A Mixed-Methods Investigation of Myopia Management Practices Among Eye Care Practitioners in China

A Mixed-Methods Investigation of Myopia Management Practices Among Eye Care Practitioners in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Mixed-Methods Investigation of Myopia Management Practices Among Eye Care Practitioners in China Jong Mei Khew, Mohd Zaki Awg Isa, Monica Jong, Fan Lu, Jun Jiang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8878774/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study explored the perceptions of myopia management practices among practitioners in diverse practice settings and geographical locations within China. It compared the perspectives of optometrists and ophthalmologists on myopia management and how the identified barriers can be addressed. Methods Mixed-method research combining qualitative and quantitative approaches was employed in this study. Stage 1 qualitative study involved face-to-face semi-structured interviews with 37 practitioners (27 optometrists and 10 ophthalmologists). Stage 2 involved a quantitative survey of 500 practitioners (401 optometrists, 99 ophthalmologists). Linear regression models were used to explore possible differences between the perceived barriers. Results The stage 1 analysis identified common barriers, including limited public awareness, treatment costs, poor compliance, and unpredictable clinical outcomes. Stage 2 validated these themes, emphasizing low public awareness, high treatment costs, lack of compliance, unpredictable outcomes, and excessive product availability. Significant geographical and practice-setting differences were evident, particularly in clinical guidance, commercialization, and instrument costs. Myopia control spectacles were most preferred and considered the most effective treatment option. Conclusions This study concluded that effective myopia management practice in China necessitates improvements in public education, addressing treatment costs, enhancing patient compliance, managing unpredictable clinical outcomes, promoting patient-centered approach, and expanding continuing education. Addressing these issues is crucial in delivering effective, accessible, and standardized myopia management care in different geographical locations and practice settings. Barriers China eye care practitioners mixed-method myopia management practice patterns Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Key Points 1. Although optometrists and ophthalmologists demonstrate substantial involvement and commitment to myopia management, significant obstacles persist, including limited public awareness, high intervention costs, suboptimal patient compliance, concerns regarding treatment predictability, and the over-commercialisation of therapeutic products. 2. Variability across practice settings and geographic regions highlights the absence of nationally standardised training frameworks and unified clinical guidelines, indicating the need for more cohesive regulatory and educational strategies, and a need for clearer clinical guidelines. 3. Strengthening clinical competencies through standardised training, enhancing public education initiatives, and prioritising patient-centred, evidence-based approaches are critical to optimising myopia management and reducing its overall burden. Introduction The incidence of myopia is increasing worldwide. A study by Holden et al. in 2016 predicted that by 2050, approximately 50% of the global population would be affected by myopia [1]. Studies have also shown significant regional variations in prevalence, with dramatic increases in East Asia, such as China and Singapore, where myopia rates could be as high as 80–90% in young adults [2–5]. This is of immediate concern from a public health perspective because myopia is associated with a range of serious eye conditions (i.e., glaucoma, cataracts, and retinal detachment), resulting in reduced quality of life due to vision loss or vision impairment [6–8]. With technological advancements, myopia management has become available to slow the progression of myopia. This can be achieved optically (orthokeratology, myopia control spectacle lenses, and soft contact lenses) or pharmaceutically (atropine). Although these options are available in most countries, 64% of patients were prescribed single-vision spectacles, and only 2.3% of all contact lens fits for children are used for myopia control [9–12]. This happened despite the global survey indicating high levels of concern among eye care practitioners about the rising prevalence of myopia [11]. The prevalence of myopia has increased in China over the past two decades. It was projected to reach 71.9% in 2050, much higher than the global projection of 50% [13]. Numerous epidemiological studies suggest that education and inadequate time spent outdoors were the major causes of the current myopia epidemic [14], and the total economic burden of myopia in China was estimated to be 173.6 billion CNY (26.3 billion US $ ), a substantial economic burden and a major concern in China [15]. While this is alarming, China is one of the few countries that has begun to address the myopia epidemic with a national-level strategy, implementing nationwide education reform, cost-reduction measures, and dissemination of information on myopia prevention and control [14]. In collaboration with various bodies, the Chinese government has developed recommendations through the Comprehensive Plan to Prevent Nearsightedness among Children and Teenagers (CPPNCT). However, it is noted that most interventions, including increased outdoor time and reduced near-work, primarily lower the incidence rather than the progression of myopia [16]. The implementation of myopia management practices in China, however, is complex, as it is a market with various categories of practitioners, different geographical disparities, and, recently, overwhelming myopia management treatment options. Eye care services in China are transforming rapidly. They were predominantly served and provided by public hospitals in the 1990s. This situation has changed rapidly with the emergence of more private hospitals and private optometry practices; however, there were still challenges faced in providing equitable and widespread care [17]. The optometry profession has also evolved rapidly in China. With the first integrated education in ophthalmology and optometry in the 1980s [18,19] optometry programs in China have developed models that include a 3-year diploma, a 4-year degree, and a 5-year medical optometry course [19]. This has produced a substantial number of optometry graduates in optical practices, hospitals, and institutions [18–20]. However, this number remains inadequate for the entire population. It has also been observed that some ophthalmologists in China have been actively involved in optometry services, particularly myopia management. Considering the heterogeneity in professional education, roles, and practice contexts among ophthalmologists and optometrists across regions, understanding variations in myopia management practices and perceptions, and strategies to overcome related barriers is crucial. Methods This research project received support from the Asia Optometric Congress and was approved by the Human Research Ethics Committee (HREC 4657) at the University of Canberra, Australia, and the Management and Science University Research Management Committee (MSU-RMC-02/FR01/01/L1/017) in Malaysia. This study employed a sequential exploratory mixed-methods design to comprehensively examine the perspectives of practitioners on myopia management in China. The qualitative phase explored barriers influencing practice, while insights gained informed the quantitative survey, which validated and quantified these themes across a larger, more diverse sample [21–23]. The initial phase involved a qualitative study with in-depth descriptive perceptions from the practitioners to decide on priority areas and areas to focus on. The interview questionnaire was developed with reference to previous studies [9–11], ensuring alignment with known barriers, while allowing for new insights. Thirty-seven eye care practitioners were voluntarily recruited from the contacts of the Asia Optometric Congress and Asia Optometric Management Academy. These practitioners were briefed on the objectives of the study, and the privacy clause was elucidated. Consent forms were signed before participation in the study. Subsequently, these practitioners participated in in-depth, semi-structured live interviews by Zoom (San Jose, USA) between March 2022 and April 2023. Each interview lasted up to 45 min and was recorded, verbatim transcribed using NVivo (Lumivero, Denver, USA), with demographic data (age, sex, qualifications, years of practice, type of practice, and geographical location) collected. The transcripts were corrected and checked by the participants before being coded. Data analysis was conducted using the Framework Method [24,25], in Quirkos (v2.5.2, Edinburgh, UK). Initial coding was deductive, deriving themes based on existing evidence, and subsequent coding was refined inductively, merged, and classified to form new themes and subthemes. The most prominent themes were identified based on the frequency of coding. Coding frequency was used as an indicator for salience, where a higher frequency indicates perceived importance. Coding was applied consistently across the dataset and categorized under relevant themes. The sample size was determined when thematic saturation was achieved, aligning with the principle of information power [26, 27]. The quantitative phase, the main component of this study, aimed to validate and quantify themes identified in the qualitative stage. Based on the coding frequency and prominence of qualitative themes, key perceptions were translated into a structured online questionnaire comprising closed-ended and multiple-choice questions. This survey covered several domains: demographic and professional education background, practice setting, perceived barriers, commonly used and perceived effective modalities, and support needed. The questionnaire was disseminated to optometrists and ophthalmologists across different geographical regions of China through multiple platforms, including institutions, professional associations, and local academic societies, from May to August 2024. Data was collected from 500 practitioners and analyzed using descriptive statistics, cross-tabulations, and triangulated with qualitative findings to enhance validity. Two linear regression models were used to conduct the matrix analysis between educational background (i.e., optometrists vs ophthalmologists), practice setting, and geographical location. The first model incorporated educational background and geographical location as independent variables, along with their interaction terms. Each barrier was analyzed individually using binary outcome coding (1 = barrier-reported; 0 = not reported). A separate model was used to examine the influence of practice setting using the same analytical framework. For categorical variables with more than two levels, such as geographical location and practice setting, significant effects were further explored through post hoc comparisons using Student’s t-tests. Results The demographic characteristics of the practitioners involved in the Stage 1 qualitative study are illustrated in Table 1. Table 1 Demographic of practitioners in the Stage 1 qualitative study Ophthalmologists (n = 10) Optometrists (n = 27) Total (n = 37) Certificate 0 4 4 Diploma 0 10 10 Degree (4-year) 0 13 13 Degree (5-year) 10 0 10 Male : Female 5 : 5 13 : 14 18 : 19 Age (mean ± SD) 44.8 ± 6.1 38.0 ± 6.5 40.3 ± 7.0 Years in practice 20 3 4 7 The principal themes identified through thematic analysis in Stage 1 are listed in Table 2. Table 2 Themes derived from thematic analysis in the Stage 1 qualitative study Financial barriers to offering myopia management Lack of a patient-centered care approach Unpredictable clinical outcome Limitations in the scope of practice in selected practice settings Lack of patient education and awareness of myopia management Lack of patient compliance Professional development support Legislation and regulation framework The demographics of 500 practitioners from different professional education backgrounds, geographical locations, and practice settings in Stage 2 quantitative study are illustrated in Table 3. Table 3 Demographic of practitioners in the Stage 2 quantitative study Ophthalmologists (n = 99) Optometrists (n = 401) Total (n = 500) Certificate 6 40 46 Diploma 20 227 247 Degree (4-year) 4 118 122 Degree (5-year) 28 7 35 Master 32 9 41 PhD 1 0 1 Doctorate 8 0 8 Male : Female 24 : 75 137 : 264 161 : 339 Age (mean ± SD) 42.0 ± 9.3 32.6 ± 9.3 34.5 ± 9.2 Years in practice 20 18 121 139 Geographical locations Capital city 33 124 157 (32%) Municipalities 14 108 122 (24%) Prefectural-level city 39 106 145 (29%) County-level city 13 63 76 (15%) Practice settings Public hospital 33 109 142 (29%) Private hospital 42 155 197 (39%) Private eye center 21 65 86 (17%) Private optometry center/optical practice 3 72 75 (15%) The availability of equipment for myopia management (i.e., corneal topography and ocular biometry) among participants in the Stage 2 study is shown in Table 4. Table 4 Availability of corneal topography or ocular biometry for myopia management Corneal Topography Ocular Biometry By practitioners Optometrists 83% 84% Ophthalmologists 86% 73% By geographical locations Capital city 89% 83% Municipalities 80% 86% Prefectural-level city 80% 79% County-level city 81% 81% By practice settings Public hospital 80% 87% Private hospital 90% 79% Private eye clinic 95% 87% Private optometry centre/optical practice 57% 76% Figures 1–5 depict the variations in perceived barriers or challenges among practitioners across different categories, practice settings, and geographical locations in the Stage 2 quantitative study. The preferred treatment options by ophthalmologists and optometrists are illustrated in Figure 6. Statistical Analysis Optometrists vs Ophthalmologists No statistically significant differences were observed between optometrists and ophthalmologists or among the four geographic locations concerning the following barriers: high treatment costs, high instrument costs, unpredictable clinical outcomes, lack of patient compliance, legislative restrictions, lack of professional ethics, and excessive product availability. In the absence of clinical guidance, there was no statistically significant difference in the proportion of optometrists (31%) and ophthalmologists (30%) identifying this as a barrier (F = 0.0; p = 0.85). The restriction on the use of cycloplegia was perceived differently by the two professional groups, with a statistically significant main effect observed (F = 8.0, p = 0.005). Only 4% of ophthalmologists identified this as a barrier, compared with 15% of optometrists. Geographical Locations Significant differences were noted among the four geographic regions (F = 3.3, p = 0.02). Post hoc analysis revealed that a higher proportion of practitioners in prefectural-level cities (47%) perceived this as a barrier compared to those in capital cities (23%), county-level cities (25%), and municipalities (26%). Concerns regarding the commercialization of the field varied significantly across geographical locations (F = 3.4, p = 0.02). Post-hoc analysis indicated that such concerns were more prevalent among practitioners in prefectural-level cities (57%) and municipalities (51%) than among those in capital cities (32%). A significant interaction was found for the barrier related to public awareness (F = 2.9, P = 0.04), indicating a more complex pattern. Overall, this concern was more prevalent in prefectural (86%) and county-level cities (73%) than in capital cities (59%) and municipalities (47%). However, this trend varied according to profession. In county-level cities, a greater proportion of ophthalmologists reported this barrier compared with optometrists (82% vs. 64%). In contrast, the reverse pattern was observed in municipalities where more optometrists than ophthalmologists perceived public awareness as a barrier (59% vs. 36%). Among optometrists, no statistically significant differences were identified in the perceived barriers related to public awareness, lack of clinical guidance, high treatment costs, unpredictable clinical outcomes, patient noncompliance, and commercialization of the field. Practice Settings Concerns regarding restrictions on the use of cycloplegia were significantly more prevalent among practitioners in private optometry centers and optical practices (40%) than among those in public hospitals (14%), private eye clinics (8%), and private hospitals (7%) (F = 17.4, p = 0.0001). Significant differences in concerns regarding the high cost of instrumentation were noted across the practice settings (F = 4.2, p = 0.006). This concern was more frequently reported by optometrists working in private optometry centers and optical practices (42%) than in the other three settings (19–28%). Similarly, concerns related to professional ethics were more prevalent among optometrists in private optometry centers and optical practices (18%) than in other work environments (5–8%) (F = 3.4, p = 0.02). Statistically significant differences were also found concerning legislative restrictions (F = 2.7, p = 0.04), with optometrists in private hospitals (7%) reporting fewer concerns than optometrists in other settings (17–18%). Concerns regarding the excessive number of products differed significantly across work settings (F = 4.2, p = 0.006). The proportion of participants expressing concern was higher in private hospitals (43%) and clinics (38%) than in public hospitals (22%). Preferred Effective Treatment and Preferred Treatment Options In the Stage 2 quantitative study, practitioners were also queried about their preferred treatment options, perceived effective treatment options, and preferred treatment options for patients. Myopia control spectacle lenses were perceived as the most effective treatment (78% of practitioners), most preferred by practitioners (85% of practitioners), and most preferred by patients (84% of practitioners). Figure 6 illustrates the preferred treatment options described by practitioners. On the need for a tool to monitor or track the real-time myopia management of patients, 436 out of 500 participants (87% of optometrists and 90% of ophthalmologists) expressed interest in this tool. Discussion In both Stage 1 and 2 studies, optometrists and ophthalmologists identified a lack of public awareness, high treatment costs, lack of patient compliance, and unpredictable clinical outcomes as the primary barriers, with myopia management perceived as overly commercialized. Lack of public awareness and high treatment costs were identified as major barriers to effective myopia management. Insufficient awareness was more evident in prefectural- and county-level cities than in capital cities and municipalities, likely reflecting stronger and more systematic public advocacy following national myopia policy in larger urban centers [28]. Statistical analyses showed that ophthalmologists in county-level cities expressed significantly greater concern about low public awareness than optometrists, whereas the opposite pattern was observed in municipalities. These findings underscore the need for strengthened public education campaigns, particularly in prefectural- and county-level cities. However, designing effective campaigns remains challenging, as higher educational attainment has been associated with greater myopia-related knowledge. Public education initiatives must therefore be inclusive of populations with diverse educational backgrounds [29]. Persistent misconceptions were also reported, including beliefs that spectacles are only required when vision deteriorates and limited awareness of the long-term consequences of myopia [29, 14]. Furthermore, the association between family income and knowledge scores highlights socioeconomic disparities in understanding. Targeted, context-sensitive public campaigns are essential to address educational and socioeconomic inequities in myopia awareness. Raising public awareness about myopia management is thus a gradual and ongoing process. Other than enhancing the communication between practitioner and patient, the involvement of various stakeholders, including government agencies such as education and health ministries, professional associations, and industry partners, is also warranted. 30 High treatment costs were a concern across all practice settings and geographical locations. The myopia management treatment process involved more than one-off product cost, as it also included consultation fees and ongoing products for the patients. This aligns with the previous study, where cost is a significant factor influencing the choice of myopia control intervention in China [14]. A cost-effective myopia management intervention is thus urgently needed to address the issue of treatment costs, either through a medical insurance scheme, government subsidies, or the provision of more affordable technologies and treatment options. Non-compliance was common across all practice settings, with no significant differences by setting or geographic location. Although not statistically significant, ophthalmologists perceived slightly better patient compliance than optometrists, potentially reflecting greater parental trust in medical practitioners. Despite this trend, non-compliance remains a major concern among clinicians. Limited awareness of the importance of regular follow-up eye examinations contributes to this issue, consistent with prior research [29]. Improving compliance requires targeted patient and parent education, clearer communication about the risks of complications associated with non-compliance and strengthened trust in optometrists providing myopia management interventions. Unpredictable clinical outcomes were a common challenge across regions and were potentially associated with insufficient clinical guidance. Although optometrists and ophthalmologists did not differ significantly in perceiving this barrier, marked geographical disparities were observed. Prefectural-level cities reported greater concern than capital cities, municipalities, or county-level cities, likely reflecting reduced access to continuing education, as most professional training and conferences are concentrated in major urban centers. The absence of clear clinical guidance in myopia management may undermine the confidence of practitioners, limit prognostic certainty, and hinder effective patient counseling regarding expected outcomes. These findings highlight the importance of clinical competence, encompassing comprehensive ocular assessment, effective practitioner–patient communication, and appropriate management of expectations. In addition, the implementation of systematic follow-up protocols is critical to support patient adherence, facilitate ongoing monitoring, and ultimately improve long-term clinical outcomes and patient satisfaction. Differences in concerns regarding cycloplegia restrictions were observed between ophthalmologists and optometrists. Only 4% of ophthalmologists identified this as a barrier, whereas 15% of the optometrists expressed similar concerns. Among optometrists, these concerns were more prevalent in private optometry centers and optical practices than in public hospitals, private eye clinics, and private hospitals. This discrepancy reflects regulatory limitations, as only qualified medical practitioners in hospital or private sector settings are authorized to administer cycloplegia. Currently, China lacks a unified legislative framework and standardized professional qualifications for optometrists, with clinical competency requirements enforced only in hospital settings [20, 31]. By contrast, several Asian regions, including the Philippines, Malaysia, Hong Kong, Singapore, and India, have established formal legislation for optometrists [32]. These findings underscore the necessity of regulatory reform in China to clarify practitioner roles and standardize optometric qualifications, thereby enhancing myopia management [33]. Optical retail market in China is crowded with myopia-management products, including around 200 myopia control spectacle lenses, most of which lack strong or without clinical evidence. The market is largely product-driven rather than patient-care-focused, leading to commercially oriented, price-driven competition. This environment complicates professional myopia management, as parents are often influenced by marketing claims rather than clinical guidance. Concerns about excessive commercialization were similar between optometrists and ophthalmologists but varied by region, with higher concern in prefectural-level cities and municipalities than in capital cities. This may reflect lower trust in practitioners and greater reliance on consumer marketing. Higher concern was also reported in private hospitals and eye clinics compared with public hospitals, possibly due to differences in public awareness and perceptions of myopia management across healthcare settings. Excessive commercialization has raised ethical concerns, particularly among optometrists in private practices. Aggressive marketing and unverified claims may prioritize sales over patient-centered care. These concerns are less prominent in capital cities, where stronger reputations and higher public trust in hospitals and eye centers help mitigate perceptions of commercialization. The cost of equipment and instrumentation is a significant barrier to effective myopia management. While perceptions of cost did not differ between optometrists and ophthalmologists across regions, they varied markedly by practice setting. Optometrists in private optometry centers and optical practices reported greater concern than those in hospital-based or private eye centers, possibly reflecting greater financial emphasis on marketing and product display rather than clinical services. Moreover, the availability of ocular biometry alone does not ensure effective care. Practitioners reported challenges in interpreting axial length data, monitoring growth trajectories, and modifying treatment strategies, highlighting critical gaps in clinical and data interpretation competencies that may undermine treatment outcomes. In this study, myopia control spectacle lenses emerged as the most preferred and perceived effective treatment option among practitioners and patients. This observation is consistent with previous studies [9, 34], where peripheral defocus spectacles were favored by practitioners. The preference may be attributed to several factors: orthokeratology is limited to patients aged over 8 years and with a refractive error of equal to or less than −6.00 D, requires access to facilities with a medical device license and qualified professionals, and is significantly more expensive than spectacle lenses. In contrast, myopia control spectacles are more affordable, widely accessible, and easily marketed because they are not classified as medical devices. The commercial availability of these products could explain their popularity. However, a more stringent product registration system may be necessary to ensure the availability of evidence-based options and to support patient-centered care. Soft contact lenses for myopia control were less favored, likely due to their higher costs, need for ongoing care, and regulatory limitations. Low-level red-light therapy was also noted; although evidence supports its efficacy, concerns remain regarding long-term retinal safety [35]. This treatment is currently classified as a Class 3 medical device by China’s National Medical Products Administration (NMPA) [36]. This study shows Chinese ophthalmologists adopt holistic myopia management, collaborating with optometrists. Interventions extend beyond atropine to orthokeratology, myopia-control spectacles, and contact lenses. High availability of corneal topographers (83%) and ocular biometers (82%) indicates strong use of technology to enhance clinical care and longitudinal monitoring of individual myopia progression. On the other hand, the high proportion of participants expressing the need for a monitoring tool to track the progress of myopia also points to the need for a device to monitor and improve patient compliance. A tracking tool or phone app would allow practitioners to gauge vision behaviors of patients, provide better insight into compliance, and facilitate clinical management more effectively. There are overwhelming myopia management options in China, with public awareness and treatment costs remaining major concerns, and this is further aggravated by the lack of patient compliance, commercially oriented practice, and unpredictable clinical outcomes [29, 30, 37, 38, 39]. This mixed-method study underscores the need for enhanced education and awareness of evidence-based myopia management among practitioners, particularly in the private retail sector. This emphasizes the importance of providing clinical training, patient-centered follow-up, education, and behavior modification, which are often overlooked in optical retail settings. Strengthening the expertise of practitioners in evidence-based practices and prioritizing patient care over commercial interests are crucial. Conclusion This research represents the first mixed-method study in China to examine the perspectives of practitioners on myopia management across practitioners in different practice settings and geographical regions within China. Optometrists and ophthalmologists have demonstrated significant activity and concern in myopia management, yet there are still common barriers to effective management, including insufficient public awareness, high treatment costs, and poor patient adherence. There were also concerns regarding unpredictable treatment outcomes and the over-commercialization of the marketing of products. This study emphasizes the need for nationwide standardized training, public education, and a patient-centered approach to myopia management, emphasizing clinical competencies and evidence-based practices to mitigate the myopia burden. Future study tracking the progress of the proposed strategies for practitioners in different geographical locations and practice settings in China might be warranted to evaluate the effectiveness of these mitigating measures. Declarations The authors declare no financial or nonfinancial competing interests with respect to the research, authorship, or publication of this article. Consent to Publish declaration The authors declare that the submitted work is original and has not been published elsewhere and adhere to the ethical principles of the journal. Ethics and Consent to Participate declarations This research study received support from the Asia Optometric Congress and was approved by the Human Research Ethics Committee (HREC 4657) at the University of Canberra, Australia, and the Management and Science University Research Management Committee (MSU-RMC-02/FR01/01/L1/017) in Kuala Lumpur, Malaysia. Author Contribution JM conducted the interview with the participants in Stage 1 study, and compiled the data collected in Stage 2 study, and is the main person writing up the manuscript, including the preparation of the tables and figures.MZ is the supervisor of Jong Mei for her Master research project, providing guidance on literature review, report writing and the scope of the project.MJ conceptualized the qualitative part of this research, supporting the draft of questionnaire used for the interview, and the methodology in thematic analysis.JJ and FL are key contributors in the quantitative part of this research, revising the questionnaires drafted by Jong Mei to suit the local condition and situation in China, and to support in disseminating the questionnaires to eye care practitioners in China.PM provided guidance on statistical analysis for the stage 2 study, and is a mentor reviewing the report writing for both the Stage 1 and Stage 2 studies.KO supported by bringing resources together to facilitate the smooth flow of this project, and supported Jong Mei in manuscript writing, formatting of the manuscript including the figures, and cross-checking the references. Acknowledgement We are very grateful to the participants in the study and thank them for participating in the study. We would also like to thank the Asia Optometric Congress, Asia Optometric Management Academy, China Optometric and Optical Association (COOA), Wenzhou Medical University, and all practitioners who participated in the Stage 1 and Stage 2 studies. References Holden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016 May 1;123(5):1036-42. Wu HM, Seet B, Yap EP, Saw SM, Lim TH, Chia KS. Does education explain ethnic differences in myopia prevalence? A population-based study of young adult males in Singapore. Optometry and Vision Science. 2001 Apr 1;78(4):234-9. Chen M, Wu A, Zhang L, Wang W, Chen X, Yu X, Wang K. 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The qualitative report. 2015 Apr 26;20(11):1772-89. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qualitative health research. 2016 Nov;26(13):1753-60. Implementation plan for the comprehensive prevention and control of myopia in children and adolescents (Chinese government). Available at: http://www.moe.gov.cn/srcsite/A17/ moe_943/s3285/201808/t20180830_346672.html; 2018. Accessed May 30, 2025. Qian Y, Lu P. Parents' or Guardians' knowledge, attitudes and practices in the prevention and Management of Childhood Myopia. Ophthalmology and Therapy. 2024 Dec;13(12):3095-109. Yang Y, Jiang J. A Survey of Myopia Correction Pattern of Children and Parent's Attitudes in China. Optometry and Vision Science. 2023 Jun 1;100(6):388-96. Liu LQ, Bi Y, Yang X, He QJ, Wan XH. Human Resource and Development Proposal of Optometry in China. Chinese Journal of Evidence-Based Medicine, 2015, 15(5): 497-499. Naidoo K, Arvind A, Abesamos-Dichoso C, Tan KO, Govender-Poonsamy P. Optometry in South-East Asia. In South-East Asia Eye Health: Systems, Practices, and Challenges 2021 Aug 19: 303-311. Singapore: Springer Singapore. Alam K, Chen J, Ho M, Gammoh Y, Jansen L, DeSouza N, Lim A, Fitzpatrick G, Neuville J. Advancing optometry education through global frameworks and international collaborations. Clinical and Experimental Optometry. 2025 Apr 3;108(3):233-9. Martínez-Pérez C, Villa-Collar C, Santodomingo-Rubido J, Wolffsohn JS. Strategies and attitudes on the management of myopia in clinical practice in Spain. Journal of Optometry. 2023 Jan 1;16(1):64-73. Youssef MA, Shehata AR, Adly AM, Ahmed MR, Abo-Bakr HF, Fawzy RM, Gouda AT. Efficacy of repeated low-level red light (RLRL) therapy on myopia outcomes in children: a systematic review and meta-analysis. BMC Ophthalmology. 2024 Feb 20;24(1):78. Wang YX, Wang N, Wong TY. Red Light Therapy for Myopia – Current Regulatory Changes in China. JAMA Ophthalmology. 2025 Mar 1;143(3):197-8. Zhan B, Huang Y, Wang B, Zhao J, Shang J, Chen Z, Zhou X. Chinese parents’ knowledge, attitude, and practice of myopia control: 2023 update. BMC Public Health. 2025 Feb 25;25(1):779. Huang Y, Chen Z, Wang B, Zhao J, Zhou X, Qu X, Wang X, Zhou X. Chinese parents’ perspective on myopia: a cross-sectional survey study. Ophthalmology and Therapy. 2023 Oct;12(5):2409-25. Public Health Ophthalmology Branch of Chinese Preventive Medicine Association. [Chinese expert consensus on comprehensive public health intervention for myopia prevention and control in children and adolescents]. Zhonghua Yi Xue Za Zhi. 2023 Oct 17;103(38):3002-9. Chinese. Additional Declarations No competing interests reported. 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Khew","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACxgYwJWFgAGQ/ALJ4+EjRwmwA0sJGrG0gLWwSIBZBLcztvYdf3aiwMDZn7zGr/JpjJ8PGwPzw0Q18Dus5l2adc0bCzLLnjNlt2W3JQIexGRvn4NMyI8fMOLdNwsbgRu6225LbmIFaeNikCWv5B9Ry/+22Yslt9URpMX6c2yBhZnCDdxvjx22HidAC9AJzzjEJY4Mz+Z+lGbcd52FjJuAXw/Ye4885NXWGG44fS/z4c1u1PT9788PHeLU0QKMDBJh5wCQe5SAgD1TyAe7KHwRUj4JRMApGwcgEAMhXRa2AVy7ZAAAAAElFTkSuQmCC","orcid":"","institution":"Management and Science University","correspondingAuthor":true,"prefix":"","firstName":"Jong","middleName":"Mei","lastName":"Khew","suffix":""},{"id":594042666,"identity":"da85b8df-1cbf-46dc-979b-5b2b199879c0","order_by":1,"name":"Mohd Zaki Awg Isa","email":"","orcid":"","institution":"Management and Science University","correspondingAuthor":false,"prefix":"","firstName":"Mohd","middleName":"Zaki Awg","lastName":"Isa","suffix":""},{"id":594042677,"identity":"6b8ff73a-9c34-4bd7-9539-3f33351a144c","order_by":2,"name":"Monica Jong","email":"","orcid":"","institution":"University of New South Wales","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"","lastName":"Jong","suffix":""},{"id":594042685,"identity":"2fee6d2b-8e34-4696-b7fd-bbd68c35804a","order_by":3,"name":"Fan Lu","email":"","orcid":"","institution":"Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Fan","middleName":"","lastName":"Lu","suffix":""},{"id":594042688,"identity":"06f7a829-ab23-431f-bae3-38c8d019e708","order_by":4,"name":"Jun Jiang","email":"","orcid":"","institution":"Wenzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Jiang","suffix":""},{"id":594042690,"identity":"608623a4-94ce-4ec1-9c47-7fb5861d8d93","order_by":5,"name":"Philip Morgan","email":"","orcid":"","institution":"University of 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Stage 2 quantitative study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/aca6d89dac9623d772f6addb.png"},{"id":103175903,"identity":"a90a2567-3a36-4571-885c-1311c1fa0d1a","added_by":"auto","created_at":"2026-02-22 16:28:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45183,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers or challenges faced by the practitioners in different practice settings (optometrists)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/80f2e63ac1dd58dfd5d0c39c.png"},{"id":103175907,"identity":"aa33afdf-a804-4f5f-88ca-8c76d2631047","added_by":"auto","created_at":"2026-02-22 16:28:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42466,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers or challenges faced by the practitioners in different practice settings (ophthalmologists)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/a6593eb0e62b246e3470197d.png"},{"id":103505455,"identity":"068cccd3-e085-4a12-8952-87df202d62c3","added_by":"auto","created_at":"2026-02-26 13:31:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":45049,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers or challenges faced by the practitioners in different geographical locations (optometrists)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/e98e6416cf1a3438ff24bd9d.png"},{"id":103175906,"identity":"231b6f8b-2990-4d48-88ea-87cd80a388fd","added_by":"auto","created_at":"2026-02-22 16:28:27","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":46575,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers or challenges faced by the practitioners in different geographical locations (ophthalmologists)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/43cf950edb2be7c2e6765e1b.png"},{"id":103175904,"identity":"cedee39b-fa98-4a52-ab68-b915eb802683","added_by":"auto","created_at":"2026-02-22 16:28:27","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":33103,"visible":true,"origin":"","legend":"\u003cp\u003ePreferred treatment options by ophthalmologists and optometrists\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/ee0eb844d53a3997623a243c.png"},{"id":105308806,"identity":"2333faf5-b6d5-4feb-bac1-c6aaaa830195","added_by":"auto","created_at":"2026-03-24 14:59:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":715487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8878774/v1/f534cc52-2b85-4253-85fe-dc9fb420c1cf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Mixed-Methods Investigation of Myopia Management Practices Among Eye Care Practitioners in China","fulltext":[{"header":"Key Points","content":"\u003cp\u003e1. Although optometrists and ophthalmologists demonstrate substantial involvement and commitment to myopia management, significant obstacles persist, including limited public awareness, high intervention costs, suboptimal patient compliance, concerns regarding treatment predictability, and the over-commercialisation of therapeutic products.\u003c/p\u003e\u003cp\u003e2. Variability across practice settings and geographic regions highlights the absence of nationally standardised training frameworks and unified clinical guidelines, indicating the need for more cohesive regulatory and educational strategies, and a need for clearer clinical guidelines.\u003c/p\u003e\u003cp\u003e3. Strengthening clinical competencies through standardised training, enhancing public education initiatives, and prioritising patient-centred, evidence-based approaches are critical to optimising myopia management and reducing its overall burden.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe incidence of myopia is increasing worldwide. A study by Holden et al. in 2016 predicted that by 2050, approximately 50% of the global population would be affected by myopia [1]. Studies have also shown significant regional variations in prevalence, with dramatic increases in East Asia, such as China and Singapore, where myopia rates could be as high as 80\u0026ndash;90% in young adults [2\u0026ndash;5]. This is of immediate concern from a public health perspective because myopia is associated with a range of serious eye conditions (i.e., glaucoma, cataracts, and retinal detachment), resulting in reduced quality of life due to vision loss or vision impairment [6\u0026ndash;8].\u003c/p\u003e \u003cp\u003eWith technological advancements, myopia management has become available to slow the progression of myopia. This can be achieved optically (orthokeratology, myopia control spectacle lenses, and soft contact lenses) or pharmaceutically (atropine). Although these options are available in most countries, 64% of patients were prescribed single-vision spectacles, and only 2.3% of all contact lens fits for children are used for myopia control [9\u0026ndash;12]. This happened despite the global survey indicating high levels of concern among eye care practitioners about the rising prevalence of myopia [11].\u003c/p\u003e \u003cp\u003eThe prevalence of myopia has increased in China over the past two decades. It was projected to reach 71.9% in 2050, much higher than the global projection of 50% [13]. Numerous epidemiological studies suggest that education and inadequate time spent outdoors were the major causes of the current myopia epidemic [14], and the total economic burden of myopia in China was estimated to be 173.6\u0026nbsp;billion CNY (26.3\u0026nbsp;billion US\u003cspan\u003e$\u003c/span\u003e), a substantial economic burden and a major concern in China [15].\u003c/p\u003e \u003cp\u003eWhile this is alarming, China is one of the few countries that has begun to address the myopia epidemic with a national-level strategy, implementing nationwide education reform, cost-reduction measures, and dissemination of information on myopia prevention and control [14].\u003c/p\u003e \u003cp\u003eIn collaboration with various bodies, the Chinese government has developed recommendations through the Comprehensive Plan to Prevent Nearsightedness among Children and Teenagers (CPPNCT). However, it is noted that most interventions, including increased outdoor time and reduced near-work, primarily lower the incidence rather than the progression of myopia [16].\u003c/p\u003e \u003cp\u003eThe implementation of myopia management practices in China, however, is complex, as it is a market with various categories of practitioners, different geographical disparities, and, recently, overwhelming myopia management treatment options. Eye care services in China are transforming rapidly. They were predominantly served and provided by public hospitals in the 1990s. This situation has changed rapidly with the emergence of more private hospitals and private optometry practices; however, there were still challenges faced in providing equitable and widespread care [17]. The optometry profession has also evolved rapidly in China. With the first integrated education in ophthalmology and optometry in the 1980s [18,19] optometry programs in China have developed models that include a 3-year diploma, a 4-year degree, and a 5-year medical optometry course [19]. This has produced a substantial number of optometry graduates in optical practices, hospitals, and institutions [18\u0026ndash;20]. However, this number remains inadequate for the entire population. It has also been observed that some ophthalmologists in China have been actively involved in optometry services, particularly myopia management.\u003c/p\u003e \u003cp\u003eConsidering the heterogeneity in professional education, roles, and practice contexts among ophthalmologists and optometrists across regions, understanding variations in myopia management practices and perceptions, and strategies to overcome related barriers is crucial.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This research project received support from the Asia Optometric Congress and was approved by the Human Research Ethics Committee (HREC 4657) at the University of Canberra, Australia, and the Management and Science University Research Management Committee (MSU-RMC-02/FR01/01/L1/017) in Malaysia.\u003c/p\u003e \u003cp\u003eThis study employed a sequential exploratory mixed-methods design to comprehensively examine the perspectives of practitioners on myopia management in China. The qualitative phase explored barriers influencing practice, while insights gained informed the quantitative survey, which validated and quantified these themes across a larger, more diverse sample [21\u0026ndash;23].\u003c/p\u003e \u003cp\u003eThe initial phase involved a qualitative study with in-depth descriptive perceptions from the practitioners to decide on priority areas and areas to focus on. The interview questionnaire was developed with reference to previous studies [9\u0026ndash;11], ensuring alignment with known barriers, while allowing for new insights.\u003c/p\u003e \u003cp\u003eThirty-seven eye care practitioners were voluntarily recruited from the contacts of the Asia Optometric Congress and Asia Optometric Management Academy. These practitioners were briefed on the objectives of the study, and the privacy clause was elucidated. Consent forms were signed before participation in the study. Subsequently, these practitioners participated in in-depth, semi-structured live interviews by Zoom (San Jose, USA) between March 2022 and April 2023. Each interview lasted up to 45 min and was recorded, verbatim transcribed using NVivo (Lumivero, Denver, USA), with demographic data (age, sex, qualifications, years of practice, type of practice, and geographical location) collected. The transcripts were corrected and checked by the participants before being coded.\u003c/p\u003e \u003cp\u003eData analysis was conducted using the Framework Method [24,25], in Quirkos (v2.5.2, Edinburgh, UK). Initial coding was deductive, deriving themes based on existing evidence, and subsequent coding was refined inductively, merged, and classified to form new themes and subthemes. The most prominent themes were identified based on the frequency of coding. Coding frequency was used as an indicator for salience, where a higher frequency indicates perceived importance. Coding was applied consistently across the dataset and categorized under relevant themes. The sample size was determined when thematic saturation was achieved, aligning with the principle of information power [26, 27].\u003c/p\u003e \u003cp\u003eThe quantitative phase, the main component of this study, aimed to validate and quantify themes identified in the qualitative stage. Based on the coding frequency and prominence of qualitative themes, key perceptions were translated into a structured online questionnaire comprising closed-ended and multiple-choice questions. This survey covered several domains: demographic and professional education background, practice setting, perceived barriers, commonly used and perceived effective modalities, and support needed. The questionnaire was disseminated to optometrists and ophthalmologists across different geographical regions of China through multiple platforms, including institutions, professional associations, and local academic societies, from May to August 2024.\u003c/p\u003e \u003cp\u003eData was collected from 500 practitioners and analyzed using descriptive statistics, cross-tabulations, and triangulated with qualitative findings to enhance validity.\u003c/p\u003e \u003cp\u003eTwo linear regression models were used to conduct the matrix analysis between educational background (i.e., optometrists vs ophthalmologists), practice setting, and geographical location. The first model incorporated educational background and geographical location as independent variables, along with their interaction terms. Each barrier was analyzed individually using binary outcome coding (1\u0026thinsp;=\u0026thinsp;barrier-reported; 0\u0026thinsp;=\u0026thinsp;not reported). A separate model was used to examine the influence of practice setting using the same analytical framework. For categorical variables with more than two levels, such as geographical location and practice setting, significant effects were further explored through post hoc comparisons using Student\u0026rsquo;s t-tests.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic characteristics of the practitioners involved in the Stage 1 qualitative study are illustrated in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 Demographic of practitioners in the Stage 1 qualitative study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003eOphthalmologists\u003c/p\u003e\n \u003cp\u003e(n = 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003eOptometrists\u003c/p\u003e\n \u003cp\u003e(n = 27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n = 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eCertificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e\u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eDegree (4-year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e\u0026nbsp;13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eDegree (5-year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e\u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eMale : Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e5 : 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e13 : 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e18 : 19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003eAge (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e44.8 \u0026plusmn; 6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e38.0 \u0026plusmn; 6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e40.3 \u0026plusmn; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100%;\"\u003e\n \u003cp\u003eYears in practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003e\u0026lt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003e5-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003e11-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003e16-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.6538%;\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.1538%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe principal themes identified through thematic analysis in Stage 1 are listed in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2 Themes derived from thematic analysis in the Stage 1 qualitative study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eFinancial barriers to offering myopia management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLack of a patient-centered care approach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eUnpredictable clinical outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLimitations in the scope of practice in selected practice settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLack of patient education and awareness of myopia management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLack of patient compliance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eProfessional development support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLegislation and regulation framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe demographics of 500 practitioners from different professional education backgrounds, geographical locations, and practice settings in Stage 2 quantitative study are illustrated in Table 3.\u003c/p\u003e\n\u003cp\u003eTable 3 Demographic of practitioners in the Stage 2 quantitative study\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003eOphthalmologists\u003c/p\u003e\n \u003cp\u003e(n = 99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003eOptometrists\u003c/p\u003e\n \u003cp\u003e(n = 401)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n = 500)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCertificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e247\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDegree (4-year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDegree (5-year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMaster\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePhD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDoctorate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMale : Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e24 : 75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e137 : 264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e161 : 339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAge (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e42.0 \u0026plusmn; 9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e32.6 \u0026plusmn; 9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e34.5 \u0026plusmn; 9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100%;\"\u003e\n \u003cp\u003eYears in practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026lt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e120\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e5-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e11-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e16-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100%;\"\u003e\n \u003cp\u003eGeographical locations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCapital city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e157 (32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMunicipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e122 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePrefectural-level city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e145 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCounty-level city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e76 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100%;\"\u003e\n \u003cp\u003ePractice settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePublic hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e142 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePrivate hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e197 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePrivate eye center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e86 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePrivate optometry center/optical practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21.9048%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.6667%;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.0952%;\"\u003e\n \u003cp\u003e75 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe availability of equipment for myopia management (i.e., corneal topography and ocular biometry) among participants in the Stage 2 study is shown in Table 4.\u003c/p\u003e\n\u003cp\u003eTable 4 Availability of corneal topography or ocular biometry for myopia management\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003eCorneal Topography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003eOcular Biometry\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eBy practitioners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eOptometrists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e84%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eOphthalmologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e86%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e73%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eBy geographical locations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eCapital city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eMunicipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e86%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003ePrefectural-level city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eCounty-level city\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003eBy practice settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003ePublic hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e87%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003ePrivate hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003ePrivate eye clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e87%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 50%;\"\u003e\n \u003cp\u003ePrivate optometry centre/optical practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e57%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.0385%;\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFigures 1\u0026ndash;5 depict the variations in perceived barriers or challenges among practitioners across different categories, practice settings, and geographical locations in the Stage 2 quantitative study.\u003c/p\u003e\n\u003cp\u003eThe preferred treatment options by ophthalmologists and optometrists are illustrated in Figure 6.\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eOptometrists vs Ophthalmologists\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were observed between optometrists and ophthalmologists or among the four geographic locations concerning the following barriers: high treatment costs, high instrument costs, unpredictable clinical outcomes, lack of patient compliance, legislative restrictions, lack of professional ethics, and excessive product availability. In the absence of clinical guidance, there was no statistically significant difference in the proportion of optometrists (31%) and ophthalmologists (30%) identifying this as a barrier (F = 0.0; p = 0.85). The restriction on the use of cycloplegia was perceived differently by the two professional groups, with a statistically significant main effect observed (F = 8.0, p = 0.005). Only 4% of ophthalmologists identified this as a barrier, compared with 15% of optometrists.\u003c/p\u003e\n\u003cp\u003eGeographical Locations\u003c/p\u003e\n\u003cp\u003eSignificant differences were noted among the four geographic regions (F = 3.3, p = 0.02). Post hoc analysis revealed that a higher proportion of practitioners in prefectural-level cities (47%) perceived this as a barrier compared to those in capital cities (23%), county-level cities (25%), and municipalities (26%). Concerns regarding the commercialization of the field varied significantly across geographical locations (F = 3.4, p = 0.02). Post-hoc analysis indicated that such concerns were more prevalent among practitioners in prefectural-level cities (57%) and municipalities (51%) than among those in capital cities (32%). A significant interaction was found for the barrier related to public awareness (F = 2.9, P = 0.04), indicating a more complex pattern. Overall, this concern was more prevalent in prefectural (86%) and county-level cities (73%) than in capital cities (59%) and municipalities (47%). However, this trend varied according to profession. In county-level cities, a greater proportion of ophthalmologists reported this barrier compared with optometrists (82% vs. 64%). In contrast, the reverse pattern was observed in municipalities where more optometrists than ophthalmologists perceived public awareness as a barrier (59% vs. 36%).\u003c/p\u003e\n\u003cp\u003eAmong optometrists, no statistically significant differences were identified in the perceived barriers related to public awareness, lack of clinical guidance, high treatment costs, unpredictable clinical outcomes, patient noncompliance, and commercialization of the field.\u003c/p\u003e\n\u003cp\u003ePractice Settings\u003c/p\u003e\n\u003cp\u003eConcerns regarding restrictions on the use of cycloplegia were significantly more prevalent among practitioners in private optometry centers and optical practices (40%) than among those in public hospitals (14%), private eye clinics (8%), and private hospitals (7%) (F = 17.4, p = 0.0001). Significant differences in concerns regarding the high cost of instrumentation were noted across the practice settings (F = 4.2, p = 0.006). This concern was more frequently reported by optometrists working in private optometry centers and optical practices (42%) than in the other three settings (19\u0026ndash;28%). Similarly, concerns related to professional ethics were more prevalent among optometrists in private optometry centers and optical practices (18%) than in other work environments (5\u0026ndash;8%) (F = 3.4, p = 0.02). Statistically significant differences were also found concerning legislative restrictions (F = 2.7, p = 0.04), with optometrists in private hospitals (7%) reporting fewer concerns than optometrists in other settings (17\u0026ndash;18%). Concerns regarding the excessive number of products differed significantly across work settings (F = 4.2, p = 0.006). The proportion of participants expressing concern was higher in private hospitals (43%) and clinics (38%) than in public hospitals (22%).\u003c/p\u003e\n\u003cp\u003ePreferred Effective Treatment and Preferred Treatment Options\u003c/p\u003e\n\u003cp\u003eIn the Stage 2 quantitative study, practitioners were also queried about their preferred treatment options, perceived effective treatment options, and preferred treatment options for patients. Myopia control spectacle lenses were perceived as the most effective treatment (78% of practitioners), most preferred by practitioners (85% of practitioners), and most preferred by patients (84% of practitioners).\u003c/p\u003e\n\u003cp\u003eFigure 6 illustrates the preferred treatment options described by practitioners.\u003c/p\u003e\n\u003cp\u003eOn the need for a tool to monitor or track the real-time myopia management of patients, 436 out of 500 participants (87% of optometrists and 90% of ophthalmologists) expressed interest in this tool.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn both Stage 1 and 2 studies, optometrists and ophthalmologists identified a lack of public awareness, high treatment costs, lack of patient compliance, and unpredictable clinical outcomes as the primary barriers, with myopia management perceived as overly commercialized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLack of public awareness and high treatment costs were identified as major barriers to effective myopia management. Insufficient awareness was more evident in prefectural- and county-level cities than in capital cities and municipalities, likely reflecting stronger and more systematic public advocacy following national myopia policy in larger urban centers [28]. Statistical analyses showed that ophthalmologists in county-level cities expressed significantly greater concern about low public awareness than optometrists, whereas the opposite pattern was observed in municipalities. These findings underscore the need for strengthened public education campaigns, particularly in prefectural- and county-level cities. However, designing effective campaigns remains challenging, as higher educational attainment has been associated with greater myopia-related knowledge. Public education initiatives must therefore be inclusive of populations with diverse educational backgrounds [29]. Persistent misconceptions were also reported, including beliefs that spectacles are only required when vision deteriorates and limited awareness of the long-term consequences of myopia [29, 14]. Furthermore, the association between family income and knowledge scores highlights socioeconomic disparities in understanding. Targeted, context-sensitive public campaigns are essential to address educational and socioeconomic inequities in myopia awareness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRaising public awareness about myopia management is thus a gradual and ongoing process. Other than enhancing the communication between practitioner and patient, the involvement of various stakeholders, including government agencies such as education and health ministries, professional associations, and industry partners, is also warranted.\u003csup\u003e30\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHigh treatment costs were a concern across all practice settings and geographical locations. The myopia management treatment process involved more than one-off product cost, as it also included consultation fees and ongoing products for the patients. This aligns with the previous study, where cost is a significant factor influencing the choice of myopia control intervention in China [14]. A cost-effective myopia management intervention is thus urgently needed to address the issue of treatment costs, either through a medical insurance scheme, government subsidies, or the provision of more affordable technologies and treatment options.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNon-compliance was common across all practice settings, with no significant differences by setting or geographic location. Although not statistically significant, ophthalmologists perceived slightly better patient compliance than optometrists, potentially reflecting greater parental trust in medical practitioners. Despite this trend, non-compliance remains a major concern among clinicians. Limited awareness of the importance of regular follow-up eye examinations contributes to this issue, consistent with prior research [29]. Improving compliance requires targeted patient and parent education, clearer communication about the risks of complications associated with non-compliance and strengthened trust in optometrists providing myopia management interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnpredictable clinical outcomes were a common challenge across regions and were potentially associated with insufficient clinical guidance. Although optometrists and ophthalmologists did not differ significantly in perceiving this barrier, marked geographical disparities were observed. Prefectural-level cities reported greater concern than capital cities, municipalities, or county-level cities, likely reflecting reduced access to continuing education, as most professional training and conferences are concentrated in major urban centers. The absence of clear clinical guidance in myopia management may undermine the confidence of practitioners, limit prognostic certainty, and hinder effective patient counseling regarding expected outcomes. These findings highlight the importance of clinical competence, encompassing comprehensive ocular assessment, effective practitioner\u0026ndash;patient communication, and appropriate management of expectations. In addition, the implementation of systematic follow-up protocols is critical to support patient adherence, facilitate ongoing monitoring, and ultimately improve long-term clinical outcomes and patient satisfaction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDifferences in concerns regarding cycloplegia restrictions were observed between ophthalmologists and optometrists. Only 4% of ophthalmologists identified this as a barrier, whereas 15% of the optometrists expressed similar concerns. Among optometrists, these concerns were more prevalent in private optometry centers and optical practices than in public hospitals, private eye clinics, and private hospitals. This discrepancy reflects regulatory limitations, as only qualified medical practitioners in hospital or private sector settings are authorized to administer cycloplegia. Currently, China lacks a unified legislative framework and standardized professional qualifications for optometrists, with clinical competency requirements enforced only in hospital settings [20, 31]. By contrast, several Asian regions, including the Philippines, Malaysia, Hong Kong, Singapore, and India, have established formal legislation for optometrists [32]. These findings underscore the necessity of regulatory reform in China to clarify practitioner roles and standardize optometric qualifications, thereby enhancing myopia management [33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOptical retail market in China is crowded with myopia-management products, including around 200 myopia control spectacle lenses, most of which lack strong or without clinical evidence. The market is largely product-driven rather than patient-care-focused, leading to commercially oriented, price-driven competition. This environment complicates professional myopia management, as parents are often influenced by marketing claims rather than clinical guidance. Concerns about excessive commercialization were similar between optometrists and ophthalmologists but varied by region, with higher concern in prefectural-level cities and municipalities than in capital cities. This may reflect lower trust in practitioners and greater reliance on consumer marketing. Higher concern was also reported in private hospitals and eye clinics compared with public hospitals, possibly due to differences in public awareness and perceptions of myopia management across healthcare settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExcessive commercialization has raised ethical concerns, particularly among optometrists in private practices. Aggressive marketing and unverified claims may prioritize sales over patient-centered care. These concerns are less prominent in capital cities, where stronger reputations and higher public trust in hospitals and eye centers help mitigate perceptions of commercialization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe cost of equipment and instrumentation is a significant barrier to effective myopia management. While perceptions of cost did not differ between optometrists and ophthalmologists across regions, they varied markedly by practice setting. Optometrists in private optometry centers and optical practices reported greater concern than those in hospital-based or private eye centers, possibly reflecting greater financial emphasis on marketing and product display rather than clinical services. Moreover, the availability of ocular biometry alone does not ensure effective care. Practitioners reported challenges in interpreting axial length data, monitoring growth trajectories, and modifying treatment strategies, highlighting critical gaps in clinical and data interpretation competencies that may undermine treatment outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, myopia control spectacle lenses emerged as the most preferred and perceived effective treatment option among practitioners and patients. This observation is consistent with previous studies [9, 34], where peripheral defocus spectacles were favored by practitioners. The preference may be attributed to several factors: orthokeratology is limited to patients aged over 8 years and with a refractive error of equal to or less than \u0026minus;6.00 D, requires access to facilities with a medical device license and qualified professionals, and is significantly more expensive than spectacle lenses. In contrast, myopia control spectacles are more affordable, widely accessible, and easily marketed because they are not classified as medical devices. The commercial availability of these products could explain their popularity. However, a more stringent product registration system may be necessary to ensure the availability of evidence-based options and to support patient-centered care. Soft contact lenses for myopia control were less favored, likely due to their higher costs, need for ongoing care, and regulatory limitations. Low-level red-light therapy was also noted; although evidence supports its efficacy, concerns remain regarding long-term retinal safety [35]. This treatment is currently classified as a Class 3 medical device by China\u0026rsquo;s National Medical Products Administration (NMPA) [36].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study shows Chinese ophthalmologists adopt holistic myopia management, collaborating with optometrists. Interventions extend beyond atropine to orthokeratology, myopia-control spectacles, and contact lenses. High availability of corneal topographers (83%) and ocular biometers (82%) indicates strong use of technology to enhance clinical care and longitudinal monitoring of individual myopia progression.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, the high proportion of participants expressing the need for a monitoring tool to track the progress of myopia also points to the need for a device to monitor and improve patient compliance. A tracking tool or phone app would allow practitioners to gauge vision behaviors of patients, provide better insight into compliance, and facilitate clinical management more effectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are overwhelming myopia management options in China, with public awareness and treatment costs remaining major concerns, and this is further aggravated by the lack of patient compliance, commercially oriented practice, and unpredictable clinical outcomes [29, 30, 37, 38, 39].\u003c/p\u003e\n\u003cp\u003eThis mixed-method study underscores the need for enhanced education and awareness of evidence-based myopia management among practitioners, particularly in the private retail sector. This emphasizes the importance of providing clinical training, patient-centered follow-up, education, and behavior modification, which are often overlooked in optical retail settings. Strengthening the expertise of practitioners in evidence-based practices and prioritizing patient care over commercial interests are crucial.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research represents the first mixed-method study in China to examine the perspectives of practitioners on myopia management across practitioners in different practice settings and geographical regions within China. Optometrists and ophthalmologists have demonstrated significant activity and concern in myopia management, yet there are still common barriers to effective management, including insufficient public awareness, high treatment costs, and poor patient adherence. There were also concerns regarding unpredictable treatment outcomes and the over-commercialization of the marketing of products. This study emphasizes the need for nationwide standardized training, public education, and a patient-centered approach to myopia management, emphasizing clinical competencies and evidence-based practices to mitigate the myopia burden.\u003c/p\u003e \u003cp\u003eFuture study tracking the progress of the proposed strategies for practitioners in different geographical locations and practice settings in China might be warranted to evaluate the effectiveness of these mitigating measures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no financial or nonfinancial competing interests with respect to the research, authorship, or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the submitted work is original and has not been published elsewhere and adhere to the ethical principles of the journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research study received support from the Asia Optometric Congress and was approved by the Human Research Ethics Committee (HREC 4657) at the University of Canberra, Australia, and the Management and Science University Research Management Committee (MSU-RMC-02/FR01/01/L1/017) in Kuala Lumpur, Malaysia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJM conducted the interview with the participants in Stage 1 study, and compiled the data collected in Stage 2 study, and is the main person writing up the manuscript, including the preparation of the tables and figures.MZ is the supervisor of Jong Mei for her Master research project, providing guidance on literature review, report writing and the scope of the project.MJ conceptualized the qualitative part of this research, supporting the draft of questionnaire used for the interview, and the methodology in thematic analysis.JJ and FL are key contributors in the quantitative part of this research, revising the questionnaires drafted by Jong Mei to suit the local condition and situation in China, and to support in disseminating the questionnaires to eye care practitioners in China.PM provided guidance on statistical analysis for the stage 2 study, and is a mentor reviewing the report writing for both the Stage 1 and Stage 2 studies.KO supported by bringing resources together to facilitate the smooth flow of this project, and supported Jong Mei in manuscript writing, formatting of the manuscript including the figures, and cross-checking the references.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are very grateful to the participants in the study and thank them for participating in the study. We would also like to thank the Asia Optometric Congress, Asia Optometric Management Academy, China Optometric and Optical Association (COOA), Wenzhou Medical University, and all practitioners who participated in the Stage 1 and Stage 2 studies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHolden BA, Fricke TR, Wilson DA, Jong M, Naidoo KS, Sankaridurg P, Wong TY, Naduvilath TJ, Resnikoff S. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. Ophthalmology. 2016 May 1;123(5):1036-42.\u003c/li\u003e\n \u003cli\u003eWu HM, Seet B, Yap EP, Saw SM, Lim TH, Chia KS. Does education explain ethnic differences in myopia prevalence? A population-based study of young adult males in Singapore. Optometry and Vision Science. 2001 Apr 1;78(4):234-9.\u003c/li\u003e\n \u003cli\u003eChen M, Wu A, Zhang L, Wang W, Chen X, Yu X, Wang K. 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Ophthalmology and Therapy. 2023 Oct;12(5):2409-25.\u003c/li\u003e\n \u003cli\u003ePublic Health Ophthalmology Branch of Chinese Preventive Medicine Association. [Chinese expert consensus on comprehensive public health intervention for myopia prevention and control in children and adolescents]. Zhonghua Yi Xue Za Zhi. 2023 Oct 17;103(38):3002-9. Chinese.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Barriers, China, eye care practitioners, mixed-method, myopia management, practice patterns","lastPublishedDoi":"10.21203/rs.3.rs-8878774/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8878774/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study explored the perceptions of myopia management practices among practitioners in diverse practice settings and geographical locations within China. It compared the perspectives of optometrists and ophthalmologists on myopia management and how the identified barriers can be addressed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMixed-method research combining qualitative and quantitative approaches was employed in this study. Stage 1 qualitative study involved face-to-face semi-structured interviews with 37 practitioners (27 optometrists and 10 ophthalmologists). Stage 2 involved a quantitative survey of 500 practitioners (401 optometrists, 99 ophthalmologists). Linear regression models were used to explore possible differences between the perceived barriers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe stage 1 analysis identified common barriers, including limited public awareness, treatment costs, poor compliance, and unpredictable clinical outcomes. Stage 2 validated these themes, emphasizing low public awareness, high treatment costs, lack of compliance, unpredictable outcomes, and excessive product availability. Significant geographical and practice-setting differences were evident, particularly in clinical guidance, commercialization, and instrument costs. Myopia control spectacles were most preferred and considered the most effective treatment option.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study concluded that effective myopia management practice in China necessitates improvements in public education, addressing treatment costs, enhancing patient compliance, managing unpredictable clinical outcomes, promoting patient-centered approach, and expanding continuing education. Addressing these issues is crucial in delivering effective, accessible, and standardized myopia management care in different geographical locations and practice settings.\u003c/p\u003e","manuscriptTitle":"A Mixed-Methods Investigation of Myopia Management Practices Among Eye Care Practitioners in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 16:28:23","doi":"10.21203/rs.3.rs-8878774/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aebe4e80-ae99-45f5-bff0-d0704d0fe952","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-24T14:58:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 16:28:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8878774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8878774","identity":"rs-8878774","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}