Background: Childhood vision disorders like amblyopia and strabismus are common yet preventable causes of lifelong visual impairment. Early detection and timely intervention are critical, but parental awareness often determines whether such problems are identified during the critical developmental period. This study was conducted to assess the awareness, knowledge, and attitudes of parents in Shimla regarding childhood vision issues and early detection practices. Materials and Methods: A descriptive, cross-sectional study was conducted via an online survey among 400 parents of children aged 0–10 years residing in Shimla, Himachal Pradesh. A structured, bilingual questionnaire assessed socio-demographics, knowledge of amblyopia and strabismus, awareness of signs and symptoms, understanding of screening guidelines, and beliefs regarding treatment. Awareness scores were categorized into four levels: Very Good, Good, Fair, and Poor. Data were analyzed using descriptive statistics. Results: The majority of parents (45.5%) were aged 30–39 years, and 58.0% had a graduate-level education or higher. While 78.0% correctly identified strabismus as eye misalignment and 82.0% recognized frequent squinting as a symptom, only 55.0% knew the correct age for the first comprehensive eye exam, and just 54.0% understood that school screenings do not rule out all eye problems. Overall, 38.0% of parents demonstrated good awareness, 34.5% fair, 15.5% very good, and 12.0% poor knowledge levels. Conclusion: Although awareness of visible symptoms was relatively high, significant knowledge gaps exist regarding less obvious signs, screening protocols, and the need for early detection. These findings underscore the need for targeted educational initiatives to improve parental knowledge and encourage timely pediatric eye care in the Shimla region.
Childhood vision disorders, particularly amblyopia ("lazy eye") and strabismus ("crossed eyes"), pose significant public health concerns due to their potential for causing long-term visual impairment if left undiagnosed or untreated during early childhood. The early years of life represent a critical window for visual development, during which the brain’s visual pathways are highly plastic and responsive to treatment. Consequently, timely detection and intervention are essential to prevent irreversible visual deficits [1-3].
Despite the availability of effective screening tools and treatments, many children—especially in regions with diverse socio-economic profiles like Shimla—fail to receive timely eye care. This gap is often rooted in limited parental awareness of early warning signs, risk factors, and the importance of routine eye examinations. Early recognition of subtle indicators, such as squinting, frequent eye rubbing, abnormal head posture, or difficulty focusing, is crucial. However, these signs often go unnoticed or are misattributed by parents unfamiliar with pediatric vision disorders [4-6].
Amblyopia, typically resulting from strabismus or uncorrected refractive errors, is a leading cause of preventable visual disability in children. If not addressed during the early developmental period, it can lead to permanent vision loss in the affected eye. Strabismus, in addition to its visual consequences—such as impaired binocular vision and depth perception—can also affect a child’s psychosocial well-being, potentially leading to issues related to self-esteem and peer interaction [7-9].
In Shimla, a region characterized by both urban and semi-urban populations, disparities in access to health information and eye care services may further contribute to underdiagnosis. Assessing parental knowledge, attitudesattitudes, and practices related to childhood vision health is critical to identifying existing misconceptions and barriers to care. Such insights can inform the development of targeted health education campaigns and enhance the effectiveness of school-based and community-based screening programs.
This study aims to evaluate the level of awareness among parents in Shimla regarding common childhood vision problems—particularly amblyopia and strabismus—and the significance of early detection and treatment. It explores parental understanding of risk factors, warning signs, appropriate ages for screening, and treatment options. The findings will serve as a foundation for designing public health initiatives aimed at reducing preventable childhood visual impairment in the region.
Study Design
A descriptive, cross-sectional online survey was conducted to assess parental awareness, attitudes, and practices related to childhood vision problems—specifically amblyopia and strabismus—and the importance of early detection. The study was designed to gather quantitative data from a diverse parent population residing in Shimla, Himachal Pradesh.
Study Area and Population
The study targeted parents or primary caregivers of children aged 0 to 10 years residing in the Shimla district. Inclusion criteria required participants to:
Have at least one child within the specified age range
Be residents of Shimla
Have access to an internet-enabled device (smartphone, tablet, or computer)
Be able to read and understand either Hindi or English
Study Duration
Data collection was carried out over a three-month period, from February 2025 to March 2025.
Sample Size and Sampling Technique
Assuming a 50% prevalence rate for adequate parental awareness of childhood vision screening (due to a lack of prior localized data), with a 95% confidence level and 5% margin of error, the minimum sample size was calculated to be 384 participants. To account for potential non-responses or incomplete submissions, a target sample size of 400 was set.
A convenience sampling approach was employed. The survey link was disseminated via:
Local parenting forums
Social media platforms such as WhatsApp and Facebook groups specific to Shimla residents
Potential partnerships with schools and pediatric clinics to facilitate digital distribution
Inclusion and Exclusion Criteria
Inclusion Criteria
Parents or primary caregivers of children aged 0–10 years
• Residents of Shimla
• Access to an internet-enabled device
• Ability to understand Hindi or English
• Willingness to provide informed electronic consent
Exclusion Criteria
Individuals residing outside Shimla
Those without children in the target age group
Healthcare professionals specializing in ophthalmology or optometry (to prevent bias in awareness assessment)
Individuals unwilling or unable to provide consent
Data Collection Instrument
A structured, bilingual questionnaire (Hindi and English) was developed using Google Forms, informed by literature review and expert consultations in ophthalmology and public health. The questionnaire consisted of four sections:
Socio-Demographic Information: Age, education level, occupation, residence area (urban/semi-urban/rural), number of children, and the age of the youngest child
Awareness of Vision Problems: Knowledge of amblyopia and strabismus, risk factors, signs and symptoms, potential consequences, timing of screenings, and treatment options
Attitudes and Beliefs: Perceptions of the seriousness of childhood vision disorders, beliefs about vision development, and perceived barriers to seeking care
Information Sources and Practices: Where parents seek health-related information, history of eye check-ups for their child, and typical actions taken when vision problems are suspected
The questionnaire underwent pilot testing with 25 parents (excluded from final analysis) to evaluate clarity, cultural sensitivity, and technical reliability. Feedback from the pilot phase was used to refine wording and layout.
Data Collection Procedure
The online survey included a preface outlining the study's purpose, voluntary nature, data confidentiality, and instructions for giving informed electronic consent. The link was circulated across selected online platforms, and participation was fully anonymous—no personally identifiable information was collected.
Scoring and Categorization
Awareness was quantified based on correct responses to knowledge-based questions in Section 2. Each correct response received one point, with total scores categorized into four awareness levels:
• Very Good Awareness: ≥80% correct answers
• Good Awareness: 60–79% correct answers
• Fair Awareness: 40–59% correct answers
• Poor Awareness: <40% correct answers
Data Analysis
Survey responses were exported to Microsoft Excel and subsequently analyzed using statistical software (e.g., IBM SPSS version 26.0). Descriptive statistics—such as frequencies, percentages, and means (± standard deviation where applicable)—were computed to summarize socio-demographic variables, awareness scores, attitudes, and practices.
Ethical Considerations
Participation required informed electronic consent, and all responses were collected anonymously to ensure confidentiality and data protection.
Socio-Demographic Characteristics of Participants
A total of 400 parents participated in the study. Most respondents (45.5%) were aged 30–39 years, and 58.0% had completed a graduate degree or higher. The majority
(65.0%) resided in urban or semi-urban areas of Shimla. Regarding family size, 78.0% had one or two children, and the target child (youngest or specified) most frequently belonged to the 3–6 years age group (42.0%).
Table 1: socio-demographic characteristics of participating parents (n = 400)
Variable | Category | Frequency (n) | Percentage (%) |
Parent's Age (Years) | 20–29 | 88 | 22.0 |
30–39 | 182 | 45.5 | |
40–49 | 110 | 27.5 | |
≥50 | 20 | 5.0 | |
Education Level | Up to Higher Secondary | 168 | 42.0 |
Graduate and Above | 232 | 58.0 | |
Residence Area | Urban/Semi-Urban | 260 | 65.0 |
Rural Shimla | 140 | 35.0 | |
Number of Children | 1 | 156 | 39.0 |
2 | 156 | 39.0 | |
≥3 | 88 | 22.0 | |
Age of Target Child | 0–2 Years | 104 | 26.0 |
3–6 Years | 168 | 42.0 | |
7–10 Years | 128 | 32.0 |
Parental Awareness of Childhood Vision Problems
Awareness levels among parents showed considerable variation. While most respondents correctly identified strabismus as eye misalignment (78.0%) and acknowledged family history as a risk factor (72.5%), fewer were aware of the recommended age for a first eye exam (55.0%) or that serious vision problems may lack visible symptoms (60.5%).
Table 2: parental awareness of childhood vision problems and early detection (n = 400)
No. | Question | Options | Correct (n) | % |
1 | What is Amblyopia commonly known as? | a) Crossed Eyes, b) Lazy Eye, c) Near-sightedness, d) Color Blindness | 292 | 73.0 |
2 | Which of these is a common cause of Amblyopia? | a) Eye infection, b) Reading in dim light, c) Unequal focus between eyes or Strabismus, d) Watching too much TV | 276 | 69.0 |
3 | What is Strabismus? | a) Difficulty seeing far, b) Cloudy lens, c) Misalignment of the eyes, d) Difficulty seeing colors | 312 | 78.0 |
4 | Can Amblyopia lead to permanent vision loss if not treated early? | a) Yes, b) No, c) Only in rare cases, d) Only if both eyes are affected | 266 | 66.5 |
5 | At what age is a child recommended to have their first comprehensive eye exam? | a) Only if problems are suspected, b) By age 10, c) After starting school (6–7 years), d) Before age 5 | 220 | 55.0 |
6 | Which of these can be a sign of a vision problem in a child? | a) Excellent handwriting, b) Frequent squinting or eye rubbing, c) Reading quickly, d) Having aligned eyes | 328 | 82.0 |
7 | Can a child have serious vision problems without obvious signs? | a) Yes, one eye can have poor vision even if the eyes look straight, b) No, problems are always visible, c) Only if the child complains, d) Only if the eyes are crossed | 242 | 60.5 |
8 | Does family history increase a child's risk of eye problems? | a) Yes, b) No, c) Only if the mother had it, d) Only if the father had it | 290 | 72.5 |
9 | Who is best qualified to treat Amblyopia and Strabismus? | a) General Physician, b) School Nurse, c) Ophthalmologist/Optometrist, d) Pharmacist | 300 | 75.0 |
10 | Is patching the good eye a treatment for Amblyopia? | a) Yes, it strengthens the weaker eye, b) No, patching is outdated, c) Only used for injuries, d) Only used for Strabismus | 284 | 71.0 |
11 | Can Strabismus resolve without treatment? | a) Yes, by age 2, b) No, it usually requires intervention, c) Only if intermittent, d) Only if caused by fatigue | 236 | 59.0 |
12 | Can untreated Strabismus affect depth perception? | a) Yes, b) No, c) Only slightly, d) Only if eyes cross inward | 296 | 74.0 |
13 | Which activity may be difficult for a child with undetected vision issues? | a) Singing, b) Running in playground, c) Reading from the board, d) Listening to the teacher | 316 | 79.0 |
14 | Should premature babies have early eye exams? | a) Yes, they have a higher risk, b) No, their eyes develop later, c) Only if <1kg, d) Only if on oxygen | 308 | 77.0 |
15 | What does a school vision screening typically check for? | a) Only color vision, b) Only infections, c) Basic acuity and signs of problems, d) Sports readiness | 252 | 63.0 |
16 | Can glasses alone correct Amblyopia? | a) Yes, always, b) Sometimes, but often other therapy is needed, c) No, glasses don’t help, d) Only sunglasses help | 260 | 65.0 |
17 | Is persistent head tilting a sign of vision issues? | a) Yes, it can be due to strabismus or refractive error, b) No, just a habit, c) Only if there's neck pain, d) Only during reading | 192 | 48.0 |
18 | Is earlier treatment of Amblyopia more effective? | a) Yes, the brain is more adaptable in young children, b) No, same at any age, c) More effective in teens, d) Depends only on treatment type | 300 | 75.0 |
19 | Does screen time cause Amblyopia or Strabismus? | a) Yes, it's a primary cause, b) No, but it can cause eye strain, c) Only if screen is too close, d) Only after 4+ hours | 244 | 61.0 |
20 | Does passing a screening mean no eye problems? | a) Yes, screening catches all, b) No, full eye exams can detect more, c) Yes, if done by a nurse, d) Only if passed twice | 216 | 54.0 |
Overall, Knowledge Classification
Participants' awareness scores were categorized based on the percentage of correct responses. As shown in Table 3, 38.0% of parents demonstrated Good knowledge, while 34.5% had Fair awareness. Only 15.5% achieved a Very Good score, and 12.0% fell into the Poor category, indicating substantial gaps in understanding.
Table 3: parental knowledge score classification (n = 400)
Knowledge Category | Score Range (%) | Frequency (n) | Percentage (%) |
Very Good | ≥ 80 | 62 | 15.5 |
Good | 60 – 79 | 152 | 38.0 |
Fair | 40 – 59 | 138 | 34.5 |
Poor | < 40 | 48 | 12.0 |
The present study aimed to evaluate the level of awareness among parents in Shimla regarding childhood vision problems, specifically amblyopia and strabismus, and to assess their understanding of the importance of early detection. The findings offer significant insights into existing knowledge gaps, highlight prevalent misconceptions, and underscore the urgent need for improved public education regarding pediatric eye health.
A key observation is that while a moderate proportion of parents demonstrated basic to good awareness, only 15.5% achieved a “Very Good” score, indicating that comprehensive understanding remains limited. Encouragingly, awareness of more visible conditions such as strabismus (78.0%) and overt symptoms like frequent squinting or eye rubbing (82.0%) was relatively high. This suggests that parents are more likely to respond to obvious physical signs. However, less than two-thirds recognized that a child could have serious visual issues without any external signs—a critical gap, considering that amblyopia often progresses silently and is most effectively treated during the early developmental window.
The relatively low awareness of the recommended timing for a child’s first eye exam—only 55.0% identified “before age 5” as correct—raises concern, as early detection is pivotal in preventing irreversible visual deficits. This is further compounded by the fact that only 54.0% of parents understood that passing a school vision screening does not guarantee absence of vision problems. Such misunderstandings can delay diagnosis, particularly of conditions that require specialized examination beyond basic screening protocols.
Interestingly, awareness that family history plays a significant role in the development of amblyopia and strabismus was recognized by 72.5% of participants, indicating some understanding of genetic predispositions. Yet, recognition of subtler clinical signs like persistent head tilting (48.0%) was lacking, which is problematic since such compensatory behaviors can indicate underlying ocular misalignment or refractive errors.
Educational level and residence were not deeply analyzed in this section but may be contributing factors worth exploring in future studies. The use of a convenience sampling method, while practical for an online survey, may limit generalizability, especially as respondents with internet access may be more health-conscious or educated. Nonetheless, the data clearly reflect a broader need for targeted health communication strategies.
The results emphasize that while many parents can identify overt vision problems, there is insufficient understanding of asymptomatic or less noticeable signs, and of the need for routine pediatric eye evaluations, particularly during early childhood. These findings mirror results from other regional and international studies, which have also pointed to poor awareness as a major barrier to timely ophthalmic intervention. As such, integrating structured eye health education into school orientations, pediatric visits, and community health outreach programs could significantly improve early detection and outcomes.
This study highlights that although most parents in Shimla possess a basic awareness of childhood vision problems such as amblyopia and strabismus, significant knowledge gaps persist—particularly regarding asymptomatic conditions, optimal screening timelines, and limitations of school-based vision checks. To prevent avoidable visual impairment in children, it is essential to strengthen parental education through targeted, community-based awareness campaigns and to promote early, routine pediatric eye examinations as a standard component of child healthcare.
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