Revisiting the concept of growth monitoring and its possible role in communitybased programmes

Summary of review¹

Growth monitoring

Numerous countries still implement growth monitoring (GM) as their main community-based nutrition activity. A health survey in 2003 showed that 154 countries worldwide used growth charts, with two-thirds of the charts covering preschool-aged children. In the mid-1980s, several consultations suggested that GM should be designed with additional promotional activities to become growth monitoring and promotion (GMP.) GMP was envisioned as a cornerstone activity that would help target at-risk children for secondary interventions, as a way of empowering caregivers and households to take an active role in preventing malnutrition of their children, and as a way to encourage the use of other services available through primary health clinics.

Differing opinions about the impact and outcomes of GM and GMP have led to different conclusions from evaluations and assessments of community-based programmes including GM. This has led to a relative lack of clarity and common ground in discussions about the value and place of GM and GMP in addressing the problem of undernutrition in children.

A recent review attempts to provide answers to questions about GM, such as its added value and possible place within communitybased programmes.

The reviewed literature showed that the objectives and expectations of GM and GMP vary, and programme evaluations are performed based on different frameworks. Furthermore, multiple reasons for the lack of impact of GMP have been cited in evaluations. These include a focus on nutrition status rather than faltering growth, a misplaced emphasis on curative rather than preventive actions, enrolment of children in GMP programmes after (instead of during) infancy, the use of GM as an isolated activity instead of a cornerstone activity, the lack of individualised advice, the lack of positive feedback for mothers whose children are growing adequately, the lack of community participation, an oversimplification of the GMP process, and poor quality of implementation.

As a result of these evaluations, agencies behind large-scale implementation of GMP were criticszed. At the same time, large programmes in Tanzania (Iringa), India (Tamil Nadu Integrated Nutrition Project), Madagascar, and Senegal showed that children whose growth is monitored and whose mothers receive nutrition and health education and have access to basic child health services have a better nutritional status and/or survival than children who do not.

The debate about GMP has remained ongoing. In 2003, a report by Save the Children UK questioned the evidence behind community nutrition projects in Bangladesh, Ethiopia, and Uganda. It also stated that "growth monitoring and promotion interventions are bound to fail unless they are explicitly linked to efforts to address the underlying causes of malnutrition."

A systematic review of the evidence for the impact of GMP in 2007 provided a comprehensive view of various programmes worldwide and provided evidence that significant reductions in malnutrition can be achieved through intensive health and nutrition education and basic healthcare without GM.

After the launch of the new growth standards by WHO in 2006, a momentum was created to revisit GM activities and rethink the best use of the years of experience. As countries have begun to adopt the new standards, many questions have been raised concerning the programmatic uncertainties of GM at the community level.

Many countries face a challenge in dealing with the question of whether or not to implement GM and GMP. Despite all the developments in nutrition programming in the past 10 years, GM still seems to be a convenient delivery mechanism for community interventions. However, national planners need better guidance on transitioning to alternative options that are not based on monitoring growth in the communities, if GM has not proven to be effective in contributing to programmes for prevention of undernutrition.

Part of the confusion about the place of GM in nutrition programmes appears to be due to lack of agreement on the definition and expected outcomes of GM and GMP. The authors of this review suggest the following clarifications:

Growth monitoring is a process of following the growth of a child compared with a standard by periodic, frequent anthropometric measurements and assessments. The main purpose of GM is to assess growth adequacy and identify faltering at early stages before the child reaches the status of undernutrition.

Community based growth monitoring is not itself an intervention that can treat growth faltering when it is identified. It is rather an activity which, in addition to making a child’s growth visible, may become an important point of contact with the caregiver and stimulate discussions at the community level. If implemented as a stand-alone activity, GM does not provide any benefits apart from knowledge about a child’s growth status.

GMP is defined as tailored counselling based on the GM results and follow-up problem solvfeasibiling with caregivers. This allows looking into growth monitoring-specific outcomes and benefits, as compared with general counselling and other interventions that could be delivered outside the GM session as well.

A community-based programme should include a number of interventions such as general counselling to caregivers (either individually or in groups) and delivery of different services within the context of the communitybased programme. These interventions and services could be delivered during the same GMP session, using the opportunity of the contact with caregivers. These services, however, are not dependent on measuring the growth of children and can also be delivered outside the GM context.

Combining GMP and additional interventions needs to be planned carefully to ensure that the quality of both is maintained. In some settings, workers may become overburdened by additional tasks and focus most of their attention on delivery of services rather than effective counselling and problem-solving with mothers.

Evidence is accumulating on the types of community interventions that are effective, practical, and sustainable. These interventions are not necessarily linked to GM, which raises the question of whether there is a need for this activity if the community-based programmes can be designed and implemented successfully without monitoring the growth of each child.

The decision to include GM and promotion sessions in community-based programmes needs to be made at the national and subnational levels after careful consideration of priorities, available resources, and the feasibility of reaching a high quality of GMP activities. In many settings where a concrete nutritional problem is affecting most of the population, such as micronutrient deficiencies or low breastfeeding rates, a targeted intervention may be a first priority for reaching quick improvements before deciding on more comprehensive community-based programmes, which could include GMP.

Although it is not strictly necessary for inclusion in any community-based programme, under certain conditions having quality GMP can add desirable aspects to these programmes. The approach of regular monitoring of child growth provides the opportunity for better community actions to prevent undernutrition.

High quality GM can:

• Provide an opportunity to prevent undernutrition before it occurs. GMP helps community workers identify infants and children who have growth faltering (or are at risk for faltering) and promotes timely actions to improve the situation within a short time frame
• Assist in focusing attention and resources on children at risk.
• Motivate families and caregivers to change and improve practices.
• Help target and tailor counselling messages.
• Produce ancillary benefits. GM sessions provide opportunities for immunisation, screening and treatment for diarrhoea, malaria, and pneumonia, counselling on various health and nutrition topics and the provision of other community-level health or preventive services as needed.

These additional benefits that are pertinent to GMP do not receive enough attention during most of the evaluations of community-based programmes.

Growth monitoring

In general, the level of commitment from the health system required for successful implementation of GM and GMP has proven difficult to maintain at a large scale, with the exception of few well-supported and well-supervised national programmes. Supportive supervision of community health workers requires ample allotment of time and funding, which may not be realistic within a strained healthcare system.

Appropriate implementation of GMP is dependent on the motivation of health workers. Experience shows that community workers can be effectively motivated to accurately measure, plot, and diagnose growth faltering but are often undervalued, under supervised, and poorly paid. The ratio of trained staff to the target population may also be inadequate.

The quality of training of community workers requires significant resources and efforts. In an evaluation of nine projects (governmentally and non-governmentally implemented) in Africa and Asia that included GM, most of the settings had adequate infrastructure to support GM but training was incomplete, leaving only a small proportion of the staff able to adequately take weight measurements.

In addition, the low educational level of community workers in some settings impedes their capacity to interpret and analyse growth measurement results, identify at-risk children, and analyse possible causes of growth faltering.

Although good coverage has been shown in small-scale programmes, reaching all targeted children is generally difficult to achieve, and attendance is often less than desired. The frequency of GMP attendance often declined in children of older age groups, and children who were most at risk attended less often than betteroff children. Health managers worldwide attribute low attendance to a lack of interest by mothers after completion of vaccination, weak awareness campaigns to motivate mothers, and the inability of parents to respond to information provided during the sessions (due to illiteracy, inability to understand the growth chart, or lack of access to foods).

A review of GMP in seven countries concluded that GMP is not implemented appropriately and attributed its failure to a lack of adequate investment and to the fact that GMP is often implemented in isolation from other necessary nutritional actions. The key implementation problems were low coverage (often the poorest children had the worst coverage), no action or low-quality action taken based on the analysis of GM data, and no agreement on the human, organisational, and financial resources needed for successful GMP.

In general, GMP has been shown to be successful in cases where it was added to an existing well-managed and well-supervised health system, where health workers and community workers were adequately trained and recognised for their work, where accurate equipment and materials were available, where communities were involved in the GMP process, and where culturally appropriate communication was developed.

Important questions to answer in evaluations of GM or GMP programmes could be:

"Does the measurement facilitate dialogue and counselling?"

"To what degree does information about child growth affect the quality of counselling?"

"To what extent can community workers provide quality tailored counselling based on growth status?"

Such questions need to be answered by looking at different outcomes, including the caregiver’s awareness of the child’s growth status, knowledge about necessary care practices, confidence and satisfaction with the acquired information during counselling sessions and child care behaviours.

¹Mangasaryan. N, Arabi. M, and Schultink. W (2011). Revisiting the concept of growth monitoring and its possible role in community-based programmes. Food and Nutrition Bulletin, vol. 32, no. 1 © 2011, The United Nations University. http://www.foodandnutritionbulletin.org/