Childhood Bullying as a Risk Factor for Late-Life Psychological Distress and Cognitive Impairment.

In the United States, non-Hispanic Black (19%) older adults are more likely to develop dementia than White older adults (10%). As genetics alone cannot account for these differences, the impact of historical social factors is considered. This study examined whether childhood and late-life psychological distress associated with dementia risk could explain part of these disparities. Using longitudinal data from 379 White and 141 Black respondents from the Panel Study of Income Dynamics, we assessed the association between childhood bullying and late-life dementia risk, testing for mediation effects from late-life psychological distress. Mediation analysis was computed via negative binomial regression modeling, stratified by race (White/Black), type of bullying experience (target, bully, and bully-target), and the age range at which the experience occurred (6-12, 13-16). The results indicated that late-life psychological distress fully mediated the association between Black respondents who were bullies and dementia risk. However, no significant association was observed among White respondents. These results suggest that interventions aimed at preventing and treating psychological distress throughout the lifespan could be crucial in mitigating the development and progression of dementia risk.

Social normative origins of the taboo gap and implications for adolescent risk for HIV infection in Zambia.

Zambian Demographic and Health Survey data reveal that increased discordance between professed attitudes and measures of behaviour regarding premarital sex among adults is strongly associated with increased risk of HIV in adolescents, particularly girls. We hypothesised that this was due to the reluctance to talk about premarital sex, resulting in a situation we call the "taboo gap" where sexual behaviour is a forbidden topic and adolescents feel unable to seek advice or sexual and reproductive health services. Our analysis revealed that the taboo gap is rooted in harmful gender norms that are perpetuated by schools, churches, cultural influences, development programmes and health systems. Challenges like food insecurity and household poverty may place girls in positions where they are vulnerable to sexual exploitation, increasing their risk of exposure to HIV. Unmarried adolescents, particularly girls, report being ridiculed when they go to reproductive health clinics, which discourages them from seeking care in the future. Strengthening peer support and parent-child interactions are important programmatic elements. We conclude that discordance serves as a novel measure and harbinger for the presence of gender norms which generated a taboo gap that impeded carseeking and increased risk for HIV among adolescents, especially girls, in Zambia. We propose that successful interventions must involve a multifaceted, gender transformative approach which engages peers and stakeholders in schools, churches, clinics, and families, particularly parents, to reduce the gendered gap in HIV risk and transmission.

Effect of imbalanced sampling and missing data on associations between gender norms and risk of adolescent HIV.

Background: Despite strides towards gender equality, inequalities persist or remain unstudied, due potentially to data gaps. Although mapped, the effects of key data gaps remain unknown. This study provides a framework to measure effects of gender- and age-imbalanced and missing covariate data on gender-health research. The framework is demonstrated using a previously studied pathway for effects of pre-marital sex norms among adults on adolescent HIV risk. Methods: After identifying gender-age-imbalanced Demographic and Health Survey (DHS) datasets, we resampled responses and restricted covariate data from a relatively complete, balanced dataset derived from the 2007 Zambian DHS to replicate imbalanced gender-age sampling and covariate missingness. Differences in model outcomes due to sampling were measured using tests for interaction. Missing covariate effects were measured by comparing fully-adjusted and reduced model fitness. Findings: We simulated data from 25 DHS surveys across 20 countries from 2005-2014 on four sex-stratified models for pathways of adult attitude-behaviour discordance regarding pre-marital sex and adolescent risk of HIV. On average, across gender-age-imbalanced surveys, males comprised 29.6% of responses compared to 45.3% in the gender-balanced dataset. Gender-age-imbalanced sampling significantly affected regression coefficients in 40% of model-scenarios (N = 40 of 100) and biased relative-risk estimates away from gender-age-balanced sampling outcomes in 46% (N = 46) of model-scenarios. Model fitness was robust to covariate removal with minor effects on male HIV models. No consistent trends were observed between sampling distribution and risk of biased outcomes. Interpretation: Gender-health model outcomes may be affected by sampling gender-age-imbalanced data and less-so by missing covariates. Although occasionally attenuated, the effect magnitude of gender-age-imbalanced sampling is variable and may mask true associations, thus misinforming policy dialogue. We recommend future surveys improve balanced gender-age sampling to promote research reliability. Funding: Bill & Melinda Gates Foundation grant OPP1140262 to Stanford University.

Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data.

BACKGROUND: Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis. METHODS: We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised. FINDINGS: Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras. INTERPRETATION: Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

Technological Progress and Health Convergence: The Case of Penicillin in Postwar Italy.

Throughout history, technological progress has transformed population health, but the distributional effects of these gains are unclear. New substitutes for older, more expensive health technologies can produce convergence in population health outcomes but may also be prone to elite capture and thus divergence. We study the case of penicillin using detailed historical mortality statistics and exploiting its abruptly timed introduction in Italy after WWII. We find that penicillin reduced both the mean and standard deviation of infectious disease mortality, leading to substantial convergence across disparate regions of Italy. Our results do not appear to be driven by competing risks or confounded by mortality patterns associated with WWII.

Men's Attitude Towards Contraception and Sexuality, Women's Empowerment, and Demand Satisfied for Family Planning in India.

Whilst the prevalence of unmet need and contraceptive use remained unchanged for 10 years (between 2005-2015) in India, gender restrictive norms and power imbalances also have persisted, preventing married women from meeting their family planning desires. Data for this study are from the 2015-6 National Family Household Survey, which contains information on fertility preferences and family planning for women in reproductive age. As a proxy for men's attitudinal norms, we aggregated men's perceptions regarding contraception (contraception is women's business, women who use contraception may become promiscuous) and control over their wife (if his wife refuses to have sex, men have the right to deny financial support, have sex with another woman, or beat wife) at district level. Using a three-level random intercepts model, we assessed individual and contextual-level associations of men's attitudinal norms and met need for contraception among sexually active women (aged 15-49) with any demand for family planning, while adjusting for women's empowerment indicators [education, job status, and adult marriage] and individual demographic factors. Our results indicate that men's attitudinal norms are negatively associated with women's contraceptive use; for instance, a 1 standard deviation increase in the proportion of men who believe that contraception is women's business was associated with a 12% reduced likelihood of contraceptive use (OR = 0.88, 95% CI 0.82-0.95). Similar associations remained or were stronger after considering only modern methods, or when excluding female sterilization. Furthermore, our contextual effects analysis revealed that women's higher education or wealth did not improve contraceptive uptake in communities with strong attitudinal norms, but working women or women married as children were more likely to use contraception in those communities. Our results suggest that men's attitudinal norms may be dominating over women's empowerment regarding family planning choices among reproductive age women. However, employment appeared to play a strong protective role associated with women's contraceptive use. It is important for programs seeking to transform gender equality and empower women in making contraceptive choices to consider women's employment opportunities and to also address male attitudinal norms in the context of the ecosystem in which men and women coexist and interact.

Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries.

BACKGROUND: There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms. METHODS: Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country. RESULTS: In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2). CONCLUSIONS: Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.

Making Pastoralists Count: Geospatial Methods for the Health Surveillance of Nomadic Populations.

Nomadic pastoralists are among the world's hardest-to-reach and least served populations. Pastoralist communities are difficult to capture in household surveys because of factors including their high degree of mobility over remote terrain, fluid domestic arrangements, and cultural barriers. Most surveys use census-based sampling frames which do not accurately capture the demographic and health parameters of nomadic populations. As a result, pastoralists are "invisible" in population data such as the Demographic and Health Surveys (DHS). By combining remote sensing and geospatial analysis, we developed a sampling strategy designed to capture the current distribution of nomadic populations. We then implemented this sampling frame to survey a population of mobile pastoralists in southwest Ethiopia, focusing on maternal and child health (MCH) indicators. Using standardized instruments from DHS questionnaires, we draw comparisons with regional and national data finding disparities with DHS data in core MCH indicators, including vaccination coverage, skilled birth attendance, and nutritional status. Our field validation demonstrates that this method is a logistically feasible alternative to conventional sampling frames and may be used at the population level. Geospatial sampling methods provide cost-affordable and logistically feasible strategies for sampling mobile populations, a crucial first step toward reaching these groups with health services.

Gender norms and health: insights from global survey data.

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study.

BACKGROUND: Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates. METHODS AND FINDINGS: Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries. CONCLUSIONS: To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

Inequality in total fertility rates and the proximate determinants of fertility in 21 sub-Saharan African countries.

In this paper, we examine the inequality in the dynamics of the total fertility rate within 21 sub-Saharan African countries by wealth quintiles. We also examine the associated inequality within each country in the proximate determinants of fertility-marriage, contraception, and breastfeeding. Applying Bongaarts' proximate determinants of fertility framework, for 14/21 countries we analyze, we find that those in the richest wealth quintiles have had a more rapid decline in fertility rates than those in the poorest wealth quintiles. The rapid decline for those in the richest wealth quintiles is attributable to delayed marriage and modest increases in contraceptive use. Although the poorest lag in fertility decline, postpartum abstinence and breastfeeding are the most important factors for them for fertility regulation. Further encouraging maternal health programs that focus on natural methods of fertility regulation will work in favor of the poorest in sub-Saharan Africa in moving through the demographic transition.

Correction: Distributional change of women's adult height in low- and middle-income countries over the past half century: An observational study using cross-sectional survey data.

[This corrects the article DOI: 10.1371/journal.pmed.1002568.].

Distributional change of women's adult height in low- and middle-income countries over the past half century: An observational study using cross-sectional survey data.

BACKGROUND: Adult height reflects childhood circumstances and is associated with health, longevity, and maternal-fetal outcomes. Mean height is an important population metric, and declines in height have occurred in several low- and middle-income countries, especially in Africa, over the last several decades. This study examines changes at the population level in the distribution of height over time across a broad range of low- and middle-income countries during the past half century. METHODS AND FINDINGS: The study population comprised 1,122,845 women aged 25-49 years from 59 countries with women's height measures available from four 10-year birth cohorts from 1950 to 1989 using data from the Demographic and Health Surveys (DHS) collected between 1993 and 2013. Multilevel regression models were used to examine the association between (1) mean height and standard deviation (SD) of height (a population-level measure of inequality) and (2) median height and the 5th and 95th percentiles of height. Mean-difference plots were used to conduct a graphical analysis of shifts in the distribution within countries over time. Overall, 26 countries experienced a significant increase, 26 experienced no significant change, and 7 experienced a significant decline in mean height between the first and last birth cohorts. Rwanda experienced the greatest loss in height (-1.4 cm, 95% CI: -1.84 cm, -0.96 cm) while Colombia experienced the greatest gain in height (2.6 cm, 95% CI: 2.36 cm, 2.84 cm). Between 1950 and 1989, 24 out of 59 countries experienced a significant change in the SD of women's height, with increased SD in 7 countries-all of which are located in sub-Saharan Africa. The distribution of women's height has not stayed constant across successive birth cohorts, and regression models suggest there is no evidence of a significant relationship between mean height and the SD of height (ß = 0.015 cm, 95% CI: -0.032 cm, 0.061 cm), while there is evidence for a positive association between median height and the 5th percentile (ß = 0.915 cm, 95% CI: 0.820 cm, 1.002 cm) and 95th percentile (ß = 0.995 cm, 95% CI: 0.925 cm, 1.066 cm) of height. Benin experienced the largest relative expansion in the distribution of height. In Benin, the ratio of variance between the latest and earliest cohort is estimated as 1.5 (95% CI: 1.4, 1.6), while Lesotho and Uganda experienced the greatest relative contraction of the distribution, with the ratio of variance between the latest and earliest cohort estimated as 0.8 (95% CI: 0.7, 0.9) in both countries. Limitations of the study include the representativeness of DHS surveys over time, age-related height loss, and consistency in the measurement of height between surveys. CONCLUSIONS: The findings of this study indicate that the population-level distribution of women's height does not stay constant in relation to mean changes. Because using mean height as a summary population measure does not capture broader distributional changes, overreliance on the mean may lead investigators to underestimate disparities in the distribution of environmental and nutritional determinants of health.

Ecological and social patterns of child dietary diversity in India: a population-based study.

OBJECTIVE: Dietary diversity (DD) measures dietary variation in children. Factors at the child, community, and state levels may be associated with poor child nutritional outcomes. However, few studies have examined the role of macro-level factors on child DD. This study seeks to 1) describe the distribution of child DD in India, 2) examine the variation in DD attributable to the child, community and state levels, and 3) explore the relationship between community socioeconomic context and child DD. RESEARCH METHODS AND PROCEDURES: Using nationally representative data from children aged 6-23 months in India, multilevel models were used to determine the associations between child DD and individual- and community-level factors. RESULTS: There was substantial variation in child DD score across demographic and socioeconomic characteristics. In an age and sex-only adjusted regression model, the largest portion of variation in child DD was attributable to the child level (75%) while the portions of variance attributable to the community-level and state level were similar to each other (15% and 11%). Including individual-level socioeconomic factors explained 35.6 percent of the total variation attributed to child DD at the community level and 24.8 percent of the total variation attributed to child DD at the state level. Finally, measures of community disadvantage were associated with child DD in when added to the fully adjusted model. CONCLUSIONS: This study suggests that both individual and contextual factors are associated with child DD. These results suggest that a population-based approach combined with a targeted intervention for at-risk children may be needed to improve child DD in India.

Distinct clusters of stunted children in India: An observational study.

Childhood stunting is often conceptualised as a singular concept (i.e., stunted or not), and such an approach implies similarity in the experiences of children who are stunted. Furthermore, risk factors for stunting are often treated in isolation, and limited research has examined how multiple risk factors interact together. Our aim was to examine whether there are subgroups among stunted children, and if parental characteristics influence the likelihood of these subgroups among children. Children who were stunted were identified from the 2005-2006 Indian National Family Health Survey (n = 12,417). Latent class analysis was used to explore the existence of subgroups among stunted children by their social, demographic, and health characteristics. We examined whether parental characteristics predicted the likelihood of a child belonging to each latent class using a multinomial logit regression model. We found there to be 5 distinct groups of stunted children; "poor, older, and poor health-related outcomes," "poor, young, and poorest health-related outcomes," "poor with mixed health-related outcomes," "wealthy and good health-related outcomes," and "typical traits." Both mother and father's educational attainment, body mass index, and height were important predictors of class membership. Our findings demonstrate evidence that there is heterogeneity of the risk factors and behaviours among children who are stunted. It suggests that stunting is not a singular concept; rather, there are multiple experiences represented by our "types" of stunting. Adopting a multidimensional approach to conceptualising stunting may be important for improving the design and targeting of interventions for managing stunting.

Variation in Anthropometric Status and Growth Failure in Low- and Middle-Income Countries.

BACKGROUND: Addressing anthropometric failure in low- and middle-income countries can have 2 targets of inference: addressing differences between individuals within populations (Wpop) or differences between populations (Bpop). We present a multilevel framework to apply both targets of inference simultaneously and quantify the extent to which variation in anthropometric status and growth failure is reflective of undernourished children or undernourished populations. METHODS: Cross-sectional data originated from the Demographic and Health Surveys program, covering children under age 5 from 57 countries surveyed between 2001 and 2015. RESULTS: A majority of variation in child anthropometric status and growth failure was attributable to Wpop-associated differences, accounting for 89%, 83%, and 85% of the variability in z scores for height for age, weight for age, and weight for height. Bpop-associated differences (communities, regions, and countries combined) were associated with 11%, 17%, and 15% of the variation in height-for-age z score, weight-for-age z score, and weight-for-height z score. Prevalence of anthropometric failure was closely correlated with mean levels of height and weight. Approximately 1% of Wpop variability, compared with 30% to 50% of the Bpop variability, was explained by mean values of maternal correlates of anthropometric status and failure. Although there is greater explanatory power Bpop, this varied because of modifiability of what constitutes population. CONCLUSIONS: Our results suggest that universal strategies to prevent future anthropometric failure in populations combined with targeted strategies to address both the impending and existing burden among children are needed.

Trends in inequalities in child stunting in South Asia.

We analysed socio-economic inequalities in stunting in South Asia and investigated disparities associated with factors at the individual, caregiver, and household levels (poor dietary diversity, low maternal education, and household poverty). We used time-series analysis of data from 55,459 children ages 6-23 months from Demographic and Health Surveys in Bangladesh, India, Nepal, and Pakistan (1991-2014). Logistic regression models, adjusted for age, sex, birth order, and place of residency, examined associations between stunting and multiple types of socio-economic disadvantage. All countries had high stunting rates. Bangladesh and Nepal recorded the largest reductions-2.9 and 4.1 percentage points per year, respectively-compared to 1.3 and 0.6 percentage points in India and Pakistan, respectively. Socio-economic adversity was associated with increased risk of stunting, regardless of disadvantage type. Poor children with inadequate diets and with poorly educated mothers experienced greater risk of stunting. Although stunting rates declined in the most deprived groups, socio-economic differences were largely preserved over time and in some cases worsened, namely, between wealth quintiles. The disproportionate burden of stunting experienced by the most disadvantaged children and the worsening inequalities between socio-economic groups are of concern in countries with substantial stunting burdens. Closing the gap between best and worst performing countries, and between most and least disadvantaged groups within countries, would yield substantial improvements in stunting rates in South Asia. To do so, greater attention needs to be paid to addressing the social, economic, and political drivers of stunting with targeted efforts towards the populations experiencing the greatest disadvantage and child growth faltering.

Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan.

Optimal growth and development in early childhood is determined by a complex interplay of child, maternal, household, environmental, and socioeconomic factors that influence nutritional intake, but interventions to reduce child undernutrition sometimes target specific risk factors in isolation. In this analysis, we assess the relative importance of 13 correlates of child stunting selected based on a collective review of existing multi-factorial frameworks: complementary feeding, breastfeeding, feeding frequency, dietary diversity, maternal height, body mass index (BMI), education, age at marriage, child vaccination, access to improved drinking source and sanitation facilities, household indoor air quality, and household wealth. The analytic sample consisted of nationally representative cross-sectional surveys from the most recent Demographic and Health Surveys for Bangladesh (2014), India (2005), Nepal (2011), and Pakistan (2013), and from the National Nutrition Survey for Afghanistan (2013). In the mutually adjusted logistic regression model for 3,159 infants aged 6-8 months, short maternal stature (OR: 2.93; 95% CI: 1.93-4.46) and lack of complementary foods (OR: 1.47; 95% CI: 1.12-1.93) were associated with significantly higher risk of stunting. For 18,586 children aged 6-23 months, the strongest correlates of child stunting were: maternal height (OR: 3.37, 95% CI: 2.82-4.03), household wealth (OR: 2.25, 95% CI: 1.72-2.94), maternal BMI (OR: 1.59, 95% CI: 1.27-2.00), minimum dietary diversity (OR: 1.48, 95% CI: 1.27-1.72), maternal education (OR: 1.36, 95% CI: 1.18-1.56), and age at marriage (OR: 1.17, 95% CI: 1.05-1.30). Full vaccination and minimum dietary frequency were also found to be important for severe stunting for children of this age group. Some differences were found in the relative ordering and statistical significance of the correlates in country-specific analyses. Our findings indicate that comprehensive strategies incorporating a broader progress on socioeconomic conditions as well as investments in nutrition specific programs are needed to improve child undernutrition in South Asia.