From leadership research to district action: Real-world evidence on childhood refractive errors in a developed coastal region of China: a multi-center analysis of 4.47 million school-based screening encounters in Southern Fujian

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Background Despite rapid economic development in coastal China, the alignment between socioeconomic growth and pediatric eye health remains poorly understood. School-based screening may provide an opportunity to bridge this knowledge gap, yet large-scale, real-world evidence from diverse urban-rural gradients is scarce. Methods This cross-sectional study analyzed 4.47 million valid screening encounters from Xiamen, Quanzhou, and Zhangzhou (2021–2024). Visual acuity (VA) and spherical equivalent (SE) were assessed. Two-way ANOVA and multivariate logistic regression were employed to identify drivers of visual impairment and uncorrected refractive error, with screening year as a covariate. Generalized Estimating Equations (GEE) with student-level clustering were applied to account for repeated measures. Sensitivity analyses confirmed dataset robustness. Results Age was the predominant driver of VA variance (η2 = 0.1132), exceeding city-level effects fivefold. Xiamen exhibited the best refractive profile but the highest uncorrected rate (94.0% in primary school), illustrating the “Xiamen Paradox”—where affluence fosters a “visibility-over-correction” bias. Conversely, Quanzhou demonstrated a “pain-driven” model with high correction adherence despite a severe myopia burden (19.0% high myopia). Crucially, county-level SE disparities (up to 1.66 D) eclipsed inter-city gaps. The 5–7-year window marked a critical refractive shift, with myopia prevalence doubling. Among primary school records, only 22.6% of visually impaired children wore spectacles, and merely half achieved adequate correction. Conclusion Economic prosperity does not automatically translate to optimal visual health. Significant “correction gaps” and intra-regional disparities necessitate a shift from uniform strategies to precision governance. Future interventions must prioritize the 5–7-year window, emphasize correction quality over mere screening volume, and tailor approaches to local socioeconomic contexts to transform economic capital into sustainable ocular health dividends effectively.

Study methods

This study was a large-scale, regional cross-sectional survey. Data were derived from student vision screening programs conducted in Xiamen, Quanzhou, and Zhangzhou, Fujian Province, spanning 2019–2024. Preliminary data inspection revealed considerable missing items—including key refractive and visual acuity (VA) parameters—during the initial phase of the COVID-19 pandemic (2019–2020), attributable to disrupted school schedules and inconsistent screening protocols. To ensure analytical validity and minimize potential confounding, these records were excluded from the primary analysis. Consequently, the final analyzed dataset comprised 4,475,132 valid screening encounters from 2021 to 2024.

Limitations

This large-scale, real-world evidence study, encompassing 4.47 million screening encounters across Southern Fujian, delineates a critical “correction gap” that belies the region's economic prosperity. We demonstrate that while economic advancement provides the infrastructural capacity for eye care, it does not automatically confer optimal visual health, as evidenced by the “Xiamen Paradox” and the substantial burden of high myopia in Quanzhou. Crucially, our findings reposition age—not economic status—as the predominant driver of refractive error, identifying the 5–7-year window as a pivotal period for public health intervention. The stark intra-regional disparities observed at the county level further challenge the utility of one-size-fits-all policies, advocating instead for precision governance tailored to local socioeconomic contexts. Moving forward, the focus must transition from mere screening volume to ensuring the quality and continuity of care, bridging the chasm between detection and effective correction. Ultimately, this study provides a transferable roadmap for transforming regional economic capital into tangible ocular health dividends, aligning with global efforts to eliminate preventable visual impairment among future generations.

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Choose one school improvement question with teachers. Protect a short shared planning cycle, agree an instructional change and use a common rubric for examining student work. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Review implementation fidelity, teacher time and independently scored student work against a recorded baseline. Examine access differences and competing explanations before attributing changes to leadership. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Xiao-feng Li; Dong-kan Li; Wei Liang; Peng Shi; Bin Lin. Real-world evidence on childhood refractive errors in a developed coastal region of China: a multi-center analysis of 4.47 million school-based screening encounters in Southern Fujian. Frontiers in Public Health (2026-08-24). https://doi.org/10.3389/fpubh.2026.1938109

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.