1. Introduction

2. Methods

2.2. Questionnaire design

This survey was a 26-item questionnaire which is described in detail elsewhere [11], mainly aimed to understand the practicing optometrists’:

• Understanding of the natural history and ocular complications associated with myopia.
• Clinical practice behavior related to the diagnosis and management of myopia in children aged 16 years or younger.
• Potential barriers to providing optimal myopia care.
• Source of evidence that clinicians use as a guide to their practice.
• Extent to which adult caregivers are involved during the decision-making process in treating childhood myopia.

Out of the 26 questions, there were 8 × multiple choice questions, 6 × matrix, 3 × open-ended, 3 × closed-ended, 3 × dropdown, 1 × Likert scale, 1 × ranking, and 1 × mixed type question (provided as supplementary material).

The definition of myopia was set at a spherical equivalent of -0.50 D or higher. Respondents were expected to complete the survey questions in the order provided by the authors and had no option to change the answer after submission. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines was used to prepare the survey (Table 1) [16].

Table 1. Summary of the survey methodology.

Table 1. Summary of the survey methodology.

S.no	Description	Survey report
1	Survey development	A pre-validated questionnaire was revised after a focus group discussion among four optometrists to finalize the questionnaire's items
2	Number and nature of items in the questionnaire	A 26-item questionnaire with a mix of open and close-ended questions
3	Reliability	Not determined
4	Mode of survey	Internet-based
5	Survey period	27 March 2021 to 27 September 2022
6	Sample frame	Open survey: Open for all optometrists across India
7	Target population	Optometrists practicing in India
8	Recruitment process	Open invitations over social media, namely Facebook, WhatsApp, E-Newsletter, and Telegram, in a target group with reminder messages every 2 weeks
9	Participation	Voluntary participation
10	Survey administration	Sequential questions administered using Google forms
11	Informed consent	E-consent
12	Incentives	None
13	Randomization of items or questionnaires	No randomization of items or questions
14	Use of adoptive questions	Yes
15	Number of screens	5
16	Review step	Review with a back button, no alteration was possible after submission
17	Preventing multiple entries from a single respondent, e.g., cookies used	Limited to one response per email and one item in the questions asked for their previous participation in the survey.
18	Data capturing	Automatic conversion into a spreadsheet
19	Data analysis	Proportions of each response were calculated, and the odds were determined (p value of <0.05 was considered statistically significant)
20	Software used for statistical analysis	GraphPad Prism (version 6.04 for Windows, GraphPad Software, La Jolla, CA, and IBM SPSS Statistics for Windows, Version 28.0, IBM Corp

3. Results

Table 2. Demographics of the survey responders.

3.1. Knowledge of childhood myopia and its complications

Almost 90% of respondents indicated having a clinical/research interest in managing childhood myopia. The majority (45.3%) responded -0.50 D as the minimum correction in spherical equivalent prescribed for myopic patients. Most of the optometrists’ responses were retinal breaks (67.4%), followed by rhegmatogenous retinal detachment (45.3%) and cataracts (44.8%) as ocular pathologies associated with high myopia > -6 D (Table 3). Identification of retinal break was statistically significant among experienced respondents (≥ ten years) (odds ratio (OR) 2.23, 95% confident Interval (CI): 1.53–3.25, p < 0.001, whereas it was not the case among respondents with interest in myopia management (OR 1.57, 95% CI: 0.60–4.05, p = 0.35). When stratified based on the primary place of practice, the odds of knowing retinal tear were equal within all practice patterns (Academic institution (OR 2.14, 95%CI: 1.49–3.06, p < 0.001), corporate practice (OR 2.14, 95%CI: 1.53–2.99, p < 0.001), hospital (OR 1.79, 95%CI: 1.17–2.74, p = 0.007), Independent practice (OR 2.11, 95%CI: 1.48–3.01, p < 0.001) and public health clinic (OR 1.98, 95%CI: 1.43–2.75, p < 0.001).

Table 3. Perspective on the associated ocular pathologies with high myopia (-6.00 D or greater).

Table 3. Perspective on the associated ocular pathologies with high myopia (-6.00 D or greater).

Ocular conditions	Percentage of respondents (%)
Retinal breaks	67.4
Rhegmatogenous Retinal Detachment	45.3
Cataract	44.8
Exudative Retinal Detachment	30.8
Primary Open Angle Glaucoma	29.7
Primary Angle Closure Glaucoma	18.6
Age-Related Macular Degeneration	16.9
Diabetic Retinopathy	7.6

3.2. Clinical workup and diagnosis of childhood myopia

Table 4 summarizes the responses to clinical procedures used to examine children with myopia for the first time. Over 75% of the respondents considered taking the family history, performing cycloplegic retinoscopy, dilated retinal examination, and cover test during the first visit. Respondents with myopia management interest and experience (≥ ten years) were more likely to note the family history of myopia (OR 3.50, 95% CI: 1.15–10.6, p = 0.02 and OR 4.45, 95% CI: 2.81–7.07, p < 0.001) and perform cycloplegic refraction (OR 3.50, 95% CI: 1.15–10.60, p = 0.02 and OR 9.00, 95% CI: 4.96–16.30, p < 0.001). Ocular biometry is performed by 46.5% of practitioners in clinical practice. Notably, 7%, 4.1%, and 5.2% responded that they never performed cycloplegic, non-cycloplegic, and dilated fundus examination procedures in the routine clinical practice on a myopic child (Fig. 1).

Table 4. Percentage of respondents who indicated performing each clinical procedure routinely on all school-aged children (5–16 years) with myopia on initial presentation.

Table 4. Percentage of respondents who indicated performing each clinical procedure routinely on all school-aged children (5–16 years) with myopia on initial presentation.

Clinical Procedures	Percentage of respondents (%)
Cycloplegic retinoscopy	86.6
Note patient family history of myopia	83.7
Dilated retinal fundus examination	76.7
Cover test (distance and near phoria)	75.0
Cycloplegic subjective refraction	70.9
Non-cycloplegic retinoscopy	62.8
Non-cycloplegic subjective refraction	62.2
Cycloplegic autorefraction	52.3
Intraocular pressure	47.1
Axial length measurement	46.5
Dynamic retinoscopy (e.g., MEM, NOTT Retinoscopy)	39.5
AC/A ratio	35.5
Non-cycloplegic autorefraction and stereopsis	34.3
Measurement of pupil size	32.6
Corneal topography	21.5
Retinal fundus photography – posterior pole	14.5
Retinal fundus photography – periphery	11.6
Peripheral defocus	8.7
Others	11.2

MEM: Monocular estimation method, AC/A: accommodative convergence over accommodation.

Figure 1. Percentage (%) of respondents who indicated performing each clinical procedure on a school-aged child with myopia at the nominated frequency.

Figure 1. Percentage (%) of respondents who indicated performing each clinical procedure on a school-aged child with myopia at the nominated frequency.

3.3. Perception on intervention

Table 5 presents the perspective on the most effective management options other than single-vision distance spectacles (full correction) for myopia management. Experienced practitioners prioritized increasing time spent outdoors (OR 2.33, 95% CI: 1.58–3.45, p < 0.001), low-moderate dose atropine (OR 2.24, 95% CI: 1.52–3.30, p < 0.001) and visual hygiene (OR 1.93, 95% CI: 1.32–2.81, p < 0.001) than the inexperienced ones. Practitioners with an interest in myopia management were less likely to prescribe bifocal spectacle lenses with prism (OR 0.05, 95% CI: 0.01–0.44, p = 0.005), peripheral defocus soft contact lenses (OR 0.05, 95% CI: 0.01–0.44, p = 0.005) and progressive addition lenses (OR 0.20, 95% CI: 0.05–0.69, p = 0.01). The likelihood of advising increased time spent outdoors was significantly higher among academic, corporate, hospital, independent and public health practices (OR 2.45–2.92, p < 0.001). Equally, low-moderate dose atropine and visual hygiene were a preferred mode of advice among all the practices (OR 1.82–3.23, p < 0.001 and OR 1.93–2.04, p < 0.01, respectively). When asked about their perspective on the alternative to prescribing single-vision distance spectacles (full correction), practitioners opted for single-vision (under-correction) as their next choice, followed by single-vision contact lenses (full-correction), low-moderate dose atropine (0.01%‒0.5%) eye drops, advice to increase the outdoor time, and Ortho-K (Fig. 2).

Figure 2. Perspective on the first three options for effective management other than single vision spectacle (full correction).

Figure 2. Perspective on the first three options for effective management other than single vision spectacle (full correction).

3.4. Influential factors on management approach

Several clinical features of the myopic patient are deemed necessary by practitioners while managing myopes (Fig. 3a). Over 50% of participants indicated that the age, current refractive error, and myopia progression over the past year are 'very important' followed by time spent in near work (40.7%).

Among the potential factors and barriers that influence optimal myopia care were concerns about the medico-legal implications of administering interventions, lack of regulatory approval of those treatments, scarcity of high-quality evidence backing up the effectiveness, inadequate consultation time, absence of clinical practice guidelines, safety of myopia management techniques which were considered 'very important' or 'important' (Fig. 3b). Experienced practitioners reported insufficient support at the workplace as a potential barrier (OR 1.88, 95% CI: 1.04–3.44, p = 0.03). Lack of minimal financial incentive in hospital-based practice (OR 1.77, 95% CI: 1.03–3.04, p = 0.03) was a barrier, whereas, for the independent practice, allotted time for consultation (OR 0.46, 95% CI: 0.23–0.95, p = 0.03), time for professional development (OR 0.47, 95% CI: 0.24–0.94, p = 0.03) and need for new equipment (OR 0.43, 95% CI: 0.21–0.86, p = 0.01) were not barriers for myopia management.

Figure 3. Percentage of respondents (%) who rated the relative importance of each: (a) potential factor when deciding upon the management approach for a child with myopia. (b) barrier limiting their ability to provide optimal clinical care to children with myopia.

Figure 3. Percentage of respondents (%) who rated the relative importance of each: (a) potential factor when deciding upon the management approach for a child with myopia. (b) barrier limiting their ability to provide optimal clinical care to children with myopia.

3.5. Management approaches to myopia in children

Single-vision distance (full-correction) spectacles were the most prescribed method of optical correction, with about 70.3% of respondents suggesting that they would ‘always’ or ‘mostly’ recommend this modality (Fig. 4). Visual hygiene and increased outdoor time were equally prescribed as the management strategy to children with myopia.

Figure 4. Percentage of respondents (%) who rated the frequency with which they prescribe each management strategy to children with myopia.

Figure 4. Percentage of respondents (%) who rated the frequency with which they prescribe each management strategy to children with myopia.

Though the perception for low-moderate dose atropine is effective (68.6%) in myopia management, it was prescribed relatively infrequently, with only 29.1% of practitioners reporting they would ‘always’ or ‘mostly’ recommend it. However, it was less likely that experienced optometrists would prescribe high-dose atropine (OR 0.40, 95% CI: 0.17–0.85, p = 0.02) and cyclopentolate (OR 0.49, 95% CI: 0.23–0.96, p = 0.04). In addition, the majority (>70%) of respondents indicated they would ‘mostly’ or ‘always’ advise on visual hygiene and increasing time spent outdoors. However, experienced optometrists were less likely to advise visual hygiene (OR 0.51, 95% CI: 0.27–0.95, p = 0.03).

Participants were asked to envision a clinical scenario for myopia management and specify when they would cease the intervention (patient age and prescription stability). Responses varied widely, with 16 years (14.5%) as the most common age criterion, and discontinuation was suggested if there was no progression in myopia for 12 months.

3.6. Source of Information

For more than half of the respondents (54.1%), the source of information for clinical management was original peer-reviewed articles, followed by their own clinical experience (52.3%), continuing medical education (CME) and conferences (50%). The least opted sources were industry information (21.5%), online forums, and resources like artificial intelligence (AI) (~20%) and ophthalmic press (19.2%) (Fig. 5a).

Figure 5. Percentage of respondents (%) who rated the relative importance of each: (a) information source in guiding their current approach to managing childhood myopia. (b) potential resources for supporting their future clinical management of children with myopia.

Figure 5. Percentage of respondents (%) who rated the relative importance of each: (a) information source in guiding their current approach to managing childhood myopia. (b) potential resources for supporting their future clinical management of children with myopia.

Among the resources that support the respondents' future clinical management (Fig. 5b), over 40% of the respondents mentioned clinical guidelines for childhood myopia management, seminars/continuing education events, and clinical tools to guide myopia management based upon the best available research evidence are very useful. Most (> 70%) marked all listed items as 'useful' or 'very useful'. The results were similar when categorized based on interest, practice, and experience, without any significant difference.

3.7. Engagement with caregivers

Over 40% emphasized discussing myopia's nature, long-term eye disease risks, and potential myopia progression with adult caregivers (Fig. 6). Over 70% found it essential to explain myopia, its physical changes, possible causes, increasing severity, and treatment benefits versus risks for a child. There were no significant differences based on experience or practice patterns, except for discussing treatment options. Regarding caregiver involvement in myopia management decisions, over 72% consider caregiver opinions or decide collaboratively after discussing management options.

Figure 6. Percentage of respondents (%) who rated the relative importance of each potential topic to discuss with an adult caregiver of a child with myopia.

Figure 6. Percentage of respondents (%) who rated the relative importance of each potential topic to discuss with an adult caregiver of a child with myopia.

4. Discussion

5. Conclusion

References

1. Sankaridurg, P.; Tahhan, N.; Kandel, H.; Naduvilath, T.; Zou, H.; Frick, K.D.; Marmamula, S.; Friedman, D.S.; Lamoureux, E.; Keeffe, J.; et al. IMI Impact of Myopia. Investigative ophthalmology & visual science 2021, 62, 2. [Google Scholar] [CrossRef]
2. Holden, B.A.; Fricke, T.R.; Wilson, D.A.; Jong, M.; Naidoo, K.S.; Sankaridurg, P.; Wong, T.Y.; Naduvilath, T.J.; Resnikoff, S. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology 2016, 123, 1036–1042. [Google Scholar] [CrossRef] [PubMed]
3. Priscilla, J.J.; Verkicharla, P.K. Time trends on the prevalence of myopia in India - A prediction model for 2050. Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists) 2021, 41, 466–474. [Google Scholar] [CrossRef]
4. Ohno-Matsui, K.; Wu, P.C.; Yamashiro, K.; Vutipongsatorn, K.; Fang, Y.; Cheung, C.M.G.; Lai, T.Y.Y.; Ikuno, Y.; Cohen, S.Y.; Gaudric, A.; et al. IMI Pathologic Myopia. Investigative ophthalmology & visual science 2021, 62, 5. [Google Scholar] [CrossRef]
5. Wolffsohn, J.S.; Whayeb, Y.; Logan, N.S.; Weng, R. IMI-Global Trends in Myopia Management Attitudes and Strategies in Clinical Practice-2022 Update. Investigative ophthalmology & visual science 2023, 64, 6. [Google Scholar] [CrossRef]
6. Gifford, K.L.; Richdale, K.; Kang, P.; Aller, T.A.; Lam, C.S.; Liu, Y.M.; Michaud, L.; Mulder, J.; Orr, J.B.; Rose, K.A.; et al. IMI - Clinical Management Guidelines Report. Investigative ophthalmology & visual science 2019, 60, M184–m203. [Google Scholar] [CrossRef]
7. Bullimore, M.A.; Richdale, K. Myopia Control 2020: Where are we and where are we heading? 2020, 40, 254–270. [Google Scholar] [CrossRef]
8. Muralidharan, A.R.; Lança, C.; Biswas, S.; Barathi, V.A.; Wan Yu Shermaine, L.; Seang-Mei, S.; Milea, D.; Najjar, R.P. Light and myopia: from epidemiological studies to neurobiological mechanisms. Therapeutic advances in ophthalmology 2021, 13, 25158414211059246. [Google Scholar] [CrossRef]
9. Jothi Balaji, J.; Viswanathan, S. Practice patterns in managing myopia differs among Indian eye care practitioners. Indian journal of ophthalmology 2022, 70, 1848–1849. [Google Scholar] [CrossRef]
10. Nti, A.N.; Owusu-Afriyie, B.; Osuagwu, U.L.; Kyei, S.; Ovenseri-Ogbomo, G.; Ogbuehi, K.C.; Ouzzani, M.; Agho, K.E.; Mashige, K.P.; Ekure, E.; et al. Trends in myopia management attitudes and strategies in clinical practice: Survey of eye care practitioners in Africa. Contact lens & anterior eye : the journal of the British Contact Lens Association 2023, 46, 101597. [Google Scholar] [CrossRef]
11. Douglass, A.; Keller, P.R.; He, M.; Downie, L.E. Knowledge, perspectives and clinical practices of Australian optometrists in relation to childhood myopia. Clinical & experimental optometry 2020, 103, 155–166. [Google Scholar] [CrossRef]
12. Di Pierdomenico, J.; González-González, R.; Valiente-Soriano, F.J.; Galindo-Romero, C.; García-Ayuso, D. Attitudes and knowledge of myopia management by Spanish optometrists. International ophthalmology 2023, 43, 4247–4261. [Google Scholar] [CrossRef] [PubMed]
13. Chaurasiya, R.K.; Sutar, S.; Gupta, A.; Pandey, R.; Agarwal, P. Knowledge, attitude, and practice of childhood myopia among Indian optometrists: A questionnaire-based study. Indian journal of ophthalmology 2023, 71, 951–956. [Google Scholar] [CrossRef] [PubMed]
14. Thite, N.; Jaggernath, J.; Chinanayi, F.; Bharadwaj, S.; Kunjeer, G. Pattern of Optometry Practice and Range of Services in India. Optometry and Vision Science 2015, 92. [Google Scholar] [CrossRef]
15. Kotrlik, J.; Higgins, C.J.I.t.; journal, p. Organizational research: Determining appropriate sample size in survey research appropriate sample size in survey research. 19 2001, 19, 43. [Google Scholar]
16. Eysenbach, G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Journal of medical Internet research 2004, 6, e34. [Google Scholar] [CrossRef] [PubMed]
17. Optometry in India. An overview of Optometry services in India in terms of optical outlets, eye hospitals and educational institutes, 2016.
18. Jong, M.; Sankaridurg, P.; Li, W.; Resnikoff, S.; Naidoo, K.; He, M. Reduced vision in highly myopic eyes without ocular pathology: the ZOC-BHVI high myopia study. Clinical and Experimental Optometry 2018, 101, 77–83. [Google Scholar] [CrossRef] [PubMed]
19. Fryer, L.K.; Shum, A.; Lee, A.; Lau, P. Mapping students' interest in a new domain: Connecting prior knowledge, interest, and self-efficacy with interesting tasks and a lasting desire to reengage. Learning and Instruction 2021, 75, 101493. [Google Scholar] [CrossRef]
20. Morgan, I.G.; Wu, P.C.; Ostrin, L.A.; Tideman, J.W.L.; Yam, J.C.; Lan, W.; Baraas, R.C.; He, X.; Sankaridurg, P.; Saw, S.M.; et al. IMI Risk Factors for Myopia. Investigative ophthalmology & visual science 2021, 62, 3. [Google Scholar] [CrossRef]
21. Biswas, S.; El Kareh, A.; Qureshi, M.; Lee, D.M.X.; Sun, C.H.; Lam, J.S.H.; Saw, S.M.; Najjar, R.P. The influence of the environment and lifestyle on myopia. Journal of physiological anthropology 2024, 43, 7. [Google Scholar] [CrossRef]
22. Luong, T.Q.; Shu, Y.H.; Modjtahedi, B.S.; Fong, D.S.; Choudry, N.; Tanaka, Y.; Nau, C.L. Racial and Ethnic Differences in Myopia Progression in a Large, Diverse Cohort of Pediatric Patients. Investigative ophthalmology & visual science 2020, 61, 20. [Google Scholar] [CrossRef]
23. Mutti, D.O.; Mitchell, G.L.; Moeschberger, M.L.; Jones, L.A.; Zadnik, K. Parental myopia, near work, school achievement, and children's refractive error. Investigative ophthalmology & visual science 2002, 43, 3633–3640. [Google Scholar]
24. He, X.; Sankaridurg, P.; Wang, J.; Chen, J.; Naduvilath, T.; He, M.; Zhu, Z.; Li, W.; Morgan, I.G.; Xiong, S.; et al. Time Outdoors in Reducing Myopia: A School-Based Cluster Randomized Trial with Objective Monitoring of Outdoor Time and Light Intensity. Ophthalmology 2022, 129, 1245–1254. [Google Scholar] [CrossRef] [PubMed]
25. Wolffsohn, J.S.; Kollbaum, P.S.; Berntsen, D.A.; Atchison, D.A.; Benavente, A.; Bradley, A.; Buckhurst, H.; Collins, M.; Fujikado, T.; Hiraoka, T.; et al. IMI - Clinical Myopia Control Trials and Instrumentation Report. Investigative ophthalmology & visual science 2019, 60, M132–m160. [Google Scholar] [CrossRef]
26. Jonas, J.B.; Ohno-Matsui, K.; Holbach, L.; Panda-Jonas, S. Retinal pigment epithelium cell density in relationship to axial length in human eyes. Acta ophthalmologica 2017, 95, e22–e28. [Google Scholar] [CrossRef]
27. Martínez-Pérez, C.; Villa-Collar, C.; Santodomingo-Rubido, J.; Wolffsohn, J.S. Strategies and attitudes on the management of myopia in clinical practice in Spain. Journal of Optometry 2023, 16, 64–73. [Google Scholar] [CrossRef]
28. Tsai, H.-R.; Wang, J.-H.; Huang, H.-K.; Chen, T.-L.; Chen, P.-W.; Chiu, C.-J. Efficacy of atropine, orthokeratology, and combined atropine with orthokeratology for childhood myopia: A systematic review and network meta-analysis. Journal of the Formosan Medical Association 2022, 121, 2490–2500. [Google Scholar] [CrossRef] [PubMed]
29. Karthikeyan, S.K.; Ashwini, D.L.; Priyanka, M.; Nayak, A.; Biswas, S. Physical activity, time spent outdoors, and near work in relation to myopia prevalence, incidence, and progression: An overview of systematic reviews and meta-analyses. Indian journal of ophthalmology 2022, 70, 728–739. [Google Scholar] [CrossRef]
30. Tsugawa, Y.; Newhouse, J.P.; Zaslavsky, A.M.; Blumenthal, D.M.; Jena, A.B. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ (Clinical research ed.) 2017, 357, j1797. [Google Scholar] [CrossRef]
31. Berntsen, D.A.; Sinnott, L.T.; Mutti, D.O.; Zadnik, K. A randomized trial using progressive addition lenses to evaluate theories of myopia progression in children with a high lag of accommodation. Investigative ophthalmology & visual science 2012, 53, 640–649. [Google Scholar] [CrossRef]
32. Heiwe, S.; Kajermo, K.N.; Tyni-Lenné, R.; Guidetti, S.; Samuelsson, M.; Andersson, I.L.; Wengström, Y. Evidence-based practice: attitudes, knowledge and behaviour among allied health care professionals. International journal for quality in health care : journal of the International Society for Quality in Health Care 2011, 23, 198–209. [Google Scholar] [CrossRef] [PubMed]
33. Brennan, N.A.; Toubouti, Y.M.; Cheng, X.; Bullimore, M.A. Efficacy in myopia control. Progress in retinal and eye research 2021, 83, 100923. [Google Scholar] [CrossRef] [PubMed]
34. Downie, L.E.; Keller, P.R.; Vingrys, A.J. An evidence-based analysis of Australian optometrists' dry eye practices. Optometry and vision science : official publication of the American Academy of Optometry 2013, 90, 1385–1395. [Google Scholar] [CrossRef] [PubMed]
35. Downie, L.E.; Keller, P.R. The self-reported clinical practice behaviors of Australian optometrists as related to smoking, diet and nutritional supplementation. PloS one 2015, 10, e0124533. [Google Scholar] [CrossRef] [PubMed]
36. Biswas, S.; Logan, N.S.; Davies, L.N.; Sheppard, A.L.; Wolffsohn, J.S. Assessing the utility of ChatGPT as an artificial intelligence-based large language model for information to answer questions on myopia. Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists) 2023, 43, 1562–1570. [Google Scholar] [CrossRef]
37. Glasman, L.R.; Albarracín, D. Forming attitudes that predict future behavior: a meta-analysis of the attitude-behavior relation. Psychological bulletin 2006, 132, 778–822. [Google Scholar] [CrossRef]
38. Li, Q.; Guo, L.; Zhang, J.; Zhao, F.; Hu, Y.; Guo, Y.; Du, X.; Zhang, S.; Yang, X.; Lu, C. Effect of School-Based Family Health Education via Social Media on Children's Myopia and Parents' Awareness: A Randomized Clinical Trial. JAMA ophthalmology 2021, 139, 1165–1172. [Google Scholar] [CrossRef]
39. Xu, H.; Wen, L.M.; Rissel, C. Associations of parental influences with physical activity and screen time among young children: a systematic review. Journal of obesity 2015, 2015, 546925. [Google Scholar] [CrossRef]