Randomised comparison of three tools for improving compliance with occlusion therapy: an educational cartoon story, a reward calendar, and an information leaflet for parents

  • A. M. Tjiam
  • G. Holtslag
  • H. M. Van Minderhout
  • B. Simonsz-Tóth
  • M. H. L. Vermeulen-Jong
  • G. J. J. M. Borsboom
  • S. E. Loudon
  • H. J. Simonsz



We previously demonstrated that compliance with occlusion therapy for amblyopia was improved by the use of an educational programme, especially in children of parents of foreign origin and who spoke Dutch poorly. The programme consisted of: (i) a cartoon story for amblyopic children that explained without words why they should patch, (ii) a calendar with reward stickers, and (iii) an information leaflet for parents. In the current study, we assessed the individual effect of each component on compliance.


We recruited 120 3- to 6-year-old children who lived in a low socio-economic status (SES) area in The Hague and were starting occlusion therapy for the first time. They were randomised to receive one of the components (three intervention groups), or a picture to colour (control group). The randomisation was blinded for treating orthoptist and researcher. Compliance was measured electronically using the Occlusion Dose Monitor (ODM). Primary outcome was percentage of compliance (actual/prescribed occlusion time). Secondary outcome was absolute occlusion hours per day. Parental fluency in Dutch was rated on a five-point scale.


Compliance could be measured electronically in 88 of the 120 children; in 32 others, it failed for various reasons. Parental fluency in Dutch was moderate or worse in 36.4 % (p = 0.327). Average compliance was 55 % standard deviation (SD) 40 (n = 18) in the control group, 89 % SD 25 in the group receiving the educational cartoon (n = 25, P = 0.002 compared with control group), 67 % SD 33 (n = 24, P = 0.301) in the reward-calendar group and 73 % SD 40 (n = 21, P = 0.119) in the parent-information-leaflet group. On average, children in the control group occluded 1:46 SD1:19 hours/day, 2:33 SD 1:18 hours/day in the group receiving the educational cartoon, 1:59 SD 1:13 hours/day in the reward-calendar group and 2:18 SD 1:13 hours/day in the parent-information-leaflet group. No child who received the cartoon story occluded less than 1 hour per day, against seven in the reward-calendar group, five in the parent-information-leaflet group and five in the control group.


Although all three components of the programme improved compliance with occlusion therapy in children in low-SES areas, the educational cartoon had the strongest effect, as it explained without words to a 4- to 5-year-old child why it should wear the eye patch.


Amblyopia Patients’ compliance Intervention Randomised controlled trial 



The Occlusion Dose Monitor was developed in 1996–1997 as a public domain project at the department of Medical Technical Development at Amsterdam Academic Medical Centre, the Netherlands. Acknowledgement for proofreading and correcting the English edition goes to Mr. D.R.M. Alexander.

This work was supported by

ZonMW-the Netherlands Organization for Health Research and Development [grant number: #6320.0008].

Financial Disclosure




Competing interests


Ethics approval

Ethics approval was provided by Erasmus MC University Medical Centre, Rotterdam.


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Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • A. M. Tjiam
    • 1
  • G. Holtslag
    • 1
  • H. M. Van Minderhout
    • 2
  • B. Simonsz-Tóth
    • 2
  • M. H. L. Vermeulen-Jong
    • 2
  • G. J. J. M. Borsboom
    • 3
  • S. E. Loudon
    • 1
  • H. J. Simonsz
    • 1
  1. 1.Department of OphthalmologyErasmus MC University Medical Centre RotterdamRotterdamThe Netherlands
  2. 2.Department of OphthalmologyMedical Centre HaaglandenThe Haguethe Netherlands
  3. 3.Department of Public Health and BiostatisticsErasmus MC University Medical Centre RotterdamRotterdamthe Netherlands

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