Purpose: 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. Design: Clinical, prospective, nonrandomized, preimplementation, and postimplementation study. Participants: 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. Main Outcome Measures: 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. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

outpatient care, Netherlands, amblyopia, article, child, clinical effectiveness, controlled clinical trial, controlled study, education, educational cartoon, electronic medical record, female, hospital, human, immigrant, lowest income group, major clinical study, male, orthoptics, patient compliance, preschool child, priority journal, social status, speech
dx.doi.org/10.1016/j.ophtha.2012.05.035, hdl.handle.net/1765/38829
Erasmus MC: University Medical Center Rotterdam

Tjiam, A.M, Holtslag, G, Vukovic, E, Asjes-Tydeman, W.L, Loudon, S.E, Borsboom, G.J.J.M, … Simonsz, H.J. (2012). An educational cartoon accelerates amblyopia therapy and improves compliance, especially among children of immigrants. Ophthalmology, 119(11), 2393–2401. doi:10.1016/j.ophtha.2012.05.035