Determining the information needs of contact lens wearers for better education and more support: a qualitative study

The use of Contact Lenses (CL) has increased tremendously over the years for a wide range of applications, including vision correction, management of corneal disorders, and cosmetics [1‐4]. Approximately 150 million people in the world use CL [2, 5, 6] to correct refractive errors such as myopia, hyperopia, and astigmatism as alternative to spectacles; and as a main therapeutic option in cases such as aphakia, keratoconus, irregular cornea, and high anisometropia which, the glasses cannot help or conditions such as ocular surface problems which need specialized lenses for their management [2, 7].

Despite the advantages of using CL [8‐11], adverse reactions with different severities may occur from clinically inconsequential to potentially vision-threatening. Discomfort, corneal staining, dryness, microbial keratitis, corneal neovascularization, allergic conjunctivitis, and corneal infection are the main complications limiting the success of the CL and eventually may lead to the discontinuation of CL [5, 7, 10, 12‐18]. One study showed that 6% of Contact Lens Wearers (CLWs) have experienced a complication each year [18] and another study in the U. S reported that one-third of the CLWs had a CL-related condition requiring a physician’s visit [19].

Most CL-related complications occur due to noncompliance with recommendations and CL care, including improper cleaning and disinfection, using the CL for more than the recommended period, incorrect use of the solution, and inadequate handwashing [13, 20, 21]. To do proper CL care and maintenance, CLWs need adequate knowledge and awareness to minimize or prevent complications [13, 16, 21]. Acquiring relevant information is an important aspect of care and support for CLWs that enable them to have greater control over their self-care [22, 23]. Therefore, CLWs should be trained – both at the beginning of CL use and periodic throughout CL wearing – to increase their knowledge, modify their behavior, and enhance their motivation about CL care and hygiene [21].

Various studies investigated the level of CLWs compliance and the impact of education on the compliance behavior of wearers and developed strategies to aid them regarding their compliance and success in using CL [20, 24, 25]. Şengör et al. assessed the consumers’ knowledge and perception of the CL to provide tips and recommendations for education and to increase consumers’ awareness [26]. Other studies [10, 16, 17, 21, 22, 27‐32] measured the relationship between awareness, knowledge, compliance, and complications of CL. Various studies have demonstrated the need for training and increasing information about the use of CL [22, 24, 29].

A training program should meet individuals’ needs to be effective [33]. The users are valuable resources for providing information regarding their needs [33, 34]. The needs assessment provides valuable information for designing educational interventions [35]. To determine the real needs of the indivituals and explore the gaps in existing educational programs, evaluating their perspectives through a qualitative approach could be helpful.

To our knowledge, there is no reported qualitative study evaluating the information needs of CLWs. Existing studies investigated the extent of non-compliant behavior of CLWs and how to use CL to develop strategies in CLWs’ education in order to gain needed information and acquire an appropriate understanding for safer CL wearing [25, 26]. Therefore, this qualitative study aimed to determine the information needs of CLWs and design interventions in the future to increase their knowledge and awareness regarding the use of CL.

Thirty-three participants both male and female were interviewed, 24 CLWs and 9 practitioners including ophthalmologists and optometrists (with Bachelor’s and Master’s academic degrees). Four participants asked for another interview.

Table 1 shows the participants’ demographic information. Some needs were identified jointly by CLWs and practitioners, but some of them were described only by either CLWs or practitioners (Tables 2, 3). Two main categories have emerged from the analysis of data, including knowledge and skill with seven subcategories that are displayed in Fig. 1. There were 36 sub-subcategories, which belong to the subcategories of basic information for the CLWs, acquaintance with the CL, caring for CL, hygiene and vigilance of CL, challenges of using CL, handling/insertion and removal of the CL, and stabilization of learned information. The sub-subcategories and examples of interview excerpts related to knowledge and skill themes are shown in Table 2 and Table 3.

The present study explored the experiences and viewpoints of CLWs, ophthalmologists, and optometrists about the information needs of CLWs. The results depicted various needs of CLWs, which are classified into two main categories, including knowledge and skills and seven subcategories.

One of the subcategories was “basic information for CLWs”. Each CLW differs in terms of occupation, environmental conditions, tear film properties, corneal status and diameter, and eye anatomical features such as interpalpebral distance and eyelid shape [26]. CLWs’ awareness of these factors facilitates the prescription of lenses, easier eye examinations, and selection of appropriate CL by practitioners. In line with our study, Fogel and Schweizer also mentioned the importance of acquaintance with reputable centers for prescribing and selling lenses. They investigated the purchase of lenses from the doctor’s office, store, and the Internet and found that those, who purchased CL over the Internet or at stores, did not follow some of the FDA CL recommendations and wearers using them could be more at risk for complications such as eye infection. Non-credible websites, non-evidence-based Internet information about CL, lack of checkup for CL by an eye care practitioner after purchasing a lens at a store or over the Internet show the importance of valid centers for prescribing and purchasing lenses [39, 40]. In agreement with our findings, another study showed that the CL brand was important for CLWs, who wanted to know more about CL brands [41]. Donshik et al. noted about the CLWs’ need for information resources and their role in improving CL compliance behaviors [25].

In the present study, “acquaintance with the CL” along with its sub-subcategories was identified as another perceived need of CLWs. In line with our findings, Unnikrishnan et al. demonstrated that CLWs needed guidance on different lens types [4]. Kumar’s et al. investigated the reason for using the CL among CLWs and found that most of them used lenses for cosmetic reasons. In their study, the participants considered beauty as the most common reason for using a lens. In contrast, Khan et al. showed that the majority of CLWs only knew that CL were used to correct refractive errors and a significant number of the participants were not aware of the important indications of CL. These studies suggested that CLWs should be more informed of the reasons for CL use [42, 43]. Other studies reported that CLWs should be informed of the advantages and disadvantages of wearing CL to overcome barriers before using it [44, 45]. Moreover, Asiri et al. explained that the majority of CLWs did not have proper information about the lifespan of CL types [46].

Regarding “caring for CL” with its sub-subcategories, consistent with our findings, Sengor and Wu reported that CLWs needed information regarding lens care and follow-ups as they had improper lens care and irregular follow-ups [26, 28]. Ibanga emphasized that CLWs should gain knowledge about proper care and pay attention to climatic conditions [47]. Zimmerman et al. explained that most of the CLWs were unaware of the risk of exposing CL or storage case to water and practitioners should better educate them to avoid exposing their lenses to any source of water [48]. Chavan et al. noted that 58% of the CLWs were uninformed of acanthamoeba infection related to use of tap water as a cleaning material for CL [49]. Other studies also noted CLWs’ insufficient knowledge of Keeping nails short [13], not sharing the CL with others [45], over wear syndrome and replacement time of reusable CL, and not using CL beyond the expiry date [13, 49, 50]. Moreover, CLWs in special groups like children, teens, allergic individuals, and those with different underlying diseases needed information based on their own condition. Providing tailored information can help the diabetic patients promote CL care behaviors [51], migraine patients wear the suitable CL to prevent CL-related stimulus that can trigger migraine attacks [52], and increase parents/children’s ability in CL use and its care [53]. Jafari et al. showed that one of the most frequent causes for the ophthalmology emergency referral was the problems related to CL and signified a need for further educational and preventive interventions to increase CLWs’ knowledge [54]. Other studies recommended that CLWs should be informed and re-educated when to use and not to use CL such as swimming, entering a hot tub, or taking shower [13, 55].

Another need for CLWs was “Hygiene and vigilance of CL” along with its sub-subcategories. In agreement with our findings, a study showed that information about make-up such as eyeliner, mascara, face and body lotion was often overlooked by practitioners and should be more explained especially to female CLWs [56]. Other studies [13, 43, 56‐58] reported that wearer’s inadequate behaviors such as improper cleaning and disinfection of CL and its cases, poor CL maintenance, lack of lens case replacement, solution misuse, reuse of solutions, improper use of the normal saline solution, and rewetting drops occurred due to lack of knowledge and understanding. Acquiring adequate knowledge could motivate wearers to be more vigilant in this regard.

In relation with “challenges of using CL” with its sub-subcategories and consistent with our results, other studies [13, 26, 59, 60] mentioned a need to utilize an approach to reduce concerns about the slip of the lens behind the eye, loss of CL, and sight-threatening infection. Numbers of studies suggest applying effective strategies to make CLWs aware of complications [16, 42, 46], the possibility of CL displacement [60], lens tolerance [61], and possible accidents such as torn or ripped CL [62]. Providing information and paying attention to eye diseases such as keratoconus, which is treated with a CL, is very important for CLWs [63].

“Handling/insertion and removal of the CL” with its sub-subcategories was another need in CLWs. Coincident with our result, Sengor emphasized the necessity of raising CLWs’ awareness by providing basic theoretical and practical education focusing on using and cleaning of CL with ophthalmologist’s supervision [26]. Donshik also suggested that the most desired way was one-on-one patient education in the clinic [25]. Review studies also explained the need to develop strategies for better hand hygiene in addition to routine education [59, 64].

Regarding “stabilization of learned information”, similar studies noted that CLWs forgot a large amount of information (50%) after leaving the first medical visit. CLWs (and practitioners accordingly) are preoccupied with lens insertion and removal at the first session of CL prescription, with a level of stress and anxiety which decreases the ability to gain the information provided about CL. The information must be repeated in a positive and enthusiastic manner. It is insufficient to provide only verbal and written instructions [25, 29, 59]. Content and format of the training should be combined with media such as video, voice, illustrations, and the Internet resources [13, 65].

In this study, both CLWs and practitioners identified a large number of educational needs. Moreover, CLWs specifically identified needs related to the subcategories of basic information, caring for CL, challenges of using CL, and stabilization of learned information. Practitioners should consider these needs and CLWs should receive sufficient information in this regard. Necessary examinations and prior preparations are the needs identified by practitioners. Providing information in this regard could results in better CLWs’ cooperation, reduce CLWs’ visits and practitioner’s workload, and prevent wasting time of practitioners and CLWs.

The results of this study showed different aspects of using CL that CLWs should be aware of them. To prevent CL complications and overcome the challenges of using CL, information needs of the individuals should be considered and proper educational interventions should be developed. The results of this study provide good insights for healthcare authorities to design future interventions to increase the knowledge and skills of CLWs.

CLWs need accurate and sufficient information to use and care for their CL. Providing appropriate information requires a proper understanding of their needs. A wider understanding of the needs of CLWs will benefit CLWs and eye care practitioners and prevent many complications and factors threatening eye health in CLWs. The findings also indicated the importance of how to convey information to the CLWs. Verbal and written education when prescribing lenses are not sufficient strategies to meet the information needs of the individuals. Therefore, new approaches must be provided to present information in a simple, detailed, and practical way with enough repetition.