Afghanistan SAFANSI Nutrition Solutions Series Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative i Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative Raising Nutrition Awareness Among Young Women in ii Afghanistan through the Female Youth Employment Initiative Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative January 2014 Raising Nutrition Awareness Among Young Women in 2 Afghanistan through the Female Youth Employment Initiative © The World Bank Group, Afghanistan All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. Published by: The World Bank Group Afghanistan Office The World Bank Street No.15 House No. 19, Opposite Palace #8 Kabul, Afghanistan www.worldbank.org Design and Processed by: Print Communication, Kathmandu Printed and bound in Nepal Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 3 A A S A F N S I N S S T he Afghanistan South Asia Food and relevant sectors. ese solutions are generated Nutrition Security Initiative (SA- by combining global evidence with in-depth FANSI) Nutrition Solutions Series knowledge of the Afghan context. Each of the is a collaboration with program im- notes in this Series is the result of careful review plementers and policymakers in Afghanistan of evidence, additional information gathering to identify and re ne promising programmatic in Afghanistan, and engagement with a range of platforms for scaling-up e ective nutrition solu- stakeholders. tions in the country. e overarching frame- work for the Series is the Government of the e Series is nanced by the South Asia Food Islamic Republic of Afghanistan’s Nutrition Ac- and Nutrition Security Initiative, a trust fund tion Framework. e Nutrition Action Frame- at the World Bank supported by AusAid and work outlines a multisectoral approach for ad- the Department for International Development dressing, in a sustainable way, the alarmingly (DFID)/UKAID. e South Asia Food and Nu- high rates of child and maternal malnutrition trition Security Initiative seeks to increase the in Afghanistan. e Series builds on the global commitment of governments and internation- knowledge base to support Afghanistan-specif- al agencies in South Asia to more e ective and ic analysis, technical assistance, and pilots that integrated food and nutrition security policies generate contextualized nutrition solutions in and programs. Raising Nutrition Awareness Among Young Women in 4 Afghanistan through the Female Youth Employment Initiative T C About the Afghanistan South Asia Food and Nutrition Security Initiative Nutrition Solutions Series ----------------------- 3 Acknowledgments ------------------------------------------------------------------------------------------------------------------ 5 Key Messages ----------------------------------------------------------------------------------------------------------------------- 6 I ------------------------------------------------------------------------------------------------------------------------ 7 M W C A --------------------------------------------------------- 7 N A F -------------------------------------------------------------------------------------------------- 8 F Y E I ---------------------------------------------------------------------------------------- 9 D F Y E I N C -------------------------------- 10 D M F Y E I N C --------- 11 Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 5 A W ith funding from the South Rokx, and Meera Shekar. e peer reviewers for Asia Food and Nutrition Se- this report were Leslie Elder and Claudia Rokx. curity Initiative, the South Asia Human Development Mariam Haidary, Wahida Obaidy, and Ju- Department of the World Bank examined the lie-Anne Graitge provided much appreciated development of the nutrition curriculum that is logistical assistance. anks also are due to the part of the Female Youth Employment Initiative many colleagues in the Ministry of Education in Balkh Province, Afghanistan. e task lead- and the Ministry of Public Health of the Islam- ers for this project were Abeyah Al-Omair and ic Republic of Afghanistan and the World Bank Luc Laviolette. Julie McLaughlin and Kees Kos- o ce in Kabul, Afghanistan who supported this termans provided overall guidance while Tawab work and responded to queries with helpful in- Hashemi, Najla Sabri, Miki Terasawa, Ian Darn- formation. ton-Hill, Wassima Qarizada, and Rachel Rosen- feld provided valuable inputs as part of the task is work was made possible by the dedicated team. Appreciated contributions into the plan- e orts of the nutrition community in Afghani- ning of this Afghanistan technical assistance stan and internationally that provided excellent task were made by Johannes Jansen, Claudia support for this endeavor. Raising Nutrition Awareness Among Young Women in 6 Afghanistan through the Female Youth Employment Initiative Key Messages t e mortality rates among infants (77 ers in the health, education, and agriculture deaths per 1,000 live births) and children sectors. One of the key commitments by under- ve (97 deaths per 1,000 live births) the Ministry of Education was to develop in Afghanistan are among the highest in a nutrition-related curriculum with special the world. One of the major contributors to attention to female students. these high mortality rates is malnutrition t Following up on the Ministry of Education’s among infants and women, in particular, commitment, the Bank- nanced Female pregnant and lactating mothers. e stunt- Youth Employment Initiative project devel- ing level among children under- ve (about oped a comprehensive nutrition education 60 percent) is one of the highest in the curriculum, soon to be delivered to female world. Almost 60 percent of Afghans have high school graduates, who are the future low diet diversity, and about 21 percent of mothers of Afghanistan and can actively women su er from chronic energy de cien- engage in their communities. e curricu- cies. lum follows the “lifecycle approach,” with t In addressing intergenerational undernu- an emphasis on the essentials of nutrition trition in Afghanistan, the Nutrition Action at the adolescence, pregnancy, and lactation Framework was developed by the stakehold- stages. Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 7 Introduction one of the major contributors to Afghanistan’s e infant mortality rate in Afghanistan, which high mortality rates—speci cally infant mortal- is 77 per 1,000 live births,1 is among the highest ity and under- ve mortality.2 As stated above, in the world. One of the major contributing fac- Afghanistan’s infant mortality rate is among the tors is malnutrition among infants and women, in highest in the world, and the under- ve mor- particular, pregnant and lactating mothers. In an tality rate in Afghanistan also is extremely high e ort to understand the underlying causes of mal- at 97 deaths per 1,000 live births. is means nutrition, the South Asia Food and Nutrition Se- that nearly one tenth of Afghan children do not curity Initiative Nutrition Solutions Series focuses reach their h birthdays.3 on the multisectoral e orts necessary to improve nutrition awareness. Speci cally, this paper focus- e levels of child undernutrition in Afghan- es on the Bank-supported Female Youth Employ- istan are very high. UNICEF nds that 59 ment Initiative, which aims to improve nutrition percent of children under the age of ve are awareness by targeting urban, female, high-school stunted, and 33 percent are underweight.4 graduates by delivering a comprehensive nutrition e stunting levels are among the highest in education curriculum within general life skills the world. Acute undernutrition (wasting) in training. e Ministry of Education, with World children under ve is 9 percent,5 which is low Bank support and in collaboration with other Is- for a poor, con ict-stricken country, but these lamic Republic of Afghanistan government minis- wasting levels remain very high in the rst two tries, is working to pilot this initiative. years of life (18.1 percent in children between one and two years old6).7 One of the causes of child undernutrition is widespread micronu- Malnutrition among Women trient de ciency. e National Risk and Vul- and Children in Afghanistan nerability Assessment shows that 57 percent of Malnutrition among infants and women, in the population in Afghanistan have very low particular, pregnant and lactating mothers, is diet diversity.8 1 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional O ce for the Eastern Mediterranean (WHO/EMRO) [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/ MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. 2 Afghanistan Public Nutrition Policy and Strategy. 2004. 3 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional O ce for the Eastern Mediterranean (WHO/EMRO) [Egypt]. 2011. Afghanistan Mortality Survey 2010. Calverton, Maryland, USA: APHI/ MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. 4 State of the World’s Children. 2009. UNICEF. 5 State of the World’s Children. 2009. UNICEF. 6 Levitt, Emily, Kees Kostermans, Luc Laviolette, and Nkosinathi Mbuya. 2011. Malnutrition in Afghanistan: Scale, Scope, Causes, and Potential Response. Washington, DC: The World Bank Group. Accessed from www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB /2010/11/15/000356161_20101115233235/Rendered/PDF/578720PUB0Maln11public10BOX353782B0.pdf. 7 Stunting is low height for age. Wasting is low weight for height. Underweight is low weight for age. 8 Afghanistan National Development Strategy: An Interim Strategy for Security, Governance, Economic Growth, and Poverty Reduction. 2006. Raising Nutrition Awareness Among Young Women in 8 Afghanistan through the Female Youth Employment Initiative e level of malnutrition also is high among wom- maternal and child undernutrition by focus- en in Afghanistan. 20.9 percent of women have low ing on the 1,000 days period from conception body mass indices, which indicate chronic energy through the rst two years of life. e Frame- de ciencies.9 48.4 percent of non-pregnant wom- work complements the Afghanistan National en of childbearing age have anemia, and 75 per- Development Strategy10 and builds on its mul- cent of them have iodine de ciencies. e World tisectoral approach, engaging the Ministries of Health Organization explains the importance of Public Health; Education; Agriculture, Irriga- young women’s health for newborns, young chil- tion, and Livestock; Rural Rehabilitation and dren, and future generations. A low body mass in- Development; and Commerce and Industry. dex and suboptimal weight gain during pregnancy e key areas of commitment by the ministries are long-recognized risk factors for the delivery of include: (a) infant and young child feeding and infants too small for gestational age. Being born care practices and micronutrient provision small for gestational age is a major predictor of by the Ministry of Public Health, (b) school neonatal mortality and morbidity, failure to grow, health and nutrition, and curriculum devel- slow cognitive development, and chronic diseases opment in nutrition-related areas, with special in adulthood. Adolescent women have the po- attention to female students by the Ministry of tential to help break the current cycle of under- Education, (c) dietary diversity, in particular, nutrition by ensuring adequate nutritional intake in food insecure households by the Ministry of required for their own healthy growth so that they Agriculture, Irrigation, and Livestock, and (d) would not be small and stunted women. activities associated with the National Solidar- ity Program and water sanitation and hygiene As part of these e orts, nutrient intake and by the Ministry of Rural Rehabilitation and weight gain during pregnancy are the two main Development.11 modi able factors in uencing maternal and in- fant outcomes. e overall objective of the Action Framework is to reduce stunting in children aged 0-24 months by 10 percentage points (from an esti- Nutrition Action Framework mated 59% to 49% by the end of 2016).12 e e Nutrition Action Framework of the Islam- following principles were used in the prepara- ic Republic of Afghanistan seeks to address tion of the Framework: 9 Malnutrition in Afghanistan: Scale, Scope, Causes, and Potential Response, PPT. Accessed from http://siteresources.worldbank.org/ INTAFGHANISTAN/Resources/Afghanistan-Reconstructional-Trust-Fund/Malnutrition_inAfghanistan_for_High_level_audience.pdf. Afghanistan: The State of Health and Development. Micronutrient Initiative. Accessed from http://www.micronutrient.org/english/ view.asp?x=601. 10 The Afghanistan National Development Strategy highlights health and nutrition in Pillar 5 under the social and economic development goals. This Pillar commits to reduce the morbidity and mortality of the Afghan population by implementing a package of health and hospital services, special programs, and human resource development. 11 The list of commitments by the ministries are as follows: (a) the Ministry of Public Health by (i) the e orts to improve infant and young child feeding and care practices, (ii) infectious disease control including improved water sanitation, hygiene, and deworming, (iii) micronutrient provision, and (iv) the treatment of severe and acute malnutrition and other nutrition-related illnesses with a focus on disease prevention; (b) the Ministry of Education by (i) school health and nutrition, (ii) curriculum development in nutrition- related areas, and (iii) behavioral change communications, in each case providing special attention to female students to encourage enrollment and attendance; (c) the Ministry of Agriculture, Irrigation, and Livestock by (i) increasing food access and availability and (ii) improving dietary diversity with a primary focus on insecure food households; and (d) the Ministry of Rural Rehabilitation and Development by (i) activities associated with the National Solidarity Program, (ii) improved water sanitation and hygiene, and (iii) social protection initiatives with special attention on women’s participation. 12 Stunting (low height for age) along with wasting (low weight for height) and being underweight (low weight for age) can serve as measures of nutritional status in the rst 1,000 days. Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 9 t Common targets and indicators with the forms an integral part of a national Food and prevalence of child stunting serving as the Nutrition Security Policy Framework, which primary impact indicator currently is being developed. Each of the par- t Coordination among the ministries and ticipating ministries also will have a small Nu- their partners, particularly in advocacy, trition Coordination Unit to support the deliv- fundraising, and overall governance ery of the Nutrition Action Framework actions t Resource availability and to coordinate with other ministries. While t Ministry-speci c identi cation of capacity the creation of technical sub-committees was development requirements considered, the recommendation at this point t An agreement to utilize the Framework as a is to begin the implementation and to create means of increasing commitment in each of sub-committees and task forces as and when the relevant sectors to the reduction of mal- required to address speci c implementation nutrition challenges. ere is agreement among the ministries that e core Islamic Republic of Afghanistan gov- a high-level coordination mechanism is nec- ernment ministries responsible for the design essary to integrate particular activities across and implementation of this Framework are be- ministries, to track progress of individual activ- ing supported, technically and nancially, by ities and of the Framework as a whole, to ad- a range of international technical and funding dress problems and limiting factors quickly and partners, including: the Canadian International e ciently, and to ensure accountability for re- Development Agency, the European Commis- sults within each of the core ministries. Follow- sion, the Global Alliance for Improved Nutri- ing extensive consultations, the team designing tion, the UN Food and Agriculture Organiza- the Nutrition Action Framework proposed that tion, the Micronutrient Initiative, the Millen- a High Level Food and Nutrition Security Steer- nium Development Goals Fund, UNICEF, the ing Committee be created under the chairman- United States Agency for International Devel- ship of the Second Vice President and be com- opment, the World Bank, the World Food Pro- prised of the ministers from each of the ve core gramme, and the World Health Organization. ministries involved in food and nutrition secu- Additionally, the Islamic Republic of Afghan- rity. Initially, the proposed Steering Committee istan’s Ministry of Finance will have nancial will meet four times per year to review progress oversight over the Framework and the activities in operationalization of the Framework and within it. to explore linkages between the participating ministries. is Steering Committee will be supported by a modest Secretariat located in Female Youth Employment the O ce of the Second Vice President, with Initiative the following core functions: coordination, data e Afghanistan Female Youth Employment collection and analysis to track the operational- Initiative is a pilot project implemented by the ization of the Nutrition Action Framework, and Ministry of Education, with support from the advocacy/communications. e Framework Bank- nanced Education Quality Improvement Raising Nutrition Awareness Among Young Women in 10 Afghanistan through the Female Youth Employment Initiative Program. e Female Youth Employment Ini- ment Shuras attached to high schools in the tar- tiative is one of the Adolescent Girls Initiative get areas. As a result, more than 2,800 female projects supported by the Bank; it promotes the high school graduates applied for the project’s economic empowerment of young women by training and employment program.14 Approxi- supporting their transition from school to pro- mately 60 percent of these young women reside ductive employment.13 At a total cost of US$2 in Mazar City, Afghanistan. 12 percent of them million, the Female Youth Employment Initia- are married.15 tive in Afghanistan aims to train and employ 1,300 female high school graduates between 18 Because these young women are the future and 30 years old in Mazar City, Afghanistan and mothers of Afghanistan and have the potential four selected districts in Balkh Province, Af- to be actively engaged in their communities, ghanistan. e young women are provided with nutrition education was included as a part of job skills training (including English, computer, the life skills training section of the curriculum. and entrepreneurship) coupled with life skills is is unique to the Female Youth Employment training that will help them build con dence Initiative, as none of the other Adolescent Girls and self-esteem in the job search, in the o ce Initiative projects throughout the world deliv- environment, and in their communities. er nutrition messages.16 In addition, the Female Youth Employment Initiative also gives a unique With support from the Education Quality Im- opportunity to reach out to urban youth, as nu- provement Program, the Female Youth Em- trition education in Afghanistan thus far has ployment Initiative reached out to all targeted focused on rural areas. School Management Shuras in order to com- municate to young women and their families. School Management Shuras were formed by the Developing the Female Education Quality Improvement Program and Youth Employment Initiative had participation by both school and communi- Nutrition Curriculum ty representatives, including women, to support Building on the multisectoral e orts in de- school management and to increase awareness signing the Nutrition Action Framework, the of the importance of girls’ education. e social Female Youth Employment Initiative nutri- mobilizers of the Female Youth Employment tion curriculum was developed by the govern- Initiative reached out to all 61 School Manage- ment stakeholders, development agencies, and 13 The Adolescent Girls Initiative projects are nanced by the Multi-donor Trust Fund, supported by the Nike Foundation, Denmark, Norway, Sweden, the United Kingdom, and Australia. There are eight projects, mostly in con ict-a ected countries, which are Afghanistan, Nepal, Jordan, Haiti, Lao PDR, Liberia, Rwanda, and South Sudan. 14 Of the 2,800 applicants, approximately 1,300-1,400 girls will be the target young women for the nutrition curriculum and the remaining 1,300-1,400 girls will be the control group for evaluation purposes. 15 The project will select 1,300 bene ciaries on a lottery basis. Those who are not selected will be a part of the control group for the Adolescent Girls Initiative impact evaluation. 16 More dominant health related issues in other Adolescent Girls Initiative projects throughout the world are sexual and reproductive health, which are part of the Nepal, Liberia, South Sudan, and Haiti projects’ life skills training. See Adolescent Girls Initiative, “Life Skills: What Are they, Why Do They Matter, and How Are They Taught?,” Learning from Practice Series, June 2013. Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 11 non-governmental organizations in the health, momentum in nutrition education in Afghani- education, and agriculture sectors, including stan and generated buy-in and ownership of the the Ministry of Public Health; the Ministry of nutrition curriculum among the various min- Education; the Ministry of Agriculture, Irriga- istries. e nal nutrition curriculum has two tion, and Livestock; the Ministry of Women’s modules, which include the basics of nutrition A airs; the Education Quality Improvement and nutrients, essentials of nutrition at di erent Program; and National Solidarity Program.17 stages of the lifecycle, and antenatal and post- By increasing the nutrition awareness of young natal care, including feeding practices. e rst urban as well as rural women, the stakeholders module focuses primarily on nutrition during emphasized the cultural sensitivity and age ap- particular times of the lifecycle, and the second propriateness of the training materials. Learn- module concentrates on strategies for promot- ing from experiences in nutrition education in ing nutrition within the community.20 e mod- Afghanistan, in particular, the delivery of the ules are comprehensive and can be delivered Essential Nutrition Actions for Afghanistan that in full at the high school level or in part at the focus on antenatal and postnatal care,18 the Fe- elementary or middle school levels or through male Youth Employment Initiative curriculum development projects related to food security development workshop adopted the “lifecycle and nutrition. approach”19 for the curriculum, with an empha- sis on nutrition needs at the adolescence, preg- nancy, and lactation stages. Delivering and Monitoring the Female Youth Employment e stakeholder workshop was followed by two Initiative Nutrition Curriculum detailed consultations hosted by the Ministries e Female Youth Employment Initiative nu- of Education and Public Health, which built trition education modules will be delivered as 17 In addition to the ministries and the Bank-supported projects, the development agencies and non-governmental organizations that participated were: the UN Food and Agriculture Organization, UNICEF, the World Health Organization, the Canadian International Development Agency, the Global Alliance for Improved Nutrition, the Nutrition Education Initiative, the Basic Vocational Education Social Organization, and the Coordination of Humanitarian Assistance. 18 The Essential Nutrition Actions provides a list of proven, action-oriented approaches to improve the nutrition status of women and children worldwide, developed by the United States Agency for International Development. For the Female Youth Employment Initiative nutrition curriculum, the following 11 messages were selected: (1) exclusive breastfeeding from 0 to 6 months; (2) introduction of complementary feeding when the infant is 6 months old, with continued breastfeeding up to 2 years old; (3) feeding a sick child extra foods during illness and 2 weeks after recovery, screening children and managing illness at therapeutic feeding centers and health service units, promoting illness prevention and home management, early health seeking by mothers and caregivers, and feeding of malnourished children; (4) adequate nutrition for pregnant and breastfeeding women; (5) consumption of more energy and protein foods by mothers; (6) ve tetanus toxoid immunizations; (7) vitamin A supplementation, consumption of foods rich in vitamin A; (8) anemia control through iron supplementation, deworming during the 3rd trimester of pregnancy, and consumption of foods rich in iron; (9) iron and folic acid supplementation for 6 months for the treatment of anemia and used in general during pregnancy; (10) use of insecticide-treated mosquito nets; and (11) control of iodine de ciency through the consumption of iodized salt and sh, and supplementation where iodized salt is not available. The Female Youth Employment Initiative nutrition curriculum modules were built on the curricula developed by the UN Food and Agriculture Organization and UNICEF. 19 The lifecycle consists of ve stages: infancy, childhood, adolescence, pregnancy, and lactation. 20 While not explicitly covered in the formal curriculum, four additional modules will be available for young women to reference on the following topics: (1) food groups, (2) digestion and food safety (including water), (3) macro and micronutrients, and (4) antenatal and postnatal care. Raising Nutrition Awareness Among Young Women in 12 Afghanistan through the Female Youth Employment Initiative a part of the 7-month job and life skills train- ing the nutrition modules, on a monthly basis. ing. e training was launched in early-No- Moreover, the nutrition modules, as a part of vember 2013, and the Female Youth Employ- the overall Female Youth Employment Initia- ment Initiative team is closely monitoring the tive training and employment program, will educational progress through an innovative be monitored by a rigorous impact evaluation Information and Communications Technol- under the Adolescent Girls Initiative program. ogy-based feedback mechanism. Out of the e evaluation will include indicators on the 2,800 Female Youth Employment Initiative Female Youth Employment Initiative partici- applicants, 92 percent of these young wom- pants’ nutrition knowledge and behavior (va- en have their own mobile phone. Using this riety of food intake) and household food ex- technology, the Female Youth Employment penditure and security.21 e baseline survey Initiative team will obtain direct bene ciary will be completed in March 2014, and the nal feedback on the quality of delivery and on the impact evaluation is planned for 2015, a er the level of satisfaction with the training, includ- project closure. 21 The food and nutrition related survey questions for the Female Youth Employment Initiative bene ciaries will include: (i) what are the four essential nutrition actions that communities should support?; (ii) questions on the frequency of eating di erent nutrition groups, such as protein (eggs, chicken, sh, and/or dairy products), vegetables, fruits, and/or nuts; (iii) and questions on food expenses, speci cally for the woman answering the questionnaire. Additionally, the household questionnaire will ask about household food expenses, consumption, and security. Raising Nutrition Awareness Among Young Women in Afghanistan through the Female Youth Employment Initiative 13 Raising Nutrition Awareness Among Young Women in 14 Afghanistan through the Female Youth Employment Initiative The World Bank Group Afghanistan Office Street No.15 House No. 19, Opposite Palace #8 Kabul, Afghanistan www.worldbank.org