Education as an intervention for myopia prevention and control
By Arief Tjitra Salim, BEng and Associate Professor Mohamed Dirani, PhD, MBA, GAICD
Myopia is a leading cause of vision loss that currently affects one in three people globally. The prevalence and severity of myopia continue to be on the rise and are expected to affect 5 billion people (half of the world’s population) by 2050, which significantly increases the global burden of high myopia and its associated blinding complications.1 Research has shown that myopia may be prevented, and its progression delayed, by reducing exposure to its environmental risk factors, including excessive near-work activity such as smart device use, a lack of time outdoors and a lack of regular and timely comprehensive eye examinations.
An increasing amount of recent research in the past 10-15 years has demonstrated the key role of environmental factors in the onset and progression of myopia.2-4 Therefore, reducing exposure to these risk factors has become a priority for both clinicians and parents alike. A 2018 global study found that as many as two-thirds of the surveyed paediatric ophthalmologists have reported to prescribe reducing screen time in children as a myopia control strategy.5 However, to supplement these efforts, evidence-based educational materials to provide their patients, including parents of young children, with the knowledge required to ensure that they adequately care for their children’s eyes are required.
Parental knowledge and behaviours about myopia
Parents require a sufficient level of knowledge about myopia, its causes, and its management strategies to be able to implement good behaviours to protect their children’s eyes. There has been limited research assessing myopia-related parental knowledge and behaviours, with most studies showing unsatisfactory levels of knowledge and health literacy regarding myopia among parents. One study in Ireland reported that more than half of parents did not believe that myopia presented a health risk to children and that only 14% would be concerned if their child developed myopia.6
The Singapore-based health technology company, Plano, had previously conducted two studies to fill this gap in research, both of which were published as comprehensive reports and are publicly available online. The first report, titled What do Singaporean parents know about myopia? was conducted in 2018 and found that among the 326 Singaporean parents surveyed, only slightly more than half (56%) correctly estimated the prevalence of myopia in Singaporean secondary school students and more than one-third were unaware of the protective behaviours that may reduce the risk of myopia in their children.
The second report, titled Parenting in the 21st century: Are parents well informed to manage eye health and smart device use in children? was conducted in collaboration with the National University of Singapore Business School and found that up to 90% of Singaporean parents were unaware that myopia can lead to other sight-threatening eye conditions. A significant proportion of parents also did not encourage good behaviours to protect their children’s eyes, with one-quarter and one-third of them, respectively, not encouraging their children to spend time outdoors and not monitoring their children’s screen time. The utilisation of eye care services in the population was also unsatisfactory, with three-quarters of parents not taking their children for annual eye examinations. Together, these two surveys highlight that a significant proportion of parents are not equipped with the knowledge required to mitigate the risk of myopia in their children.
The importance of education and the need for myopia education programs
The lack of knowledge about myopia and implementation of its management strategies among parents demonstrates a clear need for interventions that provide accessible, evidence-based, and comprehensible education on myopia to parents. Eye health education programs, including those that target parents, teachers, and children, have been shown to promote positive changes in knowledge and behaviour.
For example, after receiving a comprehensive eye health education program, the proportion of Turkish children who always wore their glasses (if required) increased from 82% to 100% (compared to 67% to 53% in the control group who did not receive any program) at 6-month follow-up. Furthermore, the proportion of children who underwent an eye examination increased from 59% to 98% (compared to 56% to 58% in the controls) and the amount of time they spent outdoors increased from 7.8 hours to 10.5 hours (compared to 8.6 hours to 7.7 hours in controls) after 6 months. Among their parents who were also provided with an information booklet, the proportion who knew how often to bring their children for eye examinations also increased from 56% to 91% (compared to 57% to 63% in the control group). Those who knew the symptoms of visual problems also increased from 55% to 96% (compared to 42% to 45% in the control group) and those who considered outdoor time very important for their children increased from 52% to 85% (compared to 65% unchanged in the control group).7
Similarly, a study conducted by the University of California, Los Angeles, examined whether providing educational pamphlets and showing a 3-minute video to preschool parents and school personnel increased follow-up rates for eye examinations among preschool children. The study found that the likelihood that children would undergo a comprehensive eye examination increased by 63% compared to those for whom the adults were not provided with the educational materials.8
Despite research showing the effectiveness of educational interventions for improving knowledge and management of eye health, there has been a lack of dissemination of such programs to parents. This may be attributed to the length and complexity of developing such programs and the resources needed for large-scale implementation. Countries with a high prevalence of myopia would benefit greatly from prioritizing the development and distribution of easily accessible myopia education programs in their public health policies to better manage the growing myopia epidemic in their population.
Digital myopia education programs – paving the way to the future
Governments, industry, and even school administrators may play a role to increase myopia-related knowledge among parents, and thus improve their behaviour to reduce the risk of myopia among their own children more efficiently by disseminating evidence-based education programs about myopia and its management through digital (online) channels.
One such digital myopia education program has been developed by Plano, which consisted of digital materials, including a 20-minute educational video as well as a downloadable digital booklet pertaining to myopia and its treatment and management strategies that were administered through an online platform (Qualtrics). The program was scientifically validated to significantly increase parents’ knowledge about myopia by 20% and that, following the program, parents adopted behaviours to prevent or slow the progression of myopia among their own children. In fact, 70% of parents who previously allowed their children to spend more than 2 hours of screen time daily now keep it under 2 hours, and that 90% of parents would now bring their children for a comprehensive eye check at least every 1-2 years compared to only 57% prior to the program.
These early findings support the large-scale distribution of digital educational programs to improve parental knowledge about myopia, to inform meaningful change in parental management of myopia, and thus, to contribute to public health efforts to mitigate the public health burden of myopia and its complications.
Arief Tjitra Salim, BEng, is the Research and Operations Lead at Plano Pte Ltd.
Mohamed Dirani, PhD, MBA, GCAID, is the Founding Managing Director of Plano Pte Ltd and an Adjunct Associate Professor at the Duke-NUS Medical School. He is also an Adjunct Principal Investigator at the Singapore Eye Research Institute and an Honorary Principal Investigator at the Centre for Eye Research Australia.
You may also find this article at Review of Myopia Management.
References
- Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. May 2016;123(5):1036-42. doi:10.1016/j.ophtha.2016.01.006
- Dirani M, Crowston JG, Wong TY. From reading books to increased smart device screen time. 01 2019;1(1):1-2.
- Foreman J, Crowston JG, Dirani M. Is physical activity protective against myopia? 10 2020;1(10):1329-1330.
- Joshua Foreman ATS, Anitha Praveen, Dwight Fonseka, Daniel Shu Wei Ting, Ming Guang He, Rupert R A Bourne,, Jonathan Crowston TYW, Mohamed Dirani. Association between digital smart device use and myopia: a systematic review and meta-analysis. Lancet Digital Health. 2021;
- Zloto O, Wygnanski-Jaffe T, Farzavandi SK, Gomez-de-Liano R, Sprunger DT, Mezer E. Current trends among pediatric ophthalmologists to decrease myopia progression-an international perspective. Graefes Arch Clin Exp Ophthalmol. Aug 3 2018;doi:10.1007/s00417-018-4078-6
- McCrann S, Flitcroft I, Lalor K, Butler J, Bush A, Loughman J. Parental attitudes to myopia: a key agent of change for myopia control? Ophthalmic Physiol Opt. May 2018;38(3):298-308. doi:10.1111/opo.12455
- Kirag N, Temel AB. The effect of an eye health promotion program on the health protective behaviors of primary school students. J Educ Health Promot. 2018;7:37. doi:10.4103/jehp.jehp_67_17
- Mehravaran S, Quan A, Hendler K, Yu F, Coleman AL. Implementing enhanced education to improve the UCLA Preschool Vision Program. J aapos. Dec 2018;22(6):441-444. doi:10.1016/j.jaapos.2018.07.346
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