A multi-sector approach for nutrition in school-age children and adolescents in Malawi

This is a summary of a Field Exchange field article that was included in issue 66. The original article was authored by Doreen Matonga, Keisha Nyirenda, Jason Chigamba and Dalitso Kang’ombe 

Doreen Matonga is a Communication for Development Specialist at UNICEF Malawi.

Keisha Nyirenda is a Nutrition Officer at UNICEF Malawi.

Jason Chigamba is a Principal Nutrition Officer at the Department of Nutrition, HIV and AIDS (DNHA) at the Ministry of Health, Malawi.

Dalitso Kang’ombe is Chief Nutrition Officer at the DNHA, Ministry of Health, Malawi.

In Malawi, the government has led the implementation of an integrated multi-sector adolescent nutrition programme including weekly iron and folic acid (IFA) supplementation for adolescent girls and a nutrition sensitive agriculture (NSA) programme.

• Weekly IFA supplementation has achieved high coverage across many schools but was impacted by COVID-19-related restrictions.
• The NSA programme led to steady improvements in adolescent girls meeting minimum dietary diversity standards. COVID-19-related impacts were mitigated through migrating learning to mobile phones.
• The integrated, multi-sector approach has been effective thus far and the Government of Malawi is leading efforts to scale up.

Background

In Malawi, nutrition programming for adolescents is guided by a National Multi-Sector Adolescent Nutrition Strategy (NMSANS) 2019-2023. The NMSANS creates a platform to address the needs of in- and out-of-school adolescents 10-19 years of age through multi-sector collaboration among various government ministries. The responsibilities of the government systems involved are outlined in Table 1.

Two programmes implemented to support improved adolescent nutrition include (1) weekly iron and folic acid (IFA) supplementation for adolescent girls; and (2) a nutrition sensitive agriculture (NSA) programme.

Table 1. Responsibilities of government systems within the adolescent nutrition programme

Weekly IFA supplementation for adolescent girls

In 2019, the Ministry of Health’s Department of Nutrition, HIV and AIDS (DNHA) and the Department of Reproductive Health, with support from UNICEF, rolled out a pilot weekly IFA programme to adolescent girls (10-19 years of age) in six districts².

In schools, a participatory approach involved adolescent girls assisting teachers in monitoring self-compliance. At community level, adolescent nutrition groups were established during which community volunteers and frontline workers engaged adolescents through nutrition education, counselling, cooking demonstrations, sporting activities and the establishment of nutrition demonstration gardens. Supplementation sessions were conducted under supervision and with the involvement of either a focal teacher in school or an HSA at community level.

NSA programme

With support from the World Bank (WB) and the European Union (EU), the Government of Malawi is implementing NSA programmes in 12 districts where dietary diversity is low³. Within the EU-supported NSA programme, in- and out-of-school adolescents (15-19 years of age) have established nutrition demonstration plots where they learn food production and preservation methods. They are also taught food preparation techniques through cooking demonstrations. To support sustainability, community leaders have contributed farming land for nutrition demonstration plots. Adolescents have also contributed to cooking demonstrations through crops harvested from the demonstration gardens and from the rearing of small livestock. In the WB-supported programme, adolescent girls are given IFA tablets.

The NSA programmes support community social mobilisation and encourage the participation of in- and out-of-school adolescents in community platforms. The programmes are delivered through the internationally recognised care group model, with specific adolescent groups established to promote the engagement of out-of-school adolescents. The frequency of meetings varies from weekly to bimonthly, intensifying during school holidays when more adolescents are present in the community. The groups are led by community nutrition volunteers and peer educators with support from health and agriculture frontline workers and SHN teachers. Nutrition education on dietary diversification using Malawi’s six food group model is provided and is complemented by education on sexual and reproductive health, WASH and other life skills.

Monitoring and evaluation

The Government of Malawi developed various monitoring tools for the IFA programme including:

• Self-compliance cards: used by adolescent girls to record weekly IFA intake
• Weekly registers for community and school platforms: used by HSAs and teachers respectively to record adolescent girls’ weekly IFA intake
• Monthly community and school reports: used to collect indicators on IFA coverage and compliance
• Commodity stock books: used to record the movement of supplies

For the NSA programme, a monitoring and evaluation framework was developed which contributes to the monitoring of national nutrition indicators.

Results

Weekly IFA supplementation

• The weekly IFA supplementation programme reached 70% of adolescent girls in 1,788 schools and 192 health facilities in 2019.
• In 2020, 47% were reached due to COVID-19 related school closures.
• Preliminary results in 2020 revealed that over 36% of adolescent girls achieved monthly compliance (consuming four or five tablets⁴ a month) over six months.

NSA programme

• 2,013 adolescent nutrition groups were established between January 2019 and March 2021, with a target of 2,725 to have been achieved by December 2021.
• As of March 2021, over 55,903 adolescents were members of the adolescent nutrition groups and approximately 378,995 benefited from nutrition extension services.
• Over 617 cooking demonstrations have been conducted reaching 7,492 adolescents.
• Minimum dietary diversity for women improved from 32% to 47% for adolescent girls between 2018 and 2021 (University of Sydney et al, 2019; FAO and UNICEF, 2021).
• Consumption of biofortified foods (e.g., vitamin A-fortified maize, iron-fortified beans and orange-fleshed sweet potatoes) increased from 12% to 19% between 2020 and 2021 (FAO and UNICEF, 2020; FAO and UNICEF, 2021).
• Consumption of animal-source foods declined from 51% to 33% between 2019 and 2020 (University of Sydney et al, 2019; FAO and UNICEF, 2020) but efforts to change behaviour and improve access to small livestock have been credited for a recent increase to 39% (FAO and UNICEF, 2021).
• Adolescent groups participating in the 2021 knowledge, attitude and practices survey demonstrated increased nutrition knowledge since the previous survey (FAO and UNICEF, 2021).

Successes

• The involvement of adolescent girls in the design and implementation of the IFA programme facilitated its acceptance and success.
• Information, education and communication materials were reviewed by adolescent girls to make these more adolescent-friendly.
• Adolescent nutrition groups have promoted the inclusion of adolescents in nutrition programmes, particularly for out-of-school adolescents.
• Participation was encouraged through incorporating sporting activities, nutrition demonstration plots, sexual reproductive health education and cooking demonstrations.
• The NSA package has provided coherent and comprehensive nutrition education using a counselling package for adolescent engagement.                 

Challenges

• A lack of data for adolescent boys and girls 10-14 years of age limits ongoing resource mobilisation to address their nutritional challenges.
• Coordination challenges occurred between education and health systems at service delivery level. Review meetings among service providers were conducted to address this.
• COVID-19 related school closures affected the coverage of nutrition programmes (including IFA coverage and compliance). As a result, DNHA developed standard operating procedures for nutrition activities in the context of COVID-19 and some adolescent girls were reached through the community platform during school closures. For the NSA programme, nutrition education and trainings were migrated to mobile phones.

Next steps

Given the effectiveness of the integrated multi-sector approach, the Government of Malawi is leading efforts to scale up the adolescent nutrition programme. The aim is to achieve nationwide coverage in 2022 and efforts are being made to bring more partners on board. In the long term, the Government of Malawi hopes to include the adolescent nutrition programme under the normal government procurement system so that it can be sufficiently budgeted and financed. At district level, this is being lobbied by the Department of Nutrition through the launch of SUN 3.0.

For more information, please contact Doreen Matonga at dmatonga@unicef.org

References

FAO and UNICEF (2020) Knowledge, attitude and practices (KAP) survey towards maternal, adolescent, infant and young child nutrition and care practices, water and sanitation and nutrition-sensitive agriculture: Report for the Afikepo Nutrition Programme and Nutrition-sensitive Agriculture component in Malawi. Available at: https://www.unicef.org/malawi/reports/report-afikepo-nutrition-programme-and-nutrition-sensitive-agriculture-component-malawi

FAO and UNICEF (2021) Knowledge, attitude and practices (KAP) survey towards maternal, adolescent, infant and young child nutrition and care practices, water and sanitation and nutrition-sensitive agriculture: Report for the Afikepo Nutrition Programme and Nutrition-sensitive Agriculture component in Malawi. Unpublished

National Statistical Office (NSO) Malawi (2017) Malawi Micronutrient Survey 2015-16. NSO, Community Health Sciences Unit Malawi, Centers for Disease Control and Prevention (CDC) and Emory University: Atlanta, GA, USA. Available at: https://dhsprogram.com/pubs/pdf/FR319/FR319.m.final.pdf

University of Sydney, University of Malawi, UNICEF and FAO (2019) Baseline report for Afikepo Nutrition Program and the Nutrition-sensitive Agriculture component in Malawi. Available at: https://dnhamalawi.org/wp-content/uploads/2020/12/AFIKEPO_Baseline-Report_FINAL-v1-1.pdf