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Strabismus. 2016 Sep;24(3):120-35. doi: 10.1080/09273972.2016.1205101. Epub 2016 Aug 2.

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

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a Department of Ophthalmology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , the Netherlands.
b Department of Ophthalmology , Rotterdam Eye Hospital , Rotterdam , the Netherlands.
c Department of Public Health , Erasmus MC, University Medical Center Rotterdam , the Netherlands.
d Department of Health - Orthoptics , Utrecht University of Applied Sciences , Utrecht , the Netherlands.
e Department of Psychology and Education , VU University Amsterdam , the Netherlands.
f Department of Medical Psychology , Erasmus MC, University Medical Center Rotterdam , the Netherlands.



This implementation study evaluated orthoptists' use of an educational cartoon ("the Patchbook") and other measures to improve compliance with occlusion therapy for amblyopia.


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.


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.


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.


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

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