People with disabilities often experience unmet healthcare needs, and the factors associated with these needs may differ across healthcare service types. This study examined service-specific factors associated with unmet healthcare needs using Andersen's Behavioral Model. We conducted a cross-sectional online survey of 201 people with disabilities registered at a regional health and medical center in South Korea and their caregivers between November and December 2024. We assessed unmet needs for outpatient services, dental care, health screening, and home-visit rehabilitation, and classified independent variables as predisposing, enabling, and need factors. Unmet healthcare needs and their associated factors differed by service type. For outpatient services, assistance required in activities of daily living was associated with unmet need. For dental care, living arrangement, multiple disabilities, and depressive symptoms were associated with unmet need. For health screening, marital status and disability registration duration were associated with unmet need. For home-visit rehabilitation, sex was associated with unmet need. These findings suggest that unmet healthcare needs among people with disabilities should be addressed through service-specific strategies that reflect the distinct barriers and associated factors for each type of care.
This article uses the 1932–1933 famine in Ukraine, now commonly known as the Holodomor, as a case study for understanding the short-term and long-term implications of famine on communities and the world. Much of the scholarship focused on famine continues to focus on the origins of famines and preventative famine modeling, but far fewer works have fully engaged with the repercussions of famine that follow mass starvation. This article argues that the reverberating effects of famines must be understood as part of the total famine experience, and it demonstrates how the Holodomor provides a useful multi-pronged model for understanding the aftermath of famine through social/cultural, political, global, and medical/health contexts. As such, the example of the Holodomor offers us new perspectives that can be used to model the aftershocks of famine that continue to resonate in both local and larger global contexts.
Despite the effectiveness of community-based management of acute malnutrition (CMAM) in treating severe acute malnutrition (SAM), recent data show that up to 60
This paper explores Fuzzy Cognitive Mapping (FCM) as an analytical approach for understanding famine as a complex, dynamic system. Traditional approaches, such as the Integrated Food Security Phase Classification (IPC), may not fully capture the non-linear interactions among social, economic, political, and environmental factors that contribute to famine. The IPC relies heavily on cross-sectional survey data and expert judgment, which can introduce errors and biases. This study applies FCM to a retrospective case study of the 2017 Ayod County crisis in South Sudan. FCM combines qualitative and quantitative data, facilitating analysis of dynamic systems even with limited data availability. The findings indicate that FCM identified famine-like conditions from March to June 2017, aligning with subsequent survey data, although Ayod was never formally classified in famine by the IPC. Continued testing of FCM is recommended to assess its suitability as part of a revised analytical toolkit for near-real-time famine risk tracking.
Famines are complex systems that change over time, and in which outcomes differ by household situation and livelihood. The “watch” famine system archetype occurs when populations engage in coping strategies to deal with a hunger gap, such as between agricultural harvests, which can interfere with future food production and mask the existence of a crisis to outside observers. I present a framework for modeling household responses to hunger. I used a partial prototype model for agrarian, horticultural, or foraging livelihoods to simulate the role of rationing and foraging as coping responses to insufficient food. Although not all dynamics were included, simulations suggested that while coping mechanisms can improve outcomes, rationing may also produce negative outcomes, due to the increased chance of death with lower energy reserves. I discuss next steps for a more complete framework, generalization to other famine systems, and implications for monitoring and responding to famine systems.
While climate change will impact all aspects of the food system, it is not clear how it will influence the risk of famine: situations of extreme starvation. Drawing on theory for how and why famines occur, we analyze the ways that changes in extreme weather might alter local agricultural yields. We present CMIP6 projections of the change in risk for specific climate changes that are relevant to agriculture: heat, frost, precipitation, and dry spells. Then, we analyze crop model projections that estimate crop yields under future climate projections. In crop models run with a future scenario in which people plant the same crops as today, we find that calorie production from attainable crop yields is projected to decrease in much of Central America, Eastern South America, much of Africa, the Eastern Mediterranean, South Asia, parts of Southeast and East Asia, and Australia. However, under a scenario in which people are allowed to switch crops, we find that there is global potential for adaptation to climate change, with certain crops in every region that are projected to increase attainable yield under climate change. There are also major yield gaps that could be closed with adaptation investments. Based on the theory and analysis, we conclude that climate change may act as a contributing, rather than determinative, factor to famine-related risk. Given that adaptation will ultimately influence whether climate change will increase the probability of famine, we recommend investments in adaptation, especially in conflict-affected regions.
Supply chains are central to food security modeling, particularly in famine-prone settings, yet traditional analyses rarely adopt a system-wide perspective that accounts for their influence. One reason is that conventional predictive approaches used in supply chain analysis and systems modeling are difficult to calibrate and validate in contexts marked by sparse data and rapidly changing conditions. Drawing on a 6-year collaboration with USAID in Uganda, we argue that in such settings, an adapted system mapping approach can enable system-level analysis and produce actionable insights. We present our approach and examine its application to the Karamoja region of Uganda, where USAID sought to strengthen household resilience. We demonstrate the value of descriptive and prescriptive models in contexts where prediction is not feasible. In Karamoja, this approach highlighted the central role of supply chains in resilience outcomes and supported collective sense-making and collaboration among practitioners.
The 2011–2012 Somalia famine was a complex humanitarian disaster shaped by interacting environmental, economic, social, and political factors. This paper applies a qualitative systems analysis to examine famine structure, dynamics, and archetypes to demonstrate how systems modelling can deepen understanding of famine as a complex system. The study addresses three questions: (1) what key variables and feedback dynamics created pressures and constraints within the Somalia famine system; (2) how system components interacted to produce outcomes such as food insecurity, malnutrition, and mortality; and (3) which system archetypes characterized system behaviour. Using a causal loop diagram (CLD), the study maps interdependencies across environmental, biophysical, economic, social, health, political, and institutional domains within the famine system. The CLD illustrates the specific reinforcing feedbacks that acted as pressures, constraining feedbacks that acted as holds and balancing feedbacks that acted as stabilizers of the system. We observe three key system archetypes: Escalation, Fixes that fail and Shifting the burden. Overall, the study demonstrates that famine emerges from dynamic system interactions rather than isolated drivers, highlighting the value of systems thinking for improving explanation, policy insight, and intervention design in complex humanitarian crises.
Yemen continues to experience one of the most severe child malnutrition and food insecurity crises on the planet. Seasonal synchronization of malnutrition often serves as an early marker of emerging famine. In this study we compiled data collected by the humanitarian agencies on several potential drivers of malnutrition such as food insecurity, conflict events, and environmental indicators (rainfall, temperature, and normalized difference vegetation index) in Yemen from 2018 to 2023. We characterized the seasonality of malnutrition outcomes and explore spatiotemporal synchronization using non-linear time series analyses. Our findings demonstrate significant seasonal profiles in child malnutrition, which could be synchronized with the peak in food insecurity and peaks in environmental indicators. The quantification of seasonal characteristics in term of seasonal peaks and their amplitude pave the way to build strong foundation for deeper understanding of famine evolution from a complex system perspective by defining processes and triggers that amplify malnutrition and escalate faming formation.
Famines are crises characterized by starvation and malnutrition-related mortality. But representative nutrition and mortality data is often impossible to collect under common famine conditions, impeding real-time estimations and near-term projections of famine severity and therefore allocation of humanitarian assistance. As a supplement to survey data, systems models may be able to project individual outcomes based on more readily available data, to guide food assistance rations, and to predict trajectories of population-level malnutrition and starvation mortality. We provide an overview of systems dynamics modeling, discuss how it has been used to understand energy and nutrient dynamics in the human body, and discuss possible applications of these models, as well as the critical research needs to apply systems dynamics models to real-world crises. We then highlight complicating aspects of famine systems that should be considered as these models are applied. The literature includes several models that could be adapted to help identify critical areas for nutrition research on the biological progression of starvation under famine conditions. By incorporating additional physiological detail, these models could be parameterized to inform humanitarian public health responses to food crises, but improved data sharing will be crucial to model development.
This paper explores the use of system dynamics modeling to better understand the 1998 Bahr el Ghazal famine in southern Sudan. Based on expert interviews and a literature review, it presents a set of causal loop diagrams that clarify the complex dynamics involved in the crisis, demonstrating how three major political ‘holds’ permitted a self-reinforcing famine system to form. A simulation of this model generates similar outcomes in mortality and malnutrition to those that occurred in the actual crisis. Based on this analysis, the paper suggests several ways that modeling could have supported a more effective response at the time of the crisis and may be able to strengthen efforts to prevent famines in the future.
Firearm violence arises from a complex interplay of local conditions and state regulations. Using coincidence analysis (CNA), we examined how combinations of city-level prevention efforts and state-level firearm policies correspond to fatal shooting rates across 100 US cities. Drawing on data from the Community Justice Violence Prevention Index, Everytown’s gun-law rankings, the US Census Bureau, and the Gun Violence Archive, we identified configurations of state policies and local efforts associated with relatively low rates of firearm-related fatalities. Five distinct pathways characterized cities with lower shooting rates, involving combinations of regional location, restraining order prohibitors, authority to deny firearm purchases, police use-of-force data collection, microstamping for new handguns, city population, ban-the-box initiatives, city-wide reporting for hate crimes, school-based violence prevention programs, and local emergency response improvements. Findings underscore how multilevel policy environments jointly shape firearm violence outcomes and demonstrate the value of configurational methods for public health and policy research.
Ethylene oxide (EtO) is a sterilant widely used for medical devices, but its use is controversial due to its carcinogenicity. In some countries, EtO is also used to fumigate food to eliminate foodborne pathogens, though this practice is banned in others. National regulations on EtO use in food vary widely; exporting countries prioritize trade facilitation and prevention of foodborne illness, while importing countries emphasize maintaining food safety and promoting domestic public health. These divergent public health priorities present challenges to establishing universal maximum residue limits (MRLs) for EtO and 2-chloroethanol (2-CE) and have resulted in the rejection of food items treated with EtO by some importing national authorities. In response, exporters have advocated for internationally harmonized tolerance levels for EtO and its derivatives to facilitate trade. This paper reviews the use of EtO in food products and the potential health effects, describes conflicting perspectives among global stakeholders, and explores the need for harmonized international standards.
Zinc is a serum trace element essential for human health involved in a conundrum of cellular processes. However, high serum zinc concentrations are associated with inflammation and dyslipidemia. We conducted a cross-sectional analysis of the 2017–2020 NHANES data (8092 adults) to investigate the relationship between dietary zinc intakes, highly sensitive C-reactive protein (hs-CRP), and serum lipids concentrations. Multivariate logistic regression analysis was conducted using four models to evaluate the association between dietary zinc intake quartiles, hs-CRP, and lipid profile components. Elevated zinc intakes were connected to reduced likelihoods of elevated hs-CRP (OR 0.69; 95
This study examines the continuity of trust across federal health equity-focused policy documents in the United States from January 2021 to February 2024 and identifies areas for future development. Guided by an institutional trust framework emphasizing competence (responsiveness, reliability) and values (integrity, openness, fairness), we conducted thematic analysis of 133 pages across six federal documents: three executive orders, one memorandum, the Department of Health and Human Services (HHS) Strategic Plan (2022–2026), and the HHS Equity Action Plan (2023). Findings show some progress embedding trust, especially in the HHS Strategic Plan and Equity Action Plan. However, limited operational detail complicates implementation. Transparency and community engagement are highlighted in several documents, yet areas like monitoring trust and addressing misinformation remain underdeveloped. While HHS made notable strides, gaps persist. Strengthening trust in public health institutions requires a more unified, cross-agency strategy that centers responsiveness, equity, and sustainability in a rapidly shifting public health environment.
India bears one of the highest burdens of vector-borne diseases (VBDs) globally, underscoring the urgency of effective control and elimination measures. While multiple factors contribute to the VBD prevalence in India, interstate migration poses a growing challenge to its control, particularly for diseases targeted for elimination. A large influx of migrants from endemic regions continuously moves into urban centres, heightening the risk of transmission into areas that were previously under control. Although VBD elimination programmes operate at the national level, states implement them in a decentralised manner based on their resources and manpower capacity, which creates fragmented execution and coordination gaps. This article highlights the urgent need to strengthen cross-state collaborations and design targeted interventions that address migration-driven VBD risks. The article calls on state health departments, labour ministries, and central agencies to coordinate efforts, enhance surveillance, improve data sharing, and engage in joint planning to drive sustained progress towards India’s VBD elimination goals by proposing a four-pillar Interstate VBD Coordination Framework.
