Strategic Co-Prevention Framework for Addressing Common Health Challenges Among Students in China

Abstract

The concurrent rise in multiple health conditions among students, including myopia, obesity, spinal curvature abnormalities, and mental health disorders, represents a critical public health challenge. These interconnected health issues necessitate comprehensive prevention strategies that simultaneously address multiple conditions through synchronized behavioral and environmental interventions. In response to this need, the National Disease Control and Prevention Administration issued the Technical Guidelines for Co-Prevention of Common Diseases in Students on 30 April 2024, marking a significant advancement in China’s student health protection initiatives. The guidelines establish three core strategic priorities: enhancing surveillance of shared risk factors, implementing a systematic tiered approach to public health interventions, and developing an integrated, multisector prevention framework. This evidence-based, comprehensive initiative provides practical solutions for preventing comorbidities and enhancing overall student health outcomes. Further research is warranted to assess long-term effectiveness, explore regional implementation challenges, and support the development of standardized monitoring and evaluation systems.

1. Introduction

The rising prevalence of common health conditions among children and adolescents—such as myopia, overweight and obesity, spinal curvature abnormalities, hypertension, dental caries, and mental health disorders—has become a significant public health concern [1,2,3,4]. These conditions are increasingly observed concurrently in individuals, a phenomenon known as comorbidity. According to the 2019 National Student Physical Fitness and Health Surveillance in China, 20.1% of students exhibited two co-existing conditions (including myopia, obesity, malnutrition, and elevated blood pressure), while 2.8% and 0.014% were affected by three and four conditions, respectively [5]. Comorbidity can be broadly categorized into three types: multiple physical conditions (e.g., obesity with myopia or hypertension), the co-occurrence of physical and mental health disorders (e.g., obesity with depression), and multiple mental health issues (e.g., anxiety with depression). Emerging evidence suggests that comorbidity increases with age, particularly accelerating during adolescence [6,7,8,9]. For example, the Helsinki Birth Cohort Study found that rapid height and weight gain before the age of 11 was associated with an increased risk of chronic multimorbidity in adulthood [7]. These findings underscore the importance of early-life health as a determinant of long-term disease burden and emphasize the necessity of early preventive measures.

These co-existing health problems often share modifiable behavioral and environmental risk factors [10,11], such as insufficient physical activity, poor dietary habits, excessive screen time, inadequate sleep, and psychosocial stressors. A growing body of evidence indicates that these shared determinants contribute not only to the development of individual conditions but also to the clustering of multiple diseases among youth populations. For instance, a study among Tibetan adolescents identified prolonged daily screen time as a common risk factor for the co-occurrence of elevated blood pressure and overweight or obesity [12]. Other research has linked unhealthy behaviors—such as smoking, alcohol consumption, and excessive screen time—to comorbid cases of myopia and depressive symptoms [13]. Furthermore, comorbidity between obesity and depression has been associated with poor dietary habits, physical inactivity, and chronic digital media exposure [14]. These findings highlight the need for integrated preventive strategies that target overlapping behavioral risks across both physical and mental health domains.

In response to the growing burden of comorbid conditions, integrated lifestyle-based interventions have emerged as promising strategies. Multi-component programs addressing diet, physical activity, screen time, and mental well-being have demonstrated positive effects on both physical and psychological outcomes. International evidence shows that interventions combining physical activity, nutrition education, and behavioral counseling can yield sustained benefits. For example, one longitudinal study found that overweight children and adolescents who participated in a comprehensive intervention experienced significant reductions in adiposity, waist circumference, and blood pressure at both post-intervention and 12-month follow-up, with improvements in overweight status persisting for up to seven years [15,16]. In China, a randomized controlled trial conducted in primary and secondary schools demonstrated that health education-based interventions promoting dietary changes, physical activity, and self-monitoring of obesity-related behaviors effectively supported the adoption of cardiovascular health habits among students [17]. These findings suggest that well-structured, multi-domain interventions can serve as an effective entry point for co-prevention efforts that address overlapping health risks.

To address the growing burden of comorbid health conditions among children and adolescents, national policy in China has increasingly shifted toward integrated prevention. The 2024 Technical Guidelines for Co-Prevention of Common Diseases in Students represent a significant policy milestone, introducing a unified strategy that targets shared behavioral risk factors across multiple physical and mental health conditions. Rather than relying on a single institutional setting, the guidelines establish a “six-in-one” collaborative framework—led by government agencies, guided by professional institutions, and implemented through coordinated efforts among schools, families, communities, and students themselves. This multi-level approach aims to enhance implementation feasibility, promote health equity, and ensure long-term impact. Given that childhood and adolescence are critical windows for habit formation and lifelong health, early identification and coordinated intervention are essential. Strengthening the design, delivery, and evaluation of co-prevention strategies will be crucial to improving youth health outcomes and reducing the future burden of disease.

2. Materials and Methods

The Technical Guidelines for Co-Prevention of Common Diseases in Students were developed by the National Disease Control and Prevention Administration in collaboration with the Ministry of Education, health experts, and public health institutions. The development process followed a structured four-phase methodology: (1) preliminary investigation to assess disease burden and risk factors; (2) guideline drafting based on data analysis and intervention mapping; (3) expert consultation involving iterative reviews by multidisciplinary panels; and (4) refinement of recommendations through stakeholder feedback.

As the epidemiological foundation for the guidelines, a nationwide student health surveillance system was established in 2018. Led by the National Disease Control and Prevention Administration, this annual monitoring project systematically assessed the prevalence and risk factors of common diseases among school-aged children and adolescents across China. A multi-method approach was employed, including anthropometric health screenings, questionnaire surveys, on-site facility inspections, and environmental assessments. The surveillance framework tracked key health indicators such as vision status, obesity, spinal curvature abnormalities, and behavioral determinants, including screen time, physical activity, sleep patterns, and dietary habits. Data were collected from diverse stakeholders—including students across all educational stages, parents, teachers, and school health professionals—providing a comprehensive understanding of student health status and contextual influences.

To ensure representativeness and data quality, the national student health surveillance program employed a multi-stage, stratified sampling strategy covering all 2852 county-level administrative divisions across 31 provinces and the Xinjiang Production and Construction Corps. Schools were selected through an urban–rural stratification scheme, and student recruitment followed a clustered random sampling approach across all educational levels, from kindergartens to universities. Routine surveillance activities encompassed three components: institutional monitoring, student health screening, and behavioral risk assessment. Data collection involved physical examinations, structured questionnaires, and on-site environmental inspections conducted by local CDC and education departments. A detailed description of sampling protocols, measurement tools, and operational procedures is provided in the Supplementary Materials.

The extensive surveillance data and stakeholder insights directly informed the development of the guidelines’ objectives, intervention strategies, monitoring protocols, and implementation pathways. Following the creation of an initial draft, the National Disease Control and Prevention Administration convened expert panels comprising specialists in public health, pediatrics, epidemiology, school health, and education to conduct critical appraisals and refine content. Contributions from key government bodies, including the Ministry of Education and the National Health Commission, ensured cross-sectoral coordination and policy coherence.

To further strengthen scientific rigor and contextual relevance, the guideline development process drew on multiple evidence sources. These included national surveillance data (2018–2023), targeted literature reviews of domestic and international studies, and benchmarking against global frameworks such as those of the World Health Organization (WHO). Although a formal evidence grading system (e.g., GRADE) was not adopted, recommendations were prioritized based on the consistency of evidence across data sources, operational feasibility in school-based settings, and expert evaluation of potential public health impact. Importantly, a stakeholder validation phase was also conducted. Draft recommendations underwent iterative revisions informed by consultation with school administrators, frontline educators, parents, and regional health authorities to ensure practical feasibility, local adaptability, and cultural appropriateness.

3. Results

The State Council’s “Healthy China Action Plan (2019–2023)” emphasized the critical need to address prevalent health issues among children and adolescents, particularly myopia, obesity, and mental health disorders. This initiative highlighted the essential roles of schools, families, and communities in promoting physical activity, improving nutrition, and creating supportive environments for healthy behavioral development. The subsequent “China National Program for Child Development (2021–2030)” further strengthened this foundation by advocating for early prevention and intervention strategies. This comprehensive program promotes an integrated approach to health through enhanced services, systematic health monitoring, and the promotion of healthy lifestyles across school, family, and community settings. These policy frameworks collectively provide the foundation for the Technical Guidelines for Co-Prevention of Common Diseases in Students, which implement coordinated interventions targeting shared risk factors through multi-disease prevention strategies.

The Technical Guidelines for Co-Prevention of Common Diseases in Students introduce an innovative “co-prevention” approach that addresses multiple student health issues by targeting common environmental and behavioral risk factors. This strategy recognizes that key factors—including insufficient outdoor activity, sedentary behavior, irregular sleep patterns, excessive screen time, poor nutrition, and limited parent–child interaction—contribute simultaneously to various conditions such as myopia, obesity, spinal curvature abnormalities, and mental health disorders. The guidelines promote evidence-based interventions focusing on regular physical activity, adequate sleep, balanced nutrition, and enhanced family engagement to concurrently reduce the risk of these interconnected health challenges. Furthermore, the guidelines leverage existing policy frameworks and evaluation protocols, typically implemented by grassroots public health professionals, to create a streamlined and efficient approach to prevention. This coordinated strategy not only optimizes resource utilization but also enhances the effectiveness of student health management initiatives.

The Technical Guidelines for Co-Prevention of Common Diseases in Students establish a comprehensive three-tiered intervention framework encompassing primary, secondary, and tertiary prevention, as detailed in

Table 1. Three-tiered prevention approach of the Technical Guidelines for Co-Prevention of Common Diseases in Students.

Tier of Prevention	Key Task	Specific Measures
Primary Prevention	Promote simple, effective intervention techniques	Advocate for the “6-1” healthy lifestyle.
		1. Ensure 1 h of physical activity per day, including 1 h of outdoor activities both inside and outside school.
		2. After 1 h of sedentary activity, take a 10 min break.
		3. Limit recreational screen time to less than 1 h per day.
		4. Keep meal times relatively fixed, with a time difference of no more than 1 h.
		5. Sleep early and wake early, reducing screen exposure by 1 h before bed.
		6. Engage in 1 h of parent–child interaction and 15 min of dialog daily.
	Improve school health environments	1. Improve school facilities for physical activity.
		2. Ensure adjustable desks and chairs that match students’ heights.
		3. Supervise and monitor the hygiene of drinking water, dining areas, toilets, and dormitories.
		4. Guide schools to offer balanced meals and promote healthy eating.
		5. Train full-time or part-time health education teachers to integrate co-prevention into the curriculum.
		6. Develop appropriate health education materials for co-prevention.
	Cultivate healthy behaviors among students	1. Promote outdoor activities and participation in physical education.
		2. Guide students to maintain balanced nutrition.
		3. Ensure adequate sleep, with stable sleep routines on weekdays and weekends.
		4. Encourage healthy hygiene habits and discourage smoking and addictive behaviors.
		5. Regulate screen time, particularly before bedtime.
Secondary Prevention	Early identification of high-risk groups	Establish a scientific risk assessment system in collaboration with schools and healthcare institutions. Identify students with insufficient myopia reserves, continuous weight gain, or significant emotional changes.
	Graded management	Create prevention records for students at different risk levels. Implement risk-based, differentiated intervention plans.
	Targeted interventions	Focus on students with high-risk behaviors (e.g., lack of physical activity, excessive screen time, unhealthy diet, poor sleep). Collaborate with families, schools, and communities to improve unhealthy behaviors and environments (e.g., mismatched desk heights, inadequate lighting).
Tertiary Prevention	Identification of comorbidities	Identify students with co-existing health issues through regular screening. Guide families to seek diagnosis and treatment at professional healthcare institutions.
	Follow-up and monitoring	Continuously monitor key cases, ensuring proper follow-up and personalized treatment. Maintain and update health records and treatment progress, focusing on managing comorbidities and optimizing health outcomes.

. Primary prevention centers on three key strategies: implementing the “6-1” healthy lifestyle model, enhancing school environments, and strengthening health education. The “6-1” model promotes six essential behaviors: regular physical activity, reduced sedentary time, limited recreational screen time, consistent meal times, regular sleep patterns, and frequent parent–child interaction. These evidence-based behaviors have demonstrated effectiveness in reducing the risk of conditions such as myopia and obesity [18,19]. Environmental improvements include upgrading health facilities, providing ergonomic furniture, optimizing lighting and ventilation, ensuring nutritious meals, training health educators, and integrating disease prevention into curricula. Health education, coordinated by public health authorities in partnership with professional institutions, schools, communities, and families, equips students with age-appropriate knowledge and skills for disease prevention and health management. Secondary prevention focuses on early identification of high-risk students through a scientific risk assessment system that utilizes comprehensive monitoring data. Regular screenings for vision, body weight, and mental health enable targeted interventions to prevent disease progression and reduce comorbidity risk [20]. Tertiary prevention addresses students with existing multiple health conditions through personalized treatment plans, systematic follow-up, and professional guidance. Healthcare professionals facilitate continuous monitoring to ensure individualized care delivery. Clinical evidence indicates that integrating early medical intervention with sustained management significantly improves outcomes for students with complex health conditions [21,22]. This evidence-based, three-tiered system provides a comprehensive strategy to address the rising prevalence of common health problems among students.

The guidelines emphasize the establishment of a “five-in-one” collaborative framework that integrates government agencies, professional organizations, schools, families, and communities for effective disease co-prevention. Schools provide the foundation through healthy learning environments and evidence-based health education, while government bodies and public health institutions contribute policy direction and technical expertise. Communities and families play crucial roles in reinforcing and sustaining healthy behaviors in students’ daily lives. This integrated approach requires coordinated efforts to strengthen health education, align monitoring and intervention strategies, and expand digital health platforms. The framework prioritizes the development of supportive environments, enhancement of public fitness facilities, and optimization of shared spaces to promote healthier lifestyles through intersectoral collaboration.

4. Discussion

The Technical Guidelines for Co-Prevention of Common Diseases in Students establish a comprehensive framework for addressing student health challenges through strategic intersectoral collaboration. Central to this approach is the “five-in-one” model, which integrates the expertise and resources of government agencies, professional organizations, schools, families, and communities. This coordinated framework optimizes resource allocation and strengthens preventive measures by leveraging the unique capabilities and responsibilities of each sector.

Empirical evidence from both domestic and international contexts supports the central mechanisms and anticipated outcomes of the co-prevention strategy. For example, a large-scale trial conducted in Tongzhou District, Beijing, involving 1666 students, demonstrated the feasibility and efficacy of integrated interventions targeting shared risk factors for myopia and obesity [23]. Over the course of one academic year, students in the intervention group experienced significantly slower progression of uncorrected visual acuity decline (Cohen’s d = 0.42, p < 0.01) and favorable, though not statistically significant, reductions in body fat percentage [23]. Furthermore, implementing a centralized digital platform to monitor physical activity and dietary behaviors provided evidence supporting the guideline’s recommendations for integrated data systems.

Internationally, a meta-analysis of 26 studies confirmed that multicomponent interventions incorporating physical activity, nutritional education, and environmental modifications significantly reduced the co-occurrence of obesity and depression (SMD = −0.24 for depression; SMD = +0.24 for quality of life) [24]. Programs adopting a tripartite “exercise–nutrition–behavior” approach yielded the most pronounced outcomes, particularly among adolescents and individuals with severe obesity. Additionally, a 24-month randomized controlled trial conducted in Australia further demonstrated sustained benefits, significantly reducing depression prevalence from 22% to 12% among obese adolescents (p < 0.01) [25]. Collectively, these findings underscore the effectiveness of synchronized, multi-domain behavioral strategies, exemplified by China’s “6 + 1” model.

The successful implementation of the co-prevention strategy relies on three operational pillars. First, a central aspect of the guidelines involves establishing nationwide surveillance infrastructure to monitor multidimensional determinants of student health. This system captures various behavioral and environmental indicators—such as physical activity, screen time, sleep duration, and school infrastructure standards—enabling early detection of adverse trends and timely implementation of evidence-based interventions. The infrastructure expands upon the annual national student health surveillance project established by the National Disease Control and Prevention Administration, which systematically gathers data on common disease prevalence, behavioral risk factors, and school health environments. These data provide a critical foundation for policy evaluation and targeted intervention planning. In the Tongzhou pilot, real-time surveillance data enabled schools and local health authorities to identify increasing sedentary behaviors and screen time during winter months. Schools subsequently introduced structured outdoor activity sessions and adjusted classroom layouts to encourage physical activity, effectively reducing sedentary behaviors and stabilizing obesity indicators. Additionally, teachers implemented standardized logs to track physical activities and eye health exercises, while digital platforms flagged early behavioral risks. This surveillance system thus served as an effective decision-support tool for proactive health management in schools.

Second, dynamic surveillance and evaluation systems are required to facilitate adaptive program management. Although comprehensive monitoring is a key emphasis of the guidelines, a standardized national framework for key performance indicators (KPIs) has yet to be finalized. Future KPI frameworks should include (1) core health outcomes such as annual trends in myopia prevalence, overweight and obesity rates, mental health screening results, and co-occurrence patterns (e.g., myopia, obesity, and spinal abnormalities); (2) behavioral process indicators such as average daily outdoor activity time, compliance with screen time guidelines, and frequency of school–family health engagement; and (3) system capacity indicators, including the proportion of schools meeting health infrastructure standards, training coverage of school health personnel, and responsiveness of interdepartmental data systems. These metrics would enable rigorous impact assessments and inform iterative policy refinements.

Third, tailoring implementation strategies to accommodate regional heterogeneity is essential for ensuring equity and scalability. Disparities in school resources, especially between urban and rural areas, remain a significant barrier. Flexible delivery models should therefore be developed to ensure that core interventions remain feasible in resource-limited settings. National initiatives such as the Rural Revitalization Program and the National Plan for Equitable Education can be leveraged to supplement funding and personnel in disadvantaged areas. Additionally, digital equity tools—including telehealth services, AI-assisted health management platforms, and mobile monitoring applications—offer scalable solutions for reducing geographical disparities. Equity-sensitive resource monitoring systems should also be established to prioritize investments and support for underserved schools.

The Technical Guidelines build upon foundational principles outlined in earlier national strategies, including the Healthy China Action Plan (2019–2023) and the China National Program for Child Development (2021–2030). While the former emphasized broad behavioral health promotion across populations, the latter aimed at establishing an integrated, equitable child health service system across urban and rural areas, covering nutrition, vision, early development, and psychological well-being. The current guidelines represent significant policy advancement by explicitly targeting comorbid conditions through an integrated co-prevention framework. By promoting multisectoral collaboration and addressing shared behavioral and environmental determinants, the guidelines facilitate more unified and effective management of overlapping health challenges among children and adolescents.

Despite their comprehensive design, several structural and operational challenges remain. First, the lack of a finalized national evaluation framework and clear implementation timelines limits the ability to measure short- and long-term outcomes effectively. Second, although the guidelines advocate for multisectoral collaboration and digital integration, inadequate data interoperability across educational, health, and administrative platforms continues to impede real-time decision-making and coordinated service delivery. Third, while the Tongzhou District pilot provides promising preliminary evidence, large-scale validation across diverse socioeconomic and geographic contexts is still required.

In practice, implementation may also be constrained by uneven resource distribution, particularly in rural schools with limited infrastructure and staffing. Institutional inertia and fragmented responsibilities among education, health, and finance sectors can further undermine coordination and accountability. Additionally, low adherence to behavioral interventions—particularly among families resistant to screen time guidelines or parental involvement initiatives—may reduce program effectiveness. Technological barriers persist as well, as the reliability and applicability of digital tools like AI-based health monitoring systems have yet to be fully validated in underserved settings, raising equity concerns.

Addressing these limitations requires longitudinal evaluations, regionally adaptive pilot programs, and iterative policy refinements. Future research should investigate context-specific enablers and barriers to implementing multi-component interventions and strengthen monitoring and evaluation systems to allow timely feedback and adjustments. Sustained engagement with stakeholders—from national authorities to local school communities—will be critical in ensuring long-term impact and sustainable behavioral change.

5. Summary

In conclusion, the Technical Guidelines represent significant progress in China’s efforts to safeguard student health through an integrated, data-driven, equity-oriented approach. By targeting shared behavioral risk factors, encouraging cross-sector collaboration, and leveraging digital infrastructure, the co-prevention strategy offers a scalable model for addressing complex, overlapping health challenges in school-aged populations. Continued refinement, grounded in real-world implementation and supported by robust evaluations, will be essential to maximizing long-term public health impacts.