Primary and secondary aged school children as “agents of change” to prevent malnutrition and related diseases in Rwanda

In Rwanda, 44% of children under five years old had chronic malnutrition in 2010. This very high rate of chronic malnutrition, also known as stunting, has many different causes including household food insecurity, poor dietary diversity, and inappropriate dietary and care practices. Tackling them requires well-coordinated, evidence-based interventions.

Since 2008, 22 United Nations agencies, programmes, and funds in Rwanda have been delivering as one, through the so-called One United Nations. With support from the Swiss Agency for Development and Cooperation, the One United Nations joint nutrition programme, comprising WHO, the Food and Agriculture Organization of the United Nations, the United Nations Children Fund, and the United Nations World Food Programme, has worked with the Government of Rwanda to deploy a multisectoral approach to address immediate causes of chronic malnutrition. The comprehensive range of interventions implemented include a nutrition comic book that aims to encourage appropriate feeding practices plus food and water safety at the household level by engaging children as so-called agents of change.

Efforts to reduce malnutrition in Rwanda are already bearing fruit. Stunting decreased from 44% to 33% between 2010 and 2020. WHO continues to implement diverse multisectoral interventions through the One United Nations joint nutrition programme to support the Government of Rwanda in reaching its ambitious goal of reducing stunting to 19% by 2024.

How did Rwanda do it, and how did the WHO Secretariat support Rwanda?

• Empowering children to mobilise their communities – In 2016, the WHO nutrition technical team worked with the Ministry of Education and colleagues from the One United Nations joint programme to develop visual and text content for a nutrition comic book. It aims to ignite the interest of children and strengthen their knowledge so they can positively influence eating behavior and dietary intake to help prevent malnutrition in their families and communities. Schools were considered an efficient distribution point for the books as most children in Rwanda spend their formative years, from early childhood to young adulthood, in a classroom environment. WHO provided technical guidance and covered the costs for development, printing and distribution of 38 844 comic books to schools in eight districts with a high prevalence of stunting.
• Programmatic monitoring and adaptation of strategy – The Ministry of Education conducted continuous monitoring visits in collaboration with the WHO Country Office in four of the eight districts. During visits, structured games were played in so-called consumer workshops to assess the effect of the comic book on children’s understanding and behaviour. Feedback was frequently positive, such as one child saying, “I decided to plant an avocado tree to help my family diversify their meals”, but it became apparent that many children needed more support to implement the lessons learned in practice. WHO and the Ministry of Education met with the Rwanda Basic Education Board and it was decided that existing book clubs would be strengthened by involving teachers who would encourage children to discuss the message and make micro plans to communicate to their families and communities. To strengthen the capacity of teachers to lead this activity, 414 schools from four districts with a high prevalence of stunting were selected to receive the books and teacher training on school health and nutrition. Monitoring, which was ongoing from 2017-2021, suggested that use of the comic book improved in the 8280 children who received continuous mobilisation support from teachers.
• Incorporating the nutrition comic book into routine teaching activities – In 2020, a decision was made to scale the comic book nationally. WHO’s technical team worked alongside the Ministry of Education and One United Nations colleagues to integrate the comic book into a national training manual for teachers on health and nutrition, and in 2021, WHO financed primary and secondary school teacher training. Delivered to 684 teachers through eLearning, the initiative has enabled the comic book to be used as didactic education material in primary and secondary schools from 2022.

“Before reading the nutrition comic book I liked to eat cake and soda and did not like vegetables. After reading the nutrition comic book I changed. I now eat vegetables and do not eat too much junk food.”

Multisectoral action was crucial to the comic books’ success. Education specialists’ technical knowledge strengthened the comic books design; the education system enabled messages to be deployed sustainably across the country by teaching professionals; and the One United Nations structure enabled the initiative to benefit from WHO and other United Nations agencies’ technical expertise as well as WHO’s financial support. This strong, coordinated effort that crossed agencies and sectors was achieved as a result of the Government of Rwanda’s strong leadership and cross-sectoral communication at the central, district, and sub-district levels.

Photo Credit: © WHO with the Republic of Rwanda Ministry of Education, United Nations in Rwanda, and the Swiss Agency for Development and Cooperation

Photo Caption: A page from the nutrition comic book deployed in Rwanda.