War-related proxy-reported distress behaviors are associated with childhood anemia: cross-sectional evidence consistent with inflammatory pathways in conflict-affected Yemen

Abstract

Children in conflict zones endure chronic psychosocial stress with unclear biological consequences. We examined whether war-related caregiver-reported distress behaviors are associated with childhood anemia and whether systemic inflammation is consistent with a proposed statistical mediating pathway in Yemen, using a cross-sectional design that precludes causal inference. A community-based cross-sectional study of 600 children (6–59 months) from ten conflict-affected districts was conducted. Caregiver-reported distress behaviors were assessed via a composite index (CPSS-5 and PFC), capturing observable behaviors rather than psychiatric diagnoses. Caregiver mental health—a potential source of reporting bias—was unmeasured. Hemoglobin and high-sensitivity C-reactive protein (hs-CRP) were measured. Multivariable regression, mediation analysis (bootstrapping), and latent class analysis were used. Mean hemoglobin: 10.2 g/dL (SD 1.4); 59.7% anemic. Each SD increase in distress was associated with a 0.38 g/dL lower hemoglobin (95% CI: -0.45 to -0.31). CRP was consistent with a partial statistical mediating role (31.6% of the total cross-sectional association). The highest distress quartile had 2.74-fold higher anemia odds (95% CI: 1.92–3.91). Stronger effects were observed among displaced children (β = -0.35 vs. -0.23, p = 0.02) and those with severe food insecurity (β = -0.41 vs. -0.21, p = 0.01). Latent class analysis identified a “High Distress/High Inflammation” phenotype (28%) with the lowest hemoglobin (9.1 g/dL) and the highest proportions of displaced (78.6%) and food-insecure (62.3%) children. War-related caregiver-reported distress behaviors show a strong, dose-dependent cross-sectional association with childhood anemia. Systemic inflammation is consistent with a partial statistical mediating role. Displaced and food-insecure children bear disproportionate burdens. Findings are correlational; causal inference requires longitudinal studies. Integrated mental health and nutritional interventions warrant consideration in humanitarian pediatric care.