Abstract
Background
Food insecurity is a major global public health concern that particularly affects refugees and is associated with adverse mental health outcomes. This study examined the relationship between food insecurity and mental health among Syrian refugees living in Türkiye (Turkey).
Methods
A cross-sectional study was conducted with 566 adult refugees (37.1% male, 62.9% female) recruited through snowball sampling between February and May 2024. Data were collected using the Food Insecurity Experience Scale (FIES), the Depression, Anxiety, Stress Scale-21 (DASS-21), and the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS).
Results
Overall, 61.3% of participants were food secure, while 25.8% and 12.9% experienced moderate and severe food insecurity, respectively. Severe food insecurity was strongly associated with higher depression, anxiety, and stress scores, and with lower wellbeing (p < 0.001). Regression analysis showed that each one-point increase in FIES score was associated with a 0.234-point decrease in wellbeing, while each one-point increase in depression score was associated with a 0.324-point decrease in wellbeing. Lower income, limited education, female gender, and larger household size were significantly linked to food insecurity.
Conclusions
This study demonstrates the close link between food insecurity and poor mental health among Syrian refugees in Türkiye. Addressing these issues requires culturally sensitive, language-accessible, and community-based interventions. Longitudinal research with objective measurements is needed to clarify causal pathways and inform sustainable policies.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28049-x.
Keywords: Food insecurity, Mental health, Syrian refugee, Depression, Anxiety, Stress
Introduction
The Syrian civil war, which began in 2011, forcibly displaced millions of people. Despite political changes in Syria, Türkiye, as a neighboring country, continues to host the largest share of the Syrian refugee population [1]. As of June 2025, approximately 2.7 million Syrians reside in Türkiye under temporary protection [2]. In new settlements, refugees experience challenges in accessing fundamental rights and services such as food, accommodation, and health services. Food insecurity is one of the most common nutritional problems among refugee populations [3].
Food insecurity (FI), as defined by the Food and Agriculture Organization (FAO), refers to the inability to access sufficient quantities of safe and nutritious food required for normal growth, development, and maintaining an active and healthy life [4]. Refugees are vulnerable to FI due to multiple economic, cultural, and social factors [5]. FI is associated with increased risk for multiple chronic diseases, including obesity, type 2 diabetes, cardiovascular disease, and mental health [6].
Food insecurity has been strongly linked to a range of common mental health problems such as stress, anxiety, depression, and sleep difficulties [7, 8]. This connection is powerful among vulnerable groups like migrants and refugees, who are more likely than host populations to experience mental health issues [5]. Refugees and asylum seekers often face higher levels of depression, anxiety, post-traumatic stress disorder, suicidal thoughts, and even severe mental illnesses—occurring up to five times more often than in host populations [9, 10]. Refugees experience several challenges during the migration process that contribute to both FI and poor mental health. These challenges include discrimination, unemployment or unstable work due to irregular or temporary legal status, financial pressures from sending remittances to family in their home country, weak or absent social support networks, and limited access to nutritious food such as fruits and vegetables [5, 7, 8]. Refugees are also more likely to suffer from vitamin and mineral shortages—such as vitamin B12 or iron—which can increase the risk of depression through biological effects [11]. In addition to poor nutrition, FI can lead to emotional distress, creating feelings of shame, guilt, and helplessness while reducing people’s sense of dignity and belonging [7, 12]. Over time, prolonged FI significantly undermines quality of life by lowering life satisfaction and increasing mental health challenges. Taken together, these factors demonstrate that FI extends beyond poverty and food availability, significantly impacting mental health and requiring careful consideration within health and social policy frameworks [5, 8, 13].
Despite Türkiye hosting the largest population of Syrian refugees worldwide [14] and this population’s vulnerability to mental health disorders [15], there is a lack of research on the relationship between FI and the mental health of Syrian refugees in Türkiye. Assessing the relationship between FI and mental health among vulnerable groups, such as refugees, is essential for guiding effective humanitarian aid and government interventions that improve wellbeing and support social integration [16]. This study aims to assess the prevalence of food insecurity and explore its association with mental health among Syrian refugees living in Türkiye.
Methods
This descriptive cross-sectional study was conducted with Syrian refugees residing in Türkiye. A total of 566 Syrian refugees (210 males and 356 females) aged 18 to 62 participated in the study. Prior to the commencement of the investigation, a power analysis utilizing G*Power 3.1.9.7 software was performed with a 95% confidence interval, targeting a minimum participation of 400 individuals. Participation was voluntary, and informed agreement was acquired from all participants prior to the initiation of the research, ensuring anonymity throughout the process. The snowball sampling method is commonly used to recruit hard-to-reach populations, such as refugees [17], and was therefore adopted in this study. Participants were recruited through social and community networks using this approach, resulting in a sample drawn from different regions of Türkiye.
The data were collected between February and May 2024 by native Arabic-speaking researchers using an Arabic questionnaire conducted either online or through face-to-face methods. Participants completed the questionnaire using only one mode, depending on accessibility and feasibility. The sociodemographic section of the questionnaire was developed by the research team, while the remaining sections were based on previously validated instruments. The English version of the questionnaire is provided in Supplementary Material 1, and the Arabic version used in data collection is provided in Supplementary Material 2.
The questionnaire consisted of five sections. The first section inquired about the sociodemographic and household-specific features of individuals. The second section inquired about height and body weight. The third section addressed inquiries regarding food insecurity status. In the fourth section, the status of depression, anxiety, and stress among individuals was evaluated; in the fifth section, the mental health status was analyzed.
Socio-demographic characteristics
The sociodemographic characteristics assessed included age, gender, marital status, educational attainment, residency status in Türkiye, proficiency in Turkish, number of children and household members, income level, employment status, primary occupation, and receipt of financial support. As the individuals hesitated to report their net income, it was asked if the family income was below or above the minimum wage of the period when the data were collected.
Anthropometric measurements
Each participant’s Body Mass Index (BMI) was computed based on self-reported body weight and height. The BMI was calculated by dividing weight (kg) by height squared (m²) and classified according to World Health Organization guidelines. Body Mass Index (BMI) of less than 18.50 kg/m² is classified as underweight, whereas values between 18.50 and 24.99 kg/m² are considered within the normal weight range. A BMI between 25.00 and 29.99 kg/m² indicates being overweight; a BMI of 30.00 kg/m² or above is categorized as obese [18].
Food Insecurity Experience Scale (FIES)
The Food Insecurity Experience Scale (FIES), developed by the United Nations Food and Agriculture Organization (FAO), was used to assess each participant’s level of food insecurity. The FIES focuses on self-reported food-related behaviors and experiences associated with increased difficulties in food access resulting from resource constraints in the past 12 months. It provides a standardized and widely applicable measure of food insecurity, enabling consistent data collection and supporting evidence-based assessments across different populations [19].
The assessment consists of eight questions, with negative responses receiving a score of 0 and positive responses earning 1 point [19]. The total FIES score ranges from 0 to 8 points and is the sum of the scores from all eight questions. Based on the total score, participants were classified as food secure (0–3), moderately food insecure (4–6), or severely food insecure (7–8) [20]. This study applied the Arabic version of the FIES [21], demonstrating a Cronbach’s alpha and omega of 0.87 in the current research.
Depression, Anxiety, Stress Scale-21 (DASS-21)
Lovibond et al. developed the Depression, Anxiety, Stress Scale-21 (DASS-21) to measure the perceived levels of stress, anxiety, and depression, comprising three subscales (depression, anxiety, and stress) [22]. The DASS-21 is a widely used and validated instrument for assessing psychological distress and has been extensively applied in studies involving migrant and refugee populations [5].
The scale has a 4-point Likert-type (0 = Never 1 = Sometimes 2 = Often 3 = Always) response structure, with a minimum score of 0 and a maximum score of 21 for each scale. The scoring is based on the overall score and the scores of the sub-classes. The scale is assessed using five distinct categories derived from each subscale score. Furthermore, scores of 0–4 on the depression subscale are categorized as normal, 5–6 as mild, 7–10 as moderate, 11–13 as severe, and 14 or higher as extremely severe. The classifications for the anxiety subscale are: normal (0–3 points), mild (4–5 points), moderate (6–7 points), severe (8–9 points), and extremely severe (≥ 10 points). The stress subscale is categorized as normal (0–7 points), mild (8–9 points), moderate (10–12 points), severe (13–16 points), and extremely severe (≥ 17 points) [22, 23].
The scale was scored using standard scoring procedures and cut-off values. The scale’s Arabic validity and reliability were assessed by Ali et al. [24]. In the present study, DASS-21 and its subscales (depression, anxiety and stress) Cronbach’s alpha were 0.94, 0.86, 0.85, and 0.84, respectively. Also, omega was 0.93, 0.86, 0.85 and 0.83.
Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)
The Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) is a brief version of the Warwick-Edinburgh Mental Wellbeing Scale and provides a reliable and widely used instrument for assessing mental well-being in population-based studies [25]. The scale comprises seven items and employs a 5-point Likert scoring system (1 = strongly disagree, 5 = strongly agree). A minimum of 7 points and a maximum of 35 points can be attained on the scale. High scores on the measure signify enhanced mental wellbeing [25]. The Arabic validity was performed by Zayed et al. [26]. In this study, Cronbach’s alpha was 0.85 and omega was 0.84.
Statistical analysis
The data were analyzed using version 28.0 of the Statistical Package for the Social Sciences (SPSS). The normality of the data distributions was evaluated using the Kolmogorov–Smirnov and Shapiro-Wilk tests. The categorical variable data are displayed as frequencies and percentages, with group differences assessed by the chi-squared test.
The study provided descriptive statistics like number (n), arithmetic mean (X), and standard deviation (SD). The t-test was utilized to evaluate the difference between groups.
The relationships among variables were examined using Pearson’s correlation test. The one-way ANOVA test was employed to compare several variables exceeding two in number. The Bonferroni correction was employed in the post hoc analysis.
Multiple linear regression analysis analyzed the independent influences of several factors on SWEMWBS scores. The multivariate analysis utilized logistic regression to explore independent determinants of food security status, based on potential factors found in prior research.
The Hosmer-Lemeshow test was employed to evaluate model fit. In logistic regression, FIES was classified into two categories: (1) the food-secure group and (2) the food-insecure group (including moderately and severely food-insecure individuals). All analyses were statistically assessed at a 95% confidence interval, with the significance level at p < 0.05.
Results
The sociodemographic characteristics of the individuals and their households were shown in Table 1. The average age of the participants was 25.3 ± 8.12 years, with 37.1% male and 62.9% female. Among the study participants, 74.2% were single, 17.1% had attained high school graduation, and 76.0 % had a bachelor’s degree. In addition, 57.4% of participants indicated a moderate to good proficiency in Turkish, whereas 31.2% reported an excellent proficiency level.
Table 1.
Sociodemographic characteristics of individuals and their households
| X ± SD/n(%)- Min-Max | |
|---|---|
| Age (years) | 25.3 ± 8.12 (18.0–62.0) |
| Gender | M: 210 (37.1%) |
| F: 356 (62.9%) | |
| Marital status | |
| Married | 146 (25.8%) |
| Single | 420 (74.2%) |
| Education level | |
| ≤Secondary school | 39 (6.9%) |
| High school | 97 (17.1%) |
| ≥University | 430 (76.0%) |
| Duration of residence in Türkiye (years) | 8.3 ± 2.63 (2.0–15.0) |
| Status in Türkiye | |
| Turkish citizen | 112 (19.8%) |
| Temporary protection | 409 (72.3%) |
| Others | 45 (7.9%) |
| Level of Turkish proficiency | |
| Very Poor | 15 (2.7%) |
| Poor | 49 (8.7%) |
| Moderate to good | 325 (57.4%) |
| Very good | 177 (31.2%) |
| Household size | 5.0 ± 2.3 (0.0–14.0) |
| Number of children | 2.4 ± 1.28 (1.0–7.0) |
| Number of employed individuals | 1.4 ± 1.02 (0.0–9.0) |
| Household income | |
| < Minimum wage | 240 (47.7%) |
| Minimum wage | 189 (33.4%) |
| > Minimum wage | 107 (18.9%) |
| Assessment of household income | |
| Income higher than expenses | 60 (10.6%) |
| Income equals expenses | 206 (36.4%) |
| Income lower than expenses | 300 (53.0%) |
| Employment status of the major income earner | |
| Unemployed | 27 (4.8%) |
| Full-time job | 328 (58.0%) |
| Part-time job | 81 (14.2%) |
| Works when available | 130 (23.0%) |
| Occupation type of the major income earner | |
| Civil servant | 33 (5.8%) |
| Worker | 213 (37.7%) |
| Private sector | 147 (25.9%) |
| Self-employed | 140 (24.7%) |
| Student | 15 (2.7%) |
| Housewife | 17 (3.0%) |
| Retired | 1 (0.2%) |
| Financial support status | |
| Yes | 76 (13.4%) |
| No | 490 (86.6%) |
| FIES score | 2.8 ± 2.68 (0.0–8.0) |
| Food Security | 347 (61.3%) |
| Moderate | 146 (25.8%) |
| Severe | 73 (12.9%) |
| SWEMWBS total score | 22.2 ± 5.45 (7.0–35.0) |
| DASS-21 total score | 25.2 ± 14.02 (0.0–63.0) |
| Depression | 7.9 ± 4.98 (0.0–21.0) |
| Normal | 144 (25.4%) |
| Mild | 78 (13.8%) |
| Moderate | 173 (30.6%) |
| Severe | 89 (15.7%) |
| Extremely severe | 82 (14.5%) |
| Anxiety | 8.1 ± 5.27 (0.0–21.0) |
| Normal | 110 (19.4%) |
| Mild | 78 (13.9%) |
| Moderate | 98 (17.3%) |
| Severe | 76 (13.4%) |
| Extremely severe | 204 (36.0%) |
| Stress | 9.0 ± 4.91 (0.0–21.0) |
| Normal | 241 (42.6%) |
| Mild | 81 (14.3%) |
| Moderate | 113 (19.9%) |
| Severe | 82 (14.5%) |
| Extremely severe | 49 (8.7%) |
| BMI classification | 23.9 ± 4.05 (16.1–37.2) |
| Underweight | 31 (5.5%) |
| Normal | 335 (59.2%) |
| Overweight | 146 (25.8%) |
| Obese | 54 (9.5%) |
M Male, F Female, FIES Food Insecurity Experience Scale, SWEMWBS Short Warwick-Edinburgh Mental Wellbeing Scale, DASS Depression Anxiety Stress Scale, BMI Body Mass Index
The duration of residence in Türkiye was 8.3 ± 2.63 years, and 72.3% of the individuals are under temporary protection status. The mean household size was 5.0 ± 2.3, but the average number of children was 2.4 ± 1.28. While an average of 1.4 ± 1.02 people work in the household, 47.7% work for less than the minimum wage. Individuals reporting that their income was less than their expenses constitute 53.0%. Among the individuals who were the primary income earners in the household, 58.0% work full-time, while 14.2% work part-time. 86.6% of individuals reported not receiving any financial support.
When evaluated by food insecurity status, 61.3% of individuals were classified as food secure, 25.8% moderately, and 12.9% severely food insecure. The average total score of individuals on the SWEMWBS is 22.2 ± 5.45, while the average score on the DASS-21 is 25.2 ± 14.02. According to the DASS-21 subscale evaluation, 25.4% of the participants fall within the normal range for the depression subscale, 19.4% for the anxiety subscale, and 42.6% for the stress subscale. When the individuals were evaluated according to BMI classification, 59.2% were classified as normal, 25.8% as overweight, 2.5% as underweight and 9.5% as obese.
Men’s average SWEMWBS and BMI values are statistically higher than women’s. (p:0.04 and p:0.009 respectively). There is no significant difference in the total scores of DASS-21 and its subscales, as well as FIES, according to gender (p > 0.05).
The classification of food insecurity and the assessment of individuals based on age, SWEMWBS, DASS-21, BMI, and household size were provided in Table 2. The average age of individuals in the severe food insecurity group is significantly higher compared to those in the food security group (p < 0.001). The SWEMWBS total score of individuals in the food security was significantly higher than those in the other two groups (p < 0.001). The DASS-21 scores and subscales of individuals in the severe food insecurity group were higher than those in the other two groups. In comparison, those in the moderate food insecurity group had higher scores than individuals in the food security group (p < 0.001). The average BMI of individuals in the food security group was lower than that of the other two groups (p < 0.001). The number of employed individuals in the food security group was higher compared to the severe food insecurity group (p < 0.001).
Table 2.
The classification of food insecurity and the assessment of individuals based on age, SWEMWBS, DASS-21, BMI, and household size
| FI1 (n:347) | FI2 (n:146) | FI3 (n:73) | p | |
|---|---|---|---|---|
| Age | 23.9 ± 6.70 a | 27.1 ± 9.82 b, c | 28.8 ± 8.84c | < 0.001 |
| SWEMWBS total score | 22.8 ± 5.5a | 21.4 ± 5.16b | 20.6 ± 5.34b | < 0.001 |
| DASS-21 total score | 22.6 ± 13.9a | 27.3 ± 12.57b | 33.4 ± 13.26c | < 0.001 |
| Depression | 7.0 ± 4.97a | 8.9 ± 4.46b | 10.6 ± 4.76c | < 0.001 |
| Anxiety | 7.2 ± 5.16a | 8.8 ± 4.91b | 11.1 ± 5.19c | < 0.001 |
| Stress | 8.3 ± 4.96a | 9.5 ± 4.57b | 11.6 ± 4.44c | < 0.001 |
| BMI | 23.4 ± 3.75a | 24.6 ± 4.26b | 25.3 ± 4.52b | < 0.001 |
| Household size | 5.1 ± 2.22 | 4.9 ± 2.42 | 5.0 ± 2.40 | 0.89 |
| Number of children | 2.3 ± 1.25 | 2.5 ± 1.33 | 2.5 ± 1.32 | 0.23 |
| Number of employed individuals | 1.5 ± 1.06 a | 1.3 ± 1.05a, b | 1.2 ± 0.64b | 0.009 |
| Duration of residence in Türkiye (years) | 8.3 ± 2.70 | 8.2 ± 2.53 | 8.3 ± 2.54 | 0.900 |
FI1: Food security; FI2: Moderate food insecurity; FI3: Severe food insecurity
SWEMWBS Short Warwick-Edinburgh Mental Wellbeing Scale, DASS Depression Anxiety Stress Scale, BMI Body Mass Index
a, b, c: For groups of different letters p < 0.05; for groups of the same letters, p > 0.05. Post-hoc analysis: Bonferroni
Table 3 presents the association between food insecurity status and participants’ sociodemographic characteristics, BMI, and mental health indicators, including depression, anxiety, and stress. The education and household income level and household income assessment of individuals in the FI1 group were significantly higher than those of the other two groups (p < 0.001). Additionally, the number of individuals who were single in the FI1 group is higher than in the other groups (p < 0.001). Participants with moderate to good and excellent language proficiency were more prevalent in the FI1 group than in other groups. (p = 0.003). The BMI classification of individuals in the FI1 group differs significantly from the other two groups (p = 0.003). In the depression and anxiety classification, the FI1 group was significantly different from the FI2 and FI3 groups. In the stress classification, the FI1 group differed from the FI3 group, while the FI2 group differed from the FI3 group (p < 0.001).
Table 3.
Association between food insecurity status and sociodemographic characteristics, BMI, mental health indicators among Syrian refugees
| FI1 (n:347) | FI2 (n:146) | FI3 (n:73) | p | |
|---|---|---|---|---|
| Marital status | ||||
| Married | 281 (81.0%) | 95 (65.1%) | 44 (60.3%) | < 0.001 |
| Single | 66 (19.0%) | 51 (34.9%) | 29 (39.7%) | |
| Education level | ||||
| ≤Secondary school | 15 (4.3%) | 16 (11.0%) | 8 (11.0%) | < 0.001 |
| High school | 43 (12.4%) | 37 (25.3%) | 17 (23.3%) | |
| ≥University | 289 (83.3%) | 93 (63.7%) | 48 (65.7%) | |
| Household income | ||||
| < Minimum wage | 88 (25.4%) | 12 (8.2%) | 7 (9.6%) | < 0.001 |
| Minimum wage | 122 (35.1%) | 50 (34.3%) | 17 (23.3%) | |
| > Minimum wage | 137 (39.5%) | 84 (57.5%) | 49 (67.1%) | |
| Assessment of household income | ||||
| Income higher than expenses | 146 (42.1%) | 100 (68.5%) | 54 (74.0%) | < 0.001 |
| Income equals expenses | 157 (45.2%) | 36 (24.7%) | 13 (17.8%) | |
| Income lower than expenses | 44 (12.7%) | 10 (6.8%) | 6 (8.2%) | |
| Status in Türkiye | ||||
| Turkish citizen | 77 (22.2%) | 24 (16.4%) | 11 (15.1%) | 0.122 |
| Temporary protection | 240 (69.2%) | 108 (74.0%) | 60 (82.2%) | |
| Others | 30 (8.6%) | 14 (9.6%) | 2 (2.7%) | |
| Level of Turkish proficiency | ||||
| Very Poor | 5 (1.4%) | 5 (3.4%) | 5 (6.9%) | |
| Poor | 21 (6.1%) | 19 (13.0) | 9 (12.3%) | 0.003 |
| Moderate to good | 198 (57.1%) | 87 (59.6%) | 40 (54.8%) | |
| Very good | 123 (35.4%) | 35 (24.0%) | 19 (26.0%) | |
| BMI classification | ||||
| Underweight | 26 (7.5%) | 2 (1.4%) | 3 (4.1%) | 0.003 |
| Normal | 214 (61.7%) | 88 (60.3%) | 33 (45.2%) | |
| Overweight | 83 (23.9%) | 37 (25.3%) | 26 (35.6%) | |
| Obese | 24 (6.9%) | 19 (13.0%) | 11 (15.1%) | |
| Depression | ||||
| Normal | 121 (34.9%) | 21 (14.4%) | 2 (2.7%) | |
| Mild | 43 (12.4%) | 22 (15.1%) | 13 (17.8%) | < 0.001 |
| Moderate | 96 (27.7%) | 55 (37.8%) | 22 (30.2%) | |
| Severe | 44 (12.6%) | 28 (19.1%) | 17 (23.3%) | |
| Extremely severe | 13 (12.4%) | 20 (13.6%) | 19 (26.0%) | |
| Anxiety | ||||
| Normal | 90 (25.9%) | 18 (12.3%) | 2 (2.7%) | |
| Mild | 51 (14.7%) | 18 (12.3%) | 9 (12.3%) | < 0.001 |
| Moderate | 64 (18.4%) | 25 (17.1%) | 9 (12.3%) | |
| Severe | 41 (11.8%) | 25(17.1%) | 10 (13.7%) | |
| Extremely severe | 101 (29.2%) | 60 (41.2%) | 43 (59.0%) | |
| Stress | ||||
| Normal | 174 (50.1%) | 54 (37.0%) | 13 (17.8%) | |
| Mild | 45 (13.0%) | 25 (17.1%) | 11 (15.1%) | < 0.001 |
| Moderate | 58 (16.7%) | 31 (21.2%) | 24 (32.9%) | |
| Severe | 46 (13.3%) | 24 (16.4%) | 12 (16.4%) | |
| Extremely severe | 24 (6.9%) | 12 (8.2%) | 13 (17.8%) | |
FI1: Food security; FI2: Moderate food insecurity; FI3: Severe food insecurity BMI Body Mass Index
The correlation matrix of individuals’ food insecurity, mental health, depression, anxiety, and stress data was presented in Table 4. A significant positive correlation was found between FIES total score and DASS-21 total score and subscales, age, BMI, and number of children. In contrast, a significant negative correlation was found between the SWEMWBS total score and the number of employed individuals in the household. SWEMWBS total score was significantly negatively correlated with DASS-21 total score, subscales, and household size. The total DASS-21 score and the except stress subscale were positively correlated with the number of years lived in Türkiye.
Table 4.
The correlation matrix of individuals’ food insecurity, mental health, depression, anxiety, and stress
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. FIES total score | 1 | -0.193** | 0.289** | 0.279** | 0.280** | 0.240** | 0.270** | 0.221** | -0.003 | 0.133* | -0.151** | -0.027 |
| 2. SWEMWBS total score | 1 | -0.314** | -0.337** | -0.244** | -0.292** | 0.004 | -0.027 | -0.087* | -0.022 | 0.005 | -0.035 | |
| 3.DASS-21 total score | 1 | 0.931** | 0.916** | 0.924** | 0.026 | 0.034 | 0.065 | 0.114* | -0.013 | 0.110** | ||
| 4. Depression | 1 | 0.773** | 0.812** | 0.012 | 0.028 | 0.074 | 0.104 | -0.014 | 0.112** | |||
| 5. Anxiety | 1 | 0.755** | 0.009 | 0.012 | 0.070 | 0.102 | 0.023 | 0.130** | ||||
| 6. Stress | 1 | 0.053 | 0.056 | 0.034 | 0.112* | -0.047 | 0.059 | |||||
| 7. Age | 1 | 0.464** | -0.120** | 0.088 | -0.123** | -0.058 | ||||||
| 8.BMI | 1 | -0.057 | 0.053 | -0.059 | -0.062 | |||||||
| 9. Household size | 1 | 0.341** | 0.096* | 0.254** | ||||||||
| 10. Number of children | 1 | 0.063 | 0.049 | |||||||||
| 11. Number of employed individuals | 1 | -0.103* | ||||||||||
| 12. Duration of residence in Türkiye (years) | 1 |
FIES Food Insecurity Experience Scale, SWEMWBS Short Warwick-Edinburgh Mental Wellbeing Scale, DASS Depression Anxiety Stress Scale, BMI Body Mass Index
*Correlation is significant at the 0.05 level .**Correlation is significant at the 0.01 level
Linear regression models of the relationship between SWEMWBS total score and FIES, Depression, Anxiety, Stress and household size were shown in Table 5. According to the multiple linear regression model, the included variables explained 12.7% of the variance in mental wellbeing (adjusted R² = 0.127; R² = 0.135; p < 0.001). Food insecurity remained a significant negative predictor of mental wellbeing after controlling for covariates. Specifically, a one-unit increase in the FIES total score was associated with a 0.234-point decrease in the SWEMWBS total score (β = −0.234, 95% CI: −0.398 to − 0.084, p = 0.005). Similarly, a one-unit increase in depression score was associated with a 0.324-point decrease in the SWEMWBS total score (β = −0.324, 95% CI: −0.485 to − 0.162, p < 0.001).
Table 5.
Linear regression models of the relationship between SWEMWBS total score and FIES, depression, anxiety, stress and household size
| SWEMWBS Total score | β coefficient (95%Cl) | SE | t | p |
|---|---|---|---|---|
| FIES total score | -0.234 (-0.398; -0.069) | 0.084 | -2.791 | 0.005 |
| Depression | -0.324 (-0.485; -0.162) | 0.082 | -3.925 | < 0.001 |
| Anxiety | 0.096 (-0.039; 0.232) | 0.069 | 1.402 | 0.161 |
| Stress | -0.106 (-0.266; 0.054) | 0.081 | -1.304 | 0.193 |
| Household size | -0.163 (-0.348; 0.022) | 0.094 | -1.734 | 0.084 |
FIES Food Insecurity Experience Scale, SWEMWBS Short Warwick-Edinburgh Mental Wellbeing Scale
Factors associated with food insecurity (FIES total score) were shown in Table 6. Gender 0.56 times, income status 0.26 times, education 0.39 times, and the number of children 2.01 times affect food insecurity.
Table 6.
Factors associated with the food insecurity status (FIES total score)
| Sociodemographic Characteristics | Odds Ratio (95% CI) | p |
|---|---|---|
| Gender | 0.56 (0.38–0.82) | 0.003 |
| Total income (monthly) | 0.26 (0.15–0.45) | < 0.001 |
| Education | 0.39 (0.25–0.58) | < 0.001 |
| Number of Individuals | 0.85 (0.56–1.26) | 0.418 |
| Number of Children | 2.01 (1.12–3.58) | 0.018 |
FIES Food Insecurity Experience Scale
Discussion
In the present study, 61.3% of Syrian refugees in Türkiye were food secure, while 25.8% experienced moderate food insecurity and 12.9% severe food insecurity Food-secure refugees had higher levels of education, family income, and number of employed household members, and were more likely to be single. They were also younger, had fewer children, and lower BMI values compared with food-insecure groups. Moreover, total SWEMWBS scores were higher among food-secure individuals, whereas DASS-21 total and subscale scores were significantly higher among those experiencing severe food insecurity.
Food insecurity among Syrian refugees remains at concerning levels globally [27]. In Lebanon, 37% of refugees faced emergency levels of food insecurity [28]. In Jordan, 42% were moderately and 36% severely food insecure [29]. In Norway, 14% of participants experienced moderate and 8% severe food insecurity [30]. In addition, 44.6% of Syrian refugees resettled in Ontario reported food insecurity [16]. More recently, among Syrian refugees in Istanbul, moderate and severe food insecurity were reported at 19.4% and 64.1%, respectively [31]. In the present study, the prevalence was also found to be 25.8% for moderate and 12.9% for severe food insecurity. Differences between studies may be attributed to variations in host country contexts, socioeconomic characteristics of study populations, and methodological differences in assessing and classifying food insecurity. In addition, the use of snowball sampling in the present study may have led to the recruitment of participants from similar socioeconomic or geographic networks, which could have influenced the observed distribution of food insecurity.
Food insecurity has been consistently associated with sociodemographic factors such as gender, age, income, education, number of children, and language proficiency [32–35]. In this study, food-secure refugees reported higher education, higher income, and more employed household members, while being younger and having fewer children. Furthermore, gender (OR = 0.56), income status (OR = 0.26), education (OR = 0.39), and the number of children (OR = 2.01) were identified as significant predictors of food insecurity status. Low household income restricts access to nutritious foods, undermining one of the core pillars of food security—food accessibility [36]. Economic constraints also force low-income households to depend on inexpensive, energy-dense, nutrient-poor foods, which may contribute to weight gain and obesity—a phenomenon described as the “food insecurity–obesity paradox” [37]. Consistent with earlier studies [38–40], food-insecure participants in this study had higher BMI values. However, the reliance on self-reported weight and height may have introduced reporting bias, particularly underreporting of body weight, which could have influenced BMI estimates and the interpretation of the relationship between food insecurity and obesity.
Refugees’ elevated risk of both food insecurity and poor mental health outcomes is well documented [11, 41–43]. Similarly, our regression analysis showed that food insecurity was significantly associated with mental wellbeing: each one-point increase in the FIES score was associated with a 0.234-point decrease in SWEMWBS, and each one-point increase in depression score was associated with a 0.324-point decrease in SWEMWBS. Additionally, among participants, 30.2%, 49.4%, and 23.2% had severe or extremely severe symptoms of depression, anxiety, and stress, respectively, with DASS-21 scores and subscales being highest in the severe food insecurity group. A study in Istanbul found prevalence rates of 36.1% for anxiety and 34.7% for depression among Syrian refugees [44]. Zangiabadi et al. (2024) reported lower rates among Syrian refugees in Canada (7.6%, 8.9%, and 8.5% for severe depression, anxiety, and stress, respectively), but similarly found significant associations with food insecurity [16]. In Lebanon, AbouRizk (2022) reported moderate and severe depression in 11.1% and 9.9% of Syrian refugee participants [45]. The higher prevalence of depression observed in our study may be explained by differences in host country socioeconomic contexts, refugees’ pre-migration socioeconomic and mental health status, and post-migration stressors [46]. This study also found that the total DASS-21 score, except for the stress subscale, was positively correlated with the number of years lived in Türkiye. Several pathways connect food insecurity to mental health [16, 30]. Food insecurity not only leads to psychological distress—including depression, anxiety, and stress—but also contributes to social isolation and feelings of shame. Limited access to culturally appropriate, nutrient-rich foods can disrupt traditional practices and daily routines, further undermining mental wellbeing. Moreover, food insecurity is linked to poor dietary quality (e.g., deficiencies in vitamin B12, iron, and vitamin D) and fears of developing diet-related chronic conditions such as obesity, hypertension, and diabetes, which can compound psychological distress [11, 35, 43]. Given the protracted nature of the Syrian conflict, refugees remain at heightened risk of both new and pre-existing mental health challenges, further exacerbated by food insecurity and their living conditions in host countries [13]. In addition, the prolonged conflict in Syria has severely disrupted the country’s mental health care system, resulting in limited access to services and a high burden of untreated mental health conditions. This context may contribute to significant pre-migration trauma among Syrian refugees, which can influence their mental health outcomes in host countries [47].
Limitations
This study has several limitations. First, its cross-sectional design allows for identifying associations but does not provide evidence of causality. Second, the snowball sampling approach limits representativeness and may have introduced selection bias. Third, body weight and height were self-reported rather than measured, which may limit the accuracy of the nutritional status assessment, particularly due to potential underreporting of body weight. Fourth, data collection occurred between February and May 2024, and seasonal variation in food insecurity could limit generalizability across the year. Future research should address these limitations by employing longitudinal study designs and objective anthropometric measurements to strengthen causal inferences and provide more precise assessments of nutritional status, thereby enhancing understanding of the relationship between food insecurity and mental health in this population. Despite these limitations, the study offers valuable insights into the prevalence and determinants of food insecurity and mental health outcomes among refugees, contributing important data to the existing literature in the context of Türkiye, a major host country for Syrian refugees.
Conclusion
In conclusion, the study finds that food insecurity was significantly associated with adverse mental health outcomes among Syrian refugees in Türkiye. Monitoring food insecurity and mental health is essential to guide timely and effective policies. Culturally sensitive, language-accessible, and community-based interventions that also consider the dietary preferences of immigrant populations are needed, including Arabic-language nutrition education programs, Turkish language support initiatives, and community-based mental health support services delivered through local centers. Future research should employ longitudinal study designs and objective anthropometric measurements to strengthen causal inferences and improve the accuracy of nutritional assessments.
Supplementary Information
Acknowledgements
We would like to thank all participants.
Authors' contributions
KE: design, conceptualization, methodology, writing, review, and editing. FA: design, analysis, methodology, writing, review, and editing. The authors have approved the final version submitted.
Funding
None.
Data availability
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The ethical approval of the study was obtained from the Ethics Committee for Social and Human Sciences Research of Tokat Gaziosmanpaşa University with the decision dated 25.01.2024 and numbered 03.19. This research was performed per the principles of the Declaration of Helsinki. Participants were apprised of the study’s goal, and their informed consent was secured before the questionnaire.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.