Background: Strabismus, commonly known as squint, is a visual condition marked by eye misalignment, impacting binocular vision and often leading to amblyopia (lazy eye) if untreated. Despite its prevalence, public awareness remains limited, particularly in underserved regions. This study assessed awareness, knowledge and preventive practices regarding strabismus among residents of Himachal Pradesh, India. Materials and Methods: A descriptive cross-sectional study was conducted among 400 adults in Himachal Pradesh using a structured online questionnaire. Data on demographics, awareness and preventive practices were collected. Knowledge scores were classified as Very Good (>80%), Good (60%-79%), Fair (41%-59%) and Poor (<40%). Analysis was conducted using SPSS v26.0 with p<0.05 significance. Results: While 81% identified strabismus as “squint” or “crossed eyes,” only 60.3% recognized vitamin A’s role in eye health and 63.3% were aware of amblyopia as a risk. Knowledge scores indicated 40.3% had “Very Good” knowledge, 37.3% “Good,” 15.8% “Fair,” and 6.8% “Poor,” with lower awareness levels prevalent among rural and less-educated participants. Conclusion: Although awareness of strabismus was promising, critical gaps in symptom recognition, risk awareness and preventive practices persist. Targeted educational campaigns, school-based screenings and improved healthcare access are essential to enhance early diagnosis and management.
Strabismus, commonly referred to as squint, is a visual condition characterized by the misalignment of the eyes, where one eye deviates inward, outward, upward, or downward while the other maintains its focus. This ocular misalignment can affect individuals of all ages, though it is most frequently observed in children. Strabismus not only compromises binocular vision but may also result in amblyopia (lazy eye), impaired depth perception and psychosocial challenges due to its visible nature. Despite its prevalence, public awareness regarding the condition's causes, symptoms and treatment options remains limited, often resulting in delayed diagnosis and suboptimal management [1-4].
The causes of strabismus are multifactorial, ranging from congenital defects and neurological issues to muscle imbalances, refractive errors, or trauma. While early detection can lead to successful intervention through corrective lenses, vision therapy, or surgical correction, untreated strabismus can result in permanent vision impairment and long-term psychological distress. Moreover, misconceptions about the condition-such as the belief that squint is untreatable or merely cosmetic-further hinder timely intervention [5-7].
In India, where access to pediatric eye care services remains inconsistent, regions with limited healthcare resources face unique challenges in managing strabismus. Rural populations and individuals with lower educational attainment may lack the necessary awareness to recognize the early signs of strabismus, further delaying intervention. Given that successful outcomes rely heavily on early detection and appropriate treatment, improving public understanding of strabismus is vital.
This study aims to assess public awareness, knowledge and preventive practices regarding strabismus among residents of Himachal Pradesh, India. By exploring demographic trends in awareness levels and identifying key knowledge gaps, the study seeks to inform future educational initiatives, promote timely eye care interventions and reduce the long-term visual and social burden associated with untreated strabismus. Findings will guide public health campaigns, school-based screenings and community outreach programs to enhance early diagnosis and improve eye health outcomes.
Research Design
A descriptive cross-sectional study was conducted to assess public awareness, knowledge and preventive practices regarding strabismus (squint) among residents of Himachal Pradesh, India. The study employed a structured online questionnaire to collect data efficiently from diverse demographic groups.
Study Area and Population
The study was conducted across various districts in Himachal Pradesh, a northern Indian state with diverse socio-economic and healthcare access profiles. The target population comprised adults aged 18 years and above from both urban and rural regions. Special emphasis was placed on populations at higher risk of strabismus-related complications, such as parents of young children, teachers and individuals engaged in healthcare or educational settings.
Sample Size and Sampling Technique
A sample size of 400 participants was calculated based on a 95% confidence interval, an estimated 50% prevalence of strabismus awareness and a 5% margin of error. To account for incomplete or erroneous responses, a 10% buffer was included. The study employed convenience and purposive sampling techniques, utilizing social media platforms such as WhatsApp, Facebook and local community groups to maximize outreach.
Inclusion and Exclusion Criteria
Inclusion Criteria
Exclusion Criteria
Data Collection Instrument
A structured and validated questionnaire was designed in collaboration with ophthalmologists, optometrists and public health experts. The questionnaire included the following sections:
The questionnaire comprised 20 multiple-choice questions and was available in both Hindi and English to ensure accessibility.
Scoring and Knowledge Classification
Responses were scored based on correct answers in the knowledge and awareness section. Scores were classified into four categories:
This scoring method helped identify groups requiring targeted educational interventions.
Data Collection Procedure
Data collection was conducted over a three-month period (October to December 2024) using Google Forms. The questionnaire link was circulated through social media platforms, local schools, parent-teacher associations and community forums to ensure participation from diverse socio-economic and occupational groups. Participants were informed about the study's purpose, assured of their anonymity and informed that participation was voluntary. Informed consent was obtained prior to survey completion.
Data Analysis
All collected data were reviewed, cleaned and organized using Microsoft Excel. Statistical analysis was performed using SPSS (version 26.0). Descriptive statistics were employed to summarize socio-demographic characteristics, awareness levels and knowledge scores.
Ethical Considerations
Ethical approval for the study was obtained from the institutional ethics committee. Participants were informed about the study’s objectives and their participation was strictly voluntary. Data confidentiality was maintained throughout the study and participants had the right to withdraw at any point without penalty.
The socio-demographic profile of the 400 participants revealed a balanced gender distribution, with males comprising 49.8% and females 50.3%. The majority of respondents were within the economically active age groups, with 35.3% aged 26-35 years and 27% aged 36-45 years, indicating a significant representation of individuals at risk of occupational or lifestyle-related vision concerns. Educational backgrounds were diverse, with 33.5% of participants holding secondary education qualifications and 33.3% possessing undergraduate degrees. Notably, 26.8% of respondents were homemakers, while office workers (22.8%) and teachers (17.8%) formed other prominent groups. Rural residents accounted for 57.3% of the sample, highlighting the importance of improving awareness in non-urban communities with potentially reduced access to ophthalmic care (Table 1).
Table 1: Socio-Demographic Characteristics of Participants
Variable | Category | Frequency (n) | Percentage (%) |
Age Group (Years) | 18–25 | 93 | 23.3 |
26–35 | 141 | 35.3 | |
36–45 | 108 | 27.0 | |
46 and above | 58 | 14.5 | |
Gender | Male | 199 | 49.8 |
Female | 201 | 50.3 | |
Education Level | No formal education | 19 | 4.8 |
Primary school | 67 | 16.8 | |
Secondary school | 134 | 33.5 | |
Undergraduate degree | 133 | 33.3 | |
Postgraduate degree | 47 | 11.8 | |
Occupation | Homemaker | 107 | 26.8 |
Office Worker | 91 | 22.8 | |
Teacher | 71 | 17.8 | |
Healthcare Professional | 39 | 9.8 | |
Student | 54 | 13.5 | |
Other | 38 | 9.5 | |
Residential Setting | Urban | 171 | 42.8 |
Rural | 229 | 57.3 |
The assessment of awareness and knowledge about strabismus revealed a mix of strengths and gaps. Encouragingly, 81% of participants correctly identified strabismus as a condition commonly known as “squint” or “crossed eyes,” while 71.5% recognized eye muscle imbalance as a common cause. Positive awareness was also noted in understanding strabismus' impact on depth perception (87.8%) and the role of ophthalmologists in managing the condition (86.5%). However, only 60.3% correctly identified vitamin A as an important nutrient supporting eye health, highlighting a gap in awareness of nutritional interventions. While 72.8% recognized eye exercises or surgery as valid treatment options, fewer participants (65.3%) identified misaligned eyes as a common symptom, indicating limited understanding of symptom recognition. Additionally, only 63.3% were aware that untreated strabismus could lead to amblyopia (lazy eye), reinforcing the need for improved educational outreach on the risks associated with delayed treatment (Table 2).
Table 2: Awareness and Knowledge of Squint (Strabismus) Among the General Population
No. | Question | Options | Correct Responses (n) | Percentage (%) |
1 | What is strabismus commonly known as? | a) Ear misalignment, b) Squint or crossed eyes, c) Throat condition, d) Skin disorder | 324 | 81.0 |
2 | What is a common cause of strabismus? | a) Loud noise, b) Poor diet, c) Eye muscle imbalance, d) Dry air | 286 | 71.5 |
3 | What part of the eye system is affected by strabismus? | a) Lens, b) Retina, c) Eye muscles, d) Optic nerve | 269 | 67.3 |
4 | Can strabismus affect depth perception? | a) Yes, b) No, c) Only in adults, d) Only temporarily | 351 | 87.8 |
5 | Which nutrient supports overall eye health? | a) Vitamin B12, b) Vitamin A, c) Vitamin K, d) Calcium | 241 | 60.3 |
6 | What should someone do if they notice a squint in their vision? | a) Ignore it, b) See an eye specialist, c) Rub eyes, d) Wait a month | 314 | 78.5 |
7 | What is a common symptom of strabismus? | a) Hearing loss, b) Sore throat, c) Misaligned eyes, d) Fever | 261 | 65.3 |
8 | Which symptom requires urgent medical attention? | a) Mild squint, b) Sudden onset of double vision, c) Occasional blur, d) Tiredness | 307 | 76.8 |
9 | Can strabismus be present at birth? | a) Yes, b) No, c) Only in the elderly, d) Only from injury | 272 | 68.0 |
10 | What is a common treatment for strabismus? | a) Ear drops, b) Eye exercises or surgery, c) Painkillers, d) Diet change | 291 | 72.8 |
11 | What is a risk of untreated strabismus? | a) Lazy eye (amblyopia), b) No risk, c) Hair loss, d) Joint pain | 253 | 63.3 |
12 | Can strabismus affect only one eye? | a) Yes, b) No, c) Only if inherited, d) Only if severe | 316 | 79.0 |
13 | How does strabismus affect vision coordination? | a) No effect, b) Disrupts binocular vision, c) Improves focus, d) Causes ear pain | 267 | 66.8 |
14 | What factor can contribute to strabismus in children? | a) High humidity, b) Family history, c) Loud noise, d) Spicy food | 258 | 64.5 |
15 | Can strabismus be corrected in adults? | a) Yes, b) No, c) Only with glasses, d) Only in youth | 263 | 65.8 |
16 | What habit may help manage strabismus symptoms? | a) Rubbing eyes, b) Avoiding screens, c) Following eye exercises, d) Using dim lights | 321 | 80.3 |
17 | What should you avoid if you suspect strabismus? | a) Drinking water, b) Delaying eye check-ups, c) Resting, d) Bright lights | 304 | 76.0 |
18 | Which of these is NOT a symptom of strabismus? | a) Double vision, b) Eye strain, c) Misaligned eyes, d) Sore throat | 243 | 60.8 |
19 | What is the first step if you notice a squint? | a) Increase screen time, b) Apply heat, c) Consult an eye doctor, d) Ignore it | 259 | 64.8 |
20 | What type of doctor treats strabismus? | a) Cardiologist, b) Neurologist, c) Ophthalmologist, d) Dentist | 346 | 86.5 |
Knowledge score classification revealed encouraging outcomes, with 40.3% of participants achieving “Very Good” knowledge scores (>80%) and 37.3% scoring within the “Good” range (60%-79%). However, 15.8% of participants demonstrated only “Fair” knowledge (41%-59%), while 6.8% exhibited “Poor” knowledge (<40%). The relatively lower scores were more prevalent among participants with minimal educational attainment and rural residents, underscoring the need for targeted educational interventions aimed at these vulnerable groups. These findings highlight the importance of community-level awareness campaigns, school-based programs and accessible eye care initiatives to enhance knowledge about strabismus prevention, symptoms and treatment options (Figure 1).
Figure 1: Knowledge score classification
The findings of this study provide valuable insights into the socio-demographic distribution, awareness levels and knowledge gaps related to strabismus (squint) among residents of Himachal Pradesh. The results highlight both encouraging trends in public understanding and concerning gaps that require targeted interventions to improve awareness, early diagnosis and effective management of strabismus.
The balanced gender distribution (49.8% males and 50.3% females) indicates an inclusive sampling approach, ensuring insights that reflect the awareness levels of both genders. The dominance of respondents in the economically active age groups (26-35 years: 35.3%; 36-45 years: 27%) reflects the relevance of addressing strabismus awareness among individuals who are parents, caregivers, or educators-groups that are critical for promoting early intervention in children.
Educational attainment among participants showed notable diversity, with a substantial proportion holding secondary (33.5%) and undergraduate (33.3%) qualifications. However, the presence of a significant segment with only primary education (16.8%) and no formal education (4.8%) underscores the need for simplified awareness campaigns accessible to individuals with limited literacy. Given that strabismus awareness heavily relies on understanding symptoms and treatment options, tailored educational strategies that accommodate varied educational backgrounds are essential.
Occupational data showed that homemakers (26.8%) and office workers (22.8%) represented key groups, reinforcing the importance of incorporating awareness initiatives in domestic and workplace settings. The sizable rural population (57.3%) further emphasizes the need to extend vision care campaigns to underserved areas, where access to healthcare facilities and specialized eye care may be limited. The prevalence of reduced awareness scores among rural participants underscores the need for targeted outreach programs to bridge these disparities.
The awareness assessment revealed both promising understanding and critical gaps. Encouragingly, 81% of participants correctly identified strabismus as "squint" or "crossed eyes," reflecting reasonable familiarity with the condition's basic identity. However, the fact that nearly 20% failed to recognize this indicates lingering gaps in fundamental awareness that may delay early detection and treatment.
Similarly, while 71.5% correctly linked strabismus to eye muscle imbalance-a positive indicator of knowledge regarding the physiological cause-fewer respondents (67.3%) recognized that strabismus specifically affects eye muscles, highlighting an incomplete understanding of its anatomical basis. This suggests the need for improved public education on the underlying mechanisms of strabismus to support better recognition and timely intervention.
Encouragingly, a strong majority (87.8%) understood that strabismus can impair depth perception, indicating positive awareness of its functional impact. Additionally, 86.5% correctly identified ophthalmologists as the appropriate healthcare providers for strabismus treatment, reinforcing a positive trend in healthcare-seeking behavior. However, this awareness may not consistently translate into action unless knowledge about early symptoms, risks and treatment options is reinforced.
Several gaps were identified in key areas that affect preventive behaviors. Only 60.3% recognized vitamin A as a vital nutrient supporting eye health, suggesting that awareness about dietary interventions for maintaining ocular muscle function is limited. Additionally, awareness of amblyopia (lazy eye) as a potential consequence of untreated strabismus was relatively low (63.3%), reflecting a gap in understanding the long-term visual risks associated with the condition. This finding is particularly concerning as amblyopia is a common and preventable outcome if intervention occurs early. The limited recognition of these risk factors emphasizes the need to educate the public about the consequences of ignoring strabismus symptoms.
Preventive strategies and treatment options also revealed gaps. While 72.8% correctly acknowledged eye exercises or surgery as treatment methods, a notable proportion remained unaware of modern therapeutic advancements, such as vision therapy, prism lenses and improved surgical interventions. Similarly, while 80.3% identified eye exercises as a helpful management strategy, public understanding of how such interventions improve visual alignment remains limited. Additionally, only 65.3% identified misaligned eyes as a common symptom, indicating a need for improved education on the visual signs of strabismus to facilitate earlier detection.
The knowledge classification further emphasized these gaps. While 40.3% of participants achieved "Very Good" knowledge scores and 37.3% achieved "Good" scores, a significant proportion demonstrated only "Fair" (15.8%) or "Poor" (6.8%) knowledge. This uneven distribution suggests that while awareness campaigns have been moderately successful in promoting general knowledge, there are still notable gaps in symptom recognition, risk understanding and preventive practices.
Participants with limited educational backgrounds and those residing in rural areas were disproportionately represented among the "Fair" and "Poor" categories, reinforcing the need for tailored educational interventions in these communities. Simplified educational materials, including visual aids, infographics and community-based workshops, can be effective in enhancing awareness in such populations. Furthermore, integrating strabismus education into school health programs can ensure children, parents and teachers are equipped with the knowledge to recognize early signs and seek timely treatment.
Implications for Public Health and Future Interventions
The findings of this study emphasize the urgent need for comprehensive public health initiatives aimed at improving strabismus awareness. Educational campaigns should focus on dispelling misconceptions, particularly the belief that strabismus is purely cosmetic or untreatable. Community-driven interventions should utilize digital media, visual demonstrations and culturally appropriate content to engage rural populations effectively. Additionally, leveraging school-based health programs to screen for strabismus and educate teachers and parents about early signs can significantly improve early diagnosis rates [8,9].
Healthcare providers must also play a proactive role in promoting eye health awareness. Integrating strabismus screening into routine eye check-ups, particularly in pediatric clinics, can ensure earlier diagnosis and prevent the progression of visual impairment. Ophthalmologists and optometrists should offer counseling to parents about preventive strategies, such as promoting balanced diets rich in vitamin A and encouraging regular eye exercises in children diagnosed with mild strabismus [10,11].
Employers and workplaces can also contribute by promoting routine eye checkups among employees, particularly those in visually intensive occupations that may exacerbate undiagnosed strabismus. Workplace awareness initiatives can emphasize the importance of early detection and treatment to preserve both vision quality and professional productivity [11,12].
This study highlights a promising level of public awareness regarding strabismus in Himachal Pradesh, yet significant knowledge gaps persist, particularly in recognizing symptoms, understanding risk factors and adopting preventive strategies. While a considerable proportion of participants demonstrated strong awareness, those with limited educational backgrounds and rural residents showed higher rates of inadequate knowledge. These disparities emphasize the urgent need for targeted educational campaigns that simplify medical information and improve access to vision care in underserved regions. By implementing school-based programs, community outreach initiatives and integrating strabismus screening into routine eye examinations, public health authorities can promote early diagnosis and reduce the long-term visual and psychosocial burden associated with untreated strabismus. Enhanced collaboration between healthcare providers, educators and community leaders will be crucial in fostering proactive eye health behaviors and improving outcomes for individuals affected by strabismus.
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