How do publicly procured school meals programmes in sub-Saharan Africa improve nutritional outcomes for children and adolescents: a mixed-methods systematic review.

Objective: This review aimed to (i) synthesise evidence of the impact of publicly procured school meals programmes on nutritional outcomes of children/adolescents (5-18 years) in sub-Saharan Africa and (ii) identify challenges and facilitators to implementing effective school meals programmes.

Design: Mixed-methods systematic review (n 7 databases). Nutritional outcomes assessed were anthropometrics (underweight, stunting, wasting, overweight/obesity), micronutrient deficiencies, food consumed and food environment. Qualitative findings were coded using a nine-step school food system framework: production of food, wholesale and trading, transportation and storage, processing and distribution, food preparation, distribution to students, student stakeholders, community involvement and infrastructure support.

Setting: Sub-Saharan Africa.

Participants: Children/adolescents (5-18 years), parents, school personnel and government officials.

Results: Thirty-three studies (twenty-six qualitative, seven quantitative) from nine sub-Saharan African countries were included. Six studies found a positive impact of publicly procured school meals programmes on nutritional outcomes (wasting (n 1), stunting (n 3), underweight (n 1), vitamin A intake (n 1) and dietary diversity (n 1)). Fifty-three implementation challenges were identified, particularly during food preparation (e.g. training, payment), distribution to students (e.g. meal quantity/quality/diversity, utensils) and infrastructure support (e.g. funding, monitoring, coordination). Implementation facilitators were identified (n 37) across processing and distribution (e.g. programme coordination), student stakeholders (e.g. food preferences, reduced stigma) and community involvement (e.g. engagement, positive perceptions). Included policy recommendations targeted wholesale and trading, food preparation, student stakeholders and infrastructure support in nine, fifteen and twenty-five studies, respectively.

Conclusions: As many challenges remain, strengthening implementation (and therefore the nutritional impact) of school meals programmes in sub-Saharan Africa requires bold commitment and improved coordination at multiple levels of governance.