Demographic factors associated with myopia knowledge, attitude and preventive practices among adults in Ghana: a population-based cross-sectional survey

Globally, the prevalence of myopia remains progressively high [1] and is projected to affect 50% of the world’s population by 2050, with about 10% expected to have high myopia (≥ 5.00D) [1]. Myopia prevalence varies depending on race and geographical region [2] with a reported prevalence of 80–90% among young adults in East Asia and 10–20% in Southeast Asia [3]. In Africa, the crude prevalence of myopia was estimated at 4.7% (95% CI, 3.9–5.7) [4], and up to 33.5% in adults [5]. In Ghana, the prevalence of myopia has been reported to be about 2% among school children [4], 25.1% in teenage secondary school students [6] and between 29.2%—54.1% in clinic-based studies [7, 8]. Judging by the trend in global epidemiology of myopia [9], the myopia situation in Africa is expected to increase due to inadequate access to eye and vision care services.

Myopia is known to have health, social and economic implications [6‐8]. In 2015, the global loss of productivity from visual impairment due to uncorrected myopia was estimated at $244 billion [6]. Among older Chinese adults, those with myopia were about 1.4 times more likely to have depressive symptoms than non-myopes [8]. Despite these, in many developing countries, myopia remain undiagnosed. If left untreated, high myopia can significantly increase the risk of several serious eye conditions and complications that can lead to blindness, so uptake of refractive services are crucial.

There is strong evidence that simple environmental and clinical factors such as increased time outdoors [9], low dose atropine eye drops [10], and optical interventions such as orthokeratology can help delay the onset and/or slow the progression of myopia [9]. The effectiveness of these clinically proven myopia interventions largely depend on compliance with management protocols and the understanding of the affected people or their guardians [11]. Notwithstanding, studies indicate that there is a lack of information about myopia, its prevention and treatment among parents/guardians of children with myopia in various places, which may impact the uptake of myopia control services. A study conducted in Ireland reported that only 46% of parents considered myopia a health risk [12] while 80% of parents in Shanghai thought myopia could be cured [13]. Among mothers in Hong Kong, Cheung et al. [14] found that more than half believed that corrective contact lenses were only meant for older children (14 years and above) [14] and not for younger ones. These results confirm the lack of knowledge about myopia among the public, necessitating the need for further research in the areas, especially in low resourced environments.

Hence, the purpose of this study was to determine the knowledge, attitude, and preventive practices of adults toward myopia in Ghana. This study will provide evidence on the level of knowledge about myopia, the attitude, and practices in relation to myopia among an African population, which can be used to provide a framework for further research in myopia control. Also, it will help design myopia educational resources for the public and assist in developing policies and planning myopia control programs in similar environments.

Myopia has long been a public health issue globally and understanding the knowledge, attitudes, and preventive practices (KAPs) related to myopia are important for promoting good vision and the general health of the population. In this study, participant demographics were different since the study was conducted across different regions such that different sub-populations may be exposed to possible varied sources of myopia information. Our results showed significant variations in the myopia KAP scores with most of the demographic variables including age, gender, marital status, work status, employment type, level of education, monthly salary level, and regions of residence. This finding implies that demographic factors are key indicators to be considered when developing any myopia awareness tool. Similar results have been reported in other studies [20], with some also showing contrasting results where no association was found between participants’ demographics and their decision to seek ortho-k or daily-wear soft contact lenses [14].

Myopia has been known over the years to be the most common type of refractive error as well as the leading cause of visual impairment and preventable blindness across the globe [21]. In assessing the awareness and knowledge of myopia among the study population, it was found that less than half of the participants had previously heard about myopia. In the segregated data, the major sources of awareness were visits to hospitals (41.9%) and schools (32.2%). The awareness level was low, given that similar studies in Singapore [22] and Saudi Arabia [23] found about 80.0% and 82.0% of participants were aware of myopia. However, these studies measured awareness in persons with refractive error. Similar studies in Singapore [24], India [25], Pakistan [26] and Kenya [20] have shown that awareness does not necessarily translate to knowledge about myopia or its complications, as demonstrated in a study by Almujalli et al. [23]. In this study, over a quarter of the participants who were aware of myopia still showed low knowledge of myopia.

Myopia progresses steadily with age [27], so one would expect that awareness and knowledge would also increase with age. However, this was not the case in the present study because of the decline in myopia knowledge observed with a decrease in the participants’ age (β = –0.138, 95%CI –1.501, –0.123; p = 0.021). Considering the ease with which young people can access various information sources including social media and other internet-based platforms, it is not surprising that young people demonstrated better knowledge of myopia compared with the older people in this study. Similar to our findings, Muma and Oboyo [20] reported that younger age was significantly associated with knowledge of myopia risk factors and corrective measures [20]. Another study in Kenya found similar results indicating that myopia knowledge scores decreased with an increase in the age of the participants [20]. The current findings are in contrast with a KAP study from Ethiopia [28] which reported that awareness and knowledge of refractive errors increase with age. The relatively low awareness of myopia in this study population overall, may be attributed to the poor eye care seeking behaviour and utilisation of eye care services, with women known to utilise health care services more than men [29, 30].

There were regional differences in the myopia knowledge scores among participants, which can be explained by the greater availability and access to health care services in the Northern regions of Ghana. Thus, the Northern region participants have good knowledge, possibly due to the presence of NGOs offering refractive error (RE) services. The knowledge of those participants is comparable to the knowledge of those in urban areas where RE services are readily available.

The somewhat average attitude scores among the participants in this study reflected the knowledge level of myopia in this study population, which may underpin wrong beliefs and attitudes towards myopia and spectacle wear. This is similar to a previous study that showed only 46% of their study participants considered myopia to be a health risk, while another 46% considered it to be an optical inconvenience [12]. Almujalli et al. also reported that 45% of students had a negative attitude towards myopic correction, 35% had a positive attitude and 20% were indifferent [23]. Population-based studies have shown that there is a high prevalence of false beliefs and attitudes toward refractive errors in general and spectacle use, were mostly informed by the sociocultural context. In rural areas, there are beliefs that poor vision is part of the ageing process and that wearing spectacles can damage the eyes, lead to dependence, or worsen eyesight. There is also a high prevalence of stigmatization, fear of being labelled as disabled or handicapped, and cost issues [31, 32]. In more affluent societies, myopia may be regarded as a sign of intelligence, but myopic correction is considered an inconvenience and a discomfort [12].

In the current study, attitude scores were higher among participants with secondary and tertiary level education when compared with those with lower levels of education. Educational level is an established social determinant of health and has been shown to potentially affect health through knowledge, health behaviours and socioeconomic status, amongst others [33, 34]. In a study in Saudi Arabia, a large proportion of school children aged 7–14 were aware of myopia but showed negative attitudes towards eyeglass users, and consequently, this led to many of the children with myopia not wearing their glasses [23]. Similarly, significant differences in altitude were also observed between regions in this study, such that participants who lived in the more urbanized regions or regions with a significant presence of NGOs providing health care, recorded higher mean scores compared to less developed regions. Similarly, those in the low-income bracket had higher knowledge and attitude scores compared to people in the high-income bracket which can be attributed to the fact that the low-earning people in our further stratification (Fig. 2) happen to live in the regions with NGOs providing refraction services. Being poor and knowing they might never get a better opportunity; they avail themselves of those services and get the management they need. Higher earning people in the same neighbourhoods would refuse to avail themselves of the services of the NGOs because of the social stigma associated with that [35] and therefore, they remain ignorant. It is also possible that with the advent of COVID-19 and its associated working-from-home practice, many employees were involved in near and screen-based tasks and accompanying increased access to information whereas employers probably played more supervisory roles possibly requiring intermediate to distant visual demands. Other studies identified history of spectacle use, history of eye examination, health education or training on eye health and older age as positively associated with a good attitude [28]. Again, the socio-demographic differences in attitude are consistent with the findings on knowledge, demonstrating the impact of education on behaviour and attitude to health care [28].

In contrast with earlier findings on knowledge and attitude, we found that those that had good knowledge of myopia and a positive attitude, were also less likely to show good preventive practice. These findings indicate that persons who are aware and knowledgeable about myopia, perhaps due to inaccessibility to refractive services or may be less likely to engage in preventive practices. These results underline the importance of public education to correct common public misperceptions and misconceptions, especially regarding health conditions. A study among Saudi women university students also found that participants had general knowledge about refractive error correction methods but more than half of them had never gone for an eye examination or only been examined once or twice in their lifetime [36]. Again, the desire for new information and experience is found to be keen among younger persons [37] and the majority of young people in Gondar city, Northwest Ethiopia agreed that visual impairment from refractive error can be prevented [28]. Although Hafeez et al. (2019) found a significant relationship between preventive practice and educational status, 46.6% of their study population did nothing to prevent myopia [26]. It may also imply that having myopia knowledge may not necessarily translate into myopia preventive practices. Therefore, it may be necessary to provide detailed information regarding the adoption of myopia preventive practices while educating people on myopia.

In preventing and slowing the progression of myopia, lifestyle changes rather than medical treatments have been reported in population studies to show positive outcomes. In our study, married individuals (who were also likely to be parents) were more positive about myopia prevention than younger and unmarried persons. Studies have reported that parents generally regard myopia as a health risk and are more concerned about myopic progression in their children, and thus, engaged in preventive practices which included limiting screen time, restricting studying/reading and encouraging the performance of outdoor tasks, and orthokeratology [12‐14]. Other less conventional preventative methods reported were ocular exercises and Acupuncture [13, 38, 39]. In another study among school children, it was indicated that, myopia could be treated by wearing of eye-glasses (30%), avoiding excess use of electronic devices (46%), good nutrition (4%) and surgery (1.0%), while 19.0% had no idea how myopia was treated [23].

In the current study, the mean preventive scores also varied significantly with the region of residence of the participants, such that those who lived in the Volta region reported higher mean scores and lowest scores for those who lived in the Northern region. In a study by McCrann et al. (2018), younger children from rural backgrounds tended to have less screen time than their older and urban-living counterparts [12]. It was not particularly clear if the less screen time for rural-dwelling children found in the study was deliberate as a preventive measure for myopia or if other factors such as availability and ownership of screened devices played a role. Preventive practices for myopia, especially in children, are crucial in slowing its progression [40] and research has shown that early onset myopia in children, if left unchecked, is more likely (than late-onset myopia) to progress to high myopia in adulthood [41, 42].

In our study, employees scored higher for myopia knowledge and attitudes whereas the self-employed only scored higher for preventive practices. The majority of those who are self-employed in Ghana stay outdoors for long periods either because of them being more mobile like going to visit other businesses or securing goods. Increasing outdoor exposure, even by just two hours a day, has a profound effect on the onset of myopia and may also reduce the progression of myopia [43].

Ghanaian participants had adequate knowledge of myopia which varied significantly between regions and was modified by socio-demographic factors. They also demonstrated good myopia preventive practices although they largely had a negative attitude towards myopia. While myopia knowledge was predicted by participants’ age, myopia preventive practices were predicted by the type of employment. Participants’ region of residence, however, could predict both myopia attitude and preventive practices. The fact that these participants had higher myopia knowledge scores, but low preventive practice scores suggest that while they were aware of myopia there was a disconnect between that awareness and acting on it to engage in preventative practices against myopia. There are a few possible reasons for this disconnect. The factors identified in this study should be considered when planning myopia health education tools for public enlightenment campaigns.