Sex-related refractive disparities in school-aged children: a population-based cross-sectional study of 4.47 million screening records
6 affiliations
- 1Xiamen Eye Center and Eye Institute of Xiamen University, School of Medicine
- 2Xiamen Clinical Research Center for Eye Diseases
- 3Xiamen Key Laboratory of Ophthalmology
- 4Fujian Key Laboratory of Corneal & Ocular Surface Diseases
- 5Xiamen Key Laboratory of Corneal & Ocular Surface Diseases
- 6Translational Medicine Institute of Xiamen Eye Center of Xiamen University
Abstract
Purpose: To delineate cross-sectional group-level sex-specific patterns of refractive development in school-aged children and to determine whether sex-related myopic disparities widen across age strata, addressing limitations in current large-scale epidemiological evidence.
Methods: This population-based cross-sectional study analyzed 4.47 million valid vision screening records from 1,623,070 unique students (ages 3–18 years) across Southern Fujian, China (2021–2024). Spherical equivalent (SE) and uncorrected visual acuity (UCVA) were measured via non-cycloplegic autorefraction. Generalized estimating equations (GEE) with an exchangeable correlation structure (ICC = 0.473) were employed to account for repeated measures. A “sex × age” interaction term was incorporated into multivariable models to evaluate whether sex-related disparities widen across age strata. Sensitivity analyses compared encounter-level versus student-level analytic units.
Results: While refractive parameters were comparable between sexes in the preschool group (≤6 years; SE difference: +0.04 D favoring females), a significant female disadvantage emerged in primary school (7–12 years; SE difference: −0.12 D), peaking in junior high school (13–15 years; SE difference: −0.20 D), followed by partial attenuation in senior high-school (≥16 years; SE difference: −0.17 D) in two of three cities. By senior high school (≥16 years), the female myopia prevalence was 88.7% versus 80.4% in males (absolute difference: 8.3 percentage points), despite partial convergence in continuous SE values. Within our limited set of available covariates (adjusted for age and city), GEE models showed female sex was associated with an overall SE difference of β = −0.141 D (95% CI −0.154 to −0.128 D), higher visual-impairment risk (OR = 1.26, 95% CI 1.22–1.30), and higher myopia risk (OR = 1.18, 95% CI 1.11–1.25), with a significant “sex × age” interaction ( p < 0.001). Sensitivity analyses confirmed robustness, with SE differences fluctuating <0.05 D across analytic units.
Conclusion: This study reveals distinct sex-related disparities in refractive status across childhood, observed in cross-sectional group-level comparisons. These group-level patterns may reflect developmental influences and potential cohort-related effects from differing historical exposures. These findings underscore the necessity of incorporating sex as a stratification factor in public health strategies. Implementing earlier and more intensive screening protocols for girls is crucial for curbing myopia progression and achieving life-course visual health equity.
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BibTeX
@article{li2026sexrelated,
title = {{Sex-related refractive disparities in school-aged children: a population-based cross-sectional study of 4.47 million screening records}},
author = {Dong-kan Li and Chun-hong Chen and Xiao-fang Zhan and Bin Lin and Xiao-feng Li},
journal = {Frontiers in Public Health},
year = {2026},
month = oct,
doi = {10.3389/fpubh.2026.1983884},
url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1983884/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Sex-related refractive disparities in school-aged children: a population-based cross-sectional study of 4.47 million screening records
AU - Dong-kan Li
AU - Chun-hong Chen
AU - Xiao-fang Zhan
AU - Bin Lin
AU - Xiao-feng Li
PY - 2026
DA - 2026/10/20
JO - Frontiers in Public Health
DO - 10.3389/fpubh.2026.1983884
UR - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1983884/full
AB - Purpose: To delineate cross-sectional group-level sex-specific patterns of refractive development in school-aged children and to determine whether sex-related myopic disparities widen across age strata, addressing limitations in current large-scale epidemiological evidence. Methods: This population-based cross-sectional study analyzed 4.47 million valid vision screening records from 1,623,070 unique students (ages 3–18 years) across Southern Fujian, China (2021–2024). Spherical equivalent (SE) and uncorrected visual acuity (UCVA) were measured via non-cycloplegic autorefraction. Generalized estimating equations (GEE) with an exchangeable correlation structure (ICC = 0.473) were employed to account for repeated measures. A “sex × age” interaction term was incorporated into multivariable models to evaluate whether sex-related disparities widen across age strata. Sensitivity analyses compared encounter-level versus student-level analytic units. Results: While refractive parameters were comparable between sexes in the preschool group (≤6 years; SE difference: +0.04 D favoring females), a significant female disadvantage emerged in primary school (7–12 years; SE difference: −0.12 D), peaking in junior high school (13–15 years; SE difference: −0.20 D), followed by partial attenuation in senior high-school (≥16 years; SE difference: −0.17 D) in two of three cities. By senior high school (≥16 years), the female myopia prevalence was 88.7% versus 80.4% in males (absolute difference: 8.3 percentage points), despite partial convergence in continuous SE values. Within our limited set of available covariates (adjusted for age and city), GEE models showed female sex was associated with an overall SE difference of β = −0.141 D (95% CI −0.154 to −0.128 D), higher visual-impairment risk (OR = 1.26, 95% CI 1.22–1.30), and higher myopia risk (OR = 1.18, 95% CI 1.11–1.25), with a significant “sex × age” interaction ( p < 0.001). Sensitivity analyses confirmed robustness, with SE differences fluctuating <0.05 D across analytic units. Conclusion: This study reveals distinct sex-related disparities in refractive status across childhood, observed in cross-sectional group-level comparisons. These group-level patterns may reflect developmental influences and potential cohort-related effects from differing historical exposures. These findings underscore the necessity of incorporating sex as a stratification factor in public health strategies. Implementing earlier and more intensive screening protocols for girls is crucial for curbing myopia progression and achieving life-course visual health equity.
SN - 2296-2565
ER -