Maternal Comprehension Of Home-Based Growth Charts And Its Effect On Growth

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Maternal Comprehension Of Home-Based Growth Charts And Its Effect On Growth



  • Background Information


In developing countries, knowledge of growth monitoring among mothers/caregivers is generally poor and the extent of practice and attitude to its use among them varies from one community to another.1 Early possession, regular use, interpretation of the chart (also known as ―road-to-health‖), and quick communication with health workers to take prompt action is a major barrier to attaining child nutrition and child under-nutrition remains a major public health concern. Malnutrition, especially under-nutrition continues to be a serious problem and a major threat to the achievement of the Millennium Development Goal (MDG) and it is estimated that 60% of under-five deaths in developing countries are attributable to it.2 Worldwide, 5 million children die every year, that is to say one child in every 6 seconds.5Malnutrition accounts for over 50% of death in children in Nigeria7.

To address these major health problems caused by malnutrition, monitoring of growth using growth chart becomes of great importance among health workers in general and mothers/caregivers in particular.

There are three types of malnutrition which are under-nutrition, over-nutrition, and nutrient deficiency.8 Over nutrition occurs when nutrients are oversupplied relative to the amounts required for normal growth, development, and metabolism. The term can refer to obesity, brought on by general overeating of foods high in caloric content, as well as the oversupply of a specific nutrient or categories of nutrients, such as mineral or vitamin poisoning, due to excessive intake of dietary supplements or foods high in nutrients (such as liver), or nutritional imbalances caused by various fad diets.34

Micronutrient deficiencies are when a child is lacking essential vitamins or minerals such as Vitamin A, iron, and zinc. Micronutrient deficiencies in children are associated with 10% of all children’s deaths.35 Under-nutrition is not getting enough protein, calories, vitamins and minerals which the body needs to function. This results in stunting, underweight and wasting. Stunting refers to low height-for-age (also  known  as chronic malnutrition), under-weight is measured by low weight-for-age and refers to a child whose weight is too low for its age and wasting is described as low weight-for- height which can be acute, moderate or severe. Under nutrition could also be due to specific nutrient deficiencies.9 The different types are Marasmus, Kwashiorkor, Marasmic-kwashiokor and Micronutrient malnutrition. Marasmus occurs when children do not get enough energy-giving food and this either result in stunting, under- weight or wasting. In Kwashiorkor, the child does not get enough variety of the right kind of food, for example if they eat only cereal-based meals, it results in stunting, under- weight, wasting and oedema. Marasmic-kwashiokor is a combination of Marasmus and kwashiorkor symptoms. Finally, in micronutrient malnutrition, the child lacks micronutrients such as vitamins A, B and C, folate, zinc, calcium, iodine and iron.7


It is estimated that about 16% of the world children are moderately under-weight, 9% severely under-weight, 10% are suffering from wasting and 27% from stunting. The worst cases are recorded in sub-Saharan region as shown in Figure 1 where 20%, 9% and 39% of under-fives are suffering from under-weight, wasting and stunting respectively. Between 2006 and 2010 alone, it was estimated that one child in every three under-five children in West and Central Africa was likely to be stunted at 5 years of age.8


In Nigeria, child mortality and malnutrition rates are far higher in the North East and North West geopolitical zones than in other parts of the country as compared and shown in Figure 2.18 Even though child mortality rate has declined slightly over the past five years, there are still about 16% of children in Nigeria who will die before they are five

(5)  years  old and above 25%  of these deaths share direct  link  with  malnutrition even

though most of the deaths will be from highly preventable causes such as malaria, respiratory infections, diarrhoea, and measles.2

Figure 2: Under-five Children Underweight by Geopolitical Zones

Source: The Nigerian Academy of Science, 2009



  Strategy for overcoming malnutrition

 Different communities have different strategies for addressing malnutrition and any prevention strategy may differ from one individual to another.2 Also, no one single strategy can stand alone and inter-sectorial collaboration is often required.10The key for effective malnutrition prevention is integrating health care, household food security and care as proposed by the model of Conceptual Framework of malnutrition by UNICEF.


A number of components of malnutrition primary prevention programs have been developed and tested over past decades throughout the world in a variety of political and Social settings. Firstly, promotion of early contact between mother and infant to improve chance for successful breast feeding is important. It is good to establish hospital and other health routines that support breast feeding while in the maternity ward and later, successful early bonding and documented breast feeding is vital as well as supporting breast feeding by health team and by legal framework that promotes, protects, and sustains the right of working women to practice it.11


Secondly, monitoring of growth and development with adequate standards (present standards are being revised based on present recommended feeding modes) is proven to be effective and intervention is instituted only when appropriate to prevent malnutrition and specific micronutrient deficits.11 Mothers should be familiar with  growth monitoring charts and be ready to take appropriate actions when growth faltering occurs.16 The degree of actions taken by the community will depend on the strength of the primary health care.1


Thirdly, it is important to introduce appropriate micronutrient rich complementary foods and supplements at 6 months of age.9 If complementary foods are needed earlier, consideration of the risks associated with interference of breast feeding should be made. Ideally these should be based on local foods that are accessible to the population.2 Micronutrient will be required in most cases and new developments include fortification at the household level either with tablets, sauces or sprinkles.13


Next is the identification of infants at risk for malnutrition and growth failure based on biological and social risk factors is a further strategy by providing adequate social and medical support for families with children at risk.11 Early identification should be based on community surveillance not only of growth but of caring practices and of critical food insecurity. Early interventions at this level are significantly more cost effective.17 This area is presently receiving insufficient attention despite being at the core of the problem.



A fifth strategy involves education of parents and adolescent girls (would be mothers) on how to promote growth and development through appropriate home environment, care, and stimulation.18 Verbal and cognitive stimulation for malnourished children results in higher growth rates than for children without such stimulation.21 Interactions with parents, caregivers, and other children are essential for the young child and these interactions can be improved by education of parents and other caregivers. Care initiatives should go beyond focusing on individual practices and behaviors to bring in dimensions of care for the family and the community.21


Finally, provision of universal coverage of children to basic health care services, full coverage for all children with immunizations to prevent infectious disease, and avoid their adverse effects on nutritional status and provide early diagnosis and treatment of diarrheal disease at the community level using oral rehydration is paramount.13 Linking this effort to the community based surveillance for effective prevention and control of mild and moderate Protein Energy Malnutrition (PEM) will compliment all other efforts.

Depending on what is available in the country the approach may not require expensive infrastructure but rather be community based and sustained. Treating hundreds or thousands of affected children will not solve the problem of malnutrition as a global public health problem.13 Unless society at large confronts this issue in its full dimension the problem will continue. Access to adequate amount and quality of food represent a basic human right and is a necessary precondition for health. In turn good nutrition and health are prerequisites for human, social, and economic development. Physicians and especially pediatricians should not be passive bystanders but rather be activists in this process.

Another good way to begin intervention strategies is to look up the UNICEF framework of the basic, underlying and immediate causes of malnutrition and seek to proffer solutions to these problems, so that the strategies can then focus on individuals, households, communities and the nation in general. Countries can save children‘s lives through these interventions by establishing adequate referral arrangements for children with complication and ensuring funding to provide free treatment and to integrate the management of severe acute malnutrition with other health activities such as the integrated Management of Childhood Illness.26

  Statement of the problem


Malnutrition accounts for over 50% of death in children in Nigeria.7Malnutrition leaves children more vulnerable to serious illness and early death.5 Globally, in 2011, an estimated 165 million children below 5 years of age were stunted and 101 million were underweight.6 Under-five deaths are increasingly concentrated in sub-Saharan Africa

and Southern Asia.7As high as 80% of the world‘s under-five deaths in 2011 occurred in only 25 countries, and about half in only five countries – including Nigeria.5According to (State of world children) SOWC 2012, 41% of under-five children in Nigeria are stunted and 23% are under-weight.14 Malnutrition, especially under-nutrition may continue to be a serious problem and a major threat to the achievement of the Millennium Development Goal (MDG) if early and regular monitoring of growth using growth  chart  (also  known  as  ―road-to-health‖),  is  not  taken  as  a  thing  of  great importance among health workers in general and mothers/caregivers in particular. Without any intervention, severe acute malnutrition has up to 60% mortality risk and children with severe acute malnutrition are nine times likely to die from any causes than those who are not.7 One such intervention, which has proven to help improve the chances of survival of such children, is the growth monitoring program.18,19 The program presents a preventive approach to addressing malnutrition problems as it gives early warning sign; and the chart can serve as veritable diagnosing tool even in the hands of the mothers.



Role of mothers in growth monitoring


It is known that of all the major interventions stressed in the Child Survival Program, growth monitoring requires the highest level of participation and instruction. It will, and often does, function the most poorly of the four growth monitoring, oral rehydration, breastfeeding and immunization (GOBI) components.16 To buttress this, the success of,without the active involvement of mothers, health workers and the community, growth monitoring child survival projects and programs depend not only on



technical interventions themselves but on their being accepted and used by the millions of mothers and other child caretakers who determine in developing countries whether a child lives or dies.24


The involvement of mothers and families in the weighing of children is part of a movement to increase the involvement of families and communities in health-related measurement.12,The dietary changes and subsequent nutritional improvement evolving from her participation in the growth monitoring program are processes she must understand and take responsibility for. Mothers‘ participation in growth monitoring helps them make informed decision which leads to fundamental change in family nutrition knowledge or practice.19


Involvement of mothers in growth monitoring improves their level of nutritional knowledge and makes them more involved due to the monthly increase in the weight of the child as recorded on the chart make meaning to them.20 Also, they appreciate the need for a line that shows a continuing upwards trend and may also assist in teaching adult numeracy, which in many situations may be as important as adult literacy.20 Furthermore, mothers‘ role is also shown in their early intervention when faltering in weight gain, as shown by a flattening of the growth curve, when educated on what to do and this may lead to improved children’s health.21When curative functions are separated, the mother will more likely understand that she is the principal actor in growth monitoring with respect to her child.24



The knowledge, understanding, practice, utilization and interpretation of growth monitoring /growth monitoring chart among mothers/caregivers in developing countries is generally poor. The extent of practice and attitude to its use among them varies from one community to another.1 Nigerian mothers are not sensitized or mobilised to have adequate knowledge and awareness of the growth monitoring chart. Subsequently their level of knowledge, utilization especially as it involves charting the growth and interpretation of the plotted measurements on the charts of their children is questionable.1


They are therefore not able to detect any weight faltering or have an idea when nutrition intervention is needed. Nevertheless growth monitoring introduced in Nigerian health system has been helpful as it is now a standard package of care at Primary health care level. In some communities UNICEF has introduced community growth monitoring programmes. The poor educational level(below primary school), age at which mothers start having children( e. g below 18 years) and low level of income are factors that negatively influence the appropriate utilization and interpretation of growth monitoring chart. The knowledge of growth monitoring chart involves the awareness of its existence, frequency of weighing, the purpose of growth monitoring chart, knowledge of vital information on the growth monitoring chart.



Of importance also is knowledge of correct taking of a child‘s weight/height and plotting of the same by the mothers. The practice of utilising the growth chart involves appropriate frequency of weighing according to the child‘s age (0 to 1yr once a month, 1 to 2yrs once in 2months, & 2 to 5yrs once in 6months), attendance at the clinic for



growth monitoring alone. Correct interpretation of the growth curves (i. e joining together the sequential plotted weights). In spite of growth monitoring as package of care at Primary health care level, knowledge remains poor.



Mothers/caregivers do not actively participate in growth monitoring practices. The most probable cause for this may be their inadequate level of understanding of the benefits of growth monitoring using the growth chart and the attendant threat of malnutrition otherwise. To effectively curtail high mortality associated with malnutrition in under- fives, mothers/caregivers should be involved in early and regular monitoring of their children‘s growth using the growth monitoring chart to know the growth trend and detect any faltering that may occur for immediate intervention. To achieve this, mothers/caregivers should have good knowledge on the proper utilization of the growth chart for growth monitoring.



  Aims and Objectives of the Research


General Objective


The aim of the study is to assess mothers‘ knowledge and understanding of the growth monitoring chart in Gwamna Awan General Hospital Kakuri, Kaduna.

Specific objectives are:


  • To assess the level of knowledge of mothers of under – fives attending the clinic on growth monitoring chart.
  • To assess the attitude of mothers of under – fives towards the growth monitoring chart.
  • To determine the practice of growth



  • To assess mothers correct interpretation of growth


  • To identify factors that influence mothers‘ knowledge of growth




  Rationale /Justification


This study has been done to ascertain whether mothers understand growth chart data and its use in charting, plotting and interpreting the growth curve. It was also to assess their attitudes towards the use of growth monitoring chart as a tool to prevent malnourishment in their children. This research highlighted the percentage of mothers/caregivers who had the awareness, knowledge, attitude to, practice and interpretation of growth monitoring chart in the study area. It also identified the socioeconomic factors that influenced their knowledge of growth monitoring chart.



The result from this study can facilitate the development of more effective strategies for creating awareness, demand for the use of growth monitoring charts, educating and counselling mothers about their children‘s growth.



This research is significant because it highlighted the need for mothers to evaluate the effects of routine growth monitoring on the child in relation to illness, malnutrition; to prevent death and late referrals for medical care, nutritionist attention, medical specialist assessment or professional social support follow-up. It points out the importance of mothers/caregivers‘ awareness on the essence of good nutrition to their children‘s health and wellbeing.16

It also highlights the need to raise the knowledge of the mothers on evaluating the effectiveness of growth monitoring as well as the need for all health workers in care of children to know how to correctly weigh, plot, interpret the plotted growth monitoring chart and communicate same to mothers. Finally, it would ignite the interest for the replication of same study in other Primary Health Care Centres, across Nigeria and Africa.1,2

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