Understanding clinical features, predictors of late presentation, and caregiver perspectives and awareness of strabismus in children: a cross-sectional study in a sub-Saharan African setting

Abstract

Background

Childhood strabismus is a common eye disorder with visual and psychosocial implications. Late presentation remains frequent, influenced by clinical and demographic factors, as well as caregiver knowledge, awareness, and perceptions in sub-Saharan Africa. This study sought to analyze the clinical features, predictors of late presentation, and caregiver perspectives and awareness of strabismus among children attending the Eye Department at Komfo Anokye Teaching Hospital.

Materials and methods

A hospital-based analytical cross-sectional study was conducted on 282 children aged 3–15 years. Data on the demographic and clinical characteristics of the participants were analyzed using SPSS Version 20. The chi-square test was used to examine the associations between late presentation and demographic and clinical features. Logistic regression analysis was used to analyze the predictors of late presentation of strabismus, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. Statistical significance was set at P < 0.05.

Results

The study included 282 children with strabismus, with a mean age at onset of 4.0 ± 1.2 years and a mean age at presentation of 10.1 ± 9.4 years. The majority (148/282, 54.5%) were males. There was a predominance of a left eye deviation (166/282, 58.9%); esotropia predominated (204/282, 72.3%), with 50% inward deviation, 83.3% constant deviation, and 85.5% equal vision in both eyes. 83% of patients presented late. Predictors of late presentation were: having no knowledge about strabismus (p = 0.01, OR = 2.6, CI: 1.3–5.5), low parental education (p = 0.013, OR = 2.3, CI: 1.2–4.4), and having no relative with strabismus (p = 0.003, OR = 3.7, CI: 1.5–8.6). Most parents (189/282, 67.30%) were aware of strabismus, with hospitals being the main source of information (87/189, 46.0%). While 133/282 (47.2%) believed that it was treatable, 149/282 (52.8%) held misperceptions.

Conclusions

Esotropia was the most common type of strabismus, with left eye deviation being the most prevalent. Having no knowledge about strabismus, low parental education, and having no relative with strabismus predicted late presentation. Even with caregiver awareness, misperceptions persisted, highlighting the need to strengthen public education and early intervention strategies.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-026-05220-x.

Introduction

Strabismus, often referred to as squint, is a major ocular disorder in childhood [1]. It is defined by misalignment of the visual axes and is associated with impaired visual function, aesthetic concerns, psychosocial challenges, and reduced vision-related quality of life [2, 3]. Epidemiological evidence from multiple regions indicates a global prevalence of approximately 1.93% [4], with reported rates ranging from 0.2% to 2.4% in sub-Saharan Africa [5]. In Ghana, a community-based survey among school-aged children documented a prevalence of 0.2% [6].

Based on the direction of deviation, strabismus is categorized into esotropia (inward deviation), exotropia (outward deviation), hypertropia (upward deviation), and hypotropia (downward deviation) [7, 8]. The primary goals of management are to restore ocular alignment and include pharmacological therapy, optical correction with spectacles or prisms, orthoptic exercises, and extraocular muscle surgery [9]. Failure to diagnose and manage the condition promptly may lead to serious ocular complications, notably irreversible visual loss resulting from untreated amblyopia [10].

Multiple factors influence the timing of presentation to health facilities among children with strabismus. Insufficient parental awareness regarding the nature of the condition, its potential consequences, and available treatment options has been identified as a major contributor to delayed care-seeking [11]. Economic constraints, including treatment costs and transportation expenses, further restrict access to timely services [12]. In addition, sociocultural factors such as religious beliefs, fear of large hospitals, and stigma associated with ocular misalignment may discourage early presentation [12].

In the present study, a six‑month interval from the onset of strabismus was used to define early and late presentation, consistent with evidence from a randomized multicenter controlled trial [13] which demonstrated that early presentation was associated with better visual outcomes and fewer adverse effects compared with late presentation. Management within this critical period is essential for restoring ocular alignment, correcting abnormal head posture, and promoting optimal binocular single vision [11].

At the Eye Department of Komfo Anokye Teaching Hospital (KATH), the second-largest tertiary eye care facility in Ghana, a growing proportion of children with strabismus reportedly present with advanced disease. Such delays are associated with poorer visual outcomes and impose substantial psychosocial and economic burdens on affected children and their families, thereby compromising quality of life [3, 14, 15].

The present study sought to identify predictors of late presentation among children attending the Eye Department of Komfo Anokye Teaching Hospital and to evaluate parental knowledge and perceptions of the condition.

Materials and methods

Study design and setting

This was a hospital-based analytical cross-sectional study conducted at the Eye Department of Komfo Anokye Teaching Hospital (KATH), a major tertiary referral center in Kumasi, Ghana, from April 2020 to January, 2021.

Study participants

Consecutive children aged 3–15 years with strabismus were recruited during the study period. Written informed consent was obtained from the parents or caregivers of all participants, and written assent was obtained from children aged ≥ 7 years before their participation. This was done to ensure both parental permission and the child’s willingness to participate were respected in accordance with ethical standards for research involving minors in clinical research.

In this study, the unit of analysis is the children, but the data source is the parent/caregiver. Thus, our study population was all children aged ≤ 15 years who presented with strabismus at the Eye Department of KATH and were eligible for inclusion. Since these children may not be able to answer questions on awareness, knowledge, medical history, and household characteristics, we collected data using structured questionnaires administered to the parents or primary caregivers of these children. Thus, while the children were the study population, parents/caregivers served as the respondents for the study. Children who were severely ill or unconscious because of comorbid medical or psychological conditions were excluded. The minimum required sample size of 271 was calculated using Cochran’s formula [16], based on a reported prevalence of 17.9% for strabismus in a Southern Ethiopian population [17]. To account for potential non-response, 282 children were recruited.

Data collection and questionnaire

Participants were recruited consecutively, and data were collected using structured questionnaires and clinical examination forms administered to the parents or primary caregivers of participating children.

The structured questionnaire was divided into six sections to capture comprehensive information relevant to the study. Section A (socio-demographic information of the children) recorded the child’s age, sex, educational level, and place of residence. Section B (socio-demographic information of the parents/caregivers) also recorded information on the parent or caregiver who answered the questions. These included: age, sex, relationship to the child, educational level (lower education = Kindergarten to Junior high school; higher education = Senior high school to tertiary education), occupation, and monthly household income. Section C (onset of strabismus and arrival time) had questions about the age at which strabismus was first noticed in the child, the duration before seeking medical attention, and the time taken to arrive at the hospital. Section D (clinical characteristics of strabismus) had information on clinical data that were obtained from the medical records of the children and confirmed during examination. Variables obtained included type of strabismus, laterality, type of deviation, and angle of deviation, among others. Section E (awareness, knowledge, and community perception about strabismus) explored parental awareness of strabismus as a condition, their knowledge of its causes and treatment options, and community attitudes toward children with strabismus. Parental awareness and knowledge about strabismus refers to the extent to which they can identify a child with strabismus, understand its causes, and the treatment options available. This was assessed using a dichotomous (yes/no) response. Parental knowledge of strabismus was assessed using a structured questionnaire consisting of five items. The questions explored recognition of strabismus (can you recognize strabismus- eye misalignment when you see it, yes / no / not sure), understanding of its causes (do you think strabismus is caused by: eye muscle problems, spiritual or cultural reasons, don’t know), awareness of its impact on vision (does strabismus affect a child’s vision if left untreated?, yes/no / not sure), knowledge of treatment options (which of the following can be used to treat strabismus? glasses, surgery, exercises/therapy, don’t know), and health seeking behavior (If you noticed strabismus in your child, how soon would you seek medical care?, immediately, after some time, not necessary). Each item was designed to capture both awareness and accuracy of knowledge in a simple, culturally appropriate format. Responses were coded dichotomously: correct answers were scored as “1” and incorrect or “don’t know” responses as “0.” A composite knowledge score was then generated by summing across the five items. For analysis, the score was dichotomized: participants who answered at least three items correctly were classified as having adequate knowledge (Yes), while those with fewer than three correct responses were classified as having inadequate knowledge (No). Sources of information and knowledge of appropriate treatment centers were also noted. Perception was assessed by evaluating community beliefs regarding whether strabismus is a medical condition, a treatable disease, or a condition attributed to spiritual or supernatural causes. Section F (Accessibility) focused on barriers and facilitators to accessing eye care services. This included: proximity to the treatment facility, how long it takes for participants to get to the treatment center, and the means by which they get to the center.

Trained interviewers conducted face‑to‑face interviews in English or local languages (Twi, Ga, Ewe), following standardized protocols to ensure consistency. Where parents were uncertain about specific items, responses were recorded as ‘don’t know’ to avoid misclassification. Completed questionnaires were reviewed daily by the principal investigator for completeness and accuracy.

We developed the questionnaire (supplementary file 1) in consultation with pediatric ophthalmologists and public health experts, drawing on information from appropriate literature to ensure content relevance and appropriateness [12–17]. The questionnaire was pretested among 20 parents/caregivers to examine its clarity, feasibility, and ease of administration. The pretesting yielded an internal consistency coefficient (Cronbach’s alpha) of 0.82, indicating strong reliability. Following feedback from the pretesting, minor adjustments were made to the wording of certain items and to the response options to improve comprehension and reduce ambiguity. In general, the validity was judged to be good, confirming that the instrument was suitable for assessing parental awareness, knowledge, and perceptions of strabismus.

Study procedure

All the children included in the study underwent comprehensive ophthalmic examinations. Visual acuity was assessed using age-appropriate methods. For infants aged 0–6 months, visual function was assessed using the objection to occlusion. The Cardiff Acuity Test was used for children aged 6–36 months, the Sheridan–Gardiner test for those aged 36–60 months, and the Snellen chart for children older than 60 months of age. Visual acuity outcomes were classified according to the International Classification of Diseases, 11th Revision (ICD-11) as normal vision (6/6–6/12), mild visual impairment (< 6/12–6/18), moderate visual impairment (< 6/18–6/60), severe visual impairment (< 6/60–3/60), and blindness (< 3/60) [18].

Anterior segment examination was performed using a portable slit-lamp biomicroscope (Topcon, United Kingdom). Posterior segment evaluation was conducted following pupillary dilation using a HEINE OMEGA 500 LED binocular indirect ophthalmoscope (HEINE Optotechnik, Germany) with Volk 20D lens (Volk Optical, USA). Cycloplegic refraction was performed in all participants using 1% cyclopentolate and 2.5% phenylephrine eye drops. Two to three drops of 1% cyclopentolate were instilled at five-minute intervals, and refraction was performed 30 min after instillation using a streak retinoscope. Spectacle correction was prescribed for participants with clinically significant refractive errors.

Strabismus assessment was conducted using the unilateral cover–uncover test, alternate cover test, and simultaneous prism cover test, with and without optical correction, using an accommodative fixation target [19]. The magnitude of deviation at distance and near fixation was measured by introducing prisms until ocular movement was neutralized. Strabismus was defined as the presence of any manifest deviation, whether constant or intermittent, at near or distance fixation as detected by cover testing [20]. Late presentation was defined as presentation to the eye department more than six months after caregivers first noticed signs of strabismus [13].

Data analysis

Data were entered, cleaned, and analyzed using the IBM SPSS Statistics version 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize the sociodemographic and clinical characteristics. Chi-square test was used to examine the associations between the demographic and clinical characteristics of patients with strabismus and late-stage disease. Multivariate logistic regression analysis was performed to identify predictors of late presentation of strabismus. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Statistical significance was set at P < 0.05.

Ethical considerations

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board of Komfo Anokye Teaching Hospital, Ghana (IRB registration number: RD/CR19/039).

Results

Sociodemographic characteristics of the children and their parents/ caregivers

A male preponderance (148/282, 52.5%) was observed. Most participants (236/282, 83.7%) were aged 0 to 10 years. The mean age of participants was 6.7 ± 3.1 years (range = 3–15 years), with a median of 6 years. The mean age at onset of strabismus was 3.8 ± 1.2 years (range = 2–5 years) for most participants (260/282, 92.2%), while the median age at onset was 4 years. The average reporting time from first suspicion to presentation was 1.8 ± 0.4 years (median = 2 years). Transportation costs averaged GHC 6.4 ± 3.0 (range = 0–10.0), with a median of GHC 7.0. Other details of the participants’ sociodemographic characteristics are displayed in Table 1.

Table 1.

Sociodemographic characteristics of children with strabismus presenting at KATH (N=282)

Characteristics	Frequency	Percentage (%)
Sex
Male	148	52.5
Female	134	47.5
Age, years
≤10	236	83.7
11-15	46	16.3
Place of residence
Rural	253	89.7
Urban	29	10.3
Age at onset of strabismus, years
2-5	260	92.2
6-11	22	7.8
Educational level of the child
None	7	2.5
Preschool	99	35.1
Basic school	175	62.1
Senior High School	1	0.4
Religion
Christian	202	71.6
Muslim	44	15.6
Traditionalist	36	12.8
Registered for NHIS	207	73.4
Age at onset of first suspicion of strabismus, years
Early childhood (2-5)
Middle childhood (6-15)	260	92.2
Relative with strabismus	22	7.8
Reporting time of strabismus	214	75.9
Early (before 6 months)
Late (after six months)	48	17
Proximity to the hospital	234	83
Near (<50 km)	118	41.8
Far (>50 km)	164	58.2

Abbreviations: km=kilometer, NHIS=National Health Insurance Scheme. The mean age and standard deviation were 6.7±3.1 years. The minimum and maximum ages were 3.0 years and 15.0 years, respectively

A total of 282 parents or caregivers participated in the study, with a female majority (76.6%). The mean and median ages of parents/caregivers were 38.6 ± 7.2 years and 36.0 years, respectively, ranging from 23 to 56 years. Most of the parents/ caregivers resided in rural areas (89.7%). Most had low education (211, 74.8%). Nearly all respondents were employed (97.5%). Christians were the majority (202, 71.6%). Regarding the relationship to the child, mothers constituted the largest group (190, 67.4%). About 30.1% (85) of parents/caregivers reported that the child’s condition was a financial burden to the family. Most children (207/282, 73.4%) were registered with the National Health Insurance Scheme. Two hundred and five (205/282, 72.7%) parents/caregivers earn an income of more than GHC 2000 per month.

Clinical characteristics of the children with strabismus

There was a predominance of a left eye deviation (166/282, 58.9%). Esotropia was the most common type (204/282, 72.3%) of strabismus among the participants (Table 2). The data on the clinical characteristics of the participants are summarized in Table 2.

Table 2.

Clinical characteristics of children with strabismus presenting at the Komfo Anokye Teaching Hospital (N=282)

Parameter	Frequency	Percentage (%)
Deviated eye
Left eye	166	58.9
Right eye	80	28.4
Both eyes	36	12.8
Direction of deviation
Inwards	141	50
Outwards	70	24.8
Superior	45	16
Inferior	26	9.2
Types of deviation
Constant	235	83.3
Intermittent	47	16.7
Types of strabismus
Esotropia	204	72.3
Exotropia	35	12.4
Hypertropia	34	12.1
Hypotropia	9	3.2
Angle of deviation, prism diopters
<20	15	5.3
20-30	50	17.7
31-60	214	75.9
>60	3	1.1
Types of angles of deviation, °
Small angle (<20)	15	5.3
Large angle (>20)	267	94.7
Equality of vision
Equal vision in both eyes	241	85.5
Unequal vision in both eyes	41	14.5
Intermittent deviation	47	16.7
Occurrence of intermittent deviation
When sick	28	59.6
When tired	15	31.9
When loss of concentration	4	8.5

Associations between the characteristics of children with strabismus and late-stage disease

Statistically significant associations were found between the following sociodemographic characteristics and late presentation: age of child (p = 0.002), age at onset of strabismus (p = 0.019), parental education (p = 0.017), age at onset of first suspicion of strabismus (p = 0.019), and parental knowledge about strabismus (p = 0.001; Table 3).

Table 3.

Associations between the demographic characteristics of children with strabismus and late-stage disease (N=282)

Characteristics	Late presentation
	Yes	No	Total	P value
	N(%)	N(%)	N(%)
Sex of the child				0.874
Male	122(43.3)	26(9.2)	148(52.5)
Female	112(39.7)	22(7.8)	134(47.5)
Total	234(83.0)	48(17.0)	282(100.0)
Age of the child, years				0.002*
0-10	189(67.0)	47(16.7)	236(83.7)
11-15	45(16.0)	1(0.4)	46(16.3)
Total	234(83.0)	48(17.0)	282(100.0)
Place of residence				0.572
Rural	210(74.5)	43(15.2)	253(89.7)
Urban	24(8.5)	5(1.8)	29(10.3)
Total	234(83.0)	48(17.0)	282(100.0)
Age at onset of strabismus, years				0.019*
2-5	212(75.2)	48(17.0)	260(92.2)
6-11	22(7.8)	-	22(7.8)
Total	234(83.0)	48(17.0)	282(100.0)
Parent/caregiver education †				0.017*
Lower education	182(64.5)	29(10.3)	211(74.8)
Higher education	52(18.4)	19(6.7)	71(25.2)
Total	234(83.0)	48(17.0)	282(100.0)
Religion of children				0.879
Christian	169(59.9)	33(11.7)	202(71.6)
Muslim	36(12.8)	8(2.8)	44(15.6)
Traditionalist	29(10.3)	7(2.5)	36(12.8)
Total	234(83.0)	48(17.0)	282(100.0)
Registered for NHIS	167(59.2)	40(14.2)	207(73.4)	0.059
Age at onset of first suspicion of strabismus, years				0.019*
Early childhood (2-5)	212(75.2)	48(17.0)	260(92.2)
Middle childhood (6-15)	22(7.8)	-	22(7.8)
Total	234(83.0)	48(17.0)	282(100.0)
Relative with strabismus	184(65.2)	30(10.6)	214(75.9)	0.025*
Proximity to the hospital				0.525
Near (<50 km)	100(35.5)	18(6.4)	118(41.8)
Far (≥50 km)	134(47.5)	30(10.6)	164(58.2)
Parental knowledge about strabismus	66(23.4) 166(58.9)	27(9.6)	93(33.0)	0.001*
Fear of surgery	169(59.9)	38(13.5)	204(72.3)	0.29
Ability to afford hospital bills		35(12.4)	204(72.3)	0.538
Parental monthly income, GHS	29(10.3)			0.622
<2000.00	205(72.7)	4(1.4)	33(11.7)
≥2000.00		44(15.6)	249(88.3)

Abbreviations: GHS, Ghana cedis; km, kilometer; NHIS, National Health Insurance Scheme. *Statistically significant associations, † = Lower education = Kindergarten to Junior high school; Higher education = Senior high school to tertiary education

No statistically significant associations were found between the clinical characteristics of the participants and late-stage disease (Table 4).

Table 4.

Associations between the clinical characteristics of patients with strabismus and late-stage disease (n=282)

Variables	Late presentation
	Yes	No	Total	P value
	N(%)	N(%)	N(%)
Type of strabismus				0.495
Esotropia	168(59.6)	36(12.8)	204(72.3)
Exotropia	30(10.6)	5(1.8)	35(12.4)
Hypertropia	27(9.6)	7(2.5)	34(12.1)
Hypotropia	9(3.2)	-	9(3.2)
Type of angle of deviation				0.514
Small angle (<20 prism diopter)	13(4.6)	2(0.7)	15(5.3)
Large angle (>20 prism diopter)	221(78.4)	46(16.3)	267(94.7)
Type of deviation				0.206
Constant	198(70.2)	37(13.1)	235(83.3)
Intermittent	36(12.8)	11(3.9)	47(16.7)
Visual acuity				0.655
Equal vision in both eyes	201(71.3)	40(14.2)	241(85.5)
Unequal vision in both eyes	33(11.7)	8(2.8)	41(14.5)
Direction of deviation				0.089
Inwards	118(41.8)	23(8.2)	141(50.0)
Outwards	60(21.3)	10(3.5)	70(24.8)
Superior	32(11.3)	13(4.6)	45(16.0)
Inferior	24(8.5)	2(0.7)	26(9.2)
Deviated eye				0.383
Left eye	139(49.3)	27(9.6)	166(58.9)
Right eye	68(24.1)	12(4.3)	80(28.4)
Both eyes	27(9.6)	9(3.2)	36(12.8)

Predictors of late presentation of strabismus

From the unadjusted regression model, the predictors of late presentation in this study were limited parental awareness and knowledge of strabismus (p = 0.01, OR = 2.6, CI: 1.3–5.5), low parental education (p = 0.013, OR = 2.3, CI: 1.2–4.4), and having no relative with strabismus (p = 0.003, OR = 3.7, CI: 1.5–8.6). From the multivariable logistic regression (adjusted odds ratio-AOR), age of patient was associated with an increased odds of late presentation (p = 0.048, AOR = 7.9, CI: 1.0–61.1). Children who are not registered under the NHIS were more than twice as likely to present late (p = 0.041, AOR = 2.5, CI: 1.0–6.1). Having a relative with strabismus reduced the likelihood of late presentation (p = 0.049, AOR = 0.5, CI: 0.2–1.0). Caregiver knowledge about strabismus significantly lowered the odds of late presentation (p = 0.011, AOR = 2.2, CI: 2.0–4.8). (Table 5).

Table 5.

Predictors of late presentation in children with strabismus at KATH (N = 282)

Predictors	OR (95% CI); P-value	AOR (95% CI); P-value
Age of child, years
0-10 vs 11-15	0.2 (0.03-1.9);0.179	7.9(1.0-61.1);0.048*
Parental education
Higher education vs	2.3 (1.2-4.4);0.013*	0.7(0.3-1.4);0.293
Lower education
Proximity to KATH
Near vs Far	1.6 (0.8- 3.3);0.220	0.6(0.3-1.2);0.137
Residence
Rural vs Urban	1.5 (0.5-4.4);0.512	0.9(0.3-2.5);0.777
Beneficiary of NHIS
Yes vs No	0.4 (0.2-1.1);0.068	2.5(1.0-6.1);0.041*
Limited parental knowledge about strabismus
Yes vs No
	2.6 (1.3-5.5);0.010*	2.2(2.0-4.8);0.011*
Relative with strabismus
Yes vs No	3.7 (1.5-8.6);0.003*	2.5(0.2-1.0);0.049*
Monthly income level, GHS
<2000.00 vs  ≥2000.00	0.5 (0.1-1.7);0.233	1.3(0.4-4.2);0.713

Abbreviations: CI, confidence interval; GHS, Ghana Health Service; KATH, Komfo Anokye Teaching Hospital. *Statistically significant association. Lower education = Kindergarten to Junior high school; Higher education = Senior high school to tertiary education. AOR, Adjusted Odds Ratio. The relatively high adjusted odds ratios observed (e.g., age of patient, AOR = 7.9) should be interpreted with caution. Such values may reflect small subgroup sizes, imbalanced category distributions, or residual confounding. The wide confidence intervals (CI: 1.0–61.1) indicate imprecision in the estimates, suggesting that while the direction of association is robust, the exact magnitude is uncertain. These findings highlight the importance of focusing on the significance and relative effect direction rather than absolute odds ratio values

Knowledge, awareness and perceptions of strabismus among parents and guardians

33% (93, 33.0%) of the parents had knowledge about strabismus, and 189 (67.0%) were aware of strabismus, with 87 (46.0%) obtaining their knowledge from a hospital (Table 6). Although some parents (133/282, 47.2%) believed that strabismus was a treatable disease, more than half of the parents/guardians (149/282, 52.8%) had misperceptions about the disease (Table 6). In a sub‑group analysis of parental education and misperceptions about strabismus, 51.2% of caregivers with lower education and 54.9% of those with higher education reported misperceptions; this difference was not statistically significant (χ² = 0.299, df = 1, p = 0.585), indicating that misperceptions were prevalent across both education groups.

Table 6.

Awareness and perceptions of parents/guardians of patients with strabismus about strabismus (N = 282)

Parameter	Frequency	Percentage (%)
Knowledge of strabismus	93	33.0
Heard (aware) about strabismus	189	67.0
Source of information on strabismus:
Hospital	87	46.0
School	23	12.2
Social media	22	11.6
Radio/Television	55	29.1
Relatives	2	1.1
Can you recognize strabismus when you see it	185	65.6
Have people with strabismus in the family	214	75.9
Best treatment center for strabismus
Hospital	227	80.5
Church	47	16.7
Native doctor	8	2.8
Perception about strabismus
It is a disease that is treatable	133	47.2
Does not consider it as a disease	94	33.3
It is an untreatable disease	44	15.6
It is a curse from the gods for punishment for sins	11	3.9

Discussion

Strabismus remains an important public health concern in many developing countries and is frequently associated with delayed access to appropriate healthcare services [21]. In the present cohort, esotropia was the most prevalent type of strabismus, with left eye deviation being the most frequent. These findings are consistent with reports by Abdul Kabir et al., who observed a high prevalence of esotropia among optometry students [22], as well as pooled estimates from sub-Saharan Africa indicating esotropia as the predominant subtype [23]. The high proportion of constant deviation (83.3%) observed in this study is clinically important, as persistent misalignment substantially increases the risk of amblyopia and compromised binocular vision, thereby adversely affecting visual development and quality of life. Notably, most participants (85.5%) demonstrated comparable visual acuity in both eyes, suggesting the presence of compensatory mechanisms despite ocular misalignment. Nevertheless, the long-term risk of adverse sensory adaptations remains considerable.

A marked predominance of left eye deviation was observed in this study. Although laterality in strabismus has received limited attention in sub-Saharan Africa, evidence from other regions suggests that ocular dominance and neurodevelopmental factors may contribute to side preference [24]. Further research is warranted to determine whether left-sided deviation is associated with distinct prognostic implications. The predominance of esotropia in this population mirrors trends reported in Western countries [4], whereas studies from Asian populations commonly describe higher rates of exotropia [25]. These findings underscore the burden of esotropia and constant deviation in Ghanaian children. Improving routine vision screening and caregiver education is indispensable for ensuring early diagnosis and intervention to reduce the risk of amblyopia and improve long-term visual outcomes.

In the present study, a substantial majority of participants (83.0%) presented more than six months after the onset of strabismus, underscoring a major gap in timely eye care and placing them at an increased risk of ocular morbidity, including amblyopia and other irreversible visual complications. This finding underscores the critical need to identify and address determinants of delayed presentation in children with strabismus and an urgent need for interventions that promote early detection and prompt referral. Beyond the quantitative predictors identified, the interval between detection and presentation represents a critical window in which caregiver decisions and actions shape outcomes. Although our study primarily captured questionnaire‑derived perceptions, future research should explore in detail what parents and caregivers actually do during this period—whether they seek informal advice, rely on traditional remedies, delay due to financial or logistical constraints, or wait for symptoms to worsen. Such qualitative insights would provide a richer understanding of the beliefs and motivations driving care‑seeking behavior. Integrating these perspectives with quantitative predictors could inform culturally sensitive education campaigns, strengthen referral pathways, and ultimately reduce delays in presentation.

This study identified several independent predictors of late presentation among children with strabismus. Age of the patient was significantly associated with delayed care, with older children nearly eight times more likely to present late. This finding suggests that strabismus is often overlooked in early childhood, only becoming a concern when visual or cosmetic issues become more pronounced at school-going age.

Delayed presentation among caregivers with lower educational levels may reflect limited understanding of the clinical significance of strabismus. In such circumstances, ocular misalignment may be perceived as a benign cosmetic variation rather than a medical disorder warranting early intervention. This misinterpretation may result in the postponement of medical consultation until visual and social complications have become established. Enhancing parental education is therefore central to improving early detection and management.

Family members often represent important sources of health information, as they serve as a source of reference for an individual with strabismus or a parent with a child with strabismus, owing to their proximity [26]. Although genetic predisposition has been implicated in the development of strabismus [27], limited literature has explored the influence of family history on care-seeking behavior. In this study, despite a substantial proportion of participants reporting a positive family history of strabismus, only a few (1.1%) caregivers obtained information from relatives. Nonetheless, the absence of a positive family history was significantly associated with delayed presentation, possibly reflecting the lack of experiential knowledge and guidance that might otherwise encourage timely medical consultation [28]. Additional research is needed to clarify this relationship.

In examining the association between enrollment in the National Health Insurance Scheme (NHIS) and time of presentation, there was no significant association (p = 0.068). However, the adjusted odds ratio showed that children who were not registered under the National Health Insurance Scheme (NHIS) were more than twice as likely to present late. This apparent discrepancy can occur because the unadjusted association (p = 0.068) did not reach statistical significance, yet the adjusted odds ratio revealed a meaningful effect once confounding variables were controlled. In practice, children not registered under NHIS may face greater financial and access barriers, making them more than twice as likely to present late. The lack of statistical significance in the crude analysis could reflect sample size limitations or overlapping influences, but the adjusted model highlights underlying systemic factors that become clearer after accounting for confounders. In interpreting the association between NHIS registration and time to presentation, it is important to note that 73.4% of participants were registered under the scheme, providing critical context for understanding its influence on care‑seeking behavior. Given that the scheme subsidizes pediatric ophthalmic care, including strabismus management [29], financial barriers to accessing treatment may have been partially mitigated in this population.

Protective factors were also observed. Caregiver knowledge about strabismus significantly reduced the odds of late presentation, underscoring the importance of public education and awareness campaigns. Similarly, having a relative with strabismus lowered the likelihood of delay, possibly due to prior exposure to the condition and recognition of its implications.

Overall, these findings highlight the need for targeted interventions—strengthening caregiver education, addressing systemic barriers within NHIS, and promoting early screening programs. Such measures could reduce delays, improve visual outcomes, and mitigate the psychosocial burden of strabismus in children. Overall, parental awareness of strabismus in this study was comparable to findings from similar studies [15, 30]. Adequate awareness is essential in promoting positive health-seeking behavior, particularly given that most affected children in this study were younger than 10 years and were therefore entirely dependent on their parents or guardians for healthcare decisions. Insufficient awareness, on the other hand, may hinder caregivers’ ability to recognize strabismus as a medical condition requiring prompt treatment and to identify appropriate healthcare pathways, thereby contributing to delayed health-seeking behavior [10]. In our study, 189 caregivers (67.0%) reported that they had heard (were aware) about strabismus. This indicates exposure to the term or condition, but not necessarily accurate understanding. It was evident that when tested further, many of those same caregivers still held misperceptions or limited knowledge about strabismus. So, while they claimed awareness, their understanding was incomplete or incorrect. This therefore reflects an important distinction between awareness and knowledge. Encouragingly, hospitals were reported as the primary source of information about strabismus by most respondents, suggesting that health facilities play a pivotal role in disseminating accurate and reliable information on strabismus. Therefore, sustained public education efforts within healthcare settings may contribute to improved awareness and earlier presentation.

Despite the expanding role of digital media in health communication [31], relatively few participants reported obtaining information from online platforms or social media. This finding contrasts with reports from Ethiopia, where electronic media constitute major sources of health information [15]. It is, therefore, disappointing that only a marginal fraction of our participants had received their information about strabismus through this means, highlighting its underutilization. While concerns exist regarding the reliability of online health information, reputable databases, such as Google, have been shown to provide useful and accurate health content and could be strategically employed to enhance public education of strabismus [32]. The limited utilization of digital resources in the present study may be attributable to lower educational attainment and reduced internet access among older adults in Ghana [33].

Although most caregivers correctly identified hospitals as appropriate centers for treatment, a considerable proportion regarded churches or traditional healers as suitable alternatives. Such sociocultural beliefs are well documented in Ghana and have been linked to delayed presentation of various medical conditions, including endocrine and rheumatologic disorders [34, 35]. Reliance on inappropriate sources of care frequently leads to disease progression and presentation at advanced stages, when irreversible visual damage may have already occurred.

Misperceptions regarding strabismus were widespread in this study, despite moderate levels of reported awareness. More than half of the respondents held inaccurate beliefs, including perceptions that strabismus is not a disease, is untreatable, or has spiritual origins. The misperceptions about strabismus documented in this study, despite 67.3% reporting awareness of the condition, highlight a critical disconnect between awareness and accurate understanding of strabismus. Misperceptions often include the belief that strabismus is not a disease. Others believe that it is an untreatable disease, and yet some maintain that it is a curse from the gods as punishment for sins. These opinions may delay presentation and treatment, thereby increasing the risk of amblyopia and binocular visual impairment in children. A study in Kenya by Mwai et al. [36] revealed that although many caregivers could recognize strabismus, there were several misconceptions about its causes and treatment [36]. Some attributed it to supernatural factors, while others believed that it was a condition that could resolve itself. Correspondingly, Abdul Kabir et al. [22] revealed a limited understanding of strabismus and amblyopia, suggesting misconceptions even among educated individuals. Cultural beliefs may strongly influence caregiver perceptions of strabismus. These misconceptions usually culminate in an overreliance on traditional remedies, which may also result in late presentation to treatment facilities and poor visual outcomes. A study on parental attitudes toward child eye health revealed that most parents overlook the seriousness of strabismus or assume that the condition can resolve itself, resulting in a late presentation. Misperceptions about strabismus accentuate the need for public health education campaigns and strategies that transcend awareness creation to the correction of false beliefs. Similar perceptions have been reported in other African settings, where strabismus is sometimes viewed as a sign of misfortune or divine punishment [37]. Hospitals, as the main source of information in the study, have the responsibility of strengthening caregiver counselling and community outreach.

Although 185 caregivers (65.6%) reported that they could recognize strabismus when they see it, this self-reported recognition did not necessarily translate into accurate knowledge. In fact, misperceptions remained common, with over half of caregivers in both lower- and higher-education groups reporting incorrect beliefs, and no significant difference between the two (χ² = 0.299, p = 0.585). These findings highlight a critical gap between perceived awareness and informed understanding. Caregivers may feel confident in identifying visible eye misalignment, yet misconceptions about its causes and implications persist. This underscores the need for targeted education strategies that move beyond simple awareness to ensure accurate knowledge and timely health-seeking behavior across all educational strata.

Collectively, these results demonstrate the need for targeted educational strategies that address prevailing myths, reinforce the medical nature of strabismus, and emphasize the benefits of early treatment. Such interventions are essential for promoting timely presentation, improving treatment uptake, and reducing the burden of amblyopia and associated psychosocial consequences. The present study contributes valuable insights into caregiver perceptions and health-seeking behavior related to pediatric strabismus in Ghana. According to Jaluthariya et al. [38], early screening and timely intervention in high-risk groups, such as preterm infants and children with developmental delays, are vital to preventing long-term visual impairment. Strengthening primary pediatric eye care services is therefore essential to ensure prompt detection and appropriate treatment. Al-Atawi [39] also explained that because children’s visual system is still developing, there is a valuable window for intervention before vision loss can significantly affect their quality of life, education, or future work opportunities.

The strengths of this study include its relatively large sample size, comprehensive clinical characterization of ocular deviations, and identification of predictors of delayed presentation, thereby providing important regional evidence in a context where data remain limited. The inclusion of parents and caregivers as respondents further enabled detailed assessment of sociodemographic factors, medical history, and the broader familial impact of the condition.

Nevertheless, several limitations should be acknowledged. The cross-sectional design restricts causal inference and limits generalizability. Residual confounding may persist despite statistical adjustment, and the observational nature of the study restricts our ability to establish temporal relationships between exposures and outcomes. These methodological constraints are inherent to the design and should be considered when interpreting the results. In addition, reliance on caregiver-reported information introduces the potential for recall and reporting bias. Some respondents may have misunderstood certain questions or possessed limited knowledge of strabismus, potentially affecting data accuracy. Although trained interviewers provided clarification during data collection, findings should be interpreted cautiously, as they primarily reflect caregiver perceptions rather than direct reports from affected children. Some categories, particularly older age groups, had relatively few participants. This may have contributed to inflated odds ratios and wide confidence intervals. The large confidence intervals (e.g., age of patient, CI: 1.0–61.1) indicate variability in the data and limit the precision of effect size estimates. Although multivariable adjustment was performed, unmeasured factors such as cultural beliefs, health-seeking behaviors, and caregiver priorities may still influence presentation patterns. Although our study captured caregiver perceptions of strabismus, including the consideration of churches and traditional healers as alternative sources of care, our data did not fully capture the specific actions taken between detection and hospital presentation, such as consulting traditional healers, seeking prayer interventions, or delaying care until symptoms worsened. We believe that explicitly linking these beliefs with reported behaviors would have provided a more comprehensive understanding of how cultural frameworks translate into delayed presentation. This therefore limits our ability to fully interpret the sequence of decisions and behaviors that contribute to delayed care. Future studies employing qualitative or mixed‑methods approaches could explore these pathways more comprehensively, providing deeper insight into the social determinants and cultural beliefs influencing care‑seeking behavior. Such evidence would complement our quantitative findings and strengthen recommendations for community‑based interventions. Another limitation is that while caregiver perceptions suggested ocular misalignment was sometimes viewed as a benign cosmetic variation, this was not empirically explored. As a result, this statement reflects interpretation rather than direct evidence. Future studies should incorporate such items to provide data‑driven conclusions. Future population-based and longitudinal studies are recommended to assess prevalence patterns and long-term visual outcomes among children with strabismus.

Conclusion

Esotropia was the predominant form of strabismus, with left eye deviation most common. This study identified a lack of awareness of strabismus and the absence of a family history of the condition as significant predictors of late presentation to eye care facilities. Although overall parental knowledge of strabismus was relatively good, notable misperceptions persisted, including the belief that strabismus is not a medical condition and that treatment may be sought from non-medical settings such as churches or traditional healers. Such misconceptions can adversely influence health-seeking behavior and contribute to delays in accessing appropriate care.

Hospitals were the most commonly reported initial source of information about strabismus, highlighting the important role of health facilities in educating the public. These findings underscore the need for strengthened and targeted health education initiatives, both within healthcare institutions and through social media and other mass communication platforms, to improve accurate knowledge, address prevailing misconceptions, and promote timely presentation for strabismus management. Therefore, strengthening public education and caregiver awareness is essential to promote early presentation and improve outcomes.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

BA and YAE had full access to all the data in the study and took responsibility for the integrity of the data and accuracy of the data analysis. DF, VAE, and SL contributed to the conceptualisation and design of the work. DF, SL, BA, VAE, and YAE acquired, analysed, and interpreted the data. DF, VAE, and SL wrote the original draft. All the authors critically revised the manuscript for important intellectual content. BA performed the statistical analysis. SL, BA, NNT, and VAE supervised the study. All authors have approved the submitted version (and any substantially modified version that involves their contribution to the study) and have agreed both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which they were not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

Nil.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The authors declare that they obtained written informed consent from the patients and/or volunteers included in the study and that this report does not contain any personal information that could lead to their identification. This study adhered to the tenets of the Declaration of Helsinki for human subjects in medical research. The study protocol was approved by the Institutional Review Board (IRB) of the Komfo Anokye Teaching Hospital in Ghana (IRB registration number REG. NO: RD/CR19/039).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.