Childhood visual impairment is an increasingly recognized public health concern worldwide, including in Saudi Arabia, where uncorrected refractive errors, amblyopia and other preventable eye conditions contribute to long-term visual disability. Early detection and timely intervention are crucial in mitigating these issues, highlighting the need for effective preventive strategies that focus on awareness, screening and proactive eye care measures. Given that children spend a significant portion of their time under the supervision of parents and teachers, these caregivers play a central role in identifying early signs of visual problems, ensuring timely medical consultations and reinforcing healthy visual habits. However, a lack of knowledge and awareness among parents and educators often leads to missed opportunities for early diagnosis and intervention. Empowering parents and teachers with accurate information on preventive eye health can significantly enhance their ability to safeguard children’s vision.   University students, particularly those pursuing careers in health sciences, represent a valuable yet underutilized resource in strengthening community-based eye health education. Their academic background, combined with their potential role as future healthcare professionals, positions them as effective advocates for disseminating crucial eye health information to parents and teachers.   By understanding university students' perspectives on how preventive eye health education can be enhanced, targeted interventions can be developed to bridge existing knowledge gaps and improve awareness at the community level. Incorporating their insights can lead to innovative, accessible and culturally appropriate educational strategies that promote early detection and prevention of childhood visual impairment. Ultimately, such efforts can contribute to reducing the burden of avoidable visual impairment and fostering a society that prioritizes children's eye health.

Eye health is crucial for a child's overall development and early detection of vision problems can prevent lifelong impairment and its long-term consequences [1-2]. Parents and teachers play a crucial role in preventing eye diseases in children and raising their awareness of early signs and preventive measures ensure timely intervention [3-4]. There has been a significant increase in the prevalence of pediatric eye diseases worldwide, driven by a combination of factors such as rising screen time, genetic predisposition, environmental influences and a lack of early detection and preventive measures [5-7].   Studies show that in Saudi Arabia up to 20% of school-aged children suffer from refractive errors, many of which go undiagnosed [8-10]. This highlights the need for targeted preventive eye health education for parents and teachers, who often first notice changes in a child’s vision [11-14]. Culturally, family plays a central role in health decisions, with norms emphasizing the responsibility of the family for children's well-being. Therefore, involving parents in health education initiatives is essential. Understanding local cultural values is critical for developing effective strategies [15-16].   University students, especially those in health and education fields, are well-positioned to promote eye health education by bridging academic knowledge with community needs. Research highlights that culturally sensitive, community-driven programs are most effective in public health initiatives [17-18]. Understanding students' perspectives on preventive eye health education is essential for developing strategies that effectively engage parents and teachers. However, challenges such as the need for adequate training, institutional support and potential resistance from parents or educators must be addressed. Collaboration among students, educators and health professionals is crucial for establishing sustainable and impactful programs.   The current study aims to explore university students' perspectives on the importance, challenges and approaches to preventive eye health education for parents and teachers.

Study Setting and Design From September 15, 2024 to January 15, 2025, this cross- sectional descriptive survey was conducted among Northern Border University students in Arar city of Saudi Arabia.   Sample Size and Sampling Method Convenient sampling technique was employed and the minimal sample size for the study (386) was calculated according to the equation:   where, "Z1-∞/2 = is the standard normal variate at 5% type 1 error (p<0.05); it is 1.96, p = the expected proportion based on previous studies, d = the absolute error (0.05), the expected proportion was considered 50% since there is no previous study in the Northern, Border region and to maximize the sample size."   Research Tool The level of awareness was assessed using a predesigned bilingual questionnaire (Arabic and English), which included an introduction section followed by a demographics section. Awareness of preventive eye health and perspectives on current education efforts were assessed through five questions in each section. The final section comprised four questions focusing on improvement suggestions. The questionnaire was distributed online via platforms such as Google Forms and university portals, as well as in-person at university campuses.   Inclusion and Exclusion Criteria Both genders who are 18 years and above and are studying at a university were included. Individuals who live outside the study area and who are mentally challenged were excluded   Statistical Analysis STATA/SE version 11.2 for Windows (STATA Corporation, College Station, Texas) was used for data management and analysis. The data were described in terms of frequency and percentage regarding categorical data and Mean±Standard Deviation (SD) regarding quantitative data. Shapiro-Wilk W test was used to examine the distribution of knowledge scores. Comparisons of students’ knowledge levels between the different study groups were carried out using the Kruskal Wallis test (χ2) and the Mann-Whitney Test (Z), as appropriate. Statistical significance was considered at p<0.05.   Ethical Approval Ethical approval number 104/24/H for this project was issued by the Local Committee of Bioethics of Northern Border University.

A total of 482 university students participated, with the majority (62.86%) aged 18-22 years. Male students comprised 68.46% of the sample. Most students (59.96%) were from the College of Medicine and the largest group (24.27%) were in their fourth year (Table 1).   Over half (55.39%) had received formal education on eye health but only 41.49% had participated in related   Table 1: Demographic and Background Characteristics of the Studied Students (N = 482) Variable No. % Age (years) 18-22 303 62.86 23-27 127 26.35 28 or above 52 10.79 Gender Male 330 68.46 Female 152 31.54 College College of Medicine 289 59.96 College of Business Administration 22 4.56 College of Home Economics 3 0.62 College of Education and Arts 32 6.64 College of Nursing 36 7.47 College of Science 24 4.98 College of Applied Medical Sciences 22 4.56 Community College 14 2.90 College of Engineering 18 3.73 College of Sciences and Arts 4 0.83 College of Pharmacy 12 2.49 College of Computing and Information Technology 6 1.24 Academic Year First Year 75 15.56 Second Year 51 10.58 Third Year 70 14.52 Fourth Year 117 24.27 Fifth Year 53 11.00 Sixth Year 80 16.60 Internship 36 7.47   Table 2: Students' Awareness of Preventive Eye Health Education for Parents and Teachers in Saudi Arabia (N = 482) Variable No. % Have you received any formal education or training on eye health? Yes 267 55.39 No 215 44.61 Have you ever participated in or organized any activities related to eye health education? Yes 200 41.49 No 282 58.51 How aware are you of common eye health issues in children (e.g., refractive errors, amblyopia)? Very aware 141 29.25 Somewhat aware 165 34.23 Not very aware 120 24.90 Not aware at all 56 11.62 Do you believe that preventive eye health education is important for parents and teachers? Strongly agree 323 67.01 Agree 101 20.95 Neutral 44 9.13 Disagree 6 1.24 Strongly disagree 8 1.66 How strongly do you feel that preventive eye health education is currently covered by your university curriculum? Strongly covered 168 34.85 Moderately covered 162 33.61 Slightly covered 91 18.88 Not covered at all 61 12.66 Total score Mean ±SD 3.16±1.47   Table 3: Relationship Between Students' Awareness of Preventive Eye Health Education for Parents and Teachers in Saudi Arabia and Their Age and Gender (N = 482) Variable No. Knowledge score (Mean±SD) Test P Age (years) 18-22 303 3.10±1.47 X2 =7.76 0.02 23-27 127 3.46±1.39 28 or above 52 2.85±1.53 Gender Male 330 3.31±1.45 Z=3.16 0.002 Female 152 2.85±1.46 P2: The Kruskal Wallis test statistic, z: The Mann-Whitney test statistic, Statistical significance was considered at p<0.05   activities. Awareness of common pediatric eye conditions varied, with 29.25% being very aware, while 11.62% had no awareness. Most students (67.01%) strongly supported preventive eye health education for parents and teachers, yet only 34.85% felt their curriculum adequately covered the topic (Table 2).   Awareness significantly differed by age (p = 0.02), with students aged 23-27 scoring highest (3.46±1.39). Gender differences were also significant (p = 0.002), with males scoring higher (3.31±1.45) than females (2.85±1.46) (Table 3, Figure 1 and 2).   About 32.37% considered current initiatives very effective, while 20.75% found them ineffective. Barriers included lack of awareness (59.13%), limited information access (42.95%), cultural factors (31.95%) and insufficient resources (30.29%). Key suggested topics for education   Table 4: Students’ Perspectives on Current Educational Efforts to Enhance Preventive Eye Health Among Parents and Teachers in Saudi Arabia (N = 482) Variable No. % How effective do you believe the current eye health education initiatives for parents and teachers in Saudi Arabia are in preventing vision-related issues in children? Very effective 156 32.37 Somewhat effective 96 19.92 Neutral 114 23.65 Somewhat ineffective 64 13.28 Very ineffective 36 7.47 Unsure 16 3.32 What are the main barriers to effective preventive eye health education for parents and teachers in Saudi Arabia?* Lack of awareness 285 59.13 Limited access to information 207 42.95 Cultural factors 154 31.95 Insufficient educational resources 146 30.29 Lack of trained professionals 158 32.78 What key topics should be included in preventive eye health education for parents and teachers?* Common eye conditions and their prevention 294 60.99 Early detection of vision problems 278 57.68 Importance of regular eye exams 246 51.04 Proper use of digital devices 200 41.49 Healthy dietary habits for eye health 134 27.8 Do you believe that incorporating preventive eye health education into the existing school curricula could benefit students and teachers? Strongly agree 212 43.98 Agree 172 35.68 Neutral 78 16.18 Disagree 18 3.73 Strongly disagree 2 0.41 How willing are you to participate in programs that aim to enhance your knowledge about preventive eye health? Very willing 222 46.06 Somewhat willing 184 38.17 Not very willing 67 13.9 Not willing at all 9 1.87 *More than one answer was allowed     Figure 1: Comparison of Students' Awareness of Preventive Eye Health Education for Parents and Teachers in Saudi Arabia by Age (N = 482)   included common eye conditions (60.99%), early detection (57.68%), regular exams (51.04%), digital device use (41.49%) and eye-healthy diets (27.80%). Most students (43.98%) strongly supported integrating eye health into school curricula and 46.06% were very willing to participate in educational programs (Table 4).   Proposed improvements included community programs (58.71%), school curriculum integration (48.34%), workshops (45.23%), digital platforms (41.91%) and volunteer initiatives (30.70%) (Table 5).     Figure 2: Comparison of Students' Awareness of Preventive Eye Health Education for Parents and Teachers in Saudi Arabia by Gender (N = 482)

Demographic Characteristics of Participants A total of 482 university students participated in this study, representing a diverse sample. The majority (62.86%) were aged between 18-22 years, with a predominance of male students (68.46%). This gender distribution may reflect the demographics of the university and participation trends in health-related research. Most students were from the College of Medicine (59.96%), with the largest group (24.27%) in their fourth year of study. Their higher representation could   Table 5: Students’ Suggestions for Improving Preventive Eye Health Education for Parents and Teachers in Saudi Arabia (N = 482) Variable No. % In your opinion, what strategies could be adopted to enhance preventive eye health education for parents and teachers in Saudi Arabia?* Developing community-based educational programs 283 58.71 Integration of eye health topics into school curricula 233 48.34 Collaboration with healthcare professionals for workshops and seminars 218 45.23 Use of digital platforms and social media for awareness 202 41.91 Encouraging volunteer opportunities in eye health 148 30.7 Do you believe technology (e.g., apps, virtual reality) could play a role in enhancing preventive eye health education? Very significant 210 43.57 Significant 164 34.02 Neutral 84 17.43 Slightly significant 13 2.7 Not significant at all 11 2.28 What types of technology do you think would be particularly effective in promoting eye health education? * Mobile health apps 253 52.49 Online educational sessions 200 41.49 Virtual reality simulations 154 31.95 Interactive webinars 142 29.46 Social media campaigns 201 41.7 *More than one answer was allowed   suggest increased engagement in academic initiatives and surveys at this stage of their education. Consistent with our findings, higher male participation in preventive health programs has been observed in Saudi Arabia [19]. In contrast, studies from Turkey [20] and Sweden [21] report greater female participation, highlighting geographical and educational differences that may influence engagement in health awareness programs.   Awareness of Preventive Eye Health Education More than half of the participants (55.39%) reported receiving formal education or training in eye health. However, despite this exposure, only 41.49% had actively participated in related activities, suggesting a disconnect between theoretical knowledge and practical application. This gap underscores the need for more interactive engagement strategies to ensure students apply their knowledge in real-world settings.   Perception of Common Eye Health Issues in Children The level of awareness regarding common childhood eye health issues varied among students. While 29.25% reported high awareness, 34.23% indicated moderate awareness. Encouragingly, a majority (67.01%) strongly agreed on the importance of preventive eye health education for parents and teachers. However, only 34.85% felt that their university curriculum adequately covered the topic, revealing a significant discrepancy between the perceived importance of eye health education and its academic representation. This suggests the need for curriculum enhancements that integrate preventive eye care more comprehensively.   Influence of Age and Gender on Awareness The study found significant associations between students’ awareness levels and their age and gender. Older students (aged 23-27 years) exhibited higher awareness levels, with a mean knowledge score of 3.46±1.39, compared to younger students (aged 18-22 years). This trend may reflect increased academic exposure to eye health topics over time. Additionally, male students had significantly higher knowledge scores than female students (3.31±1.45 vs. 2.85±1.46), warranting further exploration into gender-specific factors that influence awareness. Cultural, educational and social influences may contribute to these differences, emphasizing the need for targeted interventions to address potential disparities.   Effectiveness of Existing Eye Health Education Initiatives Student opinions on the effectiveness of current eye health education initiatives for parents and teachers were mixed. While 32.37% found these initiatives very effective, 23.65% rated them as neutral or ineffective. This finding suggests that while some programs are beneficial, others may lack accessibility, engagement or relevance. Improving the structure and outreach of these initiatives is crucial to ensuring their effectiveness in raising awareness and fostering preventive eye health practices.   Barriers to Effective Preventive Eye Health Education Several barriers to effective eye health education were identified, including lack of awareness (59.13%), limited access to information (42.95%) and cultural factors (31.95%). These findings highlight critical obstacles that hinder widespread implementation of educational programs. Addressing these challenges requires targeted interventions, such as improving accessibility to educational resources, tackling cultural stigmas and promoting community-wide understanding of eye health.   Strategies to Enhance Preventive Eye Health Education Students proposed various strategies to improve preventive eye health education. The most favored approaches included integrating eye health topics into school curricula (43.98%) and developing community-based educational programs (58.71%). These findings reinforce the importance of embedding eye health education within broader public health initiatives.   Additionally, students showed strong interest in utilizing technology for eye health education. A significant proportion (43.57%) viewed digital tools as essential, with mobile health applications (52.49%) and online educational sessions (41.49%) being the preferred platforms. These insights suggest that leveraging digital resources could enhance the accessibility and reach of eye health education programs, particularly among parents and teachers.

This study highlights a significant gap in preventive eye health education among university students, particularly in terms of formal training, participation in related activities and integration into the academic curriculum. While most students recognize the importance of eye health education for parents and teachers, there is a clear need for more comprehensive coverage of eye health topics in university curricula. Furthermore, the findings suggest that increasing awareness, overcoming barriers such as limited access to information and leveraging technology could enhance the effectiveness of preventive eye health education. Addressing these issues will be crucial in promoting better eye health practices and ensuring that students are well-equipped to educate others, particularly in school and community settings. The study also calls for future research to explore the impact of current educational initiatives and to develop strategies for more targeted and effective eye health programs.   Strengths The study provides valuable insights into university students' awareness of preventive eye health education, highlighting key areas for curriculum development and community engagement. The inclusion of demographic factors such as age and gender enables a nuanced understanding of how these variables influence awareness and perceptions of eye health.   Limitations The cross-sectional design limits the ability to draw causal conclusions and the reliance on self-reported data may introduce response bias, affecting the accuracy of the findings.   Acknowledgement The authors extend their appreciation to the Deanship of Scientific Research at Northern Border University, Arar, Saudi Arabia for funding this research work through the project number “NBU- FFR-2025-1301-03”.