Intended for healthcare professionals


Realist review to understand the efficacy of school feeding programmes

BMJ 2007; 335 doi: (Published 25 October 2007) Cite this as: BMJ 2007;335:858
  1. Trisha Greenhalgh, professor of primary health care1,
  2. Elizabeth Kristjansson, associate professor2,
  3. Vivian Robinson, doctoral candidate3
  1. 1Department of Primary Care and Population Sciences, University College London, London N19 5LW
  2. 2School of Psychology and Institute of Population Health, University of Ottawa, Canada K1N 6N5
  3. 3Institute of Population Health, University of Ottawa
  1. Correspondence to: T Greenhalgh p.greenhalgh{at}
  • Accepted 19 September 2007

A recent Cochrane review found that school feeding programmes significantly improve the growth and cognitive performance of disadvantaged children. Trisha Greenhalgh,Elizabeth Kristjansson, and Vivian Robinson look more closely at the highly heterogeneous trials to see what works, for whom, and in what circumstances

Our Cochrane review of school feeding programmes in disadvantaged children included trials from five continents and spanned eight decades.1 Although we found that the programmes have significant positive effects on growth and cognitive performance, the trials had many different designs and were implemented in varying social contexts and educational systems; by staff with different backgrounds, skills, and cultural beliefs; and with huge variation in the prevailing social, economic, and political context. Simply knowing that feeding programmes work is not enough for policymakers to decide on the type of intervention that should be implemented. We therefore looked at the trials more closely to determine the aspects that determine success and failure in various situations.

Review methods

We analysed the 18 studies (reported in 29 articles) included in our Cochrane review2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 using the methods of a realist review. Realist review exposes and articulates the mechanisms by which the primary studies assumed the interventions to work (either explicitly or implicitly); gathers evidence from primary sources about the process of implementing the intervention; and evaluates that evidence so as to judge the integrity with which each theory was actually tested and (where relevant) adjudicate between different theories.31 32

We read, re-read, and discussed the papers and constructed a matrix on an Excel spreadsheet to collate information for each trial on:

  • Study design, sample size, and outcome data

  • Nature of the experimental …

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