Predictors of nutritional recovery in children with severe acute malnutrition: a survival analysis from outpatient therapeutic care in post conflict Tigray, Ethiopia

Severe acute malnutrition (SAM) remains a leading cause of morbidity and mortality among children in low-income and conflict-affected settings. In northern Ethiopia, the recent armed conflict has severely disrupted food security, healthcare delivery, and humanitarian assistance, increasing children’s vulnerability to poor nutritional outcomes. Outpatient Therapeutic Care (OTC), a core component of the community-based management of acute malnutrition, aims to improve timely access to treatment and promote nutritional recovery at the community level. However, evidence on the determinants of nutritional recovery among children receiving OTC services in post-war contexts such as Tigray remains limited. We conducted a three-year institution-based retrospective cohort study in post-war Tigray, Ethiopia, from January 2022 to December 2025. We randomly selected 14 of 140 functional health posts and included 363 medical records. Trained health professionals retrospectively extracted data using a structured checklist. We used Kaplan–Meier curves and the log-rank test to compare time to recovery, and Cox proportional hazards regression to identify associated factors. We assessed the proportional hazards assumption using log-minus-log survival plots and Schoenfeld residuals; the global test showed no evidence of violation (p=0.085). We reported results as adjusted hazard ratios (AHRs) with 95% confidence intervals (CIs), with p<0.05 considered statistically significant. A total of 342 charts of children included in this study. The proportions of recovery, defaulters, and those who did not respond to treatment were 85.1%, 6.4%, and 8.5%, respectively, with no deaths. The median time to recovery was 42 days. Children, who received vitamin A (AHR= 2.9, 95% CI, 1.6- 5.2), referred by community volunteers for treatment (AHR =1.3, 95%CI, 1.01–1.7), vaccinated (AHR= 2.0, 95%CI, 1.3- 3.1), family travel ≤ 30 min to treatment site (AHR =1.5, 95%CI 1.13 − 1.9), without diarrhea (HR=1.36, 95%CI 1.01–1.86), and without pneumonia (HR=1.8, 95%CI, 1.2–2.6), recovered by higher rate at any unit time during follow-up period than their counter group. In post-war Tigray, recovery from severe acute malnutrition was significantly associated with Vitamin A supplementation, vaccination, community volunteer referral, and the absence of diarrhoea and pneumonia. Strengthening community referral mechanisms, restoring routine immunisation, and ensuring adherence to treatment guidelines are essential to improve recovery outcomes in post-conflict settings.