Study design and setting

A cross-sectional, qualitative study using focus group discussions (FGD) was conducted to obtain in depth insights of the knowledge, attitude and practice of parents towards CEH. The study was carried out in June 2022 in the North Gondar Zone of the Amhara region of Ethiopia, located 745 km northwest of Addis Ababa. The Zone has a total population of 3,999,113 with about a 1:1 male to female ratio [28]. Metema, Debark, and University of Gondar Hospital are three hospitals located within the Zone; the University of Gondar Hospital is the only tertiary eye care facility in the Zone.

Study participants and recruitment

The participants included parents having children age less than 12 years of age. Participants were drawn from two Woredas (i.e., third level administrative districts) in the Central Zone of the Amhara region. To recruit a diverse set of study participants, study investigators sent an introductory study letter to each Woreda office asking for their support to help identify suitable candidates. Participants were purposively selected to ensure diverse representation of demographic factors and employment type (e.g. health extension workers (HEW), farmers, teachers, religious or community leaders) where possible.

Data collection

FGD were conducted by two local health systems researchers, who received 2 days of training in qualitative data collection for the purpose of this study. Semi-structured discussion guides were developed in English, translated into Amharic language and back-translated for consistency. The discussion guides were piloted in a kebeles (i.e., smallest administrative districts in Ethiopia, akin to a neighborhood) that was not included in the study, and adaptations to questions were made. Demographic information (e.g. sex, age, kebele, religion, literacy, employment status, employment type) was collected for each participant prior to beginning the FGD. The FGD interview guide included questions on (i) knowledge (e.g. information about child eye care, knowledge about poor eyesight, barriers for accessing child eye care}, (ii) attitudes (e.g. towards spectacle wear) and (iii) practice (e.g. prevention of visual impairment, treatment and impact of visual impairment). Daily debriefing meetings with all data collectors were organized to examine major findings, review saturation, and refine research directions. All FGDs were tape recorded, transcribed and translated into English. The discussions lasted about 60 to 90 minutes and included 7–13 participants each. Recruitment of participants ended when data saturation was reached.

Data analysis

The transcripts were read to identify key themes and develop a coding framework. To do this, we first loaded the translated data into Open Code 4.03 (Umea University, Sweden), an open source computer software for analyzing qualitative data. A thematic phenomenological approach was employed to analyze the data. The coded transcripts were further analyzed and summarized into narratives for each theme and sub-theme.

Study participants

Seventy-one parents of mean age 41.1(±11.1) years participated in 7 FGD (S1 Table). Among the participants, 55 (77%) were males and 16 (23%) were females. The mean age of the participants was 41.1± 1.1 (range 26–69) years and 30 (42%) of them were in the age group of 30–39 years. In terms of employment, 19 (27%) were farmers, 14 (20%) were teachers, and 7 (12.7%) were HEWs. The majority of participants (53/71, 75%) had at least finished high school. The majority of participants (61/71, 86%) were Orthodox Christians (Table 1).

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Table 1. Characteristics of FGD participants.

https://doi.org/10.1371/journal.pone.0293595.t001

Focus group discussions

Seven major themes emerged from the thematic analysis. Two themes were related to Knowledge: (1) Information on CEH; and (2) Knowledge about child eye problems. Three themes were related to Attitudes: (3) Barriers to child eye care; (4) Use of eye glasses; and (5) Impact of childhood blindness. Two themes were related to Practice: (6) Treatment and prevention of CEH problems and (7) Cultural and traditional practices. S2 Table describes these themes, sub-themes and quotes identified during analysis, which are further discussed below.

Action #1. Improve CEH knowledge among parents via trusted sources

Our study participants indicated that their primary sources of CEH information were the media and health professionals, consistent with prior studies on parental access to health information [29,30]. However, participants acknowledged that they lacked sufficient knowledge regarding CEH, and our results demonstrated this as they misunderstood the etiologies and common causes of child eye blindness in their setting. Availability of information does not equate to knowledge creation, and it is well acknowledged that continuous knowledge translation strategies are required to educate the lay public on health issues, particularly in low resource settings, which have unique geographical, financial, and cultural considerations [31]. In order to overcome these conventional hurdles to access health information, some have argued in favor of using digital health services to distribute health information [32–34]. The increase in the internet penetration rate from 7.5 to 25% in the past 10 years in Ethiopia gives an opportunity to use the internet as a source of health information in the coming years [35]. However, such activities should be coupled with campaigns to educate the public on trustworthy sources of information, such as the Ministry of Health or other relevant professional bodies, such that misinformation is avoided. People with lived experience of vision impairment or blindness could be another knowledgeable and trusted source of information, as noted by a participant in our study. Health champions have been instrumental in raising awareness and reducing stigma for HIV/AIDS [36], and could have an equivalent role for CEH awareness in Ethiopia.

Action #2. Directly Address Common Misconceptions and Myths about Causes of Blindness and Use of Eye Glasses

An estimated 100,000 blind youngsters reside in Ethiopia alone. According to a 2017 study at a school for the blind in the same region as the current study, corneal scarring from vitamin A deficiency and measles are the leading causes of blindness [37]. Yet these were not noted by the participants in our study, who instead identified trachoma, glaucoma, and trauma as the primary causes of childhood blindness. This difference warrants further investigation, since in LMIC most research on childhood blindness is performed in schools for the blind, yet the conclusions drawn may not be representative of the community, potentially limiting the generalizability of the findings.

Moreover, no participant mentioned amblyopia as a childhood vision concern. This finding is consistent with research from India [19] and Nigeria [38] where in each study, only one parent was aware of amblyopia. In contrast, a research study from Saudi Arabia revealed that parents’ understanding of amblyopia was the greatest among other disorders [39]. Amblyopia can be prevented and treated, particularly if it is detected early in children under the age of eight [40], thus parental knowledge of this is essential.

Our study also revealed a myth in the community related to strabismus causation, where parents believed that strabismus was caused by staring at light. A prior cross-sectional community survey in Southern Ethiopia revealed that many of the participants had false beliefs regarding the cause of strabismus [41]. Similarly, a study carried out in Nigeria demonstrated that a common misconception was that strabismus could result "if a baby’s sleep is not changed from time to time" [42]. A study from Chennai, India indicated that the majority of parents in that setting believed that strabismus was a sign of good fortune and did not seek care for [19]. Sometimes, strabismus can be the first sign of ocular tumor, like retinoblastoma [43]. Poor parental education, misunderstandings, and misinformation have a negative impact on the age of strabismus presentation and management, which differs from country to country [44].

This study also revealed differences in perceptions among the study participants with regard to the use of eye glasses in children. Several participants held the misconception that wearing eyeglasses on a regular basis could impair vision. Furthermore, the stigma associated with wearing glasses was a major worry raised by the majority of participants. Similarly, study from India showed that parents were hesitant to provide spectacle correction for their children with vision problems because they perceived wearing spectacles as a stigma [19]. One study found that parents believed no child under the age of four should wear glasses at any time [45]. In a Nigerian study, parents commonly believed that children could become overly reliant on eye glasses and be unable to function without them [38]. Parental disapproval has been reported as one of the main reasons for the non-compliance with spectacle utilization among school students [46]. Identifying reasons for non-compliance with spectacle use is important for understanding the social determinants of intervention. This will help to enhance the awareness of the parents of children with refractive error, by informing health education programs.

Action #3. Educate Parents on When to Seek Eye Care for Children

Despite the above-mentioned misconceptions and gaps in knowledge, participants in this study were able to recognize signs of poor vision in children. They also were aware of negative effects of poor vision, noting how children with visual impairment tend to do poorly in school and repeatedly fail to progress. Similar findings have been shown in studies from Eswatini, Nigeria, Saudi Arabia and India [19,38,39]. Yet, our participants were unable to pinpoint the right moment to seek medical assistance, and none of the participants reported taking their children to the eye doctor for a routine checkup. Poor parental health-seeking behavior has been attributed to a lack of health information [17,47]. A European study of parental health-seeking behavior indicates that upon first notice of signs and symptoms parents initially attempt to manage the condition at home, and tend to seek medical attention when they feel they have “lost control of the situation” [48]. Improving the messaging to parents on when to seek care for routine visits as well as upon notice of CEH issues is essential to prevention of childhood blindness.

Action #4. Improve Capacity and Quality of CEH Services

Participants noted several barriers in accessing services in the context of Northwest Ethiopia. These included financial constraints, a lack of public knowledge, a shortage of qualified eye health specialists, lengthy wait times at tertiary eye care facilities, and a disregard for CEH by the health system. This is consistent with the literature showing that non-availability, non-accessibility, and non-affordability of eye care are three primary factors that contribute to the high prevalence of childhood visual impairment in Africa [2,10,11,13,29,38,49–55]. Furthermore, ineffective policies and a lack of facilities have also been mentioned as a major barrier for child eye health, particularly in low-income nations [2]. Our study highlighted that parents’ health-seeking behavior was influenced by perceived substandard health facilities. Numerous studies have revealed that socioeconomic position, access to healthcare facilities, and perceived service quality are important determinants of maternal and child health seeking behavior among different population groups [56–58]. Therefore, improving the health seeking behavior of parents must go hand in hand with improving capacity to provide excellent child eye care.

Action #5. Establish a Collaboration Between Traditional Healers and CEH Services

Traditional medicine was identified by study participants as one of the main treatment alternatives for CEH. While not explicitly stated by participants, traditional medicine presumably evades the access challenges of cost and distance, and is likely aligned with deep-rooted cultural beliefs and terminologies revealed in our study. Studies from Ethiopia showed that nearly 80% of the population relies heavily on herbal treatments as their primary source of therapy, and traditional eye medicine is widely used in the country [59–61]. However, there is no formal connection or collaboration between traditional medicine practitioners and the Ethiopian health system. A study from Eswatini showed that parents believed that traditional healers could play a role in disseminating eye health information [29]. Research conducted in Zimbabwe and Malawi suggests that a sustainable collaborative program between traditional and modern practitioners could help to reduce preventable blindness by advising against the use of harmful traditional practices [62]. Given the high use of traditional medicine for eye care, such collaborations may have utility in Ethiopia as well.

Study limitations

A main limitation was the gender imbalance in the study participants, with more fathers taking part in the study. While in many parts of Africa, females are generally the ones who take care of children at home, in Ethiopia, fathers play an important role in caregiving and are often the ones who accompany children to health visits [63]; this may have been a reason for the gender imbalance in the study.