidentiality of the information obtained was assured and maintained anonymous. Participants who had strabismus or any vision threatening eye problems were strongly advised to visit Gondar University Tertiary Eye care and Training Center Hospital. The collected data were securely locked.

3. Results

3.1. Sociodemographic Characteristics of the Study Participants. A total of 553 among 593 participants who were living in Gondar town took part in the study with a response rate of 93.25%.

Of the total participants, 53.7% (297) were males. The median age of the study participants was 33 (IQR =14) years. Most (81.4% (450)) of the study participants were orthodox Christian. Half (50.7% (305)) of the participants were employed. Of the total participants, 39.8% (308) were married. The median monthly income was 3800 ETB (IQR = 2500, Q1 = 2500, Q3 = 5000). More than half (65.3% (393)) of the participants had an education level of college and above (Table 1).

3.2. Proportion of Knowledge towards Strabismus among Study Participants. Out of 553 study participants, 52.30% (289) (95% CI: 47.9-56.4) had good knowledge about strabismus.

Among study participants who had heard about strabismus, 15 (2.7%) did not know what strabismus is. Of the study participants, the most perceived definition, cause, treatments, and consequences of strabismus were as follows: two eyes not coordinated, 72.0% (398), exposure to sunlight/ lamp, 66.4% (367), surgery, 57.1% (316), and poor cosmoses, 82.1% (347), respectively (Table 2). The most frequently mentioned source of information was from families/relatives, 42% (232), followed by radio/television, 37.4% (207), and the least one was from Internet, 15.65% (86) (Figure 1).

3.3. Factors Associated with Level of Knowledge towards Strabismus. The result of multivariable logistic regression showed that occupations and monthly income were significantly associated with knowledge about strabismus.

Those participants who were students were 2.15 times more likely to have good knowledge than those who were employed (AOR = 2.15, (95% CI: 1.11-4.13). Participants who earn a monthly income of >5000 birr were 54% less likely to have good knowledge about strabismus as compared to those who get <2500 birr (AOR = 0.48, (95% CI: 0.26-0.46)) (Table 3).

4. Discussion

This is perhaps the first study in the Amhara region and the second in Ethiopia to estimate the level of knowledge among adults towards strabismus in Gondar town, Northwest Ethiopia. In this study, 553 participants were included, of whom 52.3% (95% CI: 47.9-56.4) of participants had good knowledge regarding strabismus. This result was higher than a study conducted in Cheha district of Central Ethiopia (37%) [9]. This may be due to the difference in sociodemographic characteristics of the participants since 51.7% of participants were illiterate in Cheha study but only 9% of this study participants were illiterate [9]. On the contrary, the current study finding was lower than a study conducted in Kenya (69.60%) [26]. This discrepancy may be due to the difference in study population, which was only health profession for the study in Kenya and all adults in the community in this study.

Regarding different dimensions of strabismus, proportions of participants' knowledge about the alternative definitions (43-72%), causes (15-30%), treatments (39-57%), and consequences (29-82%) were higher than in a study conducted in Cheha district, central Ethiopia, showing knowledge about the causes (4.3-37.2%), treatments (32%), and consequences (3.8-43%). This study result is also higher than a study conducted in Nigeria (46%) [23]. This may be due to the difference in the study population who were agrarian and rural dwellers, which made them less aware of strabismus. However, this finding was lower than a study conducted in Jeddah (60-79%), India (94.7%), and Saudi (66.7%) [21,22, 27]. This is due to the difference in the study setting since these studies were hospital-based.

Participants who had monthly income >5000 birr were 54% less likely to have good knowledge as compared to those who had <2500 birr. This may be due to those having a high amount of monthly income such as merchants (46.42%) who might work for long hours, which may hinder them to access available information. Participants who were students were 2.15 times more likely to have good knowledge than those who were government employees. This may be due to students who were observed in this study who used a different source of information such as the Internet and mass media, which help them to get more knowledge about strabismus.

Source of information was an extremely important dimension that should be considered while designing relevant preventive or screening programs. Gaining knowledge from the relative (38.5%) or friends (37.5%) was the predominant source of information about strabismus. Interestingly, the Internet and radio/TV constituted a considerable proportion of reliable knowledge sources. This may be due to the messages delivered through radio/TV in a coherent and scientific manner. This was typically consistent with another study in India, Saudi, and Jeddah [21, 22, 27], in which both radio/TV and the Internet were the reliable sources of knowledge than relatives/friends.

Regarding factors, some studies did not analyze the association between all presumed factors and the overall knowledge level, rather to different dimensions of knowledge about strabismus. For example, in Cheha district, Central Ethiopia [9], age and educational status were significantly associated with the knowledge of treatment but not to the causes of strabismus. This makes a comparison of this study results with other studies difficult since the association between the overall knowledge and different factors is considered in this study.

5. Conclusion

The overall knowledge score of the study participants was moderate. More than half of the study participants had good knowledge about strabismus. It was found that being a student and having high monthly income had a statistically significant association with knowledge about strabismus. Since the type and source of information were extremely important for reliability and the level of knowledge, it is better to improve the availability of media coverage such as radio, TV, and Internet.

Data Availability

All necessary data are included within the manuscript.

Conflicts of Interest

The authors declare that they have no conflicts of interest.


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Aragaw kegne Assaye [ID], Melkamu Temeselew Tegegn [ID], Natnael Lakachew Assefa [ID], and Betelhem Temesgen Yibekal [ID]

Department of Optometry, School of Medicine, College of Medicine and Health Science, University of Gondar, Gondar town, Ethiopia

Correspondence should be addressed to Betelhem Temesgen Yibekal;

Received 21 February 2020; Accepted 7 April 2020; Published 25 April 2020

Academic Editor: Biju B. Thomas
Table 1: Sociodemographic characteristics of study participants in
Gondar town, Northwest Ethiopia, 2019.

Variables                   Frequency (n)   Percentage (%)

18-28                            175             31.6
29-39                            194             35.1
40-49                            117             21.2
50-59                            42              7.6
>60                              25              4.5
Male                             297             53.7
Female                           256             46.3
Marital status
Married                          308             55.7
Single                           220             39.8
Widowed                          13              2.4
Divorced                         12              2.2
Orthodox                         450             81.4
Muslims                          72              13.0
Protestants                      31              5.6
Monthly income
500-2500                         141             25.5
2501-3800                        138             25.0
3801-5000                        140             25.3
>5000                            134             24.2
Education level **
No formal education              50              9.0
Primary school                   17              3.1
Secondary school                 119             21.5
College and above                367             66.4
Occupations **
Employed                         290             52.4
Housewife                        57              10.3
Students                         79              14.3
Merchants                        84              15.2
Unemployed                       22              4.0
Others **                        21              3.8
Role in the community
Had role                         35              6.3
No role                          518             93.7

Others ** included farmers and retired people. Occupations **
included those from Jeddah [22] and Ethiopia [9]. Education level
** included those from Nigeria [23].

Table 2: Participants response regarding different dimensions of
strabismus (n = 553).

Different dimensions of          Response of participants
                                    Correct response

                             Frequency (n)   Percentage (%)
One eye misalignment              240             43.4
Two eye misalignment              268             48.5
Laziness of an eye                312             56.4
Abnormal eye movements            176             31.8
Two eyes not coordinated          399             72.2
Optic nerve degenerations         120             21.7
Causes/risk factors
Heredity                          88              15.9
Trauma                            182             32.9
Other eye disease                 170             30.7
Cataract                          93              16.8
Nutritional deficiency            285             51.5
Exposure to lamp/light            112             20.3
Prematurity                       28              5.1
Fever during infancy              306             55.3
Redness                           373             67.5
Beliefs                           424             76.7
Eye glasses                       219             39.6
Surgery                           316             57.1
Eye muscle exercise               95              17.2
Patching better eye               249              45
Resolves by its self              393             71.1
Eye drops                         299             54.1
Amblyopia                         349             62.9
Poor in school performance        217             39.2
Social stigma                     225             46.1
Poor cosmoses                     454             82.1
Self-depression                   320             57.9
Dependency                        161             20.1

Different dimensions of         Response of participants
                                   Incorrect response

                             Frequency (n)   Percentage (%)
One eye misalignment              313             56.6
Two eye misalignment              285             51.5
Laziness of an eye                241             43.6
Abnormal eye movements            377             68.2
Two eyes not coordinated          154             27.8
Optic nerve degenerations         433             78.3
Causes/risk factors
Heredity                          465             84.1
Trauma                            371             67.1
Other eye disease                 383             69.3
Cataract                          460             83.2
Nutritional deficiency            268             49.5
Exposure to lamp/light            441             79.7
Prematurity                       525             94.9
Fever during infancy              245             44.7
Redness                           180             32.5
Beliefs                           129             23.3
Eye glasses                       334             60.4
Surgery                           237             42.9
Eye muscle exercise               458             82.8
Patching better eye               304              55
Resolves by its self              160             28.9
Eye drops                         254             45.9
Amblyopia                         205             37.1
Poor in school performance        336             60.8
Social stigma                     298             53.9
Poor cosmoses                     99              17.9
Self-depression                   233             42.1
Dependency                        392             79.9

Table 3: Factors associated with knowledge towards strabismus
among adults in Gondar town, Northwest Ethiopia, 2019.

Variables                    Knowledge level    COR (95% CI)

                             Good     Poor
18-28                         90       85             1
29-39                        109       85     1.21 (0.80, 1.82)
40-49                         56       61     0.87 (0.54, 1.38)
50-59                         20       22     0.86 (0.44, 1.68)
>60                           14       11     1.20 (0.52, 2.79)
Male                         151      146             1
Female                       138      118     1.13 (0.81, 1.58)
Marital status
Married                      161      147             1
Single                       118      102     1.06 (0.75, 1.49)
Widowed                       5        8      0.57 (0.18, 1.78)
Divorced                      5        7      0.65 (0.20, 2.10)
500-2500                      80       61             1
2501-3800                     77       61     0.96 (0.60, 1.54)
3801-5000                     81       59     1.05 (0.65, 0.68)
>5000                         51       83     0.47 (0.29, 0.76)
Education level
No formal education           26       24             1
Primary school                9        8      1.04 (0.34, 3.13)
Secondary school              59       60     0.91 (0.47, 1.76)
College/university           195      172     1.05 (0.56, 1.89)
Occupations **
Employee                     146      144             1
Merchant                      42       42     0.99 (0.61, 1.60)
Student                       49       30     1.61 (0.97, 2.68)
Housewife                     28       29     0.95 (0.54, 1.68)
Unemployed                    12       10     1.18 (0.50, 2.83)
Others                        12       9      1.31 (0.54, 3.22)
Role in the community
Had role                      16       19     0.76 (0.38, 1.50)
No role                      273      245             1
Health insurance
No                           267      246             1
Yes                           18       22     1.13 (0.59, 2.15)
Previous eye examinations
No                           199      176             1
Yes                           90       88     0.90 (0.63, 1.29)
Eye health care training
No                           279      258             1
Yes                           10       6      1.54 (0.55, 4.30)

Variables                      AOR (95% CI)

18-28                                1
29-39                        1.56 (0.94, 2.56)
40-49                        1.27 (0.69, 2.36)
50-59                        1.27 (0.56, 2.88)
>60                          1.98 (0.63, 6.17)
Male                                 1
Female                       1.13 (0.76, 1.68)
Marital status
Married                              1
Single                       0.82 (0.52, 1.28)
Widowed                      0.42 (0.12, 1.44)
Divorced                     0.63 (0.19, 2.12)
500-2500                             1
2501-3800                    0.95 (0.57, 1.57)
3801-5000                    0.98 (0.59, 1.62)
>5000                       0.44 (0.26, 0.76)**
Education level
No formal education                  1
Primary school               1.05 (0.32, 3.42)
Secondary school             0.89 (0.40, 1.95)
College/university           1.20 (0.55, 2.62)
Occupations **
Employee                             1
Merchant                     1.35 (0.76, 2.40)
Student                     2.15 (1.11, 4.13)**
Housewife                    0.98 (0.46, 2.08)
Unemployed                   1.41 (0.54, 3.66)
Others                       1.38 (0.46, 4.10)
Role in the community
Had role                     0.87 (0.42, 1.81)
No role                              1
Health insurance
No                                   1
Yes                          1.01 (0.51, 2.02)
Previous eye examinations
No                                   1
Yes                          0.91 (0.61, 1.35)
Eye health care training
No                                   1
Yes                          1.43 (0.49, 4.14)

**P < 0.05.

Figure 1: Source of information among study participants in Gondar
town, Northwest Ethiopia, 2019.

Radio/TV                                34.4
Eye care professional/eye ...           19.3
Families/relatives                       42
Friends/neighbors                       40.9
Internet                                15.6
Campaign/outreach                       3.4

Note: Table made from bar graph.
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Article Details
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Title Annotation:Research Article
Author:Assaye, Aragaw Kegne; Tegegn, Melkamu Temeselew; Assefa, Natnael Lakachew; Yibekal, Betelhem Temesge
Publication:Journal of Ophthalmology
Geographic Code:7SAUD
Date:May 31, 2020
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