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Growth monitoring in the context of a primary health care programme
Fazlul Karim, Nasreen Huq, Laurine Brown, and A. Mushtaque R. Chowdhury
During the last decade, growth monitoring has been promoted us an important intervention for child survival, but questions have been raised about its electiveness and feasibility in less-developed countries. A growth-monitoring programme was carried out by the Bangladesh Rural Advancement Committee for over four years, covering about 20,000 children under two years of age. The programme was equally accessible to all socioeconomic groups and both sexes. Children were weighed monthly in village centres, and their mothers were given health and nutrition education. A recent evaluation found modest coverage (43 %) of the target children. Accuracy in determining ages of the target children was reasonably good, with more than 90% within 30 days of actual age. Eighty-seven per cent of the Salter round scales used gave accurate results, compared with only 17% of the Salter cylinder scales. Local volunteers, mostly women, participated in growth-monitoring sessions by weighing, recording, and demonstrating how to prepare supplementary diets. Growth monitoring was associated with increased use of selected child-survival interventions such as immunization. The nutrition status of participating children was not significantly better than that of a comparable group of children who did not participate (p =.051).
Although weighing has been used to monitor growth in children since 1910 [1], the popularity of growth monitoring as a tool for child survival is recent. Growth monitoring differs from nutrition surveillance in that the objective of the latter is research and monitoring changes over time, while growth monitoring emphasizes promoting the growth of children through one or more of the following activities: counselling, education, treatment for growth-retarding illnesses, and feeding.
With the initiation of the GOBI (growth-monitoring, oral-rehydration, breast-feeding, and immunization) strategy by UNICEF in the early 1980s, the role of growth monitoring in child survival was promoted and institutionalized. Unlike most other child-survival technologies, however, growth-monitoring programmes are difficult to implement [2], are controversial, and have not yet been accepted as a technology of choice in developing countries [1].
In 1987 growth monitoring was incorporated into a large primary health care intervention conducted by the Bangladesh Rural Advancement Committee (BRAC). A study of this component of the programme was undertaken in 1990 to help to clarify various factors contributing to the controversies surrounding the subject.
BRAC's primary health care programme
The health and nutrition status of the rural population of Bangladesh, particularly mothers and children, is unacceptably low. A national nutrition survey of 1981 found that about 80% and 97% of children 0-11 and 12-23 months of age respectively were suffering from mild to severe malnutrition [3]. The situation with respect to girls and women was even worse. Vitamin A intake was 808 IU per person per day, which meets only 40% of the requirement. Children 1-3 years old received only 25% of their vitamin C requirement. This has been attributed to numerous causes, including [4]:
In late 1986 BRAC, which is a non-government organization (NGO), launched a primary health care programme in six thanas (subdistricts), with a population of 1.2 million, with the major goal of devising a workable model of primary health care. It was hoped that such a model would ensure effective community participation and would be replicated by the government and other NGOs to improve the health and nutrition status of the population, particularly rural mothers and children. Eight components—promotion of oral rehydration therapy, immunization, vitamin A capsules, safe water, family planning, nutrition education, training of traditional birth attendants (TBAs), and basic curative services—were originally included in the programme.
A year later, to address child malnutrition specifically, growth monitoring was added, with the objectives of educating mothers about child growth, health, and nutrition through a village forum; screening malnourished children as a channel to provide health and nutrition education to their mothers; and detecting severely malnourished children in order to refer them to nearby health facilities for appropriate care.
Implementing growth-monitoring activities
All the BRAC field health workers and their supervisors underwent three days of training (two days in a classroom and one day of field practice) on the importance of growth monitoring, how to perform it, and the various equipment, materials, and techniques of nutrition education, in addition to the regular training they received from BRAC. The curriculum was designed in collaboration with UNICEF and Helen Keller International, an international NGO working in Bangladesh.
Prior to the formal launching of the activities, a two-stage pilot programme was undertaken to explore BRAC's management capacity to carry them out, to reinforce the training of health workers, and to assess people's response. The strategy was tried first in five villages of Manikganj Sadar thana and then in five villages of each of the other five thanas. Based on results from these initial experiments, the programme was gradually extended to all villages in the six thanas.
Because of cost and management considerations, and because maximum growth faltering occurs between the ages of 6 and 12 months [5], BRAC decided to recruit children from among those under one year of age and maintain them in the programme until they were two.
Entry into a village
As a first step, villagers, particularly prominent individuals such as teachers and social leaders, were contacted and briefed and their cooperation was sought in implementing the activities. Afterward a household survey was carried out to identify children 0-12 months old. Parents were then contacted and motivated about the importance of monitoring in promoting child growth and survival.
Volunteers were selected and given on-the job orientation on how to assist in growth-monitoring sessions by bringing mothers with children, recording and plotting weights on growth charts (based on NCHS standards), demonstrating how to prepare a supplementary diet, and maintaining order in the sessions.
Growth-monitoring sessions
A convenient place, preferably a house in the centre of the village, was chosen with the help of villagers as the site for sessions. The space was arranged in such a way that registration, weighing/charting, and nutrition education could be carried out sequentially. Resources such as scales, cards, and registers were provided by BRAC, and villagers provided the space and furniture.
Health workers from BRAC conducted the sessions with active support from village volunteers, including TBAs. The mothers of the target children and volunteers were informed of the programme in advance. On weighing day, one BRAC worker prepared the centre with the help of volunteers while another worker and/or volunteer reminded the mothers to bring their babies for weighing and nutrition education.
When growth faltering was identified during the weighing and charting, the mother was advised to give the child more food. Children needing treatment for illnesses were referred to government health facilities.
The volunteers demonstrated how to prepare a supplementary diet with locally available ingredients such as dark-green leafy vegetables, rice, lentils, and oil. The babies were fed as a part of the demonstration.
Health education covered supplementary diet, the diet of pregnant and lactating mothers, personal hygiene, vitamin A capsules, breast-feeding, colostrum feeding, immunization, and family planning.
Before the mothers left the centre, they were told about the next weighing date.
Follow-up
Children who were identified during a session as being severely malnourished (< 60% of median weight for age) were visited in the* homes by both health workers and medical officers of BRAC, who gave rehabilitative advice and, if necessary, referred them to nearby government health facilities. No feeding was provided.
Sustainability
Community participation played a significant role in the programme. In the early stages of introducing growth monitoring into a village, at least three BRAC workers were required to perform the entire gamut of activities. Gradually, volunteers such as village health committee members, TBAs, and mothers became involved in weighing, recording, and plotting weights, so that BRAC was able to reduce its staff involvement to 50% at the end of the programme. As noted, the villagers also contributed the space for holding sessions, as well as the demonstration food.
As a step towards sustainability, BRAC made a deliberate attempt to integrate growth monitoring with selected public-sector activities, namely the expanded programme of immunization (EPI) and the semi-mobile antenatal satellite clinics. Since the clinics were not made available in every village, however, this integration could not be carried out in all the villages. At the end of the programme, 10% of the villages had all three activities. In such villages, government workers carried out their own functions while BRAC workers and village volunteers conducted the growth monitoring.
In four years the programme expanded to 1,016 villages through 1,322 growth-monitoring centres. Approximately 20,000 children were weighed each month.