Subnational Level Research Articles

Spatiotemporal disparities in maternal mortality and the role of multiscale administrative levels: a 20-year study across Chinese counties

BackgroundChina has made progress in reducing maternal mortality ratio (MMR), yet county-level spatiotemporal heterogeneity persists. This study aims to identify spatiotemporal disparities in MMR and quantify the impacts of various administrative levels on these disparities.MethodsWe analyzed county-level MMR panel data from 1996 to 2015, employing the spatial Gini coefficient, Anselin Local Moran's I, and Getis-Ord Gi* to assess spatiotemporal disparities related to spatial inequity and geographic clustering. Additionally, we applied a Bayesian multiscale spatiotemporally varying intercepts (BMSTVI) model to unveil the national temporal trend and multiple sub-national spatial patterns in maternal mortality risk. We further quantified the relative contributions of five sub-national administrative levels using the spatiotemporal variance partitioning index (STVPI).ResultsResults suggested that from 1996 to 2015, the proportion of MMR in counties achieving Sustainable Development Goals (SDGs) increased from 27.05% to 93.40%, yet spatiotemporal disparities remained. The spatial Gini coefficient and geographic clustering analyses indicated temporally varying but spatially stable inequities patterns, highlighting the Spatial Inequity Lock-in (SILI) effect. Hotspot analysis identified sensitive and exemplary counties, underscoring the need for targeted regional interventions. The BMSTVI model indicated a declining trend in MMR risk over 20 years, with the most substantial reduction from 2003 to 2012. While the geographic distribution of high-risk areas remained relatively stable, analyses at finer administrative levels enabled more precise identification of affected locations and improved intervention effectiveness. Finally, the STVPI revealed that spatial effects contributed 83.91% (95% CIs: 78.66%−89.47%) to MMR variations, far exceeding the 11.60% (95% CIs: 7.27%−16.55%) from temporal effects. The contribution from the administrative county-level was the highest (29.15%, 95% CIs: 19.69%−35.06%), followed by contributions from the seven geographical regions (14.10%, 95% CIs: 6.61%−34.06%), rural–urban differences (13.77%, 95% CIs: 4.93%−39.2%), provincial level (12.41%, 95% CIs: 8.06%−16.85%), and city level (11.21%, 95% CIs: 7.53%−13.84%).DiscussionThese findings underscore the crucial need for region-specific, time-sensitive policies to achieve maternal health equity across Chinese counties. This study provides a robust empirical foundation for a multi-tiered adaptive policy framework grounded in systematic spatiotemporal assessment across macro, meso, and micro scales to guide targeted maternal health interventions globally.

Sub-national landscape on the years of life lost due to COVID-19 pandemic in the major cities of Southern Philippines.

In Southern Philippines, 5 697 COVID-19 deaths were reported in the major cities from March 2020 to June 2022. The pandemic's impact, despite the relatively modest death toll, was examined by analysing the Years of Life Lost (YLL) derived from disease surveillance datasets. The individual YLLs were calculated using the global disease burden approach applying 7% discounting rate and adjusting for sex, age-at-death, and the individual's city-location. The YLLs were then aggregated on a monthly basis. Descriptive analytics were used to characterise the dynamic nature over time of the YLLs. A total of 51 749.07 YLLs due to COVID-19 were estimated, i.e. 9.09 YLLs per death or 969.49 YLLs per 100 000 population. The monthly YLL ranged from 68.55 to 7 641.12. On average, the age-at-death is 59.68years with males having younger age-at-death than females. Notably, the weekly COVID-19 incidences and deaths in Southern Philippines showed synchronous peaks. The average age-at-death in Southern Philippines is at least 10years younger than both international age-at-death estimates and the Philippine life expectancy. The synchronous weekly peaks may highlight distinct pandemic dynamics for a low- and middle-income country. The YLL due to COVID-19 in Southern Philippines, at a sub-national level, is comparable to some country-level estimates, highlighting the impact of the pandemic on this island region alone.

Geographic inequalities, and social-demographic determinants of reproductive, maternal and child health at sub-national levels in Kenya

BackgroundGlobal initiatives have emphasized tracking indicators to monitor progress, particularly in countries with the highest maternal and child mortality. Routine data can be used to monitor indicators for improved target setting at national and subnational levels. Our objective was to assess the geographic inequalities in estimates of reproductive, maternal and child health indicators from routine data at the subnational level in Kenya.MethodsMonthly data from 47 counties clustered in 8 regions, from January 2018 to December 2021 were assembled from the District Health Information Software version 2 (DHIS2) in Kenya. This included women of reproductive age receiving family planning commodities, pregnant women completing four antenatal care visits, deliveries conducted by skilled birth attendants, fully immunized children at 1 year and number of maternal deaths at health facilities, from which five indicators were constructed with denominators. A hierarchical Bayesian model was used to generate estimates of the five indicators at the at sub-national levels(counties and sub counties), adjusting for four determinants of health. A reproductive, maternal, and child health (RMCH) index was generated from the 5 indicators to compare overall performance across the continuum of care in reproductive, maternal and child health across the different counties.ResultsThe DHIS2 data quality for the selected 5 indicators was acceptable with detection of less than 3% outliers for the Facility Maternal Mortality Ratio (FMMR) and less than 1% for the other indicators. Overall, counties in the north-eastern, eastern and coastal regions had the lowest RMCH index due to low service coverage and high FMMR. Full immunization coverage at 1 year (FIC) had the highest estimate (79.3%, BCI: 77.8—80.5%), while Women of Reproductive age receiving FP commodities had the lowest estimate (38.6%, BCI: 38.2–38.9%). FMMR was estimated at 105.4, (BCI 67.3–177.1)Health facility density was an important determinant in estimating all five indicators. Maternal education was positively correlated with higher FIC coverage, while wealthier sub counties had higher FMMR.ConclusionsTracking of RMCH indicators revealed geographical inequalities at the County and subcounty level, often masked by national-level estimates. These findings underscore the value of routine monitoring indicators as a potential for evidence-based sub-national planning and precision targeting of interventions to marginalized populations.

A decade of change: maternal mortality trends in Sudan, 2009–2019

BackgroundUnacceptably high levels of preventable maternal deaths persist across sub-Saharan Africa. Due to limited research on maternal mortality in Sudan, a thorough examination is crucial to develop effective reduction strategies. This study aims to analyze maternal mortality trends at national and subnational levels in Sudan from 2009 to 2019.MethodsIn this retrospective-comparative study, the researchers reviewed mortality data covering 2009 to 2019 from the reports issued by the national maternal death surveillance and response. The maternal mortality ratios for the national and state levels were adjusted based on the population of women of reproductive age. The trends were assessed for statistical significance using the Mann–Kendall test, implemented in Python (version 3.12). The cut-off p-value for significance was taken as < 0.05.ResultsThe national maternal mortality ratio declined significantly by nearly 60% from 2009 to 2019 (S = -53, p < 0.001). The states of Kassala (S = -51, p < 0.001), Gadarif (S = -43, p < 0.001), Gezira (S = -41, p = 0.002), White Nile (S = -41, p = 0.002), Blue Nile (S = -39, p = 0.003), Red Sea (S = -39, p = 0.003), Khartoum (S = -39, p = 0.003), Northern State (S = -27, p = 0.043), River Nile (S = -27, p = 0.043), and Sinnar (S = -27, p = 0.043) showed significant declining trends. Blue Nile state recorded the highest average maternal mortality ratio in the study period (339.76), while Southern Darfur (66.46) and River Nile (89.59) recorded the lowest ratios. Major causes of maternal death include Obstetric hemorrhage (45.5%), hypertensive disorders (16%), and sepsis (12.6%). Important characteristics of pregnancy-related death include condition at admission, gestational age, antenatal care, mode of delivery, and areas of delay.ConclusionsThe national maternal mortality ratio significantly declined between 2009 and 2019, with wide regional disparities. Direct causes of maternal death remain a critical challenge. Effective strategies or frameworks focused on reducing maternal mortality ratios in Sudan are strongly solicited.

A population-level analysis of armed conflict and diphtheria at the subnational level in the WHO African Region 2017–2024

BackgroundDiphtheria has been re-emerging around the world at alarming rates, raising concerns about emergency preparedness, especially when global supplies of life-saving diphtheria antitoxin are insufficient. Outbreaks have occurred in areas with suboptimal coverage of the three-dose diphtheria tetanus and pertussis (DTP3) vaccine and regions experiencing conflict, but systematic studies assessing the association between these variables and the risk of diphtheria emergence are limited. This population-level study investigated the relationship between fatalities from armed conflict, childhood DTP3 vaccination coverage, and the presence of reported diphtheria cases in countries in the World Health Organization’s (WHO) African region from 2017 to 2024.MethodsThe analysis was conducted at a subnational geographic scale (I countries = 35, N subnational regions = 541). Data sources include DTP3 coverage from the Demographic Health Surveys (DHS), conflict-related fatalities from the Armed Conflict Location and Event Database (ACLED), and diphtheria cases from the WHO. We first assessed whether a history of fatalities from armed conflict is a predictor of childhood DTP3 coverage using mixed-effects beta regression. To assess the relationship between conflict and diphtheria emergence, we fit a crude logistic regression model to assess their overall association in the study period, as well as repeated measures mixed-effects models to estimate the relationship between time-varying rates of conflict-related fatalities and diphtheria status, adjusting for diphtheria vaccine coverage estimates.ResultsConflict and subsequent childhood DTP3 vaccine coverage were negatively associated (odds ratio [OR] = 0.93, 95% CI 0.88–0.98). Conflict is also a significant predictor of diphtheria presence, both in the crude (OR = 1.41, 95% CI 1.17–1.68) and best-fitting repeated measures model (OR = 30.30, 95% CI 23.30–39.39), though risk varied by location. The best-fit model also associated lower estimates of diphtheria risk in areas with high (> 80%) and low (< 25%) vaccine coverage, though this is possibly due to underreporting of the true burden of disease in low-resource settings.ConclusionsThis exploratory analysis indicates that conflict-related fatalities are potentially helpful indicators of subnational diphtheria risk in countries in the WHO African region from 2017 to 2024. Further, it may be especially useful in cases where estimates of population-level diphtheria immunity are limited.

Do nudges need a regulatory push? Comparing the effectiveness and implementation of exemplar nudge (size-based) and non-nudge (price-based) dietary interventions.

Changing behaviour across populations is key to improving population health and achieving net zero by 2050, including changing diets. We examine the extent to which nudges, with the potential to contribute to such change, are being implemented alongside traditional approaches. We compare the effectiveness and extent of implementation into policy of two interventions to improve diets: size-based interventions that alter portion, package or tableware size, commonly considered a nudge; and, price-based interventions, including food-item taxes, not considered a nudge. We conducted four rapid reviews: two for systematic reviews with meta-analyses aimed to determine the effectiveness of size-based and price-based interventions, respectively; and two for reports to estimate the extent to which size-based and price-based interventions have been implemented in health or environment policies of governments, public authorities, or private sector organisations, at national or sub-national levels. Both sets of interventions were consistently found in research studies to be effective at reducing consumption and purchasing of unhealthy products, but price-based interventions have been implemented in policies far more often than size-based ones. At least 118 countries have implemented taxes on sugar sweetened beverages (SSBs), and 42 countries have implemented taxes on unhealthy foods. In contrast, we identified 20 reports of size-based interventions implemented at sub-national level, of which only one involved regulation. Explaining and reversing the lack of implementation of size-based interventions and other effective nudges merits prioritisation to help realise global ambitions to improve population health and achieve net zero by 2050.

Towards assessing the tobacco control law enforcement systems within Indian states: a rapid review and document analysis

Background Tobacco use contributes significantly to deaths and diseases globally. In India, it accounts for nearly two million adult deaths and costs about USD 27.5 billion annually. India has made notable strides in tobacco control ratifying the World Health Organization Framework Convention on Tobacco Control and enacting the Cigarettes and Other Tobacco Products Act, 2003. While there has been some decline in tobacco use prevalence over time, the enforcement of tobacco control laws remains suboptimal and inconsistent across Indian states. India, being a democracy with union of states, states remain crucial in implementing tobacco control laws. This study aims to inform a framework for assessing tobacco control law enforcement systems at the state level in India. Methods We used document analysis to identify tobacco control laws and guidance for their enforcement in India. We used a rapid review of literature to identify key elements of effective law enforcement by reviewing major relevant frameworks, indices, and tools. Building on the findings from these exercises and using a system thinking lens, we identified key themes that can inform a framework for assessing tobacco control law enforcement systems in Indian states. Results We identified four major themes (leadership and governance; human resources; finances; enforcement tools and materials) and several specific elements relevant to Indian contexts that could inform development of a meaningful and pragmatic framework for assessing tobacco control law enforcement systems in Indian states in order to strengthen tobacco control law enforcement. Conclusion It is important and timely to focus on tobacco control law enforcement at sub-national (state) level in India using a systems thinking approach that is informed by lessons about effective enforcement systems from across sectors.

Development of a composite index for the assessment of food systems in the Philippines

Food system assessment is vital in providing informed decisions for relevant transformations and policy shifts. In the present study, we developed and a composite index that can be utilized to quantitatively assess the status and/or performance of the food systems in the Philippines. Initially, a set of indicators were generated by Delphi approach, and relevant local data were used to develop algorithms to quantitatively operationalize the indicators which were subsequently grouped into domains by Principal Component Analysis (PCA). Equal weights were applied to indicators, and the linear additive aggregation technique was employed. The robustness of the model was also tested by uncertainty and sensitivity tests. Finally, the utility of the index was tested to describe the status of food systems in the Philippines at the across regions. Results indicate differences in regional food system scores; Central Luzon, CALABARZON, and CAR have higher scores than the other regions, while Bicol, Western Visayas, and Davao obtained relatively low scores. The sub-national level assessment indicates differences in food system concerns and priority areas across the country, providing implications for context-specific program and policy development.

Impact of the COVID-19 pandemic on the measles elimination status in Armenia

Introduction: The coronavirus disease 2019 (COVID-19) pandemic led to a decrease in immunization rates and measles surveillance, resulting in re-establishment of endemic measles transmission in many countries where measles was previously eliminated. Methodology: We conducted a retrospective study to evaluate the impact of the pandemic on the measles elimination status in Armenia. We studied the prevalence of measles from 2000 to May 2024 and predicted the trend for the coming months. We assessed trends in coverage levels of the mumps-measles-rubella (MMR)1 and MMR2 vaccines in Armenia between 2003 and 2023. The performance indicators of measles surveillance at the national and subnational levels before, after, and during the pandemic (2013-May 2024) were studied. Results: Endemic transmission of measles in Armenia was interrupted in 2008, and was sustained for many years; however, it was re-established in 2023. A total of 988 measles cases were recorded between February 2023 and May 2024. During the pandemic (2020–2022), MMR1 and MMR2 vaccine coverage decreased from the target level to 94%. Case-based measles surveillance was significantly weakened. Discarded case rate was 0.7 in 2020 and 2021, and 0.9 in 2022. After the pandemic, this indicator improved, reaching 33.3 in 2023 and 17.3 in 2024. The mean values of the numbers of discarded cases were 118 (95% CI, 73–163) in 2013–2019, and 23 (95% CI, 20–26) in 2020–2022 (p &lt; 0.05). Conclusions: The measles elimination status of Armenia was lost due to immunity gaps and weakening of measles surveillance during the pandemic.

A Bayesian approach to estimate the completeness of death registration

Civil registration and vital statistics (CRVS) systems should be the primary source of mortality data for governments. Accurate measurement of the completeness of death registration helps inform interventions to improve CRVS systems and to generate reliable mortality indicators. In this work we propose a Bayesian extension to the empirical completeness method to estimate the completeness of death registration in a population. The Bayesian models were developed using death registration data from 120 countries and 2748 country-years in 1970–2019 from the Global Burden of Disease (GBD) 2019 database. According to our findings, the credible intervals obtained under the proposed Bayesian models suggest that the covariates are reliable predictors of the logit of the completeness of death registration. To illustrate the effectiveness of our proposal, we applied the Bayesian models to estimate the completeness of death registration in the departments of Colombia in 2017. We found that most posterior mean estimates closely approximate to the observed value of completeness across the departments of Colombia and that, for nearly all departments, the observed completeness is within the credible intervals. The proposed Bayesian demographic models allow institutions to produce distributional estimates (e.g., posterior mean, quantiles, credible intervals, posterior probabilities) of the completeness of death registration at the subnational level, which can be used as evidence to strengthen their CRVS system.

Integrating Human and Animal Health in the STOP Spillover Outbreak Scenarios.

To generate and employ scenarios of sentinel human and animal outbreak cases in local contexts that integrate human and animal health interests and practices and facilitate outbreak risk management readiness. We conducted a scoping review of past outbreaks and the strengths and weaknesses of response efforts in USAID STOP Spillover program countries. This information and iterative query-and-response with country teams and local stakeholders led to curated outbreak scenarios emphasizing One Health human:animal interfaces at sub-national levels. Two core scenarios were generated adapted to each of 4 countries’ pathogen priorities and workflows in Africa and Asia, anchoring on sub-national outbreak response triggered by either an animal or human health event. Country teams subsequently used these scenarios in a variety of local preparedness discussions and simulations. The process of creating outbreak scenarios encourages discussion and review of current country practices and procedures. Guideline documents and lessons learned do not necessarily reflect how workflows occur in outbreak response in countries at highest risk for spillover events. Discussion-based engagement across One Health stakeholders can improve sub-national coordination, clarify guidelines and responsibilities, and provide a space for interagency cooperation through use of scenarios in tabletop and other exercises.

Living with the incoherent: Practical insights on implementing European restoration policies for biodiversity policy integration.

Policy incoherence is an omnipresent challenge in public administration. Focusing on the joint implementation of the European Water Framework Directive and the Habitats Directive, we analyze how administrative fragmentation hampers river restoration projects at the sub-national level in Germany. By shifting the analytical focus to institutional and administrative factors, we reveal barriers at institutional, processual and individual levels. We find that the failure of river restoration projects stems not only from practical hurdles, such as lack of resources, information, or manpower, but also from more fundamental flaws in the administrative arrangements. Based on a multi-stakeholder consultation, we argue that both bottom-up and top-down approaches can support better coordination and a local mandate for joint implementation. In particular, state-level planning can help reduce local coordination costs in the short term. The analysis highlights the critical role of individual actors and leadership, reframing and cross-sectoral coordination for policy integration.

The national and subnational burden of falls and its attributable risk factors among older adults in Iran from 1990 to 2021: findings from the global burden of disease study

BackgroundFalls among older adults (individuals aged 60 and above) are a substantial health issue worldwide. This study aimed to analyze the burden of falls and its attributable risk factors among older adults at the national and subnational levels in Iran over 32 years.MethodsUsing the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 data, we estimated the incidence, prevalence, death, and disability-adjusted life-years (DALYs) of falls and its attributable risk factors among older adults by sex, age groups, and socio-demographic index (SDI) in Iran and its provinces. We reported the estimates with their 95% uncertainty intervals (UIs). Rates were reported per 100,000 population.ResultsIn 2021 in Iran, the incidence rate of falls among older adults was 1674.0 (95% UI: 1454.9-1897.3), the prevalence rate was 11302.5 (10504.7-12095.7), the death rate was 16.9 (12.9–21.0), and the DALYs rate was 736.3 (647.6-825.4). In 2021, at the subnational level, Qazvin had the highest incidence, death, and DALYs rates for falls with values at 2329.5 (2008.8-2652.1), 24.2 (19.5–29.0), and 965.9 (856.2-1074.6), respectively, while Kohgiluyeh and Boyer-Ahmad had the highest falls prevalence rate at 16043.1 (14918.4-17149.0). In 2021, males had higher prevalence, death, and DALYs rates of falls compared to females, while females had a higher incidence rate. Among the age groups, the 90–94 age group had the highest rates of incidence, prevalence, death, and DALYs from falls. Low bone mineral density was the primary risk factor attributable to the burden of falls. There were significant positive associations between SDI and both the incidence and prevalence rates of falls. Conversely, a significant inverse association was found between SDI and the death rate.ConclusionsFrom 1990 to 2021, the incidence rate of falls has increased significantly among older adults in Iran, necessitating urgent interventions. Implementing nationwide, cost-effective strategies such as exercise programs to improve strength and balance, home hazard modifications, medication reviews to reduce fall-related risks, and routine screening programs for osteoporosis and fall risk assessment can help protect and support older people, minimizing their risk of falls.

The impact of violence and COVID-19 on Mexico's life-expectancy losses and recent bounce-back, 2015-22.

Before the COVID-19 pandemic, life expectancy in Mexico stagnated from the early 2000s, mainly due to increased homicides. During the pandemic, Mexico experienced sizable excess mortality. We aimed to assess the contribution of violence, COVID-19, and causes of death that were amenable to healthcare to life-expectancy changes between 2015 and 2022 in Mexico. We used administrative mortality and adjusted population estimates to construct life tables. We applied demographic methods to untangle contributions of causes of death to life-expectancy changes by year and sex at the subnational level. Between 2015 and 2019, life expectancy declined from 71.8 to 71.1 years for males and stagnated at 77.6 years for females. Violence among young males explains most of the decline (54.3%). Between 2019 and 2020, life expectancy decreased by 7.1 and 4.4 years for males and females, respectively. COVID-19 accounted for 55.4% of that change for males and 57.7% for females. In 2021, male life expectancy stagnated but continued to decline for females by 0.44 years due to COVID-19 deaths. In 2022, we observed unequal recovery patterns in life expectancy across regions, as northern states experienced larger improvements than central and southern states. We documented large variations in life-expectancy losses across Mexican states before, during, and after the COVID-19 pandemic. Before the pandemic, violence accounted for most of the male life-expectancy losses. During the pandemic, following COVID-19 deaths, mortality due to diabetes and causes that were amenable to healthcare contributed considerably to observed losses, with an uneven impact on the sexes.

The impact of water availability and pollution on economic growth at the sub-national level: Evidence from Mexico

The impact of water availability and pollution on economic growth at the sub-national level: Evidence from Mexico

Global subnational estimates of migration of scientists reveal large disparities in internal and international flows

Researchers are key contributors to innovation. Their migration results in talent circulation and recombination of ideas. Due to data shortage, little is known about subnational mobility of scientists and the interrelationships between their internal and international migration patterns. We used data on 30+ million Scopus publications of 19+ million authors to infer migration from changes in affiliations. Our publicly shared database of global subnational estimates of migration reveals relevant disparities in the attractiveness of subnational regions. While, at the country level, some countries have acted as a global hub that attracts scholars from throughout the world, at the subnational level, some of their regions have negative net migration rates, with implications for scientific output and regional development, as well as the perpetuation of migration corridors. On average, subnational inequalities in attracting and sending scholars have increased for international but decreased for internal migration. In most countries, there is no single trend such that all subnational regions have been sending or receiving more scholars. Instead, a mix of patterns has been simultaneously at work, on the backdrop of globalization of migration, which is an asymmetric process where specific regions and subpopulations have higher access to international migration. For most subnational regions, when they are attractive for international migrants, they are also attractive for internal migrants, which is not always the case for emigration. Our results have implications for the global circulation of academic talent by adding the dimension of internal migration to "brain drain" and "brain circulation" in international migration.

Community pharmacy density at national and subnational levels in New Zealand

ABSTRACT As community pharmacies provide essential pharmaceutical and public health services, they should be geographically accessible to populations globally. This study aimed to explore community pharmacy density and associated factors at national and subnational levels in New Zealand (NZ). Publicly available, aggregate data for 2020 were sourced. Community pharmacy density (number of community pharmacies per 10,000 population) was calculated at the national level and at the subnational level using territorial authority (TA) areas. Associations between four TA characteristics (type [cities or districts], island [North or South], older age and deprivation score) and continuous community pharmacy density were assessed via linear regression. There were 1,154 community pharmacies. Numbers of community pharmacies per 10,000 population were 2.27 for NZ, 2.25 and 2.33 for the North and South Islands, respectively, and 2.45 and 1.95 for cities and districts, respectively. The only TA characteristic associated with community pharmacy density was TA type: cities had significantly higher community pharmacy density than districts (adjusted β = 0.58, 95% confidence interval = 0.13–1.02). TAs with lowest-quintile pharmacy densities (≤1.40) were clustered towards the south of the North Island and south-west of the South Island. This study could inform development of policies aimed at providing equitable access to community pharmacies throughout NZ.

Levels, severity, and determinants of stunting in children 0-59 months in Afghanistan: Secondary analysis of Multiple Indicator Cluster Survey, 2022-23.

Childhood stunting is a critical nutritional concern for Afghanistan. Prioritizing development assistance toward child nutrition requires recent estimates on child stunting and timely insights on determinants at national and sub-national levels. This study addresses this gap by estimating the prevalence and determinants of stunting and severe stunting in children under-five using the latest publically available data. The recent wave of Afghanistan Multiple Indicator Cluster Survey (MICS 2022-23) was analyzed to estimate the prevalence of stunting (height-for-age Z-score <-2SD) and severe stunting (<-3SD) by demographic and socioeconomic characteristics. The predictors of stunting and severe stunting outcomes were examined using multivariate logistic regression analyses with four domains of independent variables - child, maternal, and household characteristics and complementary feeding practices. In Afghanistan, 44·5% of children were stunted and 21.6% were severely stunted. The southern region has the highest burden of stunting (55%). Under-five females were less likely to be stunted than males [OR 0·89, 95% CI (0·84, 0·95)]. The likelihood of stunting increased with age of the child. Lack of maternal education, lower wealth quintiles, no exposure of the mother to mass media, and poor dietary diversity were the key predictors of stunting. Determinants of severe stunting mirrored those of stunting, with the additional risk for 24-59 months age group and higher birth order. Socioeconomic status, maternal education, child age, birth order, dietary practices, and geographical location were key determinants of stunting. Targeted interventions addressing poverty, education for women, family planning, and improved nutrition are crucial to reducing childhood stunting in Afghanistan.

The Making and Unmaking of Progress: A Two-State Comparison of Organized Educators, Politics, and Fiscal Policy-Reform, 1880s - 1920s

Abstract The expansion of schooling in the early 20th Century required the modernization of state governments at the subnational level and related fiscal policy reform. Organized educators in California and Washington promoted legislation in 1920 that would increase each state’s support for schooling. In spite of similar fiscal policy goals and a shared commitment to the support of public schooling in both states, the legislation passed in California and failed in Washington. This comparative analysis of fiscal policy reform in the two states demonstrates the relationship between education fiscal policy and state formation, between tax policy and social change, the role of states as subnational sites for fiscal policy experimentation in the early twentieth century, and the role of policy feedback in fiscal policy reform. A close study of factors contributing to the divergent legislative outcomes illuminates underlying relationships between fiscal policy and associative action at state levels over the 70-year-period preceding the 1920 reform campaigns and demonstrates the centrality of education to research in fiscal sociology and political development.

Participatory modelling and scenario exploration to address the air pollution challenge in Thailand and Laos

Abstract For countries in South-East Asia, air pollution presents a complex challenge that has proven difficult to effectively address. Policy action needs to be informed by a clear understanding of the most important drivers and sources of air pollution in local contexts, and the costs and benefits of different measures in mitigating these sources. Here, we present the findings from a participatory system dynamics modelling study which aimed to support policy and decision-making to manage the transboundary air pollution challenge in Thailand and Lao PDR. The research included two participatory modelling projects undertaken at the subnational level for Chiang Rai Province and Vientiane Prefecture which developed and applied an integrated air pollution (IAP) model. The participatory model development process undertaken with governments, private sector and civil society stakeholders identified key sources of air pollution (PM2.5 emissions), socioeconomic drivers and impacts, and potential policy interventions which were incorporated into the IAP model. Model projections for 2030 identified key sources of emissions for Chiang Rai as waste burning, cooking/heating and small vehicles, while for Vientiane they were cooking/heating, cement production, waste burning, small vehicles and petrochemical sources. Through group-based scenario gaming exercises, stakeholders gained insights on the cost and efficacy of different policy options by testing alternative investment scenarios. For both Chiang Rai and Vientiane, the largest reductions in PM2.5 emissions were projected from policies that targeted the waste burning, household cooking and transport sectors. This contrasted somewhat to stakeholder perceptions regarding the dominance of air pollution sources such as open burning of agricultural residues and forest fires. We highlight key insights and implications of the study for policy and research including the use of participatory systems dynamics modelling as a method for understanding and addressing complex sustainability challenges such as air pollution.