Open access
Effect of school-­based nutrition
To cite: Osei AN, Djekic-­
Ivankovic M, Larson CP,
et al. Effect of school-­based
nutrition interventions among
primary school children in sub-­
Saharan Africa: a systematic
review protocol. BMJ Open
2023;13:e068901. doi:10.1136/
bmjopen-2022-068901
► Prepublication history and
additional supplemental material
for this paper are available
online. To view these files,
please visit the journal online
(http://dx.doi.org/10.1136/​
bmjopen-2022-068901).
Received 07 October 2022
Accepted 04 April 2023
© Author(s) (or their
employer(s)) 2023. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
1
School of Population and
Global Health, McGill University,
Montreal, Québec, Canada
2
Fred N Binka School of Public
Health, University of Health and
Allied Sciences, Ho, Ghana
Correspondence to
Dr Faith Agbozo;
​faagbozo@​uhas.e​ du.​gh
interventions among primary school
children in sub-­Saharan Africa: a
systematic review protocol
Angela Nyamekye Osei,1 Marija Djekic-­Ivankovic,1 Charles P Larson,1
Isaac Agbemafle,2 Faith Agbozo  ‍ ‍2
ABSTRACT
Introduction  Preadolescents are passing through an
intensive growth and development period that will benefit
from healthy eating practices. For those attending school,
school environments offer several potential benefits and
have been demonstrated to influence the quality of dietary
intakes and consequentially, nutritional status of school-­
aged children (SAC). Considering the amount of time
children spend in school and the enormous potential of
evidence-­based interventions, the purpose of this review
is to critically appraise peer-­reviewed literature addressing
the impact of school-­based interventions on the nutritional
status of SAC aged 6–12 years in sub-­Saharan Africa.
Methods and analysis  A systematic search will be
conducted in the following databases and online search
records: Medline, CINAHL, Web of Science, Embase, Global
health, Global Index Medicus, Cochrane library, Hinari
and Google Scholar using search terms and keywords
codeveloped with two librarians. An additional search will
also be conducted from the reference list of identified
literature. Search results of titles and abstracts will be
initially screened for eligibility criteria by two independent
reviewers and where there is disagreement, a third
reviewer will be consulted. Articles meeting these criteria
will then undergo a full-­text review for the eligibility and
exclusion criteria. The Joanna Briggs Institute critical
appraisal tool will be used to assess the risk of bias. Data
from articles meeting all study criteria will be extracted,
analysed and synthesised. A meta-­analysis will also be
conducted if sufficient data are available.
Ethics and dissemination  This systematic review is
limited to publicly accessible data bases not requiring prior
ethical approval to access. The results of the systematic
review will be disseminated through publications in peer-­
reviewed journals as well as conference and stakeholder
presentations.
PROSPERO registration number  CRD42022334829.
INTRODUCTION
Healthy eating is relevant to all age groups, but
particularly for preadolescent children who
are in an intensive growth and development
period of maturation. In spite of the proven
association between healthy consumption
of diversified diets with improved cognitive
Osei AN, et al. BMJ Open 2023;13:e068901. doi:10.1136/bmjopen-2022-068901
Protocol
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STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ The study will focus on preadolescent children in
the transition period from early childhood to ado-
lescence (6–12 years old) who are often given less
attention compared with the other age categories.
⇒ This study will follow the 2020 Preferred Reporting
Items for Systematic Reviews and Meta-­Analyses
standard reporting guidelines for systematic
reviews.
⇒ The search terms and strategies have been devel-
oped in consultation with subject expert librarians
from the partnering institutions thereby reducing the
likelihood of missing relevant literature.
⇒ The literature review is limited to published, peer-­
reviewed studies carried out in sub-­Saharan Africa,
and therefore, not generalisable to other regions of
the world.
⇒ Grey literature entailing public sector and non-­
governmental reports are often not available in elec-
tronic form nor readily accessible and are, therefore,
likely to be overlooked.
performance and lower risk for high rates
of infection,1 unhealthy dietary and lifestyle
practices persist particularly among pread-
olescent school-­ attending or school-­ going
children aged 6–12 years, here referred to
as school-­ age children (SAC).2 3 Growing
evidence from reviews show that unlike
infants and young children, older children of
school-­going age are often ignored in health
promotion activities.4 Being in their transition
period from childhood to adolescence, when
given less attention, they have higher suscep-
tibility to health and social issues when they
enter adolescence underscoring the impor-
tance of targeting this population. Schools
provide easy access to the target age group
over a long period, and therefore, tend to
be an ideal location for lifestyle modification
interventions. Schools also offer time slots,
amenities, and in most cases, a regulated
1
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environment to encourage the promotion of behaviour
modification activities.4
Outside the home, food choices are typically influ-
enced by many factors including food options available
within the individual’s external environment where the
most time is spent.5 For those SAC who continue to be
enrolled and spend a third or more of their weekday in
school,6 the school food environment (SFE) invariably
influences their dietary intakes,7 and consequentially
their nutritional status, growth and development8 and
offers a unique platform to reinforce the interventions.4
Unhealthy snacking, including high intake of sugar-­
sweetened beverages, calorie-­empty and ultraprocessed
foods, breakfast skipping, and inadequate consumption
of nutrient-­rich foods comprising fruits and vegetables
and whole grains are prevalent among SAC and can pose
future health problems.9 10 Supporting SAC to make the
right food choices is therefore beneficial not only for
their current development but later adult lives as well.
Across sub-­ Saharan Africa (SSA), economic growth,
modernisation and urbanisation is accelerating.11 Along
with it is a shift in the consumption of traditional nutrient-­
rich foods to westernised foods in SSA.12 As the availability
and affordability of these low-­quality foods increases in
and around the school environment globally, it has been
demonstrated to lead to children adopting unhealthy
eating habits.13 Moreover, left on their own to make
dietary decisions while in school, SAC are easily influ-
enced by their peers to adopt unhealthy food habits.14
It is well established that energy-­dense, nutrient-­poor
foods high in fat and sugar is contributing to overweight
and obesity in SSA,15 while overweight and obesity are
on the rise, particularly among SAC.15 The prevalence
of obesity in African SAC ranges from 5% to 40%,16
increasing the risk for cardiometabolic chronic diseases.
For instance, between 2003 and 2016, pooled prevalence
of overweight/obesity among SAC enrolled in both private
and public schools in rural and urban areas in Africa was
10.3% (95% CI 6.9% to 14.2%). Rates varied largely from
Morocco (11.0%), Kenya (14.4%), Ghana and Tanzania
(15.9%), Egypt (20.8%), South Africa (26.7%) to Uganda
(32.3%).17 While obesity presents an emerging health
threat for SSA, efforts to reduce undernutrition is slow
thereby exacerbating the double burden of malnutrition.
In Ethiopia, for example, undernutrition among primary
school children age 6–15 years is moderately high around
20% reflecting a pooled prevalence of 21.3% for stunting,
18.2% for underweight and 17.7% for wasting.18 In other
countries, stunting among SAC is a severe public health
problem affecting 36.8% in Nigeria, 42% in DR Congo
and 57% in Burundi, whereas wasting is at 13% and 18%
in Chad and Niger, respectively.19
Despite evidence suggesting that malnutrition is a
significant problem among SAC in SSA, the influence
of school-­based nutrition interventions on their nutri-
tional status has not been well explored.20 School-­based
nutrition interventions offer an important potential
opportunity to prevent or reverse undernutrition and
2 Osei AN, et al. BMJ Open 2023;13:e068901. doi:10.1136/bmjopen-2022-068901
obesity among SAC. The purpose of this study is to criti-
BMJ Open: first published as 10.1136/bmjopen-2022-068901 on 18 April 2023. Downloaded from http://bmjopen.bmj.com/ on July 12, 2023 by guest. Protected by copyright.
cally appraise the peer-­reviewed literature addressing the
impact of alternative school-­based interventions on the
dietary practices and nutritional status of SAC aged 6–12
years in SSA.
METHODS AND ANALYSIS
This systematic review is to be conducted in accordance
with the Preferred Reporting Items for Systematic Reviews
and Meta-­Analyses Protocols (PRISMA) 2015 statement.21
The protocol has been registered on the PROSPERO
database (CRD42022334829).
Eligibility criteria
Population
The populations to be included are preadolescence
school-­ age children (SAC) within the age brackets of
6–12 years and resident in SSA. This age group classi-
cally constitutes learners in primary, elementary or basic
schools in grades or classes 1–6. We will exclude studies
conducted within the school setting that focuses on chil-
dren below the age of 6 years and teenagers aged 13–19
years but where the lower and upper age limits cross over
to early childhood or adolescence, respectively, and age-­
disaggregated results are provided, such studies will be
included. Studies that focus solely on other categories
of individuals found within the school community such
as teachers, school administrators, parents, caregivers or
guardians, caterers, and food vendors as well as comple-
mentary staff providing services to children such as school
nurses will be excluded.
Interventions
The focus is on nutrition interventions provided in
primary schools. Any nutrition-­specific intervention that
is deliberately initiated and implemented within a formal
school setting will be considered regardless of the imple-
menting organisation, source of funding or duration of the
intervention. School-­based nutritional interventions also
referred to as school nutrition and feeding programmes
are set of actions intended to change a nutritional aspect
in school-­ aged children and adolescents using school
as the delivery strategy and can range from behavioural
change interventions, fortification, supplementation,
to regulatory interventions.22 Specific examples include
but not limited to school feeding programmes; school
gardening; supplementation programmes for iron, folic
acid, zinc and calcium; dietary diversification; nutrient
enhancement; nutrition education; SFE policies;
nutrition-­ friendly school initiative; food diversification
strategies targeted at increasing consumption of fruits,
vegetables, eggs, whole grain cereals, etc. The nutritional
interventions of key focus to this review are presented in
table 1.
Outcomes
The primary outcomes of interest will be clinically signif-
icant changes in the mean measures of weight, height,
 Open access

nutrition knowledge, behavioural modification related to

Table 1  Categories of nutrition interventions that this

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review will focus on the consumption of diversified and micronutrient-­dense
diets and physical activity, and academic performance of
Intervention category Key focus Ancillary focus
the learners in school. In addition, findings related to
Supplementation Iron Folic acid the impact of school environment policies on the above
Zinc
outcomes will also be collated. This could include the
Calcium
presence of private food vendors nearby a school, oppor-
Fortification Food enhancement
with different tunities for exercise and the promotion against ‘fast’ and
micronutrients junk foods. Additional methodological exclusion criteria
Regulatory School feeding School food include publications repeating data from a primary publi-
programmes environment policies cation, ethical approval procedures that are unclear or
Nutrition-­friendly unstated and where the assessment of outcomes by the
school initiative
internal (research team) are found to be biased.
Behavioural Dietary Nutrition education
diversification School gardening Study design
This review will incorporate all primary peer-­ reviewed
articles that apply one of the following quantitative study
mid-­upper arm circumference, haemoglobin and serum designs: randomised controlled trials, quasi-­experimental,
ferritin as well as the occurrence of any of the following before-­and-­after cross-­
sectional surveys, prospective or
nutritional status indicators: (1) overweight and obesity, retrospective cohorts. The review started in June 2022
(2) thinness, (3) underweight, (4) stunting and (5) and should be finalised by the end of June 2023.
anaemia. For children aged 5–19 years, applicable nutri-
tional status indicators are the body mass index for age Information sources and search strategy
z-­score which assesses thinness (below −2 SD of the median A comprehensive list of medical subject headings (MeSH)
of the WHO Child Growth Standards), overweight (above and keywords relating to “nutrition intervention”, “school
+1 SD equivalent to the 85th percentile) and obesity food environment”, “children”, and “sub-­Saharan Africa”
(above +2 SD equivalent to the 97th centile). Under- has been developed by the research team in consultation
weight and stunting are defined using the weight-­for-­age with librarians from the University of Health and Allied
and height-­for-­age z-­scores below 2 SD.23 Haemoglobin Sciences in Ghana and McGill University in Canada
levels to diagnose anaemia in children age 5–12 years (table 2). These search terms have been adapted across
is less than 115 g/L, considered as mild (110–114 g/L), the following electronic databases of peer-­ reviewed
moderate (80–109  g/L) and severe (below 80  g/L).24 journal articles and online search records: Ovid Medline,
Secondary outcomes which when reported in addition to Embase, CINAHL, Cochrane library, Web of Science,
the primary outcomes will be extracted include changes in Hinari, Global health, African Index Medicus (subsidiary

Table 2  Search terms based on medical subject headings and keywords

Search terms
Population Study Child*, Pupil*, Student*, Learner*, Boy*, Girl*, 6 to 12 years, Pre-­adolescent, Pre-­teen*, Kid*
Population
Study Sub-­Saharan Africa, Saharan Africa, Sub-­Saharan, Sub-­Sahara, Africa, Sahel region, West Africa,
context East Africa, Southern Africa, Central Africa
SSA (country list): South Sudan, Angola, Burundi, Congo, Rwanda, Sao Tome, Cameroon/
Cameroun, Central African Republic, Chad, Democratic republic of Congo, Equatorial Guinea,
Gabon, Djibouti, Eritrea, Ethiopia, Somalia, Kenya, Tanzania, Uganda, Botswana, Comoros,
Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa,
Swaziland, Zambia, Zimbabwe, Sudan, Mauritania, Gambia, Ghana, Guinea, Liberia, Nigeria, Sierra
Leone, Benin, Burkina Faso, Ivory Coast/Cote D’voire, Guinea Bissau, Mali, Niger, Senegal, Togo,
Cape Verde
Intervention Nutrition interventions, Food/Nutrition / dietary policies, Nutrition Program*, Nutrition Projects,
Nutrition strategies, Nutrition Initiatives, School-­based interventions, School food environment,
Nutrition specific interventions, School services, School nutrition, School-­based nutrition, School
nutrition policy, School nutrition intervention*, School feeding, School feeding program*, School
meal, School food, School canteen, Canteen, Cafeteria, School cooking, School breakfast,
School lunch, Lunch, School diet*, Vending machine*, Tuckshop, Food environment*, Food adj3,
environment*, Food adj3 availab*, Food adj3 access*, Deworming, Micronutrient supplementation,
Nutrition/health education, Nutrition-­friendly school, Health promotion, Restriction of advisement,
Food labeling, Dietary intake, Growth monitoring, Healthy eating, Nutrition education / counselling,
School health services, Peer counsellor / educators

Osei AN, et al. BMJ Open 2023;13:e068901. doi:10.1136/bmjopen-2022-068901 3

Open access
Figure 1  Study selection flow chart.
of the Global Index Medicus database of the WHO) and
Google Scholar search engine. Online supplemental
table 1 contains the detailed search strategy for each of
the nine databases. All reference lists of articles included
in this study will also be checked for additional sources
of information. The search will be limited to articles
published in the year 2000 and beyond.
Data management and study selection
The literature search results will be uploaded into Covi-
dence, a web-­ based software platform that facilitates
collaboration among reviewers during the study selection
process and aids the deduplication of studies from alter-
native sources. This will then be followed by an initial title
and abstract screening against the inclusion criteria using
a simple 11-­step cascade as indicated in figure 1. Eligible
studies selected will progress to the subsequent and final
stages of full-­text screening and data extraction, respec-
tively (applying the same inclusion criteria, adding exclu-
sion due to duplicate data, information bias or lack of
explicit ethical approval). Screening will be done by two
independent reviewers and at each stage, reasons neces-
sitating the exclusion of a paper documented. Disagree-
ments over the eligibility of a study will be resolved by
a third reviewer. A PRISMA flow chart will be prepared
to describe how the study selection procedure was
conducted and its results.
Data collection process and data items
A data extraction form will be developed in excel to extract
information from the included studies. It will be piloted
and amended in response to feedback from experienced
researchers in the field. One of the investigators will
independently extract information from the individual
4 Osei AN, et al. BMJ Open 2023;13:e068901. doi:10.1136/bmjopen-2022-068901
articles and the other investigators will check for accuracy
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and completeness of the data extracted. Data items will
be categorised into study characteristics (objectives, loca-
tion, description of the school setting and the food envi-
ronment, design, population and sample size, participant
demographics); and details of the intervention (the form,
duration, intensity, length of follow-­up, recruitment and
completion rates). The outcome measures (listed in the
‘Outcomes’ section) and the actual outcome (ie, the find-
ings obtained from the individual studies) will also be
extracted together with the effect of the intervention and
the strength of impact.
Quality assessment
Risk of bias of eligible studies will be assessed using
the Joanna Briggs Institute (JBI) critical appraisal tools
appropriate to this review’s eligible study designs to guide
in making an overall judgement on whether to include,
exclude or seek further information on an individual
study. Based on the range of our eligible designs, the
JBI checklist consisting of 9–13 questions will be used
to evaluate the methodological quality of studies by
determining the extent of possible biases in the design,
conduct, analysis and write-­up. The range of answers to
each question are ‘yes’, ‘no’, ‘unclear’ and ‘NA’ (non-­
applicable). Similar to the screening, methodological
quality of eligible studies will be assessed by two indepen-
dent reviewers; in the event of a disagreement, a third
reviewer will decide.
Data analysis and synthesis
Relevant data collected from each study will be used to
build evidence tables as found in online supplemental
tables 2 and 3. Where adequate data are available, a
meta-­analysis will be conducted to merge and synthe-
sise the findings of the primary quantitative nutritional
outcome measures comprising the anthropometric and
micronutrient indicators. The overall (absolute) effect
calculated will be presented graphically. A random-­effects
meta-­analysis model will be used if the eligible studies
are heterogeneous in nature. Pooled estimates will be
provided, and heterogeneity of the single studies visu-
alised using forest plots. Potential sources of heteroge-
neity in studies will be investigated using the I2 statistic
which estimates the proportion of variance in studies. I2
values of <25%, 50% and >75% are indicative of small,
moderate and large levels of heterogeneity, respectively.
The funnel plot will also be used to visually assess the
potential for publication bias. A narrative synthesis of the
findings from the eligible studies will also be thematised
and reported. Stratified analysis will be performed by the
subregions within SSA, country, sex, age and class groups,
school types and categories of interventions where such
data are sufficient.
Patient and public involvement
No patient involved.

Ethics and dissemination
The systematic review will only use published articles and
hence formal ethical approval will not be necessary. The
results from the systematic review will be disseminated
through peer-­reviewed publications, conference presen-
tations and stakeholder engagements.
CONCLUSION
The purpose of this work is to systematically review,
appraise and summarise current evidence on nutrition
interventions present in primary school environments
and their influence on dietary practices and nutritional
status of school-­age children in SSA. Data from this review
are crucial and timely because it will establish what inter-
ventions work and in what context to inform policy direc-
tions targeted at preadolescent SAC, promote healthy
SFEs and advocate for policies and programmes that are
most effective and relevant to their needs. By summarising
available data on nutrition-­specific interventions within
the SFE in SSA and their impact on the nutritional status
of school children ages 6–12 years, findings in the short
term will provide evidence-­ based data to address the
implementation of planned school-­based nutrition inter-
ventions in the future and in the long term, contribute
towards improving the nutritional status of SAC and
reducing the burden of malnutrition in the subregion,
where the disease burden is disproportionately high.
Acknowledgements  We appreciate Emily Jaeger-­McEnroe and Fred Hayibor,
both librarians at McGill University and the University of Health and Allied Sciences
respectively, for their technical support in developing the search strategy.
Contributors  FA, CPL and IA conceived the review study. ANO wrote the first
draft. CPL, MD-­I and FA supervised the process. All authors reviewed, edited and
approved the final version.
Funding  MasterCard Transitions Fund (internship award to the first author).
Competing interests  None declared.
Patient and public involvement  Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication  Not applicable.
Provenance and peer review  Not commissioned; externally peer reviewed.
Supplemental material  This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
Faith Agbozo http://orcid.org/0000-0001-7707-5658
Osei AN, et al. BMJ Open 2023;13:e068901. doi:10.1136/bmjopen-2022-068901
Open access
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