Leveraging community health workers for the delivery of nutrition interventions: insights from a study in Zambézia, Mozambique Briana Stone1*, Réka Maulide Cane2, Talata Sawadogo-Lewis1, Júlia Sambo2, Shannon E. King1, Rui Langa2, Gildo Muchanga1, Abel Drafana2, Cristolde Salomão2, Elias Matusse2, Timothy Roberton1 1 Institute for International Programs at Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA. 2 Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique. Background: In Mozambique, the national prevalence of under-five stunting is 42.3% and under-five wasting is 4.42%. Recognizing chronic malnutrition as the main problem affecting children under five, Mozambique introduced a nutritional intervention package (PIN) to be delivered by CHWs (known locally as Agentes Polivalentes Elementares – APEs) to contribute to reducing chronic malnutrition. In 2017, the PIN was approved and implemented in 8 provinces whose prevalence of chronic malnutrition is over 35%, which included Zambézia. We carried out this study to gather information on the implementation strength of the APE program in Zambézia province. For this analysis, we assessed the current state of APE’s knowledge, attitudes, and behaviors regarding child and maternal nutrition and potential opportunities for integrating nutrition into their training curriculum and delivery of services. Methods: We carried out a cross-sectional survey of APEs in Zambezia province, using single-stage cluster sampling, with districts as primary sampling units. Of our 6 randomly selected districts, one had received training on the PIN. Our questionnaire was developed based on competencies and actions that CHWs in countries with a heavy nutrition focus in their CHW programming are expected to have. The questionnaire included general nutrition issue prioritization questions and questions on six nutrition domains to gage specific knowledge of key nutrition interventions and whether APEs carry them out or not. There were 28 knowledge-based questions and 15 questions on activities carried out. We accounted for our two-stage sampling methodology and response rates using sampling weights and finite population correction. For each nutrition domain, we calculated the average percent of questions correctly answered and the average percent of nutrition activities an APE reported carrying out. We conducted two simple linear regressions to determine if there is a difference in average nutrition knowledge and average nutrition activities between APEs that received nutrition training and those that did not. Results: APEs on average correctly answered 74% of the nutrition knowledge-based questions and reported carrying out on average 49% of nutrition activities. APEs had the highest average percent correct for questions regarding anemia prevention and the lowest for growth monitoring questions. APEs that received PIN training were statistically significantly associated with a higher average percent of correctly answered questions (P= 0.014, 95% CI: 3.05% – 17.07%) and reported a statistically significantly lower average percent of nutrition activities carried out (P=0.023, 95% CI: -6.41% – -0.79%). Conclusion: Our findings show that many APEs, but not all, had nutrition knowledge and were active around a number of areas, particularly anemia prevention and childbirth nutrition. Those that received PIN training had a higher average percent of questions correctly answered but reported carrying out fewer nutrition activities. There is room to improve training to reinforce knowledge and practices among all APEs to respond to local nutrition-related needs. In order to leverage the APE program to improve nutrition, an enabling environment is needed to ensure that knowledge gained during training is aligned with activities carried out. References: 1. Levels and trends in child malnutrition. UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates. New York, Geneva and Washington (DC): United Nations Children’s Fund, World Health Organization and the World Bank Group; 2020. 2. Ministry of Health of Mozambique. Multisectoral action plan for the reduction of chronic undernutrition in Mozambique 2011 – 2015 (2020) [Internet]. Maputo; 2010 [cited 2020 Oct 12]. Available from: http://scalingupnutrition.org/wp-content Acknowledgments: We would like to acknowledge and thank the following members of the Technical Working Group of the Platform for Women's, Children's Health and Nutrition of the National Observatory of Health (PSMCN-ONS, Mozambique): Acacio Sabonete, Antonio Junior, Ananias Antonio, Diana Quelhas, Fernando Padama, Humberto Rodrigues, Maria Patricia Goncalves, Marla Amaro, Miguel Luis, Ofelia Rambique.