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

Background Food insecurity and child mental health difficulties often intersect in complex ways, yet the mechanisms underpinning these relationships remain underexplored in resource-limited settings. This study aimed to develop a conceptual framework linking food insecurity and mental health difficulties among children in a low-resource Ugandan context. Methods A qualitative design was employed, consisting of 12 focus group discussions with 36 teachers across four schools. Teachers provided accounts of children’s experiences of food insecurity and associated psychosocial difficulties, drawing on sustained observation over 9 months. Data were analysed using realist thematic analysis, with nine coder consensus meetings and member checking with all participants to enhance rigour and interpretive validity. Themes were synthesised into an integrated conceptual framework. Results The framework identified three interlinked pathways: social causation, where food insecurity (e.g., hunger, stigma, irregular meals) precipitated psychosocial distress; social drift, where pre-existing child or caregiver mental health difficulties disrupted family functioning and food provision; and bidirectional pathways, where these processes reinforced one another through recursive feedback loops. Together, the framework shows that food insecurity and child mental health difficulties interact in cyclical, context-dependent ways. Conclusions Findings highlight the cyclical, context-dependent nature of food insecurity and child mental health in resource-limited settings. Interventions are needed that integrate food security, nutrition, psychosocial support, and structural reforms. Schools represent critical entry points; however, broader policy action on poverty alleviation and social protection is also essential. This framework has provided a foundation for future longitudinal and intervention studies, as well as child-centred measurement innovations.