title: An educational cartoon accelerates amblyopia therapy and improves compliance, especially among children of immigrants.
abstract: OBJECTIVE
  We showed previously that an educational cartoon that explains without words why amblyopic children should wear their eye patch improves compliance, especially in children of immigrant parents who speak Dutch poorly. We now implemented this cartoon in clinics in low socioeconomic status (SES) areas with a large proportion of immigrants and clinics elsewhere in the Netherlands.
  
  
  METHODS
  Clinical, prospective, nonrandomized, preimplementation, and postimplementation study.
  
  
  METHODS
  Amblyopic children aged 3 to 6 years who started occlusion therapy.
  
  
  METHODS
  Preimplementation, children received standard orthoptic care. Postimplementation, children starting occlusion therapy received the cartoon in addition. At implementation, treating orthoptists followed a course on compliance. In low SES areas, compliance was measured electronically during 1 week.
  
  
  METHODS
  The clinical effects of the cartoon-electronically measured compliance, outpatient attendance rate, and speed of reduction in interocular-acuity difference (SRIAD)-averaged over 15 months of observation.
  
  
  RESULTS
  In low SES areas, 114 children were included preimplementation versus 65 children postimplementation; elsewhere in the Netherlands, 335 versus 249 children were included. In low SES areas, mean electronically measured compliance was 52.0% preimplementation versus 62.3% postimplementation (P=0.146); 41.8% versus 21.6% (P=0.043) of children occluded less than 30% of prescribed occlusion time. Attendance rates in low SES areas were 60.3% preimplementation versus 76.0% postimplementation (P=0.141), and 82.7% versus 84.5%, respectively, elsewhere in the Netherlands. In low SES areas, the SRIAD was 0.215 log/year preimplementation versus 0.316 log/year postimplementation (P=0.025), whereas elsewhere in the Netherlands, these were 0.244 versus 0.292 log/year, respectively (P=0.005; the SRIAD's improvement was significantly better in low SES areas than elsewhere, P=0.0203). This advantage remained after adjustment for confounding factors. Overall, 25.1% versus 30.1% (P=0.038) had completed occlusion therapy after 15 months.
  
  
  CONCLUSIONS
  After implementation of the cartoon, electronically measured compliance improved, attendance improved, acuity increased more rapidly, and treatment was shorter. This may be due, in part, to additional measures such as the course on compliance. However, that these advantages were especially pronounced in children in low SES areas with a large proportion of immigrants who spoke Dutch poorly supports its use in such areas.
authors.affiliation: Department of Ophthalmology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands. amtjiam@gmail.com
authors.forename: Angela M
authors.initials: AM
authors.lastname: Tjiam
authors.forename: Gerdien
authors.initials: G
authors.lastname: Holtslag
authors.forename: Elizabet
authors.initials: E
authors.lastname: Vukovic
authors.forename: Wijnanda L
authors.initials: WL
authors.lastname: Asjes-Tydeman
authors.forename: Sjoukje E
authors.initials: SE
authors.lastname: Loudon
authors.forename: Gerard J J M
authors.initials: GJ
authors.lastname: Borsboom
authors.forename: Harry J
authors.initials: HJ
authors.lastname: de Koning
authors.forename: Huibert J
authors.initials: HJ
authors.lastname: Simonsz
mesh_terms: D000550:Amblyopia / Q000208:ethnology / Q000503:physiopathology / Q000628:therapy*; D001458:Bandages; D002359:Cartoons as Topic / Q000523:psychology*; D002648:Child; D002675:Child, Preschool; D054242:Emigrants and Immigrants / Q000523:psychology*; D005006:Ethnicity; D005260:Female; D006801:Humans; D007802:Language; D008297:Male; D008991:Monitoring, Physiologic; D009426:Netherlands; D009988:Orthoptics; D010349:Patient Compliance / Q000523:psychology*; D011446:Prospective Studies; D012683:Sensory Deprivation; D012923:Social Class; D013664:Teaching Materials; D014792:Visual Acuity / Q000502:physiology