Update on our Nutrition & Health Programme In Mozambique

This (longer than usual) post give our readers some background to our programme in Mozambique – there is a short discussion at the bottom of the post.

Background

The Children’s Participation, Learning and Action for Nutrition (PCAAN) programme in Tete Province, Mozambique was implemented with our involvement between 2014 and 2016. It was funded by the Danish Government (DANIDA) and was a Government of Mozambique programme. It was one of two education initiatives that were part of the 5 year multisectoral plan for the reduction of chronic malnutrition in Tete (PAMRDC) aligned with the national strategy for the reduction of chronic undernutrition.

The aim of the PCAAN programme was to mobilise children aged 10-14 as nutrition activists and agents of change and thereby contribute to chronic undernutrition in families and communities. The programme was essentially a participatory approach to health education. It required school management to understand the approach and teachers to organise participatory classroom-based activities, ‘finding out more’ activities at home and classroom-based reflective activities.

The PCAAN programme involved 12 schools from Tsangano and 5 schools in Tete city joined the programme in 2015.

Tsangano is a farming district in Tete that has sufficient food products but nevertheless high rates of chronic malnutrition in young children.

PCAAN programme activities included training teachers, health workers, school managers, supervisors and school council members and developing a suite of nutrition education materials most of which can be viewed and downloaded for free from our website:

• A Teachers Guide on Nutrition Education
• A Poster and
• Four storybooks:
  • Everyone Counts
  • The Puzzle
  • The Rainbow Garden
  • How To Be Good At Footbal

The programme was structured around eight nutrition messages, each of which was linked to topics within the existing primary school curriculum for Grades 5-7. The content for the PCAANS programme was developed in collaboration with:

• The Provincial Directorate of Education through its Department of Nutrition and School Health; and 
• The Secretariat of Food Security and Nutrition and Health through its Department of Nutrition.

…and was linked to the content of the Mozambican Primary School Curriculum. Plus they were in line with the Provincial Multisectoral Plan for Chronic Malnutrition Reduction in Tete.

Getting to this list of eight took many meetings and consultations.

Topics include:

1. Hygiene
2. Balanced Diet
3. Rainbow Garden
4. Micronutrients
5. Sharing Food Fairly
6. Breastfeeding
7. Malnutrition
8. Growth Monitoring

Implementation was coordinated by the Technical Working Group for Nutrition, SETSAN, Tete through its focal point and technical adviser, Bibiche Sangwa who provided administrative and technical support.

The PCAAN poster below depicts the process, the policy framework and foundations, the support and some of the activities. This poster was developed with the input of teachers and trainers involved in the implementation of PCAAN and has been a key resource in training (click to see larger).

PCAAN training and the materials, supported teachers and ‘community health activists’ involved and organised selected child leaders from grades 5-7 in each school to participate in nutrition education activities. First, this was done in the ‘Interest Circle’, a Saturday morning club (and government initiative). Thereafter the members of this club shared nutrition messages and activities with their school colleagues in school during scheduled, ‘local curriculum time’ (a feature of Mozambican school system), and finally, all children from the school shared the messages and activities with family members at home and in the community. In addition, the nutrition promotion activities were featured in school and community meetings, discussions and events. The program integrated classroom and extra-curricular educational learning.

After a two-year implementation period during which there was monitoring, refresher training for lead teachers and training of trainers, the University of Zambèze, Central SETSAN and DANIDA evaluated PCAAN. The conclusion was that PCAAN delivered success in the nutrition and hygiene education of children and their families, see the PCAAN case study.

The evaluation found a significant effect on rates of breastfeeding, a switch to a more nutritious form of the staple chima (white chima to ‘brown’ unprocessed chima) and better hand hygiene. In addition, children seemed to be treated with more respect and treated more equally in terms of nutrition and hygiene as well as in general. ‘Now we can see the light of good health and our children are true heroes.’ Parents reported learning from the children, ‘With the children’s insistence, the mothers try to vary the food, consuming a lot of vegetables that they grow in the garden, which were initially meant for sale’. Increased responsibility provided for by PCAAN seems to embolden the children and feed their desire to create a better community. ‘The children help each other by teaching them about nutrition and help to keep the school healthy.’

We have a film on this phase of PCAANS too.

As the Danish support for nutrition was coming to an end, new support was required in order to embed and start the scale-up program in-and-outside Tete Province. This process has, from its beginning, been closely coordinated, supported and presented to/by SETSAN, both at the Provincial and Central level and PCAAN was recommended as a programme to integrate into future sectoral and multisectoral strategies and plans

Upscaling in Tete Province (2017-2019)

In 2017, FAO adopted the PCAAN approach, integrating it with their lower school initiative, ‘Vamos Comer Alimentos Nutritivos’. The FAO support programme was implemented in two additional districts in Tete: Macanga and Angónia, but here the focus was on distributing and using printed teachers’ manuals and pupil textbooks.

The technical and management support for this programme was also coordinated and facilitated by SETSAN and technically supported by Bibiche Sangwa. The programme managed to reach 36 schools at the end of two years. It was not continued after the pilot stage due to closure of the MDG program within FAO and other UN Agencies. Despite the positive results among schools and communities where the PCAAN approach was introduced and manifested through the demand for continuity of the program by the Provincial Directorate of Education, a gap analysis by the end of the FAO support reached the following conclusions:

• A lack of remuneration or other incentives for those teachers and health activists tasked with running the Saturday Interest Circles;
• Reliance on a level of training that might not be easy to replicate and scale-up nationally; and
• Cost for printing and distribution of materials.

A Workshop to Resolve Programme Weaknesses (February 2020)

To explore how to address these concerns and how the programme could be repurposed and become part of the existing and future national sectoral and multisectoral nutrition strategies and plan, a workshop, facilitated by Bibiche Sangwa (former SETSAN Tete technical adviser) and Clare Hanbury (the CEO of Children for Health), was conducted in February 2020 with a group of 30 children at Changara EPC, Tete. This workshop aimed to further explore the previous successes as well as the challenges of the PCAAN programme stated above and to demonstrate the ability of children:

• To identify nutrition and other health issues they face;
• To quickly learn messages and activities that can accurately spread information in a fun way;
• To work in groups to plan and implement actions they can take themselves, actions that they can share with others and actions that they can as a group share with others;
• To co-create with colleagues in Mozambique a simplified approach that does not rely heavily on lengthy textbooks, that can be integrated easily into the life of the school and teacher training activities (in-service and pre-service) but that are sufficient in scope to support and sustain the national scaling of PCAAN in the future.

The workshop more than achieved all this, with the level of joyous enthusiasm of the children taking us all by surprise! We demonstrated that this programme can encompass much more than just nutrition education and can result in behaviour change by the individual child, children as a group, their families and the communities in which they live. We demonstrated the potential for schools to be an important part of the effort to improve the health of all families in Mozambique by integrating this life skills approach to nutrition and health education into the Mozambican education system. We demonstrated that this approach can be used to address any other issue or topics of interest of the Government such as Water and Sanitation or Early Marriage – any topic in which children usefully can be activists for behaviour change. As such, this workshop brought a new phase of the programme and has been renamed PCAANS (The Participation of Children in Learning and Action for Nutrition and Health).

A slideshow of this extraordinary event can be viewed here.

An Invitation To help the GoM do a National Level Scale-up 

In the week following the workshop, Children for Health (Clare Hanbury) and the former SETSAN technical adviser (Bibiche Sangwa) met with senior officers from the Department of Nutrition and School Health at the Ministry of Education, Maputo. The purpose of the meeting was to discuss the mainstreaming of PCAANS into the local and national curriculum and making it a part of what schools do nationwide as well as future strategies and plans.

AN EPIC WIN!

At the conclusion of this meeting, Children for Health (Clare Hanbury) was invited to develop a plan to scale the PCAANS programme in Mozambique in close coordination with the Department of Nutrition and School Health and with Curriculum Development (INDE) such that any PCAANS materials developed for schools automatically would be aligned for use in schools.

COVID-19 Interferes with our plans

A few weeks following this workshop, the global pandemic hit us, the schools closed in Mozambique and there has been little scope to get the PCAANS approach funded.

Since then, Children for Health has worked on a Phase 1 whereby we work on curriculum materials with the National Directorate of Education through its Department of Nutrition and School Health and testing these with cohorts of teachers using the mobile phone. This is in preparation for the end of the pandemic and the lifting of lockdown and school closures. We believe that it will be more important than ever to be thinking of ways to mobilise and support children and ensure that there are many fun things to do as they catch up on their learning.

Discussion

I’ve recently been asked to reflect on the critical components, the ‘ingredients’ that have made this programme work and why I’ve devoted SO MUCH time and effort during these last 12 months to get PCAANS to the next stage as invited by the Government of Mozambique.

Broadly speaking it is exposing key decision-makers at all levels to the competence of children and the joyful enthusiasm with which they undertake simple health promotion and disease prevention activities. This is a mindset issue and what you see in a school or community where this is happening is not that visible… but when you speak to children it really is different. It’s worth repeating here what parents noticed and reported:

Now we can see the light of good health and our children are true heroes.

With the children’s insistence, the mothers try to vary the food, consuming a lot of vegetables that they grow in the garden, which were initially meant for sale.

The children help each other by teaching them about nutrition and help to keep the school healthy.

Even folks from international non-government agencies – soaked in the language of  ‘children’s rights’ can get quite teary when they see (for example) 10-year old boys role-playing mothers, cradling our parrot mascots, in dialogue about the importance of colostrum in the first days of a baby’s life and its relative growth and health when breastfed exclusively… after (literally – we promise) a 10-minute input from one of their teachers prior to setting up this role play.

I sometimes reflect that we just have NOT done a good enough job in communicating this basic insight. Otherwise, it would be far more widespread than it is.

Other important factors include:

• SUPPORTING THOSE TEACHERS! Teachers are on the frontline and almost always the ones that have to pick-up the ideas that others dream up for improving this or that. Often with very little support and (can you believe), they are not often part of the conversation when programmes are being designed. We hope that with our programme we can ensure teachers were not only involved, but driving the programme in ways they felt were realistic and fun. Interventions must build a careful bridge between current practice and the scientific literature on effective instruction. For more on well researched effective teaching strategies click here. 
• (From the start) The programme being amenable to being scaled up and mainstreamed as part of Government policy.
• Getting a good understanding right up front what factors affect the choices of people in their communities and looking at this through the lens of at least 5 factors including culture, systems, environment, biology, and cognitive development.
• Exploring, ‘what works’ within the existing education and other systems – in terms of curriculum, teaching, pedagogy, community support for learning, family relationships to learning institutions.
• Understanding the existing external pressures on the institutions (like schools) that you may be seeking to add to. (Many schools seem to have a lot of outside agencies pressuring them to undertake externally funded activities to further their agenda).
• To co-create with colleagues a simple enough approach that does not rely heavily on lengthy textbooks, that can be integrated easily into the life of the school and into in-service and pre-service training activities.
• Communicating the DETAIL of what contributed to the successes so that those involved can understand and feel motivated.

For example, the shift from white to brown chima in the families and villages happened when children learned of the relatively low nutritional content of highly processed white Chima – maize meal and the higher nutritional content of the less processed meal and the higher nutritional content of fresh chima. They coined the nickname, Chima ZERO  for the white Chima and, this was their idea, then they used this in dramas and songs they made up about chima – informally almost as a taunt. Brown chima was labelled Chima SIX and fresh maize was labelled Chima TEN. So using these nicknames – children were discussing, singing about their staple food and sensitising families to the need to switch to chima of higher nutritional value and to use fresh maize form from time-to-time. This is of special importance when very young children are being given chima to fill them up as a very high percentage of their diet. Teachers, local officials, and decision-makers at the provincial level loved stories like this. It helped them understand in fine detail HOW children can influence change.

Another example is the increased use of plates and sharing food out between members of the family more fairly. This happened after children took the described activity to their families where they were drawing all the foods they ate in a week on a round cardboard circle – representing a plate – and then using colours to colour in the items on the plate (or label the colour if they did not have colour pencils). This led to discussions about the use of plates and the sharing out of the coloured food equally in the family… and THIS led to a rush of families buying plates in the community. We only discovered this when we consulted teachers and asked them ‘what’s changed?’ and they told us the business people running small kiosks which sell plates among other things, were VERY pleased with the programme! This lovely result and story are documented in our storybook, Everyone Counts.

We could set out very many more detailed stories of activities that gently nudge families through discussion and the way this leads to the decision-makers in the family (often fathers), discussing with other decision-makers about the messages and ideas that the children are bringing home. The result is a genuine shift in habits within the family and habits which are sustained.

Our Role

Our roles have been to contribute to or revise the programme design process within existing structures and systems; to design and help conduct training; to take curriculum materials and discover where they can be developed and co-create new elements that will enhance or strengthen what already works… and provide tools and tips that enable programmes at every level to understand how the programme is working and what to do to amplify successes.