The Journal of School Nursing
2021, Vol. 37(2) 117-127
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1059840519850619
journals.sagepub.com/home/jsn
Valerie Holton, PhD, LCSW1, James E. Hinterlong, PhD1, Ching-Yao Tsai, MD, PhD2, Jen-Chen Tsai, RN, DNSc3, Jia Shan Wu, RN, MS3, and Yiing Mei Liou, RN, PhD1
The purpose of the study was to explore how fixed and modifiable family, activity, and school factors affect a student’s myopia risk and severity. We used national cross-sectional data from Taiwanese children in Grades 4–6. Bivariate and multivariate analyses, including logistic and ordinary least squares regression, examined factors related to children’s myopia status and severity. Age, parent myopia, and school district were associated with risk of myopia. One hour or more per day of near work (OR = 1.26) increased the odds of myopia. The same amount of time in outdoor activities (OR = 0.85) or moderate or vigorous physical activities (OR = 0.82) was associated with lower risk. Near work (β = 0.06), outdoor activity (β = –0.04), and outdoor recess (β = –0.03) predicted myopia severity. To promote healthy vision, nurses should advocate for and implement interventions that increase school children’s time outdoors and in physical activities and reduce their time on near work.
genetics, screening/risk identification, quantitative research, exercise, health/wellness, elementary
Myopia (nearsightedness) is a major public health concern and affects people across the world (Foster & Jiang, 2014; Modjtahedi, Ferris, Hunter, & Fong, 2018; Pan, Ramamurthy, & Saw, 2012). Nearly a quarter of the global population is estimated to have myopia, with 2.7% having high myopia (Holden et al., 2016). The prevalence of this vision condition is predicted to increase, with one estimate showing that by 2050, approximately 50% of the world population will have myopia and 10% will have high myopia (Holden et al., 2016). Time trends in prevalence mark myopia as a significant health concern in East Asia, as the region has experienced the highest rate of increase seen globally (Pan et al., 2012; Rudnicka et al., 2016). This is especially true in Taiwan where the prevalence among children aged 12 years is now 63.9%, one of the highest in the world (Taiwan Ministry of Health and Welfare, 2018).
Because it portends lifelong vision issues, strategies to prevent the onset and slow the progression of this disease are paramount. Myopia increases faster in children who develop it earlier (Donovan et al., 2012). People with myopia, and especially those with high myopia, are at increased risk to develop early cataracts, glaucoma, retinal detachment, vision loss, retinal degeneration, posterior kyphosis, macular degeneration, macular hemorrhage, and even blindness (Fricke et al., 2018; Modjtahedi et al., 2018; Zheng et al., 2013). The negative impacts are so significant that the World Health Organization (2013) has identified refractive errors and low vision (which includes myopia) as one of its priority eye diseases.
Myopia has a broad range of impacts on children, including their performance in school, participation in sports activities, and overall life satisfaction (Johnson, Majzoub, Lyons, Martirosyan, & Tattersall, 2016). Wong, Machin, Tan, Wong, and Saw (2009) showed that Singaporean adolescents with vision impairment, particularly undercorrected refractive errors, had statistically significant lower scores for total quality of life, psychosocial functioning, and school performance. A more recent study found that healthy adolescents with reduced visual acuity refractive errors (myopia, hyperopia, and astigmatism) reported lower social functioning and school performance compared with those with normal vision (Pan, Wu, Li, & Zhong, 2018). Alternately, having myopia may result in children spending less time in physical activities and more time in near work activities like reading and studying (Morgan & Rose, 2013), which may benefit school performance but exacerbate vision problems (Mutti, Mitchell, Moeschberger, Jones, & Zadnik, 2002).
Consequently, researchers have sought to identify factors associated with the onset and progression of myopia, particularly at younger ages. Behavioral and environmental factors likely play a crucial role. Studies have found significant effects for fixed factors such as age (Pan, Dirani, Cheng, Wong, & Saw, 2015; Rudnicka et al., 2016; Theophanous et al., 2018), gender (You et al., 2014), and parental myopia (Lim et al., 2014; Lyu et al., 2015; L. J. Wu et al., 2015). However, modifiable school-related factors are also key, such as physical activity (Modjtahedi et al., 2018), time spent outdoors (Barry, Wacogne, & Abbott, 2016; Jin et al., 2015; P. C. Wu et al., 2018), illumination levels (P. C. Wu et al., 2018; Zhou et al., 2017), and performance of near work (Lyu et al., 2015; L. J. Wu et al., 2015).
Numerous intervention strategies have been tried to reduce the effects of myopia and other vision issues in school children, such as encouraging families to follow up with vision care when problems are identified during screening (McClendon & Zeni, 2019). Once receiving care, myopia also can be addressed through glasses, contacts, and refractive eye surgery, or through pharmaceutical interventions such as orthokeratology, low-dose atropine, and specialized contact and spectacle lenses (Leo & Scientific Bureau of World Society of Paediatric Ophthalmology and Strabismus, 2017; Modjtahedi et al., 2018; Walline, 2016). However, these come with financial burden or potentially unpleasant side effects and address the severity rather than the incidence of myopia. Therefore, understanding and addressing the factors that affect the risk of childhood myopia and its severity could reduce mitigate early-life and lifelong consequences.
Given the high prevalence of myopia among pre-teen children in Taiwan, we focus the present study on children in Grades 4–6 (aged 9.5–12.6). Taiwan collects vision-related surveillance data on all schoolchildren. Combing these national data with information provided by student and their parents, this study examines the relationship between myopia and fixed, modifiable and school-related risk factors (see Figure 1). We aim to (1) estimate the prevalence rate of myopia among Taiwanese school children in Grades 4–6, (2) describe their time during and outside of school in outdoor activity, physical activity, and near work, and (3) estimate the relationship between their myopia status and severity with these factors, controlling for genetic and demographic factors.
We hypothesize that time spent in physical activity, frequency of recess during the school week, and being out of doors beyond the school day reduce the risk and severity of myopia among schoolchildren. Conversely, we propose that older children, those whose parents have myopia, and children performing greater amounts of near work each day will be at higher risk of having myopia and to have more severe refractive error.
The schoolchild growth study, funded by the Taiwan Ministry of Education, had the goal of examining children’s myopia, diet, physical activity, and behavior—factors that are instrumental to school success and overall health and functioning. The study combines primary data from a cross-sectional survey of children in fourth through sixth grades in schools across Taiwan (N = 6,200) and secondary data on myopia retrieved from the Ministry of Education’s National Health Check system. The Ministry of Education and school administrators gave permission to conduct the study in the selected schools. Student assent and parental consent were obtained. The study was approved by the Taipei Union Hospital Institutional Review Board (TCHIRB-1010603).
Given Taiwan’s diverse school settings and sizes, a multistage, stratified, systematic design was used to create a probably proportionate to size sample. Four of the nation’s 22 counties or administrative divisions, representing both densely populated urban and less populated rural areas, were selected for inclusion in the study: New Taipei City, Taichung City, Chiayi County, and Yilan County. The counties first were stratified by total number of schoolchildren and then at school, class, and student levels. Power analyses yielded a minimum sample size for each county of 1,067. Effective samples exceeded this threshold in each county, reaching 1,668 in New Taipei City, 1,900 in Taitung, 1,472 in Yilan, and 1,160 in Chiayi. We reviewed the data for inconsistencies across age, height, weight, and body mass index. Grade and age were converted to survival days and compared. Four cases contained poor quality data and were deleted, yielding an analytic sample of 6,196.
All selected students and their parents completed questionnaires. To ensure consistency and student comprehension, teachers were trained prior to leading their classes through the individual questions. Parents provided family information including their education and myopia status. Myopic students were identified as part of the routine vision screening and referral process used each semester for all students in Taiwan. School nurses conducted vision screening using Snellen’s E-visual chart. Students with a score of less than 0.9 in either eye were referred to a hospital- or community health clinic–based physician for an ophthalmologic assessment. Diagnoses and treatment plans are communicated back to the nurse, who then works with the school health center team to develop a case management plan for the child to promote follow-up.
Myopia was diagnosed using the spherical equivalent (SE) of the refractive error. SE was calculated as the spherical value of refractive error plus one half of the cylindrical value. The Taiwan Ministry of Health and Welfare defines myopia as an SE of ≤ –0.5 diopters in either eye, the standard recommended by the World Health Organization (2015). Myopia status and severity, along with other health measures, were retrieved from the National Health Check System and linked to questionnaire responses by each student’s unique identifier.
Demographic measures included the child’s sex and age in months. Parents’ highest year of education was coded as less than high school, high school, and university or graduate school. The myopia status of each parent was combined to create a three-level item: no, one, or both parents with myopia.
Students were prompted to recall their time use over the past 7 days using the International Physical Activity Questionnaire with activity cards adapted for use with Taiwanese children (Chien, Liou, & Chang, 2011; Liou et al., 2012; Liou, Liou, & Chang, 2010). Response choices were categorical and summed across their midpoints to produce a scale measure of minutes of activity per week. Outdoor activity represented the time spent in outside activities and walking to and from school. Physical activity was time in both vigorous and moderate physical activities. Near work was time spent watching TV, playing on their phone or computer, reading outside of school, taking music lessons, and studying at home or in an after-school tutoring class. Each activity scale was collapsed into a dichotomous measure showing whether the student reported 420 min (an average of at least 1 hr per day) of that activity type during the last week.
Myopia status was a dichotomous item that indicates whether the student was diagnosed with myopia (SE of ≤ –0.5 diopters in either eye). Myopia severity was a 6- point ordinal measure of refractive error in the worse eye: less than 0.50 diopters, 0.50–1.00 diopters, 1.01–2.00 diopters, 2.01–3.00 diopters, 3.01–4.00 diopters, and more than 4.00 diopters.
We conducted x2, t test, and univariate logistic regression to examine the bivariate relationships between myopia status and the covariates, and one-way analysis of variance to identify group means differences in myopia severity. We estimated a stepwise binary logistic regression model of myopia status on the covariates retaining those with a p value of less than .20. Similarly, we ran an OLS regression of myopia severity to test its association with the study variables. All p values were two sided with a set at .05; odds ratios (OR) are reported at 95% confidence intervals (CI). SPSS 24.0 was used for the analyses.
Tables 1 and 2 present the demographic characteristics of the sample compared across myopia status and as associated with myopia severity. Table 3 shows the univariate binary regressions of these on myopia status. Slightly less than half of students were found to have myopia (44.37%). Rates differed by grade at 25.34%, 39.66%, and 41.56% among fourth, fifth, and sixth graders, respectively. The unadjusted prevalence rate was higher among girls (45.9% vs. 43.0% [OR = 1.13, 95% CI [1.0, 1.25]; p = .02]) and increased significantly with age (OR = 1.02, 95% CI [1.01, 1.02], p < .001) as did myopia severity (p <.001). Comparisons by grade level showed those in sixth grade had the greatest odds of myopia (OR = 1.48, OR = 1.27 vs. fourth and fifth grades; both p <.001) and greater severity (mean = 1.27, F = 49.826, p <.001). No sex difference in severity was observed. New Taipei City, which has the highest degree of urbanization among the four districts, had the highest proportion of students with myopia (46.8%, X2 = 9.44, p = .024). Rates varied by mother’s but not father’s education, with those whose mothers had less than a high school education less likely to have myopia (F = 6.93, p = .001). Severity exhibited an inverse relationship with parent education. Post hoc analyses showed students with parents who did not complete high school had significantly lower levels of refractive error than those who finished high school or college (mother’s education F = 6.93, p = .001; father’s education, F = 4.81, p = .008). Parental myopia was strongly associated with both prevalence and severity. Those with at least one myopic parent had 5.66 times greater odds of having myopia (95% CI [4.94, 6.49], p <.001), and those with two parents with myopia had 6.58 times the odds compared with those without a myopic parent (95% CI [5.76, 7.50], p <.001). Severity also was greater with the presence of one or two myopic parents (mean 0.53 vs. 1.51 and 1.68, F = 476.73, p <.001).
At a bivariate level, there were significant relationships among students’ time in activities and their myopia status and severity. Moderate and vigorous physical activity averaging at least 1 hr per day throughout the week reduced the odds of myopia by 20% (CI [0.72, 0.90], p <.001), as did the same amount of outdoor activity time to a greater degree (OR = 0.87, CI [0.78, 0.98], p = .25). Only physical activity varied with severity (mean difference = 0.09, p = .039). Students who reported spending at least 1 hr per day on near work were more likely to have myopia (OR = 1.15, CI [1.02, 1.31], p = .027) and higher levels of severity (mean difference = 0.13, p = .004). Greater frequency of outdoor recess during the school day significantly but slightly reduced the odds of being myopic (OR = 0.97, CI [0.94, 0.99], p = .007) while also being weakly related to severity (r = –.05, p = .001).
In the controlled condition, age remained a significant predictor of myopia status; each month of additional age increased the odds of myopia (OR = 1.02, CI [1.02, 1.03], p <.001). Students in school districts other than New Taipei City were also less likely to be diagnosed with myopia. Parental education no longer related to myopia status in the controlled condition; however, parents’ myopia status was the strongest factor in predicting a student’s odds of having myopia. Having one parent with myopia increased the odds by 2.1 times (CI [1.78, 2.48], p <.001), and having two parents with myopia increased them to nearly 2.4 times (CI [2.04, 2.86], p <.001).
We used ordinary least squares regression to estimate the relationship of these individual, family, and school factors with myopia severity (see Table 4). Based on the bivariate findings, the two measures of parental education were recoded as more or less than high school. As with myopia status, age retained a significant positive relationship with myopia severity (β = 0.14, p <.001). Parental myopia was also strongly associated with greater severity for students with one (β = 0.21, p <.001) and two myopic parents (β = 0.14, p <.001). Spending at least 1 hr per day on average in outdoor activity was related to lesser severity (β = –0.14, p = .006), as was more frequent outdoor recess during school (β = –2.00, p = .046). Near work of 1 hr or more each day was associated with a more severe myopia (β = 0.06, p <.001).
In our population-based study of 6,196 children in Grades 4–6 in Taiwan, the prevalence of myopia (≤ –0.50 diopters in the worse eye) was 44.37%. Along with age, the location of the child’s school, parents’ myopia status, and time spent in moderate or vigorous physical activity, near work, and outdoor activity beyond the school day predicted their odds of having myopia. Outdoor time during and outside of school, near work, age and parental myopia, but not students’ level of physical activity, was significantly related to their myopia severity.
Consistent with the literature, we found that both prevalence and severity of myopia increase with age (Foster & Jiang, 2014; Modjtahedi et al., 2018). A review of five nationwide prevalence surveys carried out in Taiwan between 1983 and 2000 documented that myopic prevalence increased with age: 20% of 7-year-olds, 61% of 12-year-olds, and 84% of 15 year olds (Lin, Shih, Hsiao, & Chen, 2004). Our findings reinforce how important early prevention efforts are to stemming the increasing prevalence of myopia. School-based and nurse-led vision screening and referral is a key frontline opportunity to identify and intervene to help children with or at risk of vision issues like myopia.
We observed unadjusted sex differences in both myopia prevalence and severity, which became nonsignificant in the presence of other covariates such as age, school location, and parental myopia. Consistent with previous studies, we showed that parental myopia was strongly associated with its prevalence and severity in children (Hsu et al., 2016; Pan et al., 2012). Children with two myopic parents had the highest risk of myopia, followed by those with one myopic parent, and severity also was greater with the presence of one or two myopic parents. The greatest difference in odds and effect was between those with and without myopic parents after controlling for behavioral and environmental factors, suggesting a robust genetic component to myopia prevalence and progression. Given school nurses status as a trusted source of health-related information, they are in an excellent position to help ensure that children and families are aware of this risk, and that schools are prepared to monitor and appropriately respond to vision problems. We next review these specific, modifiable risk factors and then offer recommendations for nurses extending from the findings.
Our study adds to previous research suggesting that outdoor time reduces the risk of myopia and slows its progression (French, Ashby, Morgan, & Rose, 2013; Modjtahedi et al., 2018; Morgan, 2016; Pan et al., 2012; Sherwin et al., 2012; Walline, 2016; Xiong et al., 2017). We found that an hour per day of outdoor activity reduced the odds of being myopic by 0.13. This is consistent with the effect shown in a systematic review, which estimated every additional hour per day of outdoor time reduced the risk of myopia in children by 2% as well as slowed its progression (Sherwin et al., 2012).
We found mixed evidence for the importance of frequency of outdoor recess during the school day. Greater frequency predicted lesser severity but not lower odds of having myopia. However, it is not clear whether this was due to breaks in near work, time outside, or physical activity. Our study measured recess as daily participation, not time spent outdoors, which we have shown to be significant. There is reason to suggest that recess time also is important. For example, P. C. Wu, Tsai, Wu, Yang, and Kuo (2013) found that outdoor recess 3 times a day, for a total of 80 min a day, over a year was correlated with a decreased incidence of myopia. While additional research can explore this relationship further, our study points to a likely beneficial effect on eye health from more frequent outdoor time during the school day for those already diagnosed with myopia (nearly half of students in this study). It adds to the other known health benefits for children generally of being outdoors, such as reduction of childhood obesity, increased socialization, and production of Vitamin D (World Health Organization, 2015).
Our results also add to the mixed body of research on the connection between physical activity and myopia. Like another recent study (Modjtahedi et al., 2018), we found that engaging in moderate or strenuous physical activity for at least 60 min per day was associated with lower risk of myopia. We did not find evidence of a protective effect with severity when other factors, such as parental myopia and near work, were jointly considered. We cannot address the nature of the relationship between physical activity and myopia. Some studies suggest it is largely driven by time spent outdoors (French et al., 2013; Rose et al., 2008). This possibility is further supported by research differentiating the role of indoor versus outdoor sports in myopia development and progression (Dirani et al., 2009).
Prior research has not consistently observed an association between near work activities and myopia (Dirani et al., 2009; Lu et al., 2009; Saw et al., 2001). This study showed a deleterious relationship with both myopia status and severity, lending support to a growing body of evidence pointing in this direction (Hsu et al., 2016; Pan et al., 2012; Tan et al., 2000). We found near work exceeding an hour per day predicted a 0.15 increase in odds of myopia and moderate increase in severity. This is in line with the systematic review of myopia among children aged 6–18 that determined the odds of myopia increased by 2% for every one diopter hour more of near work per week (Huang, Chang, & Wu, 2015). Given the findings in this study, future research may wish to test whether ensuring children have near work breaks in conjunction with outdoor time results in greater benefits to children’s eye health. It should also explore the mechanisms that underlie this association.
The current study relied on student recall regarding their time use, which is subject to recall bias. Teacher guidance on the questionnaire and the use of activity illustrations to capture time use may have mitigated this risk to some degree. We also were not able to assess whether the specific forms of outdoor activity, their intensity, or relative amounts and timing were important to myopia prevalence or severity. Further study should explore these possibilities. In addition, limited by the study’s cross-sectional design and general aims, we could not determine the mechanisms by which outdoor time, recess, and physical activity were linked with myopia. Some have argued the effect may be due to the ability to see farther or exposure to sunlight when outdoors (Charman, 2011; Guggenheim et al., 2013; Pan et al., 2012) or the interruption of near work performed in the classroom (Hsu et al., 2016). This is an area in need of further study.
Evidence from this study reveals a mixture of fixed and modifiable factors related to myopia among Taiwanese schoolchildren. Some, like age, underscore how schools must use early diagnosis, referral, and intervention strategies to reduce the impact of myopia on the child’s health, school performance, and functioning. Others, such as student behavior or school-directed activities, require education and monitoring. School nurses are well-positioned to advocate, design, and implement these efforts (Chu, Huang, Barnhardt, & Chen, 2014; McClendon & Zeni, 2019).
School nurses already have broad and time-intensive responsibilities in school-based surveillance and health promotion (Lineberry & Ickes, 2015), so building and maintaining partnerships with teaching and administrative school personnel, vision professionals, and families is critical. First, they should actively encourage these groups to embrace healthy vision as a priority with goals that incorporate changes in behavior and environmental conditions at school and at home (Nottingham Chaplin et al., 2019).
School nurses can raise awareness of and help to address vision issues like myopia by ensuring that every child participates in vision screening, and that those found to have vision problems receive further assessment and follow-up (Jan, Timbo, & Congdon, 2017; Rodriguez, Srivastava, & Landau, 2018). For example, in Taiwan, schools follow a common protocol that is facilitated by a national, universal health-care system. After a child’s myopia is diagnosed and entered in the National Health Check system, the school nurse collaborates with the school’s health center team to create and implement a case management plan designed to mitigate disease progression. These plans generally involve going outdoors during recess time, maintaining a distance of more than 30 cm during near work, and limiting computer and phone screen time.
Parents and guardians are critical to the success of such efforts but may not readily accept or understand the importance of vision to a child’s development and performance. Taking steps throughout the process to build and nurture trust is therefore key. To illustrate, false-positive screening results lead to referral, which can be worrying and disruptive, so ensuring screening is conducted appropriately and thus limit such errors as much as possible is crucial to engaging skeptical parents (Alvi et al., 2015). More indepth formal training in vision screening and problems can help in this regard (Strawhacker, Gustafson, Kinne, & Little, 2003).
Nurses also must talk and work with parents to understand and overcome the barriers to follow-up that arise due to lack of time, money, knowledge and perceptions about vision or health care, or other constraints (Diao et al., 2016; McClendon & Zeni, 2019). Since a single approach to communicating with families is unlikely to be uniformly effective in any school community, school nurses should tailor their efforts to the needs of targeted groups. For example, phone calls or take home information may work well in some situations, whereas in others it may be helpful to enlist parents early on in home-based screenings (Rodriguez, Srivastava, & Landau, 2018) or hands-on learning activities (McClendon & Zeni, 2019).
In similar fashion, school nurses should encourage teachers to see themselves as key contributors and partners in promoting healthy vision. They should prompt these colleagues to actively monitor children’s use of assistive technologies and properly designed spectacles during school time, which is critical to follow-up adherence and also likely to benefit their academic performance (Chu et al., 2014; Johnson et al., 2016; Kodjebacheva, Maliski, Yu, Oelrich, & Coleman, 2013).
As an overarching strategy, school nurses also should ask parents and school personnel to find a way to increase children’s outdoor time. This is consistent with recent intervention studies showing outdoor activity reduced myopic progression in school children (P. C. Wu, Tsai, Wu, Yang, & Kuo, 2013). Indeed, 40 additional minutes of outdoor activity per day has been found to decrease the 3-year incidence rate (Barry et al., 2016). Even so, children in our study engaged in just under 2 hr of outdoor activity each day, so behavioral change of this size would require structured intervention and education.
School and families have many competing priorities and issues vying for attention and resources. Rather than a single strategy to achieve behavioral targets, such as instituting a significant increase in outdoor recess frequency or length, our findings generally suggest multiple independent changes may work in concert to achieve beneficial levels of outdoor time. For example, schools could simultaneously encourage parents to have their children walk to and from school when feasible, teachers to plan outdoor learning activities, consider modestly increasing recess frequency, and expanding opportunities for students to engage in moderate-to-vigorous sports and other physical activities during and after school. Nevertheless, we anticipate such proposals will likely give rise to concerns about time constraints during the school day as noted earlier in ongoing research into school-based strategies (He et al., 2015; Pan & Liu, 2016; Zhou et al., 2017). School nurses should frame myopia prevention as part of larger, health promotion initiatives given the recommended activities benefit more than vision, which may increase support. Also, school nurses should make parents aware of the importance of increasing children’s outdoor activity to extend these efforts to out-of-school time as well. Again, the aim is for school nurses to serve as a resource and partner to parents and others looking to help children.
Finally, school nurses should raise awareness among teachers and parents of the possible link between near work and myopia. Apart from parental myopia and age—two factors beyond the child’s control—near work in our study exhibits the most consistent, exacerbating relationship with myopia. This is a particular concern for Taiwanese children due to the high and rising pressure placed upon them to succeed academically, which results in long hours each day of intense reading and written work. While there was significant variability, the children in our study reported an average of 16.9 (SD = 15.4) hr of near work per week outside of school time.
School nurses should emphasize with teachers, parents, and children the importance of moderating or breaking up the amount of near work—both for school and leisure (i.e., screen time). Growing awareness and concern about computer time and digital eyestrain may make this information more salient and likely to be heeded (Sheppard & Wolffsohn, 2018). In conjunction with our earlier findings, nurses could encourage strategies that both reduce near work and concurrently increase in outdoor and physical activity. As our findings suggest, this may amplify the benefits to children’s vision.
This study finds that fixed factors may play a stronger role than modifiable factors in determining the risk of myopia or its level of severity, yet modifiable factors appear to help to prevent the onset and reduce the severity of myopia. We agree with Naidoo and colleagues (2018) that the implications to children and society of not correcting myopia far outweigh the costs of doing so. Schools provide an excellent setting for identifying and intervening with children affected by this condition, and nurses should be at the fore of future efforts aimed at addressing this public health priority.
The Ministry of Education and school administrators gave permission to conduct the study in the selected schools. Student assent and parental consent were obtained. The study was approved by the Taipei Union Hospital Institutional Review Board (TCHIRB-1010603).
The authors would like to thank Chu Hsiang-Ying and Wang Shao-Yi for their assistance.
Ching-Yao Tsai, Valerie Holton, James E. Hinterlong, and Yiing Mei Liou were involved in the conception of the manuscript. Ching-Yao Tsai, Valerie Holton, James E. Hinterlong, Jia Shan Wu, and Yiing Mei Liou contributed to the analysis and data interpretation and Ching-Yao Tsai, Valerie Holton, James E. Hinterlong, Jia Shan Wu, and Yiing Mei Liou were involved in drafting the manuscript. All authors gave final approval on the text and agree to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Schoolchild Growth Study was funded by the Ministry of Education, Taiwan.
Yiing Mei Liou, RN, PhD https://orcid.org/0000-0001-7150-9347
Alvi, R. A., Justason, L., Liotta, C., Martinez-Helfman, S., Dennis, K., Croker, S. P., ... Levin, A. V. (2015). The Eagles Eye Mobile: Assessing its ability to deliver eye care in a high-risk community. Journal of Pediatric Ophthalmology and Strabismus, 52, 98–105.
Barry, R. J., Wacogne, I., & Abbott, J. (2016). Spending an additional 40 min outdoors each day reduces the incidence of myopia among primary school children in China. Archive of Disease in Childhood: Education and Practice Edition, 101, 219.
Charman, W. N. (2011). Myopia, posture and the visual environment. Ophthalmic and Physiological Optics, 31, 494–501.
Chien, L. Y., Liou, Y. M., & Chang, P. (2011). Low defaecation frequency in Taiwanese adolescents: Association with dietary intake, physical activity and sedentary behaviour. Journal of Paediatrics and Child Health, 47, 381–386.
Chu, R., Huang, K., Barnhardt, C., & Chen, A. (2014). The effect of an on-site vision examination on adherence to vision screening recommendations. Journal of School Nursing, 31, 84–90.
Diao, W., Patel, J., Snitzer, M., Pond, M., Rabinowitz, M. P., Ceron, G., ... Levin, A. V. (2016). The effectiveness of a mobile clinic in improving follow-up eye care for at-risk children. Journal of Pediatric Ophthalmology and Strabismus, 53, 344–348.
Dirani, M., Tong, L., Gazzard, G., Zhang, X., Chia, A., Young, T. L., ... Saw, S. M. (2009). Outdoor activity and myopia in Singapore teenage children. British Journal of Ophthalmology, 93, 997–1000.
Donovan, L., Sankaridurg, P., Ho, A., Naduvilath, T., Smith, E. L, 3rd, & Holden, B. A. (2012). Myopia progression rates in urban children wearing single-vision spectacles. Optometry and Vision Science, 89, 27–32.
Foster, P. J., & Jiang, Y. (2014). Epidemiology of myopia. Eye (Lond), 28, 202–208.
French, A. N., Ashby, R. S., Morgan, I. G., & Rose, K. A. (2013). Time outdoors and the prevention of myopia. Experimental Eye Research, 114, 58–68.
Fricke, T. R., Jong, M., Naidoo, K. S., Sankaridurg, P., Naduvilath, T. J., Ho, S. M., ... Resnikoff, S. (2018). Global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: Systematic review, meta-analysis and modeling. British Journal of Ophthalmology, 102, 855–862.
Guggenheim, J. A., McMahon, G., Northstone, K., Mandel, Y., Kaiserman, I., Stone, R. A., ... Williams, C. (2013). Birth order and myopia. Ophthalmic Epidemiology, 20, 375–384.
He, M., Xiang, F., Zeng, Y., Mai, J., Chen, Q., Zhang, J., ... Morgan, I. G. (2015). Effect of time spent outdoors at school on the development of myopia among children in China: A randomized clinical trial. Journal of the American Medical Association, 314, 1142–1148.
Holden, B. A., Fricke, T. R., Wilson, D. A., Jong, M., Naidoo, K. S., Sankaridurg, P., ... Resnikoff, S. (2016). Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology, 123, 1036–1042.
Hsu, C. C., Huang, N., Lin, P. Y., Tsai, D. C., Tsai, C. Y., Woung, L. C., & Liu, C. J. (2016). Prevalence and risk factors for myopia in second-grade primary school children in Taipei: A population-based study. Journal of the Chinese Medical Association, 79, 625–632.
Huang, H.-M., Chang, D. S.-T., & Wu, P.-C. (2015). The association between near work activities and myopia in children—A systematic review and meta-analysis. PLoS One, 10, e0140419.
Jan, C. L., Timbo, C. S., & Congdon, N. (2017). Children’s myopia: Prevention and the role of school programmes. Community Eye Health, 30, 37–38.
Jin, J. X., Hua, W. J., Jiang, X., Wu, X. Y., Yang, J. W., Gao, G. P., ... Tao, F. B. (2015). Effect of outdoor activity on myopia onset and progression in school-aged children in northeast China: The Sujiatun Eye Care Study. BMC Ophthalmology, 15, 73.
Johnson, C., Majzoub, K., Lyons, S., Martirosyan, K., & Tattersall, P. (2016). Eyes That Thrive in School: A program to support vision treatment plans at school. Journal of School Health, 86, 391–396.
Kodjebacheva, G., Maliski, S., Yu, F., Oelrich, F., & Coleman, A. L. (2013). Decreasing uncorrected refractive error in the classroom through a multifactorial pilot intervention. Journal of School Nursing, 30, 24–30.
Leo, S. W., & Scientific Bureau of World Society of Paediatric Ophthalmology and Strabismus. (2017). Current approaches to myopia control. Current Opinion in Ophthalmology, 28, 267–275.
Lim, L. T., Gong, Y., Ah-Kee, E. Y., Xiao, G., Zhang, X., & Yu, S. (2014). Impact of parental history of myopia on the development of myopia in mainland China school-aged children. Ophthalmology and Eye Disease, 6, 31–35.
Lin, L. L., Shih, Y. F., Hsiao, C. K., & Chen, C. J. (2004). Prevalence of myopia in Taiwanese schoolchildren: 1983 to 2000. Annals of the Academy of Medicine, Singapore, 33, 27–33.
Lineberry, M. J., & Ickes, M. J. (2015). The role and impact of nurses in American elementary schools: A systematic review of the research. Journal of School Nursing, 31, 22–33.
Liou, Y. M., Hsu, Y. W., Ho, J. F., Lin, C. H., Hsu, W. Y., & Liou, T. H. (2012). Prevalence and correlates of self-induced vomiting as weight-control strategy among adolescents in Taiwan. Journal of Clinical Nursing, 21, 11–20.
Liou, Y. M., Liou, T. H., & Chang, L. C. (2010). Obesity among adolescents: Sedentary leisure time and sleeping as determinants. Journal of Advanced Nursing, 66, 1246–1256.
Lu, B., Congdon, N., Liu, X., Choi, K., Lam, D. S., Zhang, M., & ... Song, Y. (2009). Associations between near work, outdoor activity, and myopia among adolescent students in rural China: The Xichang Pediatric Refractive Error Study Report No. 2. Archives of Ophthalmology, 127, 769–775.
Lyu, Y., Zhang, H., Gong, Y., Wang, D., Chen, T., Guo, X., ... Kang, M. (2015). Prevalence of and factors associated with myopia in primary school students in the Chaoyang District of Beijing, China. Japanese Journal of Ophthalmology, 59, 421–429.
McClendon, S., & Zeni, M. B. (2019). Evaluation of vision referral program with school-aged children and their parents/guardians. Journal of School Nursing. doi: 10.1177/1059840518821427.
Modjtahedi, B. S., Ferris, F. L, 3rd, Hunter, D. G., & Fong, D. S. (2018). Public health burden and potential interventions for myopia. Ophthalmology, 125, 628–630.
Morgan, I. G. (2016). What public policies should be developed to deal with the epidemic of myopia? Optometry and Vision Science, 93, 1058–1060.
Morgan, I. G., & Rose, K. A. (2013). Myopia and international educational performance. Ophthalmic and Physiological Optics, 33, 329–338.
Mutti, D. O., Mitchell, G. L., Moeschberger, M. L., Jones, L. A., & Zadnik, K. (2002). Parental myopia, near work, school achievement, and children’s refractive error. Investigative Ophthalmology & Visual Science, 43, 3633–3640.
Naidoo, K. S., Fricke, T. R., Frick, K. D., Jong, M., Naduvilath, T. J., Resnikoff, S., & Sankaridurg, P. (2018). Potential lost productivity resulting from the global burden of myopia: Systematic review, meta-analysis and modelling. Ophthalmology, 126, 338–346.
Nottingham Chaplin, P. K., Baldonado, K., Bergren, M. D., Lyons, S. A., Murphy, M. K., & Bradford, G. E. (2019). 12 components of a strong vision health system of care: Components 1 and 2- family education and comprehensive communication/approval process. NASN School Nurse. doi: 10.1177/1942602X198 29842.
Pan, C. W., Dirani, M., Cheng, C. Y., Wong, T. Y., & Saw, S. M. (2015). The age-specific prevalence of myopia in Asia: A metaanalysis. Optometry and Vision Science, 92, 258–266.
Pan, C. W., & Liu, H. (2016). School-based myopia prevention effort. Journal of the American Medical Association, 315, 819.
Pan, C. W., Ramamurthy, D., & Saw, S. M. (2012). Worldwide prevalence and risk factors for myopia. Ophthalmic and Physiological Optics, 32, 3–16.
Pan, C. W., Wu, R. K., Li, J., & Zhong, H. (2018). Low prevalence of myopia among school children in rural China. BMC Ophthalmology, 18, 140.
Rodriguez, E., Srivastava, A., & Landau, M. (2018). Increasing screening follow-up for vulnerable children: A partnership with school nurses. International Journal of Environmental Research and Public Health, 15, 1572–1581.
Rose, K. A., Morgan, I. G., Ip, J., Kifley, A., Huynh, S., Smith, W., & Mitchell, P. (2008). Outdoor activity reduces the prevalence of myopia in children. Ophthalmology, 115, 1279–1285.
Rudnicka, A. R., Kapetanakis, V. V., Wathern, A. K., Logan, N. S., Gilmartin, B., Whincup, P. H., ... Owen, C. G. (2016). Global variations and time trends in the prevalence of childhood myopia, a systematic review and quantitative meta-analysis: Implications for aetiology and early prevention. British Journal of Ophthalmology, 100, 882–890.
Saw, S. M., Chan, B., Seenyen, L., Yap, M., Tan, D., & Chew, S. J. (2001). Myopia in Singapore kindergarten children. Optometry, 72, 286–291.
Sheppard, A. L., & Wolffsohn, J. S. (2018). Digital eye strain: Prevalence, measurement and amelioration. BMJ Open Ophthalmology, 3, e000146.
Sherwin, J. C., Reacher, M. H., Keogh, R. H., Khawaja, A. P., Mackey, D. A., & Foster, P. J. (2012). The association between time spent outdoors and myopia in children and adolescents: A systematic review and meta-analysis. Ophthalmology, 119, 2141–2151.
Strawhacker, M. T., Gustafson, J. K., Kinne, M. J., & Little, D. (2003). Vision screening practices in central Iowa: A follow-up evaluation. Journal of School Nursing, 19, 111–118.
Taiwan Ministry of Health and Welfare. (2018). Myopia annual report. Retrieved from https://depart.moe.edu.tw/ED4500/cp.aspx?n¼1B58E0B736635285&s¼D04C74553DB60CAD
Tan, G. J., Ng, Y. P., Lim, Y. C., Ong, P. Y., Snodgrass, A., & Saw, S. M. (2000). Cross-sectional study of near-work and myopia in kindergarten children in Singapore. Annals of the Academy of Medicine, Singapore, 29, 740–744.
Theophanous, C., Modjtahedi, B. S., Batech, M., Marlin, D. S., Luong, T. Q., & Fong, D. S. (2018). Myopia prevalence and risk factors in children. Clinical ophthalmology (Auckland, N.Z.), 12, 1581–1587.
Walline, J. J. (2016). Myopia control: A review. Eye Contact Lens, 42, 3–8.
Wong, H. B., Machin, D., Tan, S. B., Wong, T. Y., & Saw, S. M. (2009). Visual impairment and its impact on health-related quality of life in adolescents. American Journal of Ophthalmology, 147, 505–511 e501.
World Health Organization. (2013). Universal eye health: A global action plan 2014–2019. Geneva.
World Health Organization. (2015). The impact of myopia and high myopia. Retrieved from http://www.who.int/blindness/causes/MyopiaReportforWeb.pdf
Wu, L.J., You, Q.S., Duan, J.L., Luo, Y.X., Liu, L.J., Li, X., ... Guo, X. H. (2015). Prevalence and associated factors of myopia in high-school students in Beijing. PLoS One, 10, e0120764.
Wu, P. C., Chen, C. T., Lin, K. K., Sun, C. C., Kuo, C. N., Huang, H. M., ... Yang, Y. H. (2018). Myopia prevention and outdoor light intensity in a school-based cluster randomized trial. Ophthalmology, 125, 1239–1250.
Wu, P. C., Tsai, C. L., Wu, H. L., Yang, Y. H., & Kuo, H. K. (2013). Outdoor activity during class recess reduces myopia onset and progression in school children. Ophthalmology, 120, 1080–1085.
Xiong, S., Sankaridurg, P., Naduvilath, T., Zang, J., Zou, H., Zhu, J., ... Xu, X. (2017). Time spent in outdoor activities in relation to myopia prevention and control: A meta-analysis and systematic review. Acta Ophthalmologica, 95, 551–566.
You, Q. S., Wu, L. J., Duan, J. L., Luo, Y. X., Liu, L. J., Li, X., ... Guo, X. H. (2014). Prevalence of myopia in school children in greater Beijing: The Beijing childhood eye study. Acta Ophthalmologica, 92, e398–e406.
Zheng, Y. F., Pan, C. W., Chay, J., Wong, T. Y., Finkelstein, E., & Saw, S. M. (2013). The economic cost of myopia in adults aged over 40 years in Singapore. Investigative Ophthalmology & Visual Science, 54, 7532–7537.
Zhou, Z., Chen, T., Wang, M., Jin, L., Zhao, Y., Chen, S., ... Congdon, N. (2017). Pilot study of a novel classroom designed to prevent myopia by increasing children’s exposure to outdoor light. PLoS One, 12, e0181772.
Valerie Holton, PhD, LCSW, is an assistant professor at the Institute of Community Health Care, School of Nursing, National Yang-Ming University, Taipei, Taiwan.
James E. Hinterlong, PhD, is a professor and visiting scholar, Institute of Community Health Care, School of Nursing, National Yang-Ming University, Taipei, Taiwan.
Ching-Yao Tsai, MD, PhD, is a deputy superintendent in the Taipei City Hospital and an assistant professor at the Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
Jen-Chen Tsai, RN, DNSc, is a professor at the School of Nursing, National Yang-Ming University, Taipei, Taiwan.
Jia Shan Wu, RN, MS, is a doctoral candidate at the School of Nursing, National Yang-Ming University, Taipei, Taiwan.
Yiing Mei Liou, RN, PhD, is a dean and professor at the Institute of Community Health Care, School of Nursing, National Yang-Ming University, School Health Research Center, National Yang-Ming University, Taipei, Taiwan.
1 Institute of Community Health Care, School of Nursing, National Yang-Ming University, Taipei
2 Institute of Public Health, National Yang-Ming University, Taipei
3 School of Nursing, National Yang-Ming University, Taipei
Corresponding Author:Yiing Mei Liou, RN, PhD, Institute of Community Health Care, School Health Research Center, School of Nursing, National Yang-Ming University, No. 155, Sec. 2, Li-Nong St., Taipei 11221.Email: ymliou@ym.edu.tw
