Adolescent nutrition in Mozambique: putting policy into practice

Research

By Erin Homiak

Erin Homiak MPH is seconded to SETSAN Manica as Nutrition Advisor. Her role is funded by UKaid/DFID. She has been working for Concern Worldwide since January 2015 to improve coordination across government and non-government sectors in order to reduce rates of chronic undernutrition amongst women, adolescents and children and to address the root causes of gender inequality to ensure improved nutrition outcomes. Erin has worked in Mozambique since 2013, previously with Helen Keller International on their Vitamin A Supplementation Team.

The research was carried out by the Technical Secretariat for Food Security and Nutrition (SETSAN-P, Manica) Focal Point and the SETSAN Technical Advisor (Nutrition Advisor, Concern Worldwide).

The author acknowledges Cosme Cabsela Mandu, Focal Point for SETSAN-P, Manica and Dionisio Oliveira, SAAJ Focal Point for Manica Province for their support and participating in this review. Thanks also to DFID and Irish Aid for funding support.

Location: Mozambique

What we know: Adolescents are typically not targeted in health and nutrition services; this has implications for health outcomes across generations.

What this article adds: A recent review examined the extent to which national policy on adolescent nutrition (targeting anaemia control, reduced early pregnancy and nutritional education) is being implemented in Manica province, Mozambique. It found few interventions in the province target adolescents; a gap in service implementation of the Ministry of Health’s unit for adolescents (SAAJ) services; and underuse of established platforms to improve SAAJ access. Recommendations to inform nutrition programming at national, provincial and district levels include defining female adolescents as a separate target group; including pregnancy reduction in nutrition programmes that aim to reduce chronic undernutrition; designing a strategy to address early child marriage and engage men; targeting marginalised adolescents; and using existing outreach and service provision platforms to full capacity.

Global context

Adolescents are an underserved population; their needs are not reflected in services (Hainsworth et al, 2009; Save the Children, 2015; Patton et al, 2014) and interventions do not define or target adolescents who are often perceived as a healthy or low-risk group (Save the Children, 2015). Poor care-seeking behaviour due to individual and structural barriers (Temin & Levine, 2009) and stigma around family planning and use of the health system hinder service access and delivery (Temin & Levine, 2009). Lack of evidence makes policy decisions difficult; what does exist indicates that failure to target adolescents has major implications for health outcomes. Adolescent females are more likely to give birth to babies with low birth weight or who are small for gestational age and children who are more likely to become stunted and in turn give birth to small babies, thus perpetuating an intergenerational cycle of chronic undernutrition (Save the Children, 2015). Neglecting adolescent health means child mortality rates and maternal health will remain relatively unchanged (Sawyer et al, 2012).

Little is known about the micronutrient deficiencies at the population level in Mozambique (Korkalo et al, 2014), although we do know that 54% of girls and women between the ages of 15 and 49 are anaemic (Ministerio da Saúde (MISAU) et al, 2011). Teenage HIV infection rates suggest that the health needs of adolescents are not being addressed; young people (<25 years) account for 60% of new HIV infections and young women (20 to 24 years old) are infected at a rate triple that of men the same age (Hainsworth et al, 2009), highlighting the need to address the root causes of gender inequality. Adolescent pregnancy rate is high in Mozambique at 44.4% in rural and 33.2% in urban areas (UNICEF, 2015); early marriage is one of the strongest drivers. 

Under the Scaling Up Nutrition (SUN) Movement 1,000 days window of opportunity (Black et al, 2013), the pre-conception phase is not taken into account, which often coincides with adolescence. While the 1,000-day framework encompasses adolescent pregnancies, attention to prevention of pregnancy and early marriage is also needed, using a life-cycle approach to inform programme design and implementation. Programmes that address adolescent nutrition will help realise the SUN objective to increase exclusive breastfeeding (adolescents are 33% less likely to breastfeed); reduce maternal and neonatal mortality; and decrease stunting (Save the Children, 2015; Temin & Levine, 2009).

A recent review set out to understand the extent to which national policy regarding adolescent nutrition is being implemented in Manica province, Mozambique. The aim of the review was to assist the provincial authority in advocating for an expansion of current delivery channels serving adolescents and to raise their profile among the development community as an important demographic to focus on and invest in. Key findings are summarised here.

Context of Mozambique

The first objective of Mozambique’s Multi-Sectoral Action Plan for the Reduction of Chronic Malnutrition (PAMRDC) (Republic of Mozambique, 2010) specifically aims to improve the nutritional status of adolescent girls aged 10-19 (ibid, 2010). The PAMRDC is a guiding framework designed by multiple ministries and civil society partners and is monitored by SETSAN at national and provincial levels. The framework includes seven objectives, all with defined impact results, for the reduction of chronic malnutrition.

Serviços Amigos dos Adolescentes e Jovens (SAAJ) is the unit in the Ministry of Health providing public health services to adolescent males and females. The Department for Youth and Sports is the only other provincial PAMRDC partner that targets adolescents. At provincial level, SAAJ consists of one Focal Point located in the provincial capital who is responsible for the oversight of all the district-level service provision. There is an established, country-wide mechanism of peer-to-peer activists (Geração Biz), created to increase the number of adolescents who access SAAJ services with the ultimate goal of addressing the sexual and reproductive health (SRH) needs of male and female adolescents. The activists are trained and supervised by SAAJ, the Department of Education, and the Department of Youth and Sports.

Method

The study used qualitative and quantitative research methods, including key informant interviews (KIIs) and review of secondary sources, including a literature review. Participatory observations of service provision of adolescent (SAAJ) health services in three district-level facilities in Manica Province (Guro, Tambara and Manica) and training of peer-to-peer activists (Geração Biz) in Gondola district were undertaken. KIIs were conducted with the provincial SAAJ Focal Point in Manica; SAAJ health providers in Guro, Tambara, and Manica districts; the provincial Focal Point for the Ministry of Education; and several agencies including Pathfinder International, Save the Children, FHI360, CARE, UNICEF and the UN Food and Agriculture Organization (FAO).

Results

Under strategic objective 1 of the PAMRDRC, there are three defined results. Evidence was gathered on the degree to which the results were being met, as follows:

Result 1.1: Controlled anaemia in adolescents (10-19 years) within and outside schools

In Manica province, iron supplementation is implemented through health clinics and mobile brigades. Mobile brigades do not specifically target adolescents in remote communities to receive iron supplementations or family planning, and until 2015 the adolescent target group for health clinics was 15-19 year-old females (rather than 10-19 year-olds)¹

Result 1.2: Reduced early pregnancy in adolescents (10-19 years)

Family planning for adolescents is implemented through the health post; again, adolescents are not specifically targeted by the mobile brigades. SAAJ in Manica was given technical support through UNFPA from 2005 until 2013 and subsequent support from Save the Children² from 2015 in two of 11 districts in Manica Province (including training of activists, service providers and teachers and materials provision) in a two-year pilot programme funded by the Norwegian Government. There are Geração Biz activists in the district schools, but only two districts have received refresher trainings (with the support of Save the Children). Lack of resources limits further rollout.

Result 1.3: Strengthened nutrition education in different education levels as part of school curriculum, including literacy curricula

There is a national curriculum that includes a nutrition component, which is implemented at primary school level. FAO is supporting the training of teachers in nutrition in three districts of Manica province.

This snapshot from Manica shows adolescent nutrition and health is being addressed to some extent, and there are many opportunities to continue and increase the inclusion of adolescents in public health interventions. At the national level, several organisations, including Pathfinder International, UNFPA and UNICEF, work in adolescent health, focusing on SRH but not taking account of nutrition. It is important to note that there may be interventions addressing adolescent nutrition in Mozambique that have not been captured in this review.

Discussion and recommendations

The findings presented demonstrate a lack of targeting and attention to adolescent nutrition within programmes that aim to improve nutrition in Manica province, despite national policy. The review recognises the challenge for provinces to keep in constant connection with the nutrition and policy community that is centralised in Maputo. On a positive front, Mozambique is ‘ahead of the game’ with regard to having an adolescent nutrition policy, which non-governmental organisations (NGOs) and partners use as a framework to align programmes. Furthermore, the PAMRDC is multi-sectoral and includes the health, education and agricultural sectors (Republic of Mozambique, 2010; Save the Children, 2015). There are promising entry points with existing programmes.

Mozambique will not see a reduction in chronic undernutrition unless adolescent health and nutrition is prioritised. A paradigm shift is needed in the way populations are targeted, taking into consideration the life-cycle approach, including adolescents in target groups and not waiting for adolescent girls to become pregnant before engaging with them and key influencers of early marriage (Concern Worldwide, March 2014).

To translate this framework into the action it merits, the following recommendations are made:

• Nutrition interventions should define female adolescents as a separate target group whose needs are different from adult women. Interventions that define indicators specific to adolescents will generate data to inform services and interventions in the future.
• The ambition to reduce pregnancy rates in female adolescents should be mainstreamed into nutrition programmes that seek to reduce chronic undernutrition, taking gender into account and engaging men.
• All outreach mechanisms should address early child marriage to align with Mozambique’s National Strategy for the Prevention and Elimination of Early Marriage adopted by the national Government in 2015. This includes engaging men, recognising that there are many determining factors that affect early marriage.
• The current delivery platform, Geração Biz, should be utilised to full capacity in order to increase care-seeking behaviour and ensure access to SAAJ services.
• Interventions should be equitable; female adolescents who are not in school and who are likely to be most marginalised require alternative community outreach programmes, such as youth care groups, youth centres and vocational training (Roche, 2015; Save the Children, 2015).

For more information, contact info@concern.net

The full report is available at: https://www.concern.net/resources/adolescent-nutrition-missing-link-life-cycle-approach

References

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Concern Worldwide (March 2014). Barrier Analysis Report: Linking Agribusiness and Nutrition in Mozambique (LAN).

Hainsworth G, Zilhao I, Badiani R, Gregorio D & Jamisse L (2009). From inception to large scale: The Geração Biz Programme in Mozambique.

Korkalo L, Freese R, Fidalgo L, Selvester K, Ismael C & Mutanen M (2014). A Cross-Sectional Study on the Diet and Nutritional Status of Adolescent Girls in Zambézia Province, Mozambique:  Design, Methods, and Population Characteristics. [The ZANE Study] JMIR research protocols, 3(1).

Ministerio da Saúde & Instituto Nacional de Estatística (2011). Moçambique Inquérito Demográfico e de Saúde 2011. Retrieved August 13, 2013 dhsprogram.com/pubs/pdf/FR266/FR266.pdf

Republic of Mozambique (2010). Multisectoral Action Plan for the Reduction of Chronic Undernutrition in Mozambique 2011-2015.

Roche M (2015). New Global Focus Placed on Reducing Anemia in Adolescent Girls.

Save the Children (2015). Adolescent Nutrition: Policy and prgramming in SUN+ countries.

Sawyer SM, Afifi RA, Bearinger LH, Blakemore S-J, Dick B, Ezeh C & Patton GC (2012). Adolescence: A foundation for future health. The Lancet, 379(9826), 1630-1640.

Temin M & Levine R (2009). Start with a girl: A new agenda for global health. Washington, DC Center for Global Development.

UNICEF (2015). Child Marriage and Adolescent Pregnancy in Mozambique: Causes and Impacts.

¹Dionisio Oliveira (SAAJ), conversation with author, 8 April 2015.

²Isabel Mateo (Save the Children), conversation with author, 12 June 2015.