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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. Plain language title: Effect of a Joint School and Home Garden Programme on Child Health Among School-Aged Children in Nepal Plain language summary: The effects of agricultural and nutritional support programs on health are not fully understood. This article looks at school and home gardens, which are gaining attention in the research and development community, but evidence for their effects is limited, particularly for lower-income countries. We examine whether a joint school and home garden program improves blood iron levels among school children (aged 9-13 years) in rural Nepal. Low levels are an indicator for anemia—a common nutritional disorder in South Asia. Our data come from an experiment involving 30 schools and 680 children and was measured via a finger prick method 6 months after program support ended. We also evaluate if the program influenced blood iron levels through the nutritional knowledge of children and their caregivers; through the use of good food and hygiene practices at home and the children's dietary diversity. Our results indicate that the program did not lead to a direct reduction in anemia. However, for children under the age of 12, the program indirectly improved blood iron levels through behavioral changes in the use of good food and hygiene practices (e.g., washing hands before eating). We therefore argue that including education on nutrition and good food and hygiene practices as part of integrated garden support programs is key to improving children's health. [ABSTRACT FROM AUTHOR]

Food systems in many countries are experiencing a shift from traditional foods toward processed foods high in sugar, fat and salt, but low in dietary fiber and micronutrients. There is an urgent need to better understand drivers of changing food behavior, particularly for lower-income countries. This study analyzes drivers of food choice among children and parents in rural Nepal. It uses qualitative data collected through key informant interviews and focus group discussions with school children, parents and teachers. The study reveals substantial changes in food behavior during the past decade with increased consumption of rice, meat, and highly processed snack foods while an increased consumption of fruit and vegetables is not evident. It identifies cash availability is the main driver of increased rice, meat and snack food consumption. The second driver is the 2015 Nepal earthquake, which accelerated the transition from homegrown food to purchased food as people got habituated to eating more meat and snack foods while reconstruction tripled local wages and changed the food environment. This shows how humanitarian assistance in the wake of extreme shocks can unintentionally contribute to unhealthy eating habits. An integrated school and home garden intervention appears to contribute to healthier diets. [ABSTRACT FROM AUTHOR]