Complementary Therapies in Medicine (2012) 20, 385—392

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

One year study on the integrative intervention of

acupressure and interactive multimedia for visual
health in school children夽
Mei-Ling Yeh a,d, Hsing-Hsia Chen b,e, Yu-Chu Chung c,∗

a
School of Nursing, National Taipei University of Nursing and Health Sciences, No. 365, Minte Road, Taipei, Taiwan, ROC
b
Department of Applied Mathematics, Chung-Yuan Christian University, No. 200, Chungpei Road, Chung-Li City, Taoyuan, Taiwan,
ROC
c
School of Nursing, Yuanpei University, No. 306, Yuanpei Street, Hsinchu, Taiwan, ROC
Available online 6 October 2012

KEYWORDS Summary
Objective: This study used a larger sample size, added a long-term observation of the effect
School children;
of intervention, and provided an integrated intervention of acupressure and interactive mul-
Myopia;
timedia of visual health instruction for school children. The short- and long-term effects of
Auricular
the interventions were then evaluated by visual health knowledge, visual acuity, and refractive
acupressure;
error.
Interactive
Design: A repeated pretest—posttest controlled trial was used with two experimental groups
multimedia;
and one control group.
Knowledge;
Setting: Four elementary schools in northern Taiwan.
Visual acuity;
Participants: 287 School children with visual impairment in fourth grade were recruited.
Refractive error;
Method: One experimental group received the integrative intervention of acupressure and
Controlled trial
interactive multimedia of visual health instruction (ACIMU), and another received auricular
acupressure (AC) alone; whereas a control group received no intervention. Two 10-week inter-
ventions were separately given in the fall and spring semesters. The short- and long-term
effects of the interventions were then evaluated by visual health knowledge, visual acuity,
and refractive error.
Results: During the school year the visual health knowledge was significantly higher in the ACIMU
group than the control group (p < 0.001). A significant difference in the changing visual acuity
was in the three groups (p < 0.001), with the improvement in the ACIMU group. No difference
in the refractive error was found between any two groups (p > 0.05).

夽 The study was sponsored by the National Science Council (NSC-

97-2314-B-227-006-MY2).
∗ Corresponding author. Tel.: +886 3 5381183x7504.

E-mail addresses: meiling@ntunhs.edu.tw (M.-L. Yeh), hsinghsi@cycu.edu.tw (H.-H. Chen), yuchu@mail.ypu.edu.tw (Y.-C. Chung).
d Tel.: +886 2 28227101x3317.
e Tel.: +886 3 2653126.

0965-2299/$ — see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2012.09.001
386
Conclusions: This study demonstrated that a long-term period of acupressure is required to
improve school children’s visual health. School children receiving the intervention of acupres-
sure combined with interactive multimedia had better improvement of visual health and related
knowledge than others. Further study is suggested in which visual health and preventative needs
can be established for early childhood.
© 2012 Elsevier Ltd. All rights reserved.
Introduction
Myopia becomes a worldwide public health issue. Studies
have indicated that myopia is related to both genetic and
environmental factors.1—4 When both parents have myopia,
the prevalence of myopia in their children is 30—40%, which
decreases to 20—25% in children with only one parent with
myopia, and less than 10% in children with parents without
myopia.5,6 Marked geographic variations in myopia preva-
lence in child and adult populations were highest (80%)
in East Asia.7—11 A 10-fold difference, 30% vs. 3%, respec-
tively, was found between Chinese children in Singapore and
Sydney.12 Prevalence of myopia in British Asian children is
higher than that among white European and black African
children attending the same schools.13 Some independent
associations were also found between myopia and close
reading14 or over 30 min continue reading.5 Such a prolonged
near-work activity harms vision when the ciliary muscle can-
not relax long enough for the lens to regain its normal
status.2 Additionally, higher saturated fat and cholesterol
intake were associated with longer axial length in otherwise
healthy school children.15
When children exhibit myopia at younger ages, it then
progresses more rapidly.16 Early-onset myopia is associated
with high myopia in adult life.17 High myopia may deterio-
rate vision and may often be irreversible, resulting in ocular
pathologies.18 This is a costly and significant public health
issue. The average annual direct cost of myopia is US$148
per Singapore schoolchild.19 The cost of refractive correc-
tion by glasses is US$3.9—7.2 billion annually in the US.20
Myopia causes a financial burden; therefore, interventions to
preserve visual health in school children is desirable and nec-
essary. Many studies have reported the vision improvement
of myopia in the interventions of atropine treatment,21,22
outdoor activity,23 acupressure,24,25 and combined acupres-
sure and education.26
In traditional Chinese medicine (TCM), stimuli on acu-
point can be transmitted to the brain and specific organs
in the rest of the body so as to modulate physiological
reactions27 ; and enhance microcirculation around the eyes
and help to reduce eye strain and relax eye muscles.28
Acupressure has been applied as a simple, noninvasive inter-
vention to preserve the visual health of school children.24—26
Additionally, interactive multimedia has become a popular
learning approach. This type of computer-based instruc-
tion provides users with multiple stimulations and high
satisfaction, and strengthens the efficacy of learning.29
Many studies using such multimedia in learning programs
to enhance learning effects and cognition have reported
promising results.29—32 However, previous studies had short-
term intervention periods, small sample sizes, and single
geographic sampling. This study recruited a larger sam-
ple size, added a long-term observation of the effect of
M.-L. Yeh et al.
intervention, and provided an integrated intervention of
acupressure and interactive multimedia of visual health
instruction for school children. The short- and long-term
effects of the interventions were then evaluated by visual
health knowledge, visual acuity, and refractive error.
Methods
Design and sample
A repeated pretest—posttest controlled trial was used with
two experimental groups and one control group. Four ele-
mentary schools (A, B, C, and D) were recruited on a
voluntary basis in Taiwan. School children with visual impair-
ment were recruited by a convenience sampling approach
and allocated to the groups, including children in schools A
and B received integrative interventions of acupressure and
interactive multimedia of visual health instruction (ACIMU),
in school C received acupressure (AC) alone, and in school D
received no intervention. Two 10-week interventions were
separately given in the fall and spring semesters. Fig. 1
shows the participant flow chart. Inclusion criteria were:
(a) enrolled in fourth grade of the study schools; (b) a visual
acuity of Snellen equivalent ranging from 6/30 to 6/9.6 in at
least one eye; (c) able to speak, read, and understand Chi-
nese; (d) parental consent for the child to participate; and
(e) child’s assent after parental consent had been obtained.
Exclusion criteria were: (a) abnormally shaped earlobes; (b)
any wound or swollen area on the selected acupoint; (c) cur-
rently using other myopia treatments; and (d) participation
time less than six times in the course of the study. Estimated
using the G Power software, each group required 34 sub-
jects, with four measurement times and sufficient to give
80% power for detecting a medium effect size of 0.25 with
a 5% significance level as previously described by Cohen.33
Given the possibility of dropout and follow-up loss, which
was set a maximum rate of 20%, the required sample size
was estimated as a total of 123 subjects at least.
Intervention
A 10-week intervention involved acupressure and interactive
multimedia of visual health instruction. First, acupressure
was delivered onto auricular and meridian acupoint. As
shown in Fig. 2, the common acupoint on auricle and
head for improving visual health were used. Auricular
acupoint included shenmen, eye, liver, kidney, and eye
disorder1 or disorder2 .24,26,27 A seed-embedding method was
used to give stimuli on the auricular acupoint. The adhe-
sive patch with cowherb seed was renewed weekly by
the researcher and research assistant. Meridian acupoint
included jingming (UB1), zanzhu (UB2), chenggi (St1), sibai
Study on the integrative intervention of acupressure 387

Figure 1 Research design and data collected flow chart.

(St2), baihui (Du20), and fengchi (GB20), and an extra acu-
point of taiyang (Ex-HN5).26,27 The school children were
instructed to press each acupoint for 1 min per time, 3
times per day. Secondly, the interactive multimedia of visual
health instruction was applied.24 The interactive multime-
dia was constructed in an interactive format containing
files of text, images, film, and sound by which to provide
instructions.29 Major themes of the interactive multimedia
covered structure and function of the eye, visual care, auric-
ular and somatic acupoint, and manipulation of acupoint
stimulation. School children could follow the instruction to
perform acupressure on each of the selected acupoint step
by step. The validity of instruction content was assessed
by one physician and one nurse with expertise in Chi-
nese medicine, and achieved a content validity index of
1.00.29

Figure 2 Selected acupoint on auricle and head.

388
Outcome measures
The measured outcomes included visual health knowledge
questionnaire, visual acuity, refractive error, and satisfac-
tion with interactive multimedia. A visual health knowledge
scale contains 15 true—false questions.26 Higher scores indi-
cate higher levels of knowledge about visual health. KR-20
reliability was 0.67 in this study. Visual acuity was mea-
sured by a remote-controlled vision inspector (SP-015E,
Taipei, Taiwan) with the Snellen’s vision chart and a view-
ing distance of 6 m. Refractive error was measured by
auto-refraction with auto-keratorre fractometer (Topcon
KR-8100, Tokyo, Japan). Satisfaction with the utility and
feasibility of interactive multimedia was measured by a 10-
item with a 5-point rating scale.34 Higher scores indicate
greater satisfaction with interactive multimedia. The inter-
nal consistency reliability for Cronbach’s ˛ was 0.87 in this
study.
Procedure and data analysis
Ethical approval was obtained from the school where the
children were enrolled. All children in fourth grade of the
elementary schools who met the criteria were recruited.
Before the study took place, informed consent was obtained
from all parents or guardians of children. All school chil-
dren were free to withdraw from the study at any time
during the study. Two 10-week interventions were given sep-
arately in the fall and spring semesters. During the period,
the interventions were provided every Thursday morning
before classes. Following the established principles of the
study,27 acupressure was provided by the researchers who
completed the TCM training program with certification from
the Taiwan accreditation facility. Children’s compliance and
accuracy in their acupressure performance were checked
weekly by reviewing the records. Data were repeatedly col-
lected before and after interventions in the same procedure
by researcher assistants who performed the examinations of
visual acuity and refractive error, and administered ques-
tionnaires. Operation of equipment measuring visual acuity
and refractive errors was approved by the ophthalmologist.
The data were analyzed with IBM SPSS Statistics 20.0. The
demographic characteristics of the participants were ana-
lyzed using descriptive statistics, including mean, standard
deviation, and percentage. Inferential statistics were then
used to verify the homogeneity between the groups. Gen-
eralized estimating equations (GEE) were conducted to
compare knowledge of visual health and refractive error
between the groups. A p-value of 0.05 was considered sig-
nificant.
Results
Demographic characteristics
There were 287 school children from the four schools
who met the inclusion criteria and participated in the
study, and 234 (81.5%) completed, including 69 in the
ACIMU group, 55 in the AC group, and 110 in the con-
trol group. Participants who completed the study and
M.-L. Yeh et al.
those who dropped out had no statistically significant
differences in demographic characteristics (p > 0.05). Fur-
thermore, school children included 116 (49.6%) males and
118 (50.4%) females, aged 9.35 ± 0.5 years (ranged 9—10),
with no significant differences in the three groups (F = 0.58,
p = 0.56). Other characteristics are summarized in Table 1.
The Chi-square test showed no significant differences in
the three groups, except time spent watching TV (p = 0.01).
This study operationally defined a myopic eye as having a
6/30.5—6/9.6 variation of myopia in each principal merid-
ian. Findings showed 113, 94, and 198 myopic eyes in the
ACIMU, AC, and control groups, respectively. In addition,
school children’s compliance and accuracy in their acupres-
sure performance achieved 92% and 90% for the ACIMU and
AC groups, respectively.
Impacts on visual health knowledge
The mean scores of visual health knowledge at pretest, post-
test 1, and post-test 2 were, respectively, 11.08, 11.93,
and 11.97 for the ACIMU group; 11.24, 10.62, and 10.69 for
the AC group; and 12.12, 11.03, and 11.09 for the control
group. A significant difference was found at pretest between
the ACIMU and control groups (F = 6.53; p = 0.002). Table 2
summarizes estimates and 95% confidence intervals of the
differences for a model with independence correlation and
model-based estimates of variance. After controlling for the
pretest and time-dependent growth effect, the GEE model
showed a significant difference between the ACIMU and
control groups (p < 0.001) during the school year. The time
effect was different at post-test 1 (p = 0.001) and post-test
3 (p < 0.001), compared to pretest. A group-by-time interac-
tion effect was significant for the ACIMU and control groups
at post-test 1 (p < 0.001) and post-test 3 (p < 0.001), indicat-
ing that the mean scores of visual health knowledge change
was higher for school children with higher scores on the
baseline covariate.
Impacts on visual acuity and refractive error
Before interventions, the distribution of Snellen equivalent
on 6/30, 6/24, 6/18.9, 6/15, 6/12, and 6/9.6 was, respec-
tively, 12.4%, 12.4%, 21.2%, 19.5%, 18.6%, and 15.9% for the
ACIMU group; 10.6%, 16.0%, 19.1%, 17.0%, 21.3%, and 16.0%
for the AC group; and 3.7%, 23.9%, 29.3%, 22.3%, 10.1%, and
10.6% for the control group. The progression of visual acu-
ity from pretest to post-test 3 showed the variability of line
from central extend (6/9.6—6/30) to both ends (6/4.8 vs.
6/45), in which the lines of the ACIMU and AC groups had
more school children move from left to right, but the con-
trol group moved to an opposite direction. The change of
visual acuity between pretest and post-test 3 in the ACIMU
group 15.0% increased by 3 lines or more, 5.3% by 2 lines,
and 11.5% by 1 line; 24.8% decreased by 1 line, 12.4% by 2
lines, and 16.8% by 3 lines or more; and 14.2% had no change
in vision. In the AC group, 2.1% increased by 3 lines or more,
11.7% by 2 lines, and 9.6% by 1 line; 25.5% decreased by 1
line, 16.0% by 2 lines, and 13.8% by 3 lines or more; and
21.3% had no change. In the control group, 2.1% increased
by 3 lines or more, 1.1% by 2 lines, and 7.5% by 1 line; 29.4%
decreased by 1 line, 29.4% by 2 lines, and 18.7% by 3 lines
Study on the integrative intervention of acupressure 389

Table 1 Comparison of demographic characteristics among the three groups.

Variables ACIMU (n = 69) AC (n = 55) Control (n = 110) 2 (p)

n % n % n %

Gender 0.86 (0.65)

Male 31 44.9 28 50.9 57 51.8
Female 38 55.1 27 49.1 53 48.2
Parental myopia 3.88 (0.42)
None 9 14.5 10 19.2 10 9.5
One 26 41.9 24 46.2 46 43.8
Both 27 43.5 18 34.6 49 46.7
Reading/writing (h/day) 16.17 (0.01)
1 23 36.5 9 17.6 31 28.2
2 19 30.2 8 15.7 34 30.9
3 11 17.5 12 23.5 16 15.4
>3 10 15.9 22 43.1 29 26.4
TV watching (h/day) 7.53 (0.28)
1 34 54.0 28 53.8 53 48.2
2 15 23.8 10 19.2 27 24.5
3 3 4.8 3 5.8 16 14.5
>3 11 17.5 11 21.2 14 12.7
Sleeping (h/day) 9.08 (0.34)
6 7 10.9 4 7.7 13 11.9
7 9 14.1 7 13.5 19 17.4
8 29 45.3 17 32.7 43 39.4
9 15 23.4 12 23.1 19 17.4
10 4 6.3 12 23.1 15 1.8
Computer use (h/week) 12.65 (0.13)
0 5 7.8 4 7.8 19 17.3
1—2 40 62.5 26 62.5 53 48.2
3—5 8 12.5 10 12.5 16 14.5
6—7 4 6.3 1 6.3 11 10.0
>7 7 10.9 10 10.9 11 10.0
After-school learning activity (h/week) 6.34 (0.39)
0 29 47.5 21 42.0 39 37.5
1—2 14 23.0 16 32.0 40 38.5
3—4 11 18.0 7 14.0 19 18.3
>4 7 11.5 6 12.0 6 5.8

or more; and 7.5% had no change. There were significant

Table 2 Results of GEE in the visual health knowledge.
differences in changing visual acuity in the three groups
(2 = 55.70, df = 12, p < 0.001). Parameter Estimate 95% CI
The refractive error for the groups and data ranged from
+2.75D to −4.75D. The mean scores of refractive error Intercept 12.06 11.66 to 12.46***
at pretest, post-test 1, and post-test 2 was, respectively, ACIMUa −1.06 −1.68 to −0.44***
−1.21, −1.24, −1.32, and −1.30 for the ACIMU group; ACa −0.53 −1.24 to 0.17
−1.34, −1.55, −1.67, and −1.90 for the AC group; −1.23, Post test 1b −1.06 −1.63 to −0.49***
−1.29, −1.48, and −1.52 for the control group. No signifi- Post test 3b −1.08 −1.64 to −0.53***
cant difference was found at pretest in the groups (F = 2.15, ACIMU × post test 1 1.84 0.96 to 2.71***
p = 0.12). Table 3 summarizes estimates and 95% confidence ACIMU × post test 3 1.43 0.55 to 2.32**
intervals of the differences for a model with indepen- AC × post test 1 0.28 −0.70 to 1.27
dence correlation and model-based estimates of variance. AC × post test 3 0.22 −0.77 to 1.22
After controlling for time-dependent growth effect, the ACIMU: acupressure and interactive multimedia of visual health
GEE model showed no differences between any groups dur- instruction; AC: acupressure.
* p < 0.05.
ing the school year. The time effect revealed differences
** p < 0.01.
at post-test 1 (p = 0.01) and post-test 3 (p < 0.001), com- *** p < 0.001.
pared to pretest. A group-by-time interaction effect was a Referenced group: control.
significant for the ACIMU and control groups at post-test 3 b Referenced group: pretest.
(p < 0.001).
390 M.-L. Yeh et al.

the combined acupuncture and interactive media treatment

Table 3 Results of GEE in the refractive error.
predominated, as supported by the high satisfaction shown
Parameter Estimate 95% CI by the ACIMU school children in their evaluations of using
multimedia. Our finding of increased knowledge through
Intercept −1.34 −1.45 to −1.23*** multimedia instruction is consistent with results of one
ACIMUa 0.11 −0.07 to 0.29 study showed high satisfaction with the outpatient care pro-
ACa 0.13 −0.06 to 0.32 gram, especially knowledge improvement,38 and the other
Post test 1b −0.21 −0.36 to −0.05** study found high learner satisfaction and increased patient
Post test 2b −0.33 −0.48 to −0.17*** knowledge in the preoperative patient education.39 Addi-
Post test 3b −0.56 −0.72 to −0.41*** tionally, school children’s records that revealed compliance
ACIMU × post test 1 0.19 −0.07 to 0.45 and accuracy in their acupressure performance supported
ACIMU × post test 2 0.24 −0.02 to 0.49 the validation of the intervention.
ACIMU × post test 3 0.49 0.23 to 0.75*** The two separate 10-week ACIMU and AC interven-
AC × post test 1 0.13 −0.14 to 0.40 tions resulted in supporting better visual improvement and
AC × post test 2 0.06 −0.22 to 0.33 alleviation of myopic progression than no intervention.
AC × post test 3 0.25 −0.02 to 0.52 However, the ACIMU, but not the AC, resulted in promot-
ACIMU: acupressure and interactive multimedia of visual health ing better refractive error than no intervention at the
instruction; AC: acupressure. end of interventions. School children had mild myopia,
* p < 0.05.
−1.29 ± 0.57D, at the study entry, and progression dur-
** p < 0.01.
*** p < 0.001.
ing the one school year for ACIMU, AC and control groups
a Referenced group: control.
were −0.07 ± 0.72D, −0.31 ± 0.57D, and −0.56 ± 0.65D,
b Referenced group: pretest. respectively. Normally, yearly progression in myopic school
children was −0.72 ± 0.37D in China,40 and a nearly −1.0D
in Asia.41 As long as myopia onset occurs in school chil-
Satisfaction of using interactive multimedia dren, its progression will be hard to control; therefore,
it is crucial to prevent progression by appropriate inter-
The scores of satisfaction with interactive multimedia ventions at an early age. Acupressure is a noninvasive
ranged from 3.49 ± 1.16 to 4.09 ± 1.04 in the ACIMU method to prevent and treat disease by stimulating spe-
group, with the overall score of 3.85 ± 0.71. The top five cific acupoint. The stimulation related to physiological and
items were in the order of increasing information and pathological conditions can elevate endorphin levels and
knowledge of visual health (4.09 ± 1.04), vividness and regulate the sympathetic nervous system.27 It is important
interesting in multimedia (4.08 ± 1.02), usefulness of infor- that the performance of this stimulation could be followed
mation and knowledge (4.06 ± 1.00), improving visual health using interactive multimedia for reinforcement as previously
(4.03 ± 1.06), and efficacy of information and knowledge mentioned.
(4.00 ± 0.95). It is noteworthy that this study did not support the effect
of the interventions for the first 10-week period. This may
confirm that a long-term period of acupressure is required to
Discussion improve school children’s visual health. Our previous studies
found that school children who received a 15-week acupres-
This study demonstrated that the two separate 10 weeks sure treatment had better effects in alleviating myopia than
of acupressure and interactive multimedia of visual health those without that treatment.24,26 Acupressure may take as
instruction, compared to no intervention, increased visual long as consecutive 15 weeks to reach a short-term effect for
heath knowledge of school children and improved the visual growing children. Our present study supports that acupres-
acuity over one school year. This result agrees with multime- sure as an effective and valuable option for myopic children,
dia learning programs contribute to increased cognition and along with visual health knowledge and self-performed acu-
learning effects on visual health.26 The application of inter- pressure as learned using interactive multimedia, could
active multimedia is superior to conventional approaches; improve vision. Supplemental analysis found that 13.2%
multimedia resources offer words, animations, sounds, and of school children were without myopic parents, 43.8%
images to enhance learning effects. This may have an had one myopic parent, and 43.0% had two myopic par-
even wider contribution as learners are able to obtain ents. A positive association is between parental myopia and
the information they need without the limitations of time the rate of myopia progression in school children.5,6 More
and space. Multimedia technology in patient education recent population-based studies documented an association
becomes commonly used to enhance patients’ understand- between myopia and higher levels of close work among
ing of self-care related to their disease or symptoms, school children.5,14 In this study, the close work activities
including improving knowledge in hip replacement opera- reported most frequently included homework assignments,
tion and rehabilitation,32 undergoing burn rehabilitation,35 after-school learning activities, computer use, and watch-
self-care of diabetes,36 and exercise by pregnant and post- ing television. Relatively little time was devoted to physical
partum women.37 The features of interactive multimedia exercise outdoors. Participating in outdoor activities is a
applied in the present study may elevate school children’s protective factor against myopia.23 It can be difficult for
interest and motivation toward greater comprehension of parents who work full time to accompany school children
the instruction material, and may even increase self con- as they spend more time outdoors in urban environments.
fidence in the received treatment. As such, the benefits of However, heredity was the most important factor associated
Study on the integrative intervention of acupressure
with juvenile myopia, and the contribution from close work
and less exercise activity was small.42
Limitation in using a non-randomization procedure is
existed, but it is a suitable alternative when randomiza-
tion is not possible.43 Contamination was a concern in this
study when school children in the same class were assigned
to different groups. The potential threats to the selection
bias of the sample may not be avoided, such as school chil-
dren were excluded if they were undergoing treatment for
myopia. As school children were aware that they were being
observed the performance and checked the compliance, the
Hawthorne effect is a potential threat. Some uncontrolled
variables (e.g., close-work activity, less outdoor activity,
and parental myopia) may account for children myopia. Rep-
resenting and generalizing the results should be of some
concern because of sampling. Duplicate studies exploring
effects of the interventions for school children in various
grades, and its cohort effect, are suggested. In addition,
how to decrease the close-work activity could be consid-
ered. Despite the limitations, the strength of this study lies
in using a large multisite sample with a low attrition rate for
evaluating long-term effects of visual health.
Conclusions
This study demonstrated acupressure combined with
interactive multimedia had a long-term effect in the
improvement of visual health and related knowledge. The
interactive multimedia was evaluated as having high satis-
faction. Slowing myopic progression was a greater long-term
effect of visual health in acupressure combined with inter-
active multimedia than acupressure alone. Further study is
suggested in which visual health and preventative needs can
be established for early childhood. For better outcomes of
using this or other visual health interventions, participation
in visual health related interventions by active parents and
teachers in the primary schools may be worthwhile.
Conflict of interest
No conflicts of interest.
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