The incidence of myopia and the factors associated with it among primary and junior high school students in Shihezi, China, a cohort study based on the SHAP model

The incidence of myopia and the factors associated with it among primary and junior high school students in Shihezi, China, a cohort study based on the SHAP model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The incidence of myopia and the factors associated with it among primary and junior high school students in Shihezi, China, a cohort study based on the SHAP model Xiaopeng Hu, Xianyan Yuan, Hua Li, Yuting Xie, Liqun Wang, Dongsheng Rui This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7522290/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Myopia has been a major public health problem worldwide, with the highest incidence of myopia in East Asia. Investigating the incidence of myopia and its associated factors among children in primary and junior high school in underdeveloped regions of China. Methods This observational cohort study was completed in Shihezi, China, which was drawn from nine primary and secondary schools with a follow-up period from 2018 to 2023, all of which were randomly selected in proportion to the number of schools in the city. Students (with or without myopia) who have been able to participate continuously for three consecutive years starting from 2018 were eligible for inclusion. Data analysis occurred from April 2025 and May 2025. Results A total of 3,551 primary (median [P25, P75] age 7.5 [6.8, 9.0] years; 1077/2345 [45.9] girls) or junior high school (median [P25, P75] age 12.8 [12.4, 13.1]years; 585/1206 [45.9] girls) students were included. The annual incidence of myopia was 20% to 30% in primary and junior high schools. A higher hyperopic reserve in primary and junior high school students served as a protective factor against myopia onset. Female sex and parental myopia were risk factors for myopia incidence in primary school students, while >8 hours of sleep was protective in this group. Furthermore, the hyperopic reserve progressively disappeared from grades 1-2. Based on the SHAP model, the order of importance of the factors influencing the incidence of myopia was SE, segment, weight, sleep time, height, gender, and parental myopia. Conclusions The significantly higher prevalence of myopia among students in underdeveloped regions of China, combined with earlier depletion of the hyperopic reserve, suggests a potential shift toward earlier myopia onset. These findings highlight the need for early interventions in school-aged children, if confirmed through cycloplegic refraction. Children and adolescents Myopia Hyperopia reserve Incidence SHAP model Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Myopia in children has become a global public health concern, with its prevalence continuously rising worldwide, particularly in East Asia[ 1 ]. Myopia not only affects visual acuity but also serves as a significant risk factor for various vision-impairing complications, including glaucoma, myopic macular degeneration, and retinal detachment[ 2 , 3 ]. The increasing prevalence of childhood myopia, coupled with a trend toward earlier onset[ 4 , 5 ], underscores the necessity for early detection and intervention. This is crucial as associated risks may lead to severe long-term visual impairment and varying degrees of reduced quality of life[ 6 ]. With ongoing research into myopia, several interventions have emerged to delay its onset and progression, including repeated low-intensity red light therapy[ 7 ],atropine treatment[ 8 ]and increased outdoor activity time[ 9 , 10 ]. As these interventions become available alongside the trend toward earlier onset of myopia, identifying target populations and optimal timing for intervention has become particularly crucial in myopia prevention and control. During the neonatal stage, the eye exhibits hyperopic status with an average spherical equivalent refractive error of + 2.50 to + 3.00D. This physiological hyperopia is termed the hyperopic reserve[ 11 , 12 ], which represents a pre-emmetropic and pre-myopic refractive state[ 13 ]. The depletion of hyperopic reserve serves as an early warning sign for myopia development. Given the plasticity of visual development in children aged 0–6 years, myopia prevention strategies should focus on both the age groups with the highest incidence rates and the timing of hyperopic reserve depletion. This highlights the necessity of studying the onset and progression of myopia in children and adolescents. According to research by Hu et al.[ 5 ], the spherical equivalent refractive error transitions from positive to negative values between ages 6 and 7. However, this conclusion was derived from large-scale cross-sectional studies, and the precise timing of the shift from emmetropia/hyperopia to myopia remains unclear. There is a critical need for longitudinal data collected from large childhood cohorts to accurately identify periods of high myopia incidence. Such data would significantly enhance the determination of optimal intervention timing for myopia management. While numerous cross-sectional myopia studies have been conducted in China, most focus on prevalence rates and associated risk factors. Large-scale longitudinal cohort studies specifically investigating myopia incidence and hyperopic reserve dynamics remain relatively scarce. Compared with inland Chinese cities, Xinjiang demonstrates distinct regional characteristics in socioeconomic development and educational attainment disparities (relatively underdeveloped). These differences may potentially lead to unique patterns of myopia incidence among children and adolescents in this region. This study aims to investigate the incidence and progression rates of myopia among children and adolescents in Xinjiang, China, focusing on two critical refractive development phases: primary school (grades 1–6) and junior high school (grades 7–9) under non-cycloplegic refraction. This study employed the Cox proportional hazards regression model in conjunction with questionnaires and visual acuity measurements to assess the association between these characteristics and the onset of myopia, and further utilized SHAP analysis to evaluate the significance of each influential factor, thereby providing a scientific basis for determining the optimal timing of myopia prevention and control and the measures to be taken. METHODS Study Design This longitudinal cohort study utilizes data from the National Student Common Diseases and Vision Surveillance Program in Shihezi City. Initiated in 2018, the cohort enrolled students from nine primary and junior high schools designated as health surveillance sites by the Shihezi City Center for Disease Control and Prevention. These schools were proportionally selected through stratified random sampling from all educational institutions in Shihezi City, ensuring representativeness of the city’s student population. The study protocol received ethical approval from the Institutional Review Board of the First Affiliated Hospital of Shihezi University and adhered to the Declaration of Helsinki guidelines (KJ2024-491-01). Written informed consent was obtained from all participants and their parents prior to baseline assessments. The study was initiated in 2018 and has been conducted annually every October since. Each investigation year incorporates newly enrolled students into the study cohort. Baseline data are collected from participants’ initial physical examinations, with follow-up continuing until their graduation from primary or junior high school. (thereafter, the student graduates and were distributed to various junior high school or senior high school). Measurements and Outcomes Age at each examination was calculated as the difference in years between the participant’ s date of birth and the examination date. Physical examination data were collected by professionally trained technicians during annual school-based assessments starting in 2018. Participants’ height and weight were measured using calibrated equipment, with height recorded to the nearest 0.1 cm and weight to the nearest 0.1 kg, while participants stood barefoot on the measurement platform.Students were asked to remove their eyeglasses (including contact lenses) for refraction and uncorrected visual acuity (UCVA) examinations, and all subjects had refraction and visual acuity examinations performed by professional optometrists with standardized training. Uncorrected visual acuity was tested using a standard logarithmic visual acuity E chart. When testing the vision of the right eye, a non-contact black spoon-shaped ocular occluder was used to cover the left eye at a distance of 5 m. After the right eye was tested for 5 to 10 s, the left eye was tested in the same way. Non-cycloplegic refraction were detected using an autorefractor of the TOPCON KR-1 (Tokyo, Japan). Each subject was tested three times per eye, and the results were averaged. If the difference between the three results re any two results was greater than 0.5 diopters (D), each subject was re-examined. Spherical equivalent (SE) was determined using the algebraic sum of the refractive errors of the spherical and cylindrical lenses (spherical + 0.5 cylindrical)[ 14 ]. Myopia is defined as uncorrected visual acuity < 5.0 in either eye and spherical equivalent (SE) < -0.50D, and is categorized as mild myopia (-3.00D ≤ SE < -0.50D), moderate myopia (-6.00D ≤ SE < -3.00D) and high myopia (SE < -6.00D)[ 15 ]. Physical examinations were performed at all follow-up visits using the same equipment and protocol. An annual standardized questionnaire, which was developed by the Chinese Center for Disease Control and Prevention (see Appendix 1 for full details), was administered during follow-up visits to assess poor vision and associated risk factors in students. The instrument evaluated multiple domains, including parental myopia, visual environment, ocular habits, screen exposure, outdoor activity patterns, and sleep duration. Participants with previous cataract surgery, laser myopic surgery, low-dose atropine, and use of orthokeratology lenses were excluded. Additionally, participants aged 16 years were excluded as these thresholds fall outside the typical enrollment age range for first-grade students in Chinese primary and junior high schools. In all analyses, the annual prevalence of myopia was defined as the proportion of new-onset myopia cases among participants who did not have myopia in the previous year or an earlier date. Statistical Analysis Statistical analyses were performed using IBM SPSS (v27.0), with data visualization conducted in GraphPad Prism (v9.5.1) and R (v4.5.1). Continuous variables with normal distribution were expressed as mean ± standard deviation (SD), while non-normally distributed variables were summarized as median and interquartile range (IQR).Categorical variables were expressed as frequencies (n) and percentages (%). The t-test, Pearson χ 2 test, Mann-Whitney U test and Pearson correlation coefficient r were applied as appropriate. Cox proportional hazards regression models were implemented to identify risk factors for myopia incidence, analyzing data from participants without myopia at baseline with adjustment for covariates. A two-sided significance level of α = 0.05 was applied throughout the study. All statistical procedures were executed between April 2025 and May 2025. Machine learning model The SHAP framework is a technique used to quantify the contribution of each feature to the model’s predictions[ 16 ]. We assessed the effect of each myopia-influencing factor on the likelihood of myopia onset by calculating the SHAP value for each observation. The mean SHAP value for each feature was calculated to identify the key influences on myopia onset. The SHAP analysis was performed using R 4.5.1. RESULET A total of 3,551 students were included in this study, enrolled in nine primary and junior high schools in Shihezi City, Xinjiang, China. A total of 91 participants were excluded based on predefined criteria: 23 for orthokeratology lens use, 47 due to invalid autorefraction measurements, and 21 being under 6 years of age at baseline. The final analytical cohort comprised 3,551 students (2,345 in primary schools; 1,206 in junior high schools). Both the elementary and middle school cohorts were followed for 2 years, after which the middle school cohort graduated.There were no lost visits in this cohort study because the cohort was constructed using data from a cross-sectional survey, and samples with missing follow-up data were excluded during the cohort creation. The characteristics of each cohort at baseline and endpoint are presented in Table 1 . There is a significant increase in the height (Baseline: median, 129.0 cm; Follow-up endpoint: 143.0 cm; P < 0.001) and weight (Baseline: median, 28.0 kg; Follow-up endpoint: 38.4 kg; P < 0.001) of primary school children from baseline, as well as more negative SER(Baseline: median, 0 D; Follow-up endpoint:−0.63 D; P < 0.001), SEL(Baseline: median, 0 D; Follow-up endpoint:−0.62 D; P < 0.001), UCVA of OD(Baseline: median, 5.0; Follow-up endpoint: 5.0; P < 0.001), UCVA of OS(Baseline: median, 5.0; Follow-up endpoint: 5.0; P < 0.001). Junior high school students exhibited similar trends; however, compared to primary school students, they demonstrated less pronounced physical development but more significant changes in visual acuity.(Height: Baseline: median, 160.0 cm; vs Follow-up endpoint: 169.5 cm; Weight: Baseline: median, 51.0 kg; vs Follow-up endpoint: 59.6 kg; SER: Baseline: median, -1.25 D; vs Follow-up endpoint:−2.47 D; SEL: Baseline: median, -1.13 D; vs Follow-up endpoint:−2.13 D; UCVA of OD: Baseline: median, 4.8; vs Follow-up endpoint: 4.5; UCVA of OS: Baseline: median, 4.9; vs Follow-up endpoint: 4.6; P < 0.001 for all). Non-cycloplegic refraction data revealed diverging trends: myopia prevalence (including moderate-to-severe cases) demonstrated a progressive increase, whereas mild myopia prevalence exhibited a decline. In the primary school cohort, baseline-to-endpoint comparisons showed statistically significant differences in overall myopia, mild myopia, and moderate myopia (P 0.05). The junior high school cohort demonstrated statistically significant baseline-to-endpoint increases in overall myopia, mild, moderate, and severe myopia (all P < 0.001). Notably, the myopia prevalence among ninth-grade students at final follow-up reached 77.8% (938/1,206; 95% CI: 75.3 to 80.1). Table 1 Characteristics of Primary and Junior High School Cohort Participants at Baseline and Follow-up endpoint Characteristic Primary School Cohort Junior High School Cohort Baseline Follow-up endpoint Z/χ 2 P Baseline Follow-up endpoint Z/χ 2 P Age, median (P25, P75), y 7.5 (6.8, 9.0) 9.6 (8.9, 11.1) −41.899 0.001 12.8 (12.4, 13.1) 14.9 (14.6, 15.3) −30.086 0.001 Height, median (P25, P75), cm 129.0 (123.0, 136.0) 143.0 (136.5, 150.5) −41.902 0.001 160.0 (155.0, 165.0) 169.5 (163.5, 175.0) −28.835 0.001 Weight, median (P25, P75), kg 28 (24.0, 34.1) 38.4 (31.6, 48.0) −41.366 0.001 51.0 (44.0, 59.9) 59.6 (52.2, 70.9) −28.151 0.001 SER, median (P25, P75), D 0 (−0.63, 0.38) −0.63 (−1.87,−0.01) −29.793 0.001 −1.25 (−2.75,−0.38) −2.47 (−4.00,−1.13) −22.126 0.001 SEL, median (P25, P75), D 0 (−0.50, 0.38) −0.62 (−1.63, 0) −29.376 0.001 −1.13 (−2.45,−0.25) −2.13 (−3.64,−0.79) −21.560 0.001 UCVA of OD, median (P25, P75) 5.0 (4.9, 5.0) 5.0 (4.7, 5.0) −19.045 0.001 4.8 (4.4, 5.0) 4.5 (4.2, 4.9) −16.223 0.001 UCVA of OS, median (P25, P75) 5.0 (4.9, 5.0) 5.0 (4.7, 5.0) −19.831 0.001 4.9 (4.5, 5.0) 4.6 (4.2, 5.0) −14.301 0.001 Prevalence of myopia, No./Total No.(%) [95% CI] 466/2345 (19.9) [18.3 to 21.5] 950/2345 (40.5) [38.5 to 42.5] 236.985 0.001 718/1206 (59.5) [56.7 to 62.3] 938/1206 (77.8) [75.3 to 80.1] 93.248 0.001 Prevalence of mild myopia, No./Total No.(%) [95% CI] 384/466 (82.4) [78.6 to 85.8] 683/950 (71.9) [68.9 to 74.7] 33.587 0.001 442/718 (61.6) [57.9 to 65.1] 441/938 (47.0) [43.8 to 50.3] 34.568 0.001 Prevalence of moderate myopia, No./Total No.(%) [95% CI] 70/466 (15.0) [11.9 to 18.6] 230/950 (24.2) [21.5 to 27.1] 15.810 0.001 236/718 (32.9) [29.4 to 36.4] 399/938 (42.5) [39.3 to 45.8] 16.080 0.001 Prevalence of high myopia, No./Total No.(%) [95% CI] 12/466 (2.6) [1.3 to 4.5] 37/950 (3.9) [2.8 to 5.3] 1.630 0.202 40/718 (5.6) [4.0 to 7.5] 98/938 (10.4) [8.6 to 12.6] 12.662 0.001 Annual trends in spherical equivalent refraction (SER) and uncorrected visual acuity (UCVA) of the right eye (OD) are shown in Fig. 1, and trends in height and weight are shown in eFigure 1. UCVA of OD demonstrated strong negative correlations with grade advancement in both cohorts (primary school cohort: r = -0.9681; junior high school cohort: r = -0.9983). SER showed a similar inverse relationship in the primary school cohort (r = -0.9962), but no significant association was observed in the junior high cohort. Anthropometric measurements revealed strong positive correlations between grade level and both height (r = 0.9976) and weight (r = 0.9937) in primary school students, whereas these associations became non-significant in junior high students. Trends for boys and girls were generally similar, with height increasing with grade, with statistically significant differences in height between boys and girls in grades 1–3 of primary school (P 0.05), and statistically significant differences in height between boys and girls in grades 7–9 (P < 0.05). Weight increases with grade, and the difference in height between boys and girls was statistically significant in grades 1–4 of primary school (P 0.05), and statistically significant in grades 7–9 (P 0.05), and the difference in SER between boys and girls in grades 4–9 was statistically significant (P 0.05), statistically significant difference in UCVA of OD between boys and girls in grades 4–8 (P 0.05) (Schedule 1). Non-cycloplegic refraction data revealed annual myopia incidence rates of 10–21% throughout primary and junior high school (Table 2 ). The incidence of myopia among first to second-grade primary school students is 15.57% (166/1066, 95% CI: 13.44 to 17.89), and the highest incidence between third and fourth grades at 20.63% (144/698, 95% CI: 17.69 to 23.83). Across different years, the incidence was highest in 2021 at 19.11% (439/2297, 95% CI: 17.52 to 20.78). Table 2 Annual Incidence of Myopia in Primary and Junior High School Cohorts and Annual Incidence in different years Period No. Total No. (%) [95% CI] Primary school 1–2 166 1066 15.57 [13.44–17.89] 2–3 123 675 18.22 [15.38–21.35] 3–4 144 698 20.63 [17.69–23.83] 4–5 145 828 17.51 [14.98–20.28] 5–6 69 432 15.97 [12.64–19.77] Junior high school 7–8 222 1206 18.41 [16.26–20.71] 8–9 121 984 12.30 [10.31–14.51] Years 2020 352 2005 17.56 [15.91–19.29] 2021 439 2297 19.11 [17.52–20.78] 2022 256 1395 18.35 [16.35–20.48] Tables 3 and 4 show the results of Cox proportional hazards regressions for myopia onset in the primary schools cohort and the middle school cohort. After adjusting for covariates, the analysis revealed that girls (hazard ratio [HR], 1.186 [95% CI, 1.022 to 1.377] compared with boys), parental myopia (hazard ratio [HR], either myopia: 1.511 [95% CI, 1.147 to 1.989] compared with neither myopia; both myopia: 2.090 [95% CI, 1.329 to 3.285] compared with neither myopia) were risk factors for myopia development in primary school children, whereas a sleep duration exceeding 8 hours served as a protective factor (hazard ratio [HR], 8–10 hours: 0.524 [95% CI, 0.290 to 0.949] compared with 10 hours: 0.560 [95% CI, 0.319 to 0.983] compared with < 8 hours). Higher SER at baseline is a protective factor for the onset of myopia in primary school children(hazard ratio [HR], P25 to P75: 0.395[95% CI, 0.334 to 0.468] compared with the bottom quartile; the top quartile: 0.121[95% CI, 0.090 to 0.163] compared with the bottom quartile). For junior high school students, higher baseline SER was a protective factor against myopia onset (hazard ratio [HR] for the top quartile: 0.282 [95% CI, 0.179 to 0.442] compared to the bottom quartile). None of the other questionnaire-assessed factors showed a significant association with myopia onset in the Cox proportional hazards regression. Table 3 Factors Associated With Incident Myopia in Primary School Cohort by Cox Proportional Hazard Regression Analysis Baseline Characteristic No. Adjusted Hazard Ratio (95% CI) P Value Sex Male 1257 1 [Reference] Female 1088 1.186 (1.022 to 1.377) 0.025 Height, cm 144.0 (75th Percentile) 583 1.292 (0.975 to 1.713) 0.074 Weight, kg 41.4.0 (75th Percentile) 585 0.997 (0.755 to 1.317) 0.985 SER, D <−1.375 (25th Percentile) 554 1 [Reference] −1.375–0.125 1308 0.395 (0.334 to 0.468) 0.125 (75th Percentile) 483 0.121 (0.090 to 0.163) < 0.001 Sleep Time 10 hours 645 0.560 (0.319 to 0.983) 0.043 Parents Myopia Neither Myopia 630 1 [Reference] Either Myopia 223 1.511 (1.147 to 1.989) 0.003 Both Myopia 53 2.090 (1.329 to 3.285) 0.001 Table 4 Factors Associated With Incident Myopia in Junior High School Cohort by Cox Proportional Hazard Regression Analysis Baseline Characteristic No. Adjusted Hazard Ratio (95% CI) P Value Sex Male 617 1 [Reference] Female 589 1.060 (0.819 to 1.371) 0.657 Height, cm 144.0 (75th Percentile) 289 1.052 (0.717 to 1.544) 0.795 Weight, kg 41.4.0 (75th Percentile) 295 1.024 (0.718 to 1.460) 1.024 SER, D 0.125 (75th Percentile) 290 0.282 (0.179 to 0.442) < 0.001 Sleep Time 10 hours 374 0.975 (0.708 to 1.344) 0.879 Parents Myopia Neither Myopia 818 1 [Reference] Either Myopia 228 1.063 (0.757 to 1.493) 0.723 Both Myopia 85 1.140 (0.664 to 1.958) 0.635 eFigure 2 shows the survival curves for myopia incidence in participants who were non-myopic at baseline. The primary school cohort had a 61.79% probability of remaining free of myopia after two years of follow-up (1161/1879; 95% CI: 59.55 to 63.99), while the middle school cohort (junior high students non-myopic in grade 7) showed a 36.68% probability of remaining non-myopia by grade 9 (179/488; 95% CI: 32.39 to 41.12). We used SHAP to quantify the contribution of each variable to myopia prediction in our model. Figure 2 presents the risk factors ranked by their mean absolute SHAP values, while Fig. 3 showcases the same key features identified in Fig. 2 . The y-axis ranks the features by their importance in the predictive model. The x-axis reflects the SHAP value, indicating the influence of each feature on the prediction outcome. In Fig. 3 , each row represents a key feature. The color of the dots illustrates how each patient’s feature value contributes to the outcome: yellow dots indicate a high positive contribution (increasing the risk of myopia), while purple dots indicate a low or negative contribution (decreasing the risk). DISCUSSION While myopia remains a global public health challenge, current research primarily examines its prevalence in diverse regions and populations, with limited attention to incidence rates. In this longitudinal cohort study of two school-age cohorts, we observed varying degrees of myopia progression across all grades (10–21%). The incidence rate (assessed non-cycloplegia) was slightly lower than previously reported rates in China’s coastal areas[ 17 – 20 ], yet substantially higher than those in other countries[ 21 ]. Guo et al. conducted a large non-cycloplegic cohort study reporting a mean annual incidence of 24.85% after one-year follow-up; however, incidence rates across all age groups were higher than those observed in the present study[ 18 ]. In the study by Wang et al. (based on non-cycloplegic methods), the annual prevalence of myopia was 20–30%, again higher than in the present study[ 17 ]. A potential explanation for this discrepancy is that prior studies focused on economically developed coastal regions of China, whereas our study was conducted in Xinjiang—a less developed inland region with lower educational attainment and consequently lower myopia incidence. Another potential explanation for this result is that, combined with data from our previous cross-sectional surveys, the prevalence of myopia among school-age children in Shihezi, Xinjiang, exceeds national averages, and the myopia prevalence among students in the current study was higher than that in Wang et al.'s cohort of the same school-age group, indicating an earlier onset of myopia among Shihezi students—a pattern consistent with our previous findings from cross-sectional surveys[ 5 ], this observation may plausibly explain the elevated prevalence of high myopia in Shihezi students compared to Wang et al.'s study. However, these interpretations remain speculative and have not been empirically confirmed in the current study. In our cohort, the overall prevalence of myopia and high myopia increased across primary and junior secondary school students, whereas mild myopia rates declined, indicating progressive myopic deterioration with age. By grade nine, myopia and high myopia prevalence reached 77.8% and 10.4%, respectively. High myopia can cause irreversible vision loss, underscoring the critical need to slow myopia progression—a persistent challenge in public health strategies. Higher SER values emerged as the most significant protective factor against myopia incidence in both cohorts. Premature hyperopic reserve depletion—a known risk factor for myopia onset and progression to high myopia[ 22 ]—was consistent with our Cox proportional hazards regression findings, further validating the role of refractive status in myopic progression. Similarly, we observed that the hyperopic reserve was depleted as early as grades 1–2 in this population, aligning with our prior findings from cross-sectional surveys[ 5 ], This finding further indicates an earlier onset of myopia among schoolchildren in Shihezi. In the primary school cohort, female sex was associated with higher myopia risk. Sex-based SER differences became statistically significant from grade 4 onwards, with girls exhibiting lower SER values—a pattern potentially linked to their prolonged near-work activities and reduced outdoor exposure. Furthermore, earlier pubertal onset in girls may indirectly elevate myopia risk through behavioral modifications[ 23 ]. >8 hours of sleep are a protective factor for the onset of myopia in primary school children, and a Korean study showed that people who slept more than 9 hours had a 41 percent lower risk of myopia compared to those who slept less than 5 hours[ 24 ]. Parental myopia is a risk factor for the onset of myopia in primary school children. Jones et al. quantified this relationship, showing that one myopic parent increased the risk of myopia in their children by 2.08-fold, and two myopic parents increased the risk by 5.07-fold[ 25 ]. However, the present study did not observe an association between sleep duration, parental myopia, and the onset of myopia in the middle school cohort. Additionally, no significant relationship was found between other behavioral factors in the questionnaire and the onset of myopia in this study. STRENGTHS AND LIMITATIONS The strengths of this study include its large-sample longitudinal cohort design and the use of questionnaires to assess the relationship between myopia-related behavioural factors and myopia incidence. In addition, we used SHAP analysis to assess the importance of each influencing factor on the incidence of myopia. However, we acknowledge several limitations. First, the absence of ciliary muscle paralysis prior to automated optometry may have caused misclassification of some participants as myopic. Second, the geographical specificity of Xinjiang limits the generalisability of our findings to other regions of China. Third, questionnaire-based data collection introduces potential information bias. Finally, the exclusion of preschool-aged children prevents observation of myopia development in this group, necessitating future studies to clarify the critical period of myopia incidence. CONCLUSION Our study revealed that the annual incidence of myopia among school-aged children in Shihezi City (based on non-cycloplegic refraction) ranged from 10–21% in grades 1–9. A higher hyperopic reserve in elementary and junior high school students served as a protective factor against myopia onset. Female sex and parental myopia were risk factors for myopia incidence in primary school students, while > 8 hours of sleep was protective in this group; However the association of these factors with the onset of myopia in middle school students is limited. Furthermore, the hyperopic reserve progressively disappeared from grades 1–2, suggesting that myopia onset in Shihezi’s schoolchildren may initiate as early as grades 1–2. Future studies employing cycloplegic refraction and including preschool-aged children are needed to clarify the critical period for myopia onset. If validated, preventive interventions could potentially begin during preschool years. Abbreviations UCVA uncorrected visual acuity D diopters SE Spherical equivalent SD standard deviation IQR interquartile range HR hazard ratio Declarations Ethics approval and consent to participate: Informed consent was obtained from the participants and their parents in all our studies. This study followed the tenets of Declaration of Helsinki and was approved by the Ethical Review Committee of The First Affiliated Hospital of Shihezi University. Participants gave informed consent to participate in the study before taking part (KJ2024−491−01). Consent for publication ： Not Applicable. Availability of data and materials ： The dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests ： The authors declare no competing interests. Funding: Research reported in this publication received financial support from the Chinese Centre for Disease Control and Prevention (CDC); however, there was no CDC involvement of influence with any aspect of the study/initiative/ activity supported by grant. Author Contributions: Xiaopeng Hu: Resources, Conceptualization, Methodology, Formal analysis, Writing - Original Draft Xianyan Yuan: Investigation, Funding acquisition Hua Li: Formal analysis, Writing - Original Draft Yuting Xie: Investigation liqun Wang: Data Curation Dongsheng Rui: Supervision, Project administration, Conceptualization Acknowledgements: We would like to thank the Chinese Center for Disease Control and Prevention for providing data for this study. References Chung YW. 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Global risk factor analysis of myopia onset in children: A systematic review and meta-analysis. PLoS ONE. 2023;18(9):e0291470. Dong J, Zhu Z, Xu H, He M. Myopia Control Effect of Repeated Low-Level Red-Light Therapy in Chinese Children: A Randomized, Double-Blind, Controlled Clinical Trial. Ophthalmology. 2023;130(2):198–204. Chia A, Chua W-H, Cheung Y-B, Wong W-L, Lingham A, Fong A, Tan D. Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012;119(2):347–54. He M, Xiang F, Zeng Y, Mai J, Chen Q, Zhang J, Smith W, Rose K, Morgan IG. Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA. 2015;314(11):1142–8. He X, Sankaridurg P, Wang J, Chen J, Naduvilath T, He M, Zhu Z, Li W, Morgan IG, Xiong S, et al. Time Outdoors in Reducing Myopia: A School-Based Cluster Randomized Trial with Objective Monitoring of Outdoor Time and Light Intensity. Ophthalmology. 2022;129(11):1245–54. Rozema JJ, Herscovici Z, Snir M, Axer-Siegel R. Analysing the ocular biometry of new-born infants. Ophthalmic Physiol Opt. 2018;38(2):119–28. Axer-Siegel R, Herscovici Z, Davidson S, Linder N, Sherf I, Snir M. Early structural status of the eyes of healthy term neonates conceived by in vitro fertilization or conceived naturally. Invest Ophthalmol Vis Sci. 2007;48(12):5454–8. Pu J, Fang Y, Zhou Z, Chen W, Hu J, Jin S, Liu X, Wang L, Feng J, Tong H, et al. The hyperopia reserve in 3- to 6- years-old preschool children in North China: the Beijing hyperopia reserve research. BMC Ophthalmol. 2025;25(1):175. Ye L, Yang Y-Q, Zhang G-Y, Wang W-J, Ren M-X, Ge P, Zhang J, Zhang N, Liu X-Z, Zhang M-L, et al. Increasing prevalence of myopia and the impact of education in primary-school students in Xi'an, north-western of China. Front Public Health. 2022;10:1070984. Appropriate technical guidelines for the prevention and control of myopia in children. and adolescents. [ http://www.nhc.gov.cn/jkj/s5898bm/201910/c475e0bd2de444379402f157523f03fe.shtml [Accessed 15 Oct 2019]]. Ponce-Bobadilla AV, Schmitt V, Maier CS, Mensing S, Stodtmann S. Practical guide to SHAP analysis: Explaining supervised machine learning model predictions in drug development. Clin Transl Sci. 2024;17(11):e70056. Wang SK, Guo Y, Liao C, Chen Y, Su G, Zhang G, Zhang L, He M. Incidence of and Factors Associated With Myopia and High Myopia in Chinese Children, Based on Refraction Without Cycloplegia. JAMA Ophthalmol. 2018;136(9):1017–24. Guo C, Li Y, Luo L, Lin J, Qiu K, Zhang M. Progression and incidence of myopia among schoolchildren in the post-COVID-19 pandemic period: a prospective cohort study in Shantou, China. BMJ Open. 2023;13(8):e074548. Tsai D-C, Fang S-Y, Huang N, Hsu C-C, Chen S-Y, Chiu AW-H, Liu CJ-L. Myopia Development Among Young Schoolchildren: The Myopia Investigation Study in Taipei. Invest Ophthalmol Vis Sci. 2016;57(15):6852–60. Yang Y, Liao H, Zhao L, Wang X, Yang X, Ding X, Li X, Jiang Z, Zhang X, Zhang Q, et al. Green Space Morphology and School Myopia in China. JAMA Ophthalmol. 2024;142(2):115–22. French AN, Morgan IG, Burlutsky G, Mitchell P, Rose KA. Prevalence and 5- to 6-year incidence and progression of myopia and hyperopia in Australian schoolchildren. Ophthalmology. 2013;120(7):1482–91. Harb EN, Wildsoet CF. Origins of Refractive Errors: Environmental and Genetic Factors. Annu Rev Vis Sci. 2019;5:47–72. Xu R, Zhong P, Jan C, Song Y, Xiong X, Luo D, Dong Y, Ma J, Stafford RS. Sex Disparity in Myopia Explained by Puberty Among Chinese Adolescents From 1995 to 2014: A Nationwide Cross-Sectional Study. Front Public Health. 2022;10:833960. Jee D, Morgan IG, Kim EC. Inverse relationship between sleep duration and myopia. Acta Ophthalmol. 2016;94(3):e204–10. Jones LA, Sinnott LT, Mutti DO, Mitchell GL, Moeschberger ML, Zadnik K. Parental history of myopia, sports and outdoor activities, and future myopia. Invest Ophthalmol Vis Sci. 2007;48(8):3524–32. Additional Declarations No competing interests reported. Supplementary Files appendix1.docx Schedule1.docx eFigure1.tif eFirgure2.tif Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 20 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviews received at journal 25 Oct, 2025 Reviewers agreed at journal 25 Oct, 2025 Reviewers agreed at journal 24 Oct, 2025 Reviewers invited by journal 09 Sep, 2025 Editor assigned by journal 09 Sep, 2025 Editor invited by journal 08 Sep, 2025 Submission checks completed at journal 07 Sep, 2025 First submitted to journal 07 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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03:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7522290/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7522290/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-026-26517-y","type":"published","date":"2026-04-09T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91508025,"identity":"61714457-d7c0-482f-96a3-63855fae42a0","added_by":"auto","created_at":"2025-09-17 08:36:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77687,"visible":true,"origin":"","legend":"\u003cp\u003eMean UCVA of OD and SER by School Grade\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/50923f561aeab16a954e1d6a.png"},{"id":91510673,"identity":"b5f90575-415b-464f-b335-45f0bc03b186","added_by":"auto","created_at":"2025-09-17 08:44:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57662,"visible":true,"origin":"","legend":"\u003cp\u003eImportant influencing factors on myopia incidence with SHAP model\u003c/p\u003e","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/44497b444e34bf054048a287.png"},{"id":91511794,"identity":"81e59f77-e742-4306-ab12-6332de1dd9dc","added_by":"auto","created_at":"2025-09-17 08:52:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":23781,"visible":true,"origin":"","legend":"\u003cp\u003eThe importance ranking of the factors according to the mean SHAP value;\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/c436e83a99c6e3d52ed98bf6.png"},{"id":106810898,"identity":"f5b0d0e0-a934-498d-ac90-79d2f5dd25de","added_by":"auto","created_at":"2026-04-13 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08:52:55","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18042,"visible":true,"origin":"","legend":"","description":"","filename":"Schedule1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/f57c5333388f452c3384d742.docx"},{"id":91508055,"identity":"61b1f717-86f8-42fa-a793-a9fe395d06a3","added_by":"auto","created_at":"2025-09-17 08:37:00","extension":"tif","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":8074752,"visible":true,"origin":"","legend":"","description":"","filename":"eFigure1.tif","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/fb1d64b20369b41ea573648d.tif"},{"id":91511796,"identity":"ba5f5cdb-06e0-4542-b945-9547ea435612","added_by":"auto","created_at":"2025-09-17 08:52:55","extension":"tif","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":7340408,"visible":true,"origin":"","legend":"","description":"","filename":"eFirgure2.tif","url":"https://assets-eu.researchsquare.com/files/rs-7522290/v1/072761b2602286b03d0b96f5.tif"}],"financialInterests":"No competing interests reported.","formattedTitle":"The incidence of myopia and the factors associated with it among primary and junior high school students in Shihezi, China, a cohort study based on the SHAP model","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMyopia in children has become a global public health concern, with its prevalence continuously rising worldwide, particularly in East Asia[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Myopia not only affects visual acuity but also serves as a significant risk factor for various vision-impairing complications, including glaucoma, myopic macular degeneration, and retinal detachment[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The increasing prevalence of childhood myopia, coupled with a trend toward earlier onset[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], underscores the necessity for early detection and intervention. This is crucial as associated risks may lead to severe long-term visual impairment and varying degrees of reduced quality of life[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith ongoing research into myopia, several interventions have emerged to delay its onset and progression, including repeated low-intensity red light therapy[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e],atropine treatment[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]and increased outdoor activity time[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As these interventions become available alongside the trend toward earlier onset of myopia, identifying target populations and optimal timing for intervention has become particularly crucial in myopia prevention and control. During the neonatal stage, the eye exhibits hyperopic status with an average spherical equivalent refractive error of +\u0026thinsp;2.50 to +\u0026thinsp;3.00D. This physiological hyperopia is termed the hyperopic reserve[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], which represents a pre-emmetropic and pre-myopic refractive state[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The depletion of hyperopic reserve serves as an early warning sign for myopia development. Given the plasticity of visual development in children aged 0\u0026ndash;6 years, myopia prevention strategies should focus on both the age groups with the highest incidence rates and the timing of hyperopic reserve depletion. This highlights the necessity of studying the onset and progression of myopia in children and adolescents. According to research by Hu et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the spherical equivalent refractive error transitions from positive to negative values between ages 6 and 7. However, this conclusion was derived from large-scale cross-sectional studies, and the precise timing of the shift from emmetropia/hyperopia to myopia remains unclear. There is a critical need for longitudinal data collected from large childhood cohorts to accurately identify periods of high myopia incidence. Such data would significantly enhance the determination of optimal intervention timing for myopia management.\u003c/p\u003e\u003cp\u003eWhile numerous cross-sectional myopia studies have been conducted in China, most focus on prevalence rates and associated risk factors. Large-scale longitudinal cohort studies specifically investigating myopia incidence and hyperopic reserve dynamics remain relatively scarce. Compared with inland Chinese cities, Xinjiang demonstrates distinct regional characteristics in socioeconomic development and educational attainment disparities (relatively underdeveloped). These differences may potentially lead to unique patterns of myopia incidence among children and adolescents in this region.\u003c/p\u003e\u003cp\u003eThis study aims to investigate the incidence and progression rates of myopia among children and adolescents in Xinjiang, China, focusing on two critical refractive development phases: primary school (grades 1\u0026ndash;6) and junior high school (grades 7\u0026ndash;9) under non-cycloplegic refraction. This study employed the Cox proportional hazards regression model in conjunction with questionnaires and visual acuity measurements to assess the association between these characteristics and the onset of myopia, and further utilized SHAP analysis to evaluate the significance of each influential factor, thereby providing a scientific basis for determining the optimal timing of myopia prevention and control and the measures to be taken.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis longitudinal cohort study utilizes data from the National Student Common Diseases and Vision Surveillance Program in Shihezi City. Initiated in 2018, the cohort enrolled students from nine primary and junior high schools designated as health surveillance sites by the Shihezi City Center for Disease Control and Prevention. These schools were proportionally selected through stratified random sampling from all educational institutions in Shihezi City, ensuring representativeness of the city\u0026rsquo;s student population. The study protocol received ethical approval from the Institutional Review Board of the First Affiliated Hospital of Shihezi University and adhered to the Declaration of Helsinki guidelines (KJ2024-491-01). Written informed consent was obtained from all participants and their parents prior to baseline assessments.\u003c/p\u003e\u003cp\u003eThe study was initiated in 2018 and has been conducted annually every October since. Each investigation year incorporates newly enrolled students into the study cohort. Baseline data are collected from participants\u0026rsquo; initial physical examinations, with follow-up continuing until their graduation from primary or junior high school. (thereafter, the student graduates and were distributed to various junior high school or senior high school).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasurements and Outcomes\u003c/h3\u003e\n\u003cp\u003eAge at each examination was calculated as the difference in years between the participant\u0026rsquo; s date of birth and the examination date. Physical examination data were collected by professionally trained technicians during annual school-based assessments starting in 2018. Participants\u0026rsquo; height and weight were measured using calibrated equipment, with height recorded to the nearest 0.1 cm and weight to the nearest 0.1 kg, while participants stood barefoot on the measurement platform.Students were asked to remove their eyeglasses (including contact lenses) for refraction and uncorrected visual acuity (UCVA) examinations, and all subjects had refraction and visual acuity examinations performed by professional optometrists with standardized training. Uncorrected visual acuity was tested using a standard logarithmic visual acuity E chart. When testing the vision of the right eye, a non-contact black spoon-shaped ocular occluder was used to cover the left eye at a distance of 5 m. After the right eye was tested for 5 to 10 s, the left eye was tested in the same way. Non-cycloplegic refraction were detected using an autorefractor of the TOPCON KR-1 (Tokyo, Japan). Each subject was tested three times per eye, and the results were averaged. If the difference between the three results re any two results was greater than 0.5 diopters (D), each subject was re-examined. Spherical equivalent (SE) was determined using the algebraic sum of the refractive errors of the spherical and cylindrical lenses (spherical\u0026thinsp;+\u0026thinsp;0.5 cylindrical)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Myopia is defined as uncorrected visual acuity\u0026thinsp;\u0026lt;\u0026thinsp;5.0 in either eye and spherical equivalent (SE) \u0026lt; -0.50D, and is categorized as mild myopia (-3.00D\u0026thinsp;\u0026le;\u0026thinsp;SE \u0026lt; -0.50D), moderate myopia (-6.00D\u0026thinsp;\u0026le;\u0026thinsp;SE \u0026lt; -3.00D) and high myopia (SE \u0026lt; -6.00D)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Physical examinations were performed at all follow-up visits using the same equipment and protocol.\u003c/p\u003e\u003cp\u003eAn annual standardized questionnaire, which was developed by the Chinese Center for Disease Control and Prevention (see Appendix 1 for full details), was administered during follow-up visits to assess poor vision and associated risk factors in students. The instrument evaluated multiple domains, including parental myopia, visual environment, ocular habits, screen exposure, outdoor activity patterns, and sleep duration.\u003c/p\u003e\u003cp\u003eParticipants with previous cataract surgery, laser myopic surgery, low-dose atropine, and use of orthokeratology lenses were excluded. Additionally, participants aged\u0026thinsp;\u0026lt;\u0026thinsp;6 or \u0026gt;\u0026thinsp;16 years were excluded as these thresholds fall outside the typical enrollment age range for first-grade students in Chinese primary and junior high schools.\u003c/p\u003e\u003cp\u003eIn all analyses, the annual prevalence of myopia was defined as the proportion of new-onset myopia cases among participants who did not have myopia in the previous year or an earlier date.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS (v27.0), with data visualization conducted in GraphPad Prism (v9.5.1) and R (v4.5.1). Continuous variables with normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while non-normally distributed variables were summarized as median and interquartile range (IQR).Categorical variables were expressed as frequencies (n) and percentages (%). The t-test, Pearson χ\u003csup\u003e2\u003c/sup\u003e test, Mann-Whitney U test and Pearson correlation coefficient r were applied as appropriate. Cox proportional hazards regression models were implemented to identify risk factors for myopia incidence, analyzing data from participants without myopia at baseline with adjustment for covariates. A two-sided significance level of α\u0026thinsp;=\u0026thinsp;0.05 was applied throughout the study. All statistical procedures were executed between April 2025 and May 2025.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMachine learning model\u003c/h3\u003e\n\u003cp\u003eThe SHAP framework is a technique used to quantify the contribution of each feature to the model\u0026rsquo;s predictions[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We assessed the effect of each myopia-influencing factor on the likelihood of myopia onset by calculating the SHAP value for each observation. The mean SHAP value for each feature was calculated to identify the key influences on myopia onset. The SHAP analysis was performed using R 4.5.1.\u003c/p\u003e"},{"header":"RESULET","content":"\u003cp\u003eA total of 3,551 students were included in this study, enrolled in nine primary and junior high schools in Shihezi City, Xinjiang, China. A total of 91 participants were excluded based on predefined criteria: 23 for orthokeratology lens use, 47 due to invalid autorefraction measurements, and 21 being under 6 years of age at baseline. The final analytical cohort comprised 3,551 students (2,345 in primary schools; 1,206 in junior high schools). Both the elementary and middle school cohorts were followed for 2 years, after which the middle school cohort graduated.There were no lost visits in this cohort study because the cohort was constructed using data from a cross-sectional survey, and samples with missing follow-up data were excluded during the cohort creation.\u003c/p\u003e\n\u003cp\u003eThe characteristics of each cohort at baseline and endpoint are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. There is a significant increase in the height (Baseline: median, 129.0 cm; Follow-up endpoint: 143.0 cm; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and weight (Baseline: median, 28.0 kg; Follow-up endpoint: 38.4 kg; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of primary school children from baseline, as well as more negative SER(Baseline: median, 0 D; Follow-up endpoint:\u0026minus;0.63 D; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), SEL(Baseline: median, 0 D; Follow-up endpoint:\u0026minus;0.62 D; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), UCVA of OD(Baseline: median, 5.0; Follow-up endpoint: 5.0; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), UCVA of OS(Baseline: median, 5.0; Follow-up endpoint: 5.0; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Junior high school students exhibited similar trends; however, compared to primary school students, they demonstrated less pronounced physical development but more significant changes in visual acuity.(Height: Baseline: median, 160.0 cm; vs Follow-up endpoint: 169.5 cm; Weight: Baseline: median, 51.0 kg; vs Follow-up endpoint: 59.6 kg; SER: Baseline: median, -1.25 D; vs Follow-up endpoint:\u0026minus;2.47 D; SEL: Baseline: median, -1.13 D; vs Follow-up endpoint:\u0026minus;2.13 D; UCVA of OD: Baseline: median, 4.8; vs Follow-up endpoint: 4.5; UCVA of OS: Baseline: median, 4.9; vs Follow-up endpoint: 4.6; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). Non-cycloplegic refraction data revealed diverging trends: myopia prevalence (including moderate-to-severe cases) demonstrated a progressive increase, whereas mild myopia prevalence exhibited a decline. In the primary school cohort, baseline-to-endpoint comparisons showed statistically significant differences in overall myopia, mild myopia, and moderate myopia (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), though severe myopia changes remained non-significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The junior high school cohort demonstrated statistically significant baseline-to-endpoint increases in overall myopia, mild, moderate, and severe myopia (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, the myopia prevalence among ninth-grade students at final follow-up reached 77.8% (938/1,206; 95% CI: 75.3 to 80.1).\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of Primary and Junior High School Cohort Participants at Baseline and Follow-up endpoint\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003ePrimary School Cohort\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eJunior High School Cohort\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up endpoint\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ/\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up endpoint\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ/\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, median (P25, P75), y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.5 (6.8, 9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.6 (8.9, 11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;41.899\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.8 (12.4, 13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.9 (14.6, 15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;30.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight, median (P25, P75), cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e129.0 (123.0, 136.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e143.0 (136.5, 150.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;41.902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e160.0 (155.0, 165.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e169.5 (163.5, 175.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;28.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight, median (P25, P75), kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (24.0, 34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.4 (31.6, 48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;41.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.0 (44.0, 59.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.6 (52.2, 70.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;28.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSER, median (P25, P75), D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (\u0026minus;0.63, 0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;0.63 (\u0026minus;1.87,\u0026minus;0.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;29.793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;1.25 (\u0026minus;2.75,\u0026minus;0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;2.47 (\u0026minus;4.00,\u0026minus;1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;22.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSEL, median (P25, P75), D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0 (\u0026minus;0.50, 0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;0.62 (\u0026minus;1.63, 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;29.376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;1.13 (\u0026minus;2.45,\u0026minus;0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;2.13 (\u0026minus;3.64,\u0026minus;0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;21.560\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUCVA of OD, median (P25, P75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0 (4.9, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0 (4.7, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;19.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8 (4.4, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.5 (4.2, 4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;16.223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUCVA of OS, median (P25, P75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0 (4.9, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0 (4.7, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;19.831\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.9 (4.5, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.6 (4.2, 5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026minus;14.301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevalence of myopia,\u003c/p\u003e\n \u003cp\u003eNo./Total\u003c/p\u003e\n \u003cp\u003eNo.(%) [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e466/2345 (19.9)\u003c/p\u003e\n \u003cp\u003e[18.3 to 21.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e950/2345 (40.5)\u003c/p\u003e\n \u003cp\u003e[38.5 to 42.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e236.985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e718/1206 (59.5)\u003c/p\u003e\n \u003cp\u003e[56.7 to 62.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e938/1206 (77.8)\u003c/p\u003e\n \u003cp\u003e[75.3 to 80.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e93.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevalence of mild myopia, No./Total\u003c/p\u003e\n \u003cp\u003eNo.(%) [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e384/466 (82.4)\u003c/p\u003e\n \u003cp\u003e[78.6 to 85.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e683/950 (71.9)\u003c/p\u003e\n \u003cp\u003e[68.9 to 74.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.587\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e442/718 (61.6)\u003c/p\u003e\n \u003cp\u003e[57.9 to 65.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e441/938 (47.0)\u003c/p\u003e\n \u003cp\u003e[43.8 to 50.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.568\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevalence of moderate myopia, No./Total\u003c/p\u003e\n \u003cp\u003eNo.(%) [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70/466 (15.0)\u003c/p\u003e\n \u003cp\u003e[11.9 to 18.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e230/950 (24.2)\u003c/p\u003e\n \u003cp\u003e[21.5 to 27.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e236/718 (32.9)\u003c/p\u003e\n \u003cp\u003e[29.4 to 36.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e399/938 (42.5)\u003c/p\u003e\n \u003cp\u003e[39.3 to 45.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevalence of high myopia, No./Total\u003c/p\u003e\n \u003cp\u003eNo.(%) [95% CI]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12/466 (2.6)\u003c/p\u003e\n \u003cp\u003e[1.3 to 4.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37/950 (3.9)\u003c/p\u003e\n \u003cp\u003e[2.8 to 5.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40/718 (5.6)\u003c/p\u003e\n \u003cp\u003e[4.0 to 7.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e98/938 (10.4)\u003c/p\u003e\n \u003cp\u003e[8.6 to 12.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eAnnual trends in spherical equivalent refraction (SER) and uncorrected visual acuity (UCVA) of the right eye (OD) are shown in Fig. 1, and trends in height and weight are shown in eFigure 1. UCVA of OD demonstrated strong negative correlations with grade advancement in both cohorts (primary school cohort: r = -0.9681; junior high school cohort: r = -0.9983). SER showed a similar inverse relationship in the primary school cohort (r = -0.9962), but no significant association was observed in the junior high cohort. Anthropometric measurements revealed strong positive correlations between grade level and both height (r\u0026thinsp;=\u0026thinsp;0.9976) and weight (r\u0026thinsp;=\u0026thinsp;0.9937) in primary school students, whereas these associations became non-significant in junior high students.\u003c/p\u003e\n\u003cp\u003eTrends for boys and girls were generally similar, with height increasing with grade, with statistically significant differences in height between boys and girls in grades 1\u0026ndash;3 of primary school (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), not statistically significant differences in height between boys and girls in grades 4\u0026ndash;6 (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and statistically significant differences in height between boys and girls in grades 7\u0026ndash;9 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Weight increases with grade, and the difference in height between boys and girls was statistically significant in grades 1\u0026ndash;4 of primary school (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), not statistically significant in grades 5\u0026ndash;6 (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and statistically significant in grades 7\u0026ndash;9 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SER decreased with increasing grade level, the difference in SER between boys and girls in primary grades 1\u0026ndash;3 was not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and the difference in SER between boys and girls in grades 4\u0026ndash;9 was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). UCVA of OD decreased with increasing grade level, with no statistically significant difference in UCVA of OD between boys and girls in grades 1\u0026ndash;3 of primary school (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), statistically significant difference in UCVA of OD between boys and girls in grades 4\u0026ndash;8 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and not statistically significant difference in UCVA of OD between boys and girls in grade 9 (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Schedule 1).\u003c/p\u003e\n\u003cp\u003eNon-cycloplegic refraction data revealed annual myopia incidence rates of 10\u0026ndash;21% throughout primary and junior high school (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The incidence of myopia among first to second-grade primary school students is 15.57% (166/1066, 95% CI: 13.44 to 17.89), and the highest incidence between third and fourth grades at 20.63% (144/698, 95% CI: 17.69 to 23.83). Across different years, the incidence was highest in 2021 at 19.11% (439/2297, 95% CI: 17.52 to 20.78).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAnnual Incidence of Myopia in Primary and Junior High School Cohorts and Annual Incidence in different years\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePeriod\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal No.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e[95% CI]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[13.44\u0026ndash;17.89]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[15.38\u0026ndash;21.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u0026ndash;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[17.69\u0026ndash;23.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e828\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[14.98\u0026ndash;20.28]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u0026ndash;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[12.64\u0026ndash;19.77]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u0026ndash;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16.26\u0026ndash;20.71]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u0026ndash;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[10.31\u0026ndash;14.51]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eYears\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[15.91\u0026ndash;19.29]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[17.52\u0026ndash;20.78]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e[16.35\u0026ndash;20.48]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003cdiv align=\"char\" class=\"colspec\"\u003eTables \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e show the results of Cox proportional hazards regressions for myopia onset in the primary schools cohort and the middle school cohort. After adjusting for covariates, the analysis revealed that girls (hazard ratio [HR], 1.186 [95% CI, 1.022 to 1.377] compared with boys), parental myopia (hazard ratio [HR], either myopia: 1.511 [95% CI, 1.147 to 1.989] compared with neither myopia; both myopia: 2.090 [95% CI, 1.329 to 3.285] compared with neither myopia) were risk factors for myopia development in primary school children, whereas a sleep duration exceeding 8 hours served as a protective factor (hazard ratio [HR], 8\u0026ndash;10 hours: 0.524 [95% CI, 0.290 to 0.949] compared with \u0026lt;\u0026thinsp;8 hours; \u0026gt;10 hours: 0.560 [95% CI, 0.319 to 0.983] compared with \u0026lt;\u0026thinsp;8 hours). Higher SER at baseline is a protective factor for the onset of myopia in primary school children(hazard ratio [HR], P25 to P75: 0.395[95% CI, 0.334 to 0.468] compared with the bottom quartile; the top quartile: 0.121[95% CI, 0.090 to 0.163] compared with the bottom quartile). For junior high school students, higher baseline SER was a protective factor against myopia onset (hazard ratio [HR] for the top quartile: 0.282 [95% CI, 0.179 to 0.442] compared to the bottom quartile). None of the other questionnaire-assessed factors showed a significant association with myopia onset in the Cox proportional hazards regression.\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors Associated With Incident Myopia in Primary School Cohort by Cox Proportional Hazard Regression Analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline Characteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted Hazard Ratio (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.186 (1.022 to 1.377)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;131.0 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131.0\u0026ndash;144.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.166 (0.936 to 1.452)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;144.0 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.292 (0.975 to 1.713)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;28.0 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u0026ndash;41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.944 (0.760 to 1.173)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.603\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;41.4.0 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.997 (0.755 to 1.317)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSER, D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026minus;1.375 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e554\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;1.375\u0026ndash;0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.395 (0.334 to 0.468)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.125 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.121 (0.090 to 0.163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSleep Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u0026ndash;10hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.524 (0.290 to 0.949)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;10 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.560 (0.319 to 0.983)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeither Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEither Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.511 (1.147 to 1.989)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.090 (1.329 to 3.285)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFactors Associated With Incident Myopia in Junior High School Cohort by Cox Proportional Hazard Regression Analysis\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline Characteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted Hazard Ratio (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e589\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.060 (0.819 to 1.371)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.657\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;131.0 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131.0\u0026ndash;144.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.011 (0.754 to 1.356)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;144.0 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.052 (0.717 to 1.544)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;28.0 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0\u0026ndash;41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.095 (0.821 to 1.462)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.095\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;41.4.0 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.024 (0.718 to 1.460)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSER, D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026minus;1.375 (25th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;1.375\u0026ndash;0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.860 (0.565 to 1.310)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;0.125 (75th Percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.282 (0.179 to 0.442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSleep Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;8 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u0026ndash;10hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.960 (0.707 to 1.304)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.792\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.975 (0.708 to 1.344)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.879\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeither Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [Reference]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEither Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.063 (0.757 to 1.493)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth Myopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.140 (0.664 to 1.958)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.635\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eeFigure 2 shows the survival curves for myopia incidence in participants who were non-myopic at baseline. The primary school cohort had a 61.79% probability of remaining free of myopia after two years of follow-up (1161/1879; 95% CI: 59.55 to 63.99), while the middle school cohort (junior high students non-myopic in grade 7) showed a 36.68% probability of remaining non-myopia by grade 9 (179/488; 95% CI: 32.39 to 41.12).\u003c/p\u003e\n\u003cp\u003eWe used SHAP to quantify the contribution of each variable to myopia prediction in our model. Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the risk factors ranked by their mean absolute SHAP values, while Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e showcases the same key features identified in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The y-axis ranks the features by their importance in the predictive model. The x-axis reflects the SHAP value, indicating the influence of each feature on the prediction outcome. In Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, each row represents a key feature. The color of the dots illustrates how each patient\u0026rsquo;s feature value contributes to the outcome: yellow dots indicate a high positive contribution (increasing the risk of myopia), while purple dots indicate a low or negative contribution (decreasing the risk).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWhile myopia remains a global public health challenge, current research primarily examines its prevalence in diverse regions and populations, with limited attention to incidence rates. In this longitudinal cohort study of two school-age cohorts, we observed varying degrees of myopia progression across all grades (10\u0026ndash;21%). The incidence rate (assessed non-cycloplegia) was slightly lower than previously reported rates in China\u0026rsquo;s coastal areas[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], yet substantially higher than those in other countries[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Guo et al. conducted a large non-cycloplegic cohort study reporting a mean annual incidence of 24.85% after one-year follow-up; however, incidence rates across all age groups were higher than those observed in the present study[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the study by Wang et al. (based on non-cycloplegic methods), the annual prevalence of myopia was 20\u0026ndash;30%, again higher than in the present study[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A potential explanation for this discrepancy is that prior studies focused on economically developed coastal regions of China, whereas our study was conducted in Xinjiang\u0026mdash;a less developed inland region with lower educational attainment and consequently lower myopia incidence. Another potential explanation for this result is that, combined with data from our previous cross-sectional surveys, the prevalence of myopia among school-age children in Shihezi, Xinjiang, exceeds national averages, and the myopia prevalence among students in the current study was higher than that in Wang et al.'s cohort of the same school-age group, indicating an earlier onset of myopia among Shihezi students\u0026mdash;a pattern consistent with our previous findings from cross-sectional surveys[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], this observation may plausibly explain the elevated prevalence of high myopia in Shihezi students compared to Wang et al.'s study. However, these interpretations remain speculative and have not been empirically confirmed in the current study.\u003c/p\u003e\u003cp\u003eIn our cohort, the overall prevalence of myopia and high myopia increased across primary and junior secondary school students, whereas mild myopia rates declined, indicating progressive myopic deterioration with age. By grade nine, myopia and high myopia prevalence reached 77.8% and 10.4%, respectively. High myopia can cause irreversible vision loss, underscoring the critical need to slow myopia progression\u0026mdash;a persistent challenge in public health strategies.\u003c/p\u003e\u003cp\u003eHigher SER values emerged as the most significant protective factor against myopia incidence in both cohorts. Premature hyperopic reserve depletion\u0026mdash;a known risk factor for myopia onset and progression to high myopia[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u0026mdash;was consistent with our Cox proportional hazards regression findings, further validating the role of refractive status in myopic progression. Similarly, we observed that the hyperopic reserve was depleted as early as grades 1\u0026ndash;2 in this population, aligning with our prior findings from cross-sectional surveys[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], This finding further indicates an earlier onset of myopia among schoolchildren in Shihezi. In the primary school cohort, female sex was associated with higher myopia risk. Sex-based SER differences became statistically significant from grade 4 onwards, with girls exhibiting lower SER values\u0026mdash;a pattern potentially linked to their prolonged near-work activities and reduced outdoor exposure. Furthermore, earlier pubertal onset in girls may indirectly elevate myopia risk through behavioral modifications[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. \u0026gt;8 hours of sleep are a protective factor for the onset of myopia in primary school children, and a Korean study showed that people who slept more than 9 hours had a 41 percent lower risk of myopia compared to those who slept less than 5 hours[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Parental myopia is a risk factor for the onset of myopia in primary school children. Jones et al. quantified this relationship, showing that one myopic parent increased the risk of myopia in their children by 2.08-fold, and two myopic parents increased the risk by 5.07-fold[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, the present study did not observe an association between sleep duration, parental myopia, and the onset of myopia in the middle school cohort. Additionally, no significant relationship was found between other behavioral factors in the questionnaire and the onset of myopia in this study.\u003c/p\u003e"},{"header":"STRENGTHS AND LIMITATIONS","content":"\u003cp\u003eThe strengths of this study include its large-sample longitudinal cohort design and the use of questionnaires to assess the relationship between myopia-related behavioural factors and myopia incidence. In addition, we used SHAP analysis to assess the importance of each influencing factor on the incidence of myopia. However, we acknowledge several limitations. First, the absence of ciliary muscle paralysis prior to automated optometry may have caused misclassification of some participants as myopic. Second, the geographical specificity of Xinjiang limits the generalisability of our findings to other regions of China. Third, questionnaire-based data collection introduces potential information bias. Finally, the exclusion of preschool-aged children prevents observation of myopia development in this group, necessitating future studies to clarify the critical period of myopia incidence.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study revealed that the annual incidence of myopia among school-aged children in Shihezi City (based on non-cycloplegic refraction) ranged from 10\u0026ndash;21% in grades 1\u0026ndash;9. A higher hyperopic reserve in elementary and junior high school students served as a protective factor against myopia onset. Female sex and parental myopia were risk factors for myopia incidence in primary school students, while\u0026thinsp;\u0026gt;\u0026thinsp;8 hours of sleep was protective in this group; However the association of these factors with the onset of myopia in middle school students is limited. Furthermore, the hyperopic reserve progressively disappeared from grades 1\u0026ndash;2, suggesting that myopia onset in Shihezi\u0026rsquo;s schoolchildren may initiate as early as grades 1\u0026ndash;2. Future studies employing cycloplegic refraction and including preschool-aged children are needed to clarify the critical period for myopia onset. If validated, preventive interventions could potentially begin during preschool years.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUCVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003euncorrected visual acuity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ediopters\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSpherical equivalent\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003estandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einterquartile range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehazard ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from the participants and their parents in all our studies. This study followed the tenets of Declaration of Helsinki and was approved by the Ethical Review Committee of The First Affiliated Hospital of Shihezi University. Participants gave informed consent to participate in the study before taking part (KJ2024−491−01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe dataset used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eResearch reported in this publication received financial support from the Chinese Centre for Disease Control and Prevention (CDC); however, there was no CDC involvement of influence with any aspect of the study/initiative/ activity supported by grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions: Xiaopeng Hu:\u0026nbsp;\u003c/strong\u003eResources, Conceptualization, Methodology, Formal analysis, Writing - Original Draft\u003cstrong\u003e\u0026nbsp;Xianyan Yuan:\u0026nbsp;\u003c/strong\u003eInvestigation, Funding acquisition\u003cstrong\u003e\u0026nbsp;Hua Li:\u0026nbsp;\u003c/strong\u003eFormal analysis, Writing - Original Draft \u003cstrong\u003eYuting Xie:\u0026nbsp;\u003c/strong\u003eInvestigation\u003cstrong\u003e\u0026nbsp;liqun Wang:\u0026nbsp;\u003c/strong\u003eData Curation\u003cstrong\u003e\u0026nbsp;Dongsheng Rui:\u0026nbsp;\u003c/strong\u003eSupervision, Project administration, Conceptualization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe would like to thank the Chinese Center for Disease Control and Prevention for providing data for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChung YW. Myopia: a review of current concepts, association with nonophthalmological conditions, and treatment strategy in children and adolescents. Clin Exp Pediatr 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaarman AEG, Enthoven CA, Tideman JWL, Tedja MS, Verhoeven VJM, Klaver CCW. The Complications of Myopia: A Review and Meta-Analysis. Invest Ophthalmol Vis Sci. 2020;61(4):49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorgan IG, Ohno-Matsui K, Saw S-M. Myopia. \u003cem\u003eLancet\u003c/em\u003e 2012, 379(9827):1739\u0026ndash;1748.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYam JC, Tang SM, Kam KW, Chen LJ, Yu M, Law AK, Yip BH, Wang YM, Cheung CYL, Ng DSC, et al. High prevalence of myopia in children and their parents in Hong Kong Chinese Population: the Hong Kong Children Eye Study. Acta Ophthalmol. 2020;98(5):e639\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu X, Yuan X, Li H, Gong H, Fu Z, Xie Y, Wang L, Rui D. Trends in myopia prevalence among children and adolescents: a large-scale cross-sectional study in Shihezi, China. BMC Public Health. 2025;25(1):1576.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu M, Hu Y, Han M, Song J, Wu Z, Xu Z, Liu Y, Shao Z, Liu G, Yang Z, et al. Global risk factor analysis of myopia onset in children: A systematic review and meta-analysis. PLoS ONE. 2023;18(9):e0291470.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDong J, Zhu Z, Xu H, He M. Myopia Control Effect of Repeated Low-Level Red-Light Therapy in Chinese Children: A Randomized, Double-Blind, Controlled Clinical Trial. Ophthalmology. 2023;130(2):198\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChia A, Chua W-H, Cheung Y-B, Wong W-L, Lingham A, Fong A, Tan D. 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Ophthalmic Physiol Opt. 2018;38(2):119\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAxer-Siegel R, Herscovici Z, Davidson S, Linder N, Sherf I, Snir M. Early structural status of the eyes of healthy term neonates conceived by in vitro fertilization or conceived naturally. Invest Ophthalmol Vis Sci. 2007;48(12):5454\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePu J, Fang Y, Zhou Z, Chen W, Hu J, Jin S, Liu X, Wang L, Feng J, Tong H, et al. The hyperopia reserve in 3- to 6- years-old preschool children in North China: the Beijing hyperopia reserve research. BMC Ophthalmol. 2025;25(1):175.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYe L, Yang Y-Q, Zhang G-Y, Wang W-J, Ren M-X, Ge P, Zhang J, Zhang N, Liu X-Z, Zhang M-L, et al. Increasing prevalence of myopia and the impact of education in primary-school students in Xi'an, north-western of China. 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JAMA Ophthalmol. 2024;142(2):115\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrench AN, Morgan IG, Burlutsky G, Mitchell P, Rose KA. Prevalence and 5- to 6-year incidence and progression of myopia and hyperopia in Australian schoolchildren. Ophthalmology. 2013;120(7):1482\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarb EN, Wildsoet CF. Origins of Refractive Errors: Environmental and Genetic Factors. Annu Rev Vis Sci. 2019;5:47\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu R, Zhong P, Jan C, Song Y, Xiong X, Luo D, Dong Y, Ma J, Stafford RS. Sex Disparity in Myopia Explained by Puberty Among Chinese Adolescents From 1995 to 2014: A Nationwide Cross-Sectional Study. Front Public Health. 2022;10:833960.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJee D, Morgan IG, Kim EC. Inverse relationship between sleep duration and myopia. 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Invest Ophthalmol Vis Sci. 2007;48(8):3524\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children and adolescents, Myopia, Hyperopia reserve, Incidence, SHAP model","lastPublishedDoi":"10.21203/rs.3.rs-7522290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7522290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eMyopia has been a major public health problem worldwide, with the highest incidence of myopia in East Asia. Investigating the incidence of myopia and its associated factors among children in primary and junior high school in underdeveloped regions of China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eThis observational cohort study was completed in Shihezi, China, which was drawn from nine primary and secondary schools with a follow-up period from 2018 to 2023, all of which were randomly selected in proportion to the number of schools in the city. Students (with or without myopia) who have been able to participate continuously for three consecutive years starting from 2018 were eligible for inclusion. Data analysis occurred from April 2025 and May 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eA total of 3,551 primary (median [P25, P75] age 7.5 [6.8, 9.0] years; 1077/2345 [45.9] girls) or junior high school (median [P25, P75] age 12.8 [12.4, 13.1]years; 585/1206 [45.9] girls) students were included. The annual incidence of myopia was 20% to 30% in primary and junior high schools. A higher hyperopic reserve in primary and junior high school students served as a protective factor against myopia onset. Female sex and parental myopia were risk factors for myopia incidence in primary school students, while \u0026gt;8 hours of sleep was protective in this group. Furthermore, the hyperopic reserve progressively disappeared from grades 1-2. Based on the SHAP model, the order of importance of the factors influencing the incidence of myopia was SE, segment, weight, sleep time, height, gender, and parental myopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eThe significantly higher prevalence of myopia among students in underdeveloped regions of China, combined with earlier depletion of the hyperopic reserve, suggests a potential shift toward earlier myopia onset. These findings highlight the need for early interventions in school-aged children, if confirmed through cycloplegic refraction.\u003c/p\u003e","manuscriptTitle":"The incidence of myopia and the factors associated with it among primary and junior high school students in Shihezi, China, a cohort study based on the SHAP model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 08:36:50","doi":"10.21203/rs.3.rs-7522290/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-21T03:46:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T12:38:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206019715034007997474556944631035583248","date":"2025-10-26T17:05:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-25T12:23:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179540686514479913200314055323018472704","date":"2025-10-25T12:05:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245248207673435043880178555734749216503","date":"2025-10-25T03:16:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-09T08:27:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T08:22:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T07:01:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T02:32:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-09-08T02:26:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"39539549-79b4-4919-aadc-d144ffbe33a5","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:15:42+00:00","versionOfRecord":{"articleIdentity":"rs-7522290","link":"https://doi.org/10.1186/s12889-026-26517-y","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-04-09 15:57:37","publishedOnDateReadable":"April 9th, 2026"},"versionCreatedAt":"2025-09-17 08:36:50","video":"","vorDoi":"10.1186/s12889-026-26517-y","vorDoiUrl":"https://doi.org/10.1186/s12889-026-26517-y","workflowStages":[]},"version":"v1","identity":"rs-7522290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7522290","identity":"rs-7522290","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}