School gardening in Bhutan: Evaluating outcomes and impact

Meals, Education, and Gardens for In-School Adolescents: A Cluster Randomized Trial of an Adolescent Nutrition Intervention Package in Tanzania

PURPOSE

This study aimed to implement and evaluate integrated, school-based nutrition intervention packages for adolescents in Dodoma, Tanzania.

METHODS

A cluster randomized controlled trial was conducted among six secondary schools in Dodoma, Tanzania. Two schools received the full-intervention package of school meals, nutrition education, school gardens, and community workshops. Two schools received the partial-intervention package without the school meals component. Two schools served as the controls and did not receive any intervention. The intervention was implemented over one academic year. The analytical sample included 534 adolescents aged 14 to 17 at baseline and 286 parents. Outcomes included nutrition knowledge, food preferences, diet quality, food insecurity, physical activity, growth, and anemia. Linear models were used to estimate mean differences, and logistic regression models were used to estimate odds ratios (ORs).

RESULTS

Compared to the control, both the partial (OR: 0.59; 95% confidence interval [CI]: 0.35, 1.00) and full (OR: 0.49; 95% CI: 0.40, 0.59) interventions were associated with lower odds of poor diet quality among adolescents. Among the parents, both the partial (OR: 0.28; 95% CI: 0.20, 0.40) and full (OR: 0.28; 95% CI: 0.13, 0.58) interventions were associated with lower odds of poor diet quality. The partial (OR: 0.29; 95% CI: 0.18, 0.47) and full (OR: 0.47; 95% CI: 0.30, 0.72) interventions were associated with lower odds of adolescent overweight or obesity.

DISCUSSION

School-based nutritional intervention packages incorporating multiple actions may improve the diet quality of adolescents and their household members and reduce the double burden of adolescent malnutrition.

Barriers to consumption of fruits and vegetables and strategies to overcome them in low- and middle-income countries: a narrative review

This review provides an overview of the barriers to the consumption of fruits and vegetables (FVs) as well as strategies to improve the intake of FVs in low- and middle-income countries (LMICs). The importance of the consumption of FVs and its role in disease prevention are discussed briefly. Trends in the consumption of FVs in LMICs are also summarised. The WHO recommends that every individual should consume at least five servings or 400 grams of FVs per day. Epidemiological and clinical investigations have demonstrated that FVs contain numerous bioactive compounds with health-protecting activities. Despite their health benefits, the intake of FVs in LMICs remains low. Major barriers identified were socio-demographic factors, environmental conditions, individual and cultural factors, and macrosystem influences. These barriers may be lowered at the household, school, community, and national level through multi-component interventions including behaviour change communication (BCC) initiatives, nutrition education (NE), gardening initiatives, farm to institution programs (FIPs), food baskets, cash transfers, nutrition-agriculture policy and program linkages, and food-market environment-based strategies. This review has research implications due to the positive outcomes of strategies that lower such barriers and boost consumption of FVs in LMICs.

Effect of an Integrated School Garden and Home Garden Intervention on Anemia Among School-Aged Children in Nepal: Evidence From a Cluster Randomised Controlled Trial

BACKGROUND

Integrated school and home garden interventions can improve health outcomes in low-income countries, but rigorous evidence remains scarce, particularly for school-aged children and to reduce anemia.

OBJECTIVE

We test if an integrated school and home garden intervention, implemented at pilot stage, improves hemoglobin levels among school children (aged 9-13 years) in a rural district in the mid-hills of Nepal.

METHODS

We use a cluster randomized controlled trial with 15 schools each in the control and treatment groups (n = 680 school children). To test if nutritional improvements translate into a reduction of anemia prevalence, hemoglobin data were collected 6 months after intervention support had ended. Using structural equation modeling, we estimate the direct and indirect effects of the treatment through several pathways, including nutritional knowledge, good food and hygiene practices, and dietary diversity.

RESULTS

The integrated school and home garden intervention did not lead to a direct significant reduction in anemia. Causal positive changes of the treatment on nutritional outcomes, although significant, are not strong enough to impact hemoglobin levels. The program improved hemoglobin levels indirectly for children below 12 by increasing the use of good food and hygiene practices at home. These practices are associated with higher hemoglobin levels, particularly for girls, young children, and in households where caregivers are literate.

CONCLUSIONS

Even integrated school and home garden interventions are not sufficient to reduce anemia among school children. Incorporating behavioral change components around food and hygiene practices into integrated garden interventions is important to unlocking their health impacts.

Focus of Sustainable Healthy Diets Interventions in Primary School-Aged Children: A Systematic Review

Research and public policy interest regarding Sustainable Healthy Diets (SHDs) have increased during the last decades, as nutrition recommendations and diet practices should align with growing environmental concerns. SHDs encompass sociocultural, economic and environmental components of nutrition and health and raising awareness across all these dimensions, as well as providing relevant education, especially to young children, is important for adopting SHD practices. Primary school students (5-12 years old) are often the target population for interventions, as they are considered agents of change for educating the community. The objective of this systematic review is to map the SHD indicators addressed by such interventions in order to identify gaps and opportunities for future interventions in this population. Scopus, PubMed and Web of Science were searched for available publications, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA 2020) methodology. After screening for eligibility, thirteen intervention studies were included and reviewed. Results showed that indicator definitions and measuring methods were not harmonized across research efforts. Implemented SHD interventions address predominantly food waste and diet quality, while social and economic indicators are underrepresented. The standardization of SHD, focusing on measurable harmonized indicators, should be a priority for policy actors in order to enable impactful research efforts. Future interventions should incorporate clear SHD indicators to raise awareness and consider the application of composite tools or indexes to evaluate outcomes and maximize impact in the community.

School Gardening and Health and Well-Being of School-Aged Children: A Realist Synthesis

School environments can create healthy settings to foster children's health and well-being. School gardening is gaining popularity as an intervention for healthier eating and increased physical activity. We used a systematic realist approach to investigate how school gardens improve health and well-being outcomes for school-aged children, why, and in what circumstances. The context and mechanisms of the specific school gardening interventions (n = 24) leading to positive health and well-being outcomes for school-aged children were assessed. The impetus of many interventions was to increase fruit and vegetable intake and address the prevention of childhood obesity. Most interventions were conducted at primary schools with participating children in Grades 2 through 6. Types of positive outcomes included increased fruit and vegetable consumption, dietary fiber and vitamins A and C, improved body mass index, and improved well-being of children. Key mechanisms included embedding nutrition-based and garden-based education in the curriculum; experiential learning opportunities; family engagement and participation; authority figure engagement; cultural context; use of multi-prong approaches; and reinforcement of activities during implementation. This review shows that a combination of mechanisms works mutually through school gardening programs leading to improved health and well-being outcomes for school-aged children.

Meals, Education, and Gardens for In-School Adolescents (MEGA): study protocol for a cluster randomised trial of an integrated adolescent nutrition intervention in Dodoma, Tanzania

INTRODUCTION

Secondary schools have the transformative potential to advance adolescent nutrition and provide a unique entry point for nutrition interventions to reach adolescents and their families and communities. Integrated school nutrition interventions offer promising pathways towards improving adolescent nutrition status, food security and building sustainable skill sets.

METHODS AND ANALYSIS

The Meals, Education, and Gardens for In-School Adolescents (MEGA) project aims to implement and evaluate an integrated, school-based nutrition intervention package among secondary schools in the Chamwino District of Dodoma, Tanzania. MEGA is a cluster-randomised controlled trial, including six public secondary schools assigned to three different arms. Two schools will receive the full intervention package, including school meals, school gardens, nutrition education and community workshops. Two schools will receive the partial intervention package, including the school garden, nutrition education and community workshops. Two schools will serve as the controls and will not receive any intervention. The intervention will be implemented for one academic year. Baseline and end-line quantitative data collection will include 750 adolescents and 750 parents. The domains of outcomes for adolescents will include haemoglobin concentrations, anthropometry, educational outcomes and knowledge, attitudes and practices regarding nutrition, agriculture and health. The domains of outcomes for parents will include knowledge, attitudes and practices of nutrition, agriculture and health. End-line focus group discussions will be conducted among selected adolescents, parents and teachers to assess the facilitators and barriers associated with the intervention.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board at Harvard T.H. Chan School of Public Health (approval number: IRB20-1623), the Institutional Research Review Committee at the University of Dodoma (approval number: MA.84/261/02) and the Tanzania National Institute for Medical Research (approval number: NIMR/HO/R.8a/Vol. IX/3801). A manuscript with the research findings will be developed for publication. Local dissemination meetings will be held with key stakeholders.

TRIAL REGISTRATION NUMBER

NCT04788303.; ClinicalTrials.gov Identifier.

Evaluating the impacts of school garden-based programmes on diet and nutrition-related knowledge, attitudes and practices among the school children: a systematic review

BACKGROUND

Previous evidence suggests that school garden-based programmes (SGBP) may be a promising yet cost-effective intervention to improve children's knowledge, attitudes and practices (KAP) on healthy eating. This review aimed to summarise and evaluate the evidence available on the impacts of SGBP in addressing diet and nutrition-related KAP among school-aged children.

METHODS

Five databases including PubMed, Embase, Cochrane, Web of Science and Scopus were searched until February 2021. Randomised, non-randomised controlled and pre-post intervention studies investigating the impacts of SGBP on at least one of the outcomes of interest including diet and nutrition-related knowledge, attitudes towards fruits and vegetables (F&V), food diversity and dietary practice among school-aged children were included. Study selection and data extraction were performed by one reviewer and checked for accuracy by the other two reviewers in accordance with PRISMA guideline. Quality appraisal for studies included was assessed using American Dietetic Association Quality Criteria Checklist.

RESULTS

A total of 10,836 records were identified, and 35 studies that met the inclusion and exclusion criteria were included. This includes 25,726 students from 341 schools and 8 nurseries from 12 countries. Intervention duration ranged from 6 weeks to 4 years with 18 studies involving a varied degree of parental participation. SGBP, which majorly includes school gardening activities, cooking lessons and nutrition education, demonstrated beneficial effects on children's nutritional knowledge, their attitudes and acceptability towards fruits and vegetables and children's dietary practices including the actual F&V consumption and dietary diversity. However, the impacts of SGBP on such outcomes were highly influenced by various social and environmental factors including the activities/components and duration of the intervention, parental involvement, sample size, and the age of children when interventions were first introduced.

CONCLUSION

These findings suggest that SGBP may be effective in promoting children's nutritional knowledge, attitudes and acceptability towards vegetables, however, the impacts may vary by the type, the extent, and the length of the programmes, and other factors such as parent involvement. Future SGBP is suggested to implement using a combined multidisciplinary approach targeting the children, parents, and community to effectively promote healthy eating among the children and prevent childhood obesity.

Experiential Learning Interventions and Healthy Eating Outcomes in Children: A Systematic Literature Review

Experiential learning is the process where learners create meaning from direct experience. This systematic review aimed to examine the effects of experiential learning activities on dietary outcomes (knowledge, attitudes, behaviors) in children. Four databases: Education Research Complete, Scopus, Web of Science and PsychINFO were searched from database inception to 2020. Eligible studies included children 0-12 years, assessed effect of experiential learning on outcomes of interest compared to non-experiential learning and were open to any setting. The quality of studies was assessed using the revised Cochrane risk of bias tool by two independent reviewers and effect size was calculated on each outcome. Nineteen studies were conducted in primary school, six in pre-school and one in an outside-of-school setting and used nine types of experiential learning strategies. Cooking, taste-testing, games, role-playing, and gardening were effective in improving nutrition outcomes in primary school children. Sensory evaluation, games, creative arts, and storybooks were effective for preschool children. Multiple strategies involving parents, and short/intense strategies are useful for intervention success. Experiential learning is a useful strategy to improve children's knowledge, attitudes, and behaviors towards healthy eating. Fewer studies in pre-school and outside of school settings and high risk of bias may limit the generalizability and strength of the findings.

School-Based Nutrition Programs for Adolescents in Dodoma, Tanzania: A Situation Analysis

BACKGROUND

Tanzania has a double burden of malnutrition, including a high prevalence of undernutrition and an increasing prevalence of overweight and obesity among adolescents. Schools present a valuable opportunity to reach a large section of the country's adolescent population with nutrition-oriented interventions.

OBJECTIVE

The objective of this study was to assess the current state of adolescent school nutrition interventions in Dodoma, Tanzania, with emphasis on 3 potential school-based nutrition interventions, school vegetable gardens, school meals, and education (on nutrition, agriculture, and water, sanitation, and hygiene).

METHODS

Focus group discussions were conducted with several regional and district-level governmental stakeholders, including health, education, and agricultural officers. Ten public secondary schools were visited, and interviews with school administrators, teachers, students, and parents were conducted.

RESULTS

All stakeholders interviewed supported interventions to improve school-based nutrition, including school gardens, school feeding, and nutrition education. All 10 schools visited had some experience providing school meals, but parents' contributions were essential for the program's sustainability. Most schools visited had land available for a school garden program, but water availability could be challenging during certain times of the year. The teachers interviewed expressed that the curriculum on nutrition education was highly theoretical and did not allow students to practice the knowledge and skills they learned in the classroom.

CONCLUSIONS

The current school-based approach to tackling the double burden of adolescent malnutrition in Dodoma is localized and ad hoc. To leverage the potential of schools as a platform for nutrition interventions, integrated and policy-mandated interventions are needed.

Nutrition-Sensitive Agriculture: A Systematic Review of Impact Pathways to Nutrition Outcomes

The role of agriculture in reducing undernutrition is widely recognized, yet there is also consensus on the need to make the sector nutrition-sensitive. Evidence on the impact pathways from nutrition-sensitive agriculture (NSA) interventions, agricultural interventions with specific nutrition objectives, and actions detailing each temporal stage to reach nutrition outcomes is limited, however. We thus synthesized study results regarding impact of NSA interventions on nutrition outcomes relating to undernutrition, and constructed an impact pathway by mapping the evidence on each temporal stage from interventions to nutrition outcomes. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses to conduct and report our systematic review of studies on NSA interventions implemented in low- and lower-middle-income countries. Forty-three studies that met the inclusion criteria were extracted and synthesized across impact and pathways analyses. We carried out a thematic analysis of the effect of NSA interventions using evidence-based indicators and constructed the pathways by adopting a published framework on agriculture to nutrition pathways. Our findings reveal that NSA interventions can significantly improve dietary practices, and have the potential to enhance care practices and reduce occurrence of diseases, indicating their effectiveness in simultaneously addressing multiple determinants of undernutrition. However, NSA interventions have a lesser impact on nutritional status. NSA interventions lead to nutrition outcomes through 5 key pathways: food production, nutrition-related knowledge, agricultural income, women's empowerment, and strengthening of local institutions. We emphasize the need to carefully design, implement, and evaluate interventions with consideration for factors affecting impact pathways. Future research should focus on the effect of interventions combining multisector components, and pathways through non-food-production-related income, women's empowerment, strengthening of local institutions, food prices at intervention level, and expenditure on health care.

Nudging children toward healthier food choices: An experiment combining school and home gardens

School gardens have become a widely used approach to influence children's food knowledge, preferences and choices in low- and high-income countries alike. However, evidence indicates that such programs are more effective at influencing food knowledge and preferences than actual food choices. Such finding may occur because school gardens insufficiently influence the food behavior of parents and because healthy food items are not always available in children's homes. We tested this hypothesis using a one-year cluster randomized controlled trial in Nepal with 15 treatment and 15 control schools and a matched sample of 779 schoolchildren (aged 8-12) and their caregivers. Data were collected before and after the intervention during the 2018-2019 school year. In addition, children's food consumption was monitored using a monthly food logbook. Average treatment effects were quantified with a double-difference estimator. For caregivers, the intervention led to a 26% increase in their food and nutrition knowledge (p < 0.001), a 5% increase in their agricultural knowledge (p = 0.022), a 10% increase in their liking for vegetables (p < 0.001), and a 15% increase in home garden productivity (p = 0.073). For children, the intervention had no discernible effect on food and nutrition knowledge (p = 0.666) but led to a 6% increase in their liking for vegetables (p = 0.070), healthy food practices (p < 0.001), and vegetable consumption (October-December +15%; p = 0.084; January-March +26%; p = 0.017; April-June +26%; p = 0.088). The results therefore indicate both schools and parents matter for nudging children toward healthier food choices.