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Endang Achadi and Peter Berman
Malnutrition in young children is often unrecognized by the mother until it has reached a severe stage. At that stage, reversing the condition is expensive and difficult, particularly in a country like Indonesia where the prevalence of malnutrition is high and resources are limited.
Monitoring children's growth through regular monthly weighing is useful for identifying the signs of malnutrition such as faltering growth and thus making prevention easier and less expensive. It can also be used as a vehicle for educating mothers about nutrition, as a screening tool for identifying malnourished children, and as a means of evaluating the impact of interventions.
Adequate implementation of growth monitoring can be difficult, however. To reach as many of the targeted children as possible requires a good registration level, high attendance rate and regularity of attendance, and correct measurement and recording. When programmes are implemented by minimally educated community workers, the tasks may not be performed with the quality necessary to meet the requirements.
This paper develops a simple systems framework for assessing the performance of growth-monitoring programmes. This framework was used to evaluate the performance of one weighing station for over three years with regard to attendance rate, regularity of attendance, and targeting of coverage relative to the nutritional status of the children.
Growtth-monitoring programme in Indonesia
Growth monitoring is a part of the Indonesian National Family Nutrition Improvement Program that has been conducted since 1974. Its goal is to improve the nutritional status of children through a variety of integrated activities.
Convening children under five years of age monthly to weigh them at the station has been a means of reaching the children and their mothers for other programmes that will improve their nutritional and health status. Provided in those programmes are family-planning services for mothers to encourage better birth spacing, immunizations for eligible children in order to reduce morbidity and mortality from certain diseases, oral rehydration therapy (ORT) to reduce mortality caused by diarrhoea, and nutritional aids for mothers (iron tablets) and for children (vitamin A and supplementary feedings).
Growth monitoring itself has been used primarily for two purposes. First, it educates and motivates mothers to better understanding and practice in enhancing their children's health and nutritional status. Second, it identifies malnourished children and others at risk who need special intervention and referral.
Nutrition education and health education in general are given to all mothers who attend the weighing sessions, with a special focus on mothers whose children are not gaining weight, are sick, or are otherwise nutritionally at risk. The method is usually face-to-face education.
To screen malnourished children or children at risk, the programme uses the following criteria: those who fall below 60% of the median of the Harvard standard and those who demonstrate no weight gain for three consecutive weighings are considered to be in need of special intervention, such as rehabilitative supplementary feeding or treatment. They are referred to the health centre or other health facilities.
The use of these criteria has raised several questions. First, to demonstrate no weight gain, a child must attend four consecutive weighing sessions. This means that he must come regularly, which in fact is difficult to achieve. A large survey by the Ministry of Health of Indonesia in 1982 showed that only 34%-40% of the children in the surveyed area had ever been weighed. Fajans and Sudiman  noted that 64% of the children came to the weighing post only one time during the study. Considering these figures, it can be estimated that the actual regularity of attendance is much lower. Consequently, many children are obviously not screened. If the children who are excluded because of irregular attendance are those who actually most need to be screened (i.e., are nutritionally at risk), one objective of the programme will not be achieved.
Second, children who come regularly and who gain weight every month but remain malnourished will also be excluded from the programme, while in fact they probably need the intervention or need to be referred. This could occur because weight gain alone is an inadequate screening criterion.
Third, if the measurement of weight is not correct, children who do not gain weight can be misclassified as having gained. Consequently, they will be denied intervention and referral.
Figure 1 (see FIG. 1. Types of interventions and factors affecting each step of participation (*Children who are lost from coverage for referral and special intervention.) ) shows how these criteria can exclude the targeted children for intervention and referral. It also shows how low and irregular attendance can exclude children from receiving nutrition education, nutritional first aid, ORT, and so on. This figure also indicates factors that can influence the outcome of each step. Participation affects the attendance rate; correct measurements affect the classification of weight gain; and regularity of attendance affects the rate of attendance for four consecutive weighings.
The data came from the weighing registration records at Gedangan village in Central Java, from June 1978 to November 1981. The data were gathered monthly by village health workers throughout the weighing activities. Children 0-60 months old were included, with the age determined by questioning the mother or responsible adult. The scale used was a hanging scale called Dacin, which is widely used throughout Indonesia. Weights were recorded on Indonesian growth charts and registration forms. Each child's nutritional status was classified according to the percentage of the median of the Harvard reference standard .
Two indicators of weighing attendance have been calculated: a simple attendance rate, and a four-consecutive-weighings attendance rate (fig. 2). In addition to the overall rates for the whole group of all children registered during the study, the rates have also been calculated for the separate groups of children classified by nutritional status. Because the length of time a child was eligible (i.e., was between 0 and 60 months old) and registered for the programme may be different for each child, the factors were calculated individually for each child and then summed to calculate the group rates.
Factors calculated for each child:
|A = number of actual monthly weighings of individual child||B = total number of months child is eligible and registered|
|C = number of four-month periods during which child undergoes four consecutive weighings||D = total number of four-month periods during which child is eligible and registered|
Calculation of group rates, using sums of values for all
children in the group:
Attendance rate = sum of A's / sum of B's
Four-consecutive-weighings rate = sum of C's / sum of D's
FIG. 2. Indicators of weighing attendance
TABLE 1. Overall attendance rates of children 0-60 months old
Sum of actual monthly weighings
Sum of potential monthly weighings
Attendance rate (%)
|June 1978-Nov. 1981||
The attendance rate is defined as the ratio of the sum of the number of actual individual monthly weighings to the sum of the total number of months the individual children were eligible and registered for the programme.
The four-consecutive-weighings rate is defined as the ratio of the sum of the number of actual four month periods during which a child completed four consecutive weighings to the sum of the number of four-month periods during which the individual children were eligible and registered for the programme.
The calculation is made from the date of initial registration of each child until the child reached the age of 60 months or the end of the study in November 1981. For example, if a child was registered in June 1978 and was not older than 60 months in November 1981, the number of four-month periods during which it was eligible and registered would be 4 in 1978, 12 in 1979, 8 in 1980, and 11 in 1981. From June 1978 through November 1981 the total figure would be 35. If a child was registered in September 1978 and reached the age of 60 months in May 1981, the number of four-month periods during which it was eligible and registered would be 1 in 1978, 12 in 1979, 8 in 1980, and 5 in 1981, for a total of 26 from September 1978 through May 1981.
A total of 185 children were registered and eligible from June 1978 to November 1981. The attendance rate is shown in table 1 by periods. From June 1978 to November 1981 the average attendance rate was 51.1%. This suggests that on average the registered children came to the weighing post only half of the time. When this is broken down by year, the rate of attendance decreased from 80.5% in 1978 to 39.1 % in 1981. This suggests that on average the eligible children's exposure to nutrition education and nutritional aids decreased significantly between 1978 and 1981.
Table 2 shows the percentage of children who underwent four consecutive weighings at least once. The rate did not improve from 1978 to 1981, though it did not decline. It was lowest in 1980 and highest in 1979. This table suggests that, for the use of the criterion of no weight gain for three consecutive weighings, only about half of the registered children were qualified for the screening for direct intervention and referral at least once in one year from June 1978 to November 1981. This result is very different from the average rate of four consecutive weighings shown in table 3, which was only 27.7%. This suggests that, on average, children were eligible for screening only about one-fourth of the time. Therefore, using "ever weighed for four consecutive times" instead of the four-consecutive-weighings attendance rate to evaluate the screening criteria can be misleading.
TABLE 2. Percentage of children who completed four consecutive weighings at least once
|Number of registered children||Children completing 4 consecutive weighings at least once|
TABLE 3. Rates of attendance for four consecutive weighings
|Sum of actual 4 consecutive monthly weighings||Sum of potential 4 consecutive monthly weighings||Attendance rate (%)|
|June-Dec. 1978 144||294||49.0|
|Oct. 1978-Dec. 1979 369||995||37.1|
|Oct. 1979-Dec. 1980 148||722||20.5|
|Oct. 1980-Nov. 198||1183||1,039||17.6|
|June 1978-Nov. 198||1844||3,050||27.7|
Table 3 shows that the rate of attendance for four consecutive weighings decreased continuously from 49.0% in 1978 to 17.6% in 1981. This suggests that compliance with the programme was decreasing. It also implies that only about 17.6% (in 1981) to 49.0% (in 1978) of the time could registered children be screened for intervention or referral. Thus most of the time the registered children, including those who possibly were severely malnourished or at risk, were excluded from screening and therefore from possibly having intervention or being referred.
A comparison of tables 1 and 3 shows that, although the attendance rate in 1978 was high (80.5%), the rate for four consecutive weighings was much lower (49.0%). This suggests that, even if the attendance rate is high, the criteria for screening can exclude a large number of children if the regularity of weighing is low.
Table 4 indicates the attendance rates and the rates of attendance for four consecutive weighings from June 1978 to November 1981 for the children classified into groups by their nutritional status at the first weighing. The reason for separating the children by nutritional status is to identify those who are nutritionally at risk. If it turned out that the children who came irregularly were those most at risk, then the number of targeted children excluded would be even larger. Fortunately, the result shows that there was not much difference in the rates between the groups classified by nutritional status, which implies that the most vulnerable children were included proportionately in the programme.
Table 4 also shows that only about half of the children were in the category of normal nutritional status. Almost 30% were mildly or moderately malnourished, which is similar to the national figure (33.4%). About 3% of the children were considered severely malnourished, which is lower than the national figure (6 4%) .
TABLE 4. Monthly attendance rates and rates of attendance for four consecutive monthly weighings for children classified by nutritional status at first weighing
|Nutritional status||Children in nutritional status group||
Attendance for 4 consecutive monthly weighings
|No.||%||Sum of actual weighings||Sum of potential weighings||Rate (%)||Sum of actual 4 weighings||Sum of potential 4 weighings||Rate (%)|
Discussion and conclusions
At the start, the attendance rate in this growth-monitoring programme was high, suggesting that there was the potential to evaluate about 80% of the registered children in this village. Attendance decreased continuously, however, to half of its initial level by 1981. As a consequence, in 1981 for example, only about 39.1% of the children were covered for nutrition education, nutritional aids, ORT, and immunization. This also means that children who fell below 60% of the Harvard standard weight among the remaining 60.9% were deprived of the possibility of being diagnosed as malnourished, and consequently were excluded from intervention and referral.
It is clear that the number of severely malnourished children that could be identified could be enlarged by increasing the attendance rate alone. This would also increase the possibility of preventing malnutrition through nutrition education and provision of vitamin A, ORT, or immunization.
On the other hand, the rates of attendance for four consecutive weighings were much lower than the overall attendance rates. A high attendance rate does not always mean a high rate of attendance for four consecutive weighings, but a low rate of the former will certainly mean a low rate of the latter. This suggests that it is very difficult to achieve a high rate of attendance for four consecutive weighings, and to do so requires several steps.
First, of course, the overall attendance rate must be high. Second, attendance must be regular. It is clear that expecting a high level of regularity demands understanding on the part of mothers and workers, as well as time. This means that workers' and mothers' knowledge of nutrition and health must be improved to increase their understanding of the importance of weighing the children. Otherwise, many children will be excluded from the possibility of being screened.
As shown in this study, on average, only 27.7% of the registered children were screened, leaving a very high percentage (72.3%) unscreened. This implies that among the latter group, a significant number of children at risk could not get the intervention and referral simply because they came to the weighing post irregularly. The need to review this criterion is obvious.
The data show that there was no association between the monthly attendance rate or the rate of attendance for four consecutive weighings and nutritional status. This is fortunate, because if children who were excluded from the programme were those who required intervention, even fewer would be reached.
The reasons for the decreasing rate of attendance should be determined, as there was the potential to achieve a high rate of attendance in this village. It is possible that the villagers needed further encouragement and supervision for this to occur.
Similar studies from many other areas are needed to give more representative figures about this kind of programme. The data reported here have several limitations. Since the actual number of living children under five years of age could not be verified, it is possible that the figures do not represent the entire eligible population. From personal observation for a certain period of time in this village, however, it can be stated that the number of registered children was very close to the number of eligible children. Weight data were also solely based on the figures recorded on registration forms by village health workers. We could not verify whether these data were reliable. Age information was obtained by questioning the mothers, and no birth certificates were available to check the validity of the information.
We are very grateful to Dr. W. H. Mosley and Dr. M. Latham for their important comments and corrections, and to Dr. N. S. Scrimshaw for his encouragement. Data collection was supported by grants from the US Department of Education and the Ford Foundation. The Indonesian Institute of Sciences, Gajah Mada University, and the Department of Health sponsored the study. Data analysis was made possible by support from the United Nations University and the Ford Foundation.
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