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Results show 78.1% light, 18.4% intermediate, and 3.5% dark depictions, with substantial inter-rater agreement (quadratically weighted kappa 0.69). Dark skin tones were rare across textbooks and robust to analytic choices. The study frames 2021 Census comparisons as contextual benchmarks, not normative 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images in FP V-VI.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},565513,1792382639,{"code":4,"msg":81,"data":82},"success",[83,87,92,97,102,107,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":85,"slug":86},11,90,"presentations",{"id":88,"doc_module":22,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},12,"Resumes",80,"resumes",{"id":93,"doc_module":22,"doc_module_name":25,"category_name":94,"show_sort_weight":95,"slug":96},14,"Invoices",70,"invoices",{"id":98,"doc_module":22,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},15,"Posters",60,"posters",{"id":103,"doc_module":22,"doc_module_name":25,"category_name":104,"show_sort_weight":105,"slug":106},16,"Social 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 \nUniversity of Plymouth  \nHaleema Ajaib  \nUniversity of Plymouth  \nKaashish Sidhana  \nUniversity of Plymouth  \nKatey Hooper  \nUniversity of Plymouth  \nResearch Article  \nKeywords: skin tone representation, medical education, optometry, Fitzpatrick scale, content analysis, textbook imagery, health equity, visual pedagogy  \nPosted Date: July 7th, 2026  \nDOI: [https://doi.org/10.21203/rs.3.rs-9855135/v1](https://doi.org/10.21203/rs.3.rs-9855135/v1)  \nLicense: 􀁱 􀅏 This work is licensed under a Creative Commons Attribution 4.0 International License.  \nRead Full License  \nAdditional Declarations: Competing interest reported. The study was conducted as part of an undergraduate research project at the University of Plymouth.  \nAbstract  \nBackground  \nLighter skin tones are overrepresented in medical educational imagery across several disciplines, yet no study has examined optometric teaching materials. This study describes the distribution of apparent skin tone rendering in recommended undergraduate optometric textbooks used in England.  \nMethods  \nA descriptive, cross-sectional content analysis was conducted on 28 textbooks identified through purposive sampling of recommended reading lists from eight of eleven English university optometry programmes. Two independent mixed-composition teams classified 1,623 gradable graphics (1,446 photographs, 177 schematics) on the six-point Fitzpatrick skin phototype (FP) scale. Inter-rater reliability was assessed using quadratically weighted Cohen's kappa. Proportions are reported with 95% Wilson confidence intervals. Textbook-level analyses were also performed, treating the textbook as the unit of analysis. Descriptive comparisons with the 2021 Census are presented as contextual, not normative, benchmarks; no inferential hypothesis tests were conducted against the census comparator.  \nResults  \nQuadratically weighted kappa was 0 . 69, indicating substantial agreement on the ordinal scale, while unweighted exact agreement (61 .8%) reflected moderate category-by-category concordance. Across all graphics, 78 . 1% were classified as light (FP I-II; 95% CI 76 .1–80. 1%), 18 .4% as intermediate (FP III-IV; 95% CI 16.6–20.4%), and 3 . 5% as dark (FP V-VI; 95% CI 2 .7–4. 5%) . Fourteen of 28 textbooks (50%) contained no images classified as FP V-VI, and no schematic diagram across the corpus was classified as FP V-VI (0/177) . At the textbook level, median FP V-VI prevalence was 0 .9%(IQR 0 .0-3.8%), substantially below the census contextual comparator of 18.95% non-White. Findings were robust to exclusion of the single largest contributing text and restriction to books with ten or more gradable images (photographs plus schematics) .  \nConclusions  \nIn this sample of recommended optometric textbooks, graphics classified as depicting dark skin tones are rare. The finding is consistent across textbooks and robust to analytical choices. These data describe a pattern that warrants attention from publishers, educators, and curriculum developers, thoughthe study does not directly assess educational outcomes or establish a normative standard of adequate representation.  \nBackground  \nVisual imagery is a cornerstone of clinical training in medicine and its allied professions, including optometry. Educational graphics serve as tools through which clinicians learn to recognise and interpret disease presentations [1] . A well-documented tendency towards lighter skin tone depiction exists across medical educational resources, with potential implications for diagnostic training, clinical competence, and health equity [2, 3] .  \nInternational research has established the existence of this representational pattern. In the United States, Louie and Wilkes [4] demonstrated that while major anatomy textbook","cbCaisfG8s1AUvJf","https://ap.wps.com/l/cbCaisfG8s1AUvJf","pdf",833928,19,"English","# Background\n## Visual imagery and representational patterns\n## International evidence and gaps\n# Methods\n## Sampling and dataset\n## Classification and reliability\n## Statistical reporting\n# Results\n## Distribution across Fitzpatrick phototypes\n## Textbook-level prevalence\n## Robustness checks\n# Conclusions\n## Implications for publishers and educators","[{\"question\":\"What was the study’s main goal?\",\"answer\":\"To describe the distribution of apparent skin tone rendering in recommended undergraduate optometric textbooks used in England.\"},{\"question\":\"How were skin tones categorized in the analysis?\",\"answer\":\"Researchers classified 1,623 gradable graphics using the six-point Fitzpatrick skin phototype (FP) scale.\"},{\"question\":\"What were the key findings about dark skin tone depictions?\",\"answer\":\"Across all graphics, only 3.5% were classified as dark (FP V-VI), and 14 of 28 textbooks (50%) contained no images in FP V-VI.\"}]","Apparent skin tone rendering in recommended undergraduate optometric textbooks in England - a descriptive content analysis | PDF",1791855646,7]