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Huibert J. Simonsz, Angela M. Tjiam, Gerdien Holtslag, Wijnanda Asjes, Harry de Koning, Sjoukje E. Loudon; Cartoon That Explains Without Words To The Child Why It Should Patch Improves Compliance and Accelerates Visual-acuity Rise, But Integration Of Techniques For Detection And Prevention Of Noncompliance Into Orthoptists' Practice And Training Fails. Invest. Ophthalmol. Vis. Sci. 2011;52(14):6344.
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A cartoon that explains without words to a child with amblyopia why it should path improves compliance. In an implementation study, we examined whether Dutch orthoptists could make use of it, whether those working in low-SES areas benefited especially and whether techniques to detect and prevent noncompliance were integrated in training and practice.
9 Orthoptists in low-SES areas and 23 elsewhere in the Netherlands (NL) were observed 1 year before and 1 year after introduction of the cartoon. At that point also a two-day course was given about noncompliance in general, noncompliance in treatment of amblyopia, consequences of noncompliance for public health, communication with parents who speak Dutch poorly, intercultural communication, techniques for detection and prevention of noncompliance and implementation of these within the hospital setting. Knowledge, awareness, attitude, communication and actions regarding noncompliance were assessed with interviews, questionnaires and observations before and after. In children they treated, compliance was measured electronically and acuity and attendance rate were assessed.
All 9 orthoptists in low-SES areas and 17 of 23 elsewhere in the NL had used the cartoon. Few changes were noticeable among orthoptists: after the course they had more understanding for noncompliance and the child got a longer explanation. Only a quarter of orthoptists suspected noncompliance in a single patient on one day of observation, before and after the course; the others never did. In low-SES areas compliance averaged 52% (orthoptists’ estimate: 69%) in the first vs. 62% in the second year; 42% vs. 22% of the children had a compliance below 30%. Acuity rose by 0.06 vs. 0.14 LogMAR/yr (n=124, P=0.026), elsewhere in the NL by 0.10 vs. 0.16 LogMAR/yr (n=575, P<0.001). Missed appointments occurred in 36% vs. 29% of children, elsewhere in the NL 8% before and after. 25% vs. 30% had finished occlusion treatment after 1.4 years of follow-up. Integration of techniques for detection and prevention of noncompliance in practice and training (primary and continuing) failed.
The cartoon that explains without words to the child why it should patch improves compliance and accelerates acuity rise, especially in low-SES areas. Addition of techniques for detection and prevention of noncompliance is not cost-effective.
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