Knowledge, Attitudes, and Practices (KAP) Survey Study in Chinese Children’s and Adolescents’ Guardians on the Three Methods of Myopia Intervention

Knowledge, Attitudes, and Practices (KAP) Survey Study in Chinese Children’s and Adolescents’ Guardians on the Three Methods of Myopia Intervention | 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 Knowledge, Attitudes, and Practices (KAP) Survey Study in Chinese Children’s and Adolescents’ Guardians on the Three Methods of Myopia Intervention Yifan Li, Jiarui Song, Chenyu Zhang, Cindy Zhao, Rui Guo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8881110/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective To investigate the knowledge, attitudes, and practices (KAP) of the guardians of children and adolescents aged 6–12 years in eight cities across China regarding three myopia control interventions (0.01% atropine eye drops, spectacles, and contact lenses) and analyze the influencing factors. Methods A KAP questionnaire on basic knowledge, attitudes, and practices regarding myopia was developed through a literature review and expert consultation. An online survey was administered to guardians of children aged 6–12 years across eight selected cities, and the data were analyzed using SPSS 27.0. Results Among the 1,509 valid questionnaires collected, 48.1% were from the guardians of myopic children; this group exhibited a significant difference from the guardians of non-myopic children on basic myopia questions (U = 301754.0, W = 564929.0, P < 0.05), with the former (40 (35, 47)) scoring slightly higher than the latter (39 (34, 46)). Knowledge of spectacles and contact lenses was linked to positive attitudes and compliant behaviors ( P < 0.001), with favorable attitudes predicting higher compliance ( P < 0.05). Regarding 0.01% atropine eye drops, knowledge was positively correlated with attitude (r = 0.475, P 0.05). Common pitfalls in the usage of 0.01% atropine eye drops included discontinuing medication and transferring it to others. KAP scores were influenced by the demographics of the guardians, with higher education, urban residence, and an age range of 35–49 years being associated with higher KAP scores. Significant intercity disparities were observed, with Beijing demonstrating the highest adherence to atropine and Changsha exhibiting the poorest spectacle use among the surveyed cities. While clinical consultations remained the predominant information channel, the high valuation of digital media underscores their potential as a scalable complementary strategy to bridge existing knowledge gaps. Conclusion The use of spectacles and contact lenses exhibited robust KAP alignment, whereas the use of 0.01% atropine manifested a critical knowledge-behavior disconnect characterized by prevalent self-discontinuation. Higher education, urban residence, and middle age predicted better KAP scores, whereas significant intercity disparities reflected a "prevalence–awareness paradox" favoring cities whose medical centers were early adopters of 0.01% atropine for myopia control. These findings underscore the necessity of stratified educational interventions—particularly digital health education delivered by ophthalmologists and medical students—to bridge the information gaps and ensure equitable myopia guidance across diverse populations. Trial Registration Not applicable. Guardians of children/adolescents 0.01% atropine eye drops Spectacles Contact lenses Knowledge attitudes and practices (KAP) survey Influencing factors Figures Figure 1 1. Background Myopia is a highly prevalent ocular disease worldwide ( 1 ) and has a far-reaching impact on the physical health, mental health, and future of children and adolescents. According to the 2019 Clinical Management Guidelines Report by the IMI, approximately 1.45 billion people worldwide have been diagnosed with myopia, with an incidence rate of 22% ( 2 ). Myopia is particularly prominent in China. A myopia-specific survey conducted in 2022 by the Chinese National Health Commission revealed that the overall prevalence of myopia among Chinese children and adolescents is 51.9% and that the age of myopia onset is trending downward ( 3 ). By 2025, the population of myopic patients under the age of 20 in China is expected to reach 187 million ( 3 ). Studies have also shown that an earlier age of onset of myopia is related to a greater incidence of high myopia in the future. Children and adolescents aged 6 to 12 years have an especially rapid progression of myopia and are therefore in need of effective interventions ( 4 ). Under the WHO (2021) 2030 global eye health targets that mandate raising effective refractive-error coverage (eREC) to secure myopia correction for children and adolescents ( 5 ), China’s prevention and control program still underperforms because of knowledge gaps among guardians ( 6 ). The most common interventions for myopia are spectacles, contact lenses, and drugs ( 3 ). Guardians’ knowledge, attitudes, and compliance critically shape the uptake and efficacy of myopia interventions for children ( 7 – 9 ). The knowledge, attitudes, and practices (KAP) model is an important theoretical framework for studying health-related behaviors. By examining the continuous process of respondents from knowledge acquisition to attitude formation and then to behavioral change, this model provides a scientific basis for formulating targeted public health intervention measures ( 10 ). However, region-based and KAP-related studies on the role of guardians in all three common myopia intervention measures in China are lacking. This study aims to conduct a KAP survey in eight cities across the country to understand their residents’ current knowledge, attitudes, and actual behaviors regarding three myopia intervention methods and to analyze the key factors affecting KAP to provide epidemiological evidence for intervention strategies. 2. Materials and methods 2.1 Study design This prospective, cross-sectional study comprised a pilot survey (November 21–December 15, 2024) and a formal survey (January 19–February 2, 2025). Given that 0.01% atropine received NMPA approval in 2023, we strategically restricted sampling to Tier 1 and major Tier 2 cities to ensure clinical accessibility. Stratified sampling based on geographic region, economic tier (GDP per capita and total GDP), and myopia prevalence (high (> 35%) vs. low (≤ 35%) was used to select eight cities, namely, Beijing, Xiamen, Chengdu, Xi'an, Changsha, Nanjing, Taiyuan, and Dalian, providing comprehensive coverage of North, East, Southwestern, Northwestern, Central, and Northeast China. The online questionnaires targeted the guardians of children aged 6–12 years. The study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of Capital Medical University (No. 2021SY074), with informed consent obtained from all participants. 2.2 Questionnaire This questionnaire (the formal version of the extended questionnaire is provided as Additional file 2) was designed by the research team on the basis of guidelines and one white paper applied in China ( 2 , 11 ). The instrument was optimized after preliminary study and consultation with ophthalmology experts to ensure that its psychometric properties met the KAP model requirements and provided comprehensive content coverage. The questionnaire consists of two sections. The first section includes basic myopia-related questions that all respondents need to answer, including 10 questions related to demography (such as gender, age, residence, medical insurance status, etc.) and 10 questions related to basic myopia knowledge. The second section comprises three intervention-specific KAP sub-questionnaires: 23 items on 0.01% atropine eye drops, 15 on spectacles, and 23 on contact lenses. Guardians completed the sub-questionnaire(s) corresponding to their selected myopia control method(s); completion of multiple sub-questionnaires was allowed for those employing more than one intervention. Each question in the KAP section is scored on a 5-point Likert scale. Although the anchors are specific to each dimension (e.g., “strongly disagree” to “strongly agree" for attitudes; “never” to “always” for practices), the scoring was consistently oriented so that a higher score always indicated a more desirable outcome (i.e., greater knowledge, a more favorable attitude, or better adherence to recommended practice). Among the questions, numbers 27–33, 48 and 51 are reversed in polarity to reduce response bias. 2.3 Survey Procedure and Quality Control After stratified sampling, the online questionnaire was distributed through WeChat chatgroups and other social media platforms in the target cities, and QR codes were distributed around primary schools. After informed consent was obtained from the respondents, the questionnaire was filled out anonymously. Upon completing the questionnaire, the respondents verified the information for accuracy and submitted it immediately. To ensure the quality of the online survey, measures such as restricting duplicate IP addresses, setting all questions as mandatory, and controlling the time taken to complete the questionnaire were implemented to reduce duplicate or invalid responses. After collection, all the questionnaires underwent completeness checks, logical reviews, and error corrections. 2.4 Statistical Analyses Sample size determination was based on the recommendation of 5–10 participants per item for factor analysis, with a target ratio of 3–5:1 for the total questionnaire. Accounting for anticipated invalid response rates of 10–20%, the minimum target sample size was set at 1,200 participants. Stratified sampling targets were established as follows: 69–115 participants for both the 0.01% atropine eye drop and contact lens sub-questionnaires and 45–75 participants for the spectacle sub-questionnaire, reflecting the differing item counts and expected prevalence of each intervention. All analyses were conducted using SPSS Statistics version 27.0 (IBM Corp, Armonk, NY, USA). The reverse-coded items were recoded to align the scoring direction prior to analysis using the standard transformation for a symmetric Likert scale: Recoded Score = (Upper Limit + Lower Limit) - Original Score. For our 5-point scale (1 to 5), this can be simplified as follows: Recoded Score = 6 - Original Score. The normality of continuous variables (e.g., KAP scores) was assessed using the Shapiro‒Wilk test and visual inspection of Q‒Q plots. As distributions significantly deviated from normality ( P < 0.05), continuous variables are presented as the median and interquartile range [M (IQR)], and categorical variables are presented as frequencies (percentages). Group comparisons were performed using Mann‒Whitney U tests (for two groups) or Kruskal‒Wallis H tests with Dunn‒Bonferroni post hoc corrections (for ≥ 3 groups), as appropriate. Bivariate associations were examined using Spearman's rank correlation coefficients (ρ), with magnitudes interpreted as 0.10–0.29 (small), 0.30–0.49 (medium), and ≥ 0.50 (large). Multiple linear regression was employed to identify independent factors associated with KAP scores. To address potential violations of parametric assumptions (including nonnormality) and to ensure robust inference, a nonparametric bootstrap procedure was applied. The 95% confidence intervals (CIs) and p values for the regression coefficients were derived using the percentile method based on 1,000 bootstrap resamples. Two-sided tests were used throughout, with statistical significance set at α = 0.05. Effect sizes are reported alongside p values to facilitate clinical interpretation of findings. 3. Results 3.1 Demographic Information Among the 1,516 questionnaires collected, 1,509 were valid, resulting in an effective rate of 99.5%. See Table 1 for details. The guardians of myopic children accounted for 48.1% of respondents (726 individuals). Among all the guardians of myopic children, the preferred intervention method was spectacles, with 596 individuals (82.1%), followed by 0.01% atropine eye drops, with 115 individuals (15.8%), and contact lenses, with 109 individuals (15.0%). Table 1 Demographic Information of the Respondents Variable Name Option Frequency (n) Percentage (%) Gender Male 540 35.8 Female 969 64.2 Age 19–34 years 258 17.1 35–49 years 1169 77.5 50–64 years 72 4.8 65 years and above 10 0.7 Education Level Postgraduate 339 22.5 Bachelor's 652 43.2 Associate's 239 15.8 Vocational high school or high school 175 11.6 Junior high school 91 6.0 Elementary school 13 0.9 Place of Residence Urban residents 1371 90.9 Rural residents 138 9.1 Medical Insurance Status Social basic medical insurance 1295 85.8 Commercial insurance 31 2.1 Self-funded medical care 44 2.9 Public-funded medical care 108 7.2 Other 31 2.1 Occupation Factory worker 251 16.6 Healthcare institution 68 4.5 Freelancer 169 11.2 Company employee 374 24.8 Teacher 177 11.7 Student 34 2.3 Unemployed 56 3.7 Government official 97 6.4 Business manager 120 8.0 Other 163 10.8 Employment Status Employed 1310 86.8 Retired 27 1.8 Unemployed 172 11.4 3.2 Association Between Children’s Myopic Status and Guardians' Responses to Basic Questions A statistically significant difference was observed in the total score on basic questions between guardians of myopic and nonmyopic children (U = 301754.0, W = 564929.0, P < 0.05), with guardians of myopic children 40 (35, 47) scoring slightly better than guardians of nonmyopic children 39 (34, 46). Specifically, both groups strongly agreed with our statements regarding the risk factors for myopia, although the Mann‑Whitney U test indicated statistically significant differences on question 5 ("Reading and writing in environments with excessively dark or bright lighting is a risk factor for myopia") (U = 267341, Z = ‑2.360, P < 0.05) and question 6 ("Eye exercises can help delay the onset and progression of myopia") (U = 267491.5, Z = ‑2.265, P < 0.05). Significant differences emerged regarding knowledge of myopia control interventions. Guardians of myopic children reported significantly higher knowledge scores for atropine eye drops (U = 308956.0; P < 0.005; r = 0.08), spectacles (U = 350382.0; P < 0.001; r = 0.21), and orthokeratology (U = 327285.5; P < 0.001; r = 0.14). While the median scores for atropine were identical, the quartiles for myopic children’s guardians were shifted upward by 3.00 (2.00, 5.00) compared with those for nonmyopic children’s guardians (3.00 (1.00, 4.00)). For spectacles and orthokeratology lenses, the median scores for both methods were higher in the myopic group (4.00 (3.00, 5.00)) than in the nonmyopic group (3.00 (2.00, 5.00)). These findings indicate that having a myopic child is associated with measurably greater awareness of specific clinical interventions. 3.3 KAP Correlation Analysis for the Three Methods of Myopia Interventions Spearman correlation analysis revealed robust positive associations between knowledge, attitudes, and practices for spectacles and contact lenses. For spectacles, knowledge strongly predicted positive attitudes (r = 0.563, P < 0.001) and compliant behaviors (r = 0.578, P < 0.001), with attitudes also being significantly correlated with behaviors (r = 0.423, P < 0.001). Responses for contact lenses showed similar patterns: knowledge correlated with attitudes (r = 0.447, P < 0.05) and behaviors (r = 0.447, P < 0.05), while attitudes strongly predicted behavior (r = 0.602, P < 0.001). However, for 0.01% atropine eye drops, although knowledge and attitudes were positively correlated (r = 0.475, P 0.05). Detailed analysis of atropine-related behaviors revealed notable adherence deficits (Table 2 ). Despite an overall median score of 3 across all five items, the final two—self-discontinuation following perceived improvement (Item 32) and medication transfer to others (Item 33)—demonstrated the poorest performance. These items exhibited the highest proportions of low adherence scores (1–2 post-recoding), at 32.2% and 33.9%, respectively, indicating critical gaps in sustained medication compliance. Table 2 Items and Scores in the Behavioral Section of the 0.01% Atropine Eye Drops Sub‑questionnaire Item Number Descriptions (Before Recoded) Median 29 Increasing the dosage or frequency of medication on their own to enhance efficacy or when myopia worsens 3.00 (2.00, 5.00) 30 Not administering the medication according to the recommended usage time of 0.01% atropine eye drops 3.00 (2.00, 5.00) 31 Changing the medication or other myopia control methods on their own after a few days if they feel it is ineffective 3.00 (3.00, 5.00) 32 Reducing the dosage or stopping the medication on their own after myopia improves 3.00 (2.00, 5.00) 33 Transferring 0.01% atropine eye drops to other children with myopia 3.00 (1.00, 4.00) 3.4 Factors associated with KAP toward the three myopia interventions 3.4.1 Spectacles Residence was a significant predictor of knowledge scores: guardians residing in rural areas had significantly lower knowledge scores than their urban counterparts, with an average deficit of 1.97 points (B = -1.97, bootstrap 95% CI [-3.58, -0.31], P < 0.05). Parental occupation was significantly associated with attitudes toward spectacles. Specifically, unemployed guardians held a significantly more positive attitude than company employees, scoring an average of 2.97 points higher (B = 2.97, bootstrap 95% CI [0.40, 5.74], P < 0.05), while guardians who are students had significantly lower attitude scores, with an average deficit of 1.93 points (B = -1.93, bootstrap 95% CI [-3.43, -0.47], P < 0.005) . Both age and educational attainment were significantly associated with spectacle-related behavior. Guardians aged 35–49 years scored significantly higher than those aged 19–34 years, with an average increase of 1.23 points (B = 1.23, bootstrap 95% CI [0.74, 1.74], P < 0.05). Additionally, lower educational attainment among guardians was linked to less optimal behaviors among children. Compared to those with bachelor’s degree, guardians with an associate’s degree, a secondary vocational school/high school diploma or a primary school diploma had significantly reduced scores: -0.74 points for an associate’s degree (B = -0.74, bootstrap 95% CI [-1.22, -0.14], P < 0.05), -0.78 points for a secondary vocational school/high school diploma (B = -0.78, bootstrap 95% CI [-1.47, -0.25], P < 0.05), and a markedly large deficit of -5.87 points for a primary school diploma (B = -5.87, bootstrap 95% CI [-8.43, -3.32], P < 0.005) . 3.4.2 Contact Lenses Both residence and employment status were strong predictors of knowledge regarding contact lenses. Guardians living in rural areas demonstrated profoundly lower knowledge, scoring an average of 18.57 points lower than urban guardians (B = -18.57, bootstrap 95% CI [-31.98, -11.68], P < 0.005), while retired guardians also had significantly poorer knowledge, scoring 15.57 points lower than those who were currently employed (B = -15.57, bootstrap 95% CI [-24.08, -8.07], P < 0.05). Educational level was significantly associated with attitudes toward contact lenses. Guardians with associate’s degree or secondary vocational school/high school diploma held significantly less favorable attitudes than their counterparts with a bachelor’s degree, with score reductions of 3.51 points (B = -3.51, bootstrap 95% CI [-6.75, 0.51], P < 0.05) and 5.26 points (B = -5.26, bootstrap 95% CI [-8.01, -2.64], P < 0.005), respectively. 3.4.3 Atropine (0.01%) Eye Drops Bootstrap linear regression revealed a significant association between educational level and attitude scores. Secondary vocational school/high school-educated guardians had a significantly less favorable attitude than those with a bachelor’s degree, as indicated by a score that was, on average, 1.68 points lower (B = -1.68, Bootstrap 95% CI [-2.77, -0.71], P < 0.05). 3.5 Differences in KAP Scores Across Eight Cities Table 3 Intercity Variation in KAP Scores for Spectacles, Contact Lenses, and 0.01% Atropine Eye Drops cities spectacles contact lenses 0.01% atropine drops frequency KAP score frequency KAP score frequency KAP score Beijing 70 66.00 (58.00, 72.00) 17 87.00 (74.50, 95.00) 35 82.00 (72.00, 91.00) Xiamen 113 64.00 (56.00, 75.00) 16 79.00 (73.00, 84.00) 25 72.00 (57.50, 90.00) Chengdu 53 62.00 (54.00, 83.00) 7 74.00 (61.00, 88.00) 3 - * Xi’an 107 64.00 (55.00, 71.00) 11 86.00 (80.00, 88.00) 16 91.00 (73.50, 96.25) Changsha 46 60.00 (54.00, 67.25) 10 70.00 (63.00, 76.75) 3 73.00 (54.00, NC ** ) Nanjing 91 62.00 (54.00, 70.00) 20 81.50 (60.50, 91.25) 17 77.00 (73.50, 91.00) Taiyuan 60 67.50 (57.25, 79.75) 4 96.50 (78.00, 99.25) 7 67.00 (47.00, 91.00) Dalian 56 76.50 (66.25, 81.00) 24 92.50 (80.00, 99.00) 9 91.00 (78.00, 96.00) *: All observations in the data set (n = 3) scored the same (42), therefore the median and the quartiles were not reported. **: Q3 for this group was incomputable. 3.5.1 Spectacles The complete results of the Kruskal‒Wallis pairwise comparisons, along with the median scores for all the subscales across the eight cities, are provided in Additional File 3. The results of the Kruskal–Wallis H test revealed significant differences in knowledge and behavior scores across the eight cities for spectacles ( P < 0.001). Compared with the other cities (Table 3 ), Dalian had the highest median knowledge score (40.00, 32.00–40.00) by a significant margin ( P < 0.05). In terms of behavior scores, Dalian also had the highest median (14.00, 12.00–15.00), followed by Beijing (12.50, 11.00–15.00) and Taiyuan (13.00, 10.00–15.00). Changsha had the lowest median behavior score (10.50, 9.00–12.25), showing significant differences compared to Beijing and Taiyuan ( P < 0.05). 3.5.2 Contact Lenses The results of the Kruskal‒Wallis H test revealed significant differences in attitude and behavior scores regarding contact lenses across ( P < 0.05). Dalian had the highest median attitude score (26.50, 22.25–30.00), differing significantly from Changsha (19.00, 17.50–20.75) ( P < 0.05). For behavior scores, Dalian had the highest median (19.00, 16.00–20.00), differing significantly from Nanjing (16.00, 16.00–17.00) ( P < 0.05). 3.5.3 Atropine (0.01%) Eye Drops The results of the Kruskal‒Wallis H test revealed significant differences in behavior scores regarding 0.01% atropine eye drops across the eight cities ( P < 0.05). Beijing had the highest median behavior score (21.00, 15.00–24.00), differing significantly from Xiamen (16.00, 15.00–17.00) and Nanjing (16.00, 14.50–17.00) ( P < 0.05). 3.6 Sources of Information and Their Effectiveness In addition to traditional channels such as “education during doctor's clinic visits" and “information provided during school vision screenings,” the respondents to the contact lenses sub-questionnaire also rated "media and the internet" as highly effective, with a median score of 4.0 (3.0, 5.0) (Fig. 1 ). [Insert Fig. 1 about here] 4. Discussion This study provides comprehensive insights into guardians' knowledge, attitudes, and practices regarding childhood myopia control. Paradoxically, despite higher overall myopia knowledge scores among the guardians of myopic children, these guardians exhibited lower awareness of lighting conditions as a risk factor than the guardians of nonmyopic children did ( P < 0.05). A study in China found that frequently reading books or viewing screens in direct sunlight (aOR = 3.502; P = 0.023) and using only overhead lighting for reading and writing at night (aOR = 1.633; P = 0.011) were risk factors for myopia ( 12 , 13 ). As behavioral and environmental factors are widely considered causes of myopia ( 14 ), health education should emphasize the importance of potential risk factors in daily life, especially lighting conditions, reading distance, reading duration, and outdoor activities, to avoid myopia caused by a lack of awareness. As for the three myopia managements, our study found that spectacles remain the most popular correction modality nationally. Orthokeratology (OK) provides axial length inhibition comparable to that of low-dose atropine, with superior efficacy in high myopia, without systemic effects or daily medication concerns ( 15 ). Atropine eye drops demonstrate dose-dependent efficacy, with 0.05% reducing myopia incidence by 24.6% over 2 years ( 16 ) and 0.01% slowing progression with a minimal rebound effect ( 15 , 17 ). A network meta-analysis revealed synergistic effects of 0.01% atropine combined with OK, achieving efficacy comparable to that of high-dose atropine through mechanisms including increased retinal illumination and elevated higher-order aberrations—thus enabling lower drug concentrations while maintaining effectiveness ( 15 ).Orthokeratology requires rigorous lens maintenance that comes at a substantial direct expense (> 10,000 RMB/year), and 0.01% atropine costs approximately 6000 RMB/year; both entail considerably higher annual costs than spectacles (500–2,000 RMB) ( 18 ). For spectacles and contact lenses, our findings demonstrate a classic KAP positive feedback loop—enhanced knowledge fosters positive attitudes, which, in turn, promote compliant practices—consistent with the established theory ( 19 ). These findings suggest that targeted knowledge dissemination for these interventions can effectively improve compliance and clinical outcomes ( 20 ).For 0.01% atropine eye drops, knowledge demonstrated a strong positive correlation with attitude (r = 0.475, P < 0.001); however, neither knowledge nor attitude predicted behavioral adherence. This disconnect aligns with documented real-world barriers: immediate, tangible adverse effects—including photophobia and near-vision blur—supersede the theoretical understanding, frequently prompting premature discontinuation once myopic progression appears stabilized ( 15 , 17 ). Unlike spectacles, which provide immediate visual feedback, atropine requires sustained daily administration without perceptible short-term benefits while producing bothersome side effects. Furthermore, persistent parental concerns regarding long-term medication safety in children are compounded by reports of an increased side-effect burden in non-Asian populations and inconsistent cross-ethnic efficacy data ( 15 , 17 ). These factors collectively disrupt the conventional KAP cascade for this pharmacological intervention. A concerning finding in our study in the sub-analysis of 0.01% atropine eye drops was the prevalent practice of unilateral discontinuation following perceived myopia stabilization. This practice might undermine treatment efficacy, as evidence demonstrates that therapeutic benefits accrue over time and are not immediately maintained upon cessation. A meta-analysis of 17 randomized controlled trials (n = 2,955) demonstrated progressive improvement throughout treatment but documented significant rebound effects post-discontinuation, particularly with higher concentrations ( 21 ). More critically, longitudinal data indicate accelerated myopia progression following cessation: Australian research tracking children after 0.01% atropine withdrawal revealed a mean axial elongation of 0.20 mm in the treatment year versus 0.13 mm in controls, confirming rebound progression ( 22 ). These physiological rebounds likely reflect complex mechanisms involving scleral remodeling disruption, necessitating extended treatment durations (≥ 2 years) and gradual tapering protocols rather than abrupt cessation ( 23 ). Real-world data corroborate these concerns, with discontinuation rates reaching 14.9% because of logistical burdens and side effects, highlighting the imperative for enhanced guardian education on the necessity of long-term treatment ( 24 ). Such evidence emphasizes that self-discontinuation exacerbates long-term myopic progression, necessitating structured intervention to correct the misconception that treatment may be discontinued as soon as the degree of myopia stabilizes. Three independent predictors of superior KAP scores in our study were higher education, urban residence, and middle age (35–49 years). Participants with a bachelor’s degree or above demonstrated significantly better spectacle-related behaviors and more favorable attitudes toward contact lenses and atropine—findings consistent with prior research highlighting education as a fundamental determinant of health literacy and preventive care engagement ( 9 , 25 ). This educational gradient likely mediates observed urban–rural disparities, as Jia et al. demonstrated that differential educational opportunities account for 25.8% of the urban advantage in family health outcomes ( 26 ). Beyond educational barriers, rural populations face additional structural disadvantages, including limited health care access and entrenched cultural misconceptions that may further suppress KAP scores ( 25 ). Age-stratified analysis revealed peak KAP performance among caregivers aged 35–49 years, which aligns with Tian and Yu’s observation that caregivers aged 33–44 years exhibit particularly positive attitudes toward myopia management ( 27 ). This mid-life advantage likely reflects the convergence of accumulated health knowledge, established caregiving experience, and sustained motivation to adopt novel preventive strategies—qualities that may be weaker in younger caregivers (19–34 years) because of inexperience or in retired elderly populations because of reduced exposure to contemporary health information. Collectively, these demographic patterns suggest that targeted interventions should prioritize educational enrichment and accessibility enhancement for rural, less educated, and younger or elderly caregiver populations to optimize myopia control implementation. Intercity comparisons revealed distinct performance patterns: Beijing demonstrated superior atropine compliance, whereas Changsha consistently underperformed. Beijing’s advantage stemmed from its first-mover status—although 0.01% atropine received NMPA approval only in 2023, compounded formulations were accessible at leading tertiary centers as early as 2019–2021, creating a “clinical familiarity buffer” that fostered greater parental acceptance than in cities where commercial availability began after approval. Consequently, Beijing had the highest median behavior score [21.00 (15.00–24.00)], significantly surpassing economically comparable cities such as Nanjing [16.00 (14.50–17.00)] and Xiamen [16.00 (15.00–17.00)] ( P < 0.05). Conversely, Changsha, whose superior administrative unit of Hunan Province reported the lowest juvenile myopia prevalence among all samples, exhibited the poorest KAP scores, reflecting the “prevalence–awareness paradox”—a phenomenon where low-burden regions receive reduced policy investment and resource allocation ( 25 ). These findings underscore the necessity of proactive educational outreach to “low-risk” regions to dismantle geographic barriers and correct the misconception that low prevalence equates to low risk, ensuring equitable implementation of all interventions. Analysis of information sources confirmed that clinical consultations were the primary channel for myopia knowledge acquisition ( 28 ), yet guardians consistently reported unmet needs for more comprehensive physician guidance. This demand–supply gap stems from constrained outpatient consultation times and geographic barriers, particularly in disadvantaged rural populations with limited health care access ( 29 ). Notably, respondents gave high effectiveness scores to “media and internet” sources, although concerns regarding information quality and credibility persist—studies demonstrate that myopia-related online content often lacks reliability, with physician-generated materials consistently achieving superior quality ratings ( 30 ). These convergent findings suggest a hybrid solution by extending physicians’ reach through digital platforms while maintaining content authority. Specifically, structured collaboration between ophthalmologists and medical students via social media channels could circumvent temporal and geographic limitations and deliver standardized, evidence-based education that enhances guardians’ knowledge, attitudes, and behavioral compliance ( 31 ). Such an approach addresses both the accessibility barriers of traditional clinical encounters and the quality deficits of unregulated online information. Limitations This study has several methodological limitations. First, the cross-sectional design captured guardians’ KAP at a single time point, precluding causal inference and longitudinal trend analysis. Second, the sampling was restricted to eight urban centers, potentially limiting generalizability to rural and remote regions with distinct socioeconomic and health care contexts. Third, reliance on self-reported data introduces potential recall and social desirability biases. Fourth, although the questionnaire was developed on the basis of authoritative guidelines and expert consensus, confirmatory factor analysis indicated suboptimal construct validity, suggesting potential measurement imprecision in the underlying theoretical constructs. Conclusion This study delineates distinct behavioral patterns in Chinese guardians’ approaches to childhood myopia interventions. While robust knowledge, attitudes, and practices alignment was observed for spectacles and contact lenses, a critical knowledge–behavior disconnect was observed for 0.01% atropine users. Specifically, the prevalent practice of self-discontinuation represents a significant barrier to long-term efficacy, underscoring the need for targeted adherence interventions. Intercity disparities—characterized by superior performance in early-adopter cities and underperformance in low-prevalence regions—highlight the “prevalence-awareness paradox” and necessitate expanded educational outreach to epidemiologically “privileged” areas. Leveraging digital platforms for health education conducted by ophthalmologists or medical students offers a scalable solution to bridge care gaps and ensure equitable myopia guidance across diverse populations. Abbreviations KAP Knowledge, attitudes, and practices IMI International Myopia Institute WHO World Health Organization NMPA National Medical Products Administration GDP Gross Domestic Product OK Orthokeratology CI Confidence Interval Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Capital Medical University (No. 2021SY074). This ethical approval covered the entire duration of the present study. Informed consent was obtained from all guardian participants, who were adults aged 19 years or older. No data were collected directly from children under the age of 16. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution YL, JS, and CZ contributed to the study conception and design. Material preparation, data collection and analysis were performed by YL, JS, CZ and CZhao. The first draft of the manuscript was written by YL and JS, and all authors commented on previous versions of the manuscript. CZhao assisted in manuscript writing and language polishing. RG supervised the project. All authors read and approved the final manuscript. Acknowledgement The authors would like to express their sincere gratitude to Professor Fengju Zhang and her team from Beijing Tongren Hospital, Capital Medical University, for their invaluable academic guidance and expert advice on the study design. Data Availability The datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request. References Landreneau JR, Hesemann NP, Cardonell MA. review on the Myopia Pandemic: epidemiology, risk factors, and Prevention. Gifford KL, Richdale K, Kang P, Aller TA, Lam CS, Liu YM, et al. IMI – Clinical Management Guidelines Report. Invest Ophthalmol Vis Sci. 2019;60(3):M184. Myopia Prevention and Control Guidelines. (2024 Edition). Ophthalmology Advances. 2024;44(8):589–91. Flitcroft I, Ainsworth J, Chia A, Cotter S, Harb E, Jin ZB, et al. IMI—Management and Investigation of High Myopia in Infants and Young Children. Invest Ophthalmol Vis Sci. 2023;64(6):3. Keel S, Cieza A. Universal eye health coverage: from global policy to country action. Int Health. 2022;14(Supplement1):i3–5. Fu T, Yang Z, Zhang P, Yang J, Gao L. Knowledge, attitude and practice among parents of children and teenagers towards myopia prevention and control during the COVID-19 epidemic. BMJ Open. 2025;15(4):e089431. Li Q, Guo L, Zhang J, Zhao F, Hu Y, Guo Y, et al. Effect of School-Based Family Health Education via Social Media on Children’s Myopia and Parents’ Awareness: A Randomized Clinical Trial. JAMA Ophthalmol. 2021;139(11):1165. Yuan H, Lv H, Li X. The gap between parental knowledge and children practice of myopia control and challenge under COVID-19: a web-based survey in China. Front Public Health. 2024;12:1344188. Zhang R, Kuang Y, Rao J, Liu X, Fang Q, Tang Y, et al. Knowledge, attitude, and practice among parents of myopic children regarding multifocal soft contact lenses. BMC Public Health. 2025;25(1):2159. Yahya AS, Mohamed Haris NB, Shah JA, Ahmad Zaki N. Knowledge, Attitude and Practice towards the Adoption of Urban Farming: A Concept Paper. IJARBSS. 2023;13(17):Pages312–320. National Health Commission of the People’s Republic of China. Myopia Prevention and Control Guidelines (2024 Edition) [Internet]. 2024 [cited 2025 Jan 19]. Available from: http://www.nhc.gov.cn/xcs/s3574/202401/1234567890abcdef.shtml Chhabra S, Rathi M, Sachdeva S, Rustagi IM, Soni D, Dhania S. Association of near work and dim light with myopia among 1400 school children in a district in North India. Indian J Ophthalmol. 2022;70(9):3369–72. The Second Monitoring Section, Guangzhou Baiyun District Center for Disease Control and Prevention, Province G, Huang C, Chen K ZH, The Second Monitoring Section, Guangzhou Baiyun District Center for Disease Control and Prevention, Guangzhou 510445, Guangdong Province, China, Chen J et al. The Second Monitoring Section, Guangzhou Baiyun District Center for Disease Control and Prevention, Guangzhou 510445, Guangdong Province, China,. Progression of myopia among school-aged children in Guangzhou, China. Int J Ophthalmol. 2025;18(8):1561–9. Morgan IG, Wu PC, Ostrin LA, Tideman JWL, Yam JC, Lan W, et al. IMI Risk Factors for Myopia. Invest Ophthalmol Vis Sci. 2021;62(5):3. Tsai HR, Wang JH, Huang HK, Chen TL, Chen PW, Chiu CJ. Efficacy of atropine, orthokeratology, and combined atropine with orthokeratology for childhood myopia: A systematic review and network meta-analysis. J Formos Med Assoc. 2022;121(12):2490–500. Yam JC, Zhang XJ, Zhang Y, Yip BHK, Tang F, Wong ES, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023;329(6):472. Lee SH, Tseng BY, Wang JH, Chiu CJ. Efficacy and Safety of Low-Dose Atropine on Myopia Prevention in Premyopic Children: Systematic Review and Meta-Analysis. JCM. 2024;13(5):1506. Agyekum S, Chan PP, Zhang Y, Huo Z, Yip BHK, Ip P, et al. Cost-effectiveness analysis of myopia management: A systematic review. Front Public Health. 2023;11:1093836. Kang K, Bagaoisan MAP. Research Status of the Knowledge-Attitude-Practice Theory Model in Gastric Cancer Prevention. Cureus [Internet]. 2024 Jul 19 [cited 2025 Nov 12]; Available from: https://www.cureus.com/articles/273925-research-status-of-the-knowledge-attitude-practice-theory-model-in-gastric-cancer-prevention Silva CC, Presseau J, Van Allen Z, Schenk PM, Moreto M, Dinsmore J, et al. Effectiveness of Interventions for Changing More Than One Behavior at a Time to Manage Chronic Conditions: A Systematic Review and Meta-analysis. Ann Behav Med. 2024;58(6):432–44. Chen C, Yao J. Efficacy and Adverse Effects of Atropine for Myopia Control in Children: A Meta-Analysis of Randomised Controlled Trials. Li S, editor. Journal of Ophthalmology. 2021;2021:1–12. Lee SS, Nilagiri VK, Lingham G, Blaszkowska M, Sanfilippo PG, Franchina M, et al. Myopia progression following 0.01% atropine cessation in Australian children: Findings from the Western Australia – Atropine for the Treatment of Myopia (WA-ATOM) study. Clin Exper Ophthalmol. 2024;52(5):507–15. Chia A, Lu QS, Tan D. Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2. Ophthalmology. 2016;123(2):391–9. Akagün N, Altıparmak UE. Evaluation of Reasons for Discontinuation of Atropine 0.01% in Myopia Management: A Single-Center Retrospective Study from Türkiye. tjo. 2025;55(2):61–6. Osuagwu UL, Ocansey S, Ndep AO, Kyeremeh S, Ovenseri-Ogbomo G, Ekpenyong BN, et al. Demographic factors associated with myopia knowledge, attitude and preventive practices among adults in Ghana: a population-based cross-sectional survey. BMC Public Health. 2023;23(1):1712. Jia C, Long Y, Luo X, Li X, Zuo W, Wu Y. Inverted U-shaped relationship between education and family health: The urban-rural gap in Chinese dual society. Front Public Health. 2023;10:1071245. Tian Y, Yu Y. Knowledge, attitude and practice towards myopia among parents of primary school students: a cross-sectional study. BMJ Open. 2025;15(3):e093565. Zhan B, Huang Y, Wang B, Zhao J, Shang J, Chen Z, et al. Chinese parents’ knowledge, attitude, and practice of myopia control: 2023 update. BMC Public Health. 2025;25(1):779. State Key Laboratory of Ophthalmology, Center ZO, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou 510060, Guangdong Province, China, He AQ, He SY, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou 510060, Guangdong Province, China, Yao H et al. State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou 510060, Guangdong Province, China,. Investigation of children’s habits of smartphone usage and parental awareness of myopia control in underdeveloped areas of China. Int J Ophthalmol. 2022;15(10):1691–8. Kayabaşı M, Köksaldı S, Durmaz Engin C. Evaluating the quality and reliability of YouTube videos on myopia: a video content analysis. Int Ophthalmol. 2024;44(1):329. Wang Q, Zhang L, Wu Y. Application of the precision eye health education model in myopia prevention and control in adolescents. Front Pediatr. 2025;13:1554822. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.xlsx Additional File 1: Table for stratified sampling. Format: Microsoft Excel (.xlsx) Description: This file contains the raw data extracted from official municipal statistical reports (2021) and the Statistical Data on the Status of Women and Children in China (2021) that were used to stratify the eight sampled cities based on economic level and myopia prevalence. For each city, the source document (PDF) URL and access date are provided in the ‘Source’ column. Additionalfile2.docx Additional File 2: Questionnaire (English version). Format: Microsoft Word (.docx) Description: The KAP questionnaire used in this survey study translated into English. Additionalfile3.docx Additional File 3: Results of the Kruskal-Wallis comparisons on myopia-related knowledge, attitude, and behavior across eight cities Format: Microsoft Word (.docx) Description: This file provides the detailed Kruskal-Wallis test results comparing eight Chinese cities (Beijing, Changsha, Chengdu, Dalian, Nanjing, Taiyuan, Xiamen, and Xi’an) in terms of myopia-related knowledge, attitudes, and behaviors. It includes test summaries, pairwise comparisons, radar charts, and percentile distributions for each assessed domain. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 20 Mar, 2026 Editor assigned by journal 16 Mar, 2026 Editor invited by journal 20 Feb, 2026 Submission checks completed at journal 19 Feb, 2026 First submitted to journal 19 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8881110","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610294151,"identity":"fc7a8ba5-cf0d-4b02-9413-81283f074459","order_by":0,"name":"Yifan Li","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yifan","middleName":"","lastName":"Li","suffix":""},{"id":610294153,"identity":"61fb8e98-82c5-4ae2-8d33-b662ba7b38c5","order_by":1,"name":"Jiarui Song","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jiarui","middleName":"","lastName":"Song","suffix":""},{"id":610294155,"identity":"d51ab193-953f-4db3-906a-7bbe43b8ae41","order_by":2,"name":"Chenyu Zhang","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chenyu","middleName":"","lastName":"Zhang","suffix":""},{"id":610294156,"identity":"04a067d8-92fb-49a8-8dd9-d791484d2159","order_by":3,"name":"Cindy Zhao","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Cindy","middleName":"","lastName":"Zhao","suffix":""},{"id":610294160,"identity":"4c406249-6084-4d2a-aaed-e247c36c8ca7","order_by":4,"name":"Rui Guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYNACAxsog414LWkka2E4TIIW+YjkY595Cs7L8087Y8DwoewwA//sBvxaDG+kJc/mMbhtOON2jgHjjHOHGSTuHCCgZUaOMTNQS4KBdI4BM2/bYQYDiQSitJyDaPlLjBZ5CbCWAxAtjMRoMeB5lsw4xyAZ6Je0goM959J5JG4QsqU9+TDDmz928vyzkzc++FFmLcc/g5AtB5A4IDYPfvUgWxoIKhkFo2AUjIIRDwCVHDrYGRqKdwAAAABJRU5ErkJggg==","orcid":"","institution":"Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Rui","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2026-02-14 15:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8881110/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8881110/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105565941,"identity":"f37371b0-63dc-4de4-9140-7e8701f129b9","added_by":"auto","created_at":"2026-03-27 12:54:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":775810,"visible":true,"origin":"","legend":"\u003cp\u003ea. Effectiveness ratings of information sources for atropine.\u003c/p\u003e\n\u003cp\u003eb. Effectiveness ratings of information sources for spectacles.\u003c/p\u003e\n\u003cp\u003ec. Effectiveness ratings of information sources for contact lenses.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8881110/v1/5517619b80ac61a9deeff2fa.png"},{"id":108180623,"identity":"4c673096-b01f-421e-ad0d-6641797d2a0d","added_by":"auto","created_at":"2026-04-30 08:49:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1258787,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8881110/v1/2781fb54-60ae-4dcd-9ce6-64c5a86f5ec1.pdf"},{"id":105728001,"identity":"cda6e523-8739-48f5-b890-7d6132b0a7c7","added_by":"auto","created_at":"2026-03-30 11:07:51","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16901,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 1: Table for stratified sampling.\u003c/p\u003e\n\u003cp\u003eFormat: Microsoft Excel (.xlsx)\u003c/p\u003e\n\u003cp\u003eDescription: This file contains the raw data extracted from official municipal statistical reports (2021) and the Statistical Data on the Status of Women and Children in China (2021) that were used to stratify the eight sampled cities based on economic level and myopia prevalence. For each city, the source document (PDF) URL and access date are provided in the ‘Source’ column.\u003c/p\u003e","description":"","filename":"Additionalfile1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8881110/v1/13f5c2b3c9a45ce4cbfa3f8f.xlsx"},{"id":105409951,"identity":"1bcf0caf-8ba8-4681-b892-ce72ffac9831","added_by":"auto","created_at":"2026-03-25 17:11:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20207,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 2: Questionnaire (English version).\u003c/p\u003e\n\u003cp\u003eFormat: Microsoft Word (.docx)\u003c/p\u003e\n\u003cp\u003eDescription: The KAP questionnaire used in this survey study translated into English.\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8881110/v1/891ffd65b5f8ce96427ed9fb.docx"},{"id":105565702,"identity":"a0d32273-88a7-4844-b1ba-82e8d8c634bd","added_by":"auto","created_at":"2026-03-27 12:54:06","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":671945,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 3: Results of the Kruskal-Wallis comparisons on myopia-related knowledge, attitude, and behavior across eight cities\u003c/p\u003e\n\u003cp\u003eFormat: Microsoft Word (.docx)\u003c/p\u003e\n\u003cp\u003eDescription: This file provides the detailed Kruskal-Wallis test results comparing eight Chinese cities (Beijing, Changsha, Chengdu, Dalian, Nanjing, Taiyuan, Xiamen, and Xi’an) in terms of myopia-related knowledge, attitudes, and behaviors. It includes test summaries, pairwise comparisons, radar charts, and percentile distributions for each assessed domain.\u003c/p\u003e","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8881110/v1/0c5c2296cc7a781edf454e32.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge, Attitudes, and Practices (KAP) Survey Study in Chinese Children’s and Adolescents’ Guardians on the Three Methods of Myopia Intervention","fulltext":[{"header":"1. Background","content":"\u003cp\u003eMyopia is a highly prevalent ocular disease worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and has a far-reaching impact on the physical health, mental health, and future of children and adolescents. According to the 2019 Clinical Management Guidelines Report by the IMI, approximately 1.45\u0026nbsp;billion people worldwide have been diagnosed with myopia, with an incidence rate of 22% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Myopia is particularly prominent in China. A myopia-specific survey conducted in 2022 by the Chinese National Health Commission revealed that the overall prevalence of myopia among Chinese children and adolescents is 51.9% and that the age of myopia onset is trending downward (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). By 2025, the population of myopic patients under the age of 20 in China is expected to reach 187\u0026nbsp;million (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Studies have also shown that an earlier age of onset of myopia is related to a greater incidence of high myopia in the future. Children and adolescents aged 6 to 12 years have an especially rapid progression of myopia and are therefore in need of effective interventions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnder the WHO (2021) 2030 global eye health targets that mandate raising effective refractive-error coverage (eREC) to secure myopia correction for children and adolescents (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), China\u0026rsquo;s prevention and control program still underperforms because of knowledge gaps among guardians (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe most common interventions for myopia are spectacles, contact lenses, and drugs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Guardians\u0026rsquo; knowledge, attitudes, and compliance critically shape the uptake and efficacy of myopia interventions for children (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe knowledge, attitudes, and practices (KAP) model is an important theoretical framework for studying health-related behaviors. By examining the continuous process of respondents from knowledge acquisition to attitude formation and then to behavioral change, this model provides a scientific basis for formulating targeted public health intervention measures (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, region-based and KAP-related studies on the role of guardians in all three common myopia intervention measures in China are lacking. This study aims to conduct a KAP survey in eight cities across the country to understand their residents\u0026rsquo; current knowledge, attitudes, and actual behaviors regarding three myopia intervention methods and to analyze the key factors affecting KAP to provide epidemiological evidence for intervention strategies.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis prospective, cross-sectional study comprised a pilot survey (November 21\u0026ndash;December 15, 2024) and a formal survey (January 19\u0026ndash;February 2, 2025). Given that 0.01% atropine received NMPA approval in 2023, we strategically restricted sampling to Tier 1 and major Tier 2 cities to ensure clinical accessibility. Stratified sampling based on geographic region, economic tier (GDP per capita and total GDP), and myopia prevalence (high (\u0026gt;\u0026thinsp;35%) vs. low (\u0026le;\u0026thinsp;35%) was used to select eight cities, namely, Beijing, Xiamen, Chengdu, Xi'an, Changsha, Nanjing, Taiyuan, and Dalian, providing comprehensive coverage of North, East, Southwestern, Northwestern, Central, and Northeast China. The online questionnaires targeted the guardians of children aged 6\u0026ndash;12 years. The study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of Capital Medical University (No. 2021SY074), with informed consent obtained from all participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Questionnaire\u003c/h2\u003e \u003cp\u003eThis questionnaire (the formal version of the extended questionnaire is provided as Additional file 2) was designed by the research team on the basis of guidelines and one white paper applied in China (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The instrument was optimized after preliminary study and consultation with ophthalmology experts to ensure that its psychometric properties met the KAP model requirements and provided comprehensive content coverage. The questionnaire consists of two sections. The first section includes basic myopia-related questions that all respondents need to answer, including 10 questions related to demography (such as gender, age, residence, medical insurance status, etc.) and 10 questions related to basic myopia knowledge. The second section comprises three intervention-specific KAP sub-questionnaires: 23 items on 0.01% atropine eye drops, 15 on spectacles, and 23 on contact lenses. Guardians completed the sub-questionnaire(s) corresponding to their selected myopia control method(s); completion of multiple sub-questionnaires was allowed for those employing more than one intervention. Each question in the KAP section is scored on a 5-point Likert scale. Although the anchors are specific to each dimension (e.g., \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree\" for attitudes; \u0026ldquo;never\u0026rdquo; to \u0026ldquo;always\u0026rdquo; for practices), the scoring was consistently oriented so that a higher score always indicated a more desirable outcome (i.e., greater knowledge, a more favorable attitude, or better adherence to recommended practice). Among the questions, numbers 27\u0026ndash;33, 48 and 51 are reversed in polarity to reduce response bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Survey Procedure and Quality Control\u003c/h2\u003e \u003cp\u003eAfter stratified sampling, the online questionnaire was distributed through WeChat chatgroups and other social media platforms in the target cities, and QR codes were distributed around primary schools. After informed consent was obtained from the respondents, the questionnaire was filled out anonymously. Upon completing the questionnaire, the respondents verified the information for accuracy and submitted it immediately.\u003c/p\u003e \u003cp\u003eTo ensure the quality of the online survey, measures such as restricting duplicate IP addresses, setting all questions as mandatory, and controlling the time taken to complete the questionnaire were implemented to reduce duplicate or invalid responses. After collection, all the questionnaires underwent completeness checks, logical reviews, and error corrections.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical Analyses\u003c/h2\u003e \u003cp\u003eSample size determination was based on the recommendation of 5\u0026ndash;10 participants per item for factor analysis, with a target ratio of 3\u0026ndash;5:1 for the total questionnaire. Accounting for anticipated invalid response rates of 10\u0026ndash;20%, the minimum target sample size was set at 1,200 participants. Stratified sampling targets were established as follows: 69\u0026ndash;115 participants for both the 0.01% atropine eye drop and contact lens sub-questionnaires and 45\u0026ndash;75 participants for the spectacle sub-questionnaire, reflecting the differing item counts and expected prevalence of each intervention.\u003c/p\u003e \u003cp\u003eAll analyses were conducted using SPSS Statistics version 27.0 (IBM Corp, Armonk, NY, USA). The reverse-coded items were recoded to align the scoring direction prior to analysis using the standard transformation for a symmetric Likert scale: Recoded Score = (Upper Limit\u0026thinsp;+\u0026thinsp;Lower Limit) - Original Score. For our 5-point scale (1 to 5), this can be simplified as follows: Recoded Score\u0026thinsp;=\u0026thinsp;6 - Original Score.\u003c/p\u003e \u003cp\u003eThe normality of continuous variables (e.g., KAP scores) was assessed using the Shapiro‒Wilk test and visual inspection of Q‒Q plots. As distributions significantly deviated from normality (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), continuous variables are presented as the median and interquartile range [M (IQR)], and categorical variables are presented as frequencies (percentages).\u003c/p\u003e \u003cp\u003eGroup comparisons were performed using Mann‒Whitney U tests (for two groups) or Kruskal‒Wallis H tests with Dunn‒Bonferroni post hoc corrections (for \u0026ge;\u0026thinsp;3 groups), as appropriate. Bivariate associations were examined using Spearman's rank correlation coefficients (ρ), with magnitudes interpreted as 0.10\u0026ndash;0.29 (small), 0.30\u0026ndash;0.49 (medium), and \u0026ge;\u0026thinsp;0.50 (large).\u003c/p\u003e \u003cp\u003eMultiple linear regression was employed to identify independent factors associated with KAP scores. To address potential violations of parametric assumptions (including nonnormality) and to ensure robust inference, a nonparametric bootstrap procedure was applied. The 95% confidence intervals (CIs) and p values for the regression coefficients were derived using the percentile method based on 1,000 bootstrap resamples.\u003c/p\u003e \u003cp\u003eTwo-sided tests were used throughout, with statistical significance set at α\u0026thinsp;=\u0026thinsp;0.05. Effect sizes are reported alongside p values to facilitate clinical interpretation of findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographic Information\u003c/h2\u003e \u003cp\u003eAmong the 1,516 questionnaires collected, 1,509 were valid, resulting in an effective rate of 99.5%. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details. The guardians of myopic children accounted for 48.1% of respondents (726 individuals). Among all the guardians of myopic children, the preferred intervention method was spectacles, with 596 individuals (82.1%), followed by 0.01% atropine eye drops, with 115 individuals (15.8%), and contact lenses, with 109 individuals (15.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Information of the Respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOption\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;64 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor's\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociate's\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational high school or high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlace of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural residents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Insurance Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial basic medical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommercial insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-funded medical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic-funded medical care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactory worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthcare institution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFreelancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompany employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment official\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusiness manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Association Between Children\u0026rsquo;s Myopic Status and Guardians' Responses to Basic Questions\u003c/h2\u003e \u003cp\u003eA statistically significant difference was observed in the total score on basic questions between guardians of myopic and nonmyopic children (U\u0026thinsp;=\u0026thinsp;301754.0, W\u0026thinsp;=\u0026thinsp;564929.0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with guardians of myopic children 40 (35, 47) scoring slightly better than guardians of nonmyopic children 39 (34, 46).\u003c/p\u003e \u003cp\u003eSpecifically, both groups strongly agreed with our statements regarding the risk factors for myopia, although the Mann‑Whitney U test indicated statistically significant differences on question 5 (\"Reading and writing in environments with excessively dark or bright lighting is a risk factor for myopia\") (U\u0026thinsp;=\u0026thinsp;267341, Z = ‑2.360, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and question 6 (\"Eye exercises can help delay the onset and progression of myopia\") (U\u0026thinsp;=\u0026thinsp;267491.5, Z = ‑2.265, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eSignificant differences emerged regarding knowledge of myopia control interventions. Guardians of myopic children reported significantly higher knowledge scores for atropine eye drops (U\u0026thinsp;=\u0026thinsp;308956.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005; r\u0026thinsp;=\u0026thinsp;0.08), spectacles (U\u0026thinsp;=\u0026thinsp;350382.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.21), and orthokeratology (U\u0026thinsp;=\u0026thinsp;327285.5; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.14). While the median scores for atropine were identical, the quartiles for myopic children\u0026rsquo;s guardians were shifted upward by 3.00 (2.00, 5.00) compared with those for nonmyopic children\u0026rsquo;s guardians (3.00 (1.00, 4.00)). For spectacles and orthokeratology lenses, the median scores for both methods were higher in the myopic group (4.00 (3.00, 5.00)) than in the nonmyopic group (3.00 (2.00, 5.00)). These findings indicate that having a myopic child is associated with measurably greater awareness of specific clinical interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 KAP Correlation Analysis for the Three Methods of Myopia Interventions\u003c/h2\u003e \u003cp\u003eSpearman correlation analysis revealed robust positive associations between knowledge, attitudes, and practices for spectacles and contact lenses. For spectacles, knowledge strongly predicted positive attitudes (r\u0026thinsp;=\u0026thinsp;0.563, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and compliant behaviors (r\u0026thinsp;=\u0026thinsp;0.578, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with attitudes also being significantly correlated with behaviors (r\u0026thinsp;=\u0026thinsp;0.423, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Responses for contact lenses showed similar patterns: knowledge correlated with attitudes (r\u0026thinsp;=\u0026thinsp;0.447, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and behaviors (r\u0026thinsp;=\u0026thinsp;0.447, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while attitudes strongly predicted behavior (r\u0026thinsp;=\u0026thinsp;0.602, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, for 0.01% atropine eye drops, although knowledge and attitudes were positively correlated (r\u0026thinsp;=\u0026thinsp;0.475, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), neither significantly predicted actual practices (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eDetailed analysis of atropine-related behaviors revealed notable adherence deficits (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Despite an overall median score of 3 across all five items, the final two\u0026mdash;self-discontinuation following perceived improvement (Item 32) and medication transfer to others (Item 33)\u0026mdash;demonstrated the poorest performance. These items exhibited the highest proportions of low adherence scores (1\u0026ndash;2 post-recoding), at 32.2% and 33.9%, respectively, indicating critical gaps in sustained medication compliance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItems and Scores in the Behavioral Section of the 0.01% Atropine Eye Drops Sub‑questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem Number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions (Before Recoded)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreasing the dosage or frequency of medication on their own to enhance efficacy or when myopia worsens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (2.00, 5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot administering the medication according to the recommended usage time of 0.01% atropine eye drops\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (2.00, 5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChanging the medication or other myopia control methods on their own after a few days if they feel it is ineffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (3.00, 5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReducing the dosage or stopping the medication on their own after myopia improves\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (2.00, 5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransferring 0.01% atropine eye drops to other children with myopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (1.00, 4.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Factors associated with KAP toward the three myopia interventions\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Spectacles\u003c/h2\u003e \u003cp\u003eResidence was a significant predictor of knowledge scores: guardians residing in rural areas had significantly lower knowledge scores than their urban counterparts, with an average deficit of 1.97 points (B = -1.97, bootstrap 95% CI [-3.58, -0.31], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eParental occupation was significantly associated with attitudes toward spectacles. Specifically, unemployed guardians held a significantly more positive attitude than company employees, scoring an average of 2.97 points higher (B\u0026thinsp;=\u0026thinsp;2.97, bootstrap 95% CI [0.40, 5.74], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while guardians who are students had significantly lower attitude scores, with an average deficit of 1.93 points (B = -1.93, bootstrap 95% CI [-3.43, -0.47], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005) .\u003c/p\u003e \u003cp\u003eBoth age and educational attainment were significantly associated with spectacle-related behavior. Guardians aged 35\u0026ndash;49 years scored significantly higher than those aged 19\u0026ndash;34 years, with an average increase of 1.23 points (B\u0026thinsp;=\u0026thinsp;1.23, bootstrap 95% CI [0.74, 1.74], P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, lower educational attainment among guardians was linked to less optimal behaviors among children. Compared to those with bachelor\u0026rsquo;s degree, guardians with an associate\u0026rsquo;s degree, a secondary vocational school/high school diploma or a primary school diploma had significantly reduced scores: -0.74 points for an associate\u0026rsquo;s degree (B = -0.74, bootstrap 95% CI [-1.22, -0.14], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), -0.78 points for a secondary vocational school/high school diploma (B = -0.78, bootstrap 95% CI [-1.47, -0.25], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and a markedly large deficit of -5.87 points for a primary school diploma (B = -5.87, bootstrap 95% CI [-8.43, -3.32], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005) .\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Contact Lenses\u003c/h2\u003e \u003cp\u003eBoth residence and employment status were strong predictors of knowledge regarding contact lenses. Guardians living in rural areas demonstrated profoundly lower knowledge, scoring an average of 18.57 points lower than urban guardians (B = -18.57, bootstrap 95% CI [-31.98, -11.68], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005), while retired guardians also had significantly poorer knowledge, scoring 15.57 points lower than those who were currently employed (B = -15.57, bootstrap 95% CI [-24.08, -8.07], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eEducational level was significantly associated with attitudes toward contact lenses. Guardians with associate\u0026rsquo;s degree or secondary vocational school/high school diploma held significantly less favorable attitudes than their counterparts with a bachelor\u0026rsquo;s degree, with score reductions of 3.51 points (B = -3.51, bootstrap 95% CI [-6.75, 0.51], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and 5.26 points (B = -5.26, bootstrap 95% CI [-8.01, -2.64], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.005), respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Atropine (0.01%) Eye Drops\u003c/h2\u003e \u003cp\u003eBootstrap linear regression revealed a significant association between educational level and attitude scores. Secondary vocational school/high school-educated guardians had a significantly less favorable attitude than those with a bachelor\u0026rsquo;s degree, as indicated by a score that was, on average, 1.68 points lower (B = -1.68, Bootstrap 95% CI [-2.77, -0.71], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Differences in KAP Scores Across Eight Cities\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntercity Variation in KAP Scores for Spectacles, Contact Lenses, and 0.01% Atropine Eye Drops\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003espectacles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003econtact lenses\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.01% atropine drops\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKAP score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003efrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKAP score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003efrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKAP score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeijing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.00 (58.00, 72.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87.00 (74.50, 95.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e82.00 (72.00, 91.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eXiamen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.00 (56.00, 75.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.00 (73.00, 84.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72.00 (57.50, 90.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChengdu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.00 (54.00, 83.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.00 (61.00, 88.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eXi\u0026rsquo;an\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.00 (55.00, 71.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.00 (80.00, 88.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e91.00 (73.50, 96.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChangsha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.00 (54.00, 67.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.00 (63.00, 76.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73.00 (54.00, NC\u003csup\u003e**\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNanjing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.00 (54.00, 70.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81.50 (60.50, 91.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e77.00 (73.50, 91.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTaiyuan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.50 (57.25, 79.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.50 (78.00, 99.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e67.00 (47.00, 91.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDalian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.50 (66.25, 81.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.50 (80.00, 99.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e91.00 (78.00, 96.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*: All observations in the data set (n\u0026thinsp;=\u0026thinsp;3) scored the same (42), therefore the median and the quartiles were not reported.\u003c/p\u003e \u003cp\u003e**: Q3 for this group was incomputable.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.5.1 Spectacles\u003c/h2\u003e \u003cp\u003e The complete results of the Kruskal‒Wallis pairwise comparisons, along with the median scores for all the subscales across the eight cities, are provided in Additional File 3. The results of the Kruskal\u0026ndash;Wallis H test revealed significant differences in knowledge and behavior scores across the eight cities for spectacles (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Compared with the other cities (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), Dalian had the highest median knowledge score (40.00, 32.00\u0026ndash;40.00) by a significant margin (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In terms of behavior scores, Dalian also had the highest median (14.00, 12.00\u0026ndash;15.00), followed by Beijing (12.50, 11.00\u0026ndash;15.00) and Taiyuan (13.00, 10.00\u0026ndash;15.00). Changsha had the lowest median behavior score (10.50, 9.00\u0026ndash;12.25), showing significant differences compared to Beijing and Taiyuan (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.5.2 Contact Lenses\u003c/h2\u003e \u003cp\u003eThe results of the Kruskal‒Wallis H test revealed significant differences in attitude and behavior scores regarding contact lenses across (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Dalian had the highest median attitude score (26.50, 22.25\u0026ndash;30.00), differing significantly from Changsha (19.00, 17.50\u0026ndash;20.75) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For behavior scores, Dalian had the highest median (19.00, 16.00\u0026ndash;20.00), differing significantly from Nanjing (16.00, 16.00\u0026ndash;17.00) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.5.3 Atropine (0.01%) Eye Drops\u003c/h2\u003e \u003cp\u003eThe results of the Kruskal‒Wallis H test revealed significant differences in behavior scores regarding 0.01% atropine eye drops across the eight cities (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Beijing had the highest median behavior score (21.00, 15.00\u0026ndash;24.00), differing significantly from Xiamen (16.00, 15.00\u0026ndash;17.00) and Nanjing (16.00, 14.50\u0026ndash;17.00) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Sources of Information and Their Effectiveness\u003c/h2\u003e \u003cp\u003eIn addition to traditional channels such as \u0026ldquo;education during doctor's clinic visits\" and \u0026ldquo;information provided during school vision screenings,\u0026rdquo; the respondents to the contact lenses sub-questionnaire also rated \"media and the internet\" as highly effective, with a median score of 4.0 (3.0, 5.0) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here]\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study provides comprehensive insights into guardians' knowledge, attitudes, and practices regarding childhood myopia control. Paradoxically, despite higher overall myopia knowledge scores among the guardians of myopic children, these guardians exhibited lower awareness of lighting conditions as a risk factor than the guardians of nonmyopic children did (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A study in China found that frequently reading books or viewing screens in direct sunlight (aOR\u0026thinsp;=\u0026thinsp;3.502; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023) and using only overhead lighting for reading and writing at night (aOR\u0026thinsp;=\u0026thinsp;1.633; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011) were risk factors for myopia (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). As behavioral and environmental factors are widely considered causes of myopia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), health education should emphasize the importance of potential risk factors in daily life, especially lighting conditions, reading distance, reading duration, and outdoor activities, to avoid myopia caused by a lack of awareness.\u003c/p\u003e \u003cp\u003eAs for the three myopia managements, our study found that spectacles remain the most popular correction modality nationally. Orthokeratology (OK) provides axial length inhibition comparable to that of low-dose atropine, with superior efficacy in high myopia, without systemic effects or daily medication concerns (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Atropine eye drops demonstrate dose-dependent efficacy, with 0.05% reducing myopia incidence by 24.6% over 2 years (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and 0.01% slowing progression with a minimal rebound effect (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A network meta-analysis revealed synergistic effects of 0.01% atropine combined with OK, achieving efficacy comparable to that of high-dose atropine through mechanisms including increased retinal illumination and elevated higher-order aberrations\u0026mdash;thus enabling lower drug concentrations while maintaining effectiveness (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).Orthokeratology requires rigorous lens maintenance that comes at a substantial direct expense (\u0026gt;\u0026thinsp;10,000 RMB/year), and 0.01% atropine costs approximately 6000 RMB/year; both entail considerably higher annual costs than spectacles (500\u0026ndash;2,000 RMB) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor spectacles and contact lenses, our findings demonstrate a classic KAP positive feedback loop\u0026mdash;enhanced knowledge fosters positive attitudes, which, in turn, promote compliant practices\u0026mdash;consistent with the established theory (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These findings suggest that targeted knowledge dissemination for these interventions can effectively improve compliance and clinical outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).For 0.01% atropine eye drops, knowledge demonstrated a strong positive correlation with attitude (r\u0026thinsp;=\u0026thinsp;0.475, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001); however, neither knowledge nor attitude predicted behavioral adherence. This disconnect aligns with documented real-world barriers: immediate, tangible adverse effects\u0026mdash;including photophobia and near-vision blur\u0026mdash;supersede the theoretical understanding, frequently prompting premature discontinuation once myopic progression appears stabilized (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Unlike spectacles, which provide immediate visual feedback, atropine requires sustained daily administration without perceptible short-term benefits while producing bothersome side effects. Furthermore, persistent parental concerns regarding long-term medication safety in children are compounded by reports of an increased side-effect burden in non-Asian populations and inconsistent cross-ethnic efficacy data (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These factors collectively disrupt the conventional KAP cascade for this pharmacological intervention.\u003c/p\u003e \u003cp\u003eA concerning finding in our study in the sub-analysis of 0.01% atropine eye drops was the prevalent practice of unilateral discontinuation following perceived myopia stabilization. This practice might undermine treatment efficacy, as evidence demonstrates that therapeutic benefits accrue over time and are not immediately maintained upon cessation. A meta-analysis of 17 randomized controlled trials (n\u0026thinsp;=\u0026thinsp;2,955) demonstrated progressive improvement throughout treatment but documented significant rebound effects post-discontinuation, particularly with higher concentrations (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). More critically, longitudinal data indicate accelerated myopia progression following cessation: Australian research tracking children after 0.01% atropine withdrawal revealed a mean axial elongation of 0.20 mm in the treatment year versus 0.13 mm in controls, confirming rebound progression (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These physiological rebounds likely reflect complex mechanisms involving scleral remodeling disruption, necessitating extended treatment durations (\u0026ge;\u0026thinsp;2 years) and gradual tapering protocols rather than abrupt cessation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Real-world data corroborate these concerns, with discontinuation rates reaching 14.9% because of logistical burdens and side effects, highlighting the imperative for enhanced guardian education on the necessity of long-term treatment (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Such evidence emphasizes that self-discontinuation exacerbates long-term myopic progression, necessitating structured intervention to correct the misconception that treatment may be discontinued as soon as the degree of myopia stabilizes.\u003c/p\u003e \u003cp\u003eThree independent predictors of superior KAP scores in our study were higher education, urban residence, and middle age (35\u0026ndash;49 years). Participants with a bachelor\u0026rsquo;s degree or above demonstrated significantly better spectacle-related behaviors and more favorable attitudes toward contact lenses and atropine\u0026mdash;findings consistent with prior research highlighting education as a fundamental determinant of health literacy and preventive care engagement (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This educational gradient likely mediates observed urban\u0026ndash;rural disparities, as Jia et al. demonstrated that differential educational opportunities account for 25.8% of the urban advantage in family health outcomes (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Beyond educational barriers, rural populations face additional structural disadvantages, including limited health care access and entrenched cultural misconceptions that may further suppress KAP scores (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Age-stratified analysis revealed peak KAP performance among caregivers aged 35\u0026ndash;49 years, which aligns with Tian and Yu\u0026rsquo;s observation that caregivers aged 33\u0026ndash;44 years exhibit particularly positive attitudes toward myopia management (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This mid-life advantage likely reflects the convergence of accumulated health knowledge, established caregiving experience, and sustained motivation to adopt novel preventive strategies\u0026mdash;qualities that may be weaker in younger caregivers (19\u0026ndash;34 years) because of inexperience or in retired elderly populations because of reduced exposure to contemporary health information. Collectively, these demographic patterns suggest that targeted interventions should prioritize educational enrichment and accessibility enhancement for rural, less educated, and younger or elderly caregiver populations to optimize myopia control implementation.\u003c/p\u003e \u003cp\u003eIntercity comparisons revealed distinct performance patterns: Beijing demonstrated superior atropine compliance, whereas Changsha consistently underperformed. Beijing\u0026rsquo;s advantage stemmed from its first-mover status\u0026mdash;although 0.01% atropine received NMPA approval only in 2023, compounded formulations were accessible at leading tertiary centers as early as 2019\u0026ndash;2021, creating a \u0026ldquo;clinical familiarity buffer\u0026rdquo; that fostered greater parental acceptance than in cities where commercial availability began after approval. Consequently, Beijing had the highest median behavior score [21.00 (15.00\u0026ndash;24.00)], significantly surpassing economically comparable cities such as Nanjing [16.00 (14.50\u0026ndash;17.00)] and Xiamen [16.00 (15.00\u0026ndash;17.00)] (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Conversely, Changsha, whose superior administrative unit of Hunan Province reported the lowest juvenile myopia prevalence among all samples, exhibited the poorest KAP scores, reflecting the \u0026ldquo;prevalence\u0026ndash;awareness paradox\u0026rdquo;\u0026mdash;a phenomenon where low-burden regions receive reduced policy investment and resource allocation (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These findings underscore the necessity of proactive educational outreach to \u0026ldquo;low-risk\u0026rdquo; regions to dismantle geographic barriers and correct the misconception that low prevalence equates to low risk, ensuring equitable implementation of all interventions.\u003c/p\u003e \u003cp\u003eAnalysis of information sources confirmed that clinical consultations were the primary channel for myopia knowledge acquisition (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), yet guardians consistently reported unmet needs for more comprehensive physician guidance. This demand\u0026ndash;supply gap stems from constrained outpatient consultation times and geographic barriers, particularly in disadvantaged rural populations with limited health care access (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNotably, respondents gave high effectiveness scores to \u0026ldquo;media and internet\u0026rdquo; sources, although concerns regarding information quality and credibility persist\u0026mdash;studies demonstrate that myopia-related online content often lacks reliability, with physician-generated materials consistently achieving superior quality ratings (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). These convergent findings suggest a hybrid solution by extending physicians\u0026rsquo; reach through digital platforms while maintaining content authority. Specifically, structured collaboration between ophthalmologists and medical students via social media channels could circumvent temporal and geographic limitations and deliver standardized, evidence-based education that enhances guardians\u0026rsquo; knowledge, attitudes, and behavioral compliance (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Such an approach addresses both the accessibility barriers of traditional clinical encounters and the quality deficits of unregulated online information.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has several methodological limitations. First, the cross-sectional design captured guardians\u0026rsquo; KAP at a single time point, precluding causal inference and longitudinal trend analysis. Second, the sampling was restricted to eight urban centers, potentially limiting generalizability to rural and remote regions with distinct socioeconomic and health care contexts. Third, reliance on self-reported data introduces potential recall and social desirability biases. Fourth, although the questionnaire was developed on the basis of authoritative guidelines and expert consensus, confirmatory factor analysis indicated suboptimal construct validity, suggesting potential measurement imprecision in the underlying theoretical constructs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study delineates distinct behavioral patterns in Chinese guardians\u0026rsquo; approaches to childhood myopia interventions. While robust knowledge, attitudes, and practices alignment was observed for spectacles and contact lenses, a critical knowledge\u0026ndash;behavior disconnect was observed for 0.01% atropine users. Specifically, the prevalent practice of self-discontinuation represents a significant barrier to long-term efficacy, underscoring the need for targeted adherence interventions. Intercity disparities\u0026mdash;characterized by superior performance in early-adopter cities and underperformance in low-prevalence regions\u0026mdash;highlight the \u0026ldquo;prevalence-awareness paradox\u0026rdquo; and necessitate expanded educational outreach to epidemiologically \u0026ldquo;privileged\u0026rdquo; areas. Leveraging digital platforms for health education conducted by ophthalmologists or medical students offers a scalable solution to bridge care gaps and ensure equitable myopia guidance across diverse populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eKAP Knowledge, attitudes, and practices\u003c/p\u003e\u003cp\u003eIMI International Myopia Institute\u003c/p\u003e\u003cp\u003eWHO World Health Organization\u003c/p\u003e\u003cp\u003eNMPA National Medical Products Administration\u003c/p\u003e\u003cp\u003eGDP Gross Domestic Product\u003c/p\u003e\u003cp\u003eOK Orthokeratology\u003c/p\u003e\u003cp\u003eCI Confidence Interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Capital Medical University (No. 2021SY074). This ethical approval covered the entire duration of the present study. Informed consent was obtained from all guardian participants, who were adults aged 19 years or older. No data were collected directly from children under the age of 16.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eYL, JS, and CZ contributed to the study conception and design. Material preparation, data collection and analysis were performed by YL, JS, CZ and CZhao. The first draft of the manuscript was written by YL and JS, and all authors commented on previous versions of the manuscript. CZhao assisted in manuscript writing and language polishing. RG supervised the project. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to Professor Fengju Zhang and her team from Beijing Tongren Hospital, Capital Medical University, for their invaluable academic guidance and expert advice on the study design.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLandreneau JR, Hesemann NP, Cardonell MA. review on the Myopia Pandemic: epidemiology, risk factors, and Prevention.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGifford KL, Richdale K, Kang P, Aller TA, Lam CS, Liu YM, et al. 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Front Pediatr. 2025;13:1554822.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Guardians of children/adolescents, 0.01% atropine eye drops, Spectacles, Contact lenses, Knowledge, attitudes, and practices (KAP) survey, Influencing factors","lastPublishedDoi":"10.21203/rs.3.rs-8881110/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8881110/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo investigate the knowledge, attitudes, and practices (KAP) of the guardians of children and adolescents aged 6\u0026ndash;12 years in eight cities across China regarding three myopia control interventions (0.01% atropine eye drops, spectacles, and contact lenses) and analyze the influencing factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA KAP questionnaire on basic knowledge, attitudes, and practices regarding myopia was developed through a literature review and expert consultation. An online survey was administered to guardians of children aged 6\u0026ndash;12 years across eight selected cities, and the data were analyzed using SPSS 27.0.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong the 1,509 valid questionnaires collected, 48.1% were from the guardians of myopic children; this group exhibited a significant difference from the guardians of non-myopic children on basic myopia questions (U\u0026thinsp;=\u0026thinsp;301754.0, W\u0026thinsp;=\u0026thinsp;564929.0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with the former (40 (35, 47)) scoring slightly higher than the latter (39 (34, 46)). Knowledge of spectacles and contact lenses was linked to positive attitudes and compliant behaviors (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with favorable attitudes predicting higher compliance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regarding 0.01% atropine eye drops, knowledge was positively correlated with attitude (r\u0026thinsp;=\u0026thinsp;0.475, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but neither was significantly correlated with behavior (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Common pitfalls in the usage of 0.01% atropine eye drops included discontinuing medication and transferring it to others. KAP scores were influenced by the demographics of the guardians, with higher education, urban residence, and an age range of 35\u0026ndash;49 years being associated with higher KAP scores. Significant intercity disparities were observed, with Beijing demonstrating the highest adherence to atropine and Changsha exhibiting the poorest spectacle use among the surveyed cities. While clinical consultations remained the predominant information channel, the high valuation of digital media underscores their potential as a scalable complementary strategy to bridge existing knowledge gaps.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe use of spectacles and contact lenses exhibited robust KAP alignment, whereas the use of 0.01% atropine manifested a critical knowledge-behavior disconnect characterized by prevalent self-discontinuation. Higher education, urban residence, and middle age predicted better KAP scores, whereas significant intercity disparities reflected a \"prevalence\u0026ndash;awareness paradox\" favoring cities whose medical centers were early adopters of 0.01% atropine for myopia control. These findings underscore the necessity of stratified educational interventions\u0026mdash;particularly digital health education delivered by ophthalmologists and medical students\u0026mdash;to bridge the information gaps and ensure equitable myopia guidance across diverse populations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial Registration\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Knowledge, Attitudes, and Practices (KAP) Survey Study in Chinese Children’s and Adolescents’ Guardians on the Three Methods of Myopia Intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 17:11:29","doi":"10.21203/rs.3.rs-8881110/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"186994924057025706893455900835016092381","date":"2026-03-30T05:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-20T16:38:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T12:33:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-20T09:11:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T16:48:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-19T15:00:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3af7bc0e-5c14-44ed-898e-57134f55a37b","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T17:11:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 17:11:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8881110","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8881110","identity":"rs-8881110","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}