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Erschienen in: Ophthalmology and Therapy 5/2023

Open Access 14.06.2023 | ORIGINAL RESEARCH

Chinese Parents’ Perspective on Myopia: A Cross-Sectional Survey Study

verfasst von: Yangyi Huang, Zhi Chen, Bingjie Wang, Jing Zhao, Xueyi Zhou, Xiaomei Qu, Xiaoying Wang, Xingtao Zhou

Erschienen in: Ophthalmology and Therapy | Ausgabe 5/2023

Abstract

Introduction

The prevalence of myopia in young generations has dramatically increased over the years, especially in China. This study aims to understand Chinese parents’ perspectives on myopia for further improvement of treatment compliance and informing future health planning and policy.

Methods

This was a prospective cross-sectional survey study. A self-administrated, internet-based questionnaire was distributed to 2545 parents in China. Detailed information about the demographics, the awareness of myopia, related complications, and practices of myopia prevention and control of the respondents were collected. The distribution of answers was compared among different groups of children’s age, children’s refractions, and parents’ residential locations. Relationships between parental cognition and behavior were also analyzed.

Results

Eligible responses were returned by 2500 parents. A total of 55.1% of the respondents considered myopia as a disease and more than 70% of respondents did not realize pathological changes related to myopia. Most parents thought myopia could be prevented (82.0%) and controlled (75.2%), and these parents were more likely to take measures than the parents who did not think so (P < 0.001). The most common myopia control modality was spectacles (87.0%), among which single-vision spectacles are the most used (63.7%).

Conclusions

Knowledge about health risks related to myopia was lacking in Chinese parents and their practices of myopia control mainly involved single-vision glasses. Nationwide education for parents about myopia is needed to further advance outcomes of myopia prevention and control.
Hinweise

Supplementary Information

The online version contains supplementary material available at https://​doi.​org/​10.​1007/​s40123-023-00743-8.
Yangyi Huang and Zhi Chen contributed equally to this work and share the first authorship.
Key Summary Points
Why carry out this study?
The prevalence of myopia is increasing significantly and may be correlated with insufficient knowledge about myopia in parents.
The perspectives of the parents are of great importance for clinicians to recommend patient-tailored treatment for effective myopia control.
No nationwide study concerning parental perspectives on myopia has been conducted so far.
What was learned from the study?
This nationwide survey study revealed that most respondents did not have the correct awareness of pathological changes related to myopia, which was related to the negative attitudes and practices of myopia in Chinese parents.
Practices of myopia control mainly involved single-vision glasses, which may be one of the reasons that limited the efficacy of the myopia control strategy. Nationwide education for parents about myopia is needed to advance outcomes of myopia prevention and control.

Introduction

Myopia, or short-sightedness, has become one of the most common eye diseases worldwide with a dramatically increasing prevalence during the past decades [1, 2]. The circumstance in Asia is even worse compared with Europe and the USA, with approximately 80% of senior high school students being affected [3, 4]. Moreover, myopia has been reported to undergo an earlier onset in young generations, allowing a longer period for potential myopia progression and therefore resulting in higher myopia in the future [5]. Myopia may also carry significant ocular health consequences later in life due to its association with blinding eye diseases including retinal detachment, glaucoma, and cataract [3, 6].
Many efforts are being made to prevent and control myopia to reduce the growing socioeconomic burden caused by uncorrected and pathologic myopia [7]. To date, pharmacological measures such as atropine eye drops, optical measures such as orthokeratology, and increased time spent outdoors have been proven to be potential approaches [8]. All these strategies need compliance and cooperation from the children and their parents in everyday life. Recently, Li et al. [9] reported that SMS text messages reminding parents to take children outdoors effectively slowed axial elongation and myopia progression in Chinese schoolchildren, which indicated a significant parental role in myopia control. From this perspective, parents’ perspectives on myopia are of great importance for clinicians to recommend patient-tailored treatment programs for effective myopia control.
Previous studies regarding parental perspectives on myopia in China mainly involved only one district or one city [1013], which makes it difficult to evaluate the nationwide situation and analyze the difference among areas. Therefore, the current nationwide survey was conducted on Chinese parents with a self-administrated, internet-based questionnaire, with the aim of understanding the knowledge, attitudes, and practices about myopia from patients’ perspectives. It is hoped that these results would benefit clinicians for better decision-making, inform future health planning and policymaking, and eventually improve the outcomes of myopia prevention and control.

Methods

This prospective cross-sectional survey study was reported in accordance with the American Association for Public Opinion Research (AAPOR) reporting guidelines and was approved by the Ethics Committee of the Eye & ENT Hospital of Fudan University. This study was carried out in accordance with the recommendations of tenets of the Declaration of Helsinki with written informed consent from all participants.

Questionnaire Formulation

A 21-item survey was developed by experts on myopia following previous interviews of representative parents and a pretest of ten parents. Repeated discussions and revisions of the questionnaire were performed from November 2020 to December 2020. The questionnaire (Supplementary Material) consisted of five sections: (1) basic characteristics, including the age and gender of the children and self-reported refractive status of themselves and their children; (2) knowledge about myopia, including related definitions and potential complications; (3) attitude toward myopia prevention and control; (4) practices of myopia prevention and control; and (5) additional information or concerns. Standard instructions were shown before responding to each question and the estimated time required to complete the questionnaire was 15 min.

Survey Respondents, Questionnaire Distribution, and Data Collection

The target sample size of the survey respondents was first calculated using the following standards: (1) the number of respondents from the first-, second-, and third-tier cities was evenly distributed and the number of respondents from each city-level group should be no less than 300; (2) the number of respondents with non-myopic or myopic children should be no less than 450. The questionnaire (in Chinese) was then distributed through an internet-based survey platform (www.​idiaoyan.​com) in which the respondents would get a financial reward after completing the survey. Once the target sample size was achieved, the platform would close the questionnaire mission and automatically collect the results.
Anonymous responses were then screened by appointed staff who were masked from the purpose of this study. Respondents were excluded from this study if the responses were (1) inconsistent across the survey; (2) the respondents did not have children or were not familiar with the everyday life of their children, or their children were beyond 1–15 years old; (3) the parents reported other eye diseases in their children; and (4) parents who were involved in eye health care industry or practice. The survey was conducted twice, from January 2021 to February 2021 and from January 2022 to February 2022. Data analyses were performed from March 2022 to October 2022.

Statistical Analysis

All data analyses were performed using R version 4.1.0 (http://​cran.​r-project.​org) and SPSS version 26.0 (SPSS, Inc). Data following a normal distribution were expressed as mean ± standard deviation (SD), and categorical data were shown as frequencies or percentages. χ2 tests were used to analyze differences among parental groups, parental attitudes, and parental practices about myopia prevention and control. P < 0.05 was set as the significance level and all P values were two-sided.

Results

Characteristics of Respondents

The survey included 2500 respondents who were parents of children aged 1–15 years old. Among them, 1125 and 1420 parents participated in the 2021 and 2022 surveys, respectively. The qualified rate was 97.8% (1100/1125) and 98.6% (1400/1420) in 2021 and 2022, respectively. Most of these respondents were female (68.8%), and most of the children were male (53.1%). The residential locations of the respondents were evenly distributed, with 31.9%, 34.0%, and 34.1% of the respondents coming from first-, second-, and third-tier cities, respectively. The numbers of myopic parents and myopic children were 1262 (50.5%) and 1447 (57.9%), respectively. Detailed characteristics of the respondents are summarized in Supplementary Table 1.

Parents’ Knowledge of Myopia

The survey results of the “Knowledge about myopia” section are summarized in Fig. 1a and Table 1. Of the 2500 parents, 55.1% considered myopia as a disease (Fig. 1a). Parents from second-tier cities (P = 0.023) and those with older children (P = 0.001) were more likely to regard myopia as a disease. For questions about the health risk of myopia, most parents agreed that “the higher the degree of myopia, the greater the risk of eye complications” (60.6%), with the proportion being higher in parents with myopic children (63.8%, P = 0.003) and parents from the first-tier cities (61.2%, P = 0.001). In addition, most parents chose that “only moderate and high myopia would be related to pathological changes” (38.2%), and a smaller proportion of parents believed that all degrees of myopia were related to pathological changes (27.4%, Fig. 1a). This answer was also unevenly distributed across different refractive groups (P < 0.001), city levels (P < 0.001), and age groups (P = 0.004) of the parents. For their knowledge of the terminology about myopia, including astigmatism, high myopia, axial length, and manifest refraction, most parents claimed that they understood or had heard of these terms (Fig. 1a). Parents who had myopic children and who were from first-tier cities claimed to understand these terms more frequently (P < 0.05).
Table 1
Differences in the answer distribution among different refractive errors, city levels, and ages of the children
Question
Refractive status of the children
City level
Age range of the children (years)
Non-myopic
Myopic
Pa
First tier
Second tier
Third tier
Pb
0–6
7–12
13–15
Pc
Knowledge about myopia
Do you think myopia is a disease?
 Yes
650 (54.2)
728 (56.0)
0.379
408 (51.1)
485 (57.1)
485 (56.9)
0.023*
354 (49.2)
680 (57.8)
344 (57.0)
0.001*
 No
550 (45.8)
572 (44.0)
390 (48.9)
364 (42.9)
368 (43.1)
366 (50.8)
496 (42.2)
260 (43.0)
Which of the following best describes your understanding of the damage of myopia?
 The higher the degree of myopia, the greater the risk of eye complications
686 (57.2)
830 (63.8)
0.003*
488 (61.2)
510 (60.1)
518 (60.7)
0.001*
414 (57.5)
741 (63.0)
361 (59.8)
0.137
 The higher the degree of myopia, the lower the risk of eye complications
96 (8.0)
96 (7.4)
65 (8.1)
58 (6.8)
69 (8.1)
67 (9.3)
76 (6.5)
49 (8.1)
 The degree of myopia is not related to the risk of complications
168 (14.0)
169 (13.0)
132 (16.5)
96 (11.3)
109 (12.8)
98 (13.6)
161 (13.7)
78 (12.9)
 I don’t know
250 (20.8)
205 (15.8)
113 (14.2)
185 (21.8)
157 (18.4)
141 (19.6)
198 (16.8)
116 (19.2)
What degree of myopia do you think will cause pathological changes in the eye?
 Low, moderate, and high myopia would all cause pathological changes
332 (27.7)
352 (27.1)
< 0.001*
257 (32.2)
220 (25.9)
207 (24.3)
< 0.001*
186 (25.8)
347 (29.5)
151 (25.0)
0.004*
 Only moderate and high myopia would cause pathological changes
430 (35.8)
524 (40.3)
319 (40.0)
322 (37.9)
313 (36.7)
298 (41.4)
437 (37.2)
219 (36.3)
 Only high myopia would cause pathological changes
192 (16.0)
261 (20.1)
121 (15.2)
138 (16.3)
194 (22.7)
105 (14.6)
220 (18.7)
128 (21.2)
 I don’t know
246 (20.5)
163 (12.5)
101 (12.7)
169 (19.9)
139 (16.3)
131 (18.2)
172 (14.6)
106 (17.5)
Please choose your understanding of the following concepts:
 1. Astigmatism
  Never heard of it
149 (12.4)
64 (4.9)
< 0.001*
59 (7.4)
74 (8.7)
80 (9.4)
0.009*
106 (14.7)
60 (5.1)
47 (7.8)
< 0.001*
  I’ve heard of it, but I don’t fully understand it
568 (47.3)
643 (49.5)
364 (45.6)
401 (47.2)
446 (52.3)
346 (48.1)
569 (48.4)
296 (49.0)
  I know it and I understand what it means
483 (40.2)
593 (45.6)
375 (47.0)
374 (44.1)
327 (38.3)
268 (37.2)
547 (46.5)
261 (43.2)
 2. High myopia
  I know the degree of a high myopia
737 (61.4)
775 (59.6)
0.379
510 (63.9)
495 (58.3)
507 (59.4)
0.05
402 (55.8)
725 (61.6)
385 (63.7)
0.007*
  I don’t know the degree of a high myopia
463 (38.6)
525 (40.4)
288 (36.1)
354 (41.7)
346 (40.6)
318 (44.2)
451 (38.4)
219 (36.3)
 3. Axial length
  Never heard of it
436 (36.3)
298 (22.9)
< 0.001*
202 (25.3)
263 (31.0)
269 (31.5)
0.039*
232 (32.2)
342 (29.1)
160 (26.5)
< 0.001*
  I’ve heard of it, but I don’t fully understand it
391 (32.6)
415 (31.9)
266 (33.3)
276 (32.5)
264 (30.9)
267 (37.1)
352 (29.9)
187 (31.0)
  I know it and I understand what it means
373 (31.1)
587 (45.2)
330 (41.4)
310 (36.5)
320 (37.5)
221 (30.7)
482 (41.0)
257 (42.5)
 4. Manifest refraction
  Never heard of it
369 (30.8)
203 (15.6)
< 0.001*
171 (21.4)
200 (23.6)
201 (23.6)
0.472
197 (27.4)
234 (19.9)
141 (23.3)
< 0.001*
  I’ve heard of it, but I don’t fully understand it
429 (35.8)
438 (33.7)
272 (34.1)
287 (33.8)
308 (36.1)
272 (37.8)
406 (34.5)
189 (31.3)
  I know it and I understand what it means
402 (33.5)
659 (50.7)
355 (44.5)
362 (42.6)
344 (40.3)
251 (34.9)
536 (45.6)
274 (45.4)
Attitudes toward myopia prevention and control
Do you think myopia development could be prevented?
 I haven’t thought about it
108 (9.0)
109 (8.4)
< 0.001*
65 (8.1)
91 (10.7)
61 (7.2)
0.071
55 (7.6)
96 (8.2)
66 (10.9)
0.001*
 Yes
992 (82.7)
1057 (81.3)
661 (82.8)
685 (80.7)
703 (82.4)
599 (83.2)
982 (83.5)
468 (77.5)
 No
6 (0.5)
34 (2.6)
10 (1.3)
10 (1.2)
20 (2.3)
2 (0.3)
23 (2.0)
15 (2.5)
 I don’t know
94 (7.8)
100 (7.7)
62 (7.8)
63 (7.4)
69 (8.1)
64 (8.9)
75 (6.4)
55 (9.1)
Do you think myopia progression could be controlled?
 Yes
838 (69.8)
1043 (80.2)
< 0.001*
598 (74.9)
648 (76.3)
635 (74.4)
0.002*
504 (70.0)
940 (79.9)
437 (72.4)
< 0.001*
 No
143 (11.9)
89 (6.8)
96 (12.0)
71 (8.4)
65 (7.6)
84 (11.7)
67 (5.7)
81 (13.4)
 I don’t know
219 (18.2)
168 (12.9)
104 (13.0)
130 (15.3)
153 (17.9)
132 (18.3)
169 (14.4)
86 (14.2)
What do you think will happen if your child receives non-surgical treatment for myopia?
 The progression of myopia would be delayed
458 (38.2)
573 (44.1)
< 0.001*
314 (39.3)
369 (43.5)
348 (40.8)
0.534
268 (37.2)
522 (44.4)
241 (39.9)
< 0.001*
 The degree of myopia would be maintained
369 (30.8)
451 (34.7)
267 (33.5)
268 (31.6)
285 (33.4)
220 (30.6)
367 (31.2)
233 (38.6)
 The degree of myopia would be lower
373 (31.1)
276 (21.2)
217 (27.2)
212 (25.0)
220 (25.8)
232 (32.2)
287 (24.4)
130 (21.5)
Practices of myopia prevention and control
Will you take your child to do outdoor activities?
 Yes
1153 (96.1)
1252 (96.3)
0.851
767 (96.1)
815 (96.0)
823 (96.5)
0.861
695 (96.5)
1134 (96.4)
576 (95.4)
0.464
 No
47 (3.9)
48 (3.7)
31 (3.9)
34 (4.0)
30 (3.5)
25 (3.5)
42 (3.6)
28 (4.6)
How long does your child spend outdoors each week?
 ≤ 7 h
654 (54.5)
756 (58.2)
0.013*
408 (51.1)
494 (58.2)
508 (59.6)
0.003*
327 (45.4)
671 (57.1)
412 (68.2)
< 0.001*
 7 to ≤ 14 h
363 (30.2)
402 (30.9)
268 (33.6)
249 (29.3)
248 (29.1)
242 (33.6)
353 (30.0)
170 (28.1)
 14 to ≤ 21 h
167 (13.9)
127 (9.8)
114 (14.3)
90 (10.6)
90 (10.6)
137 (19.0)
136 (11.6)
21 (3.5)
 > 21 h
16 (1.3)
15 (1.2)
8 (1.0)
16 (1.9)
7 (0.8)
14 (1.9)
16 (1.4)
1 (0.2)
Will you take your child for eye examinations?
 Yes
873 (72.8)
1156 (88.9)
< 0.001*
684 (85.7)
671 (79.0)
674 (79.0)
< 0.001*
531 (73.8)
1004 (85.4)
494 (81.8)
< 0.001*
 No
327 (27.3)
144 (11.1)
114 (14.3)
178 (21.0)
179 (21.0)
189 (26.2)
172 (14.6)
110 (18.2)
What is the frequency of eye examination?
 Never
327 (27.3)
144 (11.2)
< 0.001*
114 (14.3)
178 (21.0)
179 (21.2)
< 0.001*
189 (26.2)
172 (14.7)
110 (18.3)
< 0.001*
 Sometimes, especially when I think necessary
296 (24.7)
384 (29.8)
186 (23.3)
217 (25.7)
277 (32.8)
192 (26.7)
335 (28.7)
153 (25.5)
 Once every 6 months
261 (21.8)
442 (34.3)
269 (33.7)
241 (28.5)
193 (22.8)
179 (24.9)
358 (30.6)
166 (27.7)
 Once every year
272 (22.7)
305 (23.7)
207 (25.9)
199 (23.5)
171 (20.2)
147 (20.4)
278 (23.8)
152 (25.3)
 Once every 2 years
44 (3.7)
14 (1.1)
22 (2.8)
11 (1.3)
25 (3.0)
13 (1.8)
26 (2.2)
19 (3.2)
Have you ever tried to prevent myopia development?
 Yes
1026 (85.5)
1215 (93.5)
< 0.001*
721 (90.4)
754 (88.8)
766 (89.8)
0.581
624 (86.7)
1071 (91.1)
546 (90.4)
0.007*
 No
174 (14.5)
85 (6.5)
77 (9.6)
95 (11.2)
87 (10.2)
96 (13.3)
105 (8.9)
58 (9.6)
Which of the following measures have you taken to prevent your child from myopia?
 Improve the environment of eye use
489 (47.7)
0 (NaN)
NaN
142 (44.4)
183 (52.7)
164 (45.7)
0.063
159 (41.5)
219 (51.3)
111 (51.4)
0.01*
 Remind my child to rest after a long time doing near work
557 (54.3)
0 (NaN)
NaN
166 (51.9)
185 (53.3)
206 (57.4)
0.322
202 (52.7)
246 (57.6)
109 (50.5)
0.17
 Use some eye drops to relieve the my child’s asthenopia
166 (16.2)
0 (NaN)
NaN
59 (18.4)
58 (16.7)
49 (13.6)
0.226
51 (13.3)
72 (16.9)
43 (19.9)
0.097
 Remind my child to have more outdoor time
456 (44.4)
0 (NaN)
NaN
144 (45.0)
152 (43.8)
160 (44.6)
0.951
173 (45.2)
190 (44.5)
93 (43.1)
0.882
 Remind my child not to use eyes in a dim environment, including reading and watching electronic devices
425 (41.4)
0 (NaN)
NaN
119 (37.2)
144 (41.5)
162 (45.1)
0.111
167 (43.6)
199 (46.6)
59 (27.3)
< 0.001*
 Remind my child not to use electronic devices
558 (54.4)
0 (NaN)
NaN
181 (56.6)
175 (50.4)
202 (56.3)
0.191
220 (57.4)
237 (55.5)
101 (46.8)
0.035*
 Remind my child not to do near work under a shaky situation
327 (31.9)
0 (NaN)
NaN
87 (27.2)
110 (31.7)
130 (36.2)
0.042*
108 (28.2)
157 (36.8)
62 (28.7)
0.017*
 Increase the frequency of eye massage
199 (19.4)
0 (NaN)
NaN
62 (19.4)
67 (19.3)
70 (19.5)
0.998
74 (19.3)
80 (18.7)
45 (20.8)
0.816
 Remind my child to do eye exercises
173 (16.9)
0 (NaN)
NaN
61 (19.1)
51 (14.7)
61 (17.0)
0.322
80 (20.9)
74 (17.3)
19 (8.8)
0.001*
 Take my child to regular eye examinations
350 (34.1)
0 (NaN)
NaN
123 (38.4)
124 (35.7)
103 (28.7)
0.021*
127 (33.2)
159 (37.2)
64 (29.6)
0.139
 Remind my child to eat a healthy diet
506 (49.3)
0 (NaN)
NaN
156 (48.8)
165 (47.6)
185 (51.5)
0.555
196 (51.2)
210 (49.2)
100 (46.3)
0.517
 Do visual training
139 (13.5)
0 (NaN)
NaN
47 (14.7)
38 (11.0)
54 (15.0)
0.219
38 (9.9)
54 (12.6)
47 (21.8)
< 0.001*
 Control the distance of my child’s near work
452 (44.1)
0 (NaN)
NaN
141 (44.1)
153 (44.1)
158 (44.0)
1
169 (44.1)
195 (45.7)
88 (40.7)
0.493
 Reduce the time my child spends on online courses
98 (9.6)
0 (NaN)
NaN
37 (11.6)
25 (7.2)
36 (10.0)
0.149
33 (8.6)
47 (11.0)
18 (8.3)
0.405
Has your child received any kind of treatment for myopia control?
 Yes
39 (79.6)
1196 (92.0)
0.005*
398 (90.0)
424 (92.4)
413 (92.2)
0.381
246 (93.2)
655 (91.9)
334 (89.8)
0.287
 No
10 (20.4)
104 (8.0)
44 (10.0)
35 (7.6)
35 (7.8)
18 (6.8)
58 (8.1)
38 (10.2)
Which of the following measures have you taken to control myopia progression?
 Wear glasses
23 (59.0)
1052 (88.0)
< 0.001*
343 (86.2)
362 (85.4)
370 (89.6)
0.159
206 (83.7)
577 (88.1)
292 (87.4)
0.216
 Wear orthokeratology
4 (10.3)
131 (11.0)
1
32 (8.0)
67 (15.8)
36 (8.7)
< 0.001*
14 (5.7)
82 (12.5)
39 (11.7)
0.012*
 Wear soft contact lenses
0 (0.0)
24 (2.0)
0.761
6 (1.5)
7 (1.7)
11 (2.7)
0.425
1 (0.4)
14 (2.1)
9 (2.7)
0.124
 Using eye drops
18 (46.2)
346 (28.9)
0.032*
119 (29.9)
114 (26.9)
131 (31.7)
0.301
85 (34.6)
194 (29.6)
85 (25.4)
0.059
 Taking oral drugs
4 (10.3)
65 (5.4)
0.349
21 (5.3)
26 (6.1)
22 (5.3)
0.833
16 (6.5)
31 (4.7)
22 (6.6)
0.381
 Visual training
19 (48.7)
324 (27.1)
0.005*
117 (29.4)
132 (31.1)
94 (22.8)
0.018*
97 (39.4)
182 (27.8)
64 (19.2)
< 0.001*
 Chinese traditional medicine
6 (15.4)
119 (9.9)
0.402
43 (10.8)
35 (8.3)
47 (11.4)
0.28
23 (9.3)
76 (11.6)
26 (7.8)
0.154
 Other products
18 (46.2)
282 (23.6)
0.002*
102 (25.6)
99 (23.3)
99 (24.0)
0.735
72 (29.3)
156 (23.8)
72 (21.6)
0.093
If you chose “wear glasses”, what kind of glasses have you used?
 Single-vision spectacles
10 (43.5)
675 (64.2)
0.068
217 (63.3)
228 (63.0)
240 (64.9)
0.85
109 (52.9)
367 (63.6)
209 (71.6)
< 0.001*
 Spectacles with specific designs of myopia control
13 (56.5)
377 (35.8)
126 (36.7)
134 (37.0)
130 (35.1)
97 (47.1)
210 (36.4)
83 (28.4)
Do you think the above strategies are effective in myopia control?
 This worked well for my child
27 (69.2)
665 (55.6)
0.158
233 (58.5)
240 (56.7)
219 (53.0)
0.519
139 (56.5)
382 (58.4)
171 (51.2)
0.299
 This is not effective
12 (30.8)
481 (40.3)
151 (37.9)
168 (39.7)
174 (42.1)
98 (39.8)
248 (37.9)
147 (44.0)
 I don’t know
0 (0.0)
49 (4.1)
14 (3.5)
15 (3.5)
20 (4.8)
9 (3.7)
24 (3.7)
16 (4.8)
NaN = Not a Number. Shaky situation: a situation involving background vibration. *P value less than 0.05 (i.e., statistically significant)
aComparison of the answer proportion between parents of non-myopic and myopic children
bComparison of the answer proportion among parents of first-, second-, and third-tier cities
cComparison of the answer proportion among parents of children in different age groups

Parental Attitude Toward Myopia Prevention and Control

The survey results of the “Attitudes toward myopia prevention and control” section are summarized in Fig. 1b and Table 1. Most parents regarded myopia as a condition that could be prevented (82.0%) and controlled (75.2%, Fig. 1b). Although more parents with myopic children believed myopia progression could be controlled compared with parents with non-myopic children (P < 0.001), the attitudes toward myopia prevention presented the opposite distribution (P < 0.001, Table 1). Regarding the expectations of myopia treatment, most parents believed that myopia progression could be delayed (41.2%, Fig. 1b). Parents with non-myopic and younger children and parents who were from first-tier cities presented a more optimistic expectation of the outcomes of non-surgical treatment for myopia (P < 0.05, Table 1).

Parental Practices About Myopia Prevention and Control

The survey results of the “Practices of myopia prevention and control” section are summarized in Fig. 1c and Table 1. Most parents were willing to take their children to do outdoor activities (96.2%), yet the outdoor time each week for the children was mostly less than 7 h (56.4%, Fig. 1c). The outdoor time was significantly less in myopic children (P < 0.001), less in older children (P < 0.001), and more in children from first-tier cities (P = 0.003, Table 1).
Most parents would take their children for eye examinations (81.2%), and this happens more often in parents with myopic children (P < 0.001), parents from first-tier cities (P < 0.001), and parents with children aged 7 to 12 years old (P < 0.001, Table 1). The frequency of eye examinations was correspondingly higher for these parents, with an overall 28.2% of parents taking their children to eye examinations every 6 months (Fig. 1c). Parents who thought myopia was a disease would also take their children to eye examinations more frequently (P < 0.001, Fig. 2a).
Regarding myopia prevention strategy, most parents have tried certain measures (89.6%), especially those who regarded myopia as a disease (P < 0.001) and thought myopia could be prevented (P < 0.001, Table 2). The measures mainly included reminding their children not to use electronic devices (54.4%) and to rest after a long time doing near work (54.3%, Fig. 1c). Parents with younger children were more likely to have their children do eye exercises (a practice of massaging acupoints around the ocular orbit, P = 0.001) and to prohibit the use of electronic devices (P = 0.035), while parents with older children would more likely consider doing visual training and improving the environment of eye use (P < 0.001, Table 1).
Table 2
Interactions of the awareness, attitudes, and practices of myopia prevention
Question
Overall
Do you think myopia is a disease?
Do you think myopia development could be prevented?
Yes
No
Pa
Never thought about it
Yes
No
I don’t know
Pb
Have you ever tried to prevent myopia development?
 Yes
2241 (89.6)
1278 (92.7)
963 (85.8)
< 0.001*
152 (70.0)
1897 (92.6)
36 (90.0)
156 (80.4)
< 0.001*
 No
259 (10.4)
100 (7.3)
159 (14.2)
65 (30.0)
152 (7.4)
4 (10.0)
38 (19.6)
Which of the following measures have you taken to prevent your child from myopia?
 Improve the environment of eye use
489 (47.7)
295 (50.1)
194 (44.4)
0.082
26 (39.4)
425 (48.1)
2 (40.0)
36 (50.7)
0.522
 Remind my child to rest after a long time doing near work
557 (54.3)
333 (56.5)
224 (51.3)
0.106
29 (43.9)
494 (55.9)
4 (80.0)
30 (42.3)
0.026*
 Use some eye drops to relieve my child’s asthenopia
166 (16.2)
95 (16.1)
71 (16.2)
1
5 (7.6)
153 (17.3)
1 (20.0)
7 (9.9)
0.087
 Remind my child to have more outdoor time
456 (44.4)
287 (48.7)
169 (38.7)
0.002*
26 (39.4)
402 (45.5)
1 (20.0)
27 (38.0)
0.327
 Remind my child not to use their eyes in a dim environment, including reading and watching electronic devices
425 (41.4)
265 (45.0)
160 (36.6)
0.009*
13 (19.7)
386 (43.7)
2 (40.0)
24 (33.8)
0.001*
 Remind my child not to use electronic devices
558 (54.4)
344 (58.4)
214 (49.0)
0.003*
18 (27.3)
508 (57.5)
3 (60.0)
29 (40.8)
< 0.001*
 Remind my child not to do near work under a shaky situation
327 (31.9)
200 (34.0)
127 (29.1)
0.111
21 (31.8)
282 (31.9)
3 (60.0)
21 (29.6)
0.574
 Increase the frequency of eye massage
199 (19.4)
120 (20.4)
79 (18.1)
0.401
12 (18.2)
175 (19.8)
1 (20.0)
11 (15.5)
0.838
 Remind my child to do eye exercises
173 (16.9)
85 (14.4)
88 (20.1)
0.02*
4 (6.1)
161 (18.2)
0 (0.0)
8 (11.3)
0.026*
 Take my child to regular eye examinations
350 (34.1)
227 (38.5)
123 (28.1)
0.001*
10 (15.2)
324 (36.7)
0 (0.0)
16 (22.5)
< 0.001*
 Remind my child to eat a healthy diet
506 (49.3)
286 (48.6)
220 (50.3)
0.615
30 (45.5)
442 (50.0)
1 (20.0)
33 (46.5)
0.474
 Do visual training
139 (13.5)
85 (14.4)
54 (12.4)
0.386
6 (9.1)
122 (13.8)
1 (20.0)
10 (14.1)
0.714
 Control the distance of my child’s near work
452 (44.1)
269 (45.7)
183 (41.9)
0.251
20 (30.3)
408 (46.2)
1 (20.0)
23 (32.4)
0.008*
 Reduce the time my child spends on online courses
98 (9.6)
50 (8.5)
48 (11.0)
0.216
2 (3.0)
84 (9.5)
0 (0.0)
12 (16.9)
0.042*
Shaky situation: a situation involving background vibration. *P value less than 0.05 (i.e., statistically significant)
aComparison of the answer proportion between parents who thought or did not think myopia is a disease
bComparison of the answer proportion among parents with different attitudes toward myopia prevention
Regarding myopia progression control, the most common modalities being used were spectacle glasses (87.0%), among which 63.7% were single-vision spectacles and 36.3% were spectacles with multifocal or other specific designs for myopia control (Fig. 1c). Parents who had younger children and who thought myopia could be controlled tended to choose spectacles with multifocal or other specific designs (P < 0.001, Tables 1 and 3). Eye drops were also frequently used for myopia control (29.5%), especially for parents who had non-myopic children (P = 0.032, Table 1), parents who thought myopia is a disease (P < 0.001), and parents who thought myopia could be controlled (P < 0.001, Fig. 2b and Table 3).
Table 3
Interactions of the awareness, attitudes, and practices of myopia control
Question
Overall
Do you think myopia is a disease?
Do you think myopia progression could be controlled?
Yes
No
Pa
Yes
No
I don’t know
Pb
Has your child received any kind of treatment for myopia prevention and control?
 Yes
1235 (91.5)
698 (91.1)
537 (92.1)
0.584
1006 (93.0)
76 (83.5)
153 (86.9)
< 0.001*
 No
114 (8.5)
68 (8.9)
46 (7.9)
76 (7.0)
15 (16.5)
23 (13.1)
Which of the following measures have you taken to control myopia progression?
 Wear glasses
1075 (87.0)
587 (84.1)
488 (90.9)
0.001*
867 (86.2)
71 (93.4)
137 (89.5)
0.119
 Wear orthokeratology
135 (10.9)
94 (13.5)
41 (7.6)
0.002*
117 (11.6)
5 (6.6)
13 (8.5)
0.233
 Wear soft contact lenses
24 (1.9)
16 (2.3)
8 (1.5)
0.421
21 (2.1)
1 (1.3)
2 (1.3)
0.744
 Using eye drops
364 (29.5)
237 (34.0)
127 (23.6)
< 0.001*
315 (31.3)
17 (22.4)
32 (20.9)
0.012*
 Taking oral drugs
69 (5.6)
47 (6.7)
22 (4.1)
0.061
50 (5.0)
8 (10.5)
11 (7.2)
0.083
 Visual training
343 (27.8)
208 (29.8)
135 (25.1)
0.08
298 (29.6)
17 (22.4)
28 (18.3)
0.008*
 Chinese traditional medicine
125 (10.1)
73 (10.5)
52 (9.7)
0.724
108 (10.7)
7 (9.2)
10 (6.5)
0.266
 Other products
300 (24.3)
197 (28.2)
103 (19.2)
< 0.001*
276 (27.4)
8 (10.5)
16 (10.5)
< 0.001*
If you chose “wear glasses”, what kind of glasses have you used?
 Single-vision spectacles
685 (63.7)
360 (61.3)
325 (66.6)
0.084
528 (60.9)
53 (74.6)
104 (75.9)
< 0.001*
 Spectacles with specific designs of myopia control
390 (36.3)
227 (38.7)
163 (33.4)
339 (39.1)
18 (25.4)
33 (24.1)
Data were analyzed using chi-square test
*P value less than 0.05 (i.e., statistically significant)
aComparison of the answer proportion between parents who thought or did not think myopia is a disease
bComparison of the answer proportion among parents with different attitudes toward myopia control

Discussion

Given that parents can have a tremendous influence on their child’s lifestyle choices and treatment compliance, understanding the knowledge, attitudes, and practices about myopia from a parental point of view is important and necessary for clinicians to develop better public education and myopia control strategies. Therefore, this nationwide, cross-sectional, questionnaire-based, 2-year survey study was conducted to investigate parental perspectives on myopia and its association with their practices. More than 1000 parents responded both in 2021 and 2022, covering more than 120 cities in mainland China. The exact response rate is unknown, as a questionnaire platform was used to control the sample size. However, with the stringent enrollment standards, selection bias was reduced to a minimum. Thus, the respondents were almost evenly distributed in terms of children’s age and their origin in cities.
Parental knowledge about myopia was evaluated with four questions covering the health risks of myopia and related concepts of myopia. We found that although more than half of the respondents considered myopia a disease, 44.9% of Chinese parents still did not pay enough attention to this condition. Similarly, only a small proportion of the respondents (27.4%) realized that even low myopia could be related to pathological eye changes. McCrann et al. [14] reported a similar phenomenon in the Republic of Ireland, with only 46% of Irish parents considering that myopia presented a health risk to their children. This result was also consistent with a recently published study on parents from a rural county in China [11]. As low myopia can also increase the risk of ocular pathologic changes [1517], the lack of awareness of its potential health impacts should be paid attention to. We also found that awareness of myopic complications was more common in parents with myopic children and parents who were from first-tier cities. On the basis of this finding, we hypothesize that public education resources are one of the most important influencing factors in parents’ knowledge since these parents had more opportunities to receive related information. Our study also questioned parents on their understanding of some basic terms about myopia, including astigmatism, high myopia, axial length, and manifest refraction. For parents, awareness of the meaning of these terms is crucial since these terms could be involved in the entire process of myopia diagnosis and treatment [18]. Axial length and manifest refraction are important indices for monitoring both myopia onset and progression [1921]. However, the overall understanding rate of these terms was lower than 50% in our study (axial length, 38.4%; manifest refraction, 42.4%), which would potentially hinder communication between doctors and patients [22]. The current study also found that parents who thought myopia was a disease would also take more measures to prevent or control myopia and tend to ask for professional eye care. This result was in accordance with the idea that knowledge and cognition would affect the behaviors of humans [23]. Thus, there is a great need for clinicians to educate parents about possible ocular complications and common terminology associated with myopia to further improve compliance with myopia treatment. This is especially important for parents who live in third-tier cities or whose children are not yet myopic but are at high risk of becoming myopic.
The current study also found that most parents had a positive attitude toward myopia treatment, with more than three-quarters of the respondents believing that myopia could be prevented or controlled. The optimistic perspective on myopia prevention was more profound in parents with non-myopic (82.7%) and younger children (83.2% for 0- to 6-year-old children, 83.5% for 7- to 12-year-old children, and 77.5% for 13- to 15-year-old children), partly because these parents have not suffered from the inconvenience and economic burden of myopia [24]. The attitudes toward myopia prevention and control did have an impact on the decision-making of the parents, with more optimistic views leading to more actions in eye care and myopia treatment including using atropine eye drops and spectacles with specific myopia-control designs, which have been proven to be effective [2528]. Therefore, re-education of parents on their attitude toward myopia prevention and control is essential for reaching a consensus on the treatment plan between doctors and patients, particularly for parents with younger children.
Regarding practices of myopia prevention, we evaluated the outdoor time, eye examination frequency, and possible eye care measures from parents’ perspectives. Being consistent with previous studies [2931], myopic children had less outdoor time in our study (58.2% of myopic children had an outdoor time of less than 7 h). Among the respondents, the most preferred eye care measure undertaken was to reduce the use of electronic devices (54.4%). This result is in line with the study by McCrann et al. [14] in which a large majority of Irish parents recognized the potential negative impact of digital devices on the eye. Since the global pandemic of COVID-19, electronic device usage has become more frequent as a result of quarantines and online learning. A higher prevalence of myopia was reported in China during the pandemic, especially in younger children aged between 6 and 8 years [32, 33]. However, the association between screen time and myopia has not been fully elucidated [34, 35], so it cannot be concluded whether this choice of myopia prevention would be beneficial.
Most parents chose spectacles as a strategy for myopia control in our study (87.0%), which was similar to the choices of eye care practitioners despite their awareness of more effective strategies [36, 37]. This finding also corroborated the results of previous studies [11, 14]. This could be explained by the fact that spectacles were easy to access with limited demand for eye care visits, parental care, and management of related complications when compared to atropine eye drops, ortho-k, and soft contact lenses [14, 38]. The parents who chose the single-vision spectacles may consider their easy access and usage more than their efficacy in myopia control. It should be noted that parents who considered myopia a disease were more likely to choose ortho-k (13.5%) and eye drops (34.0%) for myopia control as compared with the other parents (ortho-k, 7.6%; eye drops, 23.6%); they might consider myopia to be a more serious condition and would choose myopia control modalities with higher efficacy [39]. In addition, the information sources should also be one of the potential factors that influence parents’ choice of myopia control, which is supported by the results of a previous study regarding rural China [11]. It can be hypothesized from these results that parents made decisions based on the combination of opinions from the clinicians, socioeconomic burden, and efficacy of the strategy.
The current study has some limitations. First, although the respondents were all randomly enrolled, the respondents of the 2021 and 2022 surveys were not the same cohort; and the survey in our study must be completed online, requiring the literacy level of the parents to be high enough; therefore, selection bias cannot be avoided. Second, the refractive status of the respondents and their children was self-reported. Although it has been shown that self-reported refractive errors could also be a valid tool for the identification of myopia [40], it may still cause certain biases in the comparison among different refractive groups.

Conclusion

This nationwide survey of current trends in myopia knowledge, attitudes, and practices from parental perspectives identified a lack of parents’ understanding of potential eye health risks associated with myopia, poor awareness of eye examinations and outdoor times, and insufficient measures employed for myopia control. These factors combined might partly explain the fast-increasing prevalence of myopia in China. It can be reflected that nationwide education for parents on their knowledge, attitude, and practice toward myopia is necessary and important.

Acknowledgements

The authors would like to thank Wei Wang and Jun Yan from Carl Zeiss Company for their help with the data collection and Dantong Gu from the Eye & ENT Hospital of Fudan University for her help with the statistical analysis.

Funding

This study was supported in part by the Project of Shanghai Science and Technology (20410710100), Clinical Research Plan of SHDC (SHDC2020CR1043B), Project of Shanghai Xuhui District Science and Technology (2020–015), Project of Shanghai Xuhui District Science and Technology (XHLHGG202104), and Construction of a 3D digital intelligent prevention and control platform for the whole life cycle of highly myopic patients in the Yangtze River Delta (21002411600). The Rapid Service Fee was funded by the authors.

Medical Writing and Editorial Assistance

This paper did not receive any medical writing support and editorial assistance.

Author Contributions

Study concept and design (Yangyi Huang, Zhi Chen); data collection (Yangyi Huang, Zhi Chen, Jing Zhao, Xueyi Zhou, Xiaomei Qu, and Xiaoying Wang); data analysis and interpretation (Yangyi Huang, Zhi Chen, and Xueyi Zhou); drafting of the manuscript (Yangyi Huang, Zhi Chen, and Bingjie Wang); provide materials (Zhi Chen, Xiaomei Qu, and Xiaoying Wang); critical revision of the manuscript (Yangyi Huang, Zhi Chen, and Xingtao Zhou); supervision (Xiaoying Wang and Xingtao Zhou). All authors read and approved the final manuscript.

Disclosures

The sponsor or funding organization had no role in the design or conduct of this research. Yangyi Huang, Zhi Chen, Bingjie Wang, Jing Zhao, Xueyi Zhou, Xiaomei Qu, Xiaoying Wang and Xingtao Zhou have nothing to disclose.

Compliance with Ethics Guidelines

This study was carried out in accordance with the recommendations of tenets of the Declaration of Helsinki with written informed consent from all subjects. This study was approved by the Ethics Committee of the Eye & ENT Hospital of Fudan University.

Data Availability

The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Metadaten
Titel
Chinese Parents’ Perspective on Myopia: A Cross-Sectional Survey Study
verfasst von
Yangyi Huang
Zhi Chen
Bingjie Wang
Jing Zhao
Xueyi Zhou
Xiaomei Qu
Xiaoying Wang
Xingtao Zhou
Publikationsdatum
14.06.2023
Verlag
Springer Healthcare
Erschienen in
Ophthalmology and Therapy / Ausgabe 5/2023
Print ISSN: 2193-8245
Elektronische ISSN: 2193-6528
DOI
https://doi.org/10.1007/s40123-023-00743-8

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