Effectiveness and cost-effectiveness of school meals programmes on education, health and nutrition, social protection and agriculture in low-income and middle-income countries: a systematic review protocol

Introduction Globally, school meals programmes (SMPs), otherwise referred to as school feeding programmes, are widely implemented with the aim of improving multisectoral outcomes, including education, health and nutrition, social protection and agriculture, among other cross-cutting impact areas. Despite their widespread adoption and the broad recognition of their potential benefits, evidence on their actual impact across these diverse outcomes remains limited, fragmented and often inconclusive. This lack of consolidated and robust evidence has prompted growing interest from development and humanitarian agencies, practitioners and policymakers in generating high-quality data to inform the design, implementation and scaling of these interventions. Therefore, to address this gap, we plan to conduct a systematic review aimed at assessing the effectiveness and cost-effectiveness of SMPs on outcomes related to education, health and nutrition, social protection and agriculture in low-income and middle-income countries. Methods and analysis A comprehensive literature search will be conducted on relevant studies published between 2007 and 2025. The study will focus on four primary outcomes, which will include education, health and nutrition, social protection and agriculture. This systematic review will align with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will search seven databases: MEDLINE (via Ovid), Scopus, Web of Science, CINAHL, Embase (via Ovid), PubMed and Global Health (via Ovid) using predefined keywords. The risk of bias of randomised and non-randomised studies will be assessed using the Cochrane Risk of Bias tool and the Risk of Bias In Non-randomised Studies - of Interventions tool, respectively. Two reviewers will independently select studies, extract data and assess risk of bias. All included studies will be summarised and meta-analyses will be conducted when appropriate. Heterogeneity will be assessed using the I² statistic, subgroup analyses and meta-regression. Ethical considerations and dissemination This study will not involve the collection of primary data and will thus not require any ethical approval. The dissemination of the outcome of the study will be through global conferences, policy briefs and scientific journals. PROSPERO registration number CRD42024628180.