Ministry of Public Health Afghanistan
National Communication Strategy for Nutrition in
1000 Days of Life
2013-2016 or 18????
Sept2013
National Communication Strategy for Nutrition in
1000 Days of Life 2013 - 2016
Ministry of Public Health
Afghanistan
Foreword
Acknowledgement
1st Draft - *September2013-National Communication Strategy for Nutrition in 1000 Days of Life / 1Executive Summary????
1st Draft - *September2013-National Communication Strategy for Nutrition in 1000 Days of Life / 1Abbreviations/Acronyms
1st Draft - *September2013-National Communication Strategy for Nutrition in 1000 Days of Life / 1Content
I: Introduction
1.1.Background
1.2.Rational for National Communication Strategy on Nutrition in 1000 days of life
1.3.Communication Strategy Development Process
II: Situation of Nutrition in 1000 days
2.1.Situation Analysis
2.2.Program Analysis
2.3.Behavior Analysis-Key barriers and facilitators
2.4.Communication Participant Analysis
2.4.1.Primary, Secondary, and Tertiary Audiences for Nutrition in Pregnancy
2.4.2.Primary, Secondary, and Tertiary Audiences for Nutrition of Lactating mothers
2.4.3.Primary, Secondary, and Tertiary Audiences for Nutrition of children 0-6 months
2.4.4.Primary, Secondary, and Tertiary Audiences for Nutrition of children 6-23 months
2.5.The Communication Channels, synergy, gaps and opportunities
III: Policy Statement and Strategic Goals
3.1.Policy Statement
3.2.Strategic Goals
Communication Objective:
IV: Communication Strategy
4.1.Advocacy
4.2.Social Mobilization
4.3.Behavior Change Communication
VI. Institutional Arrangement
7.1.National Level
7.2.Provincial Level
7.3.Community Level
VII: Implementation Plan
VIII: Monitoring and Evaluation
Monitoring
Evaluation
Indicators
Input Indicators
Output Indicators
Advocacy
Social Mobilization
Behaviour Change Communication
Outcome Indicators
A. Nutrition of Pregnant Women
B. Nutrition of Lactating Mother
C. Nutrition of Children 0-6Months
D. Nutrition of Children 6-23 Months
E. Hygiene Practices during breastfeeding and complementary feeding
Impact Indicators
IX. Strategy Review Mechanism
Annex: Communication Messages
1st Draft - *September2013-National Communication Strategy for Nutrition in 1000 Days of Life / 1I: Introduction
1.1.Background
1000 days window of opportunity is a program that promotes targeted actions and investments to improve nutrition for mothers and young children during the critical 1,000 days from pregnancy to age two. These 1,000 days are critical because during this period a better nutrition can have a lifelong impact on a child’s future and help break the cycle of poverty.
The 1,000 days between a woman’s pregnancy and her child’s second birthday offer a unique window of opportunity to build healthier and more prosperous societies. The right nutrition during this time can have a profound, life-changing impact on a child’s ability to grow, learn, and rise out of poverty and has a powerful, lasting effect on a country’s stability and prosperity.
Recognizing the critical importance of nutrition in early life and the pervasiveness of the problem of malnutrition, the governments of Ireland and the United States, together with leaders from around the world, launched the 1,000 Days Partnership in September 2010 to:
1.1.Demonstrate increased stakeholder alliances, greater alignment to country-led nutrition strategies, and increased funding;
1.2.Show evidence of more children and mothers reached; and
1.3.Demonstrate impact on malnutrition indicators.
In groundbreaking research featured in its maternal and child nutrition series in 2008, The Lancet medical journal identified a critical window of time between the start of a woman’s pregnancy and her child’s second birthday in which nutrition lays the foundation for a person’s lifelong health, cognitive development and future potential. This window for impact, later termed the 1,000 days window, has revolutionized the way the world approaches the seemingly intractable problems of hunger and malnutrition. By focusing investments on improving nutrition for women and children, from pregnancy to age two, much of the serious, often irreversible, damage caused by malnutrition can be prevented.
Doing so is also extremely cost-effective. Leading economists have argued that improving nutrition is one of the best investments that can be made to achieve lasting progress in global health and development, estimating that every $1 spent on improving nutrition can have as much as a $138 return on investment
Shining a light on the strong returns on investment and the science of the 1,000 days window, the 1,000 Days partnership has brought about a sea-change in the way donor and country governments and other partners target their policies, programs and investments to improve the nutritional status of women and children.
The 1,000 Days partnership has also served as a challenge to the global community to accelerate progress toward realizing the Millennium Development Goals (MDGs) by scaling up investments in nutrition.
Nutrition improvement programmes have a unique, essential role to play in efforts to reach the MDGs. Good nutrition makes an essential contribution to the fight against poverty. It protects and promotes health; reduces mortality, especially among mothers and children; and encourages and enables children to attend and benefit from school. By indirectly strengthening communities and local economies, good nutrition contributes to the achievement of other development objectives which in turn impact upon the MDGs. For example, the increased participation of the poor and vulnerable and of women in the development process that may arise from effective community nutrition programmes will likely lead to more effective demands for improved services and to better use of existing resources. Clearly, comprehensive, mutually supportive policies and interventions designed to achieve the agreed goals and targets of the MDGs are needed. Consequently, several of MDGs (Goal 1, 2, 3, 4,5, and 6) are addressed by implementing nutrition programs.
The Afghanistan National Development Strategy (ANDS) is the Government of Afghanistan’s main strategic planning document, and it addresses nutrition and food security through the “ Nutrition Sector Strategy” and the “ Agriculture and Rural Development Sector Strategy”. However, it is vague in tackling the causes and proposed solutions of undernutrition and household food security, and both political commitment and resource allocation have remained somewhat limited.
Health and Nutrition Sector Strategy (HNSS) constitute the pillar 5 of the Afghanistan national Development Strategy (ANDS) Several sections of HNSS respond to the 1000 days window of opportunity concerns. Sub-strategy 5 of the HNSS is dedicated to Public Nutrition which emphasizes on the importance of improving the nutritional status of children from birth till 5 years of age as well as the nutritional status of pregnant mothers.
1.2.Rational for National Communication Strategy on Nutrition in 1000 days of life
The mission of health and nutrition sector as defined in HNSS, has two main components the first component focuses on improving the health and nutrition of people through provision of quality health services and the second component focuses on promotion of healthy life styles. This communication strategy is indeed addressing the second part of the mission.
Furthermore, this communication strategy shapes the behavior change communication activities of the health sector to address the gaps and barriers related to the nutrition of pregnant mothers and their children from inception till 2 years of age. Uncoordinated and non-targeted activities in the absence of any strategy not only waste the resources and energy but these would possibly create further misunderstanding and misconception among people.
This communication strategy will help the program implementers at national and provincial level to focus on few key sets of behaviors regarding nutrition. Instead of bombarding the communities with numerous messages the strategy deliver few messages targeted on a specific group of audience respecting their sociocultural backgrounds and believes. A multi-channel, multi-sectoral and multi-layered approach is the key ingredient of this strategy, investing in existing effective traditional channels of communication and employing some new innovative media.
The National Communication Strategy on Nutrition in 1000 days of life is based on evidence gathered from the community and stakeholders regarding gaps in knowledge, current attitudes of people towards the nutrition of mothers and child and barriers towards implementing specific behaviors. This strategy is developed to be aligned with all national and international policies and guidelines.
1.3.Communication Strategy Development Process
In Feb, 2013 Social and Health Development Program (SHDP), an Afghan NGO, was contracted by MoPH and with the support of UNICEF to develop a national communication strategy on nutrition for the first 1000 daysof life.
In order to develop the communication strategy the P-Process framework, which is designed to guide the development of strategic communication program and communication strategies, was used. The P-Process framework was developed by the Health Communication Partnership (HCP), which include Johns Hopkins Bloomberg, School of Public Health/Center for Communication Programs, the Academy for Educational Development, Save the Children, the International HIV/AIDS Alliance, and Tulane University’s School of Public Health and Tropical Medicine.
This framework has built based on the following key steps:
Step1. Analysis,
Step2. Strategic Design,
Step3. Developing and Testing,
Step4. Implementing
Step5. Monitoring & Evaluation and Re-planning.
The strategy development team adjusted the standard P-process framework and used this step by step road map as a guideline for the development of this communication strategy.
Step1. Analysis:
This exercise helped to identify factors inhibiting or facilitating the desired changes. This considered the basic social, cultural, and economic challenges facing the people the strategy would like to reach.
Method of Analysis:
The approach and method for completing this step included desk review of available literatures, conducting a formative research and consultative meetings with main stakeholders.
During analysis, a review of existing health and demographic data, survey results, study findings, standards guidelines, existing programs strategies/policies and other information available on the nutrition in the first 1000 days of life was carried out.
Meanwhile to cover the information gaps on nutrition in the first 1000 days of life, and obtain the information that is crucial for development of an effective communication strategy, we conducted a formative research in four provinces of four regions of Afghanistan.
Furthermore, to ensure the participation of relevant stakeholders, their inputs and insight in the process of communication strategy development, necessary consultation with stakehoders was made in the form of consultative meetings/ presentations and sharing of all steps through emails.
The analysis step was divided into two main stages of situation analysis and communication analysis.
Situation Analysis: Conduction of a situation analysis would result in an in-depth description of the nutrition in the first 1000 days of life and relevant concept being addressed. The situation analysis helped to determine severity and causes of problems around the nutrition in the first 1000 days of life.
Communication Analysis: in order to carry out a comprehensive communication analysis, the following components were considered.
a.Participants, audience analysis: in this stage of the communication analysis, efforts were made to identify partners and allies to help initiate policy change and strengthen communication interventions. At the community level, the primary, secondary, and tertiary audiences were segmented and change agents were identified. In this stage, the analysis focused to understand who/how influences feeding practices; Stage of awareness, knowledge and practice of the desired behaviors; Underlying factors and influences for behaviors and practices of different groups.
b.Behaviors analysis: in this stage of analysis, the team focused to understand the types of behaviors; the reasons and motivators for them; the facilitating factors and barriers for behaviors; the social, cultural, gender, economic and political context in which they take place; how the current social norm in the community influences them. Efforts were made to identify current behaviors existed among target groups, in consideration of optimal behaviors recommended by standard guidelines.
c.Channel analysis:
In this step, we worked to find the best ways to reach the intended audiences. In this stage efforts were made to identify the channels through which the program’s message can be delivered and the activities that can be used to deliver it. In this stage we made efforts to identify the available communication channels and analyze audiences’ media access and use. It also helped to identify the best channels for reaching each group, because populations also differ in factors such as access to information, the information sources they find reliable, and how they prefer to learn.
d.Assess communication experiences:
In this step, the analysis looked at the past and current communication experiences of various groups to promote good nutrition in the first 1000 days of life. In this stage we analyzed that what worked and what did not work. In this stage lessons learned and possible replication (or avoidance) were also analyzed.
Themes of Analysis
The analysis stage focused on the specific thematic areas of nutrition in the first 1000 days of life, which include nutrition of pregnant women, nutrition of lactating mothers, nutrition of children 0-6 months, nutrition of children 6-23 months, and hygiene practices during breastfeeding and complementary feeding.
Step2. Strategic Design/Strategy Development:
In order to proceed with the strategy development the following steps were followed for strategy design and development.
- Establish communication objectives
A set of specific objectives were developed and the key audience segments were selected.
- Developing program approaches and positioning
A behavior change model was selected upon which to base the BCC strategy program. The team then specified the assumptions underlying the basic strategy and approach. Then, the explanation to why and how the program is expected to change health behavior is provided. During this process the behavior change model was selected at all three targeted level:
-At the family and family influencer level: behavior change model at the family level focuses to help inform, influence and support individuals, families, community groups and opinion leaders.
-At the program and community level: at this stage the behavior change model focuses on communication for Social Change. It is focusing to engage, motivate and empower communities to influence norms and cultural practices.
-At policy level (MoPH departments): behavior change model at the policy level will focus to do advocacy for obtaining further political and technical support to help implementation of the nutrition program on the first 1000 days of life.
The details of behavior change model at different level are explained in the coming sections of this document.
C. Determining channels
From the past experience of implementing communication strategies it is evident that only a coordinated, multimedia approach is required for a synergistic impact. Where possible, we have been trying to achieve balance by including mass media tied to community mobilization and interpersonal communication among family, friends, community, social networks, and service providers.
Step3. Adapting / Developing & Testing
In this stage, already developed and available messages and materials identified and recommended through disk review and consultation with stakeholders were reviewed and gaps in the availability and utilization of communication materials were identified. Based on the result of literatures review and finding of formative research, concrete recommendations were provided for the development of IEC materials including type and format of materials.
Step4. Implementation
In this stage an implementation plan for the communication strategy was designed to be implemented. Meanwhile the role and responsibilities of each partner including, government, development partners,NGOs and private sector wasdefined. In the same time, the dissemination plan for strategy was developed.
Step5. Monitoring & Evaluation and re-planning of strategy
In order to ensure proper monitoring of the strategy implementation, indicators and data sources to monitor program implementation was identified.
Furthermore, to evaluate the strategy effectiveness, applicability and practicability, an evaluation mechanism is proposed. Efforts are made to ensure that the evaluation design is appropriate for the particular communication activity. Process evaluation will take place during implementation and monitors the functioning of program components. It will assess, whether messages are being delivered appropriately, effectively, and efficiently; whether materials are being distributed to the right people and in the right quantities; whether the intended program activities are occurring; and other measures of how well the program is working. Outcome evaluation will be used to assess the degree to which the communication objectives are achieved. This evaluation will help to measure the outcome and impact of strategy after its implementation. Program evaluation will provide necessary evidence to define the need and decision on the re-planning of strategy.
1st Draft-8September2013-National Communication Strategy for Nutrition in 1000 Days of Life / 1II: Situation of Nutrition in 1000 days
2.1.Situation Analysis
Globally the problem of malnutrition is posing a serious threat to the wellbeing and development of nations. This threat is geared more towards underdeveloped and poor communities.Around the world,165 million children - 1 in 4 children under age five years – are chronically malnourished[1] and malnutrition is responsible for almost half of all deaths of children under the age of five years.[2] Also malnutrition can translate to a loss of as much as 8 percent of a country’s GDP[3].By scaling up access to just ten proven nutrition interventions, we can prevent 15 percent of all deaths of children under age 5, saving 1 million children per year.[4]
According to National Nutrition Survey 2004 the prevalence of Iodine deficiency (urinary iodine < 100 μg/L) 71.9 percent[5] but according to AMICS 2010/11 around 20percent of households were consuming adequate amount of iodized salt. Same document states 50.6percent coverage of Vitamin A supplementation for children between age 6 to 59 months in Afghanistan.
Prevalence of anemia among children is recorded 33.7 and among non-pregnant women this percentage is 21.4 percent but among pregnant women this is 16.3 percent.
In the 2004 National Nutrition Survey, 98 percent of mothers reported breastfeeding their preschool child (6–59 months) at some time and over half of children (60 percent) received mother’s milk in the first two hours after birth.According to Afghanistan Health Survey 2006 only 13.8 percent of women were counseled on breastfeeding during the ANC. Meanwhile, the initiation breast feeding in the first hour after birth was 37 percent and exclusive breastfeeding found to be 70 percent. According to AMICS 2010/11 53.6 percent of children are breastfed within one hour of their birth and 54.3 percent of children under 6 months receive exclusive breastfeeding. A higher percentage (87.8 %) of children continues to receive breastfeeding till one years of age and 69.4 percent are fortunate to be breastfed till two years old and beyond. AMICS 2010/11 reports that introduction of timely (at six months age) solid and semi-solid and soft meal for children is practiced by 20.1 percent of households.
2.2.Program Analysis
At the program level the leadership, coordination and quality of existing services provides an infrastructure for successful implementation of behavior change communication strategies. The current capacity of public nutrition department for leading the nutrition related programs can be measured by fidelity of current programs with the national and international goals for improving the nutrition of the Afghans. This can be reflected by reviewing the National Nutrition Policy and Strategy (2009-2013) that is in line with the Health and Nutrition Sector Strategy (2012-2020). The later in turn designed to address the MDGs.Coordination among stakeholders of nutrition at national level is maintained through various coordination mechanisms. At the inter-ministerial level the Consultative Group of Health and Nutrition has so far created an arena for sharing information, approving key national policies and strategies and bringing together various stakeholders to avoid duplication. The Public Nutrition Task Force on the other hand helps the program to coordinate the nutrition activities between MoPH departments, UN agency and NGOs involved in nutrition related activities.
Quality of nutrition services, which is another indicator for successful implementation of a communication strategy is provided by MoPH through its contracted partners at provincial and community level and has been consistently evaluated by Balance Scored Card (BSC) and monitored by HMIS indicator progress.
Currently three types of nutrition services are provided by the MoPH through Basic Package of Health Services (BPHS) that we shortly describe each group of services in brief.
Assessment of Malnutrition: Assessment can be at national level through household surveys that can be conducted every few years. In this assessment the estimate prevalence of malnutrition (z-score using indices of weight for height [wasting], weight for age [underweight], and height for age [stunting] as well as the underlying causes will be researched and analyzed. Some other Surveys can be conducted at district or provincial level for purposes of baseline, monitoring, and evaluation or in case of obvious deterioration in nutritional situation.
Preventive services:All of these services are delivered by all levels of health facilities from health post to the district hospital.
- Vitamin A supplementation: To all children 6 months to 59 months
- Promotion of iodized salt
- Promotion of balanced micronutrient-rich foods
- Support and promote exclusive breastfeeding
- Promotion of appropriate complementary feeding for young children with behavior changes
- Community food demonstration
- Growth monitoring and promotion for less than 2 years1
- (Where applicable and linked with IMCI)
- Iron/folic acid supplementation for pregnant, lactating women
- Vitamin A supplementation post-partum
- Promotion of maternal nutritional status2
- Control and prevent diarrheal disease and parasitic infections
- Underlying causes: based on analysis of causes of malnutrition, support, and advocate for interventions to address underlying causes.
Technical support from UNICEF and WHO in implementing the above mentioned services is the key for success is worth mentioning.