Implementation of an Educational Cartoon (“the Patchbook”) and Other Compliance-Enhancing Measures by Orthoptists in Occlusion Treatment of Amblyopia

ABSTRACT

Purpose: This implementation study evaluated orthoptists’ use of an educational cartoon (“the Patchbook”) and other measures to improve compliance with occlusion therapy for amblyopia.

Methods: Participating orthoptists provided standard orthoptic care for one year, adding the Patchbook in the second year. They attended courses on compliance and intercultural communication by communication skills training. Many other compliance-enhancing measures were initiated. Orthoptists’ awareness, attitude, and activities regarding noncompliance were assessed through interviews, questionnaires, and observations. Their use of the Patchbook was measured. The study was performed in low socio-economic status (SES) areas and in other areas in the Netherlands. It was attempted to integrate education on compliance into basic and continuing orthoptic training.

Results: The Patchbook was used by all 9 orthoptists who participated in low-SES areas and 17 of 23 orthoptists in other areas. Courses changed awareness and attitude about compliance, but this was not sustained. Although orthoptists estimated compliance during patching at 70%, three-quarters never suspected noncompliance during a full day of observation in any of their patients. Explanations to parents who spoke Dutch poorly were short. In the second year, explanations to children were longer. Implementation of all 7 additional compliance-enhancing measures failed. Education on compliance was not integrated into orthoptists’ training.

Conclusion: Almost all orthoptists used the Patchbook and, as another study demonstrated, it proved to be very effective, especially in low-SES areas. Duration of explanation was inversely proportional to parents’ fluency in Dutch. Noncompliance was rarely suspected by orthoptists. Although 7 additional compliance-enhancing measures had been conceived and planned with the best intentions, they were not realized. These required extra, unpaid time from the orthoptists, which is especially scarce in hospitals in low-SES areas where the educational cartoon is most needed.

KEYWORDS:

• Adoption
• amblyopia
• implementation
• improving patients’ compliance
• occlusion therapy

Acknowledgments

The authors have no proprietary or commercial interest in any materials discussed in this article. This study was financially supported by ZonMW – the Netherlands Organization for Health Research and Development (grant number: #6320.0008). The study is registered in the Dutch trial register (ISRCTN22835481/NTR713).

The authors thank the following lecturers for their voluntary contribution to the course on compliance: Dr S. Simons, Department of Clinical Pharmacy Institute of Pharmacy, University of Bonn; Dr ER Heerdink, Department of Pharmacoepidemiology & Pharmacotherapy, Utrecht University; Dr JH Groenewoud, Expertise Centre for Transitions of Care, Rotterdam University of Applied Sciences; L. Peereboom, lecturer in communication skills, Utrecht University of Applied Sciences; and H. van Agt, Department of Public Health, Erasmus University Medical Centre Rotterdam (Erasmus MC).

Our thanks are also due to the staff at the Department of Technology Transfer at Erasmus MC in Rotterdam for their work on valorising the educational cartoon nationwide (http://www.erasmusmc.nl/tto/ktr/?lang=en).

The authors also wish to thank the 20 clinics for their contribution to the study, and particularly the 32 participating orthoptists, who are listed here in alphabetical order of clinic and surname: Amphia Hospital, Breda & Oosterhout (K. Corft, C. Klerks-Kuijpers, P. Neomagus, C. Stoop); Catharina Hospital, Eindhoven (E. van Rooijen-Troost); Flevohospital, Almere (L. Bakker, N. Bos-De Bruin); Isala Clinics, Zwolle (A. Wellner-Fokker); Kennemer Hospice, Haarlem (W. Jutte, A. Hupsch-Van den Heuvel, A. Spaan); Lievensberg Hospital, Bergen op Zoom (M. de Rooij, A. van Voorden-Van der Knaap); Máxima Medical Centre, Eindhoven & Veldhoven (E. Cockx-Huitema); Medical Clinic, Alkmaar (W. Hoogeveen, I. Huisman); Medical Centre Haaglanden, the Hague (E. van Minderhout, B. Simonsz-Tóth, M. Vermeulen-Jongen); Mesos Medical Centre, Utrecht (A. van de Bovenkamp-Scheper, A. Versteeg); Rivierenland Hospital, Tiel (T. Kooij-’t Spijker); Ruwaard van Puttenhospital, Spijkenisse (M. Kruiswijk); Sint Lucas Andreas Hospital, Amsterdam (A. Burger-Meywaard); Tergooi Hospitals, Hilversum (D. Hamers); Twenteborghospital, Almelo (T. Hart-Leemhuis, M. Hazenkamp-Boekhold, F. Jansen, D. van der Nagel-Pronk); Vlietland Hospital, Vlaardingen (S. Rousse, D. Valster); Zweeds Rode Kruis Hospital, Zierikzee, Van Weel-Bethesda Ziekenhuis, Dirksland, & Medical Centre, Middelburg (J. Kieviet-De Geus). We also thank all Dutch orthoptists for filling in the questionnaire.

Special thanks for his advice go to Prof G. Van Rij of the Department of Ophthalmology at Erasmus MC Rotterdam. Acknowledgments for proofreading and correction of the English text are due to Mr. D. Alexander, Mrs. K. Verhoef, and Mrs. A. Van Rij-De Jong.

Notes

* The authors acknowledge the contribution of Dr SE Loudon, P. Braakenburg, B. Simonsz-Tóth, Dr E. Kilic, and Z. Al Attar for translating and/or editing the translated versions of the parental information sheet in English, French, German, Turkish, and Arabic.