Poor academic performance of children can negatively impact their future employment options and socio-economic status, which ultimately can deplete the economic growth of a nation. Vision is one of the complex and interrelated processes through which learning is mastered, therefore untreated visual problems may interfere with achieving full learning potential.
Refractive error (RE) is the most common vision problem that generally initiates in early adolescence. RE is considered to have a complex relationship with academic achievement. The increased accommodative effort used by an uncorrected hypermetrope to focus at near may cause transient blurring, fatigue and asthenopic symptoms, linking hypermetropia with reading difficulties. On the other hand, an uncorrected myopic can experience interference in learning if a classroom blackboard is unclear. Anxiety through this incompetence can initiate a cycle of poor achievement.
The use of spectacles is a cost-effective solution to correct visual acuity (VA) deficits due to RE. However, prescribing for spectacles alone cannot guarantee their ownership and usage, hence an appraisal is required to find the influence of providing and using spectacles on early adolescents’ academic performance. Also, an increase in global migration has resulted in children from different parts of the world studying together, therefore an evaluation of the aforesaid influence on early adolescents from different nations needs consideration for future economic prospects of a nation.
Literature Search
Academic search engines like Google Scholar and PubMed were employed and the most up-to-date literature published since 2013 which evaluated the provision of spectacles and the educational outcomes of school-going early adolescents, was looked at. After critical appraisal, studies from diverse income nations were included to ensure a wider range of populations from different parts of the world were analysed for generalisation.
Results
Three out of four sourced articles were cluster randomised trials; two were implemented in China and the third was from Florida. Clustering allowed researchers to employ a large sample size. Glewwe et al concluded (from an analytic sample size of 15,472 adolescent students that) vision screening and spectacles improved the academic achievements in maths and reading. However, only the reading test had stronger statistical significance. While the intervention raised the possibility of succeeding in the standardised test by approximately 2%, researchers suggested applying appropriate follow-up actions to prevent a fading-out of the intervention’s effect and to sustain academic achievements.
Ma et al randomised 3,177 adolescents to control, vouchers or free spectacles groupings and compared their baseline and the end-line score in mathematics over an academic year. Notwithstanding imperfect compliance, the maths test results demonstrated statistically significant progress among the children receiving free spectacles. Although the variance was meagre, the authors concluded that academic achievements can be improved by encouraging the use of spectacles.
When 1,200 adolescent children with uncorrected refractive error (URE) were randomised in a study by Ma et al, a statistically significant improvement was found in the maths scores of the early provision group. The effect was comparable to further learning for an additional half a term. Moreover, the spectacles ownership and wear rates were found to be greater in the early provision group. However, due to self-reported data, over-estimation of actual behaviour was possible.
A follow up cross-sectional study of 1,018 rural adolescent schoolchildren in an Indian district by Gogate et al identified that academic performance was positively correlated with a greater likelihood of being acquiescent with spectacles wear. However, the parameters used to measure academic performance, were unclear. The study found that education about the benefits of spectacles wear may improve compliance.
Discussio
Maximum modification in RE is experienced in early childhood through emmetropisation. The presence of RE among the subjects under study confirmed that emmetropisation had not taken place. However, an improvement in the RE-induced reduced VA can be achieved for any school-aged children if the optical correction is provided and spectacles are worn.
The ability to see well during study time for distance and near vision is essential to flourish in academic life, although there is no statistical proof that shows academic under-achievement is attributed to URE. The critical evaluation of all included studies confirmed that academic performance can be enhanced by equipping children with spectacles. However, these studies only employed low or middle income children, making it difficult to judge if the academic performance of high-income children,
privileged to access numerous additional resources, could be influenced due to spectacles. Moreover, cluster randomisation has reduced statistical efficiency compared to individual randomisation and therefore the statistical precision of the results cannot be trusted. However, most health researchers employ cluster randomisation to examine the outcome of the interventions on the betterment of health or change of lifestyle.
Gogate et al were able to furnish a snapshot of the academic performance at a particular timeframe after the usage of provided spectacles through follow-up cross-sectional study. However, with the complicated and bidirectional relationship between the RE and VA on one extreme and academic performance on the other, drawing cause and effect inferences from the study is difficult. Moreover, the presence of mainly myopic subjects and the possibility of under-estimation of hyperopia may impose an inconclusive result. However, the study highlighted the existence of a relationship between spectacles usage and academic achievement.
Furthermore, subjects of Ma et al were also myopic and therefore their findings were limited to myopic early adolescents. Nevertheless, a linear increase in myopic trend exists, consequential to myopic progression in the past three decades through increased indoor activities stemming from the recent ‘computerisation’ revolution affecting early adolescents. Therefore, although a positive association is found between myopia and education, customised spectacles are recommended as one of the means to slow myopia progression. Notwithstanding, uncorrected hyperopia is found to have an association with reading difficulties.
An individual’s academic success is dependent on various components, yet none of the four studies showed how these variables were controlled. However, it is admitted that academic success is better predicted by vision-related factors than ethnicity and/or socio-economic status, hence URE can lead to an unfavourable academic outcome.
Overall, academic performance is not solely dependent on mathematics, and a better portrayal of a student’s educational ability is determined by their test results across all subjects. However, there is a positive interrelationship between visual dysfunction, poor reading ability and poor educational outcomes. Therefore any learning obstacle within a competitive education system can aggravate the risks of mental health problems. Hence, cost-effective reforms like spectacles are essential to improve earning potential, which necessitates improving the perceptions over spectacles and awareness among children and parents.
The imprecision and indirectness make Ma et al a low-certainty evidenced study. Moreover, self-reported data in Ma et al and Gogate et al may lead to over-estimation of actual behaviour due to information bias. Glewwe et al advise taking caution when interpreting evidence since estimates of spillover effects on good vision students in full-treatment schools was incredibly high and programme implementation had some loopholes.
Furthermore, the subjects of all studies were drawn from a small domain of large countries which limits their external validity and applicability to other settings, since the results may be specific to location, making generalisation doubtful. However, these studies, conducted in different nations, echo homogeneous results showing the possibility of a positive association between spectacles usage and educational outcome. Nonetheless, economic considerations are essential in the low- and middle-income availability provision of affordable or free spectacles can improve their availability and longer acquisition could further improve spectacles wear, which may lead to better educational outcomes.
Conclusion
The learning progress of early adolescent children can be adversely affected by blurred vision. However, using spectacles can improve VA, hence students with RE should be encouraged to acknowledge that spectacles are a valuable learning asset. The judgement of academic performance should be based across the test results of all subjects, though, any obstacle to learning within a competitive education system can restrict learning. The provision of low-cost or free spectacles can improve their availability, removing the barrier between vision problems and learning. Although there is a presence of positive reciprocity amidst myopia and education, spectacles may reduce the pace of myopic progression.
Critical evaluation of the literature indicated a positive influence of spectacles on academic achievements. However, non-inclusion of high-income children and limited external validity of articles warrants the need for additional robust research where various variables affecting educational outcomes are controlled and subjects of all kinds from various parts of the world are included.
The research could not find any article based on subjects from the UK. However, many emigrants from the countries included in these articles live in the UK, and so their relevance may be justified. Future research should include subjects from the UK to provide a clear picture of the influence spectacles has on educational outcomes within its cosmopolitan population. The results will aid in formatting policies to solve students’ visual problems and stimulate their academic performance for future economic growth.
Although each study has some limitations, they provided some indicators that the use of spectacles can improve academic performance, which necessitates improving awareness among parents and students. This gap can be successfully filled by dispensing opticians as paediatric dispensing is one of their core competencies.
An eye care professional can effectively address concerns and advise on the benefits of effective compliance of spectacles, which may aid in achieving better educational outcomes and solve non-compliance issues. Additionally, regular follow-ups with a dispensing optician will ensure that the correction effects of spectacles have not faded, and maintain the continuity of vision care in an early adolescent’s academic life. Moreover, correcting hyperopia can reduce reading difficulties and thus can bring benefit in academic performance.
Shilpa Mehta is a dispensing optician practising in the UK
• The full version of this study, with references, is available from Bill Harvey at bill.harvey@markallengroup.com