The Impact at Scale of the Ghana School Feeding Programme on Primary School-Age Children's Anthropometry: A Cluster Randomised Trial

Abstract

Background: Attention to nutrition during all phases of child and adolescent development is necessary to ensure healthy physical growth and to protect investments made earlier in life. Leveraging school feeding programmes as platforms to scale-up nutrition interventions is relevant as programmes function in nearly every country in the world. This study is aimed at evaluating the impact of the national school feeding programme in Ghana on school-age children's anthropometry indicators. Methods: A longitudinal cluster randomized control trial was implemented across the 10 regions of Ghana, covering 2,869 school age children (aged 5-15y). Communities were randomized to 1) control group without intervention; or 2) treatment group providing the reformed national school feeding programme. Primary outcomes included height-for-age (HAZ) and BMI-for-age (BAZ) scores. The analysis followed an intention to treat approach as per the published protocol for the study population and sub-group analysis by age (i.e. mid-childhood for children 5-8y and early adolescence for children 9-15y), gender, poverty and region of residence. We used single difference ANCOVA with mixed-effect regression models to assess programme impacts. Findings: School feeding had no effect on HAZ and BAZ in children aged 5-15 years. However, in per protocol subgroup analysis, the school feeding intervention improved HAZ in 5-8y old children (effect size 0.12 SDs), in girls (effect size 0.12 SDs), particularly girls aged 5-8y living in the northern regions, and in children aged 5-8 in households living below the poverty line (effect size 0.22 SDs). There was also evidence that the intervention influenced food allocation and sharing at the household level. Interpretation: Schools feeding can provide a platform to scale-up nutrition interventions in the early primary school years, with important benefits accruing for more disadvantaged children. Trial Number: Trial registered on the ISRCTN Registry as ISRCTN66918874 Funding Statement: This trial was funded by the Bill and Melinda Gates Foundation and Dubai Cares. Declaration of Interests: Aulo Gelli received support from the CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the International Food Policy Research Institute. Ethics Approval Statement: Ethical clearance was obtained from the Institutional Review Board of the Noguchi Memorial Medical Research Institute of the University of Ghana and sought at the Imperial College Research Ethics Committee. Meetings were held from early stages in the study development with relevant government ministries both at central and decentralised levels to discuss the purpose, procedures and risks involved in the study. Informed consent was obtained from parents/guardians of children through written and verbal information provided before interviews.