Food Insecurity and Child Mental Health in Masaka District, Uganda: Qualitative Study Using a Realist Thematic Analysis

Food insecurity and child mental health difficulties frequently intersect, yet the mechanisms connecting them remain underexplored in resource-limited settings. This study developed a conceptual framework to explain these complex relationships in resource-limited Ugandan settings. We conducted 12 focus group discussions with 36 teachers from four schools in the Masaka district, drawing on their sustained observations of children’s food insecurity and psychosocial difficulties over nine months. Using realist thematic analysis with nine coder consensus meetings and member checking, we identified three interconnected pathways. In the social causation pathway, food insecurity—including hunger, food-related stigma, and irregular meals—precipitated mental health difficulties. In the social drift pathway, pre-existing parental and/ or caregiver mental health difficulties disrupted family functioning and food provision, heightening vulnerability to food insecurity. Bidirectional pathways captured negative cyclical feedback loops in which food insecurity and mental health difficulties mutually reinforced each other. These processes operated dynamically and contextually within resource-limited settings. The framework underscores the need for integrated interventions that combine school-based nutrition, psychosocial support, and broader social-protection measures, and provides a foundation for future longitudinal, intervention, and child-centred measurement research.