WestminsterResearch http://www.westminster.ac.uk/westminsterresearch Public health nutrition intervention to evaluate the nutritional impact of the Ghana School Feeding Programme in Lower Manya Krobo (LMK) district, and enhancing its effectiveness through a nutrition intervention Azagba-nyako, J. This is an electronic version of a PhD thesis awarded by the University of Westminster. © Miss Jolene Azagba-nyako, 2017. The WestminsterResearch online digital archive at the University of Westminster aims to make the research output of the University available to a wider audience. Copyright and Moral Rights remain with the authors and/or copyright owners. Whilst further distribution of specific materials from within this archive is forbidden, you may freely distribute the URL of WestminsterResearch: ((http://westminsterresearch.wmin.ac.uk/). In case of abuse or copyright appearing without permission e-mail [email protected] PUBLIC HEALTH NUTRITION INTERVENTION TO EVALUATE THE NUTRITIONAL IMPACT OF THE GHANA SCHOOL FEEDING PROGRAMME IN LOWER MANYA KROBO (LMK) DISTRICT, AND ENHANCING ITS EFFECTIVENESS THROUGH A NUTRITION INTERVENTION. BY MISS JOLENE MATEKO AZAGBA NYAKO WITH TECHNICAL SUPPORT FROM THE DEPARTMENT OF NUTRITION, NOGUCHI MEMORIAL INSTUTITE OF MEDICAL RESEARCH, FOOD RESEARCH INSTUTITE, GHANA AND THE FOOD SCIENCE DEPARTMENT OF KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS OF THE UNIVERSITY OF WESTMINSTER FOR THE DEGREE OF DOCTOR OF PHILOSOPHY AUGUST 2017 ABSTRACT School feeding interventions like many other donor dependent nutrition interventions in low-income countries have often been described to be ineffective or unsustainable because they are designed with donor specific nutritional interests, which often do not reflect the indigenous dietary preference and patterns of target populations. In Ghana, over half a million school children depend on the school meals as their main stable source of food for the day however there have been several reports of lack of nutritional impact of the due to the dependence on non-indigenous foods. The aim of this study was to develop school meals (SCm) for the Ghana School Feeding Programme (GSFP) in the Lower Manya Krobo District by employing local agricultural produce as food-to-food fortification. The study is based on the tailored functional food recipe concept that seeks to enhance the effectiveness of nutrition interventions by employing indigenous knowledge of food composition and food processing to improve micronutrients profile of local available foods without compromising palatability. Maize, sweet potatoes, soybeans, Moringa oleifera, palm nut oil, anchovies were processed using traditional methods. Each SCm was formulated using nutrition data from FAO West African-Food-Composition- Table to contain at least 40% DRI for protein. AOAC (2009) methods were used to analyse the nutritional content of the SCm and two sets of sensory tests were performed to determine acceptability. In all, five SCm were developed and per 100g of each SCm, carbohydrate (with crude fibre) and protein content ranged from 68.07g to 49.18g and 16.32g to 27.52g respectively whilst fat content ranged between 4.1g and 19.4g. Calcium content ranged from 284mg to 960mg whilst iron and zinc contents range between 7.17g to 11.17g and 0.97g to 1.59g respectively. In the sensory test, SCm coded FSM123, FSM101 and FSM579 had highest mean overall acceptability scores of 7.58±0.56, 7.74±0.81 and 7.71±0.70 respectively. The efficacy and effectiveness of the SCm were tested in a 6 months pilot nutrition n (180) and 9-month scale-up intervention (n=330) together with a control group and a GSFP group. After initial deworming and malaria screening, the intervention the GSFP group received the normal school meals, the control group received three portions of fruit as incentive the SCm group receive 15g weight bases of SCm meal together with nutritional education. The results showed that participants in the SCm treatment group had an average 3.24% increase in height (p≤0.05) and 13.08% increase in weight (p≤0.0.5) over the intervention periods. There was also a 17% decrease in anaemia prevalence compared 11% decrease in the control and 9% decrease in GSFP. The results illustrate that the application of indigenous knowledge, and innovation in of nutrition could be a plausible tool in enhancing the nutrient content of school meals. The SCm seems to provide some leverage and resilience against further malnutrition and when combined with deworming, malaria treatment buttressed with behaviour change communication provided greater nutritional impact on height and weight relative to the other groups in the study. 2 TABLE OF CONTENT Abstract …………………………………………………………………….…………2 Table of content………………………………………………………………………3 List of Figures, Tables and Abbreviations………………………………………..5 Author’s Declaration ………………………………………………………………….8 Acknowledgement Dedication……………………………………………………9-10 Chapter One: Introduction………………..…………………………………………11 1.1 Background Of Ghana School Feeding ……………………… ……………12 1.2 Outlay Of Thesis ………………………………………………………………15 Chapter 2 Literature Review ……………………………………………………….16 2.1Scope: Malnutrition Childhood Malnutrition: Global Facts And Figures …16 2.1.1 Epidemiological Data: Ghanaian Facts and Trends……………….18 2.2 Malnutrition and the Burden of Childhood Disease. …………………….…20 2.2.1 Reduced Productivity………………….……………………………21 2.2 2 Increase Susceptibility And Severity of Infection………….……22 2.2.3 Decreased Academic Performance and Cognitive Ability……22 2.2.4 Double Burden of Disease…………………………………….… 23 2.3 Global Strategies to Combat Malnutrition……………………………;………25 2.3.1 Life Cycle Approach To Malnutrition………………………………25 2.3.1 School Based Nutritional Interventions……………………..……28 2.3.1.1 Brief History……………………………….…………………25 2.3.1.2 School Feeding Programme Strategies and Inputs….…29 2.3.1.3Nutritional interventions in school best practice and benefits. 2.3.2 Nutritional interventions in Ghanaian schools………………… 44 2.3.1 History……………………………………………………………… 45 2.3.2 Problem statement and rationale……………….…………………46 2.4. Proposed strategy………………………………………………………………50 2.4.1 Tailored Functional food Recipe concepts……………………… 50 2.4.2 S-cool meal concept for GSFP………………..……………………52 2.5. Scm meal concept and conceptual framework. ………………………….…53 2.5.1 Increasing the nutrient density: ……..……………..………………54 2.5.2 Building capacity by …………………………………………………56 2.5.3 Promoting timely complementary health interventions……..……57 2.6 Theoretical Basis of SCm…………………………………………………..……57 2.6.1 Study research questions ……………………………………….…58 2.6.2 Aims ……………………………………..……………………………59 2.6.3 Objectives……………………………………………….……………59 Chapter 3: Subjects, Materials and Methods………………………………….…60 3.1 Study design/approach…………………………………………………………60 3.1. Justification of choice for study design and methods……………………61 3.1.1. Cross-sectional Surveys…………………………………………61 3.1.2 Field observation: …………………………………………………63 3.1.3 Product development: ……………………………………………64 3.1.4. SCm meal intervention: …………………………………………67 3.2 Study setting………………………………………….………………………69 3.2.1Justification for study site selection………………………………71 3.3 Target population and sample size…………………………………………71 3.4 Research variables and outcome indicators………………………………72 3.5 Ethical consideration…………………………………………………………75 3.6 Field observation ……………………………………………………………76 3.6.1 Cross-section survey ……………………………………………76 3.6.2 GSFP schools field observation (on-site visits) …………………78 3.6.3 Preliminary studies …………………………………………………79 [l 3 3.7 Product formulation and Development………………………………………80 3.7.1 Raw material selection. ……………………………………………81 3.7.2 Food processing methods…………………………………………87 3.7.2.1 Rationale for processing methods…………………..….88 3.7.2.2 Food Processing Procedures……………………………92 3.7.3 Formulation and optimisation………………………………………95 3.7.4 Proximate analysis …………………………………………………95 3.7.5 Sensory Evaluation…………………………………………………96 3.7.5.1 Sensory Evaluation Subject Test Training…………….97 3.7.5.2 Adoption of recipes and meal preparation ……………98 3.7.5.3 Sensory Evaluation procedure………………………….99 3.8 SCm meal intervention……………………………………………………….100 3.8.1 Training of volunteers, enumerators and S-cool Cooks. …..100 3.8.2 Sampling and Subject recruitment …………………………..…101 3.8 .3 Feeding intervention (RCT format) ……………………………102 3.8 .3.1 Scale up processing for intervention…………………105 3.8.3.2 Anthropometric and biochemical Measurement…….106 3.8 .3 3 Quality control and compliance…………………….…107 3.9 Data and collection and collation and analysis …………………………..109 3.10 Sustainability plan………………………………………………………...113 Chapter 4 Results and Discussion: Introduction……………………………...116 4.1. Service evaluation………………………………………………………….118 4.1.1 Heads of school and teachers survey…………………………118 4.12 Caterers survey………………………………………………….127 4.1.3 Focus group discussion………………………………………….129 4.1.4 Field observation ……………………………..………………….130 4.2 S- Cool Meal Product Development Introduction ………………………..146 4.2.1 Criteria for raw material selection and Cost Calculation and Analysis………………………………………………………………….146 4.2.2 Formulations of SCm ……………………………………….……151 4.2.3 Proximate analysis …………………………………………….…153 4.2.3 Sensory Evaluation …………………………………………..……156. 4.3 SCm intervention Introduction …………………………………………….……171 4.3.1 Pilot intervention ……………………………………………..…….172 4.3.1.2 Dietary patterns……………………………………..…..175 4.3.1.3: Parasitic infestation…………………………….………189 4.3.1.4: Nutritional status………………………………….…..191 4.3.1.5 Anaemia………………………………………………….200