AWARENESS, KNOWLEDGE, AND PERCEPTION OF AMBLYOPIA AMONG PARENTS ATTENDING PEDIATRIC AND OPHTHALMOLOGY CLINICS AT KASCH RIYADH

Malak Mansour Alhaddab 1 , Afaf Moukaddem 2 and Bashaer Dabsan Albaqami 3 . 1. Faculty of Medicine. King Saud Bin Abdulaziz University for Health sciences. Riyadh. Saudi Arabia. 2. Faculty of Medicine Research Unit. King Saud Bin Abdulaziz University for Health sciences. Riyadh. Saudi Arabia. 3. Pediatric department. King Abdullah Specialist Children Hospital. Riyadh. Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 September 2019 Final Accepted: 12 October 2019 Published: November 2019

In conclusion, lack of establishing public enlightenment and health education program that regularly keep the individuals knowledgeable about the amblyopia, and lack of establishing cost-effective screening form for early detection and handling the factors that cause poor compliance to treatment lead to lateness and ineffectual treatment of amblyopia between children, so it is very important to educate parents to have enough knowledge about amblyopia and to identify symptoms that are present in their child to consult the doctor as soon as possible for necessary follow-up and to avoid negative consequences in future.
This study attempts to assess the level of parents' awareness, knowledge, and perception of amblyopia and related eye diseases in their children attending the ophthalmology and pediatric outpatient clinic in King Abdullah Specialized Children's Hospital (KASCH). National Guard Health Affairs (NGHA) -Riyadh. Saudi Arabia to emphasize the parents' role in early detection of amblyopia to get the satisfactory result of therapeutic treatment. Also, to provide an outline about the causes, consequences, diagnosis, and treatment of amblyopia for the parents' knowledge. The study shows demographic factors to detect the most significant conditions. Subsequently, relevant awareness programs will be conducted for the most deficient aspects.
Methods:-Study Area/Setting: This study was conducted at King Abdullah Specialized Children's Hospital (KASCH), in National Guard Health Affairs (NGHA) -Riyadh, Saudi Arabia. It was established in 2015, and it is the first medical referral institute for children that the Ministry of National Guard provide to be a unique addition to King Abdulaziz Medical City, Riyadh, Saudi Arabia. The participants were surveyed from ophthalmology department and pediatric department. The ophthalmology department provides exceptional high-quality eye care to infants, children, and teenagers, and delivers complete range of medical and surgical management of eye disorders. There are more than 10 pediatric ophthalmology consultants, 5 pediatric optometrists, technicians and nurses who work in the department of ophthalmology. The pediatric department includes more than 12 pediatric consultants and pediatric subspecialties.

Study Subjects: Inclusion criteria:
All Saudi parents attending pediatric ophthalmology and pediatrics clinics were included.

Sample Size and Technique:
The sample size was calculated by using online calculator, Raosoft, with a margin of error 5%. Confidence interval 95%, a population of 20.000, and a response distribution of 50% the sample size was calculated to be 377. Nonprobability convenience sampling technique was used; all parents who agreed to participate and attended to pediatric and ophthalmology clinic were included.

Data Collection Methods and Management:
Data was collected by using a structured questionnaire developed by the author herself in Arabic language. The survey questions were designed/chosen from several published literatures (Al-zahrani et al., 2018; Alshaheen & AlOwaifeer, 2018 ; Ebeigbe & Emedike, 2017 ). Data was collected in four months between pediatric and ophthalmology clinics at KASCH. The questionnaire was reviewed by 3 pediatric ophthalmologists at least for content validation, and then the survey was piloted for validity and reliability purposes and internal consistency was measured using Cronbach alpha which was = 0.86 for perception about amblyopia complications and treatment and 0.92 for perceived parents' role in amblyopia. Pilot participants gave feedback on clarity and appropriateness of the questions and their comprehension.
The questionnaire is divided into 6 parts: 1. Section one on demographic data of the participants such as: age, gender, marital status, family history of eye disease, number of children, occupation, residence… etc. 2. Section two about awareness about amblyopia detection and its diagnosis, and it was yes/no answered. For example, hearing about amblyopia; yes/ no. Amblyopia can be diagnosed by pediatric or ophthalmology doctor; yes/ no. 3. Section three about knowledge regarding amblyopia with regards to 4 dimensions including definition, possible etiologies, treatment options, and source of knowledge such as doctor, internet and social media, relatives and friends, awareness campaigns … etc. 4. Section four on perception and attitude about amblyopia complications and treatment, and it was yes/no answered. For example, there is no treatment for amblyopia; yes/no. early treatment leads to better outcome; yes/no. Amblyopia is best treated at young age; yes/no. Amblyopia worsens if left untreated; yes/no …etc. 5. Section five on perception and attitude about amblyopia complications and impact. It was measured in 4-point scale (1= strongly disagree to 4=Strongly agree). 6. Section six about awareness of the role of parents in prevention and early detection, diagnosis, treatment efficacy, compliance with treatment, follow-up, psychological and social supports of the afflicted child using 5points Likert type scale (1= not important at all to 5= very important). 7. Amblyopia knowledge score (AKS) was calculated as the number of correct answers for questions relating to definition (10 items), etiology (14 items), and options of treatment (6 items) of amblyopia.

Data Analysis:-
Statistical Package for Social Sciences (SPSS), version 22 was used to enter and analyze the data. Descriptive statistics were used to introduce participants' characteristics as well as the answers to the different questionnaire parts whereby categorical variables were presented as frequency and percentage and continuous variables as mean ± standard deviation (SD). Due to the non-normal distribution of AKS. nonparametric Mann-Whitney test was used (for testing association between score and gender, clinics, resident) and Kruskal-Wallis test for the association of score with marital status, level of education, and occupation. P-value of <0.05 was considered to reject the null hypothesis and to identify the significance level.
For ethical considerations, a consent form was given to the participants to ensure their agreement. Also, both the study protocol and questionnaires were approved by KAIMRC, and participant's privacy and confidentiality were assured and respected, no identifiers were collected and all data both hard and soft copies were stored within MNGHA premises and accessed by the research team only.

Results:-
Population's characteristics A total of 399 parents of children attending the Pediatrics (49.1%) and Ophthalmology (50.9%) departments were interviewed. Ages ranged from 20 to 60 years with a mean ± SD of 34± 8 years. More than half of participants (59.1%) were females, 85.7% were married and 84.0% living in urban areas. The summary of the sociodemographic characteristics is shown in (Table 1).

Awareness and perception about amblyopia and its diagnosis
Almost half of the total participants (48.6%) were unaware of what amblyopia is. One-third of participants (26.3%) who were aware of amblyopia believed amblyopia can be detected by the naked eye, some participants (39.9%) believed that amblyopia can be diagnosed by a GP or family doctor, and 67.2% that it can only be diagnosed by an eye specialist. Furthermore, more than half of the participants were aware that it may occur both in childhood and adulthood (Table 2).

Perceptions about amblyopia complications and treatment outcomes:
More than half of the participants (64.9%) realize that early treatment leads to better outcomes, that amblyopia is best treated at young age (60.4%), and that it worsens if left untreated (57.4%). Respondents' perception was more divided regarding the possible impact and complications of amblyopia, as half of them agreed or strongly agreed that amblyopia may cause blindness, disability, stigmatization, impaired quality of life, and school failure; whereas only one-third of participants believed it can be an economic burden for the family (Table 3).

Perceived parent's role in amblyopia management:
Majority of the participants perceived the parents' role in amblyopia as being important or very important, particularly in the following dimensions: compliance with treatment (90.2%); diagnosis (88.5%); follow up (88.5%) and early detection (87.7%). It is worth noting that approximately 21.3% would not consider the role of parents in prevention (Table 4).

Knowledge about amblyopia:
Knowledge about the definition of amblyopia showed that only 25.3% of participants correctly identified amblyopia as being a vision loss in one eye or decreased vision in one or both eyes ; whereas 36.4% misidentified it as misalignment of the eye and 32.3% as eyes do not line up in the same direction ( Figure 1). Knowledge about etiologies showed that 28.6% and 10.0% of participants correctly identified the most common etiologies of amblyopia as refractive error and cataract. While most participants misidentified maternal illness. Prematurity, fever in infancy, electronic devises usage, stroke, cerebral palsy, Down syndrome, nutrition deficiency, and trauma as etiologies of amblyopia ( Figure 2). Knowledge about treatment options showed that 42.9% and 24.3% of participants correctly identified glasses and patching the strong eye as possible treatment options; whereas more than half misidentified eye muscle exercise, surgery, and laser therapy as being part of the amblyopia treatment, respectively ( Figure 3). The majority of participants' sources on amblyopia was internet and social media (37.6%) and friend and relatives (36.6%) (Figure 4).         There is no significant difference in the amblyopia awareness in parents who have a family history or personal experience with eye problems especially problems that are associated with childhood. On the contrary, Nigerian study reported that only small number of parents know about amblyopia and this was positively associated with having a family history of the disease (Ebeigbe & Emedike, 2017 The awareness of amblyopia was higher in mother than fathers, this could be because mothers generally monitor their children's health more than fathers. Further, marital status was associated with awareness of amblyopia. Another local study conducted in different region of Saudi Arabia consistent with that there was a significant difference between the father and mother regarding awareness of amblyopia, and mothers had more knowledge about amblyopia when compared with fathers. Also, married participants were more aware of the term amblyopia than those with other marital statuses, including divorced and widowed participants (

Conclusion:-
The present study showed indications that there is a lack of awareness and knowledge regarding amblyopia and its complications. Hence, this study emphasizes an urgent need to the establishment of fundamental guidelines. For example, implementation of visual screening programs for preschool-aged children with appropriate clinical to provide early detection and proper treatment of amblyopia. In addition, teachers could contribute as well by paying more attention to children struggling in the school, awareness days, and organizing campaigns targeting public places such as schools, malls, hospitals, and universities to elevate awareness of this disorder. Furthermore, social media, internet, and mobile applications could include advertisements and ophthalmological educational videos to help to reach a large segment of the population. Finally, a stronger doctor-patient relationship can help improve family level of awareness and knowledge and increase the children's treatment outcomes.