Int Ophthalmol

DOI 10.1007/s10792-014-9902-3

ORIGINAL PAPER

Awareness, perceptions and knowledge of strabismus

among patients visiting a tertiary eye clinic in Southwest
Nigeria
Michaeline A. Isawumi • Mildred Ulaikere •
Olubusayo O. Adejumo • Modupe Adebayo •
Ramesh Kekunnaya

Received: 7 October 2013 / Accepted: 4 January 2014

Ó Springer Science+Business Media Dordrecht 2014

Abstract The purpose of this study was to assess the strabismus. Perceived causes were unknown to 53 %
perceptions, knowledge of the causes, implications and while 18.0 and 12 % mentioned eye disease and
treatment of strabismus in a black population. This was congenital-related, respectively. There was no knowl-
a descriptive cross-sectional study utilizing a total edge of treatment in 54 % of patients, while 21 and
sampling technique. Face-to-face interviews were 25 % knew about medical and surgical treatment,
performed using a structured questionnaire. Socio- respectively. The effects on social and family life were
demographic characteristics, awareness, perceived stigmatization/social misfit (23 %), psychosocial/self
causes, effect and treatment of squint were investi- pity/depression/inferiority complex (88 %), burden
gated. Data was analysed using descriptive and infer- (economic/time) (7 %), and poor cosmesis (5 %).
ential (bivariate and binary regression) analysis. A Females were significantly more aware than males
total of 405 respondents (49.6 % male, 50.4 % female) (p = 0.043, OR 0.6, CI 0.399–0.986). Age
were interviewed. Ages ranged from 11 ± 90 years (p = 0.187) and level of education (p = 0.321) had
(mean 41.26 ± 19.00). Modal age group was 17–44 no significant relationship with the levels of awareness.
(56 %). Levels of education showed that 22.0 % had Respondents who had no education were 1.25 times
no education, while primary, secondary and tertiary less likely to be aware of squint than those who had
levels were 12.6, 31.6 and 33.8 %, respectively. education (OR 0.8, CI 0.693–1.642). The awareness of
Approximately 75 % of patients were aware of the cause, effects and treatment of strabismus is poor in
this population. Females were more aware than males.

M. A. Isawumi (&) Keywords Awareness
Perceptions

College of Health Sciences, Osun State University,
Knowledge
Strabismus
Nigeria
PMB 4494, Osogbo, Osun State, Nigeria
e-mail: misawumi@gmail.com

M. Ulaikere Introduction
Eye Foundation Hospital, Lagos, Nigeria

O. O. Adejumo
M. Adebayo Strabismus is a condition in which the eyeball deviates

Department of Ophthalmology, Lautech Teaching from its straight position [1].
Hospital, Osogbo, Nigeria A study performed in the United Kingdom found that
*4 % of adults had squint with a report of high levels of
R. Kekunnaya
Jasti V Ramanamma Children’s Eye Care Center, negative psychosocial effects on relationships, work,
LV Prasad Eye Institute, Hyderabad, India and self esteem [2]. Studies have shown that children are

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also aware of these problems as seen among children in population was made up of patients who visited the
Minnesota who were made aware of strabismus through eye clinic over a 1-month period.
comments made [3]. Strabismus in our environment
could have a negative impact on various aspects of a Sampling
person’s life. A study carried out in India among
adolescents aged between 15 and 25 years showed that Total sampling of consecutive consenting participants
80 % of them had problems with their social life. This was performed. Written informed consent was obtained
situation was reversed when [90 % of them regained from the participants while ethical clearance was obtained
their self esteem and self confidence after surgery [4]. from the hospital ethics and research committee.
Personal observations by the authors brought about Face-to-face interviews using a structured ques-
this investigation, even though there is no supporting tionnaire were carried out. The questions related to
literature in this population. Apart from the poor socio-demographic characteristics like age, sex and
cosmetic appearance and loss of binocularity associ- educational status, being aware of strabismus and its
ated with strabismus, the strabismic eye is often times effects on social, family life and vision, perceived
associated with poor vision or blindness [5]. The need causes of squint, place and methods of treatment and
to correct it before the brain attains full development is effect of treatment.
therefore necessary in a growing child. Furthermore,
surgical correction has been documented to give an Data management
increase in field of vision especially following surgery
for esotropia [6]. Due to the dearth of literature on the SPSS (version 17) was used for data entry and
subject matter, this would serve as a baseline study of analysis. Descriptive and regression analysis was
peoples’ perception to the causes, consequences, performed to find associations between variables and
outcome and treatment of strabismus in Nigeria. The responses. The level of significance was determined at
findings will also serve to fill gaps in knowledge. p \ 0.05 and 95 % confidence limits.
This study will assist in raising awareness towards the
treatment of strabismus so that apart from improvement
in appearance, visual functions in terms of improved Results
vision, binocularity and stereopsis can be achieved.
A total of 405 participants were interviewed. Ages
ranged from 11 to 90 years with a mean of
Methods
Table 1 Socio-demographic characteristics of participants
Study location
Variables No. %
The study took place at the eye clinic of the Lautech Age
Teaching Hospital, Osogbo, in Osun State, Nigeria. This 8–16 16 4.0
hospital serves the people of Osun and the surrounding 17–44 227 56.0
Kwara, Ekiti, Oyo and Ondo States of Southwest Nigeria. 45–54 51 12.6
It lies in the tropical rain forest belt of Nigeria. Osogbo has 55–64 48 11.9
a population of 170,000 while the state has a population of [65 63 15.6
over 3.7 million. The people are mainly agrarian in Gender
profession as well as mainly rural in dwellings [7].
Male 201 49.6
Female 204 50.4
Study design
Education status
Primary 51 12.6
This was a descriptive cross-sectional study. Inter-
Secondary 128 31.6
viewers, trained on how to ask questions and interpret
Tertiary 137 33.8
into the local language when necessary, administered
No education 89 22.0
face-to-face a pretested questionnaire. The study

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Table 2 Awareness, perceived causes, and effects of disease and stigmatization, respectively as shown in
strabismus Table 2.
Variables (yes option only) Frequency % Approximately 50 % of participants had no per-
ceived knowledge on the treatment of strabismus
Perceived causes of strabismus (n = 405) while 25 % thought it could be cured surgically
Pregnancy/IUL related 7 1.7 (Table 3).
Congenital 49 12.1 Association and binary logistic regression between
Eye diseases related 73 18.0 awareness of strabismus and selected socio-demo-
Diet 4 1.0 graphic variables are shown in Table 4; females were
Hereditary/familial 13 3.2 significantly more aware (p \ 0.05), with age having
Beliefs 43 10.6 no significance.
Don’t know 216 53.3 Some common beliefs relating to pregnant women
Respondents are aware of strabismus 302 74.6 and strabismus occurrence include ‘sleeping face up
Strabismus has effect on sight 214 52.8 during pregnancy/lying supine’ (5 %) and ‘walking in
Strabismus has effect on social life 204 50.4 the sun’ (3 %).
Strabismus has effect on the family 112 27.7
Strabismus can be treated in the hospital 225 55.5
What are the perceived effects on social life? Discussion
Stigmatization/social misfit 93 23.1
Poor cosmesis 22 5.4 The study included both adults and children. This is
Psychosocial/self pity/depression/ 32 7.9 not unexpected because studies have revealed that
inferiority complex children are also aware of squint. In a Minnesota
Affects economic life/work 9 2.2 study, 19 out of 24 children aged between 5 and
Inability to see and walk well 21 5.2 17 years were aware of outward eye deviation [3].
No idea 228 56.2 There was no significant difference between the
Perceived effects of strabismus on the members of family number of males and females seen this study.
Burden (economic/time) 18 4.4 On cross tabulation, there were significant associ-
Stigma/marital issues 30 7.4 ations between awareness and gender with males
Can be passed unto offspring 20 4.9 being 1.66 times less likely to be aware of strabismus
Psychological effects 17 4.2 than females. In comparison, age and gender were
No idea 318 78.5 seen to have no significant impact on the perception of
strabismus by adults and children in a study carried out
in Switzerland [8].
Table 3 Participants perceived treatment of strabismus Twenty-two percent of participants had no educa-
Variables (yes option only) Frequency % tion and this was seen to have a negative effect on
awareness. Subjects with no education were 1.25 times
How can strabismus be treated (n = 302)? less likely to be aware of strabismus than subjects that
Medically 61 20.2 had received education (OR 0.8). Over 50 % of
Surgically 75 24.8 participants responded that strabismus could have an
Others 3 1.0 abnormal effect on sight and social life. The effect on
Don’t know 163 54.0 sight is usually overshadowed by cosmesis as found in
Switzerland [8]. A strabismic eye was described by
Prakash as being uniocularly blind with associated loss
41.26 ± 19.00 years. The modal age group was of binocularity and stereopsis [5]. The effect on social
17–44 years ± 1.19. life was described as being a social misfit and therefore
The summary of the socio-demographic character- becoming stigmatized. This could eventually lead to a
istics are shown in Table 1. psychological affectation with exhibition of self pity,
Apart from having no knowledge, the commonest depression and inferiority complex, etc. Other authors
perceived cause and effect of strabismus were eye had documented similar findings. In another study, for

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Table 4 Association and binary logistic regression between awareness of strabismus and selected socio-demographic variables
Awareness n (%) v2 p value

Association between awareness of strabismus and some socio-demographic variables

Gender (females) 302 (74.6) 4.108 0.043
Levels of education 239 (79.1) 3.499 0.321
Age 16 (4.0) 1.741 0.187
Awareness n (%) OR Confidence interval CI

Binary logistic regression of X and Y

Gender (male) 141 (46.7) 0.6 0.399–0.986
Educational status (no education) 63 (20.9) 0.8 0.693–1.642

example, 86 % of participants made up of teenagers These vision problems were also noticed in a study
and adults admitted to being embarrassed when among teenagers and adults, when they were seen not
strabismus was present before having had surgical to be making eye contact. They then developed some
correction [9]. In this study, nine of the subjects said it particular mannerism or postures as a means of
could affect economic life and therefore work would compensation for the squinting eyes [9].
be affected adversely. This could be corroborated in The perceived effects on members of their family
the study in which affected adults with strabismus also showed that marital issues and stigmatization were the
reported associated psychosocial effects, work-asso- most frequent concern in 7.4 % of patients. In a similar
ciated relationships and lowered self esteem [2]. In scenario, stigmatization led to 57 % of children being
another study among rural and urban dwellers in India, severely ostracized in India [10]; however, the authors
where parents were interviewed about their children, think that this could have been largely attributable to
70 % of parents were very distressed due to the ignorance. It was also thought that strabismus could be
presence of squint while 65 % and 55 % of both passed to an offspring in 4.4 % of patients; this could
parents and children, respectively, were found to be lead to an untoward effect on the family. In Nigeria
extremely distressed due to remarks by other people and in this study population in particular, these
[10]. This shows how strabismus can psychologically situations usually lead to stigmatization where the
affect both parent and child. Other authors have community would think it is a type of family
highlighted the likelihood of psychiatric disorders inheritance or trait. People with strabismus could also
being associated with strabismus [11]. Knowing what be a physical, psychological and economic burden as
strabismus is and how to prevent and treat it, is seen Table 2. A study by Edelman confirmed that
therefore of utmost importance in this society in order economic benefit was one of the functional benefits of
to forestall these tendencies. strabismus surgery [6].
Poor cosmesis was another issue which was second Interestingly, in comparison, focus group discus-
to stigmatization. In a study intended to find out how sions in Kariapatti in India revealed that parents
children aged 5–17 years became aware of their thought strabismus was untreatable and also a sign of
exodeviation, the comments overheard by them in goodluck [13].
terms of their poor cosmetic appearance made them to The perceived causes of strabismus were not known
become aware in 63 % of cases [3]. Poor cosmetic by the majority of the respondents. However, eye-
appearance could affect relationships, especially in related diseases and congenital diseases (being born
females with regard to suitors. This observation was with it) were the commonest perceived causes. This is
corroborated among Chinese adolescents and adults not unexpected since most people would think that a
who noted an improvement in relationships with diseased eye or being born with it would often lead to
friends after surgery [12]. strabismus. This, however, may be close to the truth
Participants also thought that people with strabis- since studies have frequently shown that refractive
mus could have challenges with walking and vision. errors and other eye diseases do lead to strabismus.

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The next perceived cause was beliefs. This is actually Conclusion

a broad umbrella which encompasses beliefs such as
‘the posture of pregnant women while sleeping in the The awareness of the cause, effects and treatment of
day time looking up would lead to their babies being strabismus is poor in this population. Females were
born with strabismus’. Others are walking in the sun significantly more aware while age and level of
during pregnancy, etc. education had no significant relationship with being
Intrauterine life-related abnormalities during preg- aware of strabismus. However, participants with no
nancy were also perceived to be a cause of strabismus. education were less likely to be aware of strabismus.
Some authors also proposed that due to ignorance, Strabismus awareness, therefore, needs to be raised
different communities had different types of beliefs through health education. This would allow for early
for causal or presenting factors of strabismus, even presentation for adequate management in order to
within the same country [13]. This situation is similar prevent social stigma, reduce economic burden,
to beliefs in our study population relating to causes, improve cosmesis and promote good vision.
treatment and the effects of strabismus.
In our study, the knowledge about treatment was Conflict of interest None.
low as anticipated. The majority of participants did not
know but had the belief that it could be treated in
hospital. In Kariapatti, it was considered to be an References
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