MHealth for community-based growth monitoring and promotion: Three case studies from South African settings

<i>Background</i>: Growth monitoring and promotion (GMP) activities serve as an important platform for the implementation of child survival interventions to reduce malnutrition, infectious diseases and death among children. In recent times, there has been a steady decline in GMP outcome indicators in the Lawra district. The appropriate practices of GMP help in improving knowledge, attitudes and practices of caregivers towards child nutrition and health. Therefore, this study seeks to assess knowledge, attitude and practices of growth monitoring and promotion and associated factors among caregivers. <i>Methods</i>: A descriptive cross-sectional study design was used to study 300 caregivers’. Multi-stage sampling technique was used to select the participants. A semi-structured questionnaire applying face to face interview approach was used to collect data from participants. Descriptive statistics and associations between dependent and independent variables were done using Pearson chi-square and logistic regression analysis. <i>Results</i>: The results indicated 53% of the caregivers’ with good (high) knowledge in Growth Monitoring and Promotion (GMP) activities, 98% with good (high) attitudes towards GMP activities and 70% with good (high) practices in GMP. Also, 16.2% of caregivers’ children had faltered in growth. Occupation was associated with knowledge (<i>p</i>=.013), and attitude (<i>p</i>=.014). Again, educational status (<i>p</i>=.026) was associated with knowledge in GMP, marital status (<i>p</i>=.009) and child relation with caregiver (<i>p</i>=.021) were associated with attitude in GMP. Also tribe (<i>p</i>=.019) and child relation with caregiver (<i>p</i>=.019) were significantly associated with practices in GMP. Conclusions: Notwithstanding the achievement in the coverage of GMP, implementation of Infant and Young Child Feeding (IYCF) program and Information, Education and Communication (IE&C) activities in district, the findings on GMP outcome (knowledge and practice) is not satisfactorily. District Health Directorate need to intensify and strengthen IYCF activities, home visits, health education, and growth monitoring and promotion services.

In Bangladesh, utilization of government health facility-based growth monitoring and promotion (GMP) services is notably low, prompting non-governmental organizations (NGOs) to collaborate with the government to enhance GMP service utilization through home-based delivery. Despite this, there is limited information available on home-based GMP service utilization. This study aimed to investigate the utilization of GMP services between home-based and facility-based programs and identifying key factors and barriers to caregiver engagement with GMP services in rural Bangladesh. A descriptive mixed-method study was conducted across six sub-districts from August to December 2019. Three sub-districts with home-based GMP services provided by NGOs were compared with three neighboring sub-districts offering government facility-based GMP services. A total of 3038 randomly selected mothers and children under one year old were included in the quantitative part of the study. Quantitative surveys include information on household socio-demographic information, GMP service components, knowledge, utilization, barriers, and qualitative approaches were used for data collection on caregivers and service providers perspectives on GMP services. Descriptive statistics were conducted for sociodemographic characteristics, caregivers' knowledge, perception and barriers to utilization of GMP services. Student's t-tests and chi-square tests were used to compare quantitative and qualitative variables between both GMP arms. Risk ratios (RR) with 95% confidence intervals were calculated to compare GMP knowledge. Simple logistic regression identified GMP service use levels and related barriers. Multiple logistic regression was employed to determine statistically significant associations between GMP utilization and independent variables such as caregivers who heard about GMP or GMP cards, were members of an NGO, and lacked interest in GMP services at p-value <0.05 and adjusted risk ratio (ARR) values. Thematic analysis of qualitative data was performed. Results were triangulated across sources. Children's average age was 9.8 months, with a 1:1 male-to-female ratio in both groups (home-based vs. facility-based: 51.9% vs. 50.0%). Home-based GMP services exhibited higher utilization rates, with more children receiving weight and length measurements and caregivers receiving counseling than facility-based services (40% vs. 0% utilization, respectively). Caregivers' utilization of GMP services in home-based areas was positively influenced by their knowledge of GMP or GMP cards (Adjusted risk ratio, ARR: 37.4) and their involvement with an NGO, association, or health program (ARR: 1.3). Caregivers in home-based GMP areas relied on NGO staff for service delivery, while those in facility-based areas reported no outreach from government health workers and lacked access to GMP cards due to supply issues. Across both areas, low awareness of GMP services and the absence of incentives contributed to limited utilization. GMP service utilization remains low in rural Mymensingh district of Bangladesh. Home-based GMP service utilization was 40% but none of the caregivers utilized facility-based GMP services. Higher utilization in home-based areas was linked to caregiver awareness, access to GMP cards, and NGO involvement, while key barriers included lack of government outreach, supply gaps, and absence of incentives. To improve GMP coverage, government programs should enhance community level outreach, ensure consistent supply of growth cards, and consider integrating small incentives to motivate caregivers.

There are few growth monitoring and promotion indexes, and currently none of them include any metrics that measure caregiver behaviours. No index to date combines the metrics of both community health worker activeness and caregiver barriers and facilitators towards growth monitoring and promotion (GMP). This study developed a new growth monitoring and promotion index and validated it using the Delphi Technique. The study began with phase 1, which was a scoping review of the literature on GMP indexes. Phase 2 involved a community health worker (CHW) survey which explored the process of GMP within the Umguza health system, and determined how knowledge of GMP by CHWs translated to frequency of activities. A barrier analysis was also conducted with caregivers of children under five to determine the barriers and facilitators towards GMP attendance by caregivers. Phase 3 was the construction of the index along with its validation, using the Delphi Technique where fifteen experts within the health and nutrition sector were consulted to analyse the constructs/variables of the index. A growth monitoring and promotion index was developed and validated by several technical experts in the health and nutrition sector in Zimbabwe. A new index has been developed to improve the quality of growth monitoring and promotion activities within the communities.

IntroductionInadequate physical growth and poor development of children are prevalent and significant problems worldwide, with 149 million children younger than 5 years stunted and 49 million wasted. Growth monitoring and promotion (GMP) is one of the major activities implemented with the aim of capturing growth faltering before the child reaches the status of undernutrition. In relation to this, the Amhara region, where the study area is found, is a highly burdened area for child malnutrition. Thus, it needs further investigation about the utilization of GMP services and associated factors among children younger than 2 years in the study area.ObjectiveThe aim of this study was to assess the utilization of growth monitoring and promotion services and associated factors among children younger than 2 years.MethodsA community-based cross-sectional study was conducted in the West Armachiho district, including 703 mother–child pairs, with a response rate of 94.7%. A simple random sampling technique was used to select the respondents. Both bivariable and multivariable logistic regression analyzes were performed. An adjusted odds ratio (AOR) with a 95% confidence interval was used to measure the strength of the association.ResultsThe proportion of utilization of growth monitoring and promotion services in the West Armachiho district was 13.7% (95%Cl; 11.2, 16.4). Factors such as maternal educational status (AOR = 2.17, 95%Cl; 1.05, 4.49), institutional delivery (AOR = 3.16, 95%Cl; 1.62, 6.13), family size (AOR = 2.66, 95%Cl; 1.13, 6.23), access to health facility (AOR = 3.17, 95%Cl; 1.45, 6.95), and maternal knowledge (AOR = 4.53, 95%Cl; 2.71, 7.59) were significantly associated with the utilization of growth monitoring and promotion services.ConclusionUtilization of growth monitoring and promotion services in children younger than 2 years in the West Armachiho district was low. Thus, giving due attention to the improvement of the knowledge of the mothers/caregivers about child GMP services and counseling them about the importance of facility delivery is vital to improving growth monitoring and promotion services in the area.

Mainstreaming interventions in the health sector to address maternal and child undernutrition

BackgroundUndernutrition in the critical first 1000 days of life is the most common form of childhood malnutrition, and a significant problem in low‐ and middle‐income countries (LMICs). The effects of undernutrition in children aged under five years are wide‐ranging and include increased susceptibility to and severity of infections; impaired physical and cognitive development, which diminishes school and work performance later in life; and death. Growth monitoring and promotion (GMP) is a complex intervention that comprises regular measurement and charting of growth combined with promotion activities. Policymakers, particularly in international aid agencies, have differing and changeable interpretations and perceptions of the purpose of GMP. The effectiveness of GMP as an approach to preventing malnutrition remains a subject of debate, particularly regarding the added value of growth monitoring compared with promotion alone.ObjectivesTo evaluate the effectiveness of child growth monitoring and promotion for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children under five years of age in low‐ and middle‐income countries.Search methodsWe used standard, extensive Cochrane search methods. The latest search date was 3 November 2022.Selection criteriaWe included randomised controlled trials (RCTs), cohort studies, and controlled before‐after studies that compared GMP with standard care or nutrition education alone in non‐hospitalised children aged under five years.Data collection and analysisWe used standard Cochrane methods to conduct a narrative synthesis. Our primary outcomes were anthropometric indicators, infant and child feeding practices, and health service usage. Secondary outcomes were frequency and severity of childhood illnesses, and mortality. We used GRADE to assess the certainty of evidence for each primary outcome.Main resultsWe included six studies reported in eight publications. We grouped the findings according to intervention.Community‐based growth monitoring and promotion (without supplementary feeding) versus standard careWe are unsure if GMP compared to standard care improves infant and child feeding practices, as measured at 24 months by the proportion of infants who have fluids other than breast milk introduced early (49.7% versus 70.5%; 1 study; 4296 observations; very low‐certainty evidence). We are unsure if GMP improves health service usage, as measured at 24 months by the proportion of children who receive vitamin A (72.5% versus 62.9%; 1 study; 4296 observations; very low‐certainty evidence) and the proportion of children who receive deworming (29.2% versus 14.6%; 1 study; 4296 observations; very low‐certainty evidence). No studies reported selected anthropometric indicators (weight‐for‐age z‐score or height‐for‐age z‐score) at 12 or 24 months, infant and child feeding practices at 12 months, or health service usage at 12 months.Community‐based growth monitoring and promotion (with supplementary feeding) versus standard careTwo studies (with 569 participants) reported the mean weight‐for‐age z‐score at 12 months, providing very low‐certainty evidence: in one study, there was little or no difference between GMP and standard care (mean difference (MD) −0.07, 95% confidence interval (CI) −0.19 to 0.06); in the other study, mean weight‐for‐age z‐score worsened in both groups, but we were unable to calculate a relative effect. GMP versus standard care may make little to no difference to the mean height‐for‐age z‐score at 12 months (MD −0.15, 95% CI −0.34 to 0.04; 1 study, 337 participants; low‐certainty evidence). Two studies (with 564 participants) reported a range of outcome measures related to infant and child feeding practices at 12 months, showing little or no difference between the groups (very low‐certainty evidence). No studies reported health service usage at 12 or 24 months, feeding practices at 24 months, or selected anthropometric indicators at 24 months.Authors' conclusionsThere is limited uncertain evidence on the effectiveness of GMP for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children aged under five years in LMICs. Future studies should explore the reasons for the apparent limited impact of GMP on key child health indicators. Reporting of GMP interventions and important outcomes must be transparent and consistent.

Monitoring growth, as it is now practised in most health systems in developing countries, is widely misunderstood and largely ineffective (1-5). So, it is no surprise that the process itself has been controversial, leading some academicians and practitioners to urge its elimination from community-based programmes (6-9). And still, monitoring growth is universally found in paediatric offices and academic centres throughout the world, seen as an integral part of good paediatric practice. As introduced by Morley in clinics that treated children aged under five years in Nigeria in the 1960s (10), monthly monitoring of growth has provided the foundation of good promotive child healthcare in large projects in India (11), Bangladesh (12), and Honduras (13), and in thousands of village of Indonesia (14). How did growth monitoring and promotion (GMP), once seen as the essential foundation of the United Nations Children's Fund (UNICEF)-promoted GOBI strategy for young children (growth monitoring, oral rehydration, breastfeeding, and immunization) fall into such disrepute, while the other GOBI components have proven highly robust? Part of the answer indeed lies in the poor understanding of its purposes and procedures by medical officers and health and nutrition workers as reported by Roberfroid et al. in this issue of the Journal (15). First, as well-documented in that paper, the primary purpose of GMP is rarely understood even by its implementers and much less by participating mothers. The emphasis is on the measuring--the 'monitoring' rather than the 'promotion' of growth. The growth card, all too often, is seen as a diagnostic tool for use by the health worker to detect existing malnutrition rather than a communication aid to encourage early action by the mother before malnutrition supervenes. The card, designed to draw a mother's attention to the pattern of growth of her own child, is instead used by workers as an anthropometric standard for measuring nutritional status. Thus, from the start, the primary purpose of GMP is diverted. This leads automatically to the second major error: GMP activities focus on the wrong age-group--the already-malnourished older child becomes the object of the greatest attention rather than the infant and one-year old child where most unseen and significant growth faltering is encountered (16). The opportunity for early preventive intervention to reverse growth faltering is lost in exchange for late and often ineffective, difficult, and costly therapy for established under-nutrition. There has been, in fact, anecdotal evidence in some programmes of desperately poor mothers hoping for poor growth or 'bad nutrition' with the expectation of then receiving free food for their children and families. Growth 'promotion' should begin at or even before birth, helping mothers understand that the overall well-being of her child depends on her own behaviour, even during pregnancy: how she exerts herself or rests, her personal hygiene and healthcare, exposure to smoke and other toxins, and what she eats. Early and exclusive breastfeeding has been shown to be the single most effective intervention to improve child survival and nutrition, requiring support and promotion from the moment of delivery (17). Timely introduction of adequate complimentary foods is another critical intervention in mid-infancy. These opportunities to establish healthy growth too often are lost in the attention given to the older, more obviously failing child whose weight is "below the line." GMP was designed as a communication strategy to alert mothers and workers to early signs of inadequate attention to childcare, to underlying illness or social pathology. Faltering growth, once visualized through the 'monitoring' and charting, would lead, as early GMP advocates expected, to a careful investigation of the childrearing practices and home environment, with practical actions identified to resume growth, and to appropriate positive reinforcement of those measures when successful, as seen with improved growth the following month. …

Community-based growth monitoring (GM) and growth monitoring and promotion (GMP) have been implemented worldwide. The literature provides controversial messages regarding their effectiveness. Numerous countries have GM as their main community-based activity and need guidance for future programming. The notion of GM is usually clear, but the follow-up actions include a range of activities and interventions, all under the heading of "promotion." We suggested definitions, objectives, and outcomes of the GM and GMP. By providing some clarity on these conceptual issues we attempted to provide a basis for consensus building and development of recommendations on when this activity should be promoted or discouraged. We reviewed basic concepts and global experience of GM and GMP using publications about GM and GMP, UNICEF country reports and other publications, field observations, and reports of recent expert consultations. Realistic added benefits are suggested as compared with general counseling that could also be delivered outside the GM session. We provide a narrow definition of "promotion" in GMP, in which actions are tailored to the results of monitoring, as well as suggest quality implementation criteria. GM, even if complemented by a promotional package, can have only a limited impact if it is not part of a comprehensive program. GMP cannot be viewed as a competitor to highly effective interventions, but may serve as a possible platform for their delivery. The decision to build community-based programs on a GMP platform should be based on consideration of benefits, feasibility of quality implementation, and capacity of human resources.

BackgroundMore than half of all deaths in under 5 children is related to malnutrition. Child malnutrition could be prevented through regular monitoring of the growth and development of children and the implementation of growth promotion activities referred to as growth monitoring and promotion (GMP). Mothers’/caregivers utilization of these activities through child welfare clinics could improve the growth and development of under 5 children. We evaluated mothers’ knowledge on GMP, utilization and associated factors among mother-child pairs from a poor socio-economic district in Northern Ghana.MethodsUsing an analytical cross-sectional design, participants included mothers with children aged 0–59 months, grouped into 0–11 months, 12–23 months and 24–59 months. A semi-structured questionnaire containing both closed- and open-ended questions was used to collect data. Multivariate logistic regression was used to identify determinants of GMP utilization.ResultsFour hundred mother-child pairs were included in the study. Overall, 28.5% (n = 114) of the mothers utilized GMP services. Almost 60%(n = 237) of the mothers knew the recommended age to seek for GMP service for their children. Only 9% of the mothers could correctly interpret the directions of the growth curves in their children’s Health Record booklet. Mothers with children aged 0–11 months were 3.9 times more likely (p = 0.009) to utilize GMP services compared to their counterparts with children aged 12–23 months and 24–59 months. Mothers who had low level of knowledge were 2.19 times (p = 0.003) more likely to utilize GMP services compared to their counterparts with high level of knowledge..ConclusionUtilization of GMP services was low and particularly lower in children aged 24–59 months. Mothers’ knowledge in GMP was optimal although there were notable gaps.

Community‐based growth promotion (CBGP) delivered by community volunteers aims at enhancing the traditional growth monitoring and promotion (GMP) program delivered by community health nurses through the promotion of optimum infant and young child feeding (IYCF) leading to improved child growth. This study compared IYCF knowledge and practices among caregiver–child pairs (0–24 months) receiving child welfare services from CBGP (n = 124) and GMP (n = 108) programs. Semistructured questionnaires were used to interview caregivers on IYCF knowledge/practices and validated food frequency questionnaire used to record infants’ food intakes. Group differences were determined using Chi‐square and independent samples t‐tests (P < 0.05; 95% confidence interval [CI]). Mean IYCF knowledge scores were similar (CBGP: 10.84 ± 1.69 vs. GMP: 10.23 ± 1.38, P = 0.062). However, more CBGP caregivers (17%) were highly knowledgeable than their GMP counterparts (5%) (P = 0.011). Early breastfeeding initiation (CBGP: 54% vs. GMP: 28%, P < 0.0001), exclusive breastfeeding (CBGP: 73% vs. GMP: 56%, P = 0.001), and timely complementary feeding (CBGP: 72% vs. GMP: 49%, P = 0.014) were reportedly higher among CBGP caregivers. Underweight was 11% (CBGP: 8% vs. GMP: 14%, P = 0.154). Mean dietary diversity scores (10 food groups) were similar (CBGP: 4.49 ± 1.89 vs. GMP: 3.87 ± 1.89, P = 0.057) but more CBGP caregivers (77%) achieved minimum dietary diversity than their GMP counterparts (61%) (P = 0.035). Few caregivers achieved minimum meal frequency (CBGP: 31% vs. GMP: 29%, P = 0.486) and minimum acceptable diet (CBGP: 23% vs. GMP: 21%, P = 0.464) indicators. Number of children under 5 years owned by caregiver (adjusted odds ratio [AOR]: 0.405; 95% CI: 1.13–78.53, P = 0.038), her educational level (AOR: 0.112; 95% CI: 0.02–0.90, P = 0.040), and IYCF knowledge (AOR: 0.140; 95% CI: 0.03–0.79, P = 0.026) significantly predicted optimum child feeding. Nutrition education on optimum complementary feeding and birth spacing strategies should intensify.

Can Growth Monitoring and Promotion Accurately Diagnose or Screen for Inadequate Growth of Individual Children? A Critical Review of the Epidemiologic Foundations

Growth monitoring and promotion (GMP) is critical in tracking child growth to address widespread malnutrition and health status. Attitudes influence behaviour change, including attendance of GMP, and negative attitudes are linked to non-attendance. Moreover, negative attitudes correlate with low socioeconomic position. South Africa is characterized by inequality, which may lead to negative attitudes towards GMP among caregivers with a poor socioeconomic status. Hence, this study seeks to explore the attitudes of caregivers of children under five towards GMP. A qualitative exploratory study design was used. Caregivers of children under five were purposively sampled. Twenty-three participants were interviewed one-on-one, and the data were recorded using voice recorders and field notes. Tesch’s eight steps and inductive, descriptive, and open coding techniques were used to analyse the data. Participants understood the significance of GMP and were confident their children would benefit from it; hence, they attended sessions out of love for their children. The inconsistent availability of GMP services and the behaviour of health workers affected participants’ attitude. Despite these challenges, participants felt good about GMP. Caregivers’ love for their children/grandchildren helped them overcome challenges experienced at the health facilities. Good feelings about GMP boosted caregivers’ attitudes and aided in adherence. An intervention to address element impacting attitudes of caregivers is recommended.

BackgroundGlobally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs.MethodsWe conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation.ResultsHealth workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use.ConclusionThis study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).

Growth monitoring and promotion (GMP) is both a service for diagnosing inadequate child growth in its earliest stages and a delivery platform for nutrition counselling. The widespread use of GMP services in developing countries has the potential to substantially reduce persistent child undernutrition through early diagnosis and by linking caregivers and their children to key health and nutrition services. However, researchers have questioned the effectiveness of GMP services, which are frequently undermined by underdeveloped health systems and inconsistent implementation. This analysis examined both supply‐ and demand‐side factors for GMP utility in Nepal from the perspectives of beneficiaries and service providers, particularly focusing on three components of GMP: growth assessment, analysis of growth status and counselling. The most common factors influencing GMP uptake included beneficiaries' perceptions of the relative importance of GMP and the knowledge and skill of frontline workers. Both providers and beneficiaries viewed GMP as a secondary health and nutrition activity and therefore less important than curative services. We found deficits in GMP‐related knowledge and skills among providers (i.e. health workers and female community health volunteers), as well as indications of poor training quality and coverage. Furthermore, we found variation in GMP utilization by maternal age, education and residency (alone, nuclear or extended), as well as household socio‐economic well‐being and rurality. This study is the first to assess factors influencing both beneficiaries and service providers for GMP utilization. Further research is needed to explore the implementation of improved GMP protocols and to evaluate facility‐level implementation barriers.

BackgroundOne of the strategies to promote child health and reduce child mortality is growth monitoring and promotion services. But, there is limited information on determinants of Growth Monitoring and Promotion service utilization.ObjectiveTo identify determinants of growth monitoring and promotion (GMP) service utilization among children 0–23 months of age in Legambo district, South Wollo zone, Northern Ethiopia, 2020.MethodsCommunity based un-matched case-control study was conducted on 363 (91 cases and 272 controls) study participants from March 15 to April 15, 2020. A multi-stage sampling technique was employed to select the study participants. Bivariable and multivariable logistic regressions were performed and an adjusted odds ratio with 95% confidence intervals was estimated to identify determinants of GMP service utilization.ResultsA total of 358 mothers (89 cases and 269 controls) with 98.6% response rate were included in the study. The mean (±SD) age of child was 11.66(±6.29) months among controls and 15.02 (±6.06) months among cases. Good maternal knowledge (AOR) = 2.42; 95% CI: 1.23, 4.75), favorable attitude (AOR = 2.45; 95% CI; 1.20, 4.98), counseling on GMP (AOR = 2.34; 95% CI; 1.19, 4.56), attending ante natal care services (AOR = 2.46; 95% CI: 1.18, 5.16), index child age 12–17 months (AOR = 3.45; 95% CI: 1.26, 9.41) and 18–23 months (AOR = 4.38; 95% CI: 1.53, 12.49), and short distance to health facilities (AOR = 4.53; 95% CI; 1.99, 10.28) were determinants of GMP service utilization.ConclusionIndex child age, good knowledge, favorable attitude, attending antenatal care services, receiving nutritional counseling, and a short distance to health facility were determinants of GMP service utilization. Nutritional interventions should emphasize nutritional counseling and accessibility of growth monitoring and promotion services.