Association of food insecurity with children’s emotional, behavioural, and academic outcomes in Masaka District, Uganda: a cross-sectional study

<title>Abstract</title> <p>Aims Food insecurity is an important social determinant of children's mental health and educational outcomes. However, evidence on the independent and combined roles of household and school-based food insecurity remains limited, particularly in sub-Saharan Africa. This study aimed to examine the associations of household and school-based food insecurity with children's emotional, behavioural, and academic outcomes, and investigate whether school-based food insecurity modified the associations between household food insecurity and children’s mental health difficulties among primary school children in Uganda. Methods A cross-sectional study was conducted among 661 children aged 7–13 years attending three randomly selected government-aided primary schools in Masaka District, Uganda. Household and school-based food insecurity were assessed using the Children's Food Insecurity Experience Scale (CFIES) and the School-based Food Insecurity Experience Scale (SFIES), respectively. Emotional and behavioural difficulties were measured using the Child and Adolescent Symptom Inventory-5 Teacher Rating Scale (CASI-5-T), and academic performance was obtained from school report cards. Multiple linear regression models with HC3 heteroskedasticity-consistent standard errors were used to examine the associations between household food insecurity (primary exposure) and children's emotional and behavioural difficulties and academic performance (outcomes), while assessing school-based food insecurity as both an independent exposure and a moderator of the associations between household food insecurity and these outcomes, adjusting for sociodemographic, household, and school-level factors. Results Approximately 47.2% of children reported moderate-to-severe household food insecurity, and 46.4% experienced moderate-to-critical school-based food insecurity. Clinically significant emotional and behavioural difficulties were identified in 5.3% of children, including 6.2% with elevated internalising difficulties and 4.5% with elevated externalising difficulties. Higher household and school-based food insecurity were associated with worry/anxiety (β = −1.27 and 0.87, respectively), fear/panic/OCD/PTSD/somatic (β = −0.98 and 0.25), ADHD/inattention (β = 0.92 and 0.08), oppositional/defiant (β = 0.95 and − 0.07), chronic irritability/disruptive mood dysregulation (β = 0.90 and − 0.03), and externalising symptoms (β = 0.98 and 0.03) (all p &lt; 0.05). School-based food insecurity was associated with poorer overall academic performance (β = −0.06, p = 0.048), mathematics (β = −0.08, p = 0.015), and literacy II/social studies achievement (β = −0.07, p = 0.022), whereas household food insecurity was associated only with literacy II/social studies achievement (β = −0.07, p = 0.014). School-based food insecurity modified associations between household food insecurity and worry/anxiety (β = −1.35, p = 0.006), fear/panic/OCD/PTSD/somatic (β = −0.94, p = 0.047), externalising (β = 0.86, p = 0.014), ADHD/inattention (β = 0.92, p = 0.025), oppositional/defiant (β = 0.97, p = 0.024), and chronic irritability/disruptive mood dysregulation symptoms (β = 1.09, p = 0.020), but not academic performance outcomes. Neither household nor school-based food insecurity were associated with overall composite scores of mental health difficulties or internalising conditions. Conclusions Household- and school-based food insecurity were associated with worse specific emotional, behavioural, and academic outcomes. School-based food insecurity modified associations between household food insecurity and emotional and behavioural difficulties, underscoring the importance of considering food insecurity across multiple developmental contexts. Interventions addressing food insecurity in both household and school settings may improve children's mental health and educational outcomes.</p>