Dying of starvation if not from bombs: assessing measurement properties of the Food Insecurity Experiences Scale (FIES) in Gaza’s civilian population experiencing the world’s worst hunger crisis

Abstract

Background

Since October 2023, the humanitarian crisis in Gaza has dramatically escalated and food insecurity (FI) has rapidly deteriorated. In the face of such situation, it has been recommended that accurate information on FI should be integrated in emergency reporting systems in order to better target and assess the impact of humanitarian aid. To achieve this, field practitioners, researchers and decision-makers should be equipped with user-friendly and psychometrically sound measures tailored to real-life war situations and the Palestinian context. Therefore, the present study aimed to test the psychometric properties of the Food Insecurity Experiences Scale (FIES) in a sample of Arabic-speaking community adults currently living in the Gaza Strip during the war.

Methods

This study used a cross-sectional design, snowball sampling as a recruiting strategy, and a self-administered online questionnaire to collect data from participants. It was performed during the period from September 1st to 30th, 2024. A total of 534 valid responses were received and were included in the final analysis.

Results

Approximately one out of two people in Gaza were experiencing any FI. Fit indices in confirmatory factor analysis indicated that a one-factor solution fit the data with acceptable factor loadings. Furthermore, our findings indicated that the Arabic version of the FIES presented an excellent level of reliability, with both Cronbach’s alpha and McDonald omega coefficients of 0.94. Cross-sex measurement invariance in the FIES was established at scalar and metric levels. Finaly, concurrent validity was evidenced by FIES’s positive correlations with water insecurity experiences, post-traumatic stress, depression and anxiety symptoms.

Conclusion

Altogether, our findings showed that the FIES fulfils requirements of validity and reliability. It may thus be considered as appropriate tool for assessing FI in Gazan war-affected populations currently suffering from acute FI emergency and requiring urgent action to meet their food needs. The FIES is simple, short, economic and time-effective. As a FI indicator, the Arabic FIES is useful in providing information that enables actions by policy makers and guides humanitarian-aid actors’ efforts aimed at decreasing, mitigating, or preventing severe FI, and saving lives or livelihoods.

Clinical trial number

Not applicable.

Introduction

Soon after the current war started in October 2023, the population in Gaza has been experiencing unprecedent levels of food insecurity (FI) and hunger, described as a “humanitarian catastrophe”. Since then, nearly every agricultural land and bakery were bombed and damaged or even razed; and all means of food production were destroyed [1]. Famine has been used “as a weapon of war”, causing humanitarian food assistance to be minimal and inadequate to survive, or not allowed to reach starving people [1]. Adults have been risking gunfire and death to access aid convoys; children have been suffering from lack of food and dying of malnutrition [2]. As hunger reached catastrophic levels in Gaza, people resorted to eating weeds and animal feed to survive [1]. According to the United Nations, an estimated 576,000 people in the Gaza Strip were “at imminent risk of famine” by February 2024 [1]. The Integrated Food Security Phase Classification (IPC) categorized Gaza as being at Phase 4 (Emergency Acute Food Insecurity) for both the current and projection periods (up to 30 September 2024), with the presence of households in IPC Phase 5 (Catastrophe/Famine) [3]. Phase 4 reflects extreme food shortages, acute malnutrition, excessively high disease levels, and rapidly increasing risk of hunger-related death. Phase 5 indicates an extreme lack of food leading to extremely critical levels of acute malnutrition and death. As such, the situation in Gaza over the past months have been qualified by human rights organizations and experts as the world’s worst hunger crisis, and its reach is anticipated to extend far beyond those whose lives are directly threatened, to encompass the global food security [4].

Preceding October 2023, Gaza was already facing a vulnerable food security situation because of war, occupation, the long blockade of the Strip. In the context of 57 years of Israeli occupation, Israel has carried out several significant military operations that have decimated Gaza’s infrastructure and the foundation of its economy. The protracted siege that had been in place since 2007 has led to significant economic and social difficulties, increases in violence, and political instability. Strict air, sea, and land closures, as well as restrictions on the importation of technology and necessary inputs, had a significant negative effect on Gaza’s economy, and sparked a serious humanitarian catastrophe in the heavily populated Strip. These circumstances resulted in a widespread poverty, with over 53% of the population living below the poverty line, and an unemployment rate of over 45%, which is among the highest in the world [5]. Once a vital component of Gaza’s economy, the agricultural industry has suffered terrible losses as a result of prior battles and limited access to fishing grounds and farmlands. These losses, along with the low level of industrial production have exacerbated food and economic insecurity. The suffering was further aggravated by frequent power outages and insufficient water and sanitation systems, which limited access to basic services like healthcare and education [6]. Gazans showed resilience by achieving high levels of education, but a lack of work possibilities continued the cycle of poverty and dependency. As a result, a sizeable portion of people in Gaza became, for years now, dependent on humanitarian food aid for their survival and lacking access to a nutritious sufficient diet [7]. Gazans have been suffering high malnutrition rates and related health complications, including low-birth weight, malnutrition, micronutrient deficiency, anemia and weakened immunity [8]. Since October 2023, the humanitarian crisis in Gaza has dramatically escalated and FI has rapidly deteriorated. In the face of such situation, it has been recommended that, in the short term, accurate information on FI and its indicators should be integrated in emergency reporting systems in order to better target and assess the impact of humanitarian aid [4]. In the long term, measuring FI could also be relevant and useful for informing decision-making about how to resolve challenges to food and nutrition security during the recovery phase after the war had ended. To achieve this, Field practitioners, researchers and decision-makers should be equipped with user-friendly and psychometrically sound measurement instrument tailored to real-life war situations and the Palestinian context.

Measurement instruments of FI

Many definitions are used for FI in the scientific literature, varying widely within and across disciplines, and significant differences exist in methods of assessing the FI construct [9]. There is some consensus on defining food security as “when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” [10]. Hunger is thus a possible and not a necessary outcome of FI [11]. A range of different measures have been developed and implemented worldwide to assess FI, each capturing different aspects of FI experiences. The Global Food Security Index (GFSI) assesses the quality, availability, affordability, safety, and resiliency of foods available in a given nation [12]; it is, therefore, a macro-measure that assesses FI at the national level rather than the at household and individual level. The Household Dietary Diversity Scores (HDDS) [13] and the Food Consumption Score (FCS) [14] measure the quantity and/ or quality of foods consumed by an individual and/or a household. However, their reference periods are very limited (the previous 24 h and the last seven days, respectively) compared to other measures (typically the past year or the past 30 days) [9]. In addition, the FCS only detects the household dietary diversity without accounting for variations in the intrahousehold consumption of foods [14]. The Household Food Insecurity Access Scale (HFIAS) is a 9-item measure that assesses the intensity and frequency of psychological and behavioural challenges that a household confronted in accessing foods in the last month [13]. The HFIAS was largely criticized due to its subjective nature and its varying applications across contexts [15]. Besides, the HFIAS fails to appropriately assess other pillars of food security, including utilization, stability, or availability [9]. Household Pulse Survey (HPS) assesses whether and how often households had sufficient food to eat over the past one, two or four weeks through only one question [16]; hence, the HPS has the limitations inherent in single-item assessments. Finally, the Household Food Security Survey Module (HFSSM) is a 18-item measure that evaluates the prevalence of FI in households in the specific context of the United States [17]; thus, it fails to assess FI at a cross-national level [9]. To address some of the shortcomings of existing measures described above, the Food and Agriculture Organization (FAO) developed the Food Insecurity Experience Scale (FIES) in 2014 through the Voices of the Hungry Project [18].

The Food Insecurity Experience Scale (FIES)

Although no agreement has been made among practitioners or scientists on one best evaluation measure for FI [19, 20], the FIES was one of the most commonly used worldwide. The FIES was designed to assess the severity of FI based on individuals’ experiences to access adequate food using a reference period of the past 12 months [18, 21], as well as the percentage of individuals in a given population who have experienced moderate-to-severe levels of FI [18, 22]. It is composed of eight yes-no questions assessing different levels of FI, from the least severe (i.e. worry about obtaining food; “In the last year was there a time that you were worried you would not have enough food to eat because of a lack of money or other resources?”) to the more serious (i.e. hunger; “In the last year was there a time that you were hungry but did not eat because there was not enough money or other resources for food?”) [23]. The FIES has been acknowledged as a short, standardized and valuable global tool to assess FI. It has been translated into 170 languages, and was found to be accepted worldwide and suitable for use across countries and cultures [18, 23]. Using multi-country data and nationally representative adult populations, the one-parameter logistic Rasch model was applied to examine the psychometric performance of the FIES and showed that the scale performed adequately in each country [24]. Although the suitability and usefulness of the FIES has been well-established, and despite its increasing widespread application in international and national population surveys, there has been a call for more validation studies of the scale across different nations to extend knowledge on its applicability in cross-national and cross-cultural settings [25]. This paper sought to add new psychometric information to existing knowledge about the FIES by evaluating its measurement properties in a population of Palestinians suffering from war-induced hunger.

Rationale and aim of this study

Over the past years, measuring FI has evolved from detecting perceptions to lived experiences [26]. This study proposes to assess the relevance of the FIES in assessing FI as a “lived experience” in a population facing acute, entirely man-made hunger due to the ongoing war in Gaza. Recognizing FI as experiences lived by war-affected people may help researchers comprehend the changes in these experiences across various contexts and settings, as well as over time because of war [25]. Therefore, the present study aimed to test the psychometric properties of the FIES in a sample of Arabic-speaking community adults currently living in the Gaza Strip during the war. It is hypothesized that the FIES will show a unidimensional factor structure assuming that the set of eight questions reflect a single underlying factor in both sexes with acceptable internal consistency. Further it is expected that the FIES will have good concurrent validity against measures of water insecurity, PTSD, depression, and anxiety.

Methods

Sample and procedure

This study used a cross-sectional design, snowball sampling as a recruiting strategy, and a self-administered online questionnaire to collect data from participants. It was performed during the period from September 1st to 30th, 2024. The questionnaire was distributed to potential participants through various social media sites, including Facebook, Instagram, and WhatsApp. Participants were included if they fulfilled the following inclusion criteria: (1) being aged 18 and over; (2) currently living in the Gaza strip (i.e. Gaza City, North Gaza, Deir Al Balah, Khan Younis, Rafah); and (3) willing to participate. The research protocol was granted by the scientific and ethics committee of Deanship of scientific research, Palestine Technical university – Kadoorie, Palestine. The first section of the survey questionnaire contained an informed consent statement. Each respondent was asked whether they agree to participate in this study. Only an affirmative response to this question gave them access to the main part of the survey. The voluntary nature of participation was clearly stated. Participants were also informed about the confidentiality of their personal data. Of the 546 participants who accessed the survey link, 12 (0.4%) responded negatively to the consent question, and were therefore directly withdrawn from the survey. A total of 534 valid responses were received and were included in the final analysis.

Measures

Socio-demographic information

Data regarding basic sociodemographic information of participants was collected, including sex (male, female), age, education (primary, middle, secondary, university), marital status (single, married, divorced, widowed), and current residency (refugee camps, village, city).

The Food Insecurity Experience Scale (FIES)

The FIES contains eight items which assess the extent to which a given population is endorsing different self-reported experiences of FI (e.g., limiting food intake, altering food quality, anxiety), and how severe their experiences with FI can be [27]. at the individual level [23]. The scale has undergone careful translation and linguistic adaptation in many languages (including Arabic [28]) before its application, to ensure that it can be correctly understood and universally meaningful wherever it is applied [27]. Each negative response is attributed the score of “0”, and each affirmative response is attributed the score of “1”. Total scores vary from 0 to 8. The following cutoff scores were used to categorize respondents based on their FI status: food secure (0), mild FI (1–3), moderate FI (4–6), and severe FI (7–8) [29].

The four-item Household Water Insecurity experiences Scale (HWISE-4)

The HWISE-4 contains four items measuring water insecurity experiences (e.g., “In the last 4 weeks, how frequently did you or anyone in your household worry you would not have enough water for all of your household needs?”) [30]. Items are scored on a five-point Likert type scale ranging from 0 (never, 0 times) to 4 (always (more than 20 times). A score of 4 or above is set as the cut off which accurately dichotomizes participants into water-insecure and water-secure. The Arabic validated version was used [31] (Cronbach’s alpha = 0.91 in this sample).

The impact of event Scale-6 (IES-6)

The IES-6 [32] is a shortened version of the Impact of Event Scale – Revised (IES-R) [33]. It assesses the severity of post-traumatic stress disorder (PTSD) symptoms through six items and three dimensions: intrusion (2 items), avoidance (2 items) and hyper-arousal (2 items). Response options vary on a five-point scale from 0 (not at all) to 4 (extremely). Higher total scores reflect greater levels of PTSD reactions. The Arabic validated version of the IES-6 was used in the present study [34] (Cronbach’s alpha = 0.83).

The Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is a valid and reliable scale composed of 9 items, which was used to measure the severity of depression symptoms over the last two weeks [35]. Participants are asked to indicate how often they have been bothered by nine problems (e.g., “Feeling bad about yourself or that you are a failure or have let yourself or your family down” or “Thoughts that you would be better off dead, or of hurting yourself”), with response options varying from “not at all” = 0 to “nearly every day” = 3. Total scores range between 0 and 27, with greater scores indicating higher levels of depression. We used the Arabic validated version of the PHQ-9 in this study [36, 37], which yielded a Cronbach’s alpha of 0.93 in the present sample.

The generalized anxiety disorder 7-item (GAD-7)

This scale is self-administered and composed of seven items, each of them asks the respondents on whether they have experienced one of seven generalized anxiety symptoms (e.g., “Not being able to stop or control worrying” or “Worrying too much about different things”) over the past 2 weeks [38]. Response options are the following: “Not at all” = 0, “Several days” = 1, “More than half the days” = 2, and “Nearly every day” = 3. Total scores vary between 0 and 21, with higher scores referring to more severe anxiety. The Arabic validated version was adopted in this study [36, 39], with a Cronbach’s alpha of 0.94.

Analytic strategy

There were no missing responses in the dataset. The total sample (n = 534) was divided into two subsamples; subsample 1 (1/3 of the total sample; n = 179) was used for the exploratory factor analysis (EFA), whereas subsample 2 (2/3 of the total sample; n = 355) was used for the confirmatory factor analysis (CFA). We used FACTOR 12.04.01 [40] to perform the EFA. The Kaiser-Meyer-Olkin (KMO) and the Bartlett’s statistic were used to confirm the suitability of the data. The Measure of Sampling Adequacy (MSA) at the item level value ranges from 0 to 1, with values below 0.50 indicate the need to eliminate the item [41]. The Expected Residual correlation direct Change (EREC) index was used to assess the residual correlation between two items (called doublets); items that appear repeatedly in different doublets should be removed [42]. Since the items are scored on a Likert scale, a polychoric correlation matrix was conducted [43]. We used the Unweighted Least Squares (ULS) as the method of estimation [44], with the parallel analysis used to determine the optimal number of factors to retain [45, 46]. A minimum sample of 80 participants was needed following the recommendations of Comree and Lee (ten participants per scale’s item) [47].

Consequently, we conducted a CFA via the SPSS AMOS v.28 software. We estimated a minimum sample of 160 participants based on the recommendation of 20 times per scale’s variables [48]. The maximum likelihood method was used to obtain parameters estimate. Multiple fit indices were calculated: root mean square error of approximation (RMSEA) (≤ 0.08), standardized root mean square residual (SRMR) (≤ 0.05), Tucker-Lewis Index (TLI) and Comparative Fit Index (CFI) (≥ 0.90 for both) [49]. Additionally, convergent validity was checked via the average variance extracted (AVE) ≥ 0.50 [50]. Multivariate normality was not verified at first (Bollen-Stine bootstrap p = 0.002); therefore, we performed non-parametric bootstrapping procedure.

A multi-group CFA was conducted to examine measurement invariance of FIES scores between genders [51] at the configural, metric, and scalar levels [52]. ΔCFI ≤ 0.010 and ΔRMSEA ≤ 0.015 or ΔSRMR ≤ 0.010 supported the evidence of invariance [53]. Comparison of FIES scores between genders was done using the Student’s t test.

Composite reliability was assessed using McDonald’s ω and Cronbach’s α, with values greater than 0.70 reflecting adequate composite reliability [54]. The FIES scores were considered normally distributed as shown by skewness and kurtosis values between − 1 and + 1 [55]. The association between the FIES scores and other scores was evaluated using the Pearson test.

Results

In total, 534 participants participated in this study, with a majority of participants aged 19 years and 71.9% married. A total of 227 participants (42.5%) were categorized as water-insecure. The prevalence of any FI was 50.2%, with 31.3% being classified as moderately-to-severely food insecure. Other descriptive statistics of the sample can be found in Table 1.

Table 1 Sociodemographic and other characteristics of the sample (N = 534)

Exploratory and confirmatory factor analyses (subsample 1 and subsample 2 respectively)

The KMO (= 0.91) and Bartlett’s test (p ≤ 0.001) affirmed the suitability of the data. None of the items was removed according to the MSA or EREC indices, with the parallel analysis advising a unidimensional structure (explained variance of 69.72%) supported by the Goodness of Fit Index (GFI = 0.99) being greater than 0.95, TLI = 1.01, CFI = 1.00, the UniCo (= 0.99) index greater than 0.95, the I-ECV (I-ECV = 0.93) greater than 0.85 and MIREAL (MIREAL = 0.17) lower than 0.30.

We ran a CFA using the one-factor structure obtained from the EFA. The fit indices were good (RMSEA = 0.103 (90% CI 0.083, 0.124), SRMR = 0.034, CFI = 0.963, TLI = 0.948). The standardized estimates of factor loadings deriving from the EFA and CFA were all adequate (Table 2). Composite reliability of scores was adequate in the total sample (ω = 0.91 / α = 0.90). The convergent validity for this model was confirmed (AVE = 0.64).

Table 2 Factor loadings deriving from the exploratory factor analysis (EFA) and standardized loading factors deriving from the confirmatory factor analysis (CFA) of the Food Insecurity Experience Scale in Arabic

Sex invariance (total sample)

Invariance was shown at the metric and scalar levels in terms of genders (Table 3). No significant difference was found in FIES scores between males and females (2.41 ± 3.01 vs. 2.21 ± 2.96; t(532) = 0.72; p = 0.474, Cohen’s d = 0.069).

Table 3 Measurement invariance of the Food Insecurity Experience Scale across gender

Concurrent validity

Higher FIES scores were significantly associated with higher water insecurity experience (r = 0.56; p < 0.001), higher PTSD (r = 0.25; p < 0.001), higher depression (r = 0.42; p < 0.001), and higher anxiety (r = 0.41; p < 0.001).

Discussion

Before the ongoing war, the population in Gaza was already dealing with a longstanding FI and constrained access to nutritious food. Since October 7th 2023, civilians in Gaza have been facing high levels of acute FI, along with a denial of humanitarian access and assistance. Our study had as a main goal to examine psychometric properties of the FIES among Gazan adults during the ongoing war. Findings showed that approximately one out of two people in Gaza were experiencing any FI. Fit indices in CFA indicated that a one-factor solution fit the data with acceptable factor loadings, and multigroup invariance tests demonstrated that this solution fit largely equivalently across sexes. Overall, results suggest that the FIES is a valid and reliable FI measurement instrument for the Arabic-speaking Palestinian population enduring war-related starvation.

The FIES defines FI as the lack of access to enough food for a healthy and dignified life. The FIES responses are dichotomous in nature (Yes – No), providing enough information to construct a one-dimensional measurement tool [23]. The current study extends previous research by using an EFA-to-CFA approach to explore the best-fitting model of the FIES in a group of civilians in Gaza being starved due to war. The eight FIES items loaded onto a single overall factor, suggesting that all items reflect a single continuous latent variable underlying the responses. Unidimensionality is a necessary condition for the use of summated scores and for any analyses based on FIES total scores. Unidimensionality is, therefore, an important attribute of the scale as it enables to report a single score representing the same underlying construct of experience-based FI at the individual level over the past year. This eases the interpretability of FIES scores, and lends supports to the assertion that the FIES can easily be adaptable across different populations and contexts, enabling standardized comparisons of prevalence data via the use of a single metric [56, 57]. Furthermore, our findings indicated that the Arabic version of the FIES presented an excellent level of reliability, with both Cronbach’s alpha and McDonald omega coefficients of 0.94. Our results are similar to those of a study by Helmi et al. [58] showing that the Malay-language version of FIES had acceptable internal consistency (Cronbach’s alpha = 0.759) in a population-based sample aged 15-year-old and above.

Multi-group CFA was used to examine whether the FIES was invariant across sex groups (male or female). Cross-sex measurement invariance in the FIES was established at scalar and metric levels. This means that the eight FIES questions and their response options were understood similarly across male and female respondents. Evidence of invariance should be recognized as an important consideration before arriving at any conclusions regarding sex differences in FI. This psychometric property is relevant, especially as some empirical evidence suggested that males and females may respond to FI questions differently because of their divergent food-related responsibilities and roles [59]. Finaly, concurrent validity was evidenced by FIES’s positive correlations with water insecurity experiences, PTSD, depression and anxiety symptoms. This is consistent with previous evidence from the 2014 Gallup World Poll that individual-level FI, as assessed using the FIES, and at any degree of severity, was positively correlated with specific psychosocial stressors and poorer mental health status (e.g., stress, sadness, anger, worry) across 149 countries and different global regions [60].

Based on FIES scores, 50.2% of participants experienced any form of FI and 31.3% were classified as moderately-to-severely food insecure. These rates are similar to those reported in Sudan, a country hit by conflicts, wars, economic instability, poor harvests, and which is known to be one of the most food-insecure countries globally. A recent study conducted in a sample of 330 Sudanese households using the FIES showed that 33.6–37.9% of them were affected by moderate to severe levels of FI [61]. Using the same measure, the overall prevalence of moderate or severe recent FI was estimated at 15% in government-controlled areas of Ukraine, two years after the Russo-Ukrainian War had elapsed [62]. It can be suggested that, in the context of war, countries struggling for years with long-standing conflicts, political violence and economic hardship (like Gaza and Sudan), appear to be the most affected by FI. Our findings, along with those of previous research, support the usefulness of the FIES in accurately estimating the prevalence of FI in war- and conflict-affected populations.

Study limitations

There are some limitations to this study that merit acknowledgment. The sample was gathered using an online questionnaire, which might have affected the representativeness of findings. Moreover, the study relied on snowball sampling, which is considered a powerful tool for accessing specific populations (such as war-affected individuals). At the same time, however, it may increase the likelihood of sample bias and reduce the ability to generalize findings to the broader population. In addition, this sampling method is non-probability-based, which does not allow for the estimation of sampling error or the determination of the statistical significance of the data. Due to the cross-sectional nature of our data, causality could not be inferred. Moreover, the stability of the FIES over time could not be verified, as data were collected at a single point in time. Therefore, future longitudinal research is required to enable a better understanding of the stability of FIES over time in war settings. In addition, findings could be subject to response and social desirability biases, as only self-administered measures were used.

Clinical and research implications

To the best of our knowledge, this study is among the first to undertake EFA and CFA to demonstrate construct validity of the single-factor structure of the FIES. As a unidimensional measure, the FIES offers a unique opportunity to compare prevalence estimates of FI across countries and over time using computed total scores obtained by summing the scores for all eight items. The international FIES thresholds defined by FAO to classify respondents based on their FI experiences levels are also made comparable across populations and different environmental settings [23], and can thus be successfully adopted to produce estimates of the prevalence of FI in Palestine during and after war [64].

Additionally, this study addresses the prominent measurement issue of invariance across sex groups, as it ensures that FIES items are being interpreted identically between males and females, and allows to accurately evaluate sex differences in FI experiences in future clinical and research practices. Measurement invariance is a highly valuable, yet often neglected step in psychometric research, and only a very few studies using the FIES have provided evidence in this regard. Future studies are recommended to conduct invariance tests that enable researchers to explore and to justify cross-group comparisons of mean FIES scores.

This study is also among the very limited studies to investigate the link between FI and mental health variables using standardized measures and a war-affected population. Although FI has been implicated as a causal factor for the development of mental health problems, yet the direction of this relationship remains unknown. Future longitudinal and experimental research are still needed to address this issue. Finally, further validation studies need to be done regarding the applicability of the FIES in other war and conflict settings. To minimize the potential for bias, ensure representativeness of the sample and generalizability of findings to the broader conflict-affected populations, future studies should consider applying a random sampling technique and including a larger sample size in diverse communities.

Conclusion

Altogether, our findings showed that the FIES fulfils requirements of validity and reliability, and may thus be considered as appropriate tool for assessing FI in war-affected populations currently suffering from hunger. The FIES is simple, short, economic and time-effective. It could therefore be easily implemented in war settings to measure and monitor FI for clinical, research and policy-making purposes. Evaluating other psychometric aspects of the Arabic version of the FIES, such as inter-rater reliability and convergent validity, could be prolific directions for future research.