Nutrition in Qur’an: An innovative approach to promote optimal nutrition care practices

By Nasrullah Sultani and Tamanna Ferdous

Nasrullah Sultani is the nutrition focal point and Regional Manager for the northern region for Welthungerhilfe Afghanistan. He has over 15 years of experience in the design, delivery and evaluation of nutrition and food security in Afghanistan. He is a medical graduate with a masters’ degree in public health.

Tamanna Ferdous is Regional Nutrition Advisor for Asia with Welthungerhilfe. She has a PhD from Uppsala University, Sweden in public health nutrition and 20 years of experience in international public health and emergency nutrition in Asia, Africa and Middle Eastern countries.

The authors would like to thank Saifuddin Ayobzai, Project Manager and core team member of the Nutrition in Qur’an programme at Welthungerhilfe Afghanistan and all project core team members and field staff for their continuous support and dedicated work to implement this pilot project. The authors also acknowledge Thomas ten Boer, Country Director, Welthungerhilfe Afghanistan; David Tholen, Head of Project, Welthungerhilfe Afghanistan and Julia Broska, former Head of Programmes, Welthungerhilfe Afghanistan for their leadership and support. The authors also express their appreciation to the Ministry of Public Health Afghanistan and the Ministry of Hajj and Islamic Affairs Afghanistan for their continued support. Finally, the authors thank all the mothers, children and other participants who kindly participated in this pilot project and in the knowledge, attitudes and practices survey.

Background

Despite substantial progress over the last 15 years in Afghanistan, undernutrition remains a significant problem, particularly in rural communities. The 2018 Afghanistan Health Survey¹ (AHS) revealed 6.3% of children under five years old to be wasted, 36.6% stunted and 18.7% underweight. Poor care and health-seeking practices are a key underlying cause of undernutrition. The 2018 Afghanistan Health Survey (KIT and MoPH, 2018) revealed that only 57% of infants under six months were exclusively breastfed; early initiation of breastfeeding within an hour of birth took place in only 64% of cases; and the median duration of breastfeeding was 10 months. Health-seeking practices were also revealed to be poor, with only 21% of pregnant women visiting health clinics for antenatal care four times; 40% of women visiting a health professional for postnatal care; 59% of pregnant women giving birth at a healthcare facility; and 46.8% of pregnant women receiving an iron supplement during their last pregnancy (KIT and MoPH, 2018).

Afghanistan’s population is majority Muslim. There is widespread belief in the authority of Qur’anic teaching and religious leaders have strong influence in social and political affairs at national and community level. Communities in rural areas often have more than one religious leader or local mullah, who provide guidance on personal and social issues. These individuals are key gatekeepers of information for the community and their opinions are highly respected.

Welthungerhilfe has been operational in Afghanistan since 1980, initially providing immediate aid to Afghan refugees. Welthungerhilfe Afghanistan currently manages projects in the east, north, west and central regions under five thematic areas: food and nutrition security; rural and regional development; agriculture and environment; water, sanitation and hygiene (WASH); and humanitarian assistance. The organisation’s goal is to work hand-in-hand with civil society in Afghanistan to empower socially marginalised and economically poor citizens to reinforce their resilience and ensure adequate food and nutrition throughout the year.

Nutrition in Qur’an was a Welthungerhilfe ‘Innovation Factory’² pilot project that aimed to improve awareness of and access to information on healthy nutritional behaviour by utilising the influences of religious and other opinion leaders. The pilot aimed to capitalise on the high level of trust placed in religious and other opinion leaders by bringing them together with nutrition experts to amplify nutrition messages featured in the two main scriptures of Islamic knowledge, the Qur’an and the Hadith³. 

Utilising religious leaders to influence behaviour change

The influential power of religious leaders has been utilised by health programmes in the past to promote behaviour changes at community level. In Egypt, the Islamic Advisory Group for Polio Eradication launched a training manual on ‘Polio Eradication: Mother & Child Health and Immunization’ for students of religious studies in support of polio eradication efforts. Through this training Muslim leaders were engaged to urge parents to vaccinate their children.⁴ The ‘Mobile Mullahs’⁵ initiative in Afghanistan, recognised as one of the 10 most innovative interventions in the eradication of polio by the Global Polio Eradication Initiative in 2019, engaged religious leaders across the country to spread messages about the benefits of polio vaccines during Friday prayers. In this programme religious leaders visited vaccine-refusing families to talk about Islam’s support for vaccines and persuade mothers and caregivers to vaccinate their children. This initiative was positively accepted by communities and resulted in an increase in polio coverage. Welthungerhilfe chose to use a similar approach, applied to nutrition programming.

Knowledge, attitudes and practices (KAP) survey

To inform the Nutrition in Qur’an approach, a core team of nutrition experts and well-educated religious leaders was established at national and local levels to identify barriers confronting proper nutrition care practices in the country and to develop effective strategies to overcome them. The team, led by Welthungerhilfe, consisted of nutrition experts from the Ministry of Public Health (MoPH), Save the Children International and national partners implementing the Basic Package of Health Services (BPHS), as well as representatives from the Ministry of Hajj and Islamic Affairs (MoHIA), religious leaders and other stakeholders, including civil society organisations, universities and media groups.

Methodology

In December 2017 nutrition experts from the core team carried out a knowledge, attitudes and practices (KAP) survey to understand perceptions of nutrition care, determine some of the root causes of poor nutrition care practices, and identify possible solutions. The survey was conducted in five communities (Nikerabad, Charshanbe, Meserabad, Jalalabad and Eraghli) in Sheberghan district, Jawzjan province. These communities were selected as they were existing Welthungerhilfe project sites (therefore there were logistical, administrative and cost advantages), as well as on the basis of previous observations by programme staff of the need for positive nutrition behaviour change. All five communities were in rural areas with high rates of illiteracy, each with a health post providing basic health consultations and treatment, with an average distance of around 25km to the nearest provincial hospital.

The KAP survey targeted primary caregivers of infants aged 0 to 24 months, which meant that caregivers with at least one child aged under 24 months were targeted. A total of 174 pregnant and lactating women (PLW) with at least one child aged 0-23.9 months were identified at random to participate in the assessment (based on a sample size calculation as per standard sampling formula) (Table 1).

Table 1: Calculation of sample size in five targeted communities⁶

Individual surveys were conducted in each household using a comprehensive questionnaire that collected both qualitative and quantitative data covering respondents’ knowledge, common practices and perceptions.

Results

Results of the KAP survey indicated very poor knowledge, attitudes and practices of women on nutrition care practices, cooking practices, iron and folic acid supplement consumption, and birth spacing. Of the women surveyed, 15% had knowledge on exclusive breastfeeding; 17% knew that colostrum should be given to newborns within the first hour of birth; and 30% reported providing colostrum at any time within the first 24 hours of birth. Of those surveyed, 16% knew that children should receive breastmilk up to 24 months and beyond; 14% knew that solids should be introduced at around six months; 36% were aware of the need to take iron and folic acid supplements during pregnancy and lactation; only around half (51%) understood the need for birth spacing of a minimum of two years; while the other half (49%) said that single-year birth spacing was enough.

The KAP survey results therefore indicated poor knowledge of mothers and caregivers as a key obstacle in the uptake of optimal nutrition care practices. This suggested the need for social behaviour change communication (SBCC) strategies targeting specific areas of knowledge. Results also indicated limited access to quality nutrition counselling and low knowledge and skills of health staff in this regard, suggesting the need for capacity building of health staff and improved access to services. The survey also confirmed that local religious leaders are powerful sources of information and influence in target communities and that the main contact points between religious leaders and households are male household members. For example, among the respondents using contraceptives, 61% indicated that they were doing so because religious leaders had supported their choice of birth control. Moreover, 97% of survey respondents indicated that they listen to, accept and practice recommendations given by religious leaders. These results demonstrated the potential for utilising religious leaders to communicate positive nutrition messages at community level and the need to channel such messaging through men. Other important influences on households were identified as radio and television (45% of respondents), suggesting the potential for delivery of nutrition messaging and education via radio and television programmes.

Development of Qur’an-based nutrition messages

Following a detailed analysis of the knowledge, attitudes and practices (KAP) survey findings, Welthungerhilfe convened a meeting of core team members, local religious leaders and reputed national religious leaders. The purpose of the meeting was to discuss the findings and suggest solutions from both technical and religious perspectives. A key recommendation from the meeting was the development and utilisation of key Islamic-based nutrition messages targeting households with young children in rural communities. As a result, a trilateral memorandum of understanding was signed with the Ministry of Public Health (MoPH), Ministry of Hajj and Religious Affairs (MoHIA) and Welthungerhilfe to develop nutrition messages and pilot the Nutrition in Qur’an project.

Religious experts from the core team compiled a set of 14 nutrition messages drawing from the last 14 centuries of Islamic tradition and scriptures, including the Qur’an and the Hadith, in line with World Health Organization (WHO) recommendations (Box 1). Using these agreed messages, graphic materials and campaign tools were then developed. Before producing the final documents, the acceptability of the tools was tested by local mullahs and health workers at local mosques during Friday prayers, health clinics and health posts, as well as with male and female members of the targeted communities. Discussion forums with religious leaders, nutrition experts and communities were also facilitated to discuss the implementation plan and acceptance of developed materials.

Nutrition in Qur’an pilot programme

Project implementation

A Nutrition in Qur’an pilot programme was initially planned to be undertaken for six months in selected target communities. However, due to administrative challenges (in particular delays in the signing of an agreement with government ministries), the project continued for more than one year (September 2017 to December 2018). During this time the key nutrition messages were disseminated through multiple channels. Men’s and women’s groups were formed at community level and training was delivered on key messages. During these sessions over 1,000 pregnant and lactating women received training. Imams (religious leaders who lead prayer in mosques) were trained to carry out a ‘Friday prayer campaign’, whereby a key nutrition message was discussed at Friday prayers each week for 14 weeks. Health workers, including health facility staff and community health workers (CHWs), were trained in the key nutrition messages. Fourteen radio programmes were also broadcast; these consisted of roundtable discussions on key nutrition messages between religious and nutrition experts. Videos of well-known religious leaders and local imams discussing nutrition messages, as well as posters and flyers, were also disseminated to one local health clinic, 10 health posts and 12 mosques. Videos were broadcast during the health-education sessions in health clinics and health posts and played to the women’s and men’s groups during trainings. Flyers and posters were used during trainings and awareness campaign in schools and communities and were discussed by mullahs during Friday prayers.   

Results of an endline survey

Following the six months of project implementation, an endline survey was carried out with religious leaders, nutrition experts and male and female community groups. Due to time constraints it was not possible to conduct a follow-up knowledge, attitudes and practices (KAP) survey, so focus group discussions (FGDs) were used. Eight FGDs were organised, with male (two groups) and female (four groups) community participants; nutrition experts (one group); and religious leaders (one group). Overall, 70 respondents took part. In order to capture opinions from a wider range of people, especially for the community groups, FGD participants were either selected randomly and/or recommended by the Community Development Council (CDC). Community FGDs included members of the CDC, teachers, mothers with children aged below five years, farmers and community health workers. The FGD with religious leaders included local imams or mullahs, well-known religious leaders at local and national levels, and religious leaders who represented government ministries. The FGD with nutrition experts included participants from Welthungerhilfe, local implementing health non-governmental organisations (NGOs), and staff of international NGOs, such as Save the Children.

FGD were facilitated by two individuals (a facilitator and notetaker); two observers also attended. A standard questionnaire was developed and facilitators were trained on how to encourage broad participation. Questions were asked that assessed knowledge on nutrition and healthy behaviours, potential for scale-up of the project, and perceptions of religious leaders and their ability to bring community change and how this can be achieved. Results of all FGDs were pooled and analysed together.

Findings show that, at the end of programme implementation, FGD participants had good knowledge of the benefits of breastfeeding for infants, including that breastfeeding promotes healthy growth (84% of participants), protects from diarrhoea and other infections (64%), and some knowledge that breastfeeding protects against obesity and other chronic diseases (44%). Good knowledge was also demonstrated of the benefits of breastfeeding for the mother, including delaying fertility (55%), weight loss (31%), lowering the risk of cancer (51%) and postnatal blood loss (40%), and bonding with the infant (51%). Women who participated in the FGDs also demonstrated a high level of positive health-seeking behaviours: 80% of pregnant women reported visiting a health professional four or more times during pregnancy and 78% of women reported having visited a health professional more than twice after delivery of their child. While these results cannot be compared to those of the initial KAP study due to differences in methodology and sampling, endline results do demonstrate a high level of knowledge and positive attitudes and practices that were not observed in results of the KAP study. This suggests that improvements may have taken place, although to confirm this a full KAP study in the same target community needs to be conducted. 

In terms of perceptions of religious leaders, almost all participants (97%) mentioned that religious leaders have a special place in their community and participants listen to, accept and practice recommendations given by them. In addition, 99% of participants believed that religious leaders could play an important role in improving nutrition care practices in their community. Moreover, across all FGDs (including the FGD of religious leaders), participants felt that the Nutrition in Qur’an concept was highly replicable, acceptable and scalable in Afghan society.

Limitations of this study were the short duration of the pilot programme and its limited geographical scope, as well as the different methodologies used for the baseline (KAP) and endline (FGD) studies, which limited comparison of results. Advice given by the CDC on selection of FGD participants may have introduced bias into FGD methodology, although this support enabled the FGDs to take place. Furthermore, due to the limited time frame, it was not possible to measure nutrition outcomes; therefore the impact of the project and how sustainable any impacts are over time are unknown. Nevertheless, initial feedback from participants of the FGDs suggests that the project was highly acceptable at community level and among religious leaders and has potential to bring about positive changes in nutrition knowledge, attitudes and practices among community members. 

Scalability of the concept

Since the pilot project was carried out, an in-country scale-up initiative has been funded by the German Federal Ministry for Economic Cooperation and Development and is currently under implementation in three provinces in Afghanistan (Samangan, Jawzjan and Herat). The project can be easily adapted, replicated and scaled up in other Islamic countries as the nutrition messages identified adhere to the Qur’an and the Hadith. Countries where Welthungerhilfe is currently active have already showed interest in replicating this programme, including Pakistan and Sahel countries.

In Afghanistan, Welthungerhilfe seeks partners to integrate the Nutrition in Qur’an concept within its wider development and humanitarian programming. Discussions are taking place with the Ministry of Public Health around the integration of Nutrition in Qur’an into government health programmes countrywide, including growth monitoring, integrated management of acute malnutrition, nutrition education and outreach. This level of integration would ensure high project coverage and sustainability.  

Conclusion

The Nutrition in Qur’an pilot was an innovative project that demonstrates the potential for integrating nutrition messaging with religious beliefs in Afghanistan, utilising religious leaders as key agents of change. The project was highly acceptable to community members and religious leaders and has potential for widespread scalability. To further inform scale-up efforts more research is needed into the impact of the programme on changes in nutrition knowledge, attitudes and practices and nutrition status of pregnant and lactating women and young children. The project concept could prove to be relatively cost-effective, given that existing platforms are used for behaviour change communication channels, although a cost-benefit analysis is needed to prove this and further inform future scale-up.

For more information please contact Nasrullah Sultani.