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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
That growth monitoring can be an important tool in promoting child survival is beyond doubt, but its effectiveness in all developing countries has yet to be proved [1]. A reason for this controversy is the confusion between monitoring and nutrition surveillance [7]. Growth monitoring involves much more than just surveillance, such as nutrition education and community participation [9]. The BRAC programme in Bangladesh included these activities and thus provided an opportunity to examine growth monitoring in the light of several questions that surround it. Is it difficult to implement? Does it really facilitate better use of other child-survival interventions and community participation? Does it improve children's nutrition? We attempted to throw some light on these Issues.
With respect to the operational aspects of the programme, the experience was mixed. Some of the activities, such as age determination, mothers' interpretation of growth cards, and reading and recording of weights, were done reasonably well. The ability of the Bangladeshi mothers to understand the meaning of the growth charts was remarkably good compared with what has been observed elsewhere, as in Zaire [10]. Two major factors may have contributed to this result. First, the health workers explained to the mothers how to interpret the charts on the basis of the weights of their own children. Second, the mothers kept the cards, which gave them a chance to consult them at home. The health workers kept their own registers to follow severely malnourished children in their homes.
Not all of the results were encouraging, however. The coverage of target children was less than 50%. A large proportion of the weighing scales of a particular make were faulty, and this had escaped the notice of the programme managers.
The low coverage was a major failure. Our discussion with programme staff revealed a number of reasons for it. The principal effort to recruit children for monitoring was during their first six months of life. Many of the babies were born in their maternal grandparents' house and did not return to their own home before six months, and they tended to be missed. Since BRAC did not provide any other food or health service, weighing was not enough motivation for many mothers to bring their children. Superstitions and (in some areas) bad internal communication were other reasons. Incomplete registration of birth was yet another reason. This was BRAC's (and the villagers') first experience with growth monitoring. Low coverage is not uncommon in other settings, however. In one large programme in India, coverage was 28% and 49% for children 0-6 and 7-12 months old respectively [11]. Although the coverage was low, there was no sex bias in recruitment; both boys and girls participated equally. Also there was no socioeconomic difference between participants and non-participants, implying that children from all strata had equal access to the programme.
The participation of the community was commendable, given that this was their first exposure to growth monitoring and despite cultural taboos against weighing babies. Clearly, it was facilitated by the presence of BRAC. A pertinent question is what will happen when BRAC withdraws. For such a programme, complete withdrawal is not feasible; some staff must be left behind to support it. It was hoped that the village health committee would take over the programme after BRAC's withdrawal. Initial evaluations do not suggest that this will happen in the foreseeable future, however. If the programme is to continue, BRAC must maintain some presence in the villages.
Our data tend to support the suggestion that growth monitoring leads to better use of other child-survival interventions. Households whose children participated did better in most of the interventions that were investigated. It is not clear from the analysis, however, whether they represent a self-selected group who embrace all interventions, whether immunization or growth monitoring.
The data we analysed did not show any measurable impact of growth monitoring statistically. However, with a p value of .051, the nutritional impact cannot be rejected outright. It should be remembered that only a few of the factors that cause malnutrition in Bangladesh were addressed through the monitoring. For a sustained impact, other causes such as poverty must be addressed.
Another aspect for which growth monitoring has been criticized is its cost. Unfortunately, we have not been able to examine this because of our inability to apportion costs for this component separately from those of the overall programme. Our impressions, however, suggest that the costs were quite high at the beginning of the programme, particularly with respect to staff involvement. Depending on how much community participation is obtained, they can be reduced over time.
One positive aspect of the programme was the partial success in having several activities undertaken under one umbrella (health post, as BRAC calls it). In several villages, growth monitoring was integrated with immunization and antenatal clinics, which helped the mothers to participate and encouraged health workers from BRAC and the government to interact with each other. This occurred in only 10% of the villages, however; in the others, the BRAC workers were not as successful. Growth monitoring is also a designated activity for government family welfare clinics, but it is infrequently done [12]. In other places where it has been more successful, such as in Tamil Nadu in India [13], it is part of an institutional activity involving several sectors such as agriculture, local government, and health and welfare.
This evaluation has been of value to BRAC. After careful review, it included growth monitoring in its new Women's Health and Development Programme but with several modifications suggested by the results of this study. To increase coverage, registration of births (and deaths) and of migration has been institutionalized and will be done quarterly in the programme areas (population, 2 million). The cylinder scales, which were found to be defective, have all been replaced by round scales. A standard weight is being provided to each programme area for daily appraisal of the accuracy of the scales. Assistance to severely malnourished children in terms of food supplementation is also being considered.
The new programme is also different in that BRAC will never completely withdraw. After the three-year women's health and development phase, the institutional development and credit components of BRAC programmes [14] will be introduced. Through this village-level effort, the poorer households will be identified and components such as children's education [15] and credit [14] will be introduced that will facilitate addressing other causes of malnutrition in a systematic and sustained manner.
The authors acknowledge with gratitude the following individuals for their assistance in various stages of the study: Abbas Bhuiya, International Centre for Diarrhoeal Disease Research, Bangladesh; Lincoln Chen, Harvard University; Rezaul Karim, BRAC; Lyne Pacquet, formerly of Helen Keller International; Jon Rohde, UNICEF, New Delhi; and Nancy M. Gerein, Canadian International Development Agency, Ottawa.