Depression is commonly treated with either psychotherapy or antidepressants, but patients differ widely in their comparative responses. Identifying the most effective treatment for each individual is crucial to optimizing scarce resources, particularly in low-resource settings. This study evaluated the feasibility and acceptability of a precision treatment trial comparing psychotherapy based on behavioral activation (the Healthy Activity Program) with antidepressant medication (fluoxetine) in adults with depression in primary care settings in India. A single-blind, two-arm randomized controlled pilot was conducted with adults aged ≥18 years with moderate to severe depression (PHQ-9 score≥10) from eight primary healthcare centers in Bhopal, India. Primary outcomes were feasibility and acceptability, assessed using indicators of study implementation (recruitment, randomization, treatment fidelity, completeness of assessments, biologic sample collection, and safety) and participant engagement (retention and treatment adherence). Secondary outcomes included changes in depressive symptoms, remission, and patients’ subjective sense of improvement at the 3-month endpoint. Of 578 individuals screened, 180 were eligible and 76 (42%) enrolled. Retention was 82% at 3 months. Psychotherapy participants attended 5.6/6-8 sessions, while medication participants consumed 57.9% of prescribed doses. Completion rates of study assessments were high (72–100%), and missing data were minimal, although some baseline measures were burdensome and were subsequently shortened for the main trial. Biologic sample collection was feasible, with 67% of participants consenting to blood draws. Depressive symptoms improved across both arms, with 45.2% achieving remission. However, treatment responses varied substantially within each arm (psychotherapy: –9.1 [SD=6.5]; medication: –7.6 [SD=6.9]), indicating marked individual heterogeneity. This pilot demonstrated the feasibility and acceptability of implementing a precision treatment trial for depression in Indian primary care, identified refinements to optimize procedures for the main trial, and supported the potential to identify the optimal treatment for each patient.

While community volunteers are increasingly recognized for addressing supply-side gaps in healthcare delivery (e.g., provider shortages), their role in mitigating demand-side barriers (e.g., stigma) remains underexplored. This qualitative study investigated the experiences, knowledge, and roles of community volunteers in Goa, India. We examined barriers and facilitators to community-based work, and strategies for integrating community participation and outreach in demand-side interventions. We conducted semi-structured, in-depth interviews with 35 community volunteers who deliver health and socio-developmental programs (e.g., "social workers", village council members, lay health providers). Thematic analysis revealed that volunteers' work encompassed demand-related tasks such as connecting community members to government welfare schemes, organizing educational events, and providing informational or material resources via contextually-relevant, relationship-driven strategies, such as leveraging influential community leaders and social connections (including via WhatsApp). Participants demonstrated awareness of the social origins of distress (e.g., unemployment), especially post-COVID-19, and expressed willingness to vertically integrate mental health in their work. Facilitators included social recognition, personal satisfaction, and family and political backing. Lack of community support and resources (e.g., insufficient government funding) were significant barriers in continuation of work for community volunteers. These findings suggest the potential of community volunteers as demand-side change agents for mental health interventions, underscoring the necessity of integrating local knowledge, social networks, and non-monetary community-based incentives into scalable global health programs.

BACKGROUND:Compulsory and free basic education policies (hereafter called education policies) are essential for enhancing educational attainment, which has been linked to improved offspring health outcomes. However, existing studies do not provide strong evidence with causal inference on how these policies influence offspring mortality in low-income and middle-income countries (LMICs). Furthermore, although COVID-19 has substantially disrupted education systems in LMICs, its long-term consequences for offspring mortality remain unclear. METHODS:We extracted individual-level data from the nationally representative Demographic and Health Surveys from 1986 to 2022, and macro-level data on countries' population projection, COVID-19-related changes, and other social and economic indicators from multiple databases. Offspring deaths were measured using four indicators: neonatal mortality, infant mortality, childhood mortality, and deaths in children younger than 5 years (under-5). We identified 20 countries with at least two survey rounds and changes in education policies during varying survey periods. Using a difference-in-differences design with a two-way fixed-effects model, we investigated the effects of education policies on offspring mortality for mothers and fathers. The treatment group included observations from post-policy surveys, with younger parents exposed to the policy and older ones not, whereas the control group used pre-policy survey data. Subgroup analyses by household wealth status, place of residence, sex of the child, and sex of the household head were performed to explore potential heterogeneity in education policies' impact. We used mathematical modelling to project offspring deaths from 2030 to 2050 attributable to COVID-19-induced loss in educational instruction time and increased school dropout levels, assuming no further policy interventions to mitigate these losses. FINDINGS:A total of 347 013 mothers (100 113 control; 246 900 treatment) and 201 612 fathers (86 152 control; 115 460 treatment) were included in the study. Exposure to education policies was associated with significant reductions in offspring mortality among mothers, which was -11·71 per 1000 livebirths (95% CI -20·29 to -3·12, p=0·0093) for neonatal deaths, -18·66 (-27·06 to -10·25, p<0·0001) for infant deaths, -20·33 (-28·85 to -11·81, p<0·0001) for childhood deaths, and -20·43 (-28·96 to -11·90, p<0·0001) for under-5 deaths, compared with those not exposed to education policies. The effects among fathers were also statistically significant for all types of offspring deaths. Subgroup analyses revealed that education policies have significantly more pronounced impacts among those with lower household wealth. Projections for 2030 to 2050 suggest that reductions in parental education due to COVID-19 might contribute to increases in offspring deaths under a worst-case scenario with no compensatory policy interventions, with the largest effects arising from the loss of parental instruction time rather than from school dropouts. The impact is expected to peak around 2038, when under-5 deaths attributable to reduced parental instruction time and increased school dropouts are projected to reach 449 154 (95% CI 240 774-657 535) and 10 918 (7697-14 139), respectively, compared with a scenario without COVID-19-related educational disruptions. INTERPRETATION:Education policies significantly reduced offspring mortality in LMICs, with greater benefits for populations with lower household wealth. Modelling indicated that interruptions to educational instruction time led to a substantial increase in offspring mortality. There is a critical need for policies to mitigate educational disruptions to prevent offspring deaths. FUNDING:Research Fund, Vanke School of Public Health, Tsinghua University.

Task-sharing psychosocial interventions to frontline health workers can expand access to mental health care. However, training remains a major barrier to scale. Here, in this randomized controlled trial, we evaluated the effectiveness and cost-effectiveness of two digital training approaches compared with classroom-based training for improving knowledge to deliver behavioral activation for depression. Accredited Social Health Activists in rural Madhya Pradesh, India, were randomized to self-directed digital training (DGT), digital training plus remote coaching (DGT+) or face-to-face classroom-based training (F2F). The primary outcome was change in knowledge scores from before training to after training. Among 339 Accredited Social Health Activists enrolled, completion rates were 87% (DGT), 96% (DGT+) and 92% (F2F). Knowledge scores improved across all groups. F2F and DGT+ showed comparable improvements. DGT performed worse but not significantly worse than F2F (P = 0.077). Average per-participant costs were US$209.26 for F2F, US$150.42 for DGT+ and US$121.24 for DGT. Cost-effectiveness analyses showed digital approaches were more cost-effective at lower willingness-to-pay thresholds. Findings suggest that digital training, especially when supported by coaching, offer scalable and lower-cost alternatives to classroom-based training for expanding workforce capacity to deliver depression care. Further research is needed to determine whether knowledge gains translate into clinical competency and effective care delivery. ClinicalTrials.gov Identifier: NCT04157816 . Frontline health workers in rural Madhya Pradesh, India, trained with digital training approaches to deliver behavioral activation intervention for depression achieved comparable improvements in knowledge, especially when supported by remote coaching, to health workers that were trained using face-to-face classroom-based training.

Background Task-sharing with non-specialist providers offers a promising solution to the mental health workforce shortage in low-resource settings. Supervision is essential to ensure treatment quality, but is often constrained by limited specialist availability. Aims This study evaluated the costs of developing PEERS, a smartphone app that can facilitate registering and scheduling supervision sessions, collecting patient outcomes, rating therapy quality and assessing supervision quality among community-based non-specialist providers delivering behavioural activation for depression. Method The PEERS digital application was developed between June 2021 and September 2022 for use in Madhya Pradesh and Goa, India. Development involved contributions from researchers, clinicians, technology experts and end users. Activity-based costing was used to systematically document the inputs and expenditures involved in developing the PEERS app and its accompanying training materials from a health systems perspective. Key cost components included human resources, leadership, IT support and infrastructure. Results Total development costs were US＄130 027, with the costs of information technology accounting for the largest share (81%; US＄105 110). Human resource contributions accounted for 17% (US＄22 523), which included oversight and contributions from international research collaborators. Additional costs included overhead and infrastructure (US＄2393). Conclusions Digital tools are increasingly being used to expand access to and support the delivery of mental health interventions in low-resource settings, yet few studies report on the development costs. By estimating the costs and resources required for developing a digital app for peer supervision, this study can inform efforts to facilitate broader implementation and adaptation of the app for use in other settings.

Background: Economic burdens of tuberculosis (TB) in high-income settings remain overlooked. None of the 40 countries reporting TB cost surveys to the World Health Organization (WHO) were high-income. We conducted the first such survey in a high-income country, Taiwan, to assess WHO End TB Strategy’s zero catastrophic total cost target. Methods: Nationwide cross-sectional survey data were collected from households sampled from 2018 National TB Registry. Following WHO’s protocol, we extrapolated costs throughout the TB episode. Catastrophic total cost was defined as total costs, consisting of direct medical and direct non-medical and indirect costs, exceeding 20% of annual household income. Predictors of catastrophic total cost were assessed using multivariable logistic regression. Findings: Of 481 people with drug-susceptible TB (DS‑TB) and 64 with multidrug-resistant TB (MDR‑TB), 72% were male; mean age was 65. Mean total costs (95% Confidence Interval, CI) were US$2,316 (US$2,083-2,550) for DS‑TB and US$6,665 (US$4,460-8,869) for MDR‑TB. For DS‑TB, indirect, non‑medical, and medical costs comprised 57%, 29%, and 14%; for MDR‑TB, 67%, 29%, and 4%. Catastrophic total cost affected 23% (95% CI: 19-27%) of DS‑TB households and 52% (39-64%) of MDR‑TB households. Household income below the minimum cost of living, diagnosis of MDR-TB, and lack of private health insurance were the predictors of catastrophic total costs. Interpretation: Despite the well-functioning national TB program and national health insurance, a subset of TB-affected households in Taiwan faced substantial financial burdens. Integrated strategies tailored to different cost components are essential to achieve the End TB goal.

Background and Objective:In 2018, the Philippine Congress passed the Universal Healthcare (UHC) Law and its implementing rules which mandated the enrollment of all Filipinos to PhilHealth, the national social health insurance corporation. The Department of Health (DOH) and PhilHealth will leverage their strategic purchasing power by affiliating Health Care Provider Networks (HCPNs), established within the geopolitical boundaries of a province or a highly urbanized city, through service level agreements. This study aims to shed light on what is expected from providers, payers, and regulators to implement UHC successfully. Methods:The researchers conducted an inductive, content analytic qualitative study guided by the World Health Organization's (WHO) Building Blocks Framework to determine the understanding and acceptance of the implementing rules of the UHC Law and the perceived barriers and enablers from the provider, payer, and regulator stakeholders in three provinces in the Philippines. Purposive sampling was utilized to provide the best representation across different economic and physical settings. A content analysis was done through an inductive process of coding concepts, which was the basis for categories grouped and matched deductively with the WHO framework. This formed the broader sub-themes and were used for the final data interpretation. Results:A total of 16 focus group discussions (FGDs) and nine in-depth interviews (IDIs) were performed with 84 participants. Inductive thematic analysis of categories and subcategories showed that the participants support the goals and objectives of the UHC Law. Still, perceived barriers refer to the lack of and improper use of funds, the need to clarify the implementing guidelines, and the role of politics. The participants indicated that solidarity and social connectedness with health system adaptability and resilience are enablers for the success of UHC reforms. Conclusion:Proposals to mitigate the barriers include expanding the funding source, clarifying rules on the financial management system, and providing guidelines on health delivery integration to ensure access to patient care. Decentralization with autonomy will allow the stakeholders to align health programs with local needs. Proper representation in decision-making bodies is desirable to establish strong community involvement and solidarity. Resilience and adaptability based on a feedback loop are imperative.

Objective To assess the cost of co-creating an adaptation of the International Guide for Monitoring Child Development (intervention for use by community health workers (CHWs)) in rural Guatemala and India. Methods We developed survey instruments to capture the costs, from health-system and societal perspectives, ofadapting the guide with local partners and international experts in the two sites. We included the costs of human resources, information technology, and infrastructure and logistic support. To improve the transparency and comparability of cost estimates, we reported the required resources for adaptation, such as time and expertise of human resources, and the quantity, function and usage time of the resources used. Findings Adaptation of the guide took 14 months in India and 18 months in Guatemala during 2021-2022.Total costs by site were 38 174.57 United States dollars (US$) in Guatemala, US$ 39 287.15 in India and US$ 81 846.59 for international consultants. International consultants accounted for about half of the costs, and the Guatemala and India sites each accounted for about a quarter of the costs. Human resources were the largest contributor to the adaptation costs in both sites (90.1%; 34 398.20/38 174.57 in Guatemala and 94.8%; 37 262.74/39 287.15 in India) followed by infrastructure support and information technology. Conclusion Since most of the required steps to adapt the guide for use by CHWs have now been done by our study, we expect future adaptation costs to be lower. The methods used in this study provide an example of how to cost intervention adaptations in the future.

Objective:To assess the cost of co-creating an adaptation of the International Guide for Monitoring Child Development (intervention for use by community health workers (CHWs)) in rural Guatemala and India. Methods:We developed survey instruments to capture the costs, from health-system and societal perspectives, of adapting the guide with local partners and international experts in the two sites. We included the costs of human resources, information technology, and infrastructure and logistic support. To improve the transparency and comparability of cost estimates, we reported the required resources for adaptation, such as time and expertise of human resources, and the quantity, function and usage time of the resources used. Findings:Adaptation of the guide took 14 months in India and 18 months in Guatemala during 2021-2022. Total costs by site were 38 174.57 United States dollars (US$) in Guatemala, US$ 39 287.15 in India and US$ 81 846.59 for international consultants. International consultants accounted for about half of the costs, and the Guatemala and India sites each accounted for about a quarter of the costs. Human resources were the largest contributor to the adaptation costs in both sites (90.1%; 34 398.20/38 174.57 in Guatemala and 94.8%; 37 262.74/39 287.15 in India) followed by infrastructure support and information technology. Conclusion:Since most of the required steps to adapt the guide for use by CHWs have now been done by our study, we expect future adaptation costs to be lower. The methods used in this study provide an example of how to cost intervention adaptations in the future.

[This corrects the article DOI: 10.1016/j.lanwpc.2025.101674.].

Background The divorce rate has increased globally and in China. Literature from developed countries and few developing countries has shown the negative impact of parental divorce on children’s health and development. This cross-sectional study aimed to examine the association between parental divorce and early childhood development (ECD) in China.Method This study used data collected from four provinces in China and reported by parents or other caregivers of 62 899 children, aged 3–5 years old, in 2017 and 2018. We constructed three types of ECD outcomes: (1) overall score of the early Human Capability Index (eHCI), (2) score of each domain of the eHCI, and (3) a dichotomous variable indicating a child developmentally on track, defined by ranking above the 20th percentile of overall eHCI scores in the corresponding age group in the pooled dataset. To understand the link between parental divorce and ECD outcomes, we used the propensity score matching method to match children from divorced families to those from intact families. We applied generalised linear regression models in data analysis using both the full sample and matched sample.Results A total of 3.8% (N=2409) of young children came from divorced families. Children whose parents divorced had significantly lower overall eHCI scores (OR: 0.95, 95% CI 0.92 to 0.98) and lower odds of being developmentally on track (OR: 0.79, 95% CI 0.71 to 0.89), compared with their counterparts after matching. Statistically significant differences were observed in nearly all of nine domains of eHCI, especially for physical health, reading and social and emotional skills. Subgroup analyses showed more prominent associations in Shanghai.Conclusion Children from divorced families showed slower early sociopsychological and physical development than their peers. Efforts are needed to help this vulnerable group minimise the differences.

The relationship between education and cardiovascular health (CVH) metrics in low- and middle-income countries (LMICs) remains unclear. This study explores the associations between education and ideal cardiovascular health score (CVHS), as well as seven CVH metrics. This cross-sectional study extracted data from the STEPwise approach to surveillance surveys in 36 LMICs between 2010 and 2020. We assessed CVHS using the sum score in seven metrics defined by American Heart Association: (1) ≥ 150 min/week of moderate, or 75 min/week of vigorous activity, or an equivalent combination; (2) BMI < 25 kg/m2 for non-Asians (< 23 kg/m2 for Asians); (3) fruit and vegetable intake ≥ 4.5 servings per day; (4) nonsmoking; (5) blood pressure < 120/80 mmHg (untreated); (6) total cholesterol < 200 mg/dL (untreated); and (7) fasting blood glucose < 100 mg/dL (untreated). The ideal CVHS score ranged from 5 to 7. We disaggregated prevalence of ideal CVHS and seven metrics by education, and constructed Poisson regression models to adjust for other socioeconomic factors. Among 81,327 adult participants, the overall ideal CVHS prevalence for the studied countries was highest among individuals with primary education (52.9

Adolescents are the future leaders of our world. Ensuring their health and wellbeing-now and in the future-is one of the strongest mechanisms available to safeguard the collective future of humanity and to secure a more just society and a healthier and more productive planet. Investments in the current generation of 10-24-year-olds will reap a triple dividend, with benefits for young people today, the adults they will become, and the next generation of children they will parent. These potential benefits are particularly relevant for Africa and Asia, where around 82% of the world's adolescents currently live, a proportion that is projected to rise to 85% by 2100.

Background:Women experiencing co-occurring forms of intimate partner violence (IPV; ie, physical, sexual, and/or psychological) often face more severe psychological and health consequences than those experiencing a single form. However, research on IPV co-occurrence in low- and middle-income countries (LMICs) remains limited. This study examines the prevalence of IPV co-occurrence in LMICs and its education-based inequalities. Methods:Data from the most recent Demographic and Health Surveys in 49 LMICs (2011-2023) were used. Our primary outcome was IPV co-occurrence, defined as a woman aged 15-49 ever experiencing any two or three forms of physical, sexual, or psychological IPV from her partner within the past year. We categorised IPV co-occurrence into four subtypes: co-occurrence of (1) physical and sexual IPV, (2) physical and psychological IPV, (3) sexual and psychological IPV, and (4) all three forms of IPV. We analysed the prevalence of IPV co-occurrence and its subtypes by women's education levels, calculating odds ratios to assess inequalities. Nonparametric restricted cubic splines were used to explore nonlinear relationships between education and IPV. Findings:The study included a total of 344,661 women. The weighted prevalence of IPV co-occurrence varied widely across countries-from 2.4% in Armenia to 38.9% in Papua New Guinea. Overall, women with no education were most at risk, experiencing an adjusted prevalence of 14.3% (95% CI: 13.3-15.2), compared to 11.8% (95% CI: 10.8-12.9) among those with primary education, 9.9% (95% CI: 9.3-10.6) for secondary education, and 5.3% (95% CI: 4.5-6.2) for higher education. The prevalence of IPV co-occurrence involving sexual IPV was highest among women with primary education, with 4.1% (95% CI: 3.4-4.8) reporting concurrent physical and sexual violence, compared to 1.5% (95% CI: 1.1-1.9) to 3.7% (95% CI: 3.2-4.1) among other education levels. Interpretation:IPV co-occurrence remains high, particularly among women with little or no education. Education-focused interventions are urgently needed to reduce IPV risk and its severe impact. However, the findings may be influenced by potential reporting biases and cross-country variability in IPV measurement methodologies, which may limit generalizability. Funding:The China National Natural Science Foundation (Grant numbers 72203119) and The Research Fund, Vanke School of Public Health, Tsinghua University.

Introduction We aimed to determine the impact of antenatal interventions to optimise maternal nutrition and infection management on birth outcomes in Ethiopia.Methods We conducted a pragmatic, open-label, 2×2 factorial randomised clinical effectiveness study among pregnant women enrolled <24 weeks gestation in 12 rural health centres in Amhara, Ethiopia. Eligible health centres were randomised to deliver an enhanced nutrition package (ENP) (iron-folic acid, iodised salt and targeted micronutrient fortified balanced energy protein (BEP) supplementation for undernourished women) or routine nutrition care (iron-folic acid only). Individual women were randomised to receive an enhanced infection management package (EIMP) (genitourinary tract infection screening-treatment and enhanced deworming) or routine infection care (syndromic management). The primary outcomes were birth weight and length; secondary outcomes were gestational age, preterm delivery, small-for-gestational-age, low birth weight, stillbirth, newborn weight-for-age and length-for-age z-scores, newborn head circumference, and maternal anemia. Analysis was intention to treat.Results From August 2020 to December 2021, 2392 women were randomised (604 ENP+EIMP, 600 ENP alone, 593 EIMP alone and 595 neither package) and followed until June 2022, with 2170 pregnancy outcomes analysed (565 ENP+EIMP, 549 ENP, 525 EIMP, 531 neither). In the ENP arm, 427 (36%) women were eligible for BEP and consumed on average 74 days. The prevalence of genitourinary tract infection was low (4.9%), while parasitic stool infections were common (31%). There was no difference in birth weight (ENP vs not-ENP: adjusted mean difference −4 g (−83 to 75); EIMP vs not-EIMP: 18 g (−35 to 70); ENP+EIMP vs neither: 14 g (−81 to 109)) or birth length (ENP: −0.3 cm (−1.1 to 0.5); EIMP: 0.2 cm (−0.1 to 0.5); ENP+EIMP: −0.1 cm (−1.2 to 1.1)) between study arms. In the ENP+EIMP group, the stillbirth rate was lower compared with the arm receiving neither package (7.1/1000 vs 24.7/1000 births; adjusted relative risk: 0.29 (0.09 to 0.94)). The packages did not significantly affect other secondary outcomes.Conclusions In this pragmatic study implemented within the Ethiopian health system, enhanced nutrition and infection packages did not affect birth weight or length. While stillbirth rates were lower in the group receiving both packages, these findings need to be supported by additional studies.Trial registration number ISRCTN15116516.

Geographic information systems (GIS) are computer-based spatial mapping tools widely used in public health to examine service availability and access disparities and healthcare utilization. While GIS has supported evidence-based health planning in various domains, its application in mental healthcare service delivery remains underexplored. Our scoping review aimed to address this gap by exploring the scope and type of GIS usage in studying three dimensions of mental health (MH) service delivery (availability, accessibility and utilization), across all geographical locations, settings and populations. We conducted a scoping review following the Joanna Briggs Institute methodology. We included peer-reviewed English-language studies using GIS to examine service delivery (availability, accessibility or utilization) for any MH condition diagnosed through standardized criteria or validated tools. Seven databases were searched (Medical Literature Analysis and Retrieval System Online [MEDLINE], PsycINFO, Excerpta Medica Database [Embase], Global Health, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Cochrane Central Register of Controlled Trials [CENTRAL] and Web of Science) between January and April 2024. This review included 58 studies predominantly from high-income countries. A wide range of GIS methods were employed across studies, including hotspot analysis, network analysis and spatial analysis. Six studies explored availability, generally through measures like distribution of facilities across a population, and resource availability within 5-10-mile network buffers. Forty-six studies explored the spatial accessibility of MH services and substance-use treatment facilities using GIS. Six studies examined service utilization patterns. Equity emerged as a recurring theme across all three dimensions. GIS has the potential to emerge as a powerful tool in MH research, particularly in mapping disparities, informing service delivery and identifying high-risk zones. Expanding GIS use in trial design, implementation science and policy advocacy could help bridge critical gaps in MH service delivery, ensuring more equitable and data-driven decision-making.

This study examined recent trends in the burden of mental disorders, substance use disorders, and suicide among children and adolescents, and reviewed child and adolescent mental health (CAMH) policies and services in eight high-income jurisdictions (Australia, Hong Kong, Japan, Macao, New Zealand, Singapore, South Korea, and Taiwan) in the Western Pacific Region. Data on disability-adjusted life years (DALYs) of mental and substance use disorders and suicide were extracted from global and national datasets. A narrative review on CAMH policies and services was conducted using English and local language sources. Mental and substance use disorders accounted for 14.9%-24.2% of total DALYs among individuals under 20 years, with suicide rates of 10-19-year-olds increasing in several jurisdictions since the early 2010s. While all jurisdictions had mental health laws addressing minors and legislated protections against harms, only Australia had a stand-alone CAMH policy, and large gaps in workforce and service data remained. Strengthening suicide prevention efforts, improving CAMH data systems, enhancing CAMH-focused legislation, and learning from best practices on youth engagement and cross-sector collaboration are recommended to advance CAMH systems in the region.

Economic evaluations of artificial intelligence (AI) in healthcare are expanding rapidly, yet underlying costing methods remains heterogenous, and frequently incomplete for health technology assessment (HTA) and policy decision-making. In our systematic review of 55 studies published between 2010 and 2025, we found that fewer than half of the studies reported explicit costing methods; most pricing analyses failed to describe the basis of fees, subscription terms, or duration of coverage; and few analyses distinguished between average and incremental costs or accounted for economies of scale. Lifecycle expenditures including development, validation, integration, maintenance, retraining, and decommissioning were largely omitted, while electricity consumption, data hosting, and cloud infrastructure costs were almost never considered. Sensitivity analysis was the exception rather than the norm, and reporting of cost offsets such as reduced hospital admissions or workforce time savings was inconsistent. To address these gaps, we propose a 20-item reporting checklist to standardise the costing and pricing of AI interventions. The checklist complements existing HTA frameworks while capturing features unique to AI, such as continuous retraining, reliance on data infrastructure, and recurrent maintenance. We also introduce an AI Costing Inventory and Calculator that operationalises a lifecycle approach, enabling systematic recording of resource use, unit costs, inflation adjustments, and total and incremental costs, including offsets. These tools extend the emerging CHEERS-AI reporting framework by embedding a lifecycle perspective into costing, thereby enabling consistent estimation of resource and cos components and strengthening the methodological foundations of AI economic evaluation for policy use. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study acknowledge the Ministry of Education, Taiwan, through the Yushan (Mount Jade Scholar) Fellow Program (MOE-112-YSFMN-0003-002-P1). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.

BACKGROUND:Understanding the changing metabolic health burden among children and adolescents is crucial for current and future public health resource allocation in China, particularly given rapid population ageing. We aimed to estimate trends in the metabolic burden in children and adolescents aged 7-18 years from 2000 to 2030, using overweight, obesity, and hypertension as proxy indicators. METHODS:We extracted age, sex, height, weight, and blood pressure data for Han children and adolescents aged 7-18 years, as recorded in five cycles of the Chinese National Surveys on Students Constitution and Health in the years 2000, 2005, 2010, 2014, and 2019. We used demographic indicators reported by the Seventh National Population Census in 2020 to represent the demographic situation in 2019 and UN population estimates and projections for China to derive the national age structure from 2000 to 2030. We calculated the 2019 age-standardised prevalence rates of overweight and obesity, hypertension, comorbid overweight and obesity with hypertension, severe obesity, and severe hypertension. Direct standardisation was applied to adjust for the effect of changes in population structures and derive age-specific prevalence estimates from 2000 to 2030. A population development index that captures demographic trends while accounting for the influence of age structure was calculated from birth rate, death rate, and proportions of the population aged 0-14 years and older than 65 years. Correlation coefficients (r) and corresponding p values for the association between the population development index and metabolic burden were calculated with general linear regression models. Multinomial regressions were applied to model age-specific and sex-specific prevalence rates as a function of time. We used decomposition analysis to evaluate the individual contributions of age-specific prevalence, age distribution, and population growth to the net change in case numbers. FINDINGS:The final analysis of national survey data included 1 106 416 observations. In 2019, the age-standardised prevalence rates were 21·5% (95% CI 21·3-21·7) for overweight and obesity, 16·6% (16·4-16·8) for hypertension, 5·5% (5·4-5·6) for overweight and obesity with hypertension, 1·6% (1·5-1·6) for severe obesity, and 2·1% (2·0-2·2) for severe hypertension. China's population of children and adolescents aged 7-18 years is predicted to decrease from 276 million in 2000 to 181 million in 2030 (-34·4%). Between 2000 and 2030, we estimate increases of 39·0 million (180·6%) cases of overweight and obesity, 7·1 million (131·5%) cases of overweight and obesity with hypertension, 4·3 million (430·0%) cases of severe obesity, and 1·2 million (34·3%) cases of severe hypertension. Between 2000 and 2030, we estimate a slight decrease of 0·3 million (-0·8%) cases of hypertension. A significant negative association between population development index and metabolic burden was observed for 2019 (r=-0·485, p=0·0062) and projected for 2030 (r=-0·417, p=0·020). Decomposition analysis indicated that rising age-specific prevalence is the primary driver of increasing numbers of metabolic cases, partially offset by population decline. INTERPRETATION:In the context of China's declining youth populations, increases in the prevalence, clinical severity, and absolute case numbers of overweight and obesity with hypertension signal a worsening metabolic health burden. Beyond public health policies to shape healthier lifestyle patterns, enhanced efforts are needed to prepare China's primary health-care system and optimise the allocation of paediatric health-care resources. FUNDING:National Key R&D Program of China, National Natural Science Foundation of China, Beijing Natural Science Foundation, Peking University Talent Introduction Program Project, Clinical Medicine Plus X-Young Scholars Project of Peking University, UK Medical Research Council, and the Abdul Latif Jameel Institute for Disease and Emergency Analytics at Imperial College London, funded by a donation from Community Jameel.

Child and adolescent mental health (CAMH) disorders have become a public health concern in China, yet evidence on resource allocation remains limited. This scoping review synthesizes English- and Chinese-language peer-reviewed and grey literature to assess four domains related to CAMH: legislation and policy, financing and health insurance coverage, service delivery and utilization, and available interventions. While China has established a comprehensive legislative and policy framework for CAMH, resources remain insufficient to fully implement it. In 2020, per-adolescent (aged 10-19 years) spending on mental health curative care in China was 27.6 RMB (equivalent to $4.6 in 2023 USD), with households covering 58.1% and the government only 14%. Insurance rarely covers psychotherapy or counselling for children and adolescents. CAMH workforce and infrastructure remain limited and concentrated in urban areas. Intervention studies are mostly small-sample and focus on short-term outcomes. Evidence on cost-effectiveness is scarce. Key recommendations include expanding health insurance coverage, improving CAMH workforce and infrastructure, especially in underserved regions, and strengthening evidence-based policymaking through establishing a national-level monitoring system and conducting large-sample, long-term studies.