This paper investigates the interrelationships among local government debt, fiscal decentralization, and public health. The investigation begins by constructing a theoretical model to analyze the inherent connections between these variables. Subsequently, an empirical analysis is conducted using data from China between 2015 and 2021. The findings demonstrate a bidirectional relationship between fiscal decentralization, local government debt, and public health. Specifically, it is observed that an increase in local government debt has adverse effects on both fiscal decentralization and public health, while fiscal decentralization has a positive impact on public health. These insights are consistently validated through rigorous regression methodologies, affirming the robustness and significance of these relationships. Health, as a fundamental social and economic right, represents a primary responsibility for governments worldwide . The posIn response, China’s central government has taken steps to bolster public health development through the augmentation of fiscal budgets and healthcare system reforms . NeverthExamining the finance mechanisms, local governments in China play a pivotal role in financing public health infrastructure . For theIn the lens of fiscal decentralization, China is recognized as one of the most fiscally decentralized nations worldwide . Fiscal To contribute to this body of knowledge, we conducted empirical and model analyses using data from 31 Chinese provinces spanning the period from 2015 to 2021. Our findings indicate that a rise in local government debt leads to a reduction in fiscal decentralization, attributable to resource reallocation for debt service. Conversely, fiscal decentralization induces an increase in local debt when expenditures exceed revenues. An enhancement in public health corresponds with increased fiscal decentralization expenditure, denoting a more substantial resource allocation towards health. Simultaneously, as public health conditions improve, there is a recorded decline in fiscal decentralization income, indicative of reduced reliance on fiscal decentralization for income generation. Moreover, the results unveil that an upswing in government debt results in curtailed investments in public health, potentially exacerbating health conditions. In contrast, public health improvements trigger an increase in government debt, which is likely a consequence of extensive investments in health infrastructure and services.In this study, the model proposed by Holmstrom and Milgrom  is refinρ) among regional governments, the risk cost is calculated as An effort function, denoted as The model further incorporates conditions for Participation (CR) and Incentives (IN), which are formulated as Equations (2) and (3), respectively, as follows:Upon differentiation of the aforementioned equations, the Certainty Equivalent (CE) of the national government is derived and found to be zero. Equations (4) and (5) can be expressed as follows:By solving these equations, the optimal values of α and β are obtained, as shown in Equations (6) and (7):The maximum value is determined by converting these constraints into IR and CR constraints. Equation (8) can be expressed as follows:Further guidance obtained Equations (9) and (10):β are obtained, which represent the weight assigned by the central government to debt control (α) and public health infrastructure development (β) within their incentive scheme.Upon solving Equations (9) and (10), the coefficients α and Equations (9) and (10) are solved, yielding the following results:The variable Simplifying further, as show in Equation (14):The model accentuates the endeavors undertaken by local governments to proficiently manage government debt and boost public health infrastructure. The overall output (Z) manifests from the interaction of these dual efforts. A shift towards more rigorous debt control by local governments can lead to a contraction in resources available for public health infrastructure enhancement. This situation reveals a potential compromise between these two critical priorities, compelling the central government to negotiate a balanced approach, ensuring proficient management of both areas. The concept of fiscal decentralization refers to the degree of fiscal authority transitioned from the central government to local entities. In this model, the role of managing government debt and fostering public health infrastructure development is assigned to local governments. An escalation in fiscal decentralization could grant local governments increased autonomy and resources, which could be allocated towards public health infrastructure advancement. With respect to government debt and fiscal decentralization: a surge in fiscal decentralization may confer additional authority and accountability on local governments in managing their debt. Heightened fiscal decentralization could equip local governments with the capacity to more effectively respond to local needs, potentially optimizing debt management and indirectly favoring the health sector. This interaction underlines the intricate and nuanced dynamics among fiscal decentralization, government debt, and public health, necessitating careful consideration and policy development in these interconnected domains.Drawing from the model, the following hypotheses are proposed:H1: Fiscal Decentralization and Local Government Debt: A rise in local government debt results in reduced fiscal decentralization due to resource diversion for debt service. On the flip side, fiscal decentralization amplifies local debt when expenditure outstrips revenue.H2: Public Health and Fiscal Decentralization: Improved public health corresponds with increased fiscal decentralization expenditure and potential reductions in fiscal decentralization income as health conditions ameliorate.H3: Government Debt and Public Health: An inverse relationship between government debt and public health is proposed, where increased debt leads to curtailed public health investments. Concurrently, improved public health is associated with escalated government debt.In the literature review, a detailed exploration of the complex nexus between fiscal decentralization and local government debt is undertaken by numerous studies. Consistency with the conclusions drawn by Lam, et al.  and Jia,Conversely, the assertion that fiscal decentralization can be curtailed by heightened local government debt is supported by studies carried out by Nguyen and Anwar , Li and The theory of fiscal federalism is relevant in this context, postulating that local governments have better positioning to understand and cater to the unique needs of their constituencies . ExpectaA significant body of research suggests a negative correlation between fiscal decentralization and public health outcomes. Rotulo, et al.  and ArenConversely, there is also research demonstrating a positive correlation between fiscal decentralization and public health outcomes. For example, studies by Jin and Zou  and AsfaThese diverse findings indicate that the impact of fiscal decentralization on public health is highly context-dependent and influenced by multiple factors, including government income and expenditure. Yet, few researchers have investigated the relationship between fiscal decentralization and public health within different models of fiscal decentralization. Fiscal decentralization of income, where local governments have control over their revenue sources, can have a complex impact on public health outcomes. On the other hand, fiscal decentralization of expenditure, where local governments control how their funds are spent, has a different impact on public health outcomes. This area presents a fertile ground for future research to explore and understand these complex dynamics more fully.The fiscal stress theory, a crucial concept in the field, proposes that rising government debt can cause budgetary pressures, necessitating austerity measures, potentially including cuts to public health spending . This thTheoretical analyses and empirical results drawn from the existing literature indicate a bidirectional relationship between government debt and public health. While increasing government debt can adversely impact public health, advancements in public health can conversely lead to a rise in government debt. Given the significant implications of both government debt and public health for societal wellbeing and economic stability, further research to unravel this complex relationship is crucial. Such an understanding will assist in the development of policy responses that can effectively manage the involved trade-offs, and strike a balance between fiscal sustainability and public health outcomes.According to the WHO’s report  in 2021,Each aspect of public health is distinctly influenced by the extent and strategy of fiscal decentralization. It is plausible that fiscal decentralization might afford local governments more control over their budgets, which could lead to increased investments in priority sectors such as preventive care or health infrastructure. Nevertheless, decentralization could potentially accentuate disparities if wealthier regions possess the capability to dedicate more resources to health services compared to their less prosperous counterparts. This underlines the complex interrelation between fiscal decentralization and health expenditures . Prior sOur research methodology builds upon the established framework for fiscal decentralization proposed by the Organization for Economic Co-operation and Development (OECD). This comprehensive approach entails broad measures of government expenditure and revenue, inclusive of total spending, revenue, and intergovernmental transfers. This methodology offers an extensive macroeconomic perspective of fiscal decentralization and has been extensively deployed in previous research, owing to its efficacy in interpreting economic discrepancies across countries.However, the aim of our study is to delve into the intricacies of fiscal decentralization within distinct provinces, thereby requiring the incorporation of additional dimensions. To this end, we introduce two pivotal variables: fiscal decentralized expenditure (FDE) and fiscal decentralized income (FDI). Both FDE and FDI serve to provide an encompassing overview of local governmental public sector activities. Their merit as robust measures of fiscal decentralization within the context of China has been corroborated by the research conducted by Zhang, et al. , Zhang, With the implementation of the revised Budget Law of the People’s Republic of China on 1 January 2015, local governments have been permitted solely to issue government bonds as a means to accrue debt. Specifically, Article 35, paragraph 3 of the Budget Law unequivocally mandates that local entities must not amass debt through any alternative mechanisms. Special bonds, which are issued by provincial governments for public welfare projects with certain income, undertake to repay the principal and interest within a stipulated timeframe using government funds or special revenues corresponding to those public welfare projects. Since 2015, these special bonds have constituted the primary form of bonds issued by local governments. Therefore, in this paper, special bonds are deployed as a representation of local government debt.Perinatal mortality is an effective representation of public health levels, and it is a significant metric for assessing public health and the health status of the nation ,47,48,49Fiscal transparency is incorporated as an exogenous variable; fiscal transparency can enhance economic activity by cultivating an atmosphere of trust; it can also potentially affect provincial fiscal conditions. Density of medical institutions is deemed an exogenous variable. An increased density of medical institutions may foster better healthcare access, thereby enhancing overall population health. Concurrently, it might also impact medical staff density as the number of healthcare facilities in a region can shape the distribution and availability of medical staff. Medical staff density is also selected as an exogenous variable. The accessibility and density of medical staff could directly influence the quality of healthcare services, thereby affecting the overall health of the population. Gross domestic product at the provincial level is selected as an exogenous variable as well. The level of GDP could reflect a province’s economic prosperity, which may have implications for health infrastructure. A province’s financial capacity could impact resource allocation towards health infrastructure.A combination of single equation models and simultaneous equation models (SEMs) is utilized in this study to explore the relationships among fiscal decentralization, local government debt, and public health. These mathematical models serve distinct analytical roles, with a more comprehensive and accurate examination of these relationships being offered by SEMs. This enhanced scrutiny arises from two main factors. Firstly, the impact of correlations among individual equations on regression outcomes is not considered in single equation models. For example, an influence on local government debt is exerted by fiscal decentralization while, reciprocally, the shape of fiscal decentralization can be altered by debt through changes in resource distribution and local government behavior. Secondly, biases in estimation results can emerge due to the interconnectedness of independent variables and error terms within the model, when single equation models are used.In light of these considerations, the two-stage least squares (2SLS) estimator is employed in the SEM to examine the interrelationships among the equations, enhancing the robustness of the estimates. SEM is selected as the benchmark estimation method, as opposed to ordinary least squares (OLS), because biased estimates can be produced by the OLS estimator in the context of potential endogeneity concerns. Consequently, the following equations have been developed:i and t refer to the province and the year, respectively. The error terms in three distinct equations are represented by ε, μ, and The explanation of variables can be found in As shown in As shown in To mitigate the risk of spurious regression in model estimation and to ensure that significant bias is not inherent in the experimental results, a combination of two distinctive tests is employed, Levin, Lin, and Chu test (LLC) and Augmented Dicky–Fuller test (ADF). The outcomes of these tests are presented in The first model in both tables conducts regressions for FDE, while the second model uses FDI as the dependent and independent variables. Implications of Local Government Debt on Fiscal Decentralization: Elevated local government debt necessitates a strategic reallocation of resources, with priority given to debt service. This situation limits the financial autonomy of local governments and impacts fiscal decentralization. Empirical evidence substantiates this proposition, demonstrating a reduction in fiscal decentralization associated with an increase in local government debt, irrespective of whether measured by expenditure or income.Effect of Fiscal Decentralization on Local Government Debt: Fiscal decentralization, involving the transfer of fiscal responsibilities from central to local governments, incorporates the ability to generate revenue as well as the obligation to allocate funds. In situations where fiscal responsibilities surpass revenue-raising capacities, local governments accumulate debt to fulfill their obligations. This study affirms this, illustrating a significant impact of FDE and FDI on local government debt. Hypothesis 1 is thus confirmed based on empirical results.The SEM regression analysis from The relationship between fiscal decentralization and public health suggests a cyclical pattern. Improvements in public health could lead to a decrease in FDI, potentially demonstrating a reallocation of resources towards enhancing health infrastructure and services. Conversely, increased fiscal decentralization, providing local governments greater control over resources, contributes to public health improvements through the implementation of tailored, responsive policies and interventions. Therefore, the available evidence supports Hypothesis 2.Effect of Government Debt on Public Health: The SEM regression results, represented in Impact of Public Health on Government Debt: Despite the SEM regression outcomes, depicted in The panel vector autoregression (PVAR) model, an advantageous fusion of panel data and vector autoregressive models, is capable of addressing the endogeneity issues and lag periods of variables, thereby facilitating the study of variable interactions . To accuDrawing from the results of the three information criteria—the Bayesian information criterion (BIC), Akaike information criterion (AIC), and Hannan–Quinn information criterion (HQIC)—it can be seen in The tabulated results exhibit outcomes derived from a PVAR model. This model explores the temporal relationship between an array of variables, namely, FDE and FDI, GD and PH. “L” and “L2” denote the first and second lags of these respective variables. The corresponding coefficients embody the estimated influence of the lagged independent variables on the dependent variables.Both FDE and FDI demonstrate significant interrelations in Regarding PH, both tables exhibit significant correlations with FDE and FDI. In The consistency of these findings across different tables substantiates a sturdy association between fiscal decentralization, local government debt, and public health. These findings retain their validity across various methodological approaches.Presented in In As As shown in The Hausman test results derived from The Hausman test results from Consequently, this study conclusively negates the presence of spatial effects.The empirical findings from this study corroborate burgeoning literature emphasizing the intricate relationship between fiscal decentralization and local government debt. An elevated debt burden of local governments undeniably curtails their financial autonomy, leading to a measurable decrease in fiscal decentralization. This resonates with prior studies  that illThis research has shed light on the intricate dynamics that connect fiscal decentralization, local government debt, and public health by employing both single equation models and simultaneous equation models. The findings suggest that fiscal decentralization contributes to a decrease in local government debt. However, when it comes to public health outcomes, an increase in local government debt is primarily associated with a decline in health outcomes, indicating that debt is affecting the availability of resources for health services.Interestingly, this study reveals that increases in medical resources, such as the density of medical institutions and medical staff, do not necessarily lead to improved public health outcomes. This finding challenges conventional wisdom and highlights the need for further research on the efficient allocation and utilization of medical resources. The study emphasizes the importance of prudent fiscal management at the local level, particularly in the context of fiscal decentralization. Furthermore, it underscores the need for targeted and effective health policies that take into account the fiscal context and realities of local governments.


Previous evidence about the impact of parenthood on health for older adults is mixed, perhaps due to variation in number of children and context. Higher numbers of children could lead to support or strain, depending on individual and country contexts. Yet, no studies currently exist that examine associations between the number of children and several health indicators among older adults across multiple global regions.We analyze cross-sectional data (1992–2017) of 166,739 adults aged 50+ across 24 countries from the Health and Retirement Study family of surveys to document associations between the number of children, treated as a categorical variable, and 5 health outcomes . We perform multivariable analyses by estimating logistic regression models for each country and each outcome.Multiple comparisons between categories of number of children revealed at least 1 significant difference in each country, and a majority of significant differences indicated those with more children had poorer health. The risk of poorer health for parents of multiple children was observed in 15 countries, but in some countries, fewer children predict poorer health. The greatest number of differences was identified for depression and chronic conditions, and very few for functional limitations.We observe a greater probability that more children are associated with poorer health in later life, especially for chronic conditions and depression. However, a universal global or regional pattern could not be identified. These findings raise new questions about how country contexts shape fertility and health. Against the backdrop of global demographic shifts—including fertility declines and population aging—a plethora of research has emerged that examines linkages between fertility and later-life health . As chilTo date, however, few studies have undertaken a cross-national examination of the associations between the number of children and health, especially across multiple health outcomes and countries . DespiteNumber of children may be associated with older adults’ health through several underlying and complex mechanisms, which sometimes appear to result in conflicting findings. First, individuals select into parenthood by various life-course factors that could be confounded with later-life health. For instance, although some studies find that healthier individuals typically have larger families , other sChallenges associated with larger family sizes may, in some instances, be offset by the psychosocial benefits of childbearing and rearing. Parenthood may trigger individuals to adopt healthier lifestyles, for example, stop smoking . Older pFinally, the potential later-life health (dis)advantages of having (many) children earlier in the life course are conditioned by the broader socioeconomic contexts in which individuals are embedded. For example, the potential costs and psychosocial strains associated with childrearing vary based on family and community resources, welfare state support , and socExisting evidence on associations between number of children and later-life health examines a myriad of outcomes, including mortality, physical health , circulatory/metabolic , and mental health—with the bulk of studies utilizing samples of older adults in developed countries . StudiesThere is also evidence that the association between the number of children and health association is not universal, as patterns vary depending on country context and health outcomes. Studies of English older adults suggest that four or more children are associated with poorer health for women and men . In NorwIn the United States, women aged 50 and older who had six or more completed pregnancies reported worse health  compared to women with fewer than six children, including no children . CulturaBeyond Europe and the United States, literature on the number of children and later-life health in middle-income countries is burgeoning. Chinese women with more children were more likely to report severe disability, chronic conditions, and worse overall health . Other sGiven that most existing studies suggest that more children tend to be associated with poorer later-life health, having fewer children may confer more health benefits. Yet, empirical evidence about this pattern is also inconclusive. In studies of one or two high-income countries, lifetime childlessness was associated with higher risks of poor health and mortality among older women in England and Wales ; higher In studies of multiple countries using one or two health outcomes, being a parent of one child  was associated with depressive symptoms in Eastern Europe . StudiesTo our knowledge, only one study examined many countries and multiple health outcomes to find evidence of both higher and lower risks of poor health . Using dTherefore, overall, the existing literature provides conflictual evidence and a blurred picture of the connection between the number of children and health in later-life cross-nationally, including patterns that may vary by country and health dimensions. Nevertheless, there is clear evidence of variation across country contexts, suggesting the need for further cross-national studies with large numbers of countries.This study investigates associations between number of children and older adults’ health across five dimensions . We adopt a cross-national perspective to compare links between the number of children (childless to four or more children) and the probability of poor health in 24 high- and middle-income countries. We expect variation in the magnitude and direction of associations between the number of children and health across countries and health outcomes. We treat number of children as a categorical variable. Distinct from previous studies, we compare all possible levels of number of children in terms of health outcomes rather than use a fixed reference category.Our study draws on cross-national harmonized data from the global family of the Health and Retirement Study (HRS) provided by the Gateway to Global Ageing repository (g2aging.org). Our current analysis relies on four studies covering the United States (HRS); Mexico ; Europe and Israel (SHARE); and China . Altogether, this provides us with 24 high- and middle-income countries. As all these surveys are longitudinal, the datasets include multiple observations  for most respondents. Our pooled dataset uses the first-observation approach wherein we select the first observation of each respondent, after pooling all waves in each dataset. This approach allows us to focus on relationships between number of children, which is an almost perfectly time-invariant measure in our sample of older adults, and health at older ages, while maximizing available sample sizes. Although the surveys vary in sampling strategies, interview methods, and respondent selection, the participation rates for the baseline and refreshment samples were generally high  thereby As the HRS studies vary in the minimum age of respondents , we restrict our sample to respondents aged 50 years and older for comparability. Further, we exclude 11,720 (6.6%) observations with missing values on any of the explanatory or outcome variables. This provides a final analytic sample of 166,739 individuals from 1992 to 2017. Following previous research , we adopOur cutoff of four or more children partly reflects the distribution of our data  and is consistent with prior research . We alsoFirst, we present descriptive statistics of our key variables by country . Second,To identify health outcomes more clearly by number of children, our multivariable analysis included comparisons between each level of the number of children variable in terms of their resulting predicted probabilities. The extensive fully adjusted results with predicted probabilities are presented in Existing studies show that fertility has different impacts on women and men, which also differs by age; therefore, we additionally run separate analyses by gender and age groups (50–64 and 65+).Our multivariable analysis aimed to identify which category of number of children poses a statistically significant higher probability of poorer health within each country. Although we analyze all possible comparisons between single categories of number of children, to ease the interpretation, we focus on identifying whether higher versus lower number of children, or lower versus higher, poses a greater risk of poorer health. Higher versus lower number of children means 4+ children versus 3, 2, 1, and 0; 3 children versus 2, 1 and 0; 2 children versus 1, and 0 children; and 1 child versus childless. Lower versus higher number of children means the inverse comparisons.Of our total 2,400 comparisons, only 237 (10%) were statistically significant at the 5% level, including 117 (5%) differences that were at least 5 pp, which we consider to be more substantial. Among all statistically significant differences, 158 (67%) were related to a greater risk of poorer health for higher versus lower number of children, and the remaining 79 (33%) for lower versus higher number of children. Among the substantial (5+ pp) and statistically significant differences, however, 90 (77%) were identified for higher versus lower number of children and only 27 (23%) for lower versus higher number of children. Overall, the greatest number of statistically significant differences among health outcomes were noted for depression , and the lowest for ADL . We also observe great heterogeneity among countries in associations between the number of children and our five health outcomes: from only one statistically significant difference in Luxembourg, Croatia, and Poland to 24 significant differences in Spain.In the following sections, we present detailed results. First, we present the number of countries (out of 24) with statistically significant differences in associations between the number of children and health. Second, we present significant differences by health measure and number of children. Our presentation of results focuses on substantial and statistically significant differences (at least 5 pp). These differences are presented in dark colors: dark yellow for higher versus lower number of children, and dark blue for lower versus higher number of children.Across all health measures, 15 countries  showed a greater probability of poorer health for higher number of children versus lower number of children (dark yellow color), and 9 countries (38%) for lower number of children versus higher number of children (dark blue color). Three countries—France, Ireland, Switzerland—had evidence of poor health for both higher and lower number of children.Considering differences by number of children and health outcome, we observed that greater risk of poor health for higher versus lower number of children (yellow color) occurred more often: for depression in 12 countries, chronic conditions in 11 countries, and self-rated health in eight countries. For ADL and IADL, substantial differences were identified only in single countries. The highest number of countries where lower number of children predicted greater risk of poorer health (blue color) was noted for self-rated health (six countries), and in single countries for other health measures, excluding ADL.Higher versus lower number of children predicts poorer self-rated health in eight countries: Czechia, Germany, Greece, Hungary, Ireland, Mexico, Poland, and Spain. These differences  are related to four or more children, suggesting that parents of four or more in these countries are at higher risk of poor SRH compared to parents of less than four . In two countries, this disadvantage also applies to parents of less than four children: parents of three, two, and one child versus childless in Hungary, and parents of three and two children versus one child in Ireland.In six countries, we observed poorer self-rated health for lower versus higher number of children. No children versus other categories predicted poorer SRH in four countries . Having one child versus other categories also predicts poorer SRH in four countries . In Israel only, parents of two versus three, and four or more children showed higher risks of poor SRH.Higher versus lower number of children (four or more children vs childless or one child) predicted having at least one ADL in three countries . In Hungary, having one child was associated with having ADL limitations compared to being childless. We did not observe any substantial statistically significant differences for lower versus higher number of children.Higher versus lower number of children was associated with a higher risk of having IADL limitations in two countries (Hungary and Ireland). In both cases, parents of four or more children had a higher probability of IADL limitations versus childless (Ireland) and parents of two children (Hungary). In Hungary, parents of three versus two children had a greater risk of IADL limitations.Lower versus higher number of children was associated with IADL limitations in three countries . No children versus other categories were related to greater IADL risk in two countries . In Israel, parents of one child had a higher risk of IADL limitations.Higher versus lower number of children predicted greater risk of having at least one chronic condition in 11 countries . These patterns include risk among those with four or more children (vs childless) in eight countries and those with one child (vs childless) in five countries. We also observed the pattern of poorer health of all parents versus childless in three countries .Risk of at least one chronic condition for lower versus higher number of children was observed only in two countries (higher risk among fewer than three children in Israel and among childless in Slovenia).Greater risk of depression for higher versus lower number of children was found in 12 countries, the highest number of countries compared to other health measures, including Croatia, Czechia, France, Germany, Hungary, Ireland, Italy, Mexico, Portugal, Spain, Sweden, and Switzerland. Higher risks of depression were evident mainly among parents of three (eight countries) or four or more children (nine countries) compared to childless .We found a higher probability of depression for lower versus higher number of children in only two countries—Denmark (one child vs four or more) and Ireland (three vs four or more).Age group differences showed that older parents (65 years and older) of multiple children have a higher probability of chronic conditions than parents from the younger age group (50–64). However, younger parents (50–64) of multiple children have poorer self-rated health and higher risk of depression than older parents. Additionally, younger parents of one child or childless have a higher risk of IADL than those in the older age group.The number of children shapes an individual’s health in myriad ways across the life course. Yet, the potential health (dis)advantages associated with the number of children vary according to the type of health measure considered as well as country contextual factors. Few existing studies examine the association between the number of children and multiple dimensions of health cross-nationally, and where available, the studies focus on cross-national variation within one global region: Europe .Using cross-national harmonized data representing older adults from diverse global regions , our study adopts a nuanced approach with comparisons across five categories of the number of children with attention to comparing pairs of the levels of the number of children across a sample of 24 countries and five health dimensions.The results of our analysis yield complex patterns across numbers of children, health outcomes, and countries. Specifically, we find that (1) in most countries, higher numbers of children are associated with poorer health; (2) of the five health outcomes examined, depression was most commonly associated with higher numbers of children, and (3) substantial cross-national variation exists to the extent that regional patterns could not be identified. Taken together, these findings suggest that higher numbers of children do not appear to be beneficial for health in a majority of countries—especially in terms of mental health—and it is difficult to identify any regional or income-based pattern to the cross-country differences observed, underscoring the need for significantly more cross-national studies on this topic.Overall, among the statistically significant and substantial differences, a higher number of children predicted poorer health in most (77%) of cases. Consistent with prior studies e.g., , we founThus, the association between the number of children and health is complex. Although having more children can mean more potential social control or support resources in later life, adult children are not guaranteed to be available to offer support due to multiple factors including geographic proximity or role strain of managing multiple social roles and responsibilities. Furthermore, having more and fewer (though less often for the latter) children is associated with higher probabilities of poor health and may reflect various social selection factors that precede childbearing. These factors may include the poorer health and lower socioeconomic resources of parents prior to childbearing, or a potentially smaller social network of parents with fewer children.Complexity is even greater when adding subgroups of older people to our examinations. Mothers of multiple children are more disadvantaged by chronic conditions than men, whereas fathers of multiple children are at greater risk of depression than mothers. Younger parents (50–64 years old) of multiple children have a greater risk of poor self-rated health and depression than older parents. Our results also reveal substantial variation across health outcomes and country contexts, described in the next sections.Higher number of children was most clearly linked to poorer health when examining depression, but with substantial variation across countries. Previous studies found conflicting findings, with either higher or lower number of children predicting the risk of depression or no statistically significant association. Similar to findings from Mexico  and EuroConsistent with previous cross-national studies of European older adults , we alsoLikewise, for chronic conditions, higher number of children predicts poorer health more often than lower number of children, with parents of four or more children appearing to be particularly disadvantaged. This pattern aligns with the results of previous studies in various countries  in most countries in our study. Existing evidence showed more limitations of parents of multiple children e.g., , but ourIn addition to variation across health outcomes, we observe substantial variation between countries. Yet, we cannot point to any specific broad contextual links between fertility and later-life health—similar associations can be found in high- or mid-income countries, in Western and Eastern Europe, and across welfare regimes and cultural  contexts. However, we identify special country cases worth further investigation.The first interesting case is the United States, where the link between fertility and older adults’ health is very weak . Hence, here any potential health benefits/disadvantages of higher or lower number of children are likely moderated by other factors, such as sociocultural differences, for example, ethnicity, as identified in previous studies . For exaSecond, in Israel, all substantial associations were related to the disadvantages of lower number of children . This finding somewhat confirms previous studies showing higher mortality risks of childless women and mothers of one child, perhaps linked to nonpregnancy biological factors as well as psychosocial and lifestyle factors . SimilarIn addition, Hungary is the only country with substantial health risk of higher number of children across all health measures. In Hungary, having multiple children may be a widespread health disadvantage.Finally, there is a group of countries with clear health risks of higher number of children (four or more children) for at least three measures, mainly from Southern Europe: Greece, Portugal, and Spain , but also including Mexico and Czechia. These patterns suggest possible contextual social and economic conditions including (limited) social welfare family benefits that might cause strains, particularly for those with large families.n = 65 or parents with 4+ children, n = 130). Therefore, some of the insignificant associations might the result of low sample size. Additionally, missing data on variables leading to the exclusion of 6.6% of the observations might be not at random, thereby undermining the representativeness of some country samples. Relatedly, systemic disparities in the underreporting of civil registration within China  are relatively low  that may elucidate the conditions that shape existing linkages between family size and later-life health in diverse populations across the globe.gbad123_suppl_Supplementary_MaterialClick here for additional data file.


Pharmaceutics entitled “Biomimetic and Functional Nanomaterials for Molecular Imaging,” which focuses on the exciting advancements in molecular imaging facilitated by biomaterials and nanotechnology. The development of non-invasive imaging technologies has revolutionized disease diagnosis, the study of the mechanisms of action, and the exploration of novel therapeutic approaches. In recent years, the convergence of biomaterials and nanotechnology has paved the way for innovative medical imaging techniques, propelling molecular imaging into a multidisciplinary discipline with tremendous potential.Welcome to this Special Issue of the journal Nanotechnology has played a pivotal role in transforming molecular imaging from a mere image acquisition process to a comprehensive field that combines sensitivity, selectivity, functional imaging, and the integration of therapeutic and diagnostic functions within molecular platforms (known as theranostics). By leveraging nanotechnology and existing imaging modalities such as magnetic resonance imaging (MRI), X-ray computerized tomography (CT), positron emission tomography (PET), and ultrasound imaging, the field of molecular imaging is becoming an essential technology in biomedicine.Given the wide-ranging applications of biomaterials in biomedical research and, specifically, in the field of molecular imaging, this Special Issue aims to present noteworthy research and review articles that showcase the current state-of-the-art in biomaterial assessment, recent technological breakthroughs, and their functions and applications in molecular imaging.“Synthetic Antiferromagnetic Gold Nanoparticles as Contrast Agents for MRI and CT” .“Iron Oxide Conjugation for dual MRI and Fluorescent Imaging of Brain Tumors” .“Divalent Manganese Ions for Cross-Linking and MRI Contrast in Intrathecal Injection of Hydrogel-Embedded Stem Cells” .“Molecular Imaging for Myelin Quantification in Organotypic Cultures” .“Iron Oxide-Bold Nanoparticles for In Vivo Imaging and Photothermal Therapy” .“Quantification of Iron Oxide Nanoparticle Uptake in Mouse Brachiocelphalic Artery Atherosclerotic Plaque using T2-Weighted MRI” .“Review of New Approaches in Nanomedicine for Ischemic Stroke” .We are thrilled to present a collection of insightful papers that exemplify the progress being made in the field. The articles selected for this Special Issue include:These papers highlight the diverse applications and significant contributions that biomaterials and nanotechnology bring to molecular imaging. From enhancing imaging contrast and targeting specific tissues to enabling therapeutic and cell interventions and quantifying disease progression, these studies exemplify the transformative potential of this interdisciplinary field.We extend our gratitude to the authors for their valuable contributions and the reviewers for their diligent efforts in ensuring the high quality of the published work. Their collective efforts have made this Special Issue a comprehensive source of the latest advancements and insights in biomaterials and nanotechnology for molecular imaging.We hope that this Special Issue serves as a valuable resource for researchers, clinicians, and stakeholders interested in the rapidly evolving field of molecular imaging. We anticipate that the findings presented here will inspire further exploration, collaboration, and innovative applications in the ever-expanding realm of biomaterials and nanotechnology for improved disease understanding, diagnosis, and treatment.We hope that readers enjoy reading this Special Issue, and we hope that it will stimulate fruitful discussions and future breakthroughs in the fascinating field of molecular imaging.


The authors share the experience of developing a national preexposure prophylaxis program monitoring and evaluation implementation guide in Zambia, which can inform approaches to meet similar needs in other sub-Saharan African countries. Under the leadership of the Zambia Ministry of Health, stakeholders developed a national monitoring and evaluation (M&E) implementation guide to measure the uptake, use, safety, and cost of preexposure prophylaxis (PrEP).The guide builds upon global indicators and incorporates specific indicators to meet the country’s needs and provide a comprehensive overview of the PrEP cascade. The development and use of indicators along the PrEP care continuum are still in the initial stages in most countries.As other countries scale up PrEP services and plan for a robust M&E program, they should consider the following: implementation of a patient-level health information system, use of a people-centered approach that allows flexibility for PrEP modalities and location of service delivery (both community and facility), and training of health care workers. National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide, and discuss the guide’s implications for other countries in sub-Saharan Africa.The HIV care continuum comprises well-defined steps and indicators. In contrast, indicators along the preexposure prophylaxis (PrEP) cascade are still in the early stages of implementation. Monitoring and evaluation (M&E) of PrEP services is critical to optimizing PrEP uptake and adherence during periods of HIV risk. We provide an overview of global indicators for PrEP, describe the development process and outcomes of Zambia’s 2022 National Pre-Exposure Prophylaxis (PrEP) Program Monitoring & Evaluation Implementation Guide. This guide is aligned with the existing global indicators from the World Health Organization and the U.S. President’s Emergency Plan for AIDS Relief and adapted to the country’s needs, context, and health information systems. Zambia’s experience in developing the guide has highlighted the importance of strengthening client-level monitoring systems for HIV prevention, ensuring flexibility of the PrEP monitoring system to accommodate PrEP delivery modalities and differentiated service delivery models, and training health workers to enhance PrEP services and deliver care PrEP services along the continuum to prevent HIV acquisition effectively.During the scale-up of PrEP, the Zambia Ministry of Health (MOH) and the National HIV/AIDS/STI/TB Council recognized the need for a national unified monitoring system to guide the effective implementation of PrEP services. Stakeholders from the MOH, civil society, professional organizations, funding agencies, and implementing partners developed the Using a collaborative and consensus-based approach, Zambia developed its first national PrEP M&E implementation guide to provide standardized guidelines for optimizing the delivery, monitoring, and evaluation of PrEP service delivery. Zambia’s experience can inform other countries in sub-Saharan Africa as they develop national M&E implementation approaches for PrEP. President’s Emergency Plan for AIDS Relief (PEPFAR) has been instrumental in the HIV global response. PEPFAR supports more than 50 countries, including Zambia, to achieve HIV epidemic control. To maintain a coordinated and data-driven HIV response, PEPFAR has invested in and supported national health information systems to collect HIV-related data. In 2017, PEPFAR introduced a cross-program PrEP indicator that measured the number of individuals newly initiated on PrEP, known as PrEP_NEW.According to the latest 2021 UNAIDS statistics, more than 147,397 individuals in Zambia were receiving PrEP services, representing a major increase from 3,823 individuals in 2018.A major increase in PrEP recipients in Zambia between 2018 and 2020 prompted the need for a unified monitoring system across the entire PrEP cascade.,The National PrEP Program M&E Implementation Guide aligns with the existing global indicators from the WHO and PEPFAR.BOXZambia Preexposure Prophylaxis Risk-Based Eligibility Criteria (2022)Vaginal and/or anal intercourse without condoms with multiple sexual partnersSexually active with a partner who is known to be HIV-positive or at substantial risk of being HIV-positiveSexually active with an HIV-positive partner who is not on effective treatment  or not virally suppressed History of sexually transmitted infectionsHistory of postexposure prophylaxis useSharing injection material or equipmentPersons at substantial risk for HIV infection, defined as engaging in one or more of the following activities within the last 6 months, are recommended for preexposure prophylaxis:Zambia’s experience in developing a national PrEP M&E implementation guide can assist other countries in establishing a similar national implementation guide aligned with global indicators and responsive to the local context. This experience is especially relevant because, as of 2020, the number of users initiating PrEP in SSA is 290,891, comprising 44% of global PrEP users.,–Electronic health record (EHR) systems are increasingly used to deliver and manage clinical care, including HIV services, in resource-constrained settings.In Zambia, the national EHR SmartCare has been primarily designed and funded to support HIV care by optimizing the efficiency and quality of care. SmartCare had been deployed to over 80% of government health facilities as of 2022. In Zambia, SmartCare has been expanded to include a PrEP module, addressing a common shortcoming in SSA, which is that EHR systems often lack data on non-HIV conditions or medications such as PrEP.In Zambia, a national PrEP task force reviews the latest clinical evidence related to PrEP, including PrEP medications, and ensures that health systems adopt these changes in terms of health information systems, guidelines, and training of health care workers. This organizational structure is well positioned to plan and coordinate PrEP services systematically as they evolve.–As of 2022, the medications licensed and approved for HIV PrEP in Zambia include the daily oral combination pills of TDF/FTC and TDF/3TC. However, as trials continue for additional types and formulations of PrEP—including long-lasting injectable forms of PrEP —more PrEP medications are likely to be commonly available in SSA.M&E systems for PrEP need to accommodate new types of PrEP medications, which will impact the frequency and type of clinical services received.,A robust monitoring system for PrEP can provide insight into the PrEP uptake and use across different populations and settings. The usefulness of longitudinal monitoring for PrEP for policymakers, program implementers, and clinicians resides in a country’s ability to use data efficiently to improve PrEP delivery by identifying gaps and implementing strategies responsive to the local context and clients’ needs. PrEP data, combined with other HIV-related data sources, can deliver a more targeted approach to HIV prevention. For example, many countries across SSA are now implementing HIV recency testing, distinguishing recent HIV infection (last 12 months) from long-term infection.–Effectively monitoring individuals along the PrEP cascade requires health care workers to be knowledgeable and skilled in counseling individuals at risk for HIV on the efficacy of PrEP toward HIV acquisition and the importance of maintaining adherence during periods of high risk. The barrier of stigma deters individuals from accessing PrEP services and threatens the successful scale-up of PrEP services.Using a collaborative and consensus-based approach, Zambia has developed its first national PrEP M&E implementation guide to standardize guidelines for optimizing the delivery of PrEP services to individuals at risk for HIV infection. The guide builds upon global indicators and incorporates specific indicators to meet the country’s needs and provide a comprehensive overview of the PrEP cascade. The implementation guide developed for the Zambia PrEP program will help to address key questions in PrEP implementation and scale-up, thus improving program quality. Zambia’s experience can inform other countries in SSA as they develop their own national M&E implementation approaches for PrEP.


The burden of drowning is gaining prominence on the global agenda. Two United Nations system resolutions in 3 years reflect rising political support, but priorities remain undefined, and the issue lacks a global strategy. We aimed to identify strategic priorities for advancing global drowning prevention using a modified Delphi method.An advisory group was formed, and participants recruited with diverse expertise and backgrounds. We used document review, and data extracted from global health partnerships to identify strategic domains and draft priorities for global drowning prevention. Participants rated the priorities in two Delphi rounds, guided by relevance, feasibility and impact on equity, and where consensus was ≥70% of participants rating the priority as critical.We recruited 134 participants from research (40.2%), policy (26.9%), technical (25.4%) and community (7.5%) backgrounds, with 38.1% representing low- and middle-income countries. We drafted 75 priorities. Following two Delphi rounds, 50 priorities were selected across the seven domains of research and further contextualisation, best practice guidance, capacity building, engagement with other health and sustainable development agendas, high-level political advocacy, multisectoral action and strengthening inclusive global governance. Participants scored priorities based on relevance (43.2%), feasibility (29.4%) and impact on equity (27.4%).Our study identifies global priorities for drowning prevention and provides evidence for advocacy of drowning prevention in all pertinent policies, and in all relevant agendas. The priorities can be applied by funders to guide investment, by researchers to frame study questions, by policymakers to contrast views of expert groups and by national coalitions to anchor national drowning prevention plans. We identify agendas including disaster risk reduction, sustainable development, child and adolescent health, and climate resilience, where drowning prevention might offer co-benefits. Finally, our findings offer a strategic blueprint as the field looks to accelerate action, and develop a global strategy for drowning prevention. Previous studies call for expanded research on drowning burden and solutions across contexts, and for strengthened capacity for multisectoral action.The need for framing drowning prevention, in ways to increase prioritisation in non-health sectors, and for inclusive global governance and accountability frameworks, is well established.Our study identifies 50 strategic priorities for global drowning prevention, across the domains of: (1) research and contextualisation of drowning prevention, (2) best practice guidance, (3) capacity building, (4) engagement with other health and sustainable development agendas, (5) high-level political advocacy, (6) multisectoral action and (7) inclusive global governance with strengthened accountability.Our findings provide a framework to promote multisectoral action for drowning prevention, engage other health and sustainable development agendas and inform the development of a global strategy for drowning prevention.Our study provides further evidence for advocacy of drowning prevention in all pertinent policies and agendas, and at global, regional and national levels.In policy and practice our research provides a list of issues, ideas and areas in need of attention, and that may have utility across the many stakeholders and disciplines that have potenital to impact on drowning prevention.The priorities could be used by funders to guide investment decisions, by researchers to frame study questions in identified gaps, by policymakers to contrast views of expert groups and by national coalitions to anchor national drowning prevention plans. Advocates and agencies working in sustainable development agendas might note our priorities and ask what co-benefits drowning prevention might offer.Drowning prevention has struggled to gain political prioritisation, despite an estimated 236 000 lives lost annually, 90% in low- and middle-income countries (LMICs), and being among the 10 leading causes of death for people aged 1–24 years, in every region of the world.The resolutions: United Nations General Assembly (UNGA) Resolution on Global Drowning Prevention, April 2021, A/RES/75/273,The UNGA resolution invites WHO, which has increased its drowning prevention efforts since 2014,8–11This study aims to establish consensus on the strategic priorities for the advancement of drowning prevention over the next 5–10 years, to inform a global strategy for drowning prevention.We conducted document review, followed by a five-step online Delphi consensus study . The stu12Our objectives were twofold: to assess challenges and opportunities in global drowning prevention through comprehensive literature review, and to identify domains and strategic priorities in other partnerships where WHO plays a role to address health and development issues.First, we searched PubMed, The Cochrane Library, Web of Science, Embase ’ or ‘drowning, near (MeSH)’) and the web databases of WHO, Iris, World Bank, UNICEF (search terms ‘drowning’ or ‘water safety’) to identify areas that contribute to or impede progress of the global agenda for drowning prevention. We included English language articles only but note that future drowning prevention studies need to map scientific and policy content authored in languages other than English, especially as it relates to policy documentation of national governments. The search included reports, empirical studies, policies, strategies and data broadly associated with drowning prevention. We included global and regional level documents published by UN agencies, multilaterals, international non-governmental organisation (NGOs) and development agencies covering multiple countries or regions.https://www.who.int/about/collaboration/partnerships). Search results informed the selection of domains and drafting of strategic priorities , selecting members from existing research and policy networks of both authors. Advisory group members included technical experts covering research, policy and practice, and a breadth of contexts reflective of study participant groups including from LMICs. Meetings were held virtually.We used a purposive snowball sampling technique to recruit eligible participants. The eligibility criteria were based on expertise and work context. We included policymakers, researchers, programme managers or advocates for affected communities; and those working in UN agencies, governments, NGOs, foundations, academic institutions or communities affected by drowning; and active within a field with scope for connection to drowning prevention.Participants were identified through document analysis, existing networks and referrals from participants. The study was promoted by drowning prevention groups who posted an advertisement on social media, in newsletters or by sending an email invitation. We targeted expanded reach to under-represented groups through personal networks, social media postings or email invitations. Participants were directed to the online Participant Information Statement and Consent Form throughout the recruitment phase via a link. Potential participants were required to read the form before providing implied consent by registering for the study and receiving the Delphi survey.We used REDCap,Participants were asked to rate priorities using a 9-point scale; 1–3 being of limited importance, 4–6 being of moderate importance and 7–9 being of critical importance for reducing global drowning burden. Participants had the option to use ‘no-comment’ if unable to rate a priority. Initially, consensus was defined as ≥50% of participants rating a measure as critical (7–9), but it was later adjusted to ≥70% with advisory group agreement, and considering similar study consensus thresholds.14 15At the completion of the first Delphi survey, priorities that reached high levels (≥80%) of consensus were confirmed, and those with lower than 65% support were removed. The remaining priorities were taken into the second-round. In each round, open text fields collected qualitative data.In round two we asked participants to indicate a guiding principle; relevance, feasibility, equity or all the above, for decision-making in each domain. We described relevance as the extent to which addressing this challenge, issue or solution would reduce the burden of drowning prevention at global, regional or national levels. We described feasibility as the extent to which addressing the challenge, issue or solution is practical or feasible given resources, technical barriers and other support. We described equity as the extent to which addressing the challenge, issue or solution would address drowning prevention in under-resourced populations.The scores and feedback were tabulated using SPSS and presented for advisory group input. Adjustments between rounds included merging similar priorities, and redrafting based on feedback.There was no public/patient involvement in this study. Participants did not receive any compensation. They will receive an email link to access the results, unless they opted out of such in the consent process.The funding source  played no role in the design, methods, data collection or analysis of study results.Following our review, we selected seven domains covering: (1) research and further contextualisation of drowning prevention, (2) best practice guidance, (3) capacity building, (4) engagement with health and sustainable development agendas, (5) high-level political advocacy, (6) multisectoral action  facilitating multisectoral action, and (6b) sectors for multisectoral action) and (7) inclusive global governance with strengthened accountability. We drafted 75 prospective strategic priorities across the domains.A total of 134 experts participated from 46 countries. Participant characteristics included community , policy , research  and technical backgrounds  . ParticiIn the first Delphi survey we presented 75 strategic priorities across 7 domains of which 25 priorities were rated as critically important by ≥80% of participants .Based on the first-round findings, we excluded 17 priorities that had insufficient support (<70%) and 7 priorities were merged following feedback. Two priorities were scored highly by LMIC participants but failed to meet the round one threshold overall: best practice guidance and capacity for lifeguard (69.5%), and partnerships with the small-scale artisanal fisheries sector (69.6%) and were included in round two based on advisory group advice.We presented 26 priorities in round two where all but one priority achieved consensus (≥70%) of participants rating them as critical (score 7–9).We established consensus for 50 strategic priorities, across research and further contextualisation of drowning prevention (n=7), best practice guidance (n=7), capacity building (n=7), engagement with health and sustainable development agendas (n=4), high-level political advocacy (n=5), multisectoral action (n=12) and for inclusive global governance (n=8) .In round one, we presented 12 draft priorities in the research and further contextualisation of drowning prevention domain, with focus on challenges across populations, environments and activities.In round one, research investigating social and demographic factors and both the burden and the effectiveness of interventions addressing child and adolescent drowning were rated highly. In round two, research investigating behavioural factors including risk taking, alcohol and other drug use, and use of safety equipment were rated highly.Four research priorities did not meet the criterion in round one and were removed. The most notable being investigating the influence of migration in transit and settlement on drowning prevention, where low levels of support, especially among researchers and technical experts, meant that the priority was removed.We identified nine draft priorities in the best practice guidance domain, which we described as techniques, methods or approaches that through research or experience have proven to support drowning prevention.In round one, the highest rated priorities were systematic approaches to teaching children swimming and water safety skills, and community education and training interventions. In round two, guidance for integrating drowning prevention into existing disaster preparation, response and resilience systems was rated highly. We removed the priorities for guidance for safe boating, shipping and ferry regulations, and alcohol-related drowning in recreational settings in round one as both were below the inclusion criterion.We identified 10 draft priorities for capacity building, which we describe as the process of developing and strengthening skills, processes, and resources that organisations and communities need to avoid, reduce, mitigate against drowning.16In round one, the strengthening of capacity for data systems to measure, map and monitor drowning burden at all levels was the highest rated priority, followed by capacity for policy-based approaches to prevention, and capacity for implementation research in round two. The priority for strengthening of capacity for lifeguard and rescue services (pool and open water) received low level of support in round one and was omitted.We identified nine draft priorities in the engagement with health and sustainable development agendas domain.In round one, engagement with the Disaster Risk Reduction agenda and to the Sendai Framework, and engagement with the Sustainable Development Agenda 2030,In round two, child and adolescent health, and climate and health agendas reached the inclusion criterion.We identified 10 draft priorities in the high-level political advocacy domain, which is considered important to accelerating and sustaining progress.In round one, strategies for high-level advocacy of drowning prevention for the least developed countries, landlocked developing countries and small island developing states and the development of an accountability framework aligned to the UN Resolution on Global Drowning Prevention, achieved strong consensus. The draft priority seeking to implement strategies for engagement with the International Olympic Committee Peace and Development through Sport Initiative scored the lowest of any priority and was removed in round one.In round two, engagement with UN agencies like UNICEF, United Nations office for Disaster Risk Reduction International Maritime Organization (IMO), International Labour Organization, International Office for Migration and United Nations Development Programme (UNDP) rated highly.The multisectoral action for drowning prevention domain was initially presented in two subdomains: priorities for facilitation of multisectoral action and sectors for multisectoral action.We identified five draft priorities in the subdomain for facilitation of multisectoral action, aiming to address the notion that successful multisectoral action needs deliberate activities, specific techniques and governance aimed at leveraging the strengths of diverse sectors for collective impact.We identified 12 draft priorities in the subdomain of sectors for multisectoral action. In round one, partnerships with the early childcare and development, education and the emergency response sectors, including with police and fire departments, achieved strong consensus. Four sectors were removed after round one including 1) tourism, 2) sport, physical activity and leisure, 3) water, sanitation and hygiene, and 4) agriculture and rural development.We identified eight draft priorities for inclusive global governance with strengthened accountability. All priorities achieved greater than 80% consensus in round one or two and were confirmed.In round one, participants prioritised increased funding, development of regional strategies, establishing a global partnership or alliance and the inclusion of groups from high burden populations in decision-making and global governance. Developing a global strategy for drowning prevention, and a business case for establishing a global fund for drowning prevention were added after round two.The priorities were analysed and ranked across all participants groups . The higThe priorities were analysed by setting and expertise . LMIC paIn round two, participants were asked to indicate the guiding factor used to determine their scores in each domain. Overall participants scored priorities based on relevance (43.2%), feasibility (29.4%) and impact on equity (27.4%). There was minor variation across domains, except the high-level political advocacy domain where each factor was applied more evenly To our knowledge this is the first multistakeholder and geographically diverse consultation on strategic priorities for drowning prevention, and it comes at a time where increased high-level political focus brings new energy, resources and diverse interests to this previously underappreciated health and development challenge. Recent studies,Recognition of the need for multisectoral action for drowning prevention is growing.Policy coordination is likely to be a key challenge in advancing drowning prevention. Where cross-sectoral coordination is currently assigned by national governments, the ministries chosen are not homogenous across countries or regions. For example, drowning prevention is led by the Ministry of Labour, Invalids and Social Affairs in Vietnam, Ministry of Public Health in Thailand and Department of Fire and Rescue in Malaysia. Should a future UNGA convene a ministerial conference on drowning prevention, it is highly likely that the ministers represented could span the full spectrum of government sectors. This heterogeneity adds intrigue to decisions around core skill sets for capacity building and makes the sharing of lessons across countries both critical and complex. The richness and potential for interactions across sectors may function as an important social experiment and should be investigated further to strengthen drowning prevention action and inform other multisectoral policy agendas. There is scope for drowning prevention researchers and policymakers to investigate how other issues deal with complexities when housed within different government departments, for example, road traffic injury can be transport and/or public health, including through use of public–private partnerships.Navigating drowning prevention in the context of the Sustainable Development Goals (SDGs), and other key global development agendas presents challenges and requires a clear set of objectives and a plan of action. Consensus identified four development agendas where integration may impact on drowning prevention.First, pursuing partnerships in disaster risk reduction with alignment with the Sendai Framework,Second, alignment to the Sustainable Development Agenda 2030 and the SDGs is strongly supported and is known to have had positive influence on policy support during the UNGA resolution process.Drowning prevention advocates should not lose sight of the fact that the SDGs are nearing an end (2030), and the process to develop a subsequent agenda will commence in coming years. Strategies to enhance the positioning of drowning prevention in future sustainable development strategies requires planning and investment now.Third, participants prioritised partnering with child and adolescent health agendas, where the known impacts on children, and successful interventions like daycare and survival swimming present continued opportunities.31Fourth, several domains acknowledged the significance of integrating drowning prevention within climate and health agendas. Research on drowning prevention in the intersections between climate and disaster, and for social and economic factors in populations with a high burden of drowning is essential.Our study reinforces the importance of building inclusive global governance and strengthened accountability. The emergence of drowning on global health agendas, has been attributed to a small and cohesive coalition of actors, who advocated for drowning prevention in the absence of any formal governance.8Our study identified high levels of participant support for the formation of a global level alliance for drowning prevention. In July 2023, WHO announced the establishment of a Global Alliance for Drowning Prevention. The initial membership consists of five UN agencies; IMO, the UNDP, the Food and Agriculture Organization of the United Nations (FAO), UNICEF and WHO, and five non-state actors: the Royal Life Saving Society - Australia; Royal National Lifeboat Institution (RNLI), UK; the Centre for Injury Prevention and Research, Bangladesh; the George Institute for Global Health; and Bloomberg Philanthropies, who together must take on the responsibility of building inclusive models for governance.Governance priorities also called for increased funding for advocacy, research, policy and implementation, the inclusion of groups from high burden populations in decision-making and the development of contextually relevant regional action plans.Drowning prevention requires deliberate actions to create multistakeholder platforms that include multilaterals, governments, policy, civil society, academic and donor groups in decision-making, meaning the importance of the global alliance cannot be understated. A challenge rests in how, and whether combining diverse sector perspectives at global level, may influence the nature and momentum for community level collaboration. Opportunities may exist where global alliance members have resources, networks or programmes already situated in high drowning burden communities and countries. For example, where FAO is working on climate resilience in an artisanal fishery community where a drowning burden can be identified—can drowning prevention interventions be successfully embedded to protect children from drowning in water near households?Other health and sustainable development agendas have advanced their objectives through multistakeholder partnerships, complimented by a global strategy. WHO indicated that the development of a global strategy for drowning prevention is among the initial tasks of the global alliance. A global strategy for drowning prevention could include each of the domains in this study, and further prioritisation and selection from the strategic priorities identified . HoweverGrowth in drowning prevention research has been rapid, and its role in understanding issue characteristics critical to generating political awareness.Data collection in the WHO Western Pacific and South East Asia regional status reports,Beyond national estimates, the priority for research investigating social and demographic factors is consistent with calls to focus on the social determinants of drowning and to look upstream for drowning prevention measures, particularly for children and adolescents.The contrasting perspectives between research, policy and technical experts need further consideration. Significant variances included that the need for research across life stages and in open waters environments including beaches, rivers and lakes, were rated much lower by research experts than policy or technical experts. Several studies point to a much greater need for intervention research compared with further epidemiological studies, especially in well studied areas in HIC settings.The low rating, and ultimate exclusion, of actions for drowning prevention for migrants in transit and settlement may reflect an uncertain burden, weaknesses in existing approaches,Several domains showed significant difference in viewpoints among experts, sometimes enough for a priority to be excluded in our study results. The requirement for guidance for alcohol-related drowning in recreational settings was rated as important by technical experts, but less important by research and policy experts, so was not included. Alcohol is a significant factor in adult drowning in Australia,The differences between LMIC and HIC participant priorities were most prominent in the areas of multisectoral action and strengthened governance, where LMIC participants were more likely to support convening multistakeholder meetings and forums and were less supportive of the need for national and subnational drowning prevention plans than HIC participants. The need for funding and resources was also more important to LMIC participants.Overall, differences across expert groupings for priorities provides insight into roles and relationships across sectors and expertise. This variation reinforces the need for multidisciplinary approaches and geographically diverse participation in global priority setting, and community engagement when priorities are intended to affect change at local levels. Our study reinforces the value of Delphi method in priority setting activities, specifically as a tool combining the feedback from large heterogenous stakeholder groups.Our study has resulted in a longer list of priorities than expected, and in some respects the length of our list undermines the notion of strategic priorities. We take the view that several factors make a comprehensive list vital for the advancement of drowning prevention at this point in its development. First, the multidisciplinary and multisectoral nature of drowning prevention makes an inclusive list important to ensuring engagement and the support of such multifarious interests. Second, our priorities are framed at a global level and need to allow for emerging recognition of contextual diversity in both drowning burden and opportunities for prevention at regional, national and community levels. The emergence of drowning prevention over the past two decades has largely been driven by knowledge generated from a limited number of countries in the Asian continent,Delphi method has been implemented in previous drowning prevention studies,Delphi method has been criticised for potential impacts of bias, which we attempted to minimise by increasing the diversity of participants, achieving a large panel size, and providing and analysing open text fields. Every effort was made to ensure representation from LMIC groups, but the proportion is less than the drowning burden for these areas, and is perhaps a reflection of gaps in existing capacity for drowning prevention.Our consensus definition established a priori, was ≥50% of participants rating a priority of high range importance. This was adjusted to ≥70% after round one in consultation with the advisory group as it was deemed to be too low. A review of 98 Delphi studies found consensus threshold was often set arbitrarily and not reported, and when it was reported a median consensus threshold was ≥75%.14Our study was conducted in English, so may have excluded non-native English speakers. We surveyed preferences for languages other than English and while noting that each completed the survey, 24.6% suggested they preferred a language other than English. The highest was Bangla, (4.6%) followed by French (3.7%), a Chinese language (3.0%), Portuguese (3.0%) or Spanish (3.0%).Our study identifies strategic priorities for global drowning prevention and provides evidence for advocacy of drowning prevention in all pertinent policies, and in all relevant agendas. While framed as global priorities, our research provides a list of issues, ideas and areas in need of attention, and that may have utility across the stakeholders and disciplines that contribute to drowning prevention at regional, national and community levels. Applications of the findings of our study include: (1) national coalitions can use the priority domains to anchor national drowning prevention policy and planning, (2) the priorities could be used by funders to guide investment policies and decisions, (3) researchers might frame study questions in identified gaps, (4) policymakers might find insight in contrasting views of the expert groups who participated and (5) advocates and organisations working in the health and sustainable development agendas named might note our priorities and ask what value drowning prevention might offer to their objectives, whether for disaster risk reduction, sustainable development, child and adolescent health or climate resilience. Finally, our findings offer a blueprint to advance global drowning prevention as the field looks to accelerate action, establish a global alliance and develop a global strategy for drowning prevention.