Household income sources and mobility drivers of dietary diversity among refugees with hypertension and/or type 2 diabetes in Bidibidi Settlement, Uganda

Background Dietary diversity is a key indicator of food group variety and is widely used as a proxy for nutrient adequacy among individuals living with chronic conditions, such as hypertension (HTN) and type 2 diabetes mellitus (DM). In refugee settings, structural constraints may limit dietary diversity. However, evidence on dietary diversity among refugees already living with HTN and/or DM remains limited. This study aimed to examine the associations between household income sources and cross-border mobility and dietary diversity among refugees with HTN and/or DM in Bidibidi Refugee Settlement, northern Uganda. Methods We conducted a community-based cross-sectional survey between September and December 2024 among 1,010 adult refugees with HTN and/or DM, recruited using a chain- referral sampling approach incorporating elements of respondent-driven sampling (RDS). Dietary diversity was assessed by a 24-hour recall and summarized as a dietary diversity score (DDS), calculated by summing the number of different food groups consumed (range 0–9). Household income sources (humanitarian aid, informal income, and formal income) was used as a proxy for socioeconomic status, and cross-border mobility was defined as self-reported return trips to South Sudan. Multivariable linear regression was used to examine associations with DDS, adjusting for potential confounders. Results Participants consumed an average of two food groups in the previous 24 hours (mean DDS 2.0 ± 0.64), indicating very low dietary diversity. In adjusted analyses, greater cross-border mobility was associated with lower dietary diversity. Compared with participants reporting no return trips, DDS was lower among those with one return trip (adjusted β = −0.28; 95% CI: −0.38 to −0.17) and among those with multiple return trips (adjusted β = −0.46; 95% CI: −0.57 to −0.35). Household income source was also associated with dietary diversity. Relative to reliance on humanitarian aid, formal income was associated with higher dietary diversity (adjusted β = 0.25; 95% CI: 0.10 to 0.41), while informal income was associated with lower dietary diversity (adjusted β = −0.10; 95% CI: −0.18 to −0.01). Conclusion Dietary diversity among refugees living with HTN and/or DM in Bidibidi Refugee Settlement was extremely limited and was associated with cross-border mobility and household income sources. These findings suggest that dietary patterns in this setting are shaped primarily by structural constraints affecting food access and livelihood opportunities among displaced populations. However, the cross-sectional design limits causal inference, and the use of unweighted chain-referral sampling limits the generalizability of descriptive estimates to the wider refugee population.