yStructural Barriers to Health Services and Child Nutrition in Rohingya Camps: Cross-Sectional Evidence from the AAAQ Healthcare Access Framework

Background Persistent child malnutrition in Rohingya refugee camps despite sustained humanitarian food assistance implicates institutional determinants that extend beyond household-level dietary factors [1–4]. We examined whether a reproducible, AAAQ-derived Healthcare Access Index (measuring availability, accessibility, acceptability, and quality of health services) accounts for observed associations between food assistance modality (electronic vouchers vs. in-kind rations) and child anthropometric outcomes. Methods Cross-sectional analysis of 523 children aged 6–23 months using the IFPRI replication dataset (Harvard Dataverse DOI: 10.7910/DVN/5BAN6C) [5]. Primary outcomes were stunting (HAZ < − 2), wasting (WHZ < − 2), and underweight (WAZ < − 2) per WHO 2006 standards [6]. Exposure was food assistance modality. The Healthcare Access Index was constructed via exploratory factor analysis (EFA) of five AAAQ-aligned items (eigenvalue 2.34, variance explained 47.0%, Cronbach's α = 0.78). Analyses employed survey-weighted logistic regression with multiple imputation (m = 20 datasets), propensity score weighting (AUC = 0.62), and inverse probability weighting (IPW) with weight trimming (effective n = 498). Sensitivity analyses included E-value computation and Rosenbaum bounds testing. Results Stunting prevalence was 34.8% (95% CI: 30.8–38.9%); wasting 16.0% (12.8–19.6%); underweight 29.7% (25.9–33.8%). In unadjusted analysis, voucher receipt was associated with lower odds of stunting (OR 0.66, 95% CI: 0.44–0.99; p = 0.048; Fragility Index = 1). This association attenuated substantially after adjustment for the Healthcare Access Index and covariates (OR 0.76, 95% CI: 0.46–1.25; p = 0.275), with the Access Index independently associated with stunting (OR 1.28, 95% CI: 1.03–1.59; p = 0.026). IPW-adjusted estimates were consistent (OR 0.77, 95% CI: 0.48–1.24; p = 0.28). No significant voucher-access interaction was detected (p = 0.41). A monotone gradient in stunting prevalence across healthcare access barrier tertiles was observed: 28.7% (low barriers), 34.3% (medium), and 41.6% (high; p-trend = 0.003). For wasting and underweight, no significant associations with food modality were detected in any model specification. Conclusions The borderline crude association between voucher receipt and stunting was not robust to adjustment for measured healthcare access barriers. The Healthcare Access Index demonstrated a significant independent association with stunting and revealed a dose-response gradient that is consistent with structural health system barriers as a determinant of chronic undernutrition. These findings argue for integrated nutrition–health system programming in humanitarian settings. The E-value of 1.56 indicates that unmeasured confounders of moderate strength could explain residual associations; longitudinal data are required to establish causality.