In Part 1 of this blog, we explored the rationale for a public health approach to myopia. Also, we outlined some of the strategies that have been used so far and have demonstrated a positive short-term effect. We will now examine how a successful public health strategy for myopia might be implemented, and what policy measures might generate sufficient impact to reverse the myopia epidemic.
Research evidence, impactful interventions, performance management systems, strategic partnerships and compelling communication are the essential features of effective public health strategies. Innovation is important across each of these features, but the glue which pulls everything together is political commitment. This provides the traction necessary to deliver and sustain progress. Unfortunately, our efforts towards a public health solution for the myopia epidemic have been somewhat haphazard, and it seems clear that the above requirements for effective public health are not yet established.
This explains why just four Asian countries have committed national resources to this approach and why we do not yet have sufficient evidence to know whether any combination of behavioural interventions can deliver the required long-term public health impact required.
The first, and perhaps most important, step in tackling the myopia epidemic is to raise its public and political profile and secure the commitment to invest in the resources and policies required to address it successfully. Only when myopia is a public health agenda and becomes firmly established as a national and global priority can we expect to see a positive long-term impact.
Figure 1: Evidence-based advocacy will be key to securing the political support to tackle myopia
As discussed previously, measures such as increasing school-based time outdoors have seen a reduction in myopia incidence, prevalence and progression. While these short-term effects are encouraging, the evidence relating to the possible long-term benefit is essentially non-existent. We do have a more established evidence base regarding the efficacy of optical and pharmaceutical interventions to control myopia progression.
Perhaps the most justifiable public health approach to myopia, therefore, should involve public policy measures that maximize the possible benefits of a primary care-based practitioner-led strategy. Public policy provisions that (a) require active myopia treatment as the standard of care, (b) target pre-myopes for preventive guidance and therapy (e.g., prescribing low dose atropine or plano-powered peripheral defocus contact lenses) and (c) enable primary care practitioners to make myopia control treatments accessible (and affordable) to all myopes which may enhance the health and socio-economic impact achievable.
Any significant impact on population health is likely to depend on the wide-scale implementation of public health and primary care reform. The policy measures would have to address the various financial, educational, technological, legislative and other barriers which have limited the uptake of myopia control in clinical practice. The use of adjunct behavioural strategies can then support the practitioner-led approach and make it easier for families and communities to change their behaviour in ways that promote better eye health.
Figure 2: Some of the components required to promote behaviour change through public health measures
Myopia control is very much an emerging discipline, both as a primary care management strategy and as a public health priority. The sheer number of people at risk and the complex behavioral forces driving myopia, make this an urgent public health priority.
Supporting primary care solutions through carefully crafted public policy measures can provide a cost-effective means of preventing ocular disease. Combining these with simple and inexpensive ways to reduce near work and increase outdoors time at home and in school, can provide sufficient population level impact, but will only succeed with sufficient buy-in from clinicians and if the necessary supports are put in place to deliver and monitor change.