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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 186-192

Refractive errors and spectacle compliance among truckers in India


Mission for Vision, Mumbai, Maharashtra, India

Date of Submission08-Sep-2020
Date of Acceptance01-Sep-2021
Date of Web Publication17-Mar-2022

Correspondence Address:
Dr. S G Prem Kumar
Mission for Vision, Office 45, Maker Chamber VI, 220 Jamnalal Bajaj Marg, Nariman Point, Mumbai - 400 021, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_143_20

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  Abstract 


Introduction: Reliable data on eye health among Indian truckers are scanty. The purpose of this study was to assess the prevalence of refractive errors and the subsequent long-term spectacle compliance and suggest appropriate strategies to improve these in this population.
Methods: A cross-sectional study was conducted between October 2017 and March 2018 among truckers. Gross ophthalmologic examination was performed, including visual acuity and refraction. Six months to one-year post provision of spectacles, follow-up with truckers was undertaken to understand the spectacle usage patterns and its compliance. Descriptive statistics and Chi-square tests were conducted to assess the association between the type of refractive errors, spectacle compliance, and select sociodemographic and clinical variables.
Results: A total of 709 (78.8%) truckers completed interviews and gross eye examination. The prevalence of any refractive errors in the worst eye was 45.8% (95% CI 42.1%–49.6%). The prevalence of presbyopia with or without distance vision was 33% (95% CI 29.6%–36.6%) and myopia with or without astigmatism was 10% (95% CI 7.9%–12.5%). Among those who were prescribed spectacles, 27.1% needed distance correction, 33.8% needed near correction, and 39.1% needed both, at least in one eye. Long-term spectacle compliance was at 54.7%. The predominant barriers for spectacle compliance were “did not collect” (63.9%), followed by “discomfort” (20.8%).
Conclusion: The prevalence of uncorrected refractive errors was high among truckers. Long-term spectacles compliance was moderate. There is an urgent need for tailor-made targeted interventions to address the eye health needs of truckers in India.

Keywords: Cataract, compliance, refractive error, spectacle, truck driver


How to cite this article:
Kumar S G, Jadhav A, Patel S, Vishwakarma P, Kundu S, Kurian E. Refractive errors and spectacle compliance among truckers in India. J NTR Univ Health Sci 2021;10:186-92

How to cite this URL:
Kumar S G, Jadhav A, Patel S, Vishwakarma P, Kundu S, Kurian E. Refractive errors and spectacle compliance among truckers in India. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Nov 30];10:186-92. Available from: https://www.jdrntruhs.org/text.asp?2021/10/3/186/339800




  Introduction Top


The WHO's Universal Eye Health: A Global Action Plan 2014–2019 calls for “universal eye health,” a framework to scale up services and expand access to all.[1] Truck drives and their helpers are associated with significant health risks including eye health and their constant mobile lifestyle provides little room to seek timely medical help.[2],[3],[4] The trucking industry in India, by and large, is in the hands of small private operators and is stated to be highly fragmented and unorganized. It is estimated that there are about 3,960,933 registered medium and heavy commercial trucks in India as on end March 2016 and about 6–7 million truck drivers and their helpers (hereafter referred to as truckers) in India, of whom approximately 4 million are long-distance truckers. [5,6] Very little is known about the ocular morbidities and eye-health seeking behaviors of truckers in India and elsewhere. Recent studies have pointed out at varying degrees of visual impairments among truckers ranging from 21.5% to 46.7%, including one study which reported low levels of spectacle use in this population. [4, 7, 8]

As the calls for universal eye health grow louder, which pledges access to everyone irrespective of economic status, ethnicity, gender, place of habitat, and disability status, the need to generate sufficient evidence locally to inform policy is ever greater. In this backdrop, we present this study from the five Indian states with the objective of determining the frequency of eye disorders in truckers and their compliance with corrective spectacles, and comparing the pattern seen in this study and that of others.


  Methods Top


We conducted a cross-sectional study of truckers who transited through or halted at designated truck fleets spread across five Indian states during 2017–2018. Appropriate IRB approvals were obtained and this study adhered to the tenets of the Declaration of Helsinki.

Sample size and selection of participants

Assuming a refractive error prevalence of 46% from the previous literature in this population[7] with a statistical significance of 5% and 95% power, 598 truckers would be required. This was increased to 718 to account for 20% attrition rate, as truckers are a highly mobile and difficult to reach population. Long-haul truckers working on trucks of N1 and N2 categories as per the Central Motor Vehicles Rules of India travelling a minimum of 800 km one-way[9] and those aged between 16 and 65 years with primary occupation as a trucker for at least 3 months prior to the study and speaking any of six languages—Hindi, Haryanvi, Kannada, Marathi, Telugu, or English—were considered eligible to participate. The potential participants were recruited from 15 halt points across five Indian states. The halt points included private parking areas, transport company parking areas, and parking areas around fuel stations. Proportional sampling technique was followed to maintain adequate representation of truckers to their estimated available numbers at each halt point based on a scoping exercise. As trucks were parked in an organized fashion in most of these halt points, systematic listing of the trucks parked from entry to exit point was undertaken to document the vehicle number, whether long-haul truck or not, number of truckers per truck with their age and language spoken by them. This information was used to identify the eligible truckers for the study. A potential respondent was chosen to participate in the study from every 3rd or 5th truck depending on the sample size required from each halt point with the first respondent chosen randomly from the sampling interval. To avoid re-interview, a record of the truck registration number of the already recruited truckers was maintained to avoid duplication. Five interviews on an average were conducted each day.

Data collection

Potential participants were contacted by a team of two trained interviewers from October 2017 to March 2018. Written informed consent for participation was sought from each participant following which the interviewers conducted interview using a questionnaire designed specifically to meet the objectives of this study. The questionnaire was translated into local languages for administration by ensuring conceptual and semantic equivalence with the English version. The bilingual study research staff worked with a set of truckers throughout the process of translation and back-translation to address inconsistencies and cultural nuances relevant in this context, and to arrive at appropriate wording for those with a low literacy level. Each participant was asked a series of questions about sociodemographics, ocular and extra ocular-morbidities, and spectacle usage history. Interviews were conducted in private either in a separate room provided by the transport agency on request or in many instances inside the truck cabin in order to ensure privacy. Immediately following face-to-face interviews, vision screening, refraction, and gross eye examination were performed. All ophthalmic evaluations were performed by trained optometrists. The average interview and eye evaluation time were 45 minutes. A standard Snellen tumbling E chart was used to assess visual acuity, which was viewed at a distance of six meters. All measurements were taken in full daylight with available correction. Near vision was checked with n-notation chart at habitual reading distance to arrive at near power. General anterior segment screening was done using a torchlight followed by a detailed posterior segment evaluation using direct ophthalmoscope.

Post-comprehensive ophthalmic evaluation

All participants identified with other ocular anomalies like cataract or glaucoma were referred to the nearest partner hospital for further evaluation and treatment. Participants who were identified with refractive errors were prescribed spectacles and were asked to return to the same transportation fleet to collect spectacles free of cost within the next two weeks. For six months to one year post comprehensive ophthalmic evaluations, efforts were made to re-contact all the participants who were prescribed spectacles to assess and document spectacle compliance.

Definitions

Measures of visual impairment (VI) were classified into six broad categories as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[10] Presbyopia was defined as near vision worse than N6 or N8 at 40 cm.[11]

Myopia was defined as spherical power which is equal to or more than – 0.5 diopter sphere. Hyperopia was defined as spherical power which is equal to or more than + 0.5 diopter sphere. Simple astigmatism was defined as spectacle cylinder prescription having cylinder power equal to or more than 0.75 diopter cylinder with spherical power being Plano or +/– 0.25 diopter sphere. Myopia with astigmatism was defined as spectacle cylinder prescription having cylinder power equal to or more than 0.75 diopter cylinder with spherical power – 0.50 diopter sphere and more, and hyperopia with astigmatism was defined as spectacle cylinder prescription having cylinder power equal to or more than 0.75 diopter cylinder with spherical power + 0.50 diopter sphere and more. Presbyopia was defined as near addition power + 0.75 diopter sphere and more in one or both eyes. No refractive error was defined as Plano power or +/– 0.25 spherical or cylinder power.[12],[13],[14],[15],[16] Patients who were not offered refraction due to the presence of ocular comorbidities and subsequently referred to the nearest base hospital were categorized as undetermined.

Data analysis

Microsoft office Excel 2013 and SPSS software (version 20.0, IBM SPSS science Inc., Chicago, IL) were used for data analysis. Descriptive statistics are reported for relevant quantitative variables. χ2 tests were conducted to assess the association between the type of refractive errors, barriers for spectacle compliance with select sociodemographic and clinical variables. A P value of 0.05 was considered as statistically significant for all the estimates. 95% confidence intervals are reported as appropriate.


  Results Top


A total of 730 truckers aged 16–75 years were recruited for the study from 15 halt points of whom 709 (97.1%) were interviewed and underwent gross eye examination.

Sociodemographic and clinical characteristics

Of the 709 participants, 674 (95.1%) were truck drivers. The median age of truckers was 36 years (range 17–75 years). Majority of the truckers were ever married (n = 579, 81.7%). Major ocular complaints reported by truckers were eye irritation/redness/watering (4.5%) followed by photophobia (3.4). According to eye examination results, a total of 325 (45.8%) had refractive errors and cataracts were diagnosed in 8 (1.1%) truckers. As per the preliminary diagnosis, a total of 314 (44.3%) were advised corrective spectacles or sunglasses and another 228 (40.6%) were advised annual follow-up eye examination. A significantly higher proportion of truckers had no or mild VI (n = 670, 94.5%). Truckers who were 50 years or older had significant moderate VI (7.6%, P < 0.001). Binocular near vision of N8 or worse was 4.8% (n = 33) and increased with age (P < 0.001) [Table 1].
Table 1: Sociodemographic and Clinical Characteristics of Truckers Who Participated in the Study

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Refractive errors and prescription of spectacles

The grades of different types of REs are presented in [Table 2]. Using the spherical equivalent, the overall prevalence of any RE in the worse eye was 45.8% (95% CI 42.1%–49.6%) and increased significantly with age (P < 0.001). The prevalence of myopia with or without astigmatism was 10% (95% CI 7.9%–12.5%) and decreased significantly with increasing age (P < 0.001). The prevalence of hyperopia with or without astigmatism plus presbyopia was 9.4% (95% CI 7.4%–11.9%) and increased significantly with age (P < 0.001). The prevalence of presbyopia with or without distance vision was 33% (95% CI 29.6%–36.6%) and increased significantly with age (P < 0.001). The prevalence of presbyopia alone without distance vision was 17.5% (95% CI 14.8%–20.5%) and also increased significantly with age (P < 0.001). The highest prescription of distance vision spectacles was noted significantly among younger truckers while that of near vision and bifocal lenses among truckers aged 40 years and above (P < 0.001) [Figure 1].
Table 2: Prevalence of Different Combinations of Distance and Near Vision Problems in Truckers

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Figure 1: Type of spectacles prescribed among truckers identified with refractive errors by age group

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Re-contact with truckers and spectacle compliance

Attempts were made to re-contact all the truckers who were prescribed spectacles to assess its compliance. A total of 159 truckers (overall: 50.3%) were successfully re-contacted six months to one-year post provision of spectacles. Of those who were successfully contacted, 87 (54.7%) truckers reported using spectacles and 72 (45.3%) reported not using them. The usage of spectacles significantly increased with age (P = 0.046) [Figure 2].
Figure 2: Long-term spectacle compliance among those who were prescribed spectacles

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Upon further investigation to assess the barriers for spectacle compliance, “did not collect” was reported to the major reason for non-compliance (63.9%), followed by “discomfort” (20.8%). Neither the type of spectacle prescribed nor age of the trucker was significantly associated with the various barriers reported [Table 3].
Table 3: Barriers For Spectacle Compliance Amongst Truckers in India

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  Discussion Top


We report on refractive errors and spectacle compliance pertaining to one of the most difficult to reach populations in the country owing to their constant mobile lifestyles. Nearly half (45.8%) of all truckers screened in this study were diagnosed with refractive errors, with presbyopia with or without distance vision being predominant type of RE followed by myopia. Our findings on refractive error were consistent with other similar investigations from the rest of the country and elsewhere. A recent assessment by Sightsavers India, which screened 17,546 truckers in various eye camps, revealed that about 46.7% were detected with uncorrected refractive errors and another 3.1% with other ocular eye morbidities, although it did not report on the type of refractive errors.[7] Erdogan and colleagues found a refractive error prevalence of 21.5% in 200 heavy vehicle drivers in Turkey.[8] A recent Government of India assessment by its National Highway Authority of India, which screened over 700 truck drives at a toll-plaza in the National Capital Region revealed that about 70% of truck drivers screened had uncorrected refractive errors.[17] Similar higher prevalence of refractive error was also reported among truck drivers from other parts of the world. [18,19] Higher rates of refractive errors reported in all of these various studies, including that of ours, make truckers a priority group for targeted eye-care interventions. Owing to their mobile lifestyles and unavailability of health care facilities on the peripheries of cities and towns (where bulk of truck parking lots are designated) render truckers unable to utilize the existing health care systems. Intensive and targeted efforts to reach out to this population at the truck parking lots, transportation hubs and dhabas (roadside hotel where truckers stop for food and rest) through mobile eye screening clinics/vans seem a viable approach to reach out to this group, although a scientific investigation into such an approach is warranted. Though not related to eye care, evidence from other public health prevention initiatives in India reveal a limited programmatic exposure targeting truckers. [20,21] Thus, any such measures to consistently reach out to this population should be well planned, feasible, and cost-effective.

Refractive errors detected in the study population were mainly presbyopia with or without distance vision, predominantly seen in the >40 years' age group and myopia in combination with astigmatism, predominantly seen in those aged <40 years. Presbyopia and its presentation in combination with myopia, hyperopia, or astigmatism is a significant public health challenge. Subjects with both presbyopia and myopia/hyperopia are required to wear bifocal or progressive lenses, which are expensive and may hamper with driving, particularly under low-illumination levels. [22,23] On the other hand, truckers diagnosed with presbyopia alone need glasses only for near vision, which may not affect their driving, but could hamper their near-vision tasks such as using a mobile phone. Ensuring availability of low-cost bifocal lenses and interventions aimed at educating truckers about the importance and use of spectacles are needed.

Spectacle usage was relatively low among truckers aged <40 years as compared to older drivers. Spectacles coverage is one of the important impact indicators for primary eye care services. Spectacle compliance among truckers is an issue as reported by other studies too. A study done in southern Indian city of Hyderabad revealed low spectacle usage among truck drivers.[4] Sightsavers India, as part of their truckers' initiative “Eye OK Please!” also reported low to moderate spectacle compliance, with as many as 39% of truckers never used spectacles provided ever.[7] Bekibele and colleagues report from a study on truckers in Ibadan, Nigeria on very low levels of spectacle compliance.[19] The two predominant barriers for spectacle non-compliance reported in this study were “did not collect” (64%) and “discomfort” (21%). As majority of truckers were prescribed either near vision or bifocal lens, which did not affect their driving-related tasks, this could have discouraged them from getting their free pair of spectacles. The provision of spectacles on the same day, specifically for the presbyopic correction would address this issue to an extent. All the eye-screening camps and interventions targeting truckers should plan for a dedicated counselor imparting vital eye care information to truckers along with educating them on the importance of usage of spectacles. The Sightsavers India report on truckers' eye health indicates low levels of awareness and understanding on basic eye care and the relationship between good vision and road safety. This report also reported on the higher levels (80%) of willingness among truckers for participation in future eye camps.[7] A dedicated counselor at eye screening camps targeting truckers coupled with intensive information, education, and communications strategies targeting truckers would negate the many misconceptions pertaining to spectacle usage and encourage them to use spectacles thereby improving compliance.

Our study has certain limitations. Truckers, being highly mobile owing to the nature of their work, re-contacting them to assess long-term spectacle compliance was a huge challenge. The compliance data reported in this study was limited and thus needs to be interpreted with caution. Certain subjects who were diagnosed with myopia may require to undergo dilated fundus examination by an ophthalmologist to rule out retinal thinning, which was not done in this study.


  Conclusion Top


In conclusion, a higher proportion of truckers have refractive errors with presbyopia being the predominant type of refractive error diagnosed. Long-term spectacle compliance was generally moderate and comparatively low among younger drivers. Targeted interventions specifically designed to address the eye health needs of truckers that include mobile clinics and intensive and targeted awareness and information, education, and communication strategies and counseling could be a way forward.

Declaration of patient consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors wish to thank Bridgestone India Private Limited for their support for eye services to truckers. We wish to thank the participants of this study and the staff of the partner hospitals for assisting with study logistics, data collection, and conducting eye screening. The authors wish to thank Ms. Uttara Jhaveri, for her contribution in compiling data. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the organisations that facilitated this study, or the institutions employing the authors.

Financial support and sponsorship

The truckers India study was supported by Bridgestone India Private Limited, Pune, India. The funding sponsors had no role in study design, in the collection, analyses, or interpretation of data, in the writing of the manuscript, and in the decision to publish the results.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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