Abstract
Purpose:
Data on social-emotional aspects among children with strabismus in India are scanty. We compared the emotional symptoms (ES), loneliness and social dissatisfaction (LSD), and self-esteem (SE) and their associated risk factors among children with and without strabismus in India.
Methods:
A cross-sectional case–control study design was used to recruit 101 children with strabismus aged 8 to 18 years and a control group of 101 children that were age- and gender-matched. Interviews were performed using standardized scales to assess ES, LSD, and SE. Variations in the intensity of ES, LSD, and SE were assessed using multiple classification analysis (MCA).
Results:
A total of 202 children participated in the study. The mean ES, LSD, and SE scores were 3.4 (standard deviation [SD] 1.9), 48.4 (SD 3.2), and 22.1 (SD 3.8) for the strabismus group and 1.8 (SD 1.5), 33.3 (SD 3), and 31.3 (SD 2) for the non-strabismus group, respectively. Among the strabismus group, the highest levels of mean ES, LSD, and SE scores were observed among children facing problems in performing daily tasks. Amongst the non-strabismus group, children studying at the primary level and those facing neglect had the highest mean scores. In MCA, being affected with strabismus had the highest effect on the intensity of ES, LSD, and SE with a beta (b) value of 0.223 (P = 0.016), 0.922 (P < 0.001), and 0.853 (P < 0.001).
Conclusion:
A significantly high proportion of children with strabismus deal with elevated levels of ES, LSD problems, and low SE as compared with non-strabismus children, highlighting the need to address the poor social-emotional health of children.
Keywords: Emotional symptoms, India, loneliness, self-esteem, strabismus
Social-emotional issues such as loneliness and social dissatisfaction (LSD) and low self-esteem (SE) are increasingly being recognized as priority public health problems and policy issues for children and adolescents.[1] UNICEF estimates that psychosocial distress and poor mental health afflict far too many children and when ignored, it undercut their capacity to learn, work, build meaningful relationships, and contribute to the world.[2] Children with strabismus often suffer from several psychosocial and emotional consequences viz. poor self-image, negative social bias, ridicule at school, ostracization, depression, anger and outrage, increased social anxiety, poor interpersonal relationship, inhibition, low SE and low confidence, and poor quality of life (QoL).[3-15] Though very limited, research conducted in the Indian context suggests that social-emotional problems such as loneliness, behavioral, and interpersonal conflicts are relatively common in children and adolescents and may contribute to impaired feelings of SE.[5,16,17]
A recent systematic review to ascertain the global and regional prevalence of childhood strabismus revealed a wide variation across the globe, which severely affects their functionality and QoL.[18] The pooled prevalence of strabismus in India was estimated at 0.7%, way below refractive error (RE), and pediatric cataracts.[18] Evidence also points to the improvements in the physiological, functional, psychological, social-emotional, and QoL of children post-treatment.[3,4,19,20] Given the cultural differences in the perception of strabismus across geographies,[1,18] local data must be generated to inform decision-making and to set priorities. To the best of our knowledge, there are currently a handful of studies on the effects of strabismus on the social–emotional attributes of Indian children. In this study, we provide a comparison of social-emotional attributes such as ES, LSD, and SE among children with strabismus and those without to contribute to building local evidence to guide relevant policies and programs.
Methods
Study design and setting
A school eye health program was undertaken in the Nashik district of Maharashtra in collaboration with the Tulsi Eye Hospital, Nashik. As part of this program, 51,673 children were screened covering 99 government and government-aided schools. A total of 153 children were diagnosed with strabismus and were referred to a partnering tertiary eye hospital for further evaluation and treatment. Subsequently, a total of 101 children turned up at the hospital. A cross-sectional case–control study design was used to compare the three social-emotional scores viz. (i) emotional symptoms (ES), (ii) loneliness and social dissatisfaction (LSD), and (iii) SE in a group of children diagnosed with strabismus, with an age- and gender-matched control group of normal non-strabismus children. The Institutional Review Board of Mission for Vision, Mumbai, approved the study.
Participants and sampling
We adopted a non-probabilistic convenience sample to include all 101 children who showed up at the hospital. Children received a comprehensive ophthalmic diagnostic evaluation by qualified ophthalmologists. A control group of 101 children from local government and government-aided schools that could be age- (within 6 months) and gender-matched to the strabismus group were recruited for the study. In sum, the study included 202 children or 101 strabismus-control pairs. The children aged 8–18 years and who could understand at least one of the three languages–Marathi, Hindi, or English were considered eligible for the study. Children were excluded from the control group if they had a documented disability or had special education.
Data collection
The data collection was conducted from September 2019 to March 2020. Standard research protocols were followed during data collection in accordance with the Helsinki Declaration. Data collection involving the strabismus group was conducted at the hospital premises as and when such referred children visited the base hospital for further evaluation. Each potential participant was contacted by an interviewer trained in the study procedures with the assistance of the hospital staff. The study was explained, and informed consent was sought for participation. For children aged 8 to 14 years, child assent and written consent from the concerned parent/guardian were obtained, and written informed consent was provided by children 15–18 years of age. Children in the non-strabismus group were recruited based on a detailed list generated with the help of the local schools, and children were randomly selected from this list to be included in the study. Official permissions for the interviews were obtained from the school principal before the start of the interviews. Detailed residential addresses of the sampled children were obtained from the school records and arrangements for face-to-face interviews with the children at their residences were made. Prior intimation and appointment from the parent/guardian were obtained for face-to-face interviews telephonically. Before the start of the interviews, for children aged 8 to 14 years, child assent and written consent from the concerned parent/guardian were obtained; and written informed consent was provided by children 15–18 years of age. All participants had the right to refuse participation or stop the interview at any time. The interview was conducted in privacy. The average interview time was 45 min, and the responses were recorded digitally using a tablet.
Visual acuity measurement
Measures of visual impairment (VI) were classified into six broad categories as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as mild or no VI (equal to or better than 6/18), moderate VI (worse than 6/18 to 6/60), severe VI (worse than 6/60 to 3/60), blindness (worse than 3/60 to no light perception).[21] The visual acuity (VA) details for the strabismus group were obtained from the patient medical records available at the treating hospital. The VA measurement involving the non-strabismus group was carried out by interviewers, who are well-trained in assessing the VA using a Snellen tumbling E chart before the start of face-to-face interviews. The respondent was made to stand/sit at a particular place, that is, well-lit and the interviewer would stand holding the E chart facing the patients at a distance of 6 m. The 6 m distance was measured using a precisely measured rope. Starting from the top, the participant was asked to point the exact direction of the hands (up, down, left, and right) of the letter “E” on the chart. Based on the number of lines the respondent read on the chart, a determination of the VA of the patient was made.
Measures
The interview documented the socio-demographic and clinical characteristics of subjects including age, sex, education, VA, and spectacle use. Details on preoperative VA, type of strabismus, eye affected by strabismus, and etiology of the eye conditions were extracted from the individual patient medical records available with the treating hospital.
We also recorded children's social–emotional problems. The term “social–emotional issues” refers to a variety of difficulties or obstacles that children encounter when trying to control their emotions, or interact with others in a socially acceptable way. Research indicates that these problems may significantly affect a child's QoL, academic success, and general well-being.[3,5-8,10-14] Common social–emotional issues in children include emotional symptoms such as depression and anxiety, social skill deficit, attention deficit hyperactivity disorder (ADHD), low SE, LSD, oppositional defiant disorder (ODD), and autism spectrum disorder (ASD). We have assessed the three most common social–emotional issues affecting children viz. ES, LSD, and SE amongst the study population.
Emotional symptoms
The Strengths and Difficulties Questionnaire (SDQ), which is designed to assess behavioral disorders in children aged 5 to 18 years, was used to document emotional symptoms.[22-27] This scale was previously used to assess emotional symptoms in ophthalmic patients suffering from strabismus including among Indian children.[24-27] The SDQ covers four dimensions of internalizing (“emotional symptoms” and “peer problems”) and externalizing mental health problems (“conduct problems,” “hyperactivity/inattention”) as well as prosocial behavior. We used the ES sub-scale on the study population. The respondents were asked to rate the degree to which they experienced each symptom on a 3-point frequency scale (not true, somewhat true, and certainly true). The possible scores ranged from 0 to 10. A score of 0–5 is considered normal, 6 is borderline, and between 7 and 10 is considered abnormal for ES.[22,23] The scale was translated into the local languages for use and then was back-translated and field-tested to ensure proper readability. As cultural validity was a major concern in translating this scale, the researchers closely collaborated with mental health experts and child counselors to achieve the accuracy of cultural understanding and translation for these scales. The Cronbach's alpha for the emotional symptoms sub-scale in this study was a = 0.72.
Loneliness and social dissatisfaction
We used the 24-item LSD scale to assess children's feelings of loneliness.[28-31] Of the 24 items, 16 primary items assessed feelings of loneliness, feelings of social adequacy, and subjective estimations of peer status. The other eight filler items asked about children's hobbies and preferred activities, which were not analyzed further. Children responded to the items on a 4-point scale (1 = not true at all, 4 = always true). The average scores of the 16 primary items were used to indicate children's levels of LSD, with higher scores indicating greater LSD. The LSD scale too was translated into the local languages for use and then was back-translated and field-tested to ensure proper readability. In the current study, Cronbach's alpha for the LSD items was a = 0.87.
Self-esteem
The 10-item Rosenberg Self-Esteem (SE) scale was used to measure children's global trait SE.[32] Participants indicated their agreement with the 10 statements on a scale ranging from 1 (strongly disagree) to 4 (strongly agree). This scale has been widely used across cultures, including India.[33,34] The average scores of the items were used to indicate children's levels of self-esteem, with higher scores indicating higher SE. The SE scale too was translated into the local languages for use and then was back-translated and field-tested to ensure proper readability. Cronbach's alpha for the SE ratings in this study was a = 0.83.
Neglect and mistreatment
A history of neglect or mistreatment by friends, family, or relatives was documented. Neglect was defined as the denial of basic needs such as food and/or shelter. Mistreatment was defined as subjecting patients to verbal abuse, the threat of violence, physical beatings, or mental abuse. “Neglect” and “mistreatment” were assessed separately. Additionally, current difficulty in performing daily tasks and requiring help was also documented.
Statistical analysis
Microsoft Office Excel 2013 and SPSS statistical software (version 20.0, IBM SPSS Science, Chicago, IL) were used to analyze the data. Descriptive statistics for ES, LSD, and SE scores are reported for relevant variables, and independent sample t-test and one-way ANOVA test were used to assess significance as appropriate.[35] The distribution and association of ES, LSD, and SE scores with select socio-demographic, clinical, and behavioral attributes are presented separately for the two groups. Multiple classification analysis (MCA) was performed to assess the variation in the intensity of ES, LSD, and SE with select factors. We used ES, LSD, and SE scores as continuous variables in MCA as clinical cut-off scores for these conditions are not readily available for adults in India.
Results
Participation and demography
A total of 202 children aged 8–18 years participated in this study. Table 1 describes the socio-demographic, clinical, and behavioral characteristics of the study population. The proportion of boys and girls was more or less equal in both groups. The median age for both groups was 12 (range 9–18 years) and 13 (range 8–18 years), respectively. The majority of the children in both groups were attending secondary schooling.
Table 1.
Demographic, clinical, and behavioral characteristics of the study population
| Variable | Categories | Total (%) n=202 | Strabismus group (%) n=101 | Non-strabismus group (%) n=101 |
|---|---|---|---|---|
| Age | 10 years or below | 48 (23.8) | 24 (23.8) | 24 (23.8) |
| 11 to 14 years | 93 (46) | 51 (50.5) | 42 (41.6) | |
| >14 years | 61 (30.2) | 26 (25.7) | 35 (34.7) | |
| Sex | Boy | 99 (49) | 50 (49.5) | 49 (48.5) |
| Girl | 103 (51) | 51 (50.5) | 52 (51.5) | |
| Education | Never been to school | 1 (0.5) | 0 (0) | 1 (1) |
| Class 1–5 | 70 (34.7) | 42 (41.6) | 28 (27.7) | |
| Class 6–12 | 131 (64.9) | 59 (58.4) | 72 (71.3) | |
| Uncorrected visual acuity in the worst eye | No/Mild VI | 185 (91.6) | 84 (83.2) | 101 (100) |
| Moderate VI | 8 (4) | 8 (7.9) | 0 (0) | |
| Severe VI | 2 (1) | 2 (2) | 0 (0) | |
| Blindness | 7 (3.5) | 7 (6.9) | 0 (0) | |
| Turn in the eye | Right eye | 31 (30.7) | 31 (30.7) | -- |
| Left eye | 36 (35.6) | 36 (35.6) | -- | |
| Both eyes | 34 (33.7) | 34 (33.7) | -- | |
| The direction of the eye turn | In (esotropia) | 36 (35.6) | 36 (35.6) | -- |
| Out (exotropia) | 56 (55.4) | 56 (55.4) | -- | |
| Up (hypertropia) | 6 (5.9) | 6 (5.9) | -- | |
| Down (hypotropia) | 3 (3) | 3 (3) | -- | |
| Wear eyeglasses | Yes | 25 (12.4) | 25 (24.8) | 0 (0) |
| No | 171 (84.7) | 71 (70.3) | 101 (100) | |
| Facing problems in performing daily tasks | Yes | 29 (14.4) | 29 (28.7) | 0 (0) |
| No/cannot say | 173 (85.6) | 72 (71.3) | 101 (100) | |
| Ever faced neglect from friends/family/relatives | Yes | 58 (28.7) | 55 (54.5) | 3 (3) |
| No | 144 (71.3) | 46 (45.5) | 98 (97) | |
| Ever faced mistreatment from friends/family/relatives | Yes | 52 (25.7) | 51 (50.5) | 1 (1) |
| No | 150 (74.3) | 50 (49.5) | 100 (99) |
Clinical characteristics and visual acuity
The grades of uncorrected visual acuity (UVA) in the worst eye are presented in Table 1. A total of 185 (91.6%; strabismus group: 83.2%, non-strabismus group: 100%) had mild or no VI. In the strabismus group, about 8% had moderate VI, followed by severe VI in 2% of children, and around 7% were blind. The majority experienced the turn of the left eye (35.6%) and over half (55.4%) had the turn in the outward direction. About 12% in the strabismus group and none in the non-strabismus group were wearing eyeglasses.
Facing difficulties, mistreatment, and neglect
Children in the strabismus group (N = 29, 28.7%) were significantly more likely to report facing difficulties in performing daily tasks as compared to the non-strabismus group (P < 0.001). Similarly, a significant proportion of children in the strabismus group (N = 55, 54.5%) reported facing neglect by family/friends/relatives as compared with those in the non-strabismus group (N = 3, 3%; P < 0.001). A total of 52 (25.7%) children reported facing mistreatment from family/friends/relatives, of whom a significant majority were in the strabismus group (50.5%; P < 0.001). [Table 1].
Distribution of scores
Table 2 shows the distribution of mean scores for ES, LSD, and SE with select variables for the children in both groups. The overall mean ES, LSD, and SE scores were 3.4 (standard deviation [SD] 1.9), 48.4 (SD 3.2), and 22.1 (SD 3.8) for the strabismus group and 1.8 (SD 1.5), 33.3 (SD 3), and 31.3 (SD 2) for the non-strabismus group, respectively. Among the strabismus group, the highest levels of mean ES, LSD, and SE scores were observed among children who had faced problems in performing daily tasks, those who faced neglect from family/friends/relatives, and those who were blind, or with severe VI. Among the non-strabismus group, the highest levels of mean ES, LSD, and SE scores were observed for children studying at the primary level, those who reported facing neglect from friends/family/relatives, and among boys.
Table 2.
Distribution of emotional Symptoms (ES) score, the loneliness and social dissatisfaction (LSD) score, and self-esteem (SE) scores by select variables among strabismus and non-strabismus children in Nashik, Maharashtra
| Variable | Categories | Strabismus group | Non-strabismus group | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
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| n=101 | Emotional symptoms score | Loneliness and social dissatisfaction score | Self-esteem score | n=101 | Emotional symptoms score | Loneliness and social dissatisfaction score | Self-esteem score | ||||||||
|
|
|
|
|
|
|
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| Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD | Mean | SD | ||||
| Age* | 10 years or below | 24 | 3.5 | 2.3 | 48.6 | 4.6 | 22.9 | 3.5 | 24 | 2.0 | 1.5 | 33.3 | 2.5 | 31.2 | 2.3 |
| 11 to 14 years | 51 | 3.3 | 1.8 | 48.6 | 2.8 | 21.7 | 4.2 | 42 | 2.1 | 1.8 | 33.0 | 2.6 | 31.4 | 2.0 | |
| >14 years | 26 | 3.5 | 1.9 | 47.8 | 2.3 | 22.1 | 3.3 | 35 | 1.3 | 1.1 | 33.7 | 3.8 | 31.4 | 1.8 | |
| Sex† | Boy | 50 | 3.2 | 1.9 | 48.3 | 3.0 | 22.3 | 3.7 | 49 | 1.7 | 1.5 | 33.0 | 3.1 | 31.6 | 2.1 |
| Girl | 51 | 3.6 | 1.9 | 48.5 | 3.4 | 21.9 | 3.9 | 52 | 1.9 | 1.6 | 33.6 | 3.0 | 31.1 | 1.9 | |
| Education‡ | Never been to school | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 2.0 | -- | 35.0 | -- | 30.0 | -- |
| Class 1–5 | 42 | 3.8 | 2.1 | 48.6 | 3.8 | 22.2 | 3.8 | 28 | 2.1 | 1.7 | 33.4 | 2.4 | 31.1 | 2.3 | |
| Class 6–12 | 59 | 3.1 | 1.7 | 48.3 | 2.7 | 22.0 | 3.8 | 72 | 1.7 | 1.5 | 33.2 | 3.3 | 31.5 | 1.9 | |
| Uncorrected visual acuity in the worst eye§ | No/mild VI | 84 | 3.3 | 2.0 | 48.4 | 3.2 | 23.6 | 3.9 | 101 | 1.8 | 1.5 | 33.3 | 3.0 | 31.3 | 2.0 |
| Moderate VI | 8 | 3.6 | 0.9 | 48.6 | 2.3 | 22.0 | 3.3 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| Severe VI | 2 | 1.5 | 0.7 | 51.5 | 3.5 | 21.0 | 1.4 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| Blindness | 7 | 4.7 | 2.1 | 47.4 | 4.4 | 22.3 | 3.8 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| Facing problems in performing daily tasks¶ | Yes | 29 | 4.6 | 1.8 | 48.8 | 3.3 | 21.5 | 4.2 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| No/cannot say | 72 | 2.9 | 1.8 | 47.4 | 3.1 | 22.3 | 3.6 | 101 | 1.8 | 1.5 | 33.3 | 3.0 | 31.3 | 2.0 | |
| Ever faced neglect from friends/family/relatives** | Yes | 55 | 3.8 | 1.7 | 48.7 | 3.4 | 22.4 | 3.8 | 3 | 2.0 | 1.0 | 37.0 | 1.0 | 29.7 | 0.6 |
| No | 46 | 2.9 | 2.0 | 48.1 | 3.0 | 21.7 | 3.8 | 98 | 1.8 | 1.6 | 33.3 | 3.1 | 31.4 | 2.0 | |
| Ever faced mistreatment from friends/family/relatives†† | Yes | 51 | 4.0 | 1.8 | 48.4 | 3.7 | 22.2 | 3.8 | 1 | 2.0 | -- | 31.0 | -- | 31.0 | -- |
| No | 50 | 2.8 | 1.8 | 48.4 | 2.6 | 22.0 | 3.8 | 100 | 1.8 | 1.5 | 33.4 | 3.0 | 31.4 | 2.0 | |
SD refers to standard deviation. * Independent sample t-test for significance: P=0.814, 0.601, and 0.490 for ES, LSD, and SE for strabismus children; P=0.044, 0.567, and 0.876 for ES, LSD, and S for non-strabismus children. †Independent sample t-test for significance: P=0.223, 0.721, and 0.547 for ES, LSD, and SE for strabismus children; P=0.580, 0.327, and 0.229 for ES, LSD, and SE for non-strabismus children. ‡Independent sample t-test for significance: P=0.045, 0.645, and 0.815 for ES, LSD, and SE for strabismus children; P=0.460, 0.462, and 0.529 for ES, LSD, and SE for non-strabismus children. §Independent sample t-test for significance: P=0.135, 0.471, and 0.674 for ES, LSD, and SE for strabismus children; P values could not be computed for non-strabismus children as there were fewer than two groups. ¶Independent sample t-test for significance: P<0.001, 0.050, and 0.323 for ES, LSD, and SE for strabismus children; P values could not be computed for non-strabismus children as there were fewer than two groups. ** Independent sample t-test for significance: P=0.020, 0.346, and 0.373 for ES, LSD, and SE for strabismus children; P=0.822, 0.334, and 0.137 for ES, LSD, and SE for non-strabismus children. ††Independent sample t-test for significance: P=0.001, 0.892, and 0.737 for ES, LSD, and SE for strabismus children; P=0.898, 0.443, and 0.862 for ES, LSD, and SE for non-strabismus children
There was no significant variation in the level of ES, LSD, and SE scores with age in both groups [Fig. 1]. Pearson's correlation coefficients were calculated to analyze the relations of SE with ES and LSD in both groups. The results are displayed in Table 3. Overall, the correlation coefficients obtained reveal the existence of significant negative correlations of SE with ES and LSD assessed, except between SE and ES in the non-strabismus group. A significant negative correlation was confirmed between SE and LSD in the strabismus group.
Figure 1.
Distribution of emotional symptoms (ES), loneliness and social dissatisfaction (LSD), and self-esteem (SE) scores for age among strabismus and non-strabismus children in Nashik
Table 3.
Pearson r correlation coefficients among the emotional symptom, loneliness/social dissatisfaction, and self-esteem for the strabismus and non-strabismus group
| Self-esteem | |||
|---|---|---|---|
|
| |||
| Total (n=202) | Strabismus group (n=101) | Non-strabismus group (n=101) | |
| Emotional symptoms | −0.42* | −0.29 | 0.02 |
| Loneliness and social dissatisfaction | −0.77* | −0.58** | −0.14 |
*P<0.001; **P<0.05
Determinants of ES, LSD, and SE
Table 4 shows the MCA for the adjusted predicted mean scores for ES, LSD, and SE scores. As expected, being affected with strabismus had the highest effect on the intensity of ES, LSD, and SE with a beta (β) value of 0.223 (P = 0.016), 0.922 (P < 0.001), and 0.853 (P < 0.001), respectively, followed by facing problems in performing daily tasks had the most impact on ES (β 0.196) and LSD (β 0.065) scores, and those aged between 11 and 14 years on SE (β 0.092).
Table 4.
Multiple classification analysis for the effect of selected variables on emotional symptoms, loneliness and social dissatisfaction, and self-esteem amongst children in Nashik, Maharashtra
| Variable | Categories | n=202 | Adjusted predicted mean | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||
| Emotional symptoms | Loneliness and social dissatisfaction | Self-esteem | |||||||||
|
|
|
|
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| Mean | Beta | P | Mean | Beta | P | Mean | Beta | P | |||
| Age | 10 years or below | 48 | 2.6 | 0.047 | 0.761 | 40.5 | 0.028 | 0.841 | 27.6 | 0.092 | 0.365 |
| 11 to 14 years | 93 | 2.7 | 40.9 | 26.5 | |||||||
| >14 years | 61 | 2.5 | 41.1 | 26.4 | |||||||
| Sex | Boy | 99 | 2.4 | 0.081 | 0.195 | 40.7 | 0.018 | 0.507 | 27.0 | 0.047 | 0.236 |
| Girl | 103 | 2.8 | 41.0 | 26.5 | |||||||
| Education | Never been to school | 1 | 2.8 | 0.11 | 0.576 | 44.6 | 0.05 | 0.337 | 25.5 | 0.077 | 0.482 |
| Class 1–5 | 70 | 2.9 | 41.3 | 26.2 | |||||||
| Class 6–12 | 131 | 2.4 | 40.6 | 27.0 | |||||||
| Eye condition | Strabismus | 101 | 3.0 | 0.223 | 0.016 | 48.4 | 0.922 | <0.001 | 22.0 | 0.853 | <0.001 |
| No strabismus | 101 | 2.2 | 33.3 | 31.4 | |||||||
| Uncorrected visual acuity in the worst eye | No/mild VI | 185 | 2.6 | 0.101 | 0.483 | 40.8 | 0.034 | 0.67 | 26.6 | 0.087 | 0.248 |
| Moderate VI | 8 | 2.5 | 41.2 | 28.7 | |||||||
| Severe VI | 2 | 1.3 | 43.5 | 25.2 | |||||||
| Blindness | 7 | 3.3 | 41.0 | 27.8 | |||||||
| Facing problems in performing daily tasks | Yes | 29 | 3.6 | 0.196 | 0.004 | 39.6 | 0.065 | 0.054 | 25.8 | 0.072 | 0.136 |
| No/cannot say | 173 | 2.4 | 41.1 | 26.9 | |||||||
| Ever faced neglect from friends/family/relatives | Yes | 58 | 2.8 | 0.067 | 0.478 | 41.6 | 0.058 | 0.165 | 27.3 | 0.062 | 0.297 |
| No | 144 | 2.5 | 40.6 | 26.5 | |||||||
| Ever faced mistreatment from friends/family/relatives | Yes | 52 | 3.0 | 0.124 | 0.203 | 40.6 | 0.021 | 0.619 | 26.7 | 0.003 | 0.926 |
| No | 150 | 2.5 | 41.0 | 26.7 | |||||||
| Full model | 202 | 0.304 | <0.001 | 0.863 | <0.001 | 0.716 | <0.001 | ||||
F-test significance reported
Discussion
We found a significantly higher proportion of children with untreated strabismus dealing with elevated levels of ES, LSD, and low SE as compared with non-strabismus children in the city of Nashik. Over a quarter of children with strabismus reported facing difficulty in performing daily activities and over half reported being neglected and mistreated by family/friends/relatives as compared to the non-strabismus group. Most evidence supporting the psychological and emotional aspects involving children with strabismus comes from the QoL studies, using diverse QoL tools of which psycho-social aspects are a small subset.[3,12-15] To the best of our knowledge, ours is the first study to explicitly look at the social–emotional aspects such as ES, LSD, and SE amongst Indian children with untreated strabismus. Elevated levels of ES and LSD and low SE among children with untreated strabismus is a concern that needs attention and highlight the unmet social–emotional needs of these children. There is a strong intervention implication for social–emotional outcomes among children with untreated strabismus as the strategies aiming to improve early case detection would yield desired psychosocial benefits for these children and their families. Evidence suggests that early detection can help minimize visual dysfunction, allow for normal development of binocular vision and depth perception, and prevent psychosocial dysfunction.[36,37]As children spend most of their active time at school, teachers present an enormous opportunity in early case detection. Training and actively involving school teachers as part of school screening initiatives and investing in awareness generation activities in the communities and schools to sensitize teachers, parents/caregivers about strabismus could aid in early case detection and prompt treatments, although a robust scientific investigation into such efforts is warranted.
We found a strong and significant negative correlation between SE and LSD, specifically amongst the strabismus group, which is consistent with evidence that points to a strong link between loneliness and self-esteem.[38,39] Individuals with low SE are likely to feel rejected and are disapproving of others; in addition, they may lack the self-confidence and social skills required for initiating and developing relationships, factors that are related to loneliness.[39] A recent meta-analysis found that interventions can reduce loneliness and improve SE.[40] The psychosocial and emotional needs of children with strabismus are most often neglected in the eye care program design. As most pediatric eye care curative services are provided from standalone eye health facilities, and with an increase of case detection through school eye screening initiatives, there is a need for specific interventions and importantly to build and sustain robust referral mechanisms with qualified mental health practitioners. Regular counseling of affected children and their caregivers that includes the teaching of emotion management and imparting social skills is required.
There are some limitations of this study to be taken into consideration. As validated social–emotional scales for children are not readily available in India, we used ES, LSD, and SE, which have been used in various cultures. However, all psychological measures should be interpreted with caution in different cultures. We, therefore, used continuous scales and not the clinical cut-off score reflecting Western norms as it may be inappropriate for this study population. We also relied on self-reported social–emotional symptoms during the interview and were unable to confirm psychiatric diagnoses. For this reason, conclusions from the present study should be confined to the construct of social–emotional symptomology, rather than extend to specific diagnoses. The cross-sectional nature of these data does not allow temporal or causal explanations as these data do not allow comment on social–emotional issues in these children post-treatment.
Conclusion
The social–emotional needs of children with untreated strabismus are most often neglected in the eye program design. Efforts to boost early case diagnosis and provision of adequate and timely psycho-social support are necessary. There is a need for specific tailor-made interventions that address the psychosocial needs of these children and to train the existing eye care service providers and school teachers in the identification of social–emotional issues and incorporating these into their regular service delivery mechanisms would address this problem to a certain degree. In conclusion, this study has contributed to building evidence, and further work is needed to understand the long-term impacts of strabismus and its correction on a child's social–emotional state. The urgent need to address the poor social–emotional health of children, particularly those with strabismus, in India is highlighted.
Availability of data and materials
Access to the local database is available upon request to the corresponding author.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Data Availability Statement
Access to the local database is available upon request to the corresponding author.