Health impacts of Armed Conflict in Ethiopia: A Scoping Review of Evidence from 2018-2023

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In Ethiopia, recurrent and protracted internal conflicts have severely disrupted health systems and affected vulnerable populations. However, a comprehensive synthesis of the health impacts of armed conflict in the Ethiopian context has been lacking. Method We conducted a scoping review using the Arksey and O’Malley framework, guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Comprehensive searches were conducted in PubMed and Google Scholar, supplemented by targeted searches of organizational websites. Studies published in English up to December 2023 that assessed the impacts of armed conflict on health in Ethiopia were included. Data were charted and thematically analyzed. Results Of 230 identified, 19 studies met the inclusion criteria. The studies addressed six thematic areas. Maternal and reproductive health (n = 5), mental health (n = 5), health system disruption (n = 4), nutrition (n = 4), chronic diseases (n = 2), and malaria outbreak (n = 1). Health system disruption (51%), gender-based violence (40%), post-traumatic stress disorder (40%), depression (66.5%), anxiety (63%), chronic diseases treatment disruption (80%), and malaria outbreak; 26.5/1000 attack rate and 43% slide positive rate were key findings. Conclusion This scoping review revealed that armed conflict in Ethiopia has had a profound and interrelated impact on public health, disproportionately affecting women, children, and internally displaced populations. The findings underscore the urgent need for coordinated, multisectoral interventions that restore essential health services, strengthen mental health support, and ensure continuity of care for chronic and infectious diseases. Future research should focus on underexplored areas such as nutrition, malaria, and chronic disease management using diverse and longitudinal study designs. armed conflict health system sexual and reproductive health malnutrition chronic disease mental health malaria Ethiopia Figures Figure 1 Figure 2 Figure 3 1. Introduction Armed conflict is increasingly recognized as a major public health threat in modern society. One of the most disruptive consequences of armed conflict is forced population displacement, which exposes the affected population to devastating health outcomes [ 1 ]. Internal displacement reached a global record in 2022, with 71.1 million people living in displacement at the end of the year [ 2 ]. The impact of armed conflict on health can be direct or indirect. Death and disability due to armed conflict, either of combatants or non-combatants, have a direct impact, while the negative effect on the health system, economic system, and social system is an indirect impact of armed conflict [ 1 ]. Evidence indicated that armed conflict is the leading cause of disability- adjusted life years (DALYs) lost [ 3 ]. Moreover, conflict and humanitarian crises were among the top ten global public health challenges in 2022, next to COVID-19, human resources for health, and health financing [ 4 ]. Economically, armed conflict exerts further indirect pressure on public health by diverting resources. As of 2023, global military spending reached $ 2443 billion, accounting for 2.3% of the world’s Gross Domestic Product (GDP) [ 5 ]. Beyond immediate effects, armed conflict can impose long-term and intergenerational consequences. Prolonged displacement, poverty, and lack of access to health and education can have a cascading effect on the health of children and future generations [ 6 ]. These conditions exacerbate existing inequalities, hinder development, and create cycles of poor health outcomes that can persist long after conflict has ended [ 1 ]. Ethiopia is one of the countries severely affected and currently being affected by armed conflict. The country continues to face a chronic and escalating internal displacement [ 7 ]. In the country, the outbreak of internal displacement started in 2018 when Ethiopia recorded the third highest new displacements worldwide, with more than 3 million IDPs for the first time [ 8 ]. Then, the number of displaced persons has escalated during the Northern Ethiopian conflict, which erupted in early November 2020 and increased the number of IDPs to more than 5 million in the country [ 9 ]. As of 2023, more than 20 million crises affected people were in need of humanitarian assistance in the country [ 10 ]. According to Office of the United Nations High Commissioner for Human Rights (UNOCHA) Ethiopia situation report 2023, humanitarian partners continue to mobilize resources to increase the humanitarian response in Northern Ethiopia and elsewhere in the country, prioritizing the most urgent needs, including health needs [ 10 ]. Among the affected populations, 20.5 million people were in need of basic needs, 7.4 million were in need of nutrition, and 17.4 million were in need of health services [ 10 ]. Armed conflict in Ethiopia caused multitudes of challenges for displaced persons, the host community, and the general population in the war-affected areas of the country, including health challenges [ 10 , 11 ]. Evidence based on a complex emergency database indicated that excess mortality was observed among Ethiopian IDPs [ 12 ]. A review study on the health of conflict-induced internally displaced women in Africa, including Ethiopia, also revealed that mental health, sexual and reproductive health, and malaria were major health problems among internally displaced women [ 13 ]. Tesfaw et al., in their work, showed that degradation in the livelihood and housing conditions, socio-cultural confusion, loss of identity, family disintegration, and limited access to basic services, including health care services were identified as challenges faced by Ethiopian IDPs [ 11 ]. An unpublished thesis work by Arbouw et al. revealed that IDPs are exposed to undernutrition, lack of access to safe drinking water, and health services and shelter [ 14 ]. Recent evidence also showed that armed conflict has had a negative impact not only on the conflict-affected areas of the country but also the whole social, economic, health and developmental aspects of the country [ 10 ]. The armed conflict in northern Ethiopia damaged the health system in Tigray Regional State [ 15 ], as well as Afar and Amhara [ 16 ] Regional States of the country. As a result, community access to health care has been severely compromised, and many people, including IDPs, face death, disability, and poor health outcomes [ 17 – 19 ]. To date, there is limited evidence on the impact of armed conflict on health in Ethiopia. To our knowledge, no study has comprehensively compiled this evidence. This scoping review aims to fill this evidence gap by synthesizing existing research on the topic. Beyond addressing the existing evidence gap, the findings will inform stakeholders such as humanitarian agencies, government bodies, and health practitioners to guide targeted interventions, policy decisions, and health services planning in conflict-affected settings. Objective This scoping review aims to identify and synthesize the existing evidence on health impacts of armed conflict in Ethiopia. 2. Methodology A scoping review study design was employed to establish and map what literature is emerging. The scoping review used a framework developed by Arksey and O’Malley (2005), scoping review methodology [20]. The framework follows a five-stage approach: (1) develop research question, (2) article search, (3) article selection, (4) data extraction, and (5) data analysis [20]. The review was reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-ScR), Extension for Scoping Review Guidelines [21]. 2.1. Search strategy Although we planned to include grey literatures during our first plan, we did not get grey literatures relevant to our review. As a result, we only included the published articles for this review. Publications were searched primarily using PubMed and Google Scholar. Other sources like the Internal Displacement Monitoring Center (IDMC) and United Nations Human Rights Commission for Refugees (UNHCR) websites were also searched, particularly to find grey literature relevant to the topics of interest. However, we did not find grey literature relevant to the topics of interest in the current review. We tried to identify grey sources through targeted searches of organizational websites such as IDMC, UNCR, WHO (World Health Organization), and IOM. However, many potentially valuable documents were not indexed, lacked searchable metadata, or were inaccessible through standard databases. The populations of interest for this review are all populations affected by armed conflict in Ethiopia. We used the following search strings for PubMed search by combining with MeshTerms: ("Armed Conflicts" OR "War" OR "Conflict" OR "Civil Unrest" OR "War zone" AND ("Health" OR "Health Impact" OR "Health Services" OR "Maternal Health" OR "Mental Health" OR "Sexual and Reproductive Health" OR "Malnutrition" OR "Health System Disruption" OR "Malaria" AND ("Ethiopia" ) and ("Armed conflict" OR "war" OR "civil unrest" OR "ethnic violence") AND ("health outcomes" OR "maternal health" OR "reproductive health" OR "mental health" OR "malnutrition" OR "health system disruption" OR "malaria" OR "health services") AND "Ethiopia" for Goggle Scholar. Moreover, the broad initial search targeted armed conflict in general with the search terms that are combined with words related to health needs, health problems, and the impact of war conflict on health and Ethiopia. Reference lists of selected articles were scanned for additional sources to include in the review. 2.2. Article screening and selection The articles’ screening process was undertaken using the Preferred Reporting Items for Review and Meta-Analysis (PRISMA-ScR) flow chart for the selection of literature for this scoping review study. Initially, an independent search was conducted based on the aftermentioned search terms by two authors (TA and SA). Secondly, titles and abstracts were screened using the inclusion and exclusion criteria to identify potentially relevant articles. Then, the full texts of selected articles were reviewed to confirm that the studies met the predetermined inclusion criteria. Finally, the titles and contents of the articles were screened to assess their eligibility for inclusion in the review. The articles that need clarity were assessed, and a decision was made to include the eligible articles. When disagreements arose, they were resolved by agreement or the arbitration of the third author (DD). To be clear about the article screening and selection, look at the PRIMA flow chart in Figure 1 . As shown in Figure 1 (PRIMA Flow Chart), the total number of documents (i.e., 230 documents) was identified and retrieved via databases and other sources. Then, duplicates were removed using EndNote. The titles and the abstracts were reviewed for the remaining documents and articles that were unrelated to themes or did not provide information about the health in the context of conflict in Ethiopia were discarded. Full text assessment was done for the screened articles, and some articles were again excluded for justifiable reasons. Finally, the remaining 19 articles were included in this scoping review (Figure 1). 2.3. Inclusion and exclusion criteria Published articles with different study designs on health and conflict in the context of Ethiopia, published till the end of 2023, and published in the English language were included in this review. The population of interest in the articles is persons affected by armed conflict in Ethiopia. Articles with no relevant data on the health and conflict in the context of Ethiopia, focusing on conflict-affected persons who migrated outside of their country’s borders and published in languages other than English, were excluded from the review process. 2.4. Data extraction and charting Information about each article was first extracted and recorded on a Microsoft Excel Spreadsheet, which was prepared for this review purpose. The information recorded in the extraction sheet includes author name, year of publication, title, research questions or objectives, method, sample size, data source, study area of focus, study period, summary of findings, and summary of conclusion, recommendation, and implications ( Supplementary 1 ). The extracted information was re-charted in a Microsoft Word table for reporting purposes in the manuscript. The information included in this table were author, year of publication, purpose of the study, study setting/location or region, and summary of results [ Table 1 ]. Table 1. Summary of Studies Included in the Review Author, publication year Purpose of the study Design Region Population Summary of results Abebaw et al. [2022] Assess health impacts war in Amhara region. Cross-sectional Amhara Conflict affected populations 50% of facilities looted or damaged; 10,333 chronic patients disrupted; 7,000+ women lost maternal care; 934 SGBV cases; $27M in health system losses. Arage et al.[2023] Explore health consequences of northern conflict Qualitative Amhara General population Death, food insecurity, supply chain interruptions and forced displacement, sexual violence, health system breakdown, supply chain interruption, health care system damage, and health care provider displacement Fisseha et al.[2023] Assess war- related SGBV in Tigray Cross-sectional Tigray Women Nearly 40% of women have experienced SGBV; young women are the most affected. 89.7% of SGBV survivors received no support. Gedef et al.[2023] Assess institutional delivery in conflict zones Cross-sectional Amhara Women 48.1% gave birth in facilities; ANC follow-up and displacement influenced delivery choice. Gebeyaw et al.[2023] Assess PTSD among children Cross-sectional Amhara Children 70% experienced mental trauma; 36.45% developed PTSD. Gebrehiwet et al.[2023] Assess chronic diseases during conflict Cross-sectional Tigray Chronic diseases patients Only 21% continued care; TB, hypertension, and diabetes mellitus were most affected. Gebretsadik et al.[2023] Assess malnutrition in children Cross-sectional Tigray Children 6-59 months Severe, moderate, and global acute malnutrition are 5.1%, 21.8%, and 26.9%, respectively. Gesesew et al.[2021] Assess health system before and during the war. Analytical Tigray Health system Collapse of MCH services within 90 days; 100% of health posts are nonfunctional. Gutema et al.[2023] Impact of conflict on health infrastructure. Mixed-method Oromia Health system Over 1000 facilities and 159 vehicles damaged; acute malnutrition observed. Debash, et al.[2023] Investigate malaria outbreaks Case–control Amhara General population 13,136 confirmed cases, a 26.5 per 1000 attack rate, and a 43% positivity rate O’Connell et al.[2022] Evaluate SRH needs of IDPs Qualitative Somali IDPs Fragile security, limited access to GBV services, and provider shortages. Kemei et al.[2023] Explore insecurity among IDP children Qualitative Oromia IDP children Children faced academic, economic, physical, and mental health challenges. Makango et al.[2023] PTSD among IDPs in camps Cross-sectional Amhara IDPs 67.5% screened positive for PTSD; there was high mental distress in the camp. Mengstie et al.[2023] Undernutrition among lactating mothers Cross-sectional Amhara IDP mothers 54.8% of undernourished mothers are linked to low dietary diversity and large family size. O’Connell et al, [2021] Factors associated with SGBV Qualitative Somali IDPs SGBV is linked to culture, religion, displacement, and inequality. Teshome et al.[2023] PTSD among war survivors Cross-sectional Amhara War survivors 40% had PTSD, 65.5% depressive symptoms, and 63.1% anxiety symptoms. Titiyos et al.[2020] Assess SRHR needs of IDPs Cross-sectional Somali IDP women 50% had 5+ births; 78.3% received ANC; SRHS access was limited. Weldegiargis et al. [2023] Assess food insecurity in conflict zones Cross-sectional Tigray Households Food insecurity increased by 43.3 percentage points post-conflict. Yigzaw et al.[2023] Deliver mental health and psychological support Mixed-method Amhara War survivors Common diagnoses: PTSD, MDD, grief, and females are more affected. Abbreviations: M = Millions, SGBV = Sexual and Gender-Based Violence. ANC = Antenatal Care, PTSD = Post-Traumatic Stress Disorder, TB = Tuberculosis, MCH = Maternal and Child Health, GBV = Gender-Based Violence, SRHS = Sexual and Reproductive Health Services, MDD = Major Depressive Disorder 2.5. Data Synthesis The articles included in the review were coded and summarized based on areas of focus and were thematically analyzed based on their content. Since we used Arksey and O’Malley (2005) [20], we did not apply quality appraisal for this scoping review because the focus of this review was to identify, map, and synthesize the available evidence on health and armed conflict and to forward recommendations for further research. But the paper has benefited from the expertise of researchers. 3. Results As illustrated in the PRISMA diagram (Fig. 1 ), a total of 230 documents were initially identified through database searching (150 from PubMed and Google Scholar and 80 from other sources). After removing 50 duplicate records, 180 records remained for title and abstract screening. Of these, 110 records were screened, and 70 records were excluded based on irrelevance to the health impact of armed conflict in Ethiopia. The remaining 40 full-text articles were assessed for eligibility. Among these, 21 articles were excluded-15 focused on refugees, and 6 were excluded for other reasons, such as insufficient data on health outcomes or lack of methodological quality. Finally, 19 articles met the inclusion criteria and were included in the review. Articles were charted in Microsoft Word using a table based on the study’s characteristics of author, publication year, purpose of the study, design of the study, location/ region of the study, and summary of the results (Table 1 ). After the detailed review of each article, we grouped articles under the following themes: health system disruptions, maternal health and reproductive health, mental health, nutrition, chronic disease, and malaria. Based on the classified themes, four (n = 4) studies assessed health system disruption, five (n = 5) studies assessed maternal and reproductive health conditions, another five (n = 5) studies assessed mental health conditions, four (n = 4) studies assessed nutritional problems, two (n = 2) study assessed chronic diseases and one (n = 1) assessed malaria in the context of armed conflict (Fig. 2 ). The result shows that the most frequently studied themes were maternal and reproductive conditions and mental health, followed by health system disruption and malnutrition. The methodology used in the studies varied, and most studies (n = 14) used quantitative methodology, four (n = 4) studies used qualitative method, and one (n = 1) study used mixed method. Regarding to study location/ region, nine (n = 9) studies were conducted in Amhara region, five (n = 5) studies were conducted in Tigray region, three (n = 3) studies were conducted in Somali region, and two (n = 2) studies were conducted in Oromia region (Fig. 3 ). The result shows that highest number of studies were conducted in Amhara Region followed by Tigray Region indicating the conflict-related health impacts are mostly documented in the northern part of Ethiopia. The cumulative result indicated that the highest number of studies was conducted in Amhara Region and Tigray, Region indicating that the health consequences of armed conflict are mostly documented in northern Ethiopia. 3.1. Health System Disruption One of the themes discussed in this review is the impact of armed conflict on the health system and delivery of health care. Four studies investigated the impact of armed conflict on the public health system and services in this review. A study conducted in armed conflict-affected zones of the Amhara region revealed that more than half(51%) of health facilities and their infrastructure have been destroyed due to the northern Ethiopian war conflict that began in November 2020 in the Tigray region and expanded into Amhara and Afar regions in 2021[ 16 ]. The study reported that 10,333 patients with chronic disease follow-up were interrupted; 29632 civilians died due to conflict, more than 70 thousands pregnant, lactating mothers had interrupted their follow up-care, 1035 unwanted pregnancies, and 934 cases of sexual and gender-based violence (SGBV) occurred [ 16 ]. A qualitative study in the same region found that conflict-related deaths, famine, supply chain disruptions, displacement, health system collapse, and lack of transportation and medications severely hampered access to and delivery of health care services [ 22 ]. The study also reported the long-term impact of the armed conflict, including destruction of health facilities, disrupted immunization services, post-traumatic stress disorders, lifelong disabilities, and significant economic loss. The armed conflict in the Amhara region resulted in a loss of US $ 27,015,585.98 to the health care system, creating nearly the same amount of money for its recovery and rehabilitation [ 16 ]. Another study in the Tigray region revealed that health care systems were destroyed and services were disrupted due to the armed conflict [ 15 ]. At six months of the armed conflict, only 27.5% of hospitals, 17.5% of health centers, and 11% of ambulances were functional, and all health posts (712) in the region were not functional. The study reported that prior to conflict, antenatal care, skilled birth attendance, postnatal care, and child vaccination coverage were 94%, 73%, 63% and 73%, respectively. However, delivery of these services was halted in the first 90 days of the armed conflict. Widespread destruction of livelihoods occurred along with physical damage to health facilities and functional breakdown of the health care system, including disrupted services, workforce shortages, and limited access to essential supplies. The collapse of the health care system was a common problem during the armed conflict [ 15 ]. Similarly, a study conducted in the Oromia region found that health care facilities and vehicles, including ambulances, were damaged during the armed conflict. As a result, essential services such as inpatient and outpatient were severely disrupted [ 22 ]. The study reported that 1,072 public health facilities were destroyed or looted during the armed conflict. Moreover, 159 vehicles, including ambulances, were damaged [ 23 ]. 3.2. Maternal and Reproductive Health Maternal and reproductive health emerged as one of the key themes in this review, with five studies examining the issues in the context of armed conflict in Ethiopia. A study assessing institutional delivery service utilization in the context of armed conflict in Amhara Region reported that only 48.1% of mothers gave birth at health facilities, and displacement was negatively associated with institutional delivery use [ 24 ]. Another study conducted in Tigray Region revealed that nearly 40% of women experienced at least one type of gender-based violence (GBV). Sexual, physical, and psychological violence, including rape, was reported among women of reproductive age. Trauma, sexually transmitted infections including Human Immuno-Deficiency Virus (HIV), and unwanted pregnancy were the most common reported poor SRH outcomes [ 3 ]. Another study conducted in the Somali region among IDPs showed that nearly 90% of respondents reported ever hearing about SRH and nearly 70% reported receiving family planning information [ 25 ]. Among participants, 64% did not know where SRH services were available, and nearly 60% approved the use of family planning [ 25 ]. A qualitative study among IDPs in the same region revealed that GBV was a common SRH problem, and misconceptions, stigma and discrimination, the need for spousal permission, religious beliefs, and fear of side effects were some of the persistent barriers to using SRH services [ 26 ]. The study uncovered that knowledge on GBV among the communities surveyed was limited, and several types of GBV, including early and forced child marriage, domestic violence, and female genital mutilation and cutting, were common cultural practices. The study also indicated that many GBV cases were unreported due to fear of stigma and bad consequences, lack of trust in the justice system, and the preference for family and community-level arbitration [ 26 ]. Another similar study conducted among IDPs also revealed that knowledge of sexual and gender-based violence (SGBV) was limited among the surveyed communities [ 27 ]. Like that of the above study [ 26 ] SGBVs, are common cultural practices among the surveyed communities [ 27 ]. In this study, it was reported that socioeconomic inequalities, discriminatory cultural and religious beliefs, harmful traditional practices, and conflict and displacement were risk factors for SGBV and the patriarchal norm also perpetuates certain forms of violence against women, including socializing domestic, economic, and emotional violence as acceptable, while limiting the opportunities of women for self-empowerment and collective action [ 27 ]. Abebaw N et.al in their descriptive study added that 1035 and 934 women and girls experienced unwanted pregnancies and SGBVs respectively as a result of the armed conflict in Amhara region [ 16 ]. 3.3. Mental Health Mental health problems are a major health challenge among conflict-affected populations. Prior researches report high levels of post-traumatic stress disorder (PTSD) among conflict affected populations [ 28 ]. In this review, we identified five studies addressing mental health problems among conflict affected populations in Ethiopia. A study conducted among conflict-affected children and adolescents in Amhara Region revealed that nearly 70% of children had experienced trauma and over one-third developed PTSD [ 18 ]. Another study in the same region also publicized that 45% of participants reported various mental health problems such as PTSD, major depressive disorder (MDD), adjustment disorder, protracted bereavement disorder, and insomnia. PTSD was the most common reported diagnosis (38 cases), followed by MDD (4 cases), prolonged grief (3 cases), and neurological disorder (2 cases). Females were more vulnerable to PTSD compared to males [ 2 ]. Moreover, a study conducted among war survivors in the region showed that nearly 40% of participants developed PTSD, 66.5% experienced depressive symptoms, and 63.1% had experienced anxiety symptoms. Witnessing the death or serious injury of close family members, high perceived stress, symptoms of depression and anxiety, chronic illness, physical assault, exposure to combatant situations, and being female were risk factors associated with PTSD [ 29 ]. Furthermore, a qualitative study exploring the lived experience of IDP children in Ethiopia highlighted the psychological consequences of insecurity and lack of protection in IDP camps. The study found that children faced numerous challenges related to poor socio-economic conditions, which contributed to physical and emotional distress and increased vulnerability to mental health problems. Socio-economic and contextual factors were found to interact and influence the overall well-being of children in IDP settings [ 30 ]. Lastly, a study conducted among IDPs in Debre Berhan reported that two-thirds of the conflict-affected participants screened positive for PTSD. Witnessing property destruction, experiencing trauma, repeated displacement, psychological distress, and unemployment were contributing factors [ 31 ]. 3.4. Nutrition Nutrition is one of the key thematic areas explored in this review. Four studies examined the impact of armed conflict on nutritional outcomes in Ethiopia. A study conducted in Sekota IDP camps, located in Wagehmra Zone of Amhara Region, among lactating mothers found that 54.8% of IDP mothers were undernourished [ 32 ]. Having a large family size, short birth interval, low maternal daily meal frequency, and low dietary diversity score were more contributing factors for undernutrition [ 32 ]. Similarly, another study assessing the broader health impact of armed conflict revealed that around 17,764 pregnant or lactating women had been screened for malnutrition in a conflict-affected setting [ 16 ]. Moreover, a study conducted among internally displaced children in Tigray Region demonstrated that the prevalence of severe, moderate, and global acute malnutrition was very high (5.1%,21.8%, and 26.9%, respectively) [ 33 ]. Child age, child sex, vitamin-A supplementation, and history of diarrhea were found to be individual-level predictors of malnutrition, while poor drinking water source, poor toilet facility, and severe food insecurity were predictors of malnutrition at the community level [ 33 ]. Besides, a study done to assess the status of household food insecurity in the conflict-affected population [ 34 ] highlighted that 75% of households experienced food insecurity. Overall, the results suggested that food insecurity and undernutrition are highly prevalent among the armed conflict-affected population in Ethiopia. 3.5. Chronic Diseases Chronic disease is another key thematic area explored in this review. Two studies examined the impact of armed conflict on chronic disease management in Ethiopia. A study conducted in Tigray Region reported that among 4645 patients who were receiving treatment before the conflict, only 21% continued their care during the conflict period [ 19 ]. The highest rate of treatment interruption was observed among type 1 diabetes, with 80% discontinuing their treatment and care [ 19 ]. Another study in Amara Region also indicated that more than 10,000 patients with chronic disease have interrupted their treatment and follow-up [ 16 ]. Cumulatively, the evidence suggests a substantial disruption in chronic disease management among conflict-affected populations in Ethiopia. It also underscored that the severe breakdown in the continuity of care for chronic diseases during armed conflict putts affected individuals at heightened risk of complications and mortality. 3.6. Malaria The least discussed theme in this review in the context of conflict is malaria. Surprisingly, only one study investigated malaria outbreaks in the context of armed-conflict. The findings demonstrated that a total of 13,136 confirmed cases of malaria were detected with an overall attack rate of 26.5 per 1000, and slide positivity rate was 43.0% [ 24 ]. This study also revealed that under-five children were severely affected by the malaria outbreak, and the presence of mosquito breeding sites, staying outside overnight, and lack of awareness on malaria transmission and prevention were the main contributors to the malaria outbreak in the study area. 4. Discussion This scoping review explored a wide range of impacts of armed conflict on health in Ethiopia. It has synthesized the findings across six thematic areas: health care system, maternal and reproductive health, mental health, nutrition, chronic diseases, and malaria. The results show that the effects of conflict are multifaceted and interlinked on vulnerable population, women, children, and the internally displaced population, bearing the greatest burden. 4.1 Health System Disruption: A Foundational Challenge The reviewed evidence highlights the devastating effect of armed conflict on Ethiopia’s health care system. Over half of health facilities were reported to be destroyed, result in an estimated economic loss of $ 27 million and widespread service interruptions, including for chronic diseases and maternal health care [ 16 ]. The findings also highlighted that war-related fatalities, famine, disruptions of supply chains, and forced displacement; violence and rape; health workers displacement and dearth of medication, together with insecurity and lack of transportation occurred and significantly affected the provision and utilization of health services were common problems occurred as a consequences of armed conflict [ 16 , 22 ]. Furthermore, findings under this theme demonstrated that previously well-functioning health care delivery systems in Tigray Region and Oromia Region were partially or completely damaged, and health service delivery was negatively impacted. Previous evidence from other similar settings reinforced the findings [ 35 ]. The evidence from the WHO report on social determinants of health in conflict-affected countries revealed that health systems in conflict situations are usually immediately disrupted at the start of the conflict [ 35 ]. For example, evidence from a recent armed conflict in Sudan revealed that the country’s health system collapsed immediately after the occurrence of the armed conflict. Attacks on the health care system and health care workers, closure of hospitals, and occupation of health facilities by armed groups have suspended critical services such as immunization, nutrition, and emergency care [ 36 , 37 ]. The collapse of the health system underpins disruptions across all health domains. It compromises maternal and reproductive health services, limits access to mental health support, exacerbates malnutrition and food insecurity, and interrupts chronic disease management and malaria control, thereby having a cascading effect that severely undermines overall population health. 4.2. Maternal and Reproductive Health: Disproportionate Impact Maternal health and SRH services have been significantly affected by armed conflict. A study conducted in Amhara Region revealed that less than half of mothers delivered in a health facility, and displacement was negatively associated with the use of institutional delivery services [ 24 ]. Evidence from other similar settings revealed that maternal and child health services are negatively affected during armed conflict [ 38 , 39 ]. For example, A review study done on internally displaced women in Africa revealed that internally displaced women faced a multitude of maternal and reproductive health problems [ 13 ]. Also, a study in northeastern Nigeria revealed that lower reproductive, maternal, neonatal, and child health(RMNCH) status [ 40 ]. A recent Lancet series on the health of women and children in the context of conflict indicated that women and children shoulder a significant burden of morbidity and mortality at the time of armed conflict [ 38 ]. Reproductive-age women living close to high-intensity conflicts are three times more likely to die than their counterparts [ 38 ]. The findings are reinforced by the evidence from the United Nations Population Fund Agency (UNFPA) report [ 41 ]. The COVID-19 pandemic and ongoing conflicts have severely weakened the healthcare system, limiting access to maternal and SRH services [ 41 ]. Maternal and reproductive health outcomes are closely connected to a broader health system, mental health, and nutritional status. Conflict-related service disruptions and displacement increase women’s vulnerability to poor outcomes, which is further exacerbated by exposure to sexual and gender-based violence and the lack of adequate psychological support. 4.3. Sexual and Gender-Based Violence. A Weapon of War SGBV is another topic discussed under this theme. SGBV has been discussed in studies conducted in Tigray Region [ 3 ], Somali Region [ 25 – 27 ], and Amhara Region [ 16 ]. Historically, SGBV is documented as a weapon and consequence of war used strategically by armed groups. Women and girls experience brutal SGBV in different armed conflict-affected countries as a weapon of war [ 42 ]. Furthermore, a study conducted on IDPs in the Somali Region of Ethiopia [ 26 ] has reported that women and girls experienced several types of GBV, including early and forced marriage, domestic violence, female genital mutilation, and cutting. The findings are supported by a review article on ‘reproductive health in conflict’ which revealed that SGBV was a common sexual and reproductive problem faced by the women and girls in conflict situations [ 43 ], Ethiopia, Bangladesh, Lebanon, Jordan, Rwanda, the Gaza Strip, and other conflict affected countries [ 44 ]. SGBV is interrelated with other themes discussed in this review. It causes both indirect physical and psychological harm and is closely related to mental health disorders and maternal health outcomes. It also places additional strain on the already weakened health system, highlighting the need for integrated services that address both medical and psychological needs. 4.4. Mental Health. An Overlooked Emergency Mental health problems were found to be major problems across studies, particularly among children and women [ 28 , 45 ]. A study in the Amhara Region revealed that a significant proportion of children had experienced trauma [ 18 ]. Similar findings were reported from Colombia, which has been affected by protracted conflict [ 46 ]. Evidence from other conflict-affected settings showed that mental health problem is a common health problem among the conflict-affected population, including children [ 46 – 49 ]. Children are among the vulnerable groups of the population during armed conflict [ 38 ]. Evidence revealed that 1in 10 children is affected by armed conflict worldwide [ 50 ]. Likewise, a study conducted in the same region revealed that a significant proportion of participants reported a range of mental health problems, including PTSD, major depressive disorder (MDD) [ 2 ]. A qualitative study added that IDP children experienced mental health problems due to a lack of protection in IDP camps, implying that children are vulnerable to physical and emotional health problems, which provoke mental health disorders [ 30 ]. The findings are supported by evidence from similar settings in Colombia, northern Uganda [ 51 ]. Moreover, a study included in this review showed that nearly 40 percent of participants experienced PTSD [ 29 ]. A review study has documented that the prevalence of mental disorder symptoms has ranged from 32–52% [ 48 ]. Lastly, a study conducted among camped IDPs at Debre Berhan town revealed that more than two-thirds of the affected population had reported PTSD. The study also reported that the prevalence of PTSD was high among internally displaced people [ 31 ]. Evidence presented in the aftermentioned studies is supported by studies from other similar settings. For example, a review study indicated that war-affected populations, including IDPs, are prone to various mental health problems, including PTSD [ 28 ]. Additional studies revealed that displaced women were vulnerable to an array of mental health disorders [ 13 , 45 ]. Mental health problems are interrelated with other problems discussed in this review. They are amplified by trauma from SGBV, displacement, food insecurity, and the burden of chronic diseases. The inadequate health infrastructure further limits access to care, creating a complex web of interrelated vulnerabilities affecting recovery and resilience. 4.5. Nutrition: Conflict-Driven Malnutrition and Hunger This review revealed that armed conflict in Ethiopia disrupts food production; increases food insecurity, leading to malnutrition and famine [ 52 ]. It has been the main driver of food insecurity, hunger, and malnutrition in the conflict-affected areas of the country [ 38 ]. As of 2023, more than 20 million people were in need of emergency food assistance in Ethiopia, which is directly linked to armed-conflict [ 53 ]. The situation is aggravated by high inflation of food prices. As of October 2021, the inflation has reached 34.2% [ 52 ]. In this review, three studies investigated the issue of nutrition. A study done in Amhara Region among displaced lactating mothers has reported a significant proportion of breastfeeding mothers experienced under-nutrition [ 32 ]. A 2023 OCHA prediction shows that there are 954,487 pregnant and lactating mothers with acute malnutrition and need urgent supplementary nutrition assistance [ 53 ]. Evidence from previous studies showed that neonatal morbidity and mortality are higher in war conflict-affected regions due to in part to maternal malnutrition, which is caused by armed-conflict [ 1 ]. Another study, which was conducted in Tigray, Ethiopia, among conflict-affected children, has investigated the nutritional status of children in the context of armed conflict. The findings of this study revealed a high prevalence of malnutrition with severe, moderate, and global acute malnutrition all reported at concerning levels [ 33 ]. The findings are supported by the evidence from previous studies [ 54 , 55 ]. Malnutrition has a cross-thematic relationship with other themes discussed in this paper. It exacerbates susceptibility to infections such as malaria and worsens maternal and child health outcomes. It also interacts bidirectionally with mental health and chronic diseases, highlighting a critical need for coordinated nutrition and health interventions in conflict-affected settings. 4.6. Chronic Disease: A Hidden Crisis Despite being less studied, chronic diseases have been profoundly affected by armed conflict. Two studies investigated the issue of chronic diseases in the context of armed conflict. A study in Tigray Region revealed that chronic disease care and follow-up have been severely interrupted [ 19 ]. The study revealed that before the armed conflict, 4645 patients were following their treatment for chronic diseases. However, only one-fifth of patients continued their treatment during the armed conflict period. The most dramatic interruption was reported among type 1 diabetic patients [ 19 ]. Evidence from other conflict-affected settings showed similar findings. For example, a study from Syria revealed that access to and utilization of health care services, including outpatient consultation, were limited in conflict-affected areas of the country [ 39 ]. Another study conducted in Amhara Region also revealed that more than two-thirds of patients faced treatment interruption [ 56 ]. Chronic disease treatment interruption is thematically related to other problems discussed in this review paper. It is linked to poor health service availability and the perceived stress of participants. It also increases the risk of complications that are worsened by coexisting malnutrition, psychological stress, and reduced access to comprehensive health services, illustrating the compounded health challenges faced by conflict-affected populations. 4.7. Malaria: Underreported yet Ongoing Threat Malaria is one of the themes discussed in this review. Notably, only one study investigated the malaria outbreak. The study indicated that a total of 13,136 confirmed cases, an overall attack rate of 26.5 per 1000, and a 43.0% slide positivity rate [ 24 ]. It also disclosed that under five children were severely attacked, and the presence of mosquito breeding sites, staying outdoors overnight, and lack of awareness on malaria transmission and prevention were the main contributors of the malaria outbreak [ 24 ]. Ethiopia is one of 41 countries experiencing rising malaria rates exacerbated by armed conflict and humanitarian crises [ 57 ]. Evidence indicated that armed conflict disrupts health care services, hampering surveillance and control of vector-born disease including, malaria [ 58 ]. In contrast to our finding, evidence from the conflict-affected settings showed an inverse relationship between the frequency of malaria cases and armed conflict [ 58 , 59 ]. For instance, a study from Sri Lanka revealed that the country has eliminated malaria despite being affected by a protracted armed conflict [ 60 ]. Malaria outbreak during armed conflict is related to other problems. It is influenced by disrupted health services, population displacement, and malnutrition, which together heighten vulnerability to infection and complicate disease surveillance and control efforts. 5. Integrated thematic insights The findings of this review demonstrated that the health impacts of armed conflict in Ethiopia are not isolated but deeply interconnected. The collapse of the health system is a primary disruptor, causing widespread interruptions of essential services [ 15 , 16 , 22 , 23 ]. Disrupted maternal and reproductive health care raises risks during pregnancy and childbirth and limits access to family planning and safe delivery [ 3 , 16 , 24 , 25 ]. Survivors of SGBV lack vital medical, psychological, and legal support, worsening their trauma [ 3 , 26 , 27 ]. Mental health problems worsen due to direct conflict exposure and indirect effects like displacement and loss of care [ 2 , 18 , 29 – 31 ]. Disrupted nutrition programs increase undernutrition, especially among children and lactating mothers, which further harms mental and physical health [ 32 – 34 ]. Malnutrition weakens immunity, increasing vulnerability to infections like malaria [ 24 ], while disease surveillance breakdowns hinder timely response [ 24 , 58 ]. Chronic diseases, requiring consistent care, are neglected during conflict, leading to treatment gaps and complications [ 16 , 19 , 56 ]. These chronic conditions interact with malnutrition and stress, creating a vicious cycle [ 19 , 32 , 33 ]. SGBV, mental illness, malnutrition, and chronic diseases worsen without functional health systems and are intensified by conflicts and socioeconomic impacts [ 3 , 16 , 26 , 27 , 34 ]. These findings show that the conflict-related health effects in Ethiopia are interlinked and reinforcing. Addressing them separately limits effectiveness [ 13 , 38 , 41 ]. A coordinated, integrated multi-sectoral approach is essential to mitigate these complex health challenges. While the scoping review did not appraise study quality, it is important to note that many included studies used a cross-sectional design, limiting causal inference. Additionally, several studies relied on self-reported data which may be subject to recall and reporting biases, especially in sensitive areas such as SGBV and mental health. These limitations should be considered when interpreting the findings [ 3 , 27 , 29 , 30 ]. 6. Conclusion This scoping review revealed that armed conflict imposed widespread and interconnected challenges in Ethiopia. Health system disruption was the most documented theme, showing many facilities damaged, services interrupted, and health care workers displaced. Maternal and reproductive health services were more significantly affected, showing reduced institutional deliveries and a high rate of SGBV. Mental health issues like PTSD, depression, and anxiety were common among the conflict-affected populations, especially women and children. Although less frequently studied, nutritional problems such as undernutrition and food insecurity were prevalent, especially among displaced mothers and children. Chronic disease management was also severely impacted, with treatment interruption increasing the risk of complications. Malaria outbreaks were reported in conflict-affected areas, exacerbated by poor living conditions and reduced access to preventive services. To address these challenges, a coordinated and multi-sectoral response is essential. Policymakers should prioritize restoring health infrastructures, integrating mental health into the primary health care, and implementing service-oriented SGBV interventions. Humanitarian organizations must deploy mobile health units, support community-based psychosocial services, and ensure continuity of care for chronic disease. Local authorities should facilitate access to essential SRH services, strengthen community-led SGBV response systems, and scale up targeted nutrition programs for high-risk populations. Future researchers should focus on underexplored areas such as nutrition, chronic disease, and malaria within conflict settings, using diverse study designs including longitudinal and mixed-method approaches to generate actionable evidence that can guide effective policy and humanitarian response. 7. Limitation This paper has some limitations. First, the exclusion of articles with languages other than English leads to language bias. Second, many of included studies used cross-sectional designs, limiting causal inference. Third, several studies relied on self-reported data, which may lead to recall and reporting biases, especially in sensitive areas such as SGBV and mental health. Lastly, despite a comprehensive search strategy based on predefined inclusion and exclusion criteria, there remains the possibility that some relevant studies were inadvertently missed. This is an inherent limitation in scoping reviews, particularly in conflict settings where research may be unpublished, inaccessible, or inconsistently indexed in major databases. These limitations should be considered when interpreting the findings. Abbreviations IDPs Internally Displaced Persons AU African Union TPLF Tigray People Liberation Front ENDF Ethiopian National Defense Force OCHA United Nations Office for the Coordination of Humanitarian Affairs WASH Water, Sanitation and Hygiene SRH Sexual and Reproductive Health WHO World Health Organization GDP Gross Domestic Product IOM International Organization for Migration IDMC Internal Displacement Monitoring Center UNHCR United Nations Higher Commissioner for Refugees PRISMA Preferred Reporting Items for Systematic Review And Meta-Analysis SGBV Sexual Gender-Based Violence GBV Gender Based Violence HRP Humanitarian Response Plan HIV Human Immune Deficiency Virus SGBV Sexual and Gender Based Violence IAWG Inter Agency Working Group SRHR Sexual and Reproductive Rights MISP Minimum Initial Services Package PTSD Post-traumatic stress disorder MDD Major Depressive Disorder AIDS Acquired Immune Deficiency Syndrome Declarations Acknowledgement We would like to acknowledge the Bahir Dar University College of Medicine and Health Sciences researchers for their invaluable expert evaluation of this work. Authors’ contribution TA conceived the study and the design. TA and SA undertook the review to gather the included studies. TA wrote the first draft. All authors revised the second draft. All authors contributed to the final manuscript. All authors approved the final manuscript. Funding We did not receive any funding for this review paper. Availability of data and material All data generated and analyzed during this study are included in this article. Ethical approval and consent to participate Not applicable Consent for publication Not applicable Competing interests We declare that we have no competing interests. References Garry S, Checchi F. Armed conflict and public health: into the 21st century. J Public Health. 2020;42(3):e287–98. Yigzaw N, et al. Comprehensive mental health and psychosocial support for war survivors at Chenna Kebele, Dabat woreda, North Gondar, Ethiopia. BMC Psychiatry. 2023;23(1):172. Fisseha G, et al. 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J Public Health (Oxf). 2022;44(2):215–6. Marlow HM, et al. The Sexual and Reproductive Health Context of an Internally Displaced Persons' Camp in Northeastern Nigeria: Narratives of Girls and Young Women. Front Reprod Health. 2021;3:779059. Jones NA, Pincock K, Abu Hamad BA. Adolescents in Humanitarian Crisis: Displacement, Gender and Social Inequalities. Abingdon, Oxon & New York, NY: Routledge, Taylor & Francis Group; 2021. Owoaje ET, et al. A review of the health problems of the internally displaced persons in Africa. Niger Postgrad Med J. 2016;23(4):161–71. Gómez-Restrepo C et al. Mental health in displaced children by armed conflict - National Mental Health Survey Colombia 2015. Actas Españolas de Psiquiatría, 2018. 46(2): pp. 51–57. Trujillo S, Giraldo LS, Trujillo N. Mental health outcomes in communities exposed to Armed Conflict Experiences. BMC Psychol. 2021;9(1):127. Moreno–Chaparro J, et al. Mental health consequences of armed conflicts in adults: an overview. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6549200","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502357197,"identity":"ffdd55e0-13f2-4994-ac9a-56e9ebf1f9c2","order_by":0,"name":"Tilksew Ayalew Abetie","email":"","orcid":"","institution":"Bahir Dar University","correspondingAuthor":false,"prefix":"","firstName":"Tilksew","middleName":"Ayalew","lastName":"Abetie","suffix":""},{"id":502357199,"identity":"ec0c79d1-c9a2-4d87-8472-6ea54bea5cd6","order_by":1,"name":"Simachew Animen Bante","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYFACxgYQyQPEbEBsAxJpPECKljSwCAEtCADSchjMwquFf3Zz64aPO+pkdNsPP3vwse283dr2w0BbamyicWmRuHOw7ebMM4d5zM6kmRvObLudvO1MIlDLsbTcBlx6biS23eZtO8BjdiCHTZp32+1kswNALYwNh3FqkQdp+dtWx2N2/g2b9N9t55LNzj/Er8UApIWxjZnH7AbQFsZtB+zMbhCwxRCo5WZvG9AvN56ZSfb+S04wuwG0JQGPX+RupD+78bOtzt7sfPIziR9n7ICM9IcPPtTY4PY+OkgEq0wgVjkI2JOieBSMglEwCkYGAAD3WWpC1UvnFwAAAABJRU5ErkJggg==","orcid":"","institution":"Bahir Dar University","correspondingAuthor":true,"prefix":"","firstName":"Simachew","middleName":"Animen","lastName":"Bante","suffix":""},{"id":502357200,"identity":"8b5eecfd-d2b9-4311-9422-918d8c199aa7","order_by":2,"name":"Desta Debalkie Atnafu","email":"","orcid":"","institution":"Bahir Dar University","correspondingAuthor":false,"prefix":"","firstName":"Desta","middleName":"Debalkie","lastName":"Atnafu","suffix":""}],"badges":[],"createdAt":"2025-04-28 15:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6549200/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6549200/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-25365-6","type":"published","date":"2025-11-14T15:58:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89465234,"identity":"986df31a-aef5-4dbc-b082-2b3870e46b4b","added_by":"auto","created_at":"2025-08-20 08:24:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22445,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Chart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6549200/v1/04daf1b8ce8ddb59d7b08e97.png"},{"id":89465747,"identity":"a178dab7-6542-4830-aac6-5eb1c8913993","added_by":"auto","created_at":"2025-08-20 08:32:13","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71264,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of reviewed studies by thematic focus: maternal and reproductive health (n=5), mental health (n=5), health system interruption (n=4), nutrition (n=4), chronic disease (n=2), and malaria (n=1).\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6549200/v1/a9610c0ebefa0745dbcde252.jpg"},{"id":89465756,"identity":"a4205257-d3be-4b07-af21-80b7cbb72750","added_by":"auto","created_at":"2025-08-20 08:32:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":108392,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of reviewed studies by geographic region\u003cstrong\u003e: \u003c/strong\u003eAmhara Region (n=9), Tigray Region (n=5), Somali (n=3), and Oromia (n=2).\u003c/p\u003e","description":"","filename":"fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6549200/v1/bd970b654ee96d133451ed41.jpg"},{"id":96105800,"identity":"7399f9db-681d-4343-91aa-27e280fbfed3","added_by":"auto","created_at":"2025-11-17 16:11:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1268510,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6549200/v1/dec7837a-eae0-4918-b536-d19d8b003969.pdf"},{"id":89465235,"identity":"eb1b8490-0550-4232-8b72-0a9290ce2712","added_by":"auto","created_at":"2025-08-20 08:24:13","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16915,"visible":true,"origin":"","legend":"","description":"","filename":"Extractionspreadsheet.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6549200/v1/61a5ee882d70f009293a9fed.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health impacts of Armed Conflict in Ethiopia: A Scoping Review of Evidence from 2018-2023","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eArmed conflict is increasingly recognized as a major public health threat in modern society. One of the most disruptive consequences of armed conflict is forced population displacement, which exposes the affected population to devastating health outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Internal displacement reached a global record in 2022, with 71.1\u0026nbsp;million people living in displacement at the end of the year [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The impact of armed conflict on health can be direct or indirect. Death and disability due to armed conflict, either of combatants or non-combatants, have a direct impact, while the negative effect on the health system, economic system, and social system is an indirect impact of armed conflict [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Evidence indicated that armed conflict is the leading cause of disability- adjusted life years (DALYs) lost [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Moreover, conflict and humanitarian crises were among the top ten global public health challenges in 2022, next to COVID-19, human resources for health, and health financing [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEconomically, armed conflict exerts further indirect pressure on public health by diverting resources. As of 2023, global military spending reached \u003cspan\u003e$\u003c/span\u003e 2443\u0026nbsp;billion, accounting for 2.3% of the world\u0026rsquo;s Gross Domestic Product (GDP) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBeyond immediate effects, armed conflict can impose long-term and intergenerational consequences. Prolonged displacement, poverty, and lack of access to health and education can have a cascading effect on the health of children and future generations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These conditions exacerbate existing inequalities, hinder development, and create cycles of poor health outcomes that can persist long after conflict has ended [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEthiopia is one of the countries severely affected and currently being affected by armed conflict. The country continues to face a chronic and escalating internal displacement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the country, the outbreak of internal displacement started in 2018 when Ethiopia recorded the third highest new displacements worldwide, with more than 3\u0026nbsp;million IDPs for the first time [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Then, the number of displaced persons has escalated during the Northern Ethiopian conflict, which erupted in early November 2020 and increased the number of IDPs to more than 5\u0026nbsp;million in the country [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As of 2023, more than 20\u0026nbsp;million crises affected people were in need of humanitarian assistance in the country [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to Office of the United Nations High Commissioner for Human Rights (UNOCHA) Ethiopia situation report 2023, humanitarian partners continue to mobilize resources to increase the humanitarian response in Northern Ethiopia and elsewhere in the country, prioritizing the most urgent needs, including health needs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among the affected populations, 20.5\u0026nbsp;million people were in need of basic needs, 7.4\u0026nbsp;million were in need of nutrition, and 17.4\u0026nbsp;million were in need of health services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eArmed conflict in Ethiopia caused multitudes of challenges for displaced persons, the host community, and the general population in the war-affected areas of the country, including health challenges [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Evidence based on a complex emergency database indicated that excess mortality was observed among Ethiopian IDPs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A review study on the health of conflict-induced internally displaced women in Africa, including Ethiopia, also revealed that mental health, sexual and reproductive health, and malaria were major health problems among internally displaced women [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Tesfaw et al., in their work, showed that degradation in the livelihood and housing conditions, socio-cultural confusion, loss of identity, family disintegration, and limited access to basic services, including health care services were identified as challenges faced by Ethiopian IDPs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. An unpublished thesis work by Arbouw et al. revealed that IDPs are exposed to undernutrition, lack of access to safe drinking water, and health services and shelter [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Recent evidence also showed that armed conflict has had a negative impact not only on the conflict-affected areas of the country but also the whole social, economic, health and developmental aspects of the country [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The armed conflict in northern Ethiopia damaged the health system in Tigray Regional State [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], as well as Afar and Amhara [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Regional States of the country. As a result, community access to health care has been severely compromised, and many people, including IDPs, face death, disability, and poor health outcomes [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, there is limited evidence on the impact of armed conflict on health in Ethiopia. To our knowledge, no study has comprehensively compiled this evidence. This scoping review aims to fill this evidence gap by synthesizing existing research on the topic. Beyond addressing the existing evidence gap, the findings will inform stakeholders such as humanitarian agencies, government bodies, and health practitioners to guide targeted interventions, policy decisions, and health services planning in conflict-affected settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eThis scoping review aims to identify and synthesize the existing evidence on health impacts of armed conflict in Ethiopia.\u003c/b\u003e\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eA scoping review study design was employed to establish and map what literature is emerging. The scoping review used a framework developed by Arksey and O\u0026rsquo;Malley (2005), scoping review methodology [20]. The framework follows a five-stage approach: (1) develop research question, (2) article search, (3) article selection, (4) data extraction, and (5) data analysis [20]. The review was reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-ScR), Extension for Scoping Review Guidelines [21]. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.1. Search strategy\u003c/h2\u003e\n\u003cp\u003eAlthough we planned to include grey literatures during our first plan, we did not get grey literatures relevant to our review. As a result, we only included the published articles for this review. Publications were searched primarily using PubMed and Google Scholar. Other sources like the Internal Displacement Monitoring Center (IDMC) and United Nations Human Rights Commission for Refugees (UNHCR) websites were also searched, particularly to find grey literature relevant to the topics of interest. However, we did not find grey literature relevant to the topics of interest in the current review. We tried to identify grey sources through targeted searches of organizational websites such as IDMC, UNCR, WHO (World Health Organization), and IOM. However, many potentially valuable documents were not indexed, lacked searchable metadata, or were inaccessible through standard databases. The populations of interest for this review are all populations affected by armed conflict in Ethiopia. We used the following search strings for PubMed search by combining with MeshTerms: \u003cem\u003e(\u0026quot;Armed Conflicts\u0026quot; OR \u0026quot;War\u0026quot; OR \u0026quot;Conflict\u0026quot; OR \u0026quot;Civil Unrest\u0026quot; OR \u0026quot;War zone\u0026quot; AND (\u0026quot;Health\u0026quot; OR \u0026quot;Health Impact\u0026quot; OR \u0026quot;Health Services\u0026quot; OR \u0026quot;Maternal Health\u0026quot; OR \u0026quot;Mental Health\u0026quot; OR \u0026quot;Sexual and Reproductive Health\u0026quot; OR \u0026quot;Malnutrition\u0026quot; OR \u0026quot;Health System Disruption\u0026quot; OR \u0026quot;Malaria\u0026quot; AND (\u0026quot;Ethiopia\u0026quot; ) and (\u0026quot;Armed conflict\u0026quot; OR \u0026quot;war\u0026quot; OR \u0026quot;civil unrest\u0026quot; OR \u0026quot;ethnic violence\u0026quot;) AND (\u0026quot;health outcomes\u0026quot; OR \u0026quot;maternal health\u0026quot; OR \u0026quot;reproductive health\u0026quot; OR \u0026quot;mental health\u0026quot; OR \u0026quot;malnutrition\u0026quot; OR \u0026quot;health system disruption\u0026quot; OR \u0026quot;malaria\u0026quot; OR \u0026quot;health services\u0026quot;) AND \u0026quot;Ethiopia\u0026quot;\u0026nbsp;\u003c/em\u003efor Goggle Scholar. Moreover,\u0026nbsp;the broad initial search targeted armed conflict in general with the search terms that are combined with words related to health needs, health problems, and the impact of war conflict on health and Ethiopia. Reference lists of selected articles were scanned for additional sources to include in the review.\u003c/p\u003e\n\u003ch2\u003e2.2. Article screening and selection \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe articles\u0026rsquo; screening process was undertaken using the Preferred Reporting Items for Review and Meta-Analysis (PRISMA-ScR) flow chart for the selection of literature for this scoping review study. Initially, an independent search was conducted based on the aftermentioned search terms by two authors (TA and SA). Secondly, titles and abstracts were screened using the inclusion and exclusion criteria to identify potentially relevant articles. Then, the full texts of selected articles were reviewed to confirm that the studies met the predetermined inclusion criteria. Finally, the titles and contents of the articles were screened to assess their eligibility for inclusion in the review. The articles that need clarity were assessed, and a decision was made to include the eligible articles. When disagreements arose, they were resolved by agreement or the arbitration of the third author (DD). To be clear about the article screening and selection, look at the PRIMA flow chart in \u003cstrong\u003eFigure 1\u003c/strong\u003e. As shown in \u003cstrong\u003eFigure 1\u003c/strong\u003e (PRIMA Flow Chart), the total number of documents (i.e., 230 documents) was identified and retrieved via databases and other sources. Then, duplicates were removed using EndNote. The titles and the abstracts were reviewed for the remaining documents and articles that were unrelated to themes or did not provide information about the health in the context of conflict in Ethiopia were discarded. Full text assessment was done for the screened articles, and some articles were again excluded for justifiable reasons. Finally, the remaining 19 articles were included in this scoping review\u003cstrong\u003e\u0026nbsp;(Figure 1).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.3. Inclusion and exclusion criteria \u0026nbsp;\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003ePublished articles with different study designs on health and conflict in the context of Ethiopia, published till the end of 2023, and published in the English language were included in this review. The population of interest in the articles is persons affected by armed conflict in Ethiopia. Articles with no relevant data on the health and conflict in the context of Ethiopia, focusing on conflict-affected persons who migrated outside of their country\u0026rsquo;s borders and published in languages other than English, were excluded from the review process.\u003c/p\u003e\n\u003ch2\u003e2.4. Data extraction and charting\u003c/h2\u003e\n\u003cp\u003eInformation about each article was first extracted and recorded on a Microsoft Excel Spreadsheet, which was prepared for this review purpose. The information recorded in the extraction sheet includes author name, year of publication, title, research questions or objectives, method, sample size, data source, study area of focus, study period, summary of findings, and summary of conclusion, recommendation, and implications (\u003cstrong\u003eSupplementary 1\u003c/strong\u003e). The extracted information was re-charted in a Microsoft Word table for reporting purposes in the manuscript. The information included in this table were author, year of publication, purpose of the study, study setting/location or region, and summary of results [\u003cstrong\u003eTable 1\u003c/strong\u003e].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Summary of Studies Included in the Review\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"757\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor, publication year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePurpose of the study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSummary of results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eAbebaw\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eet al. [2022]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess health impacts war in Amhara region.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eConflict affected populations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e50% of facilities looted or damaged; 10,333 chronic patients disrupted; 7,000+ women lost maternal care; 934 SGBV cases; $27M in health system losses.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eArage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eet al.[2023]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eExplore \u0026nbsp; \u0026nbsp; \u0026nbsp;health consequences of northern conflict\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eGeneral population\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eDeath, food insecurity, supply chain interruptions and forced displacement, sexual violence, health system breakdown, supply chain interruption, health care system damage, and health care provider displacement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eFisseha\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;et al.[2023]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess \u0026nbsp;war- related SGBV in Tigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eWomen\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eNearly 40% of women have experienced SGBV; young women are the most affected. 89.7% of SGBV survivors received no support.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;Gedef\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eet al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess institutional delivery in conflict zones\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eWomen\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e48.1% gave birth in facilities; ANC follow-up and displacement influenced delivery choice.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eGebeyaw\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eet al.[2023]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess PTSD among children\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eChildren\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e70% experienced mental trauma; 36.45% developed PTSD.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eGebrehiwet\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eet al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess chronic diseases during conflict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eChronic diseases patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eOnly 21% continued care; TB, hypertension, and diabetes mellitus were most affected.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eGebretsadik et al.[2023]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess malnutrition in children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eChildren 6-59 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eSevere, moderate, and global acute malnutrition are 5.1%, 21.8%, and 26.9%, respectively.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eGesesew et al.[2021]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess health system before and during the war.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eAnalytical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eHealth system\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eCollapse of MCH services within 90 days; 100% of health posts are nonfunctional.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eGutema et al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eImpact of conflict on health infrastructure.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eMixed-method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eHealth system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eOver 1000 facilities and 159 vehicles damaged; acute malnutrition observed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eDebash, et al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eInvestigate malaria outbreaks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCase\u0026ndash;control\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eGeneral population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e13,136 confirmed cases, a 26.5 per 1000 attack rate, and a 43% positivity rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eO\u0026rsquo;Connell et al.[2022]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEvaluate SRH needs of IDPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSomali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eFragile security, limited access to GBV services, and provider shortages.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eKemei et al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eExplore insecurity among IDP children\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eQualitative \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eOromia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDP children\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eChildren faced academic, economic, physical, and mental health challenges.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMakango et al.[2023]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePTSD among \u0026nbsp;IDPs in camps\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDPs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e67.5% screened positive for PTSD; there was high mental distress in the camp.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eMengstie et al.[2023]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eUndernutrition among lactating mothers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDP mothers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e54.8% of undernourished mothers are linked to low dietary diversity and large family size.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eO\u0026rsquo;Connell et al, [2021]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eFactors associated with SGBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eQualitative\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSomali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDPs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eSGBV is linked to culture, religion, displacement, and inequality.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eTeshome et al.[2023]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePTSD among war survivors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eWar survivors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e40% had PTSD, 65.5% depressive symptoms, and 63.1% anxiety symptoms.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eTitiyos et al.[2020]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess SRHR needs of IDPs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSomali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eIDP women\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003e50% had 5+ births; 78.3% received ANC; SRHS access was limited.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eWeldegiargis et al. [2023]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eAssess food insecurity in conflict zones\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eCross-sectional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eTigray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eHouseholds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eFood insecurity increased by 43.3 percentage points post-conflict.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYigzaw et al.[2023]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eDeliver mental health and psychological support\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003eMixed-method\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAmhara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eWar survivors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 246px;\"\u003e\n \u003cp\u003eCommon diagnoses: PTSD, MDD, grief, and females are more affected.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 757px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e M = Millions, SGBV = Sexual and Gender-Based Violence. ANC = Antenatal Care, PTSD = Post-Traumatic Stress Disorder, TB = Tuberculosis, MCH = Maternal and Child Health, GBV = Gender-Based Violence, SRHS = Sexual and Reproductive Health Services, MDD = Major Depressive Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003e2.5. Data Synthesis \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe articles included in the review were coded and summarized based on areas of focus and were thematically analyzed based on their content. Since we used Arksey and O\u0026rsquo;Malley (2005) [20], we did not apply quality appraisal for this scoping review because the focus of this review was to identify, map, and synthesize the available evidence on health and armed conflict and to forward recommendations for further research. But the paper has benefited from the expertise of researchers.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eAs illustrated in the PRISMA diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), a total of 230 documents were initially identified through database searching (150 from PubMed and Google Scholar and 80 from other sources). After removing 50 duplicate records, 180 records remained for title and abstract screening. Of these, 110 records were screened, and 70 records were excluded based on irrelevance to the health impact of armed conflict in Ethiopia. The remaining 40 full-text articles were assessed for eligibility. Among these, 21 articles were excluded-15 focused on refugees, and 6 were excluded for other reasons, such as insufficient data on health outcomes or lack of methodological quality. Finally, 19 articles met the inclusion criteria and were included in the review. Articles were charted in Microsoft Word using a table based on the study\u0026rsquo;s characteristics of author, publication year, purpose of the study, design of the study, location/ region of the study, and summary of the results (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After the detailed review of each article, we grouped articles under the following themes: health system disruptions, maternal health and reproductive health, mental health, nutrition, chronic disease, and malaria. Based on the classified themes, four (n\u0026thinsp;=\u0026thinsp;4) studies assessed health system disruption, five (n\u0026thinsp;=\u0026thinsp;5) studies assessed maternal and reproductive health conditions, another five (n\u0026thinsp;=\u0026thinsp;5) studies assessed mental health conditions, four (n\u0026thinsp;=\u0026thinsp;4) studies assessed nutritional problems, two (n\u0026thinsp;=\u0026thinsp;2) study assessed chronic diseases and one (n\u0026thinsp;=\u0026thinsp;1) assessed malaria in the context of armed conflict (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The result shows that the most frequently studied themes were maternal and reproductive conditions and mental health, followed by health system disruption and malnutrition.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe methodology used in the studies varied, and most studies (n\u0026thinsp;=\u0026thinsp;14) used quantitative methodology, four (n\u0026thinsp;=\u0026thinsp;4) studies used qualitative method, and one (n\u0026thinsp;=\u0026thinsp;1) study used mixed method. Regarding to study location/ region, nine (n\u0026thinsp;=\u0026thinsp;9) studies were conducted in Amhara region, five (n\u0026thinsp;=\u0026thinsp;5) studies were conducted in Tigray region, three (n\u0026thinsp;=\u0026thinsp;3) studies were conducted in Somali region, and two (n\u0026thinsp;=\u0026thinsp;2) studies were conducted in Oromia region (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The result shows that highest number of studies were conducted in Amhara Region followed by Tigray Region indicating the conflict-related health impacts are mostly documented in the northern part of Ethiopia. The cumulative result indicated that the highest number of studies was conducted in Amhara Region and Tigray, Region indicating that the health consequences of armed conflict are mostly documented in northern Ethiopia.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Health System Disruption\u003c/h2\u003e\u003cp\u003eOne of the themes discussed in this review is the impact of armed conflict on the health system and delivery of health care. Four studies investigated the impact of armed conflict on the public health system and services in this review. A study conducted in armed conflict-affected zones of the Amhara region revealed that more than half(51%) of health facilities and their infrastructure have been destroyed due to the northern Ethiopian war conflict that began in November 2020 in the Tigray region and expanded into Amhara and Afar regions in 2021[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The study reported that 10,333 patients with chronic disease follow-up were interrupted; 29632 civilians died due to conflict, more than 70 thousands pregnant, lactating mothers had interrupted their follow up-care, 1035 unwanted pregnancies, and 934 cases of sexual and gender-based violence (SGBV) occurred [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A qualitative study in the same region found that conflict-related deaths, famine, supply chain disruptions, displacement, health system collapse, and lack of transportation and medications severely hampered access to and delivery of health care services [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The study also reported the long-term impact of the armed conflict, including destruction of health facilities, disrupted immunization services, post-traumatic stress disorders, lifelong disabilities, and significant economic loss. The armed conflict in the Amhara region resulted in a loss of US\u003cspan\u003e$\u003c/span\u003e27,015,585.98 to the health care system, creating nearly the same amount of money for its recovery and rehabilitation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Another study in the Tigray region revealed that health care systems were destroyed and services were disrupted due to the armed conflict [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. At six months of the armed conflict, only 27.5% of hospitals, 17.5% of health centers, and 11% of ambulances were functional, and all health posts (712) in the region were not functional. The study reported that prior to conflict, antenatal care, skilled birth attendance, postnatal care, and child vaccination coverage were 94%, 73%, 63% and 73%, respectively. However, delivery of these services was halted in the first 90 days of the armed conflict. Widespread destruction of livelihoods occurred along with physical damage to health facilities and functional breakdown of the health care system, including disrupted services, workforce shortages, and limited access to essential supplies. The collapse of the health care system was a common problem during the armed conflict [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, a study conducted in the Oromia region found that health care facilities and vehicles, including ambulances, were damaged during the armed conflict. As a result, essential services such as inpatient and outpatient were severely disrupted [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The study reported that 1,072 public health facilities were destroyed or looted during the armed conflict. Moreover, 159 vehicles, including ambulances, were damaged [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Maternal and Reproductive Health\u003c/h2\u003e\u003cp\u003eMaternal and reproductive health emerged as one of the key themes in this review, with five studies examining the issues in the context of armed conflict in Ethiopia. A study assessing institutional delivery service utilization in the context of armed conflict in Amhara Region reported that only 48.1% of mothers gave birth at health facilities, and displacement was negatively associated with institutional delivery use [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another study conducted in Tigray Region revealed that nearly 40% of women experienced at least one type of gender-based violence (GBV). Sexual, physical, and psychological violence, including rape, was reported among women of reproductive age. Trauma, sexually transmitted infections including Human Immuno-Deficiency Virus (HIV), and unwanted pregnancy were the most common reported poor SRH outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Another study conducted in the Somali region among IDPs showed that nearly 90% of respondents reported ever hearing about SRH and nearly 70% reported receiving family planning information [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Among participants, 64% did not know where SRH services were available, and nearly 60% approved the use of family planning [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A qualitative study among IDPs in the same region revealed that GBV was a common SRH problem, and misconceptions, stigma and discrimination, the need for spousal permission, religious beliefs, and fear of side effects were some of the persistent barriers to using SRH services [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The study uncovered that knowledge on GBV among the communities surveyed was limited, and several types of GBV, including early and forced child marriage, domestic violence, and female genital mutilation and cutting, were common cultural practices. The study also indicated that many GBV cases were unreported due to fear of stigma and bad consequences, lack of trust in the justice system, and the preference for family and community-level arbitration [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Another similar study conducted among IDPs also revealed that knowledge of sexual and gender-based violence (SGBV) was limited among the surveyed communities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Like that of the above study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] SGBVs, are common cultural practices among the surveyed communities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, it was reported that socioeconomic inequalities, discriminatory cultural and religious beliefs, harmful traditional practices, and conflict and displacement were risk factors for SGBV and the patriarchal norm also perpetuates certain forms of violence against women, including socializing domestic, economic, and emotional violence as acceptable, while limiting the opportunities of women for self-empowerment and collective action [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Abebaw N et.al in their descriptive study added that 1035 and 934 women and girls experienced unwanted pregnancies and SGBVs respectively as a result of the armed conflict in Amhara region [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Mental Health\u003c/h2\u003e\u003cp\u003eMental health problems are a major health challenge among conflict-affected populations. Prior researches report high levels of post-traumatic stress disorder (PTSD) among conflict affected populations [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this review, we identified five studies addressing mental health problems among conflict affected populations in Ethiopia. A study conducted among conflict-affected children and adolescents in Amhara Region revealed that nearly 70% of children had experienced trauma and over one-third developed PTSD [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Another study in the same region also publicized that 45% of participants reported various mental health problems such as PTSD, major depressive disorder (MDD), adjustment disorder, protracted bereavement disorder, and insomnia. PTSD was the most common reported diagnosis (38 cases), followed by MDD (4 cases), prolonged grief (3 cases), and neurological disorder (2 cases). Females were more vulnerable to PTSD compared to males [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, a study conducted among war survivors in the region showed that nearly 40% of participants developed PTSD, 66.5% experienced depressive symptoms, and 63.1% had experienced anxiety symptoms. Witnessing the death or serious injury of close family members, high perceived stress, symptoms of depression and anxiety, chronic illness, physical assault, exposure to combatant situations, and being female were risk factors associated with PTSD [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, a qualitative study exploring the lived experience of IDP children in Ethiopia highlighted the psychological consequences of insecurity and lack of protection in IDP camps. The study found that children faced numerous challenges related to poor socio-economic conditions, which contributed to physical and emotional distress and increased vulnerability to mental health problems. Socio-economic and contextual factors were found to interact and influence the overall well-being of children in IDP settings [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Lastly, a study conducted among IDPs in Debre Berhan reported that two-thirds of the conflict-affected participants screened positive for PTSD. Witnessing property destruction, experiencing trauma, repeated displacement, psychological distress, and unemployment were contributing factors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Nutrition\u003c/h2\u003e\u003cp\u003eNutrition is one of the key thematic areas explored in this review. Four studies examined the impact of armed conflict on nutritional outcomes in Ethiopia. A study conducted in Sekota IDP camps, located in Wagehmra Zone of Amhara Region, among lactating mothers found that 54.8% of IDP mothers were undernourished [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Having a large family size, short birth interval, low maternal daily meal frequency, and low dietary diversity score were more contributing factors for undernutrition [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, another study assessing the broader health impact of armed conflict revealed that around 17,764 pregnant or lactating women had been screened for malnutrition in a conflict-affected setting [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, a study conducted among internally displaced children in Tigray Region demonstrated that the prevalence of severe, moderate, and global acute malnutrition was very high (5.1%,21.8%, and 26.9%, respectively) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Child age, child sex, vitamin-A supplementation, and history of diarrhea were found to be individual-level predictors of malnutrition, while poor drinking water source, poor toilet facility, and severe food insecurity were predictors of malnutrition at the community level [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Besides, a study done to assess the status of household food insecurity in the conflict-affected population [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] highlighted that 75% of households experienced food insecurity. Overall, the results suggested that food insecurity and undernutrition are highly prevalent among the armed conflict-affected population in Ethiopia.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Chronic Diseases\u003c/h2\u003e\u003cp\u003eChronic disease is another key thematic area explored in this review. Two studies examined the impact of armed conflict on chronic disease management in Ethiopia. A study conducted in Tigray Region reported that among 4645 patients who were receiving treatment before the conflict, only 21% continued their care during the conflict period [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The highest rate of treatment interruption was observed among type 1 diabetes, with 80% discontinuing their treatment and care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another study in Amara Region also indicated that more than 10,000 patients with chronic disease have interrupted their treatment and follow-up [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCumulatively, the evidence suggests a substantial disruption in chronic disease management among conflict-affected populations in Ethiopia. It also underscored that the severe breakdown in the continuity of care for chronic diseases during armed conflict putts affected individuals at heightened risk of complications and mortality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.6. Malaria\u003c/h2\u003e\u003cp\u003eThe least discussed theme in this review in the context of conflict is malaria. Surprisingly, only one study investigated malaria outbreaks in the context of armed-conflict. The findings demonstrated that a total of 13,136 confirmed cases of malaria were detected with an overall attack rate of 26.5 per 1000, and slide positivity rate was 43.0% [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This study also revealed that under-five children were severely affected by the malaria outbreak, and the presence of mosquito breeding sites, staying outside overnight, and lack of awareness on malaria transmission and prevention were the main contributors to the malaria outbreak in the study area.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis scoping review explored a wide range of impacts of armed conflict on health in Ethiopia. It has synthesized the findings across six thematic areas: health care system, maternal and reproductive health, mental health, nutrition, chronic diseases, and malaria. The results show that the effects of conflict are multifaceted and interlinked on vulnerable population, women, children, and the internally displaced population, bearing the greatest burden.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Health System Disruption: A Foundational Challenge\u003c/h2\u003e\u003cp\u003eThe reviewed evidence highlights the devastating effect of armed conflict on Ethiopia\u0026rsquo;s health care system. Over half of health facilities were reported to be destroyed, result in an estimated economic loss of \u003cspan\u003e$\u003c/span\u003e27\u0026nbsp;million and widespread service interruptions, including for chronic diseases and maternal health care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The findings also highlighted that war-related fatalities, famine, disruptions of supply chains, and forced displacement; violence and rape; health workers displacement and dearth of medication, together with insecurity and lack of transportation occurred and significantly affected the provision and utilization of health services were common problems occurred as a consequences of armed conflict [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, findings under this theme demonstrated that previously well-functioning health care delivery systems in Tigray Region and Oromia Region were partially or completely damaged, and health service delivery was negatively impacted. Previous evidence from other similar settings reinforced the findings [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The evidence from the WHO report on social determinants of health in conflict-affected countries revealed that health systems in conflict situations are usually immediately disrupted at the start of the conflict [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. For example, evidence from a recent armed conflict in Sudan revealed that the country\u0026rsquo;s health system collapsed immediately after the occurrence of the armed conflict. Attacks on the health care system and health care workers, closure of hospitals, and occupation of health facilities by armed groups have suspended critical services such as immunization, nutrition, and emergency care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The collapse of the health system underpins disruptions across all health domains. It compromises maternal and reproductive health services, limits access to mental health support, exacerbates malnutrition and food insecurity, and interrupts chronic disease management and malaria control, thereby having a cascading effect that severely undermines overall population health.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.2. Maternal and Reproductive Health: Disproportionate Impact\u003c/h2\u003e\u003cp\u003eMaternal health and SRH services have been significantly affected by armed conflict. A study conducted in Amhara Region revealed that less than half of mothers delivered in a health facility, and displacement was negatively associated with the use of institutional delivery services [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Evidence from other similar settings revealed that maternal and child health services are negatively affected during armed conflict [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. For example, A review study done on internally displaced women in Africa revealed that internally displaced women faced a multitude of maternal and reproductive health problems [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Also, a study in northeastern Nigeria revealed that lower reproductive, maternal, neonatal, and child health(RMNCH) status [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A recent Lancet series on the health of women and children in the context of conflict indicated that women and children shoulder a significant burden of morbidity and mortality at the time of armed conflict [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Reproductive-age women living close to high-intensity conflicts are three times more likely to die than their counterparts [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The findings are reinforced by the evidence from the United Nations Population Fund Agency (UNFPA) report [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The COVID-19 pandemic and ongoing conflicts have severely weakened the healthcare system, limiting access to maternal and SRH services [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Maternal and reproductive health outcomes are closely connected to a broader health system, mental health, and nutritional status. Conflict-related service disruptions and displacement increase women\u0026rsquo;s vulnerability to poor outcomes, which is further exacerbated by exposure to sexual and gender-based violence and the lack of adequate psychological support.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Sexual and Gender-Based Violence. A Weapon of War\u003c/h2\u003e\u003cp\u003eSGBV is another topic discussed under this theme. SGBV has been discussed in studies conducted in Tigray Region [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], Somali Region [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and Amhara Region [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Historically, SGBV is documented as a weapon and consequence of war used strategically by armed groups. Women and girls experience brutal SGBV in different armed conflict-affected countries as a weapon of war [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Furthermore, a study conducted on IDPs in the Somali Region of Ethiopia [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] has reported that women and girls experienced several types of GBV, including early and forced marriage, domestic violence, female genital mutilation, and cutting. The findings are supported by a review article on \u0026lsquo;reproductive health in conflict\u0026rsquo; which revealed that SGBV was a common sexual and reproductive problem faced by the women and girls in conflict situations [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], Ethiopia, Bangladesh, Lebanon, Jordan, Rwanda, the Gaza Strip, and other conflict affected countries [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. SGBV is interrelated with other themes discussed in this review. It causes both indirect physical and psychological harm and is closely related to mental health disorders and maternal health outcomes. It also places additional strain on the already weakened health system, highlighting the need for integrated services that address both medical and psychological needs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.4. Mental Health. An Overlooked Emergency\u003c/h2\u003e\u003cp\u003eMental health problems were found to be major problems across studies, particularly among children and women [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A study in the Amhara Region revealed that a significant proportion of children had experienced trauma [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similar findings were reported from Colombia, which has been affected by protracted conflict [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Evidence from other conflict-affected settings showed that mental health problem is a common health problem among the conflict-affected population, including children [\u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Children are among the vulnerable groups of the population during armed conflict [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Evidence revealed that 1in 10 children is affected by armed conflict worldwide [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Likewise, a study conducted in the same region revealed that a significant proportion of participants reported a range of mental health problems, including PTSD, major depressive disorder (MDD) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A qualitative study added that IDP children experienced mental health problems due to a lack of protection in IDP camps, implying that children are vulnerable to physical and emotional health problems, which provoke mental health disorders [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The findings are supported by evidence from similar settings in Colombia, northern Uganda [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Moreover, a study included in this review showed that nearly 40 percent of participants experienced PTSD [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A review study has documented that the prevalence of mental disorder symptoms has ranged from 32\u0026ndash;52% [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Lastly, a study conducted among camped IDPs at Debre Berhan town revealed that more than two-thirds of the affected population had reported PTSD. The study also reported that the prevalence of PTSD was high among internally displaced people [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Evidence presented in the aftermentioned studies is supported by studies from other similar settings. For example, a review study indicated that war-affected populations, including IDPs, are prone to various mental health problems, including PTSD [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Additional studies revealed that displaced women were vulnerable to an array of mental health disorders [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Mental health problems are interrelated with other problems discussed in this review. They are amplified by trauma from SGBV, displacement, food insecurity, and the burden of chronic diseases. The inadequate health infrastructure further limits access to care, creating a complex web of interrelated vulnerabilities affecting recovery and resilience.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.5. Nutrition: Conflict-Driven Malnutrition and Hunger\u003c/h2\u003e\u003cp\u003eThis review revealed that armed conflict in Ethiopia disrupts food production; increases food insecurity, leading to malnutrition and famine [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. It has been the main driver of food insecurity, hunger, and malnutrition in the conflict-affected areas of the country [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. As of 2023, more than 20\u0026nbsp;million people were in need of emergency food assistance in Ethiopia, which is directly linked to armed-conflict [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The situation is aggravated by high inflation of food prices. As of October 2021, the inflation has reached 34.2% [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In this review, three studies investigated the issue of nutrition. A study done in Amhara Region among displaced lactating mothers has reported a significant proportion of breastfeeding mothers experienced under-nutrition [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A 2023 OCHA prediction shows that there are 954,487 pregnant and lactating mothers with acute malnutrition and need urgent supplementary nutrition assistance [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Evidence from previous studies showed that neonatal morbidity and mortality are higher in war conflict-affected regions due to in part to maternal malnutrition, which is caused by armed-conflict [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Another study, which was conducted in Tigray, Ethiopia, among conflict-affected children, has investigated the nutritional status of children in the context of armed conflict. The findings of this study revealed a high prevalence of malnutrition with severe, moderate, and global acute malnutrition all reported at concerning levels [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The findings are supported by the evidence from previous studies [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Malnutrition has a cross-thematic relationship with other themes discussed in this paper. It exacerbates susceptibility to infections such as malaria and worsens maternal and child health outcomes. It also interacts bidirectionally with mental health and chronic diseases, highlighting a critical need for coordinated nutrition and health interventions in conflict-affected settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.6. Chronic Disease: A Hidden Crisis\u003c/h2\u003e\u003cp\u003eDespite being less studied, chronic diseases have been profoundly affected by armed conflict. Two studies investigated the issue of chronic diseases in the context of armed conflict. A study in Tigray Region revealed that chronic disease care and follow-up have been severely interrupted [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The study revealed that before the armed conflict, 4645 patients were following their treatment for chronic diseases. However, only one-fifth of patients continued their treatment during the armed conflict period. The most dramatic interruption was reported among type 1 diabetic patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Evidence from other conflict-affected settings showed similar findings. For example, a study from Syria revealed that access to and utilization of health care services, including outpatient consultation, were limited in conflict-affected areas of the country [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Another study conducted in Amhara Region also revealed that more than two-thirds of patients faced treatment interruption [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Chronic disease treatment interruption is thematically related to other problems discussed in this review paper. It is linked to poor health service availability and the perceived stress of participants. It also increases the risk of complications that are worsened by coexisting malnutrition, psychological stress, and reduced access to comprehensive health services, illustrating the compounded health challenges faced by conflict-affected populations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.7. Malaria: Underreported yet Ongoing Threat\u003c/h2\u003e\u003cp\u003eMalaria is one of the themes discussed in this review. Notably, only one study investigated the malaria outbreak. The study indicated that a total of 13,136 confirmed cases, an overall attack rate of 26.5 per 1000, and a 43.0% slide positivity rate [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It also disclosed that under five children were severely attacked, and the presence of mosquito breeding sites, staying outdoors overnight, and lack of awareness on malaria transmission and prevention were the main contributors of the malaria outbreak [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Ethiopia is one of 41 countries experiencing rising malaria rates exacerbated by armed conflict and humanitarian crises [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Evidence indicated that armed conflict disrupts health care services, hampering surveillance and control of vector-born disease including, malaria [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. In contrast to our finding, evidence from the conflict-affected settings showed an inverse relationship between the frequency of malaria cases and armed conflict [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. For instance, a study from Sri Lanka revealed that the country has eliminated malaria despite being affected by a protracted armed conflict [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Malaria outbreak during armed conflict is related to other problems. It is influenced by disrupted health services, population displacement, and malnutrition, which together heighten vulnerability to infection and complicate disease surveillance and control efforts.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Integrated thematic insights","content":"\u003cp\u003eThe findings of this review demonstrated that the health impacts of armed conflict in Ethiopia are not isolated but deeply interconnected. The collapse of the health system is a primary disruptor, causing widespread interruptions of essential services [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDisrupted maternal and reproductive health care raises risks during pregnancy and childbirth and limits access to family planning and safe delivery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Survivors of SGBV lack vital medical, psychological, and legal support, worsening their trauma [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMental health problems worsen due to direct conflict exposure and indirect effects like displacement and loss of care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Disrupted nutrition programs increase undernutrition, especially among children and lactating mothers, which further harms mental and physical health [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Malnutrition weakens immunity, increasing vulnerability to infections like malaria [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], while disease surveillance breakdowns hinder timely response [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eChronic diseases, requiring consistent care, are neglected during conflict, leading to treatment gaps and complications [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. These chronic conditions interact with malnutrition and stress, creating a vicious cycle [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. SGBV, mental illness, malnutrition, and chronic diseases worsen without functional health systems and are intensified by conflicts and socioeconomic impacts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings show that the conflict-related health effects in Ethiopia are interlinked and reinforcing. Addressing them separately limits effectiveness [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. A coordinated, integrated multi-sectoral approach is essential to mitigate these complex health challenges. While the scoping review did not appraise study quality, it is important to note that many included studies used a cross-sectional design, limiting causal inference. Additionally, several studies relied on self-reported data which may be subject to recall and reporting biases, especially in sensitive areas such as SGBV and mental health. These limitations should be considered when interpreting the findings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis scoping review revealed that armed conflict imposed widespread and interconnected challenges in Ethiopia. Health system disruption was the most documented theme, showing many facilities damaged, services interrupted, and health care workers displaced. Maternal and reproductive health services were more significantly affected, showing reduced institutional deliveries and a high rate of SGBV. Mental health issues like PTSD, depression, and anxiety were common among the conflict-affected populations, especially women and children. Although less frequently studied, nutritional problems such as undernutrition and food insecurity were prevalent, especially among displaced mothers and children. Chronic disease management was also severely impacted, with treatment interruption increasing the risk of complications. Malaria outbreaks were reported in conflict-affected areas, exacerbated by poor living conditions and reduced access to preventive services.\u003c/p\u003e\u003cp\u003eTo address these challenges, a coordinated and multi-sectoral response is essential. Policymakers should prioritize restoring health infrastructures, integrating mental health into the primary health care, and implementing service-oriented SGBV interventions. Humanitarian organizations must deploy mobile health units, support community-based psychosocial services, and ensure continuity of care for chronic disease. Local authorities should facilitate access to essential SRH services, strengthen community-led SGBV response systems, and scale up targeted nutrition programs for high-risk populations. Future researchers should focus on underexplored areas such as nutrition, chronic disease, and malaria within conflict settings, using diverse study designs including longitudinal and mixed-method approaches to generate actionable evidence that can guide effective policy and humanitarian response.\u003c/p\u003e"},{"header":"7. Limitation","content":"\u003cp\u003eThis paper has some limitations. First, the exclusion of articles with languages other than English leads to language bias. Second, many of included studies used cross-sectional designs, limiting causal inference. Third, several studies relied on self-reported data, which may lead to recall and reporting biases, especially in sensitive areas such as SGBV and mental health. Lastly, despite a comprehensive search strategy based on predefined inclusion and exclusion criteria, there remains the possibility that some relevant studies were inadvertently missed. This is an inherent limitation in scoping reviews, particularly in conflict settings where research may be unpublished, inaccessible, or inconsistently indexed in major databases. These limitations should be considered when interpreting the findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIDPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternally Displaced Persons\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAfrican Union\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTPLF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTigray People Liberation Front\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eENDF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEthiopian National Defense Force\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOCHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Office for the Coordination of Humanitarian Affairs\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWASH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWater, Sanitation and Hygiene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSexual and Reproductive Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGDP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGross Domestic Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIOM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Organization for Migration\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIDMC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternal Displacement Monitoring Center\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNHCR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Higher Commissioner for Refugees\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePreferred Reporting Items for Systematic Review And Meta-Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSGBV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSexual Gender-Based Violence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGBV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGender Based Violence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHumanitarian Response Plan\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immune Deficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSGBV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSexual and Gender Based Violence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIAWG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInter Agency Working Group\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSRHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSexual and Reproductive Rights\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMISP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMinimum Initial Services Package\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePost-traumatic stress disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMDD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMajor Depressive Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcquired Immune Deficiency Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the Bahir Dar University College of Medicine and Health Sciences researchers for their invaluable expert evaluation of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTA conceived the study and the design. TA and SA undertook the review to gather the included studies. TA wrote the first draft. All authors revised the second draft. All authors contributed to the final manuscript. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe did not receive any funding for this review paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analyzed during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that we have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGarry S, Checchi F. 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BMJ Global Health. 2021;6(12):e007453.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"armed conflict, health system, sexual and reproductive health, malnutrition, chronic disease, mental health, malaria, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-6549200/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6549200/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eArmed conflict is becoming a major public health threat in contemporary society with both immediate and long-term consequences. In Ethiopia, recurrent and protracted internal conflicts have severely disrupted health systems and affected vulnerable populations. However, a comprehensive synthesis of the health impacts of armed conflict in the Ethiopian context has been lacking.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eWe conducted a scoping review using the Arksey and O\u0026rsquo;Malley framework, guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Comprehensive searches were conducted in PubMed and Google Scholar, supplemented by targeted searches of organizational websites. Studies published in English up to December 2023 that assessed the impacts of armed conflict on health in Ethiopia were included. Data were charted and thematically analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 230 identified, 19 studies met the inclusion criteria. The studies addressed six thematic areas. Maternal and reproductive health (n\u0026thinsp;=\u0026thinsp;5), mental health (n\u0026thinsp;=\u0026thinsp;5), health system disruption (n\u0026thinsp;=\u0026thinsp;4), nutrition (n\u0026thinsp;=\u0026thinsp;4), chronic diseases (n\u0026thinsp;=\u0026thinsp;2), and malaria outbreak (n\u0026thinsp;=\u0026thinsp;1). Health system disruption (51%), gender-based violence (40%), post-traumatic stress disorder (40%), depression (66.5%), anxiety (63%), chronic diseases treatment disruption (80%), and malaria outbreak; 26.5/1000 attack rate and 43% slide positive rate were key findings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis scoping review revealed that armed conflict in Ethiopia has had a profound and interrelated impact on public health, disproportionately affecting women, children, and internally displaced populations. The findings underscore the urgent need for coordinated, multisectoral interventions that restore essential health services, strengthen mental health support, and ensure continuity of care for chronic and infectious diseases. Future research should focus on underexplored areas such as nutrition, malaria, and chronic disease management using diverse and longitudinal study designs.\u003c/p\u003e","manuscriptTitle":"Health impacts of Armed Conflict in Ethiopia: A Scoping Review of Evidence from 2018-2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-20 08:24:04","doi":"10.21203/rs.3.rs-6549200/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-18T08:16:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T09:02:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T06:39:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272295184197943035350398672175660603992","date":"2025-08-13T16:22:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155574045995794556513494247703832808109","date":"2025-08-12T06:36:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T05:30:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T01:41:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-06T13:12:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0cb3e127-4a6a-40ac-a99d-4f045a745e7b","owner":[],"postedDate":"August 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:09:04+00:00","versionOfRecord":{"articleIdentity":"rs-6549200","link":"https://doi.org/10.1186/s12889-025-25365-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-14 15:58:41","publishedOnDateReadable":"November 14th, 2025"},"versionCreatedAt":"2025-08-20 08:24:04","video":"","vorDoi":"10.1186/s12889-025-25365-6","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25365-6","workflowStages":[]},"version":"v1","identity":"rs-6549200","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6549200","identity":"rs-6549200","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}