Challenges

Although noticeable progress has been made in Malawi in reducing malnutrition since joining the Scaling Up Nutrition (SUN) Movement in 2011, poor nutrition in adolescents remains a public health challenge. The Malawi Demographic and Health Survey 2015/16 revealed that approximately 35 per cent of adolescent girls (15-19 years of age) are anaemic while 13 per cent are underweight. In addition, the prevalence of overweight among adolescent girls increased from 4 per cent in 1992 to 7 per cent in 2015/16. School-age children and younger adolescents also face nutritional challenges, with anaemia affecting 22 per cent and zinc deficiency affecting 60 per cent of this age group (National Statistical Office Malawi, 2017). Dietary quality for adolescent girls remains suboptimal with only 17 per cent of girls (10-19 years of age) meeting minimum dietary diversity for women (MDD-W) standards.

Toward a Solution

Despite significant progress in reducing the burden of undernutrition in children under 5 years of age, poor nutrition in adolescents (10-19 years of age) remains a public health challenge. Existing nutrition policies and interventions have traditionally focused on the first thousand days with less consideration given to the growth and development of adolescents, and non-pregnant adolescent girls were neglected from stunting reduction strategies in Malawi. In order to guide the implementation of nutrition programmes and interventions, a National Multi-sectoral Nutrition Policy (NMSNP) and a National Multi-sectoral Nutrition Strategic Plan (NMSNSP) 2018-2022 were developed. To prioritize nutrition programming for adolescents and ensure that they can contribute to economic growth and national development, evidence-based advocacy by various stakeholders led to the development of a National Multi-sectoral Adolescent Nutrition Strategy (NMSANS) 2019-2023 that aims to improve the nutritional status of both in- and out-of-school adolescents 10-19 years of age.

In 2019, the Ministry of Health’s Department of Nutrition, HIV and AIDS (DNHA) and Department of Reproductive Health, with the support of the United Nations Children’s Fund (UNICEF), rolled out a pilot weekly iron folic acid (IFA) programme to adolescent girls. The programme targeted girls in schools and community settings, with each girl expected to take 50-52 IFA tablets per year. Following the approval of NMSANS, key messages were developed and awareness-raising was conducted with key district and community-level service providers, community leaders and adolescents to ensure programme acceptance prior to implementation. In the European Union-supported nutrition-sensitive agriculture (NSA) programme, in- and out-of-school adolescents 15 to 19 years of age have established nutrition demonstration plots where they learn diverse methods of food production and preservation to ensure the continued availability and variety of safe, seasonal, nutrient-dense foods in households. They are taught food preparation techniques through cooking demonstrations using local recipes and locally available foods provided by the community. To further ensure sustainability, community leaders have also contributed farming land for nutrition demonstration plots. Adolescents have contributed to the cooking demonstrations through crops harvested from the demonstration gardens and from the rearing of small stock. In the World Bank- and European Union-supported NSA programme, adolescent girls are also given IFA tablets. The Government of Malawi developed various monitoring tools for the IFA programme to collect monthly data on coverage, compliance and dietary diversification practices at community and school levels. These tools showed that the weekly IFA supplementation programme reached 70 per cent of adolescent girls in 1,788 schools and 192 health facilities in 2019 and 47 per cent in 2020, due to COVID-19 related school closures. The preliminary results in 2020 revealed that over 36 per cent of adolescent girls achieved monthly compliance (girls consuming four or five tablets a month) for the six months that they received supplements before and after school closures. 

For the NSA programme, a monitoring and evaluation framework was developed, the data from which contributes to the monitoring of national nutrition indicators. These frameworks revealed that out of a targeted 2,725 adolescent nutrition groups 2,013 were established between January 2019 and March 2021 with the establishment of groups continuing until December 2021. As of March 2021, over 55,903 adolescents were members of the adolescent nutrition groups and an estimated 378,995 adolescents have benefited from nutrition extension services including nutrition education, water, sanitation and hygiene (WASH) and reproductive health. Over 617 cooking demonstrations have been conducted, providing 7,492 adolescents with knowledge and skills around food preparation, preservation and utilization. Additionally, steady improvements in maternal dietary diversity for women have been demonstrated, increasing from 32 per cent to 47 per cent for adolescent girls between 2018 and 2021. By the end of 2023, the NSA programme aims to reach 392,559 adolescents across the 10 districts. To adjust programmes to respond to identified needs, UNICEF is also supporting the Government to carry out a landscape analysis of school-age and adolescent nutrition, which will inform plans to scale up integrated school health and nutrition interventions.

The integrated multisectoral approach to improving the nutritional status of adolescents in Malawi has proved effective and promises to make a significant contribution to national development. On the one hand, weekly iron and folic acid supplementation was able to achieve high coverage across many schools before COVID-19. On the other, the NSA programme implemented in Malawi led to steady improvements in adolescent girls meeting minimum dietary diversity standards with the impact of COVID-19 being mitigated through creative learning solutions. To ensure programme acceptance and success, and to maximize benefits, adolescent girls were carefully and intentionally involved in the design and implementation of the IFA intervention. The primary messages and information, education and communication materials for the intervention were designed by technical experts but reviewed by adolescent girls, whose recommendations were incorporated to make the materials more adolescent-friendly. In addition, the creation of adolescent nutrition groups has facilitated the inclusion of adolescents in nutrition programmes. Previously, Malawi lacked a standardized approach towards nutrition education for adolescents. However, through the development and roll-out of the adolescent NSA package, coherent and comprehensive nutrition education has been provided to adolescents using a counselling package for adolescent engagement. The success can be scaled up and replicated through experience-sharing with other developing countries facing similar challenges.