Addressing adolescent anaemia in Afghanistan through a school-based programme
Lisez cet article en français ici
Dr Zakia Maroof is a nutrition specialist working with UNICEF Afghanistan.
Dr M Homayoun Ludin is the Director of Public Nutrition and the National Nutrition Officer/ Advisor with the Ministry of Public Health in Afghanistan.
Suzanne Fuhrman is the Nutrition Manager at UNICEF Afghanistan.
In Afghanistan there are about 7.7 million adolescents in the 10-19 year age group, half of whom are girls. Adolescence provides a second window of opportunity for growth after the first 1,000 days, but early marriage and pregnancy in this age group, which occurs mainly in low- and middle-income countries such as Afghanistan, can lead to malnutrition. Anaemia among adolescent girls is 30.9%, while thinness in this age group (based on body mass index (BMI)) is 8%1.
It is estimated that 3.7 million children aged 7–17, of whom 2.2 million are girls, do not attend school in Afghanistan. Over 80% of these children are in the seven provinces that are the most conflict-prone and insecure (Uruzgan, Zabul, Hilmand, Kandahar, Paktika, Logan and Wardak); Uruzgan also has the highest percentage (97.9%) of girls out of school. However, children attending school has increased nine-fold since 2001 to over 9.2 million children in 2015, of whom 39% are girls2.
A school-based programme
The life-cycle approach calls for addressing anaemia in children and adolescents. Since 2015 the Ministry of Public Health (MoPH) and Ministry of Education (MoE) have jointly started provision of a weekly iron folic acid supplementation (WIFS) programme to school-going adolescent girls (aged 10-19 years) to improve their school performance and boost pre-pregnancy stores of iron for a healthy reproductive life. The programme also has a deworming component for all school-going adolescent girls in order to increase iron absorption and general health.
A memorandum of understanding specifies clear roles and responsibilities for each ministry. This was initially signed for three years (2015-2017), but has now been renewed until 2023. By December 2018 the programme had reached 1.16 million school-going adolescent girls (10-19) with iron and folic acid (IFA) supplementation in all 34 provinces.
Training for teachers
Training for focal point teachers and academic supervisors was required as this was a new nutrition programme in Afghanistan to be delivered through schools. Some schools in the country operate in two to three shifts per day to accommodate all students in its catchment area and each shift has its own management team; therefore, two focal point teachers from each shift were nominated and trained on WIFS who are responsible for programme coordination.
The WIFS programme delivery involves a ‘fixed day’, once-a-week approach for teacher-supervised IFA administration and a counselling and communication component. The distribution of supplements is accompanied by messages on the benefits of adequate iron intake, including increased mental and physical productivity and the long-term risks of anaemia in adolescents, including maternal mortality and morbidity. Focal point teachers are trained to deliver relevant dietary advice, such as iron-rich food sources and iron-absorption inhibitors, including avoiding taking tea with a meal. The programme also provides an opportunity for counselling on reproductive health and the risks of teenage pregnancy. Moreover, WIFS of adolescent girls has been integrated with the National School Health Policy, along with other initiatives such as Menstrual Hygiene Management, which aims to improve school retention and quality of learning for adolescent girls and to provide the continuum of care between adolescent and maternal nutrition.
Measuring programme performance
Both government ministries have been supported in developing annual monitoring plans, including setting up a national WIFS database.
A study in 2018 measured programme performance from interviews with 1,600 students from 40 schools in four provinces to identify lessons learned for WIFS3. The study found increased awareness of anaemia and its definition of low levels of haemoglobin (Hb) in the blood among school-going adolescent girls (92% of students). A knowledge of symptoms associated with anaemia, such as low energy and shortness of breath, was demonstrated by 69% of girls, but knowledge of how to prevent anaemia was not widely noted. The presence of a statistically significant and higher mean Hb level among respondents who had been exposed to the WIFS programme longer than respondents with recent exposure suggests WIFS may have contributed to improved health outcomes for adolescent female students.
The programme was first rolled out in 10 provinces and focused on the use of interpersonal communication (IPC) for community mobilisation. One of the main challenges is adherence to IFA supplementation, with problems of negative social media that had associated the supplements with female infertility (the IFA tablets were thought to be contraceptive pills).
In response, a national media campaign was conducted to support community acceptance at the second stage of the programme, when WIFS was scaled up to all provinces. Programme assessment confirmed that messages through TV and other media platforms had contributed to increased knowledge and information of students and teachers on anaemia. Monitoring reports also confirmed that the media campaign had played a critical role in increasing awareness and demystifying the programme. To further address the issue, a set of IPC materials was developed and disseminated targeting different audiences such as parents, teachers, students, religious leaders and other community stakeholders.
Supply-chain management also needs further improvement of data discrepancy between the central education management information system and provincial data. To address this issue, supply levels have been included in the revised WIFS database to capture provincial data, which will help to provide more accurate forecasting and distribution.
IFA supplementation to adolescent girls is also facing sustainability challenges, since all components of the programme (training, monitoring and reporting, supply of IFA and deworming tablets) are currently financed by UNICEF through different funding sources as the government does not have sufficient resources to provide full support, including procurement of IFA tablets. In addition, reaching all adolescent girls, especially those who are out of school, is a significant challenge. Even for those in school, frequent closures due to insecurity, natural disasters and weather conditions cause gaps in supplementation.
Sufficient time is needed to create an enabling environment; a longer period during the start-up phase may have helped to better coordinate organisations involved and provided an opportunity to conduct a baseline assessment to have data for comparison. By the time the assessment began, the programme was already underway in some provinces, so the study compares students in provinces with long-term implementation against provinces that had started the programme less than a month previously.
Experiences of the WIFS programme from the initial roll-out in Afghanistan highlights the need for awareness-raising and increasing knowledge among all stakeholders, such as parents, teachers and community members (including religious leaders and other decision-makers), prior to the actual supplementation. Programme adherence significantly improved after the media campaign. However, implementing such national campaigns are expensive and resource-intensive.
There are plans to expand WIFS to out-of-school adolescent girls, beginning with the Accelerated Learning Centres in 2019. These centres are attended by girls who have missed school for different reasons and are therefore older than their classmates. To increase WIFS awareness at community level, a perception study is planned towards end of 2019 to find creative ways for increased adherence.
1National Nutrition Survey Afghanistan (2013).
2National Education Strategic Plan (2017-2021): Ministry of Education (2016).
3Third-Party Monitoring and Assessment of the Weekly Iron and Folic Acid Supplementation (WIFS) Project Final Report, Sayara Research (2018).
More like this
FEX: Weekly iron and folic acid supplementation and nutrition education for adolescent girls in Africa and Asia
View this article as a pdf Lisez cet article en français ici By Anjali Bhardwaj, Lucy Murage, Shibani Sharma, Dhian Dipo, Christine Makena, Marion Roche and Mandana...
FEX: Weekly iron and folic acid supplementation and nutrition education for adolescent girls in Africa and Asia
This is a summary of a Field Exchange field article that was included in issue 66. The original article was authored by Anjali Bhardwaj, Lucy Murage, Shibani Sharma, Dhian...
FEX: Adolescent girls’ nutrition and prevention of anaemia: a school-based multisectoral collaboration in Indonesia
View this article as a pdf Research snapshot1 In Indonesia, the national prevalence of anaemia among females aged 15-24 years is 18.4%. Screening of junior high-school...
Nepal’s success story: What helped to improve maternal anaemia?
View this article as a pdf Dr Ram Padarath Bichha is Director of the Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal. Kedar...
FEX: Current evidence on anaemia and micronutrient supplementation strategies in school-age children and adolescents
View this article as a pdf Lisez cet article en français ici By Elena Hemler, Wafaie Fawzi and Stephanie Wrottesley Elena Hemler is senior project coordinator for the...
FEX: 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...
FEX: Results and lessons learned from WFP’s efforts to support adolescent girls in Niger
By Alexandra Pirola, Benedict Tabiojong Mbeng and Mica Jenkins View this article as a pdf Lisez cet article en français ici Benedict Tabiojong Mbeng is Head of...
Addressing maternal nutrition service delivery gaps in Afghanistan: Policy and programming opportunities
View this article as a pdf Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan. Dr Homayoun Ludin is an Afghan doctor working with the Ministry of...
FEX: An integrated multi-sector approach to improve the nutritional status among school-age children and adolescents in Malawi
View this article as a pdf By Doreen Matonga, Keisha Nyirenda, Jason Chigamba and Dalitso Kang'ombe Doreen Matonga is a Communication for Development Specialist at UNICEF...
en-net: Screening and Treatment protocols in Anaemia amongst adolescent girls
At Jharkhand, India over 70-90% of Adolescent girls are anaemic. The State provides a once-a-week IFA supplement at schools to prevent anaemia amongst adolescents girls. Last...
en-net: Adolescent Nutrition
Has anyone done any work on adolescent nutrition? What areas where considered and what indicators were used. I would appreciate reference materials too sorry, the correct...
NEX: Breaking the cycle of malnutrition: Designing an adolescent programme in Nepal
Lisez cet article en français ici View this article as a pdf Min Raj Gyawali is the Senior Manager for Health Services with the Suaahara II programme in...
FEX: Non-nutrition interventions to prevent anaemia in school-age children and adolescents
View this article as a pdf Lisez cet article en français ici By Natalie Roschnik, Andrew Hall, Moussa Sacko and Sian Clarke Natalie Roschnik is Senior Nutrition...
FEX: Consumption of iron-rich foods among adolescent girls in Nepal: Identifying behavioural determinants
By Ajay Acharya, Pooja Pandey Rana, Bhim Kumari Pun and Basant Thapa View this article as a pdf Ajay Acharya is a Family Planning Specialist for the USAID-funded Suaahara II...
FEX: People-driven SBC in Practice Combating Stunting in Indonesia
View this article as a pdf By Julia Weatherson, Ritu Ghosh, Eriana Asri, Octavia Mariance and Firda Dewi Yani and Tutut Sri Purwanti Hnin (Julia) Weatherson is the Asia...
en-net: 26 April 2016 - Webinar on Weekly Iron and Folic Acid Supplementation of Adolescents in India
The Accelerated Reduction Effort on Anaemia (AREA) Community of Practice is organizing a webinar on India's Weekly Iron and Folic Acid Supplementation (WIFS) programme for...
FEX: One UN for nutrition in Afghanistan - Translating global policy into action: A policy shift to tackle wasting
View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with Dr. Jamil Bawary, Integrated Management of Acute Malnutrition...
FEX: Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts
View this article as a pdf Lisez cet article en français ici By Zivai Murira and Harriet Torlesse Zivai Murira is Nutrition Specialist at United Nations Children's...
FEX: Improving the nutritional well-being of school-age children through the Nutrition-Friendly Schools Initiative (NFSI) in the State of Palestine
View this article as a pdf By Selena Bajraktarevic, Kanar Qadi, Amani Badwan, Younis Awadallah and Rania Abueita This Field Exchange report is a summary of the cumulative...
Harnessing the potential of India’s medical colleges to bring maternal nutrition services to scale
View this article as a pdf Dr Sebanti Ghosh is Programme Director with Alive & Thrive (A&T), India. Dr Kaushal Kishore is a member of the Indian Administrative Service (IAS)...
Reference this page
Dr Zakia Maroof, Dr M Homayoun Ludin and Suzanne Fuhrman (). Addressing adolescent anaemia in Afghanistan through a school-based programme. Nutrition Exchange 12, July 2019. p22. www.ennonline.net/nex/12/adolescentanaemiaafghanistan