Prevalence and multi-level factors associated with acute malnutrition among children aged 6–59 months from war affected communities of Tigray, Northern Ethiopia, 2021: a cross-sectional study

**Background:** Armed conflicts disproportionately affect children, with about 60% of chronically food-insecure people globally living in conflict-affected countries. In Tigray, GAM among children aged 6–59 months increased from 10% in 2019 (pre-war) to 28% in 2021 after eight months of war, and SAM increased from 1% to 6%. Despite this, context-specific factors contributing to acute malnutrition in conflict-affected Tigray had not been empirically identified.

**Methods:** A community-based cross-sectional study was conducted from July 15 to August 15, 2021, across six zones (excluding the Western zone for security reasons) and 52 randomly selected districts of Tigray. A two-stage random sampling method selected 20 households per Tabia (smallest administrative unit), with four Tabias per district. The initial sample was 4,368, but after excluding children under 6 months (n=444), those without MUAC measurements (n=308), and outliers (n=2), the final sample was 3,614 children aged 6–59 months. Data were collected via interviewer-administered structured questionnaires translated into the local language (Tigrigna). MUAC measurements were taken from the upper left arm. Household food insecurity was measured using the Household Food Insecurity Access Scale (HFIAS). Multivariable multilevel logistic regression analysis was used, with four models fitted: intercept-only, individual-only, community-only, and combined. Adjusted odds ratios (AOR) with 95% CI were estimated, and statistical significance was set at p < 0.05.

**Key Results:** The prevalence of severe acute malnutrition (SAM, MUAC < 11.5 cm) was 5.1%, moderate acute malnutrition (MAM, MUAC 11.5–12.4 cm) was 21.8%, and global acute malnutrition (GAM, MUAC < 12.5 cm) was 26.9%. Zonal variation was substantial: Mekelle zone had the lowest GAM prevalence (13.3%) while Southeastern zone had the highest (36.7%). In the final combined multilevel model (Model 4, lowest AIC/BIC), individual-level factors significantly associated with acute malnutrition included: older child age (24–59 months vs. 6–8 months: AOR = 0.13, 95% CI: 0.10–0.18), female child sex (AOR = 1.24, 95% CI: 1.05–1.48), lack of vitamin A supplementation (AOR = 1.30, 95% CI: 1.05–1.65), and history of diarrhea in the last nine months (AOR = 1.22, 95% CI: 1.02–1.53). Community-level factors significantly associated included: unimproved drinking water source (AOR = 1.31, 95% CI: 1.08–1.58), unimproved toilet facility (AOR = 1.24, 95% CI: 1.01–1.52), mild food insecurity (AOR = 2.36, 95% CI: 1.42–3.91), and severe food insecurity (AOR = 1.55, 95% CI: 1.16–2.07). The intra-class correlation (ICC) in the combined model was 0.03, indicating 3% of variance was attributable to clustering. Notably, 81.1% of children did not receive vitamin A supplementation, 99.1% did not receive measles vaccine, and 98.7% did not receive deworming during the first nine months of conflict. Additionally, 59% of households were severely food insecure, and 85.3% of respondents were not visited by Health Extension Workers during the war period.

**Clinical Implications:** The GAM prevalence of 26.9% far exceeds the WHO emergency threshold of 15%, representing a severe public health crisis. Compared to pre-war levels (GAM 8.9%, SAM 2.9%), this represents a relative increase of 66.9% and 43.1%, respectively, corresponding to IPC Phase 5 (famine). The study highlights that conflict disrupts essential health services (vaccination, vitamin A supplementation, deworming), WASH infrastructure, and food systems, creating a synergistic effect on child malnutrition. Younger children (6–8 months) are particularly vulnerable, likely due to delayed introduction of complementary foods and incomplete vaccination. The strong association between food insecurity and malnutrition underscores the need for immediate food assistance. The authors recommend regular nutrition screening, appropriate referral of malnourished children, and large-scale humanitarian assistance including food, nutrition supplies, WASH supplies, and healthcare. However, they note these interventions are extremely difficult to achieve under ongoing armed conflict, and call for immediate international intervention.