Li L, Lam J, Lu Y, Ye Y, Lam DSC, Gao Y, Sharma A, Zhang M, Griffiths S, Congdon N. Attitudes of Students, Parents, and Teachers Toward Glasses Use in Rural China. Arch Ophthalmol. 2010;128(6):759-765. doi:10.1001/archophthalmol.2010.73
To use focus groups to understand barriers to glasses use among children in rural China.
Separate focus groups were conducted between December 17, 2007, and August 5, 2008, for the following 3 groups at each of 3 schools in rural China: children aged 14 to 18 years with myopia of less than −0.5 diopters in both eyes, those children's parents, and those children's teachers. Participants were also asked to rank their responses to questions about glasses use. The focus group transcripts were coded independently by 2 investigators using qualitative data management software.
Respondents of all 3 types indicated that glasses purchase and wear should be delayed in children with early myopia and might be harmful to the eyes. Parents and students reported being uncertain about children's actual myopia status and whether glasses should be worn. Parents ranked their most common reason for not buying glasses as being “too busy with work,” whereas “too expensive” ranked low. Inconvenience was ranked as an important reason for not wearing glasses among all 3 student groups. “Accuracy of lens power” was the first-ranked requirement for glasses among all student groups, whereas “new and attractive styles” was ranked last by all. All 3 types of respondents believed that wearing glasses or failing to wear them might worsen myopia.
Educational programs are needed to address significant knowledge gaps in families and schools about glasses use in rural China. Cost and the need for attractive styles may not be significant barriers to use in this setting, raising the possibility of paying for such programs through cost recovery.
The number of persons with visual impairment because of refractive error ranges from 82 million to 184 million, comprising one-third to nearly half of all those with impaired vision.1,2 Studies3- 5 in a variety of developing countries have documented that 35% to 85% of persons with refractive error are without glasses, even among groups with a strong requirement for highly acute vision such as professional drivers.6 The focus in combating this problem has often been on increasing the availability of refractive services.7,8 However, growing evidence suggests that poor demand for refractive services may also play a role in some populations. Although there appears to be willingness to pay modest amounts for glasses for adults3,9,10 and children11 in some areas, studies6,12,13 have documented relatively poor demand for glasses in other groups. A similar problem exists in the developed world as well. Preslan and Novak14 report that in a group of children in Baltimore, Maryland, identified during screening as having amblyopia, strabismus, and refractive error, only 30% had sought recommended treatment at the time of the 1-year follow-up.
Low demand for refractive services may extend beyond failure to own glasses: studies in Africa15 and Latin America16 have documented rates of wear among children as low as 13% even after provision of free glasses. The problem of limited use of refractive services is particularly prevalent among children in rural China. Approximately 30% to 60% of rural Chinese secondary students have myopia17,18 (spherical equivalent ≤−0.50 diopters [D] in both eyes), whereas nearly two-thirds of these children do not own or wear appropriate glasses.11 Refractive error is associated with significant decrements in self-reported visual function in these children.18 The difference in visual function reported by children with −3.5 D to less than −2.5 D of myopia, compared with those with refractive error of −0.5 D or greater, was 16.2 points on a scale of 0 to 100.18 This finding exceeds the difference between adults with postoperative visual acuity above and below 6/60 in the operated-on eye after cataract surgery measured using an identical visual function instrument19 in the same region.20
Nevertheless, when a group of nearly 700 rural Chinese children were identified by screening as needing glasses, two-thirds failed to obtain them, including half those with habitual visual acuity of 6/18 or less, despite an educational intervention promoting glasses use targeted at parents, teachers, and children themselves.21 The principal reason for failure to purchase glasses was lack of perceived need among 60% of children, whereas concerns about price were cited by only 16%.21 Vision impairment was significant among children not wearing glasses: 50% had uncorrected visual acuity worse than 6/15.11
Although some studies of glasses use in children have attempted to examine attitudes toward22 and basic factors (eg, symptoms) underlying23 glasses use, much remains to be learned about barriers to compliance with glasses use in this group. The focus group (FG) modality is well suited to seek a deeper understanding of this important area.
Focus groups can be helpful to assess barriers to desired behaviors that cannot be adequately measured by survey questions24,25 and to understand potentially complex factors underlying health disparities.26 In this article, we report on a series of 9 FGs studied in 3 separate locations in rural China. In each location, children with myopia who did and did not routinely wear glasses, their parents, and their teachers were enrolled separately. The goal of this investigation is to better understand why some children and families fail to purchase and wear glasses based on responses from key participants in these decisions.
The See Well to Learn Well (SWLW) project is an ongoing randomized trial of interventions to promote glasses use among 10 000 secondary schoolchildren in 3 towns in the rural Chaoshan region of southern China. Participants are selected at random by class from year 1 and year 2 at all junior and senior high schools in the area (generally, ages 14-18 years). The current project was performed in 3 schools (1 senior high school and 2 junior high schools) that took part in the SWLW project, selected at random in the Fuyang and Liangying townships. Study personnel obtained written informed consent from all participants (or their parents, in the case of students). The ethics committees at the Chinese University of Hong Kong and the Joint Shantou International Eye Center (Guangdong Province, China) approved the protocol in full, and the study followed the tenets of the Declaration of Helsinki.
Fuyang is a township of 97 000 people (according to 2004 census data) with 5 junior and 1 senior high schools, whereas the population of Liangying is 67 000 (2004) and has 6 junior and 1 senior high schools. These towns are located within 80 km (a 90-minute drive) of Shantou, a city of 4.97 million persons (according to 2006 census data) in eastern Guangdong Province. Most adults (>80%) in Fuyang and Liangying are employed in agriculture and farming. In the 3 schools studied, the proportion of children with myopia (both eyes’ spherical equivalent ≤−0.5 D) ranged from 25% to 58%, whereas the proportion wearing glasses at the time of examination was between 8% and 30%.
Three key constituencies (parents, teachers, and students) took part in FGs at each of the 3 schools. The intent was to include 7 to 9 participants in each group to maximize the potential for interaction while minimizing the possibility of some participants not having the opportunity to speak. Total participation in the student groups was 28 children, whereas 20 parents and 21 teachers took part.
Study personnel selected students aged 14 to 18 years (9 boys and 19 girls) at random from students screened at the 3 participating schools who had visual acuity less than 6/12 OU correctable to at least 6/6 with refraction. Among participants, 10 reported the use of glasses and 18 denied wearing them. The mean (SD) spherical equivalent refractive error of participants was −2.16 (1.12) D (range, −0.625 to −4.0 D) in the right eye.
Interviewers selected parents at random from among those with children who met the eligibility criteria and contacted them by telephone through the principal's office at schools. Among 20 parents (11 fathers and 9 mothers), 13 had children who wear glasses and 7 had children who did not. No parents reported wearing glasses to correct distance vision, although their visual acuity and refractive error were not measured.
Teachers were selected at random from among those whose classes were chosen for the SWLW project. Among the 21 teachers (10 men and 11 women), 7 reported wearing glasses to correct myopia; their examiners did not measure their visual acuity or level of refractive error.
All participants in the FGs received a meal and small gift, but no payment was given. Children had completed vision screening in the SWLW project, but none of the study interventions promoting glasses use, including the transmittal of results of vision screening and refraction to children and their parents, had been performed by the time those children took part in the FGs.
After 1 week of intensive training by an experienced FG researcher (J.L.), 2 native speakers of the Chaoshan dialect (Y.L. and Y.Y.) were chosen as facilitators. They prepared a brief general introduction to the FG process and chose 2 to 3 open-ended questions on each of the following topics: (1) level of understanding about myopia, (2) decisions behind the purchase and use of glasses, (3) requirements and expectations for children's glasses, (4) perceived effect of myopia, and (5) concerns about children's vision and strategies to improve vision.
The 2 facilitators prepared separate draft scripts for the student, parent, and teacher FGs based on the introduction and questions used. All coauthors reviewed the drafts, and an experienced FG researcher (J.L.) subsequently revised them.
Nine FGs were conducted between December 17, 2007, and August 5, 2008: 1 each for students, parents, and teachers at each of the 3 schools. The student FGs lasted a mean of 90 minutes, whereas the parent and teacher groups each lasted approximately 70 minutes. All FGs were conducted in Chaoshan dialect and/or Mandarin, digitally recorded, and subsequently transcribed into written Chinese.
After completion of the FGs, participants in the student and parent groups were asked to rank a number of potential responses to the following 2 questions: “What are your expectations/requirements for glasses?” and “Why do myopic children not wear (parents not buy) spectacles?” Participants in the teacher group were asked to rank responses to the question: “What is the impact of uncorrected myopia on students?” In addition to preselected responses, additional options were added at the time of each FG to accurately reflect the content of discussions. The rankings were performed anonymously.
The 2 FG facilitators coded all interview transcripts separately (NVivo 8.0; QSR Inc, Melbourne, Australia) after independent review of all 9 transcripts and agreement on a coding scheme. The final scheme was entered as “tree nodes,” which were identical for the 2 coders (Table 1). The interrater coding reliability (Cohen κ) was calculated using the “coding comparison” query provided by NVivo as percentage agreement of passages coded to the appropriate nodes. By convention, a κ greater than 0.7 is considered acceptable interrater reliability.24
Participant-ranked responses to questions such as “Why do myopic children not wear glasses?” were analyzed using SPSS statistical software, version 17.0 (SPSS Inc, Chicago, Illinois) (Table 2). Where a total of x responses was to be ranked, x points were assigned for each participant who ranked the response highest, x − 1 for a second-place ranking, and so forth, with a lowest ranking receiving a score of 1. A total score for each response was calculated as the sum of points awarded across all participants, which was then divided by the maximum possible score to facilitate comparison across groups of different sizes. Thus, the maximum score would be 100% and the minimum score for a group of 10 children would be 10%.
The κ values were calculated for the 2 coders for student groups, parent groups, and teacher groups. Those values were 0.81, 0.71, and 0.72, respectively.
Knowledge levels among students, parents, and teachers varied widely. In all 3 groups, there were individuals who admitted having no clear idea of what myopia was, many who understood it concretely as blurred vision in the distance, and a small number who gave accurate anatomical definitions in terms of images being focused anterior to the retina. Some parents and teachers mentioned the role of genetic inheritance, whereas a number of participants in the parents' group offered less well-defined ideas, such as “using the eyes too much” and “makes your vision worse.”
Students' view of their current vision ranged from very negative (“My vision is bad; worse all the time”) to accepting (“I feel my vision is not all that bad”) to uncertain (“I’m not really clear if I have myopia right now”).
Although some students were pragmatic about the purchase of glasses (“depends on the degree of myopia,” “[I will need glasses] when things in the distance are blurry, when things are not clear”), there was concern about avoiding “unnecessary” glasses use among students (“When you have only a little myopia, it can be treated without glasses”), parents (“Early childhood myopia can be treated successfully; you shouldn't be in a hurry to get glasses”), and teachers (“They should not get glasses before the age of 18”).
Several parents mentioned that they had never taken their children to get glasses or did not know whether glasses were needed because their children had never been examined. Some students mentioned that their parents did not have time to take them to get glasses made.
The highest-ranked reasons (on a scale of 0 to 1, see the Analysis of Data subsection in the “Methods” section) given by parents for why they had not purchased glasses were “too busy with work to buy them” (0.905) and “child never examined” (0.786). “Too expensive” (0.452) ranked in the bottom 3 reasons.
The student and parent groups at all 3 schools were asked to rank their requirements for satisfactory glasses. All 3 parent groups included “glasses of good quality” as their highest-ranked response, whereas 2 groups each ranked “glasses power accurate” and “glasses are safe” highly (score, ≥0.60). “Do not worsen myopia,” “comfortable to wear,” and “inexpensive” were ranked highly by 1 group each.
All 3 student groups ranked “glasses power accurate” highest, whereas 2 groups each ranked “glasses of good quality” and “glasses are safe” highly (score, ≥0.60). One group each ranked “capable of preserving my vision” and “inexpensive” highly. All 3 student groups ranked “new and attractive styles” last among all choices, with scores in the 0.35 to 0.45 range.
All 3 groups emphasized 2 common themes about children's glasses use: wearing glasses only when visually necessary and the desire to avoid harm to the eyes, specifically worsening of myopia. The view that either wearing glasses or failure to wear glasses might accelerate the progression of myopia was commonly expressed among students (“wearing glasses will make the power of myopia get worse all the time, the eyes change shape,” “wear glasses to keep myopia from getting worse”), parents, and teachers (“if glasses aren't worn, the amount of myopia will keep getting more”). Students and teachers also commented that parents were concerned that wearing glasses would weaken children's eyes. Uncertainty as to whether glasses should be worn was emphasized by parents and students.
When asked to speculate why their students did not wear glasses, teachers mentioned factors that related to parental attitudes and those of students. Teachers believed that parents were hindered by lack of knowledge and a lack of appreciation of the importance of vision. Teachers described the principal barriers to glasses wear among children as lack of concern and understanding and worry about the appearance of glasses.
All 3 of the student groups ranked inconvenience of glasses wearing among their top 2 responses, whereas other highly ranked responses (score, >0.6) varied widely, with 1 student group each listing “did not know I was myopic,” “glasses too expensive,” “afraid glasses will change the shape of the eye (eg, induce progressive myopia),” “current vision clear enough,” and “parents won't agree.”
All 3 groups agreed that myopia had an effect on students' lives inside and outside the classroom, with many respondents talking about the social cost of failure to recognize faces and the deleterious effect on classroom performance. Parents (none of whom wore glasses to correct distance vision) tended to emphasize the inconvenience of glasses use and of dependence on glasses. All 3 groups raised the possibility of injury from poor vision (“you can't see the road surface when riding a bike, so it's easier to fall”) and/or from glasses use (“the eyes can be harmed during sports”). Students, teachers, and parents all emphasized the possibility that myopia might influence or curtail children's career choices.
Teachers' groups were asked to rank the various potential effects of children's failing to wear glasses in order of importance. All 3 groups included “affects students' grades” and “impact on daily living” among their top-ranked (score, ≥0.6) responses, with “harms the eyes” and “affects students' self-confidence” being ranked highly by 1 group each.
In discussing how best to protect children's vision in the classroom and at home, parents focused on monitoring children's visual tasks and enhancing general health (“give them nutritional supplements,” “have them get plenty of exercise,” “get enough rest”). Specific strategies to prevent or retard myopia favored by parents included limiting the closeness of or time spent on near-work, optimizing posture while reading and writing, using appropriate lighting, and using nutritional, pharmaceutical, and topical remedies and popular nostrums (“perform eye exercises,” “look at something green”). Many parents emphasized that they were uncertain about what to do to optimize their child's vision or to prevent myopia.
Teachers favored many of the same behavioral, medical, and popular remedies for myopia prevention suggested by parents. In addition, they emphasized the importance of cooperation with parents and students, while advocating various classroom and broader-based strategies to optimize children's vision. These approaches included seating children according to their visual needs, holding classroom meetings about myopia, cooperating with local authorities in screening programs, encouraging children with myopia to wear their glasses, and watching television programs that provide information on myopia. Student groups also expressed a strong desire to prevent or retard myopia, mentioning many of the same behavioral, medical, and pseudomedical approaches emphasized by parents and teachers.
Myopia among children in rural China is widespread17,18 and associated with significant deficits of vision17,18 and visual function18; however, it lacks optimal correction in approximately two-thirds of cases.11 The current report indicates that the key participants in decisions that affect children's refractive care, namely, students, parents, and teachers, are all highly motivated to avoid damage to children's vision from myopia. However, our findings suggest that a number of barriers prevent this concern from being translated into effective action. These barriers include a lack of understanding of myopia and its effect on vision, lack of access to precise information about the refractive state of children's eyes, misplaced concern that glasses will be harmful to the eyes, and emphasis on unproven remedies to prevent or retard myopia as an alternative to refractive correction. These critical gaps in knowledge appear to affect all 3 groups that took part in the current research.
Evidence from randomized controlled trials among children with myopia has been comprehensively reviewed27 and suggests that the wearing of glasses has no effect on the progression of refractive error. The current report suggests, supported by population-based studies in the area,11 that many parents, teachers, and students in rural China advocate not correcting early or modest myopia in children in the belief that this will be healthier for the vision in the long term and has little effect on performance. However, data from children in this region demonstrate that significant deficits in visual function are found with even modest amounts of myopia,20 and studies28,29 have now shown that correction of even low myopia is associated with significant improvement in visual function. The amounts of refractive error going uncorrected in rural China are significant: in the Xichang Pediatric Refractive Error Study,11 we reported a mean refractive error of −2.50 D and a median visual acuity less than 6/12 among myopic children not owning glasses and a mean refractive error of −3.00 D and a median visual acuity less than 6/15 among those owning but not wearing glasses. Habitual acuity was 6/24 or less in 25% of the latter children.
Our results have apparent implications for refractive programs in rural China. Students, parents, and teachers need access to basic information on myopia, the visual benefits of myopia correction, the safety of glasses use, and the refractive status of children's eyes. The SWLW project, a randomized controlled trial designed to assess the effect of educational interventions aimed at teachers and children on the purchase and wear of children's glasses, is currently underway in the area.30 However, creative strategies are needed to extend these school-based interventions to parents, who play a critical role in the use of glasses. Evidence suggests that current government-run school vision screening programs in rural China are ineffective because of poor validity in the detection of vision problems in children.31
Besides the obvious need for more and better programs, the current results raise additional issues. Parents, students, and teachers indicated that rural Chinese parents, most of whom work as farmers in this area, find it too inconvenient to take their children to buy glasses. Programs providing glasses at schools could help resolve this, although recovering program costs through sale of glasses in this setting may be difficult because of practical issues and opposition to school sales among parents and educational authorities.
The great importance attached by the student groups to accuracy of lenses is noteworthy, particularly given the widespread and documented problem with lens accuracy in rural China.30 This concern about accuracy may have implications for the increasingly widespread use of ready-made glasses in refractive programs,32 although there is some trial evidence to suggest that the modest inaccuracies resulting from their careful use may be acceptable to children.32
The fact that concerns about cost do not appear to be the principal barrier to use of glasses in this setting, consistent with previous data from rural China,11,21 has important potential implications for cost recovery from glasses programs. The finding that rural children do not seem to be overly concerned with new styles or the appearance of glasses suggests the possibility that savings from a reduced glasses inventory, together with funds from cost recovery, might be used to support the educational interventions that the current report indicates are needed as an integral part of glasses provision in this setting.
The results and recommendations of this study must be understood within the context of its limitations. The FG approach relies on obtaining detailed and nuanced responses from a small number of individuals to potentially complex questions. As such, these results are complementary to more quantitative data exploring reasons for nonuse of glasses among children with myopia in China.11,21,23 However, given their subjective nature and the small number of responders, these results can only be applied with caution to this region and particularly to other parts of China. The use of multiple FGs for each type of respondent helps in some ways to overcome this problem, particularly when there is apparent unanimity among groups, but the number of individuals represented is still small. Our transcripts went through a translation process from Chaoshan dialect to Mandarin, which could offer further opportunities for misinterpretation.
Nevertheless, we believe the FG method allows a more complex understanding of some of the important barriers of knowledge and belief standing in the way of better use of sight-saving refractive services in rural China. This is particularly true when these results are taken in the context of the growing body of quantitative data about use of glasses in this and other areas of the world.
Correspondence: Mingzhi Zhang, MD, Joint Shantou International Eye Center, Dongxia North Road, Shantou, Guangdong, PRC 515041.
Submitted for Publication: June 8, 2009; final revision received December 4, 2009; accepted December 9, 2009.
Financial Disclosure: None reported.
Funding/Support: The SWLW project is supported by a grant to Oxford University from the Li Ka Shing Foundation, Hong Kong Special Administrative Region.