Visual environment in schools and student depressive symptoms: Insights from a prospective study across multiple cities in eastern China

Objective: To investigate the effects of the school visual environment on depressive symptoms in children and adolescents based on cohort study in eastern China. The school visual environment-related indicators included in this study comprise personal factors (visual impairment) and school-related factors (classroom lighting, school green spaces and school air quality). Method: The follow-up cohort comprises 15,348 students from 283 primary and secondary schools in eastern China. This represents the one-year outcomes of a school-based myopia-mental health cohort study. Data collection includes basic demographics (age, gender, region, etc.), physical examination indicators, behavioral indicators, and school visual environment-related indicators. Result: After a one-year follow-up, we found that compared to the more severe vision impairment group ( <= 4.0), healthy vision group ( >= 5.0) had a positive effect against the occurrence of depressive symptoms during consecutive follow-ups, with an RR value of 0.61 (95% CI: 0.57-0.66). Higher values of blackboard illumination appear to be associated with greater positive effects, with an RR (Q75%-Q100% range) value of 0.87(95% CI: 0.81-0.93). School green spaces seem to exhibit relatively good positive effects when in the Q25%-Q75% range. The combination of physical activity (Weekly high-intensity exercise) with school air quality(PM 2 . 5 <= 50%) showed a better positive effect, with an RR value of 0.51(95%CI:0.48-0.55). Conclusion: When addressing students' depressive symptoms, it is crucial to improve the visual environment both at the school level and in students' personal level. Paying appropriate attention to modifiable behaviors, like regular participation in high-intensity exercise sessions, can help alleviate students' depressive symptoms.