A “Survey of public Awareness on Low Vision Rehabilitation in China” questionnaire was designed and used to demonstrate the current state of LVR awareness. There were two subscales of awareness items in the questionnaire, which was the public subscale and vision professional subscale, respectively. If the interviewee was a vision professional, including ophthalmologists, optometrists, eye nurses, vision therapists, and vision company practitioners, then they answered items for vision professionals, otherwise they answered items facing to the public. An additional part of the questionnaire was items designed for people with visual impairments. This part aimed to reveal their situation on visual rehabilitation services.

The Delphi method (15–18) was used to select items and test the effectiveness and reliability of the questionnaire. An item bank (57 items) was collected through literature review and professional experiences. Two rounds of expert consultations were conducted based on the item bank. The expert consultations involved 20 experts, including seven low vision specialists, one rehabilitation training professional, eight ophthalmologists, three statistics experts, and one special education expert. One ophthalmologist's advice was not reliable and was excluded. After two rounds of expert consultations and a pilot study, a finalized questionnaire was produced, which included eight demographic items for all participants, 10 for the public, 16 for the vision professionals, and four for the visually impaired (Appendix 1). The Cronbach's α is 0.7 in vision and non-vision professional items.

An online mobile application named Wenjuanxing, which has functions equivalent to Amazon Mechanical Turk, was used to distribute the questionnaire. Individuals scan a QR code to access and answer the questionnaire.

This survey was conducted with two distinct participant groups: the general public and vision professionals. The questionnaire was distributed through representative hospitals in all provinces across China. Additionally, the survey was distributed to vision professionals attending the Vision China Conference in 2022 and 2023. Vision China Conference is one of the large-scale visual conferences in China. Attendees include ophthalmologists, optometrists, nurses, researchers, and visual enterprise employees, representing a highly representative cohort in vision professionals.

The sum score of all items of each participant was used to determine the person's LVR awareness. The mean score of an item of all the participants was used to assess the awareness of a particular item. If all the items were answered correctly, a maximizing score would be obtained.

Data was analyzed using a Chinese version of SPSS 25.0. Mean ± SD and median (quantile) were used to describe quantitative data. Frequency and composition ratios were used to describe categorical data. The sum score of each subscale was calculated. Principal component analysis (PCA) was used for questionnaire structure analysis. One-way analysis of variance (ANOVA) and logistic regressions were performed to show the relations of scores with demographics. p < 0.05 were considered as statistically significant.

A total of 1,482 questionnaires were collected, among which 952 was from the public and 530 was from the vision professionals. Six vision professional participants were excluded because they were < 18 years old, so 524 valid vision professional questionnaires were analyzed (Table 1).

Regardless of the public and the vision professionals, the majority of the participants was from Eastern China (57.9% in the public; 48.2% in the vision professionals, Figure 1). The age, gender, education level proportion and visual acuity was all similar in both groups. About 70% of the public and 90% of the vision professionals lived in urban areas, respectively. Details were listed in Table 1 and Figure 2.

The majority of the public participants were without medical education background (60.8%). For vision professional participants, 59.5% worked in a tertiary hospital/institute, and 68.8% knew how to refer low-vision patients to LVR departments (Table 1, Figure 3).

The mean sum score of all items in the public group accounted for 37.0% of the maximizing score (17.4/47.0). All the items could be categorized into 3 principal components, which accounted for 71% of the total variations, using principal component analysis (PCA). The three components were interpreted as awareness of LVR (PC1), awareness of low vision (PC2), understanding of the current living status of low vision population (PC3). The percentage of the mean score of the three principal components accounted for 31.0, 58.1 and 32.1% of the maximizing score, respectively (Table 2).

The mean sum score of all items of the vision professionals accounted for 55.6% of the maximizing score (32.3/58.0). All the items were also categorized into three principal components, which accounted for 60% of the total variations, using PCA. The 3 components were interpreted as Detailed information of LVR (PC1), Overall impression of LVR (PC2), understanding of the current living status of low vision population (PC3). The percentage of the mean score of the three principal components accounts for 59.5, 57.8 and 36.0% of the maximizing score, respectively (Table 3).

Multiple logistic regressions of sum scores of total items in the public group indicated that participants with higher education levels [OR (95% CI): vocational school, 0.5 (0.3, 0.9); bachelor's degree, 0.4 (0.2, 0.7), master's degree or above, 0.4 (0.2, 0.7)], with medical background [OR (95% CI): 0.4 (0.3, 0.5)], with good visual acuity [OR (95% CI): 0.4 (0.3, 0.7)], having eye checked every year or less [OR (95% CI): 0.4 (0.2, 0.7)] (Table 4).

For the vision professionals, participants who aged elder than 40 years old [OR (95% CI): 0.5 (0.3, 0.9)], with a better visual acuity [OR (95% CI): moderate, 0.2 (0.0, 0.9), good, 0.1 (0.0, 0.5)] demonstrated a better awareness of low vision. Besides, vision professionals who knew the low vision referral process of the institute which he/she worked in [OR (95% CI): 0.5 (0.3, 0.9)] showed a better awareness than those who did not know (Table 5).

The sum score of total items above the average was defined as high awareness and below the average was defined as low awareness. For the public, the main sources of obtaining LVR information were through doctors' advice (about 29%) and news media or internet (about 28%). A higher percentage of participants obtain parts of the knowledge from public awareness activities in the high awareness group, compared to the low awareness group (22.7 vs. 14.6%, p < 0.05). For the vision professionals, the main sources of obtaining LVR information in the low awareness group was through medical school education (30.0%) while in the higher awareness group, knowledge pathways were pluralistic, including medical school education, continual education, conference, and peer exchanges. A higher percentage of participants obtain parts of the knowledge from self-learning in the high awareness group compared to the low awareness group (17.0 vs. 12.6%, p < 0.05, Figure 4).

The mean score of total items was only one third of the maximal score in the public. The low awareness of LVR was not only demonstrated in low cognition of what is LVR, but also manifested in less attention to the living status of people with low vision. The public with higher levels of education and having medical background demonstrated better awareness. It is no doubts that people working in medical system have a better cognition of health compared to the public. Participants with better education have a higher possibility to represent a better level of cognition (24–27), or have better learning abilities, which leads to effective pathways to obtain LVR-related knowledge (28).

The average score of total items in the vision professionals is about one half of the maximal score, which is far from enough for a qualified vision professional. Most vision professionals know what low vision is and believe that visual rehabilitation training is necessary, while lack the awareness on how to deliver LVR. Vision professionals also show low attention to the survival status of individuals with low vision. Similar results have been presented in previous studies (29, 30). Research by Jose indicated that 64.0% of vision professionals lack awareness of LVR, and 62.1% of the vision professionals lack relevant training, which is a major obstacle to providing LVR services (31).

It is surprised to found that a better awareness of LVR of a vision professional was not related to whether an institution had a visual rehabilitation center or not, but associated with a settled process of low vision referral. We speculated that referral process indicated that this institution has a high possibility of implementing LVR services. Even if a doctor did not deliver LVR themselves, a timely referral informed a low vision person where to get LVR services, was equally helpful (32). The presence of a referral process allows resources and information sharing among staff, therefore, they would have a better understanding of LVR. This speculation is supported by literature researches. Data showed that the level of a hospital is not determined by department settings, but relies on high quality services (33, 34).

Although the public awareness on detailed LVR is limited at this moment, participants with visual impairments who have received rehabilitation services show a positive attitude toward visual rehabilitation (Figure 5), which is consistent with previous findings (4, 35–37).

The study also showed that the public mainly obtain low vision rehabilitation information through doctors' advice and public media. This emphasizes that the first visit doctor delivers low vision rehabilitation advice to the patient is important (38). The truth that participants who undergone eye check more frequently shew better awareness could also demonstrate the statement. The second method revealed form the results was that vision professionals should increase positive guidance and scientific education of LVR though public media. A survey conducted in Australia concerning LVR services revealed that 85% of Australian participants stated that receiving information about LVR was a facilitating factor in utilizing low vision services (32). However, negative behaviors and attitudes from ophthalmologists in introducing and recommending LVR services to patients have been found to be barriers to patients' acceptance of LVR services (32, 39).

In summary, public awareness can be gradually influenced (40). Doctors' advice in the clinic and scientific education though public media would help to improve the situation.

The primary approach of obtaining information was through studying during medical school education, for vision professionals with low awareness of LVR. For vision professionals with higher awareness, they get their knowledge from diverse ways, such as medical school education, continual education, academic conferences, and peer exchanges.

The results revealed that to improve basic low vision knowledge and awareness, college or university education would be helpful. Besides, university and college time is crucial for personal growth and the reshaping of values (41, 42). Low vision education during this period would help to create a systematic impression and be much more efficient than later casual learning (43).

Comprehensive and cutting-edge knowledge of low vision would mainly come from literatures and academic discussions. And standard LVR procedures would be provided in continual education courses (44). The cultivation of a better awareness and abilities in the later stage, attending more low vision conferences, symposiums and continual education would be a second chance.

The participants of the present study covered various provinces and cities nationwide in China, but with a primary concentration in eastern China and the hospitals involved were relatively in a high level in China. As the eastern side is much more developed than the northwest and southwest of China, if the awareness of the eastern area was not sufficient, then other areas would be even lower. The study might overestimate the current awareness of the public and the vision professional in China, but would not impact the solutions it revealed. Another limitation of the study comes from a cross-sectional study with self-reported answers, which can't tell why the study subjects lack awareness as well as the quantitative effectiveness the solutions, which needs later longitudinal studies to confirm.