Improvements in economic, social, and food security outcomes of Palestinian refugee women and diet diversity of Palestinian schoolchildren in Lebanon: the Healthy Kitchens, Healthy Children intervention

Abstract

BackgroundPalestinian refugees living in Lebanon continue to face social and economic exclusion that hinders their ability to improve their living conditions and livelihoods. This study aimed to investigate the effect of a two-pronged intervention that employed women through social enterprises to deliver a subsidised healthy daily school meal to elementary schoolchildren in Palestinian camps. MethodsWe established two healthy kitchens in community-based organisations in Palestinian camps; these kitchens employed 32 women to provide daily meals to children attending primary schools. We used mixed methods to assess the effect of participating in the intervention on the women's economic, social, and food security outcomes. We also assessed the impact of the subsidised meal programme on children's dietary diversity, nutritional status, school absenteeism, and achievement in two intervention schools, compared to two control schools. Difference-in-difference and regression analyses were conducted to examine the associations between participation and outcomes, controlling for potential confounders. Quantitative and qualitative data analyses were conducted using Stata 13·0 and NVivo 10, respectively. Written informed consent was obtained from women and parents, followed by assent from children prior to participation. All study protocols were approved by the Institutional Review Boards of the American University of Beirut and the University of Maryland. FindingsAt baseline, women's median household expenditure was US$169 per capita per month. Additional income due to the intervention was equivalent to US$110 per month, which translated into increases in total household and food expenditures (p=0·040), as well as a reduction in food insecurity (p=0·006). Qualitative data found improvements in morale, social support, and decision making. There were 648 children in the control group, and in the meal programme group there were 260 children with low participation (LP; participated less than 50% of total school days) and 454 with high participation (HP; participated more than 50% of total school days). There was a significantly greater increase in overall diet diversity score (Δ0·32, p=0·0060) and dairy consumption (odds ratio 1·2, 95% CI 1·1–1·3) in the HP group compared to controls. Both LP and HP groups were more likely to consume proteins, and less likely to consume sweetened beverages and desserts than controls. Furthermore, the HP group had a significant increase in haemoglobin (p=0·05) and both LP and HP groups had a significant decrease in school absenteeism (p=0·04) compared with controls. InterpretationThis study provides evidence of the positive effect of the Healthy Kitchens, Healthy Children model on economic, food security, and social outcomes of marginalised women, as well as diet diversity, haemoglobin, and school outcomes of children. This intervention contributed to human capital gains in two generations of protracted refugees. FundingThe Nestle Foundation for the Study of Problems of Nutrition in the World.