While socioeconomic gradients in regional health inequalities are firmly established, the synergistic interactions between socioeconomic deprivation and climate vulnerability within convenient proximity and neighbourhood locations with health disparities remain poorly explored and thus require deep understanding within a regional context. Furthermore, disregarding the importance of spatial spillover effects and nonlinear effects of covariates on childhood stunting are inevitable in dealing with an enduring issue of regional health inequalities. The present study aims to investigate the spatial inequalities in childhood stunting at the district level in Pakistan and validate the importance of spatial lag in predicting childhood stunting. Furthermore, it examines the presence of any nonlinear relationships among the selected independent features with childhood stunting. The study utilized data related to socioeconomic features from MICS 2017–2018 and climatic data from Integrated Contextual Analysis. A multi-model approach was employed to address the research questions, which included Ordinary Least Squares Regression (OLS), various Spatial Models, Machine Learning Algorithms and Explainable Artificial Intelligence methods. Firstly, OLS was used to analyse and test the linear relationships among selected variables. Secondly, Spatial Durbin Error Model (SDEM) was used to detect and capture the impact of spatial spillover on childhood stunting. Third, XGBoost and Random Forest machine learning algorithms were employed to examine and validate the importance of the spatial lag component. Finally, EXAI methods such as SHapley were utilized to identify potential nonlinear relationships. The study found a clear pattern of spatial clustering and geographical disparities in childhood stunting, with multidimensional poverty, high climate vulnerability and early marriage worsening childhood stunting. In contrast, low climate vulnerability, high exposure to mass media and high women’s literacy were found to reduce childhood stunting. The use of machine learning algorithms, specifically XGBoost and Random Forest, highlighted the significant role played by the average value in the neighbourhood in predicting childhood stunting in nearby districts, confirming that the spatial spillover effect is not bounded by geographical boundaries. Furthermore, EXAI methods such as partial dependency plot reveal the existence of a nonlinear relationship between multidimensional poverty and childhood stunting. The study’s findings provide valuable insights into the spatial distribution of childhood stunting in Pakistan, emphasizing the importance of considering spatial effects in predicting childhood stunting. Individual and household-level factors such as exposure to mass media and women’s literacy have shown positive implications for childhood stunting. It further provides a justification for the usage of EXAI methods to draw better insights and propose customised intervention policies accordingly.

This study presents the determinants of childhood stunting as the consequence of child malnutrition. We checked two groups of factors—the socio-economic situation and climate vulnerability—using disaggregated sub-regional data in the spatial context. Data related to the percentage of stunted children in Pakistan for 2017 were retrieved from MICS 2017-18 along with other features. We used three quantitative models: ordinary least squares regression (OLS) to examine the linear relationships among the selected features, spatial regression (SDEM) to identify and capture the spatial spillover effect, and the Extreme Gradient Boosting machine learning algorithm (XGBoost) to analyse the importance of spatial lag and generate predictions. The results showed a high degree of spatial clustering in childhood stunting at the sub-regional level. We found that a 1 percentage point (p.p.) increase in multi-dimensional poverty may translate into a 0.18 p.p. increase in childhood stunting. Furthermore, high climate vulnerability and common marriages before age 15 each exacerbated childhood stunting by another 1 p.p. On the contrary, high female literacy and their high exposure to mass media, together with low climate vulnerability, may reduce childhood stunting. Model diagnostics showed that the SDEM outperformed the OLS model, as AIC_OLS = 766 > AIC_SDEM = 760. Furthermore, XGBoost generated the most accurate predictions in comparison to OLS and SDEM, having the lowest root-mean-square error (RMSE).

While the relationship between socioeconomic status and Early Childhood Development (ECD) is well-documented, less is known about how developmental outcomes and child malnutrition cluster and interact across geographically proximate areas. This study applies spatial analysis to examine regional disparities in ECD in Pakistan and to assess the extent of spatial dependency in these outcomes. Using cross-sectional data from multiple indicator cluster survey (120,151 children across 144 districts) covering 2017- 2018, Moran’s I statistics revealed significant positive spatial autocorrelation, consistent with Tobler’s First Law of Geography. Districts with high (or low) ECD outcomes tended to be surrounded by similar districts. A distinct core periphery pattern emerged, with Punjab and Gilgit-Baltistan forming high-high clusters and Sindh, Khyber Pakhtunkhwa and Balochistan forming low-low clus- ters. Ordinary Least Squares (OLS) and Spatial Error Models (SEM) confirmed that stunting, underweight and overweight negative- ly affect ECD, while female literacy, access to mass media and child engagement in playing activities influence development posi- tively. Wasting showed no significant relationship. Results reveal that unobserved regional factors contribute to child development across districts, indicating that developmental deficits often cluster geographically. These findings extend spatial dependency theory to the ECD context in South Asia, underscoring the need for geographically coordinated interventions that address both local deter- minants and regionally shared underlying influences on child development.

Child malnutrition remains a critical global health challenge, yet most existing studies rely on static risk estimates and overlook the spatial–temporal nature of environmental exposures and localized socioeconomic disparities. To address this gap, we integrated Earth observation-derived environmental indicators, geolocated conflict events, socioeconomic variables, and child health outcomes, and applied a Fixed Effects Two-Stage Least Squares Spatial Durbin Error Model (FE-2SLS-SDEM). We found distinct hotspots of joint vulnerability, where areas experiencing both high conflict intensity and recurrent droughts show significantly higher rates of childhood stunting. High conflict intensity, drought severity, diarrheal prevalence, and inadequate sanitation significantly increase stunting, while maternal and paternal education, improved sanitation, economic development (proxied by nighttime light intensity), and agricultural productivity reduce it. Among these determinants, female education demonstrated the most pronounced inverse relationship with childhood stunting. Additionally, exposure to both drought severity and high conflict intensity independently and in combination worsens childhood stunting not only within affected regions but also in nearby localities. Our results underscore the urgency of geographically targeted, multisectoral, and action-oriented policies aimed at strengthening community and health system capacities to mitigate the converging risks of climate change and conflict on child malnutrition.