FormalPara 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 [10,11,12,13], 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).

Fig. 1
figure 1

Overall answer distribution of the survey. The answer distribution of questions concerning a knowledge about myopia, b attitudes toward myopia prevention and control, and c practices of myopia prevention and control

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Table 1 Differences in the answer distribution among different refractive errors, city levels, and ages of the children
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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).

Fig. 2
figure 2

Relationships between parents’ cognition and behaviors. a Parents who thought myopia is a disease were more likely to take their children to eye examinations with higher frequency (P < 0.001). b Parents who thought myopia could be controlled tended to choose eye drops (P = 0.012), visual training (P = 0.008), and other products (P < 0.001) more than parents who had the opposite attitude

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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
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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
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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 [15,16,17], 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 [19,20,21]. 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 [25,26,27,28]. 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 [29,30,31], 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.