Abstract
Food environments can play important roles in shaping nutrition and health outcomes. One such environment that has potential to affect youth is the school food environment. In contrast to higher-income countries, however, there is a critical evidence gap on the role of school food environments on children and adolescents in low- and middle-income countries. This mixed-methods study contributes to filling this gap by investigating the role of school food environments on dietary behaviours of children and adolescents in Ghana. It draws on data from household and school questionnaires as well as focus group discussions collected as part of the baseline for an impact evaluation of the Ghana School Feeding Programme (GSFP). Multi-level regression models were fitted with random intercepts at the individual, household and community levels. Excerpts from the focus group discussions provided a deeper understanding of quantitative findings. Children and adolescents who received free school meals provided by the GSFP or who lived further away from school were less likely to go home for lunch. More than half of sampled schools reported offering foods for sale by independent vendors, the most common being meals followed by confectionery, fruit and sugar-sweetened beverages. Predictors of bringing money to school to buy food included non-receipt of free school meals, adolescence, greater commuting distance from home, household asset score, and urban location. Policy efforts focusing on the school food environment may contribute to healthy dietary behaviours for children and adolescents with positive impacts over the lifecourse.
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Notes
Groundnut is the Ghanaian word for peanuts. Similarly, okro in other countries may be known as okra or lady’s fingers.
Data from the Ghana Education Service is available from the website: http://www.ghanaeducationdata.com/ (link downloaded November 28, 2015).
School food environment measures were effectively at the community level as there was one school per community in the data.
Kanfer is similar to abolo, which is ground, soaked corn flour with sugar that is steamed or baked on leaves.
Newspaper articles have reported on delays and eventual releases of payments. For example, the Ghana Business News, July 2013: https://www.ghanabusinessnews.com/2013/07/26/gsfp-confirms-owing-caterers/ (link downloaded April 7 2015), and Ghana web, March 2014: http://www.ghanaweb.com/GhanaHomePage/regional/artikel.php?ID=303945 (link downloaded April 7, 2015).
References
Abiba, A., Grace, A., & Kubreziga, K. (2012). Effects of dietary patterns on the nutritional status of upper primary school children in tamale metropolis. Pakistan Journal of Nutrition, 11, 591–609.
Abizari, A., Moretti, D., Zimmermann, M. B., et al. (2012). Whole cowpea meal fortified with NaFeEDTA reduces iron deficiency among Ghanaian school children in a malaria endemic area. The Journal of Nutrition, 142, 1836–1842.
Adamson, A., Spence, S., Reed, L., Conway, R., Palmer, A., Stewart, E., et al. (2013). School food standards in the UK: implementation and evaluation. Public Health Nutrition, 16(6), 968–981.
Agbozo, F., Atito, P., & Abubakari, A. (2016). Malnutrition and assoocaited factors in children: a comparative study between public and private schools in Hohoe municipality, Ghana. BMC Nutrition, 2(1), 32.
Akyeampong, K., Djangmah, J., Oduro, A., Seidu, A., Hunt, F. (2007). Access to basic education in Ghana: the evidence and the issues. Consortium for Research on Education Access, Transitions and Equity. http://www.academia.edu/257932/Access_to_Basic_Education_In_Ghana_The_Evidence_and_the_Issues. Accessed 2 September 2015.
Alderman, H., & Bundy, D. (2012). School feeding programs and development: are we framing the question correctly? The World Bank Research Observer, 27(2), 204–221.
Armar-Klemesu, M., Pelto, G., Folson, G. et al. (2014). A focused ethnographic study of food consumption patterns and their social and cultural context in pregnant and breastfeeding women and in adolescents. DSM Sight and Life, 2014.
Aurino, E., & Morrow, V. (2015). “If we eat well, we can study”: dietary diversity in the everyday lives of children in Andhra Pradesh and Telangana, India. Oxford: Young lives working paper 144.
Aurino, E., Fernandes, M., & Penny, M. E. (2017). The nutrition transition and adolescents’ diets in low-and middle-income countries: a cross-cohort comparison. Public Health Nutrition, 20(1), 72–81.
Banchonhattakit, P., Tanasugarn, C., Pradipasen, M., Miner, K. R., & Nityasuddhi, D. (2009). Effectiveness of school network for childhood obesity prevention (Snocop) in primary schools of Saraburi province, Thailand. The Southeast Asian Journal of Tropical Medicine and Public Health, 40, 816–834.
Bundy, D., Burbano, C., Grosh, M., Gelli, A., Jukes, M., & Drake, L. (2009). Rethinking school feeding: Social safety nets, child development, and the education sector. Washington, DC: World Bank Publications.
Claasen, N., van der Hoeven, M., & Covic, N. (2016). Food environments, health and nutrition in South Africa. Cape Town: PLAAS, UWC and Centre of Excellence on Food Security. Working Paper 34.
Cusatis, D., & Shannon, B. (1996). Influences on adolescent eating behavior. The Journal of Adolescent Health, 18(1), 27–34.
De Onis, M., Blössner, M., & Borghi, E. (2010). Global prevalence and trends of overweight and obesity among preschool children. The American Journal of Clinical Nutrition, 92(5), 1257–1264.
De Villiers, A., & Faber, M. (2015). The school food environment: shaping the future health of the nation. South African Journal of Clinical Nutrition, 28(1), 4–5.
Dehne, L., & Riedner, G. (2001). Adolescence—a dynamic concept. Reproductive Health Matters, 9(170), 11–15.
Dunn, J., Liu, K., Greenland, P., Hilner, J., & Jacobs, D. (2000). Seven-year tracking of dietary factors in young adults: the CARDIA study. American Journal of Preventive Medicine, 18(1), 38–45.
Faber, M., Laurie, S., Maduna, M., Magudulela, T., & Muehlhoff, E. (2014). Is the school food environment conducive to healthy eating in poorly resourced south African schools? Public Health Nutrition, 17(6), 1214–1223.
Filmer, D., & Pritchett, L. (2001). Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography, 38(1), 115–132.
Francis, M., Nichols, S. S., & Dalrymple, N. (2010). The effects of a school-based intervention programme on dietary intakes and physical activity among primary-school children in Trinidad and Tobago. Public Health Nutrition, 13, 738–747.
Gaglianone, C. P., Taddei, J. A. D. A. C., Colugnati, F. A. B., Magalhães, C. G., Davanço, G. M., Macedo, L. D., & Lopez, F. A. (2006). Nutrition education in public elementary schools of São Paulo, Brazil: the reducing risks of illness and death in adulthood project. Revista de Nutrição, 19(3), 309–320.
Gelli, A., Hawkes, C., Donovan, J., Harris, J., Allen, S., de Brauw, A., et al. (2015). Value chains and nutrition: a framework to support the identification, design, and evaluation of interventions. IFPRI discussion paper 01413.
Gelli, A., Masset, E., Folson, G., Kusi, A., Arhinful, D., Asante, F., Ayi, I., Bosompem, K., Watkins, K., Abdul-Rahman, L., Agble, R., Ananse-Baden, G., Mumuni, D., Aurino, E., Fernandes, M., & Drake, L. (2016). Evaluating the impact of school meals on nutrition, education, agriculture and other social outcomes in Ghana: Rationale, randomised design and baseline data. Trials, 17(1), 37.
Ghana Statistical Service. (2012). Population and housing census: Summary report of final results. Accra: Ghana Statistical Service. Available online at: http://www.statsghana.gov.gh/docfiles/2010phc/Census2010_Summary_report_of_final_results.pdf.
Glanz, K. (2009). Measuring food environments: a historical perspective. American Journal of Preventive Medicine, 36(4S), S93–S98.
Greenhalgh, T., Kristjansson, E., & Robinson, V. (2007). Realist review to understand the efficacy of school feeding programs. BMJ, 335(7625), 858–861.
Hawkes, C., Smith, T., Jewell, J., Wardle, J., Hammond, R., Friel, S., et al. (2015). Smart food policies for obesity prevention. The Lancet, 385(9985), 2410–2421.
Herforth, A., & Ahmed, S. (2015). The food environment, its effects on dietary consumption, and potential for measurement within agriculture-nutrition interventions. Food Security, 7(3), 1–16.
Hirschman, J., & Chriqui, J. (2013). School food and nutrition policy, monitoring and evaluation in the USA. Public Health Nutrition, 16(6), 982–988.
Jacobs, K. L., Mash, B., Draper, C. E., Forbes, J., & Lambert, E. V. (2013). Evaluation of a school-based nutrition and physical activity programme for grade 4 learners in the western cape province. South African Family Practice, 55(4), 391–397.
Kristjanssen, E., Gelli, A., Welch, V., Greenhalgh, T., Liberato, S., et al. (2015). Costs, and cost-outcome of school feeding programmes and feeding programmes for young children. Evidence and recommendations. International Journal of Education Development, 48(May), 79–83. doi:10.1016/j.ijedu-dev.2015.11.011.
Kroger, J. (2003). Identity development during adolescence. Blackwell Handbook of Adolescence, 4, 204–226.
Kubik, M., Lytle, L., Hannan, P., Perry, C., & Story, M. (2003). The association of the school food environment with dietary behaviors of young adolescents. American Journal of Public Health, 93(7), 1168–1173.
Lachat, C., Nago, E., Verstraeten, R., Roberfroid, D., Van Camp, J., & Kolsteren, P. (2012). Eating out of home and its association with dietary intake: a systematic review of the evidence. Obesity Reviews, 13(4), 329–346.
Living Standards Measurement Survey – Ghana Socioeconomic Panel Survey (LSMS). (2009-2010). Collected by Institute of Statistical, social and economic research - University of Ghana, Economic Growth Center - Yale University for the World Bank.
Lytle, L. (2009). Measuring the food environment: state of the science. American Journal of Preventive Medicine, 36(4S), S134–S144.
Mallick, N., Ray, S., & Mukhopadhyay, S. (2014). Eating behaviours and body weight concerns among adolescent girls. Adv Public Health. doi:10.1155/2014/257396.
Manyanga, T., El-Sayed, H., Teye Doku, D., & Randall, J. (2014). The prevalence of underweight, overweight, obesity and associated risk factors among school-going adolescents in seven African countries. BMC Public Health, 14, 887.
Masset, E., & Gelli, A. (2013). Improving community development by linking agriculture, nutrition and education: design of a randomised trial of “home-grown” school feeding in Mali. Trials, 14(1), 55.
Meko, L., Slabber-Stretch, M., Walsh, C., Kruger, S., & Nel, M. (2015). Nutritional environment at secondary schools in Bloemfontein, South Africa. South African Journal of Clinical Nutrition, 28(1), 53–54.
Mikkilä, V., Räsänen, L., Raitakari, O., Pietinen, P., & Viikari, J. (2005). Consistent dietary patterns identified from childhood to adulthood: the cardiovascular risk in young Finns study. Brit J Nutr, 93(6), 923–931.
Morrow, V., Barnett, I., & Vujcich, D. (2014). Understanding the causes and consequences of injuries to adolescents growing up in poverty in Ethiopia, Andhra Pradesh (India), Vietnam and Peru: a mixed method study. Health Policy and Planning, 29(1), 67–75.
Muthuri, S., Francis, C., Wachira, L., LeBlanc, A., Sampson, M., Onywera, V., et al. (2014). Evidence of an overweight/obesity transition among school-aged children and youth in sub-Saharan Africa: a systematic review. PloS One, 9(3), e92846.
Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., Margono, C., et al. (2014). Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the global burden of disease study 2013. The Lancet, 384(9945), 766–781.
Oosthuizen, D., Oldewage-Theron, W. H., & Napier, C. (2011). The impact of a nutrition programme on the dietary intake patterns of primary school children. South African Journal of Clinical Nutrition, 24(2), 75–81.
Owusu, J. (2013). Assessment of dietary intakes and nutritional status of school age children participating in school feeding programs in Otinbi and Danfa. MPhil, University of Ghana. Accessed 2 September 2015.
Parish, A., & Gelli, A. (2015). Trade-offs in costs, diet quality and regional diversity: an analysis of the nutritional value of school meals in Ghana. African Journal of Agricultural, and Nutrition, Development, 15(4), 10217–10240.
Pelto, G., Armar-Klemesu, M., et al. (2013). The focused ethnographic study ‘assessing the behavioral and local market environment for improving the diets of infants and young children 6 to 23 months old’ and its use in three countries. Maternal and Child Nutrition (2013), 9(Suppl. 1), 35–46.
Popkin, B. (1998). The nutrition transition and its health implications in lower-income countries. Public Health Nutrition, 1(01), 5–21.
Powell, C., Walker, S., Chang, S., & Grantham-McGregor, S. (1998). Nutrition and education: a randomized trial of the effects of breakfast in rural primary school children. The American Journal of Clinical Nutrition, 68(4), 873–879.
Prince, A. K., & Laar, A. (2014). Nutritional status of school-age children in the Nkwanta south district – Volta region of Ghana. European Scientific Journal, 10(30), 1857–7881.
Sichieri, R., Trotte, A. P., de Souza, R. A., & Veiga, G. V. (2009). School randomised trial on prevention of excessive weight gain by discouraging students from drinking sodas. Public Health Nutrition, 12, 197–202.
Silveira, J., Taddei, J., Guerra, P., & Nombre, M. (2011). Effectiveness of school-based nutrition education interventions to prevent and reduce excessive weight gain in children and adolescents: a systematic review. The Journal of Pediatrics, 87(5), 382–392.
Sniders, T., & Bosker, R. (1999). Multilevel analysis. An introduction to basic and advanced multilevel modeling. London: Sage Publications.
Snilstveit, B., Stevenson, J., Phillips, D., Vojtkova, M., Gallagher, E., et al. (2015). Interventions for improving learning outcomes and access to education in low- and middle-income countries: a systematic review, 3ie final review. London: International Initiative for Impact Evaluation (3ie).
Story, M., Neumark-Sztainer, D., & French, S. (2002). Individual and environmental influences on adolescent eating behaviors. Journal of the American Dietetic Association, 102(3), S40–S51.
Story, M., Kaphingst, K. M., Robinson-O'Brien, R., & Glanz, K. (2008). Creating healthy food and eating environments: Policy and environmental approaches. Annual Review of Public Health, 29, 253–272.
Tong, A., Sainsbury, P., & Craig, J. (2015). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. 2007; 19 (6): 349–57.
UNICEF. (2012). Progress for children: a report card on adolescents. New York: UNICEF.
US Centers for Disease Control and Prevention (CDC). (1996). Guidelines for school health programs to promote lifelong healthy eating. MMWR. Morbidity and Mortality Weekly Report, 45(RR-9), 1–33.
US Department of Agriculture. (2012). Nutrition standards in the National School Lunch and school breakfast programs; final rule. Federal Register; Rules and Regulations.
Vargas, I. C., Sichieri, R., Sandre-Pereira, G., & da Veiga, G. V. (2011). Evaluation of an obesity prevention program in adolescents of public schools. Revista de Saúde Pública, 45, 59–68.
Vepsalainen, H., Mikkila, V., Erkkola, M., et al. (2015). Association between home and school food environments and dietary patterns among 9-11 years old children in 12 countries. International Journal of Obesity Supplements, 5, S66–S73.
Verstraeten, R., Van Royen, K., Ochoa-Avilés, A., Penafiel, D., Holdsworth, M., & Donoso, S. (2014). A conceptual framework for healthy eating behavior in Ecuadorian adolescents: a qualitative study. PloS One, 9(1). doi:10.1371/journal.pone.0087183.
Weschler, H., Devereaux, R., Davis, M., & Collins, J. (2000). Using the school environment to promote physical activity and healthy eating. Preventive Medicine, 31(2), S121–S137.
Acknowledgements
This work was financially supported by the Bill and Melinda Gates Foundation and Dubai Cares. The authors acknowledge the Ghana School Feeding Programme and a number of individuals. The contributions of Lesley Drake, Kwabena Bosompem, Felix Asante, Irene Ayi, Daniel Kojo Arhinful, and Edoardo Masset are acknowledged for leading the overall impact evaluation. Tony Kusi provided field supervision and data analysis support. Rosanna Agble provided guidance on nutrition. Edoardo Masset contributed to the design of the household survey and Eric Ockrah developed the school questionnaire. Daniel Mumuni contributed to the implementation of the survey, liaised with the GSFP and provided feedback on the manuscript at various sages. Individuals at the Ghana School Feeding Programme who were instrumental in the study design and in the provision of valuable technical support include the National Coordinator, Mr. S.P Adamu, Mrs. Susan Torson, Nutrition Programme Manager, and Mrs. Kate Quarshie of the Ghana Health Service. The Partnership for Child Development Ghana team also provided a critical role in the implementation of the impact evaluation and liaising with the Ghana School Feeding Programme. These individuals include Getrude Anase-Baiden, Abigail Bondzie, Fred Amese and Lutuf Abdul-Rahman.
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All authors made substantial contributions to the conception and design, data acquisition, data analysis, interpretation of analysis results and the drafting of the manuscript. MF developed the concept and led the quantitative analysis and writing of the manuscript, while EA contributed the use of food environments as a guiding framework and the mixed methods approach as well as significant contributions to the manuscript text. GF provided critical inputs to the conduct of the survey and conducted the qualitative analysis of the focus group transcripts. GF also contributed to the construction of variables, reviewed analysis output for the quantitative analysis and contributed to the writing of the manuscript. AG designed the household questionnaire and identified the sampling approach. In addition, he provided overall guidance on the analytic approach for the quantitative analysis, sample definition and the variable construction.
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The household and school surveys were conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the University of Ghana Noguchi Memorial Institute for Medical Research (NMIMR) Institutional Review Board. Consent to voluntarily participate in the study was sought from respondents after giving them general information about the study, details of data to be collected, risks and discomforts, benefits, confidentiality and their right to leave the research at any point in time. They were also given contact details of one researcher for further information. Participants signed a consent form to indicate such, or made a cross to indicate consent if they could not sign.
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The authors report no conflicts of interest.
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Fernandes, M., Folson, G., Aurino, E. et al. A free lunch or a walk back home? The school food environment and dietary behaviours among children and adolescents in Ghana. Food Sec. 9, 1073–1090 (2017). https://doi.org/10.1007/s12571-017-0712-0
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DOI: https://doi.org/10.1007/s12571-017-0712-0