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This publication is with permission of the rights owner (Sage) freely accessible., 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., Bill and Melinda Gates Foundation https://doi.org/10.13039/100000865, Peer Reviewed