Caixin Reports on REAP: Giving Rural Children Eyeglasses

How prevalent is poor vision in rural China and why isn't the problem being addressed?

How prevalent is poor vision in rural China and why isn't the problem being addressed? Read more to learn about REAP's efforts to shed light on the issue.

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Caixin Report: Anemic Babies

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Several rural “left behind” children from Anyang in Henan Province are given a vision test.

Two years ago, Yan Biao—who sits in the last row in his classroom—told his father that he was having trouble seeing the blackboard. When he copied math problems from the board during class, he would often copy them down wrong. He wanted to get a pair of glasses.

His dad didn’t worry about it much. “At that time I just assumed he’d seen other kids in his class wearing glasses and now he wanted them too." 

This year Yan Biao is an 11 year-old sixth-grader at a rural elementary school in northern Shaanxi Province. He is now one of seven kids in his class who wear glasses. One year ago, researchers from the Rural Education Action Program (REAP)—a collaborative research organization formed by Stanford University, the Chinese Academy of Sciences, and other prominent research institutions—traveled to his elementary school and administered free vision screenings to all the fourth and fifth grade students. They also gave out free fitted eyeglasses to all the students they found to be nearsighted.

“If the school hadn’t given him a pair of glasses, I definitely wouldn’t have taken the initiative to get him fitted for a pair myself,” Yan Biao’s father said. “I guess I didn’t even understand the concept of nearsightedness.”

This is one of the key findings of REAP’s Vision Protection Program. “No matter if it’s the principal, the teachers, or the parents, no one is aware of these kids’ nearsightedness,” says REAP’s co-director, Professor Scott Rozelle, a development economics professor at Stanford University. Most Chinese think of rural children as growing up surrounded by nature, with little school pressure and lots of time to play outside. “How could they possibly be nearsighted?” 

In fact, all the same TV shows and computer games that are so popular in urban areas also fill up rural children’s free time. In fact, rural children’s rate of nearsightedness is slowly rising because they spend so much time in front of a screen.  By conducting visual screenings in 253 poor elementary schools across Shaanxi and Gansu Province, REAP found that 24% of all fourth and fifth grade students are nearsighted.

Even more troubling than the overlooked rate of nearsightedness, most rural children do not have access to appropriate vision correction services. In REAP’s study, only one out of every six nearsighted students had been prescribed eyeglasses.

“If you can’t see clearly, how can you learn?” In Scott Rozelle’s opinion, the scarcity of eyeglasses is in fact a huge problem for China’s educational equity and public health.

Rural Children are Nearsighted Too

It’s not the case that Yan Biao’s father hasn’t taken note of his son’s vision problems. He noticed that starting in fourth grade, his son was already squinting his eyes and sitting closer and closer to the TV.

From this he concluded that his son was watching too much television. “Ever since he was little he liked watching TV. He would begin watching TV in the morning and continue watching all day long until he went to bed. Even when he was eating he would be watching TV.” Yan Biao’s father tried to control his son’s TV time. At least when he was at home, Yan Biao was not allowed to turn on the TV, but the Yan family has over 6 acres of land to keep them busy. In addition, they own more than forty sheep and twenty pigs so both parents spend all their time outside working. “We simply can’t pay that much attention to the kids.”

“Watch TV, play computer games, watch more TV.” In another rural elementary school in northern Shaanxi Province, this is how 11 year-old Jiang Hang describes his weekend activities. Because he boards at school during the week, when he gets home for the weekend he doesn’t leave the house. From the cartoons that play at 5 in the morning to the soap operas that come on at 8 at night, he spends all day sitting in front of the TV.

“The problem with rural children is no different from the situation of urban kids.” Jiang Hang’s homeroom teacher—Teacher Chen, the math teacher for fifth grade—says that in addition to watching plenty of TV, more and more families have purchased computers. Now as soon as students get home they go online. Either that or they grab hold of their parents’ cell phones and play games. “The only difference might just be that in the cities, parents are more strict with their kids. In rural areas, many kids have been left behind by parents who have migrated to urban areas for work. Their grandparents are simply unable to control the kids’ behavior.”

Still, if you ask how many students in his class are nearsighted, Teacher Chen is unable to say. In this rural elementary school, there are no regular health exams. Even though every classroom has an eye chart taped to the wall, no one has ever actually used the chart to administer a vision test to any of the students.

On November 11, 2013, when REAP volunteers visited Teacher Chen’s elementary school, it was the first time any of the students had ever been given an eye exam. Forming a long line outside the classroom, all 52 fifth graders were brought in one by one and given a preliminary vision screening by REAP volunteers. Every student who couldn’t clearly see the letters at the 0.5 level was “filtered out” and taken downstairs to have a full eye exam including pupil dilation, computer eye screening and lens insertion testing. 

At the start, Teacher Chen estimated that her class would have four or five students with any kind of vision problem. In the end, the result shocked her—out of her 52 students, 24 students had worse than 20/40 vision. Of these, 18 students needed corrective lenses with the majority falling between 20/100 and 20/200.

This high level of nearsightedness was consistent with REAP’s findings in previous studies. In administering eye exams to nearly 20,000 fourth and fifth graders across northwestern rural China, REAP found that the average rate of nearsightedness is 24%. Fourth graders are nearsighted at a rate of 21%, and fifth graders at 27%. In Shaanxi Province the rate is 31%, which is much higher than Gansu’s 18%. Surveys conducted among junior high school students were even more troubling—after administering eye exams to 5,211 seventh and eighth grade students, REAP found that the proportion of students with eye problems was fully 57%.

Scott Rozelle explains that these findings match up with research conducted by other organizations both in China and abroad. As economic conditions improve in a given area, the rate of nearsightedness tends to rise. As children get older, the likelihood that they will be nearsighted also increases.

Dr. Xiao Baixiang—the deputy director of ophthalmology at the Sun Yat-sen Ophthalmology Center’s Office for the Prevention and Treatment of Blindness—explains that the academic world has reached a consensus on the primary causes of nearsightedness. Nearsightedness is now known to be related to genetic and ethnic factors, as well as visual habits, outdoor exercise and eating habits. 

Based on what limited data is available at present, it seems that vision impairment is even more common among urban children than rural children. As for whether or not rural children’s vision has been declining in the past few years, there is no reliable data available to draw a conclusion. “Until now, no one had ever considered that Chinese rural children’s eyesight might be such a big problem,” says Rozelle.

Unaware Adults

Compared to the other issues that REAP focuses on—including rural children’s anemia and undernutrition—nearsightedness is the easiest health problem to “treat.” All that’s necessary is to give each nearsighted child a pair of suitable eyeglasses.

However, before REAP came to their school to do a survey, there were only two students in Teacher Chen’s class that wore glasses. One of the children has weak vision and has worn glasses since he was very young. The other child already has 20/300 vision and has no choice but to wear glasses.

REAP’s previous surveys have discovered similar situations. Among elementary school children in fourth and fifth grade, only 16% of nearsighted students are wearing glasses. In Gansu Province the rate is 11%; in Shaanxi Province it’s 19%. By the time students reach junior high, only 10% of nearsighted students have been prescribed glasses. REAP’s research in other regions is similarly concerning. In Shanghai’s migrant community schools, students that wear glasses only make up 15% of the total nearsighted cohort. In rural junior high schools in Guangzhou, the proportion is 17%.

“In urban classrooms, almost all the kids are wearing glasses, but in rural elementary schools, you almost never see students that wear glasses,” Professor Scott Rozelle emphasizes. This definitely isn’t because rural children’s eyesight is better. Rather it’s because they have never had the opportunity to have their vision corrected. 

Right after finishing the eye exam in her classroom, Rong Rong can already experience the magic of a fitted pair of glasses. When she puts on the test eyeglass frames set to her new prescription, she stands in the doorway of the optometrist’s office and looks around in every direction. “I can finally see those characters across the way clearly!” she says. However, when she is asked whether she will ask her parents to get her fitted for a pair of glasses, Rong Rong is very hesitant. “The boys in my class will make fun of me,” she says.

Many of the boys actually think that wearing glasses is cool. However, Jiang Hang—who was been diagnosed with 20/150 nearsighted vision—still isn’t willing to wear them. “My dad says that if you aren’t already nearsighted, as soon as you put on glasses you will become nearsighted.”

“It’s not a question of money.” When you ask why rural children don’t wear glasses, almost all teachers and principals give the same answer.

Teacher Chen believes that even though there are some very poor families that rely on welfare subsidies for their living, for the vast majority of families in rural areas, buying a 100 or 200 RMB ($16-$32 USD) pair of glasses for their child presents no real problem. “Instead it’s a problem of insufficient knowledge.” 

The principal at Yan Biao’s school is nearsighted, but even the principal often doesn’t wear his glasses. “It’s not convenient and I don’t dare to wear them when I exercise. In the winter when I walk into a room they fog up and I can’t see anything. For children it’s even more of a pain.”

The principal candidly admits that most rural parents—including himself—believe that wearing glasses makes children’s eyesight get worse and that glasses even make your eyes change shape so as to impact your physical appearance.

“My dad says, if you can get away with not wearing glasses, it would be better not to.” After Yan Biao received his free glasses from the REAP program and went home, his dad still stubbornly believed that if his son wore glasses, it would make his eyesight decline. 

REAP discovered in their survey that 20% of rural doctors believe that elementary school students shouldn’t wear glasses even if they are already nearsighted. The proportion of principals that hold the same point of view is fully 51%. 70% of parents and 74% of students also hold this belief. More than one third of principals, parents and students all agree with the statement, “Wearing glasses makes vision deteriorate.” In fact, scientific research has proven that if nearsighted students aren’t prescribed glasses to correct their poor vision while they’re still young, they face a high risk of developing poor vision. In this way they may well be subjected to permanent visual impairment. 

As compared to wearing glasses, rural teachers and students believe much more strongly in the benefits of so-called “eye exercises.” When a REAP volunteer asked rural students, “What is the effect of visual exercises?” the students all immediately responded, “They improve your vision and protect your eyes.”

REAP’s survey discovered that fully 90% of rural doctors believe that eye exercises are an effective way to correct nearsightedness. More than half of rural principals, parents and students also believed this to be true. However, the fact is that outside of China, there are no other countries or regions in the world that promote eye exercises. There is also no evidence whatsoever that eye exercises can prevent or alleviate nearsightedness.

The roots of this misperception run deep. When asked whether they would allow their children to wear glasses if their nearsightedness was impacting their grades, more than half of rural parents still resolutely answered, “No.”

Breaking the Vicious Cycle

Even though many parents and teachers don’t trust eyeglasses, the actual benefits that glasses bring to children that need them are self-evident.

“Test grades obviously improve, students raise their hands more actively in class, and quite clearly become more self-confident.” Yan Biao’s math teacher says he has seen big changes in many of his students’ grades—after last year’s vision test, all of them received a free pair of eyeglasses.

Yan Biao is a counter-example. Because of his own carelessness, three months ago he dropped and broke his free eyeglasses. Since then, his dad has hesitated to get him a new pair. His math grade dropped from 47 points to 27 points. “I can’t see the blackboard anymore.” Yan Biao laments.

In Scott Rozelle’s eyes, the scarcity of corrective eyeglasses brings about a whole series of problems. Poor vision seriously impacts children’s academic performance, reduces their chances of advancing to the next grade level in school, and changes the course of a student’s entire academic career. If a large cohort of rural students are thereby unable to get a good education, it will directly influence the quality of China’s future labor force. With a poor quality labor force, China will be unable to continue its current economic transformation and which will then place a burden on the rest of the world as the country falls into the “Middle Income Trap.”

By changing only one factor—providing a pair of corrective eyeglasses—children’s academic performance improves enormously. REAP separated its 250 sample schools into two separate groups—one group received glasses and the other did not. Comparing students of the same level of nearsightedness seventh months later, the math test scores of the students that had been given corrective eyeglasses had increased by 0.65 standard deviations—this is a difference equivalent to two extra semesters of school.

Scott Rozelle explained that while REAP has conducted intervention experiments on nutrition, anemia and many other factors that influence educational performance, this vision intervention had the most obvious impact of all. The effect of vision on academic performance has greatly surpassed many people’s expectations.

In one rural school in northern Shaanxi Province, Scott Rozelle found one more explanation for this phenomenon. He discovered that students with poorer vision generally have poorer grades and are more likely to be placed by their teachers in the back row of the classroom where they can see the blackboard even less clearly. In this way, these students are caught in a vicious cycle.

Visual Health Should Not be Overlooked

“You can bring about big changes just by wearing glasses.” Even though the principle is quite simple, REAP has discovered that getting kids to wear glasses is not as easy as one might imagine.

REAP has designed three different methods to tackle rural China’s vision care problem: the first was to offer visual health training to students, teachers and parents. This included showing students an informational video and illustrated booklet as well as giving teachers and parents a training handbook. These materials all emphasized the importance of wearing glasses and tried to counteract several common misperceptions about visual health. Unfortunately, the results of this training session were disappointing. 

REAP found that before and after the training session, the proportion of parents that had their children fitted for glasses only increased by 2%. Some volunteers discovered that many parents and teachers assumed that REAP had come to these schools only looking to sell glasses.

The second approach REAP designed was to give nearsighted children a glasses “voucher”—parents could take this voucher to the county seat and obtain a free pair of glasses. The result of this intervention was that 84% of parents went to exchange the voucher for a pair of free glasses. The third approach REAP used was to have an optometrist deliver the free pair of prescribed glasses directly into the children’s hands.

In the end, the unexpected result was that even when students were given a free pair of corrective lenses, 20% of them still did not wear their glasses regularly. The explanation the children gave was still that their parents or teachers wouldn’t let them wear them because they believed wearing glasses makes your vision worse. 

In the end, directly distributing free eyeglasses is the most effective way of enabling children to see more clearly. However, should buying glasses for children be the government’s responsibility? Many participants in REAP’s program continue to have different opinions. Qin Xiaodong of Essilor, the lens sponsor of the program, believes that the provision of eyeglasses should be left to the market. Meanwhile, government funding should be invested in more front-end work—providing more effective visual health education and enforcing visual screening requirements.

Lu Mingkai, the former deputy director of the Shaanxi Provincial Education Department, has been closely following the state of rural students’ visual problems for many years. In his opinion, health education—the first step in preventing nearsightedness—is seriously lacking. Common topics such as how children can protect their vision and how they can be properly fitted for glasses should be covered in school and through community education. Especially within the education system, schools should not only launch activities dedicated to visual health awareness, but these efforts should also become basic school evaluation indicators. As compared to the training programs of an NGO that has just entered a school campus, he believes that publicity disseminated directly by the education system will be able to more easily earn teachers’ and parents’ trust.

Another task involves providing students with regular eye screenings. As Lu Mingkai explains, in most urban schools, students receive a general health examination once every year. In rural areas, on the other hand, departments of education and health often defer responsibility for funding regular health checkups. If finances haven’t been specially earmarked, many schools don’t actually carry out these health checkups—let alone visual screenings. Even in those rural schools that do carry out health checkups, the test results are never given to children’s parents but simply left in the school’s files. “Once the checkup is over, they’re done.” In the end, parents are simply not made aware of their children’s visual situation or any of the consequences of nearsightedness. 

In the eyes of many participants of REAP’s program, changing people’s outdated ways of thinking, remains one of the biggest challenges for rural education work.