Improving the nutritional well-being of school-age children through the Nutrition-Friendly Schools Initiative (NFSI) in the State of Palestine

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By Selena Bajraktarevic, Kanar Qadi, Amani Badwan, Younis Awadallah and Rania Abueita

This Field Exchange report is a summary of the cumulative results that were attained through the Nutrition-Friendly Schools Initiative interventions implemented between December 2018 and June 2021 in the State of Palestine. The authors wish to acknowledge the generous financial support from the Government of Norway and the UNICEF Global Nutrition Thematic Fund for this work. Thanks are also extended to all implementing partners, particularly during the difficult period of implementation resulting from the COVID-19 pandemic. 

Location: Gaza and West Bank

 

What this article is about: This article outlines the Nutrition-Friendly Schools Initiative, a UNICEF-supported intervention targeting healthy dietary and physical activity habits and the improved nutritional status of school-age children.

 

Key messages:

• Contextualising innovative Nutrition-Friendly School approaches and tailoring interventions towards the COVID-19 response achieved high coverage of school-age Palestinian children, building the foundations for future interventions.
• Initially, the absence of a National Nutrition Adolescent protocol, including clear procedures on school-age children nutrition screening and treatment, posed a significant challenge to the early stages of implementation. However, the introduction of revised National Nutrition Protocols mitigated this challenge, highlighting the value adolescent-specific public health and nutrition policies.

Background 

Approximately 4.8 million Palestinians live in the State of Palestine (SoP) with an estimated 2.9 million people living in the West Bank and 1.9 million in the Gaza Strip. The Palestinian population is predominantly young with 48% under 15 years of age and 30% between 15-29 years of age (PCBS, 2017). Palestine is affected by a protracted humanitarian crisis related to ongoing political divisions, chronic conflict and a deepening socio-economic crisis. As a result, Palestinian children and adolescents face vulnerability to violence and hardship with limited access to essential services including health, nutrition, education and safe water and sanitation.  The most recent household poverty survey (PCBS, 2017) found that 29.2% of Palestine’s population live in poverty (14% in the West Bank, 53% in the Gaza Strip) and 16.8% live in what is classified as ‘deep’ poverty¹  (5.8% West Bank, 33.8% Gaza Strip). Extremely high levels of food insecurity persist (47% in the Gaza strip compared to 16% in West Bank (PCBS, 2017)) and current estimates from December 2020 suggest that 2.2 million people (including 1.1 million children) are in need of humanitarian aid (UNICEF, 2021).

The situation is more acute in Gaza given the recurrent hostilities, the long-standing restrictions on movement and access to goods which, along with an ongoing electricity crisis, have exacerbated pre-existing vulnerabilities leading to unprecedented levels of unemployment, poverty and high rates of food insecurity, all of which have been compounded by the COVID-19 pandemic. The Palestinian Micronutrient Survey conducted in 2013 indicated a high prevalence of anaemia among children, adolescents and pregnant women with a noticeably higher prevalence in the Gaza Strip (31% in adolescents) compared to the West Bank (22% in adolescents). Anaemia prevalence rates were 10.5% in adolescent boys but almost one in every five girls was classified as having anaemia. Furthermore, surveillance by the Ministry of Education (MoE) found that Palestine faces a double burden of malnutrition in adolescents with rising rates of overweight, particularly among teenage girls (16.6%) and accompanying diet-related noncommunicable diseases. As of 2018, the indicators related to adolescent nutrition had not improved despite the implementation of a variety of health and nutrition activities. This highlighted the urgent need for community-based adolescent-focused nutrition interventions. 

Given this, from 2018 the Nutrition-Friendly Schools Initiative (NFSI) was implemented with support from UNICEF. This aimed to assist the government’s efforts in a school-based multi-sector approach to address malnutrition among adolescent girls from the most vulnerable districts in the West Bank and the Gaza Strip. The NFSI approach included policy dialogue and advocacy with the Palestinian authorities to change the education policy to promote adequate adolescent nutrition as well as a component that focused on modelling and scaling up effective interventions within schools and communities. This included supporting capacity-building activities, community mobilisation initiatives and the provision of supplies such as micronutrient supplements.  

The NFSI Programme 

The NFSI programme aimed to support the MoE and the Ministry of Health (MoH) to establish healthy dietary and physical activity habits and improve the nutritional status of school-age children. The programme aimed to strengthen the involvement of parents, families and communities, complementing formal ongoing school interventions and creating an enabling environment for sustainable positive change around nutrition and healthy lifestyles through the evidence-based Nutrition Friendly Schools (NFS) model (WHO, 2021). As a package of interventions to promote healthy dietary habits, the NFSI framework outlines 26 essential criteria within five broad components: school nutrition policies, school community awareness and capacity-building, nutrition and health-promoting curricula, supportive school environments for healthy nutrition and supportive school nutrition and health services. 

As SoP was the first country in the region to implement the NFSI, the international NFSI was adapted to the country context, translated into Arabic and endorsed by the MoE with support from a national NFSI steering committee. The steering committee included representatives from local and international partners including UN agencies (UNICEF, WFP, WHO), the MoE, the MoH, local non-governmental organisations (NGOs) and others. The MoE, in coordination with a local NGO partner and the MoH, led the process and developed an action plan to support the implementation of the NFSI in the country. The plan was endorsed by the steering committee and the MoE designed a practical manual that incorporated national objectives as well as the implementation strategy and guidelines. The MoE approved the initiative and endorsed it under the National School Nutrition Programme which was part of the National Education Strategy.  

The initiative launched locally in 2018 and included an initial self-assessment conducted by 24 schools (10 schools in the West Bank and 14 in the Gaza strip) that were the first to join the initiative. The assessment was conducted to evaluate the needs of schools in relation to the 26 criteria within the NFSI. Subsequently, an additional 10 schools from the West Bank joined, of which eight were in northern and middle governorates and two in East Jerusalem, bringing the total to 34 schools. Based on the findings of the self-assessment, the schools subsequently developed action plans, outlining key activities to implement the NFS criteria. This was followed by a capacity-building programme for teachers and school-aged children to develop school-based policy and action plans.

Key activities within the NFSI implementation

As part of this initiative, UNICEF and partners supported the MoE to conduct a number of interventions including broad-based strategy and capacity-building activities, communication related activities and special events. Specifically, activities included:

• Revising and upgrading the national school nutrition strategy to incorporate the NFS approach.  
• Revising, updating and translating the Palestinian Maternal, Child and Adolescent National Nutrition Protocol in order to reflect currently accepted best practices on adolescents’ nutrition in line with the NSFI. 
• Developing a referral system between schools and primary health care clinics in the targeted governorates to refer any school-age child with anaemia for further investigation and treatment. 
• Revising and updating the current training package on school nutrition to integrate the NFSI steps and relevant guidelines (undertaken by the MoE and a local NGO partner with UNICEF support).
• Developing a package of nutrition interventions, including NFSI standards, which included the revision of curricula to include life skills and health and nutrition promotion messages alongside physical activities (supported by UNICEF). The MoE and local partners produced several Arabic brochures and leaflets on the NFSI, its objectives and the steps necessary to become NFS accredited. These were distributed to all school children and key community representatives.  

More specifically, at school level a number of activities were conducted (as outlined in the action plans). Broad activities to support the NFSI included: 

• Refurbishing 10 schools to improve the water and sanitation facilities as part of the enabling environment interventions. 
• Providing canteen and sports equipment and hygiene materials. 
• Providing micronutrient supplements through the MoH for anaemic children (referred from schools to the primary health care clinics). 
• Implementing a capacity-building programme for school teachers, administrators and school-age children to develop their knowledge and raise awareness of optimal nutrition behaviours. The capacity-building programme involved a two day training targeting 34 school principals followed by cascade training at school level for teachers and administrative staff. 

Communication-related activities included: 

• Conducting awareness-raising sessions on anaemia and lifestyle modifications. This was through face-to-face sessions and virtual platforms targeting school-aged children. 
• Developing and disseminating positive messages on healthy diets and hygiene promotion. This included the development of an interactive game for school-age children, based on topics within the school health curriculum, which included messages on nutritional information and optimal health practices.
• Developing educational and communication material for community awareness. This included messaging through radio and television channels on healthy lifestyle practices, nutritious foods, diet diversity and the importance of physical activity. Parents were also provided with educational and informational material regarding the NSFI programme and the importance of healthy nutrition.

Special event-related activities included: 

• Conducting monthly or weekly group breakfast events in targeted schools where children were encouraged to bring healthy breakfast foods from their homes to eat together at school. 
• Holding drawing competitions in schools at both the local and national level to identify the ‘best’ healthy/nutrition-related painting. The drawings that won were included in the annual school calendar. 
• Composing and producing theatre plays and songs by children at school open days to promote healthy lifestyles. All activities were conducted using the equipment that was delivered to these schools from the NFS programme. 
• Developing school plays for school-age children in 10 schools that targeted healthy habits and nutrition messages and developing school gardens and planting vegetables for consumption by children. 

All activities were documented on a closed Facebook group for all the West Bank schools with 160 active members including school directors, teachers and health committees. 

COVID-19 related impacts and adaptations

The spread of COVID-19 aggravated existing vulnerabilities, affecting children’s wellbeing and further limiting boys’ and girls’ access to essential services such as education, health and protection. Survey data found that the COVID-19 crisis and the associated lockdown measures also affected the dietary and lifestyle habits of children and adolescents in SoP² . While being forced to stay at home, children became at risk of gaining weight and becoming overweight due to overeating, consuming ultra-processed foods and a lack of physical activity. This was concerning as SoP was already increasingly grappling with the triple burden of malnutrition. The new reality obliged the MoE, with the support of UNICEF and partners, to reformulate previously agreed activities under the NFSI and consider online and virtual delivery methods. 

The programme’s activities shifted to ensure hygiene standards were met and moved to online schooling platforms. Emergency activities included the procurement of new resources for schools such as temperature testing scanners, hygiene kits for school staff and canteen owners, lunch boxes for schoolchildren, dignity kits for girls, soap for handwashing and portable monitors to display educational videos and other messages related to health, nutrition and COVID-19 related precautions. Social and other media platforms (including videos, game applications, helpline services and Facebook posts) were used to promote nutritional messages and physical activity during the restrictions. A tele-counselling dietary programme for children, adolescents and their families was also launched through a hotline. Furthermore, as part of work to shift messaging to digital platforms, a game application was developed on healthy nutrition, targeting school children between 12 and 15 years of age. The game was accessible for free use via the Google Store. The idea behind the application was that it could be downloaded onto parents’ phones so that both parents and children could learn and play at the same time. The game consisted of 12 levels, with each addressing one topic related to healthy eating and physical activity.

Furthermore, the capacity-building component of the initiative shifted to an online platform. The online training was organised to target participants including the principals from the 10 new schools as well as field workers and staff within the School Health Department.

Results

The total number of school children reached in the first phase (24 schools) was 12,929 in both the West Bank and the Gaza Strip (3,453 in the West Bank with 61.7% girls and 9,473 in the Gaza Strip with 93.4% girls). In the second phase, an additional 10 schools were added to the programme in the West Bank, including East Jerusalem. In these additional schools, 3,709 schoolchildren were reached of whom 47% were female. In total 16,638 schoolchildren benefited from school activities including haemoglobin and anthropometry screening, awareness sessions on healthy lifestyles and nutritious foods, hygiene promotion activities and other physical education activities implemented through the NFSI programme. In addition, almost 395 teachers from all 34 schools have been trained within the capacity-building programme. One-day face-to-face training to introduce the updated protocol was conducted at the end of February 2020 in the Gaza Strip and six five-hour virtual training sessions were conducted for the West Bank. The virtual training sessions in the West Bank included almost 100 participants from different Palestinian and international institutions including the MoH, the MoE, local universities, the United Nations Relief and Works Agency (UNRWA) and international and local NGOs.

To measure the impact of the NFSI in 2020, UNICEF supported the MoE and a local NGO partner to conduct haemoglobin and anthropometric assessments of school-age children before the intervention to assess the prevalence of anaemia among school-age children. A total of 16,638 children from the 34 NSFI Schools (61% girls) were screened by school health teams. Thirty-three percent of screened school-age children (5,490) were found to be anaemic and 22.7% of those surveyed were found to be underweight while, on the other hand, 35.3% of those were found to be overweight or obese. Anaemia figures were little changed from the previous micronutrient survey conducted in 2013.However, the burden of school-aged children with overweight and obesity appeared to have increased.  

In response to the screening results, UNICEF procured micronutrient supplements which were administered through MoH facilities to anaemic school-age children. In addition, an SMS-based feedback mechanism was established between parents and school teachers to ensure that children’s nutritional status (using height and weight measurements) was monitored appropriately. Central to this was the follow-up of anaemia treatment and check-ups at health clinics. 

Within the NSFI, efforts were also made to improve monitoring systems and data availability including indicators on the nutrition of school-age children (anaemia prevalence rates and nutritional status estimates including obesity rates).

Successes, challenges and lessons learned 

Successes

One of the biggest successes of the initiative was that the NFSI was able to reach a large number of adolescents despite the challenging context within SoP. In the initial stage of the NFSI, 20 schools were targeted (10 in the West Bank and 10 in the Gaza Strip). However, due to the high population density within the Gaza Strip and the disparity between the number of schools, the number of available structures and the number of students, 75% of Gaza’s elementary schools operate in two shifts. This means that the same school building serves the number of students in two schools. This allowed the MoE, with support from UNICEF and partners, to reach more children so in total 14 schools were reached instead of the 10 originally targeted in the Gaza Strip.  

Nutrition among school-age children became a national priority. Through the implementation of innovative NFSI and inter-ministerial coordination, the Palestinian authorities committed to enhance nutrition among school-age children and to ensure proper actions to address malnutrition among this age group.

In coordination with nutrition partners, UNICEF supported the MoH to update the Maternal, Child and Adolescent National Nutrition Protocol by integrating a chapter on adolescent nutrition as well as a chapter on COVID-19 and its implications for nutrition outcomes. This is the first time that SoP has included adolescent nutrition in the national nutrition protocol and defined clear procedures and steps to address the screening and treatment of malnutrition among adolescents. 
The COVID-19 pandemic brought with it many challenges but the ability of the initiative to shift quickly to digital platforms and mobilise and actively engage school-age children in the dialogue about healthy nutrition, through activities such as the game application, was deemed a success. Additionally, awareness among school-age children towards healthy nutrition behaviours increased.

Challenges and bottlenecks

A number of challenges were faced in the implementation of the NSFI. For example, the absence of a national protocol for adolescent nutrition, including clear procedures on nutrition screening of school-age children, was noted to be a tremendous challenge in the early stages of implementation as was the lack of a clear referral system for anaemic adolescents from schools to health facilities. To overcome this challenge, the MoH and MoE, with technical support from UNICEF and partners, revisited the National Nutrition Protocol and included procedures for adolescents including for referrals of malnourished adolescents. The revised protocols greatly helped to ensure that adolescent nutrition was prioritised and that school-aged children received nutrition screening. It further enabled a streamlined referral process so that children were not ‘lost’ between education and health services. 

Another challenge was experienced in relation to coordination among various nutrition partners. In order to enhance the dialogue on adolescent nutrition, frequent meetings at the national and subnational level were held including the Gaza nutrition technical working group. This engagement helped to improve inter-ministerial coordination as well. 

Understandably, the spread of COVID-19 led to many challenges as activities had to shift from in-person to remote engagement. Weak internet connectivity in some areas limited school-age children’s participation in online activities. In order to overcome these challenges, many innovations were developed such as those listed above. This enabled the NFSI to continue in spite of the pandemic. 

Lessons Learned

One of the most valuable lessons learnt during the NFSI implementation was the importance of inter-ministerial cooperation and the engagement of all relevant nutrition partners working within the health, education, protection and water, sanitation and hygiene sectors and communities to address malnutrition among school-age children. This resulted in the organisation of frequent consultation workshops that enabled discussions on learnings and how to overcome any challenges. At the national level, a strategic consultation workshop took place entitled “Investment in Nutrition in Palestine” during which the NFSI initiative was presented and discussed. This workshop resulted in key recommendations being incorporated in the Palestinian NFSI and taken into consideration for future phases. Some of the recommendations are reflected above and included: 

• The importance of updating the National Nutrition Protocol to include adolescent nutrition
• The need to adopt the NFSI as a MoE policy to scale up the initiative across the country 
• The need to ensure standards were set for NFSs
• The importance of regularly engaging communities and particularly parents in the initiative to ensure that the activities in the NFSI were sustained and that, as far as possible, healthy eating behaviours were maintained  

Conclusion

UNICEF and nutrition partners were able to implement the NFSI activities in SoP to a high standard despite the challenges faced such as COVID-19. A wide range of innovative activities were developed at school level before the pandemic and this laid the groundwork for implementation during the pandemic. In the coming years, UNICEF and national partners are looking to expand implementation. It is planned that the following activities will be included as next steps: 

• Continued advocacy with the MoH and MoE to implement updated protocols 
• The scale-up of the initiative to all schools in Palestine including public, private and UNRWA schools
• Continued community engagement through communication for development initiatives targeting young people and parents to promote healthy lifestyles and good nutrition including support to maintain the interactive nutrition game platform and helpline for counselling 
• Generating evidence and measuring the results of the innovative NFSI approach and impact on the nutritional status of school-age children

For further information, please contact Selena Bajraktarevic at sbajraktarevic@unicef.org 
Additional media content for the initiative can also be found via here. 

¹National monetary standards for poverty in Palestine, as set by PCBS in 2011, are defined as a poverty line of 2,293 NIS (US$637) per month for a family of two adults and three children. ‘Deep poverty’ is classified as a monthly income of NIS 1,832 (US$509) or less per month for basic items such as food, clothing and housing.

²Living with the COVID-19 pandemic: adolescent experiences in the State of Palestine (Gender & Adolescents Global Evidence: August 2021)

References

PCBS (2017) Palestinian Expenditure and Consumption Survey (PECS). 

Household Poverty Survey, PCBS , 2017

PCBS (2012) Living Standards in the Palestinian Territory: Expenditure, Consumption, Poverty, 2011.Socio-Economic & Food

UNICEF (2021) HAC State of Palestine https://reliefweb.int/sites/reliefweb.int/files/resources/2021-HAC-State-of-Palestine.pdf

WHO (2021) Nutrition action in schools: a review of evidence related to the nutrition-friendly schools initiative, ISBN: 9789241516969

Juzoor (2020) Impact of COVID-19 lockdown on dietary and lifestyle behaviours among adolescents in Palestine. Available at: https://journalofhealth.co.nz/wp-content/uploads/2020/06/DHH_Hatim_Impact-of-COVID.pdf