By analyzing 3845 completed questionnaires from the latest schoolchildren’s myopia survey in Taiwan, we found several associations between parental behavior and children’s myopia. First, the strength of parental behavior of children’s myopia prevention and control showed a decreasing trend that followed children’s age. Second, parental behavior and children’s myopic status may have a reciprocal effect. Third, parental behavior influences children’s daily activities, especially in the time spent on their near work activities and electronic device use at an early age.
Contrary to the positive association between beneficial parental behavior rate and degree of myopia in children found in our study, Zhou et al. found that parents’ attitudes and behaviors toward children’s visual care were associated with a lower risk of myopia in children [13]. They suggested that parental behavior influences children’s behavior regarding eye care, thus reducing the risk of myopia. The explanation for our finding may be the reciprocal effect between children’s myopia and parental behavior. It is possible that children’s myopic status may strengthen parents’ eye care behavior if they are aware of and recognize it as a health concern. The positive association between beneficial parental behavior and children’s myopia may reflect the effect of school-based vision surveillance system in Taiwan. In Taiwan, there are mandatory yearly vision examinations for every child from 4 years of age. In elementary school, children with uncorrected visual acuity of less than 20/20 are advised to consult an eye care professional. Subsequently, parents receive a notification about how to conduct beneficial behaviors toward myopia control and treatment options for myopia. We observed that parents of children with moderate myopia presented a higher rate of beneficial parental behavior than children with mild or without myopia (Fig. 1). Additionally, we observed that parents’ acceptance of medical treatment was significantly associated with children’s myopia status in the PCA at the elementary school level (Fig. 2). Therefore, we speculated that routine vision checks that effectively detect children’s vision problem may increase parents’ awareness and strengthen their behaviors for children’s eye care, although longitudinal studies are necessary to elucidate the causal relationships.
Another explanation is that parental behavior toward eye care has a limited protective effect on myopia development among children in Taiwan. An educational system involving intensive reading starting in early childhood in Taiwan is one of the key factors for the increased prevalence of myopia over generations for the whole population [14, 15]. Extremely high educational pressure and extended extracurricular learning at cram schools from a young age in East Asian societies result from a competitive school entrance system. In our study, we found that the prevalence of beneficial parental behavior reduced gradually from kindergarten to high school. We also found that parental behavior had minor impact on children’s outdoor activity time. One of the proposed explanations is that the concept of the protective role of outdoor activities on myopia prevention was introduced in just recent decade [7] and was unfamiliar to the parents of high schoolers. Another possible explanation is that when families are operating within the context of a school system that is highly competitive from an early age, the range of reasonable choices for parents is inevitably restricted, and parents’ ability to get their children more involved in outdoor activities is more constrained. Therefore, the preventive effect of beneficial parental behavior in children’s myopia development is incrementally counteracted after a few years of extensive educational pressures and cannot be observed in our cross-sectional study.
Our finding in the association between beneficial parental behavior and children’s myopia is likely to be a phenomenon unique to Taiwan, and probably other East and Southeast Asian countries with developed myopia epidemics and vigorous vision surveillance systems. It may not be observed in Western populations because they have a lower myopia incidence and a less academically competitive educational system. However, with the expected rising of global myopia prevalence, our finding may add new information in understanding the relationship between parental behavior and children’s myopia and help to improve the strategies in myopia control. In Taiwan, the effect of beneficial parental behavior may not be strong enough to concur the overwhelming environmental impact on myopia development because it is difficult for parents to make choices that effectively prevent their children from myopia development. Therefore, an education reform that substantially reduces academic loads in young children is of primary importance. Moreover, school-based programs promoting children’s outdoor activity should also be implemented due to the limited influence of parental behavior on children’s time outdoors [2, 7]. Finally, a well-functioning surveillance system for children’s vision that effectively inform the parents about children’s myopic status may help enhancing the beneficial parental behavior.
Although the association between beneficial parental behavior and children’s myopia prevention at the elementary school level was not observed in this study, we found that beneficial parental behavior was associated with less high myopia in high school children. High myopia represents the long-term outcome of unfavorable myopia progression [16]. Genetic predisposition, prolonged near work time, lack of active rest during the study, reduced outdoor activities, and inadequate sleeping time were all reported risk factors for myopia progression and high myopia [16,17,18,19,20]. Digital screen time, which contributes to further near workload, is also considered an important aggravating factor in myopia progression [6, 21]. Aside from genetic predisposition, these environmental factors are modifiable through the adjustment of children’s behaviors.
Many researchers have identified a strong relationship between parenting behaviors and children’s health status [22, 23]. The influence of parental behavior on children’s healthy behavior and medical compliance has been documented [8,9,10]. A systemic review found that parents’ encouragement increases children’s physical activity engagement and that less electronic device use of the parents is followed by minimized use in their children [11]. Our study also found a correlation between beneficial parental behavior and less total near work time or electronic device usage in children, especially at younger ages. We suggest that beneficial parental behavior toward children’s eye care may not reverse the incidence of myopia in Taiwan; however, myopia progression could be controlled by modifying children’s behaviors, thus preventing high myopia formation. Nevertheless, further longitudinal studies are necessary to elucidate the relationship between parental behaviors, children’s behavior patterns, and myopia status overall.
There are some limitations to our study. First, the cross-sectional design of our study could only demonstrate the association, rather than a causal relationship, between parental behavior and children’s myopia status. Second, the survey of parental behavior was based on questions quantified using scoring scales. The cut point of beneficial parental behavior was defined by the third quartile of the total score distribution, which requires further validation for appropriateness. PCA was performed to complement information loss through dichotomous grading of behavior scores. Third, the amplitude of myopia in both the father and mother is related to myopia in children in a dose-dependent manner [24]. In our study, information on parental myopia was obtained using a questionnaire without objective and quantitative measurements. Finally, our study focused only on regular parental behaviors toward children’s eye care. However, variable aspects of parenting, including parenting style, role modeling, self-efficacy, and perception of children’s health needs, may play a role in children’s health.