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Growth Monitoring: IntermediateTechnology or Expensive Luxury?

CHILD-health workers around the world have littleexcuse for not having heard of GOBI, the acronym de-vised by UNICEF to describe the means for effectingthe "child survival revolution". UNICEF has been

publicising extensively the four components of

GOBI-growth monitoring, oral rehydration, breastfeeding, and immunisation. Scientific evaluation hasbeen less well applied to the first of the four than to theothers. Morley,’ who pioneered the use of growthcharts in West Africa in the 1960s, has given five rea-sons to support their adoption as an integral compo-nent of primary health care: (1) early detection of mal-nutrition; (2) advice on the timing of supplementaryfeeding; (3) selection of children at high risk of

malnutrition; (4) health education and involvement ofthe mother in the child’s comprehensive care

(including immunisation and child spacing); and (5)epidemiological studies on undernutrition. Morley hasalso commended on the different modes of use ofgrowth charts in developed and developing countries.In the former they are used (by paediatricians) mainlyin the follow-up of children with abnormal growth,while in the latter they are used (by all grades of healthworker) to promote growth and prevent malnutritionin a population of children. As a result of the extensivemarketing of growth monitoring by UNICEF andothers, "road to health" charts are being adopted foruse in primary health care by more and more countriesaround the world: the image of the child being weighedunder a tree at a rural clinic is almost synonymous withgood primary health care.

1. UNICEF. State of the world’s children 1984. Oxford: Oxford University Press, 1983.2. Morley D. Growth charts-curative or preventive? Arch Dis Child 1977; 52: 395-98.3 Gopalan C, Chatterjee M Use of growth charts for promoting child nutrition. A

review of global experience. Nutrition Foundation of India (B-37 Gulmorhar Park,New Delhi), 1985.

Reviewing the global experience of growth monitor-ing in promoting child nutrition Gopalan and

,Chatterjee3 now cast grave doubts on these highhopes. Their report suggests that the aims referred toabove are far from being met; that health workers arenot using charts properly (and that the expectation thatthey will may be unrealistic); and that the measurementof mid-arm circumference should replace weighing inthe monitoring of growth at primary level. The reporttakes as its main evidence experience from the Inte-grated Child Development Services (ICDS) schemein India, with some additional information fromIndonesia and the Philippines. Very little documentaryevidence was available from Africa or South America,which rather biases the review (according to a WHOsource quoted in the report, "African experience isnegligible").Many practical difficulties in measuring and chart-

ing children’s weights and interpreting the data areilluminated in the report. Weighing-scales are seldomstandardised, are frequently unsuitable, and are rarelymanufactured within the country. There is a highpercentage of errors in charting weights-up to

80%-even when it is done by undergraduates.Insufficient space is provided on the charts for the largewriting of semi-literates. Mothers’ participation in theprocess was difficult to achieve-particularly with poormothers who are especially in need of help. The timeallocated for each child at clinics was too short (2-5min) to allow for health education. Only 20% ofchildren in the ICDS areas were weighed every month,though a persistent well-motivated worker could in-crease attendance. The cost of the exercise may be

remarkably high:$21 million might be the initial

expenditure on scales alone for the whole of India.However, it is with regard to the use of the data at pri-mary care level that the report is most worrying. Pri-mary level workers were generally concerned only withthe degree of the child’s malnutrition rather than withthe shape of the growth curve. Often single dots on thechart were not joined up, and a low rate of gain (a vitalpointer to the need for intervention) was not consideredvery important. When an underweight child was de-tected, follow-up action consisted mainly in the provi-sion of a food supplement. There was a lack of

emphasis on infection or other illness as the cause ofgrowth faltering, and in general the system of referral- was inadequate. The section of the card on reasons forspecial care was "invariably left blank". However, adescription of three small-scale projects at Ludhiana,Jamkhed, and Vellore showed that, when weighing isseen not as an end in itself but as an entry point into thefamily, nutrition education will be more effective andthe prevalence of malnutrition may be reduced.On the vital question of mothers’ participation the

report is also gloomy. According to the workers inter-viewed, "mothers were not interested in the weighingof their children... because they could not relateweight to their children’s health". In two areas it wasreported that mothers frequently lost home-based

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cards. In the Indonesian study, workers did not knowthe specific messages to be given to mothers whose chil-dren were not gaining weight. Jamkhed workersbelieved that the child health card made a much smallercontribution to improved health practices than didother health education measures. On the training ofworkers to use growth charts (and this seems to be themajor deficiency) Gopalan and Chatterjee stress thatfour stages are essential-first the weighing and read-ing of scales, second the recording of weight after ageverification, third the interpretation, and finally thefollow-up action that is seen to be necessary. Theyjudge the last to be the most important but at presentthe weakest.

In summary, the report suggests that workers do not

appreciate that the weighing itself makes no differenceto the child: that the chart is simply a tool which willfacilitate action. The success stories that have been

reported come from small-scale operations with a dedi-cated leadership. In large-scale programmes, resultsare poor and are not commensurate with the costs of

implementation. Gopalan and Chatterjee question theconcept that the severity of malnutrition should bemeasured before intervention is offered, in commu-nities where most children are malnourished. Theyargue (and this is a different matter from the principleof growth monitoring) that such surveillance shouldnot be used simply to identify the beneficiaries for asupplementary feeding programme. Such programmesshould instead be targeted at the most deprived commu-nities. They rightly comment that if growth monitoringis to be used to prevent malnutrition, it must first detectearly growth faltering, and then provide appropriateremedies.The strategy recommended in the report as an

alternative to weighing all children at primary carelevel is a two-pronged one. At home or in the village, itsuggests all children be screened by measurement ofmid-arm circumference (growth charts would still beused). The Echeverri strip, after validation, could beadopted for the infant period when the usual strip is notsuitable. The children so identified as requiring fur-ther care would be referred to second-order clinics for

weighing and charting.The report, weighted though it is towards the Indian

subcontinent, should be examined carefully by all pri-mary health care programme planners. The main prob-lem area identified is in the training and supervision ofthe field workers, and Gopalan and Chatterjee admitthat this was at fault in the ICDS schemes. Selection,training, and supervision of health workers is founddifficult in primary health care as a whole, and not justin growth monitoring. Werner4 has argued for small"community-supportive" rural health schemes ratherthan large national ones which tend to be "community-oppressive". In the small schemes that have been

reported, mothers have shown themselves able to,

4. Werner D. Health care and human dignity-a subjective look at community-based ruralhealth programmes in Latin America. Contact (Christian Medical Commission),August, 1980, pp 2-16.

understand and keep the chart. UNICEF in its 1985report cites a Ghanaian study’ indicating that 66% ofnear-illiterate mothers could interpret charts correctlyand an Indonesian study’ in which 67% of mothersunderstood about child health and growth and the needto weigh children monthly. In a Philippines healthcentre, 8 -only 1% of over 2000 regularly attendingmothers forgot to bring their charts-a success

attributed to the education campaign run in the clinic.The superiority of mid-arm circumference for

monitoring of growth must also be open to doubt.Gopalan and Chatterjee note two objectives of growthmonitoring-the detection of early growth faltering,and the provision of direction and support for healthworkers. The advantage of mid-arm circumferenceover weighing for attaining these objectives is not clear.By its nature mid-arm circumference is a screeningtechnique (and a valuable one) which cannot showgrowth faltering. It will detect malnutrition but not

prevent it. The second objective depends on the healthinfrastructure rather than on the technique itself; thesuccess of any kind of growth monitoring will dependon the field workers, and in turn on their selection,training, and supervision.The incorporation of a simple weight graph into a

comprehensive child-health card or booklet provides avisible point of contact between scientific high-tech-nology health care and people-centred primary healthcare. In developed countries such a chart is beingused9to involve parents in their child’s health care to a

greater extent. In developing countries, the system isgaining momentum and showing its potential. Healthplanners should ponder deeply before radically alter-ing their strategy on growth monitoring, though theyshould be prepared to adapt their approach to fit localrealities, and should remember that any system is onlyas good as the workers who operate it.

Private Nursing Homes and the OldPRIVATE or voluntary long-stay nursing homes are

now believed to provide nearly one-third of all non-acute health facility placements in England and Wales(rather less in Scotland), and the proportion is growingas the private sector develops.’ The size of the projectedover-65 population of the UK in 1996 is little differentfrom that in 1986, but there will be nearly 250 000(14%) more over-80s. The National Health Service, onthe other hand, is projected to grow at only 1% perannum in the immediate future, and the elderly willmake disproportionate demands on health services,acute and long-term.

5. UNICEF. State of the world’s children 1985. Oxford: Oxford University Press, 1984.6. Growth monitoring Primary Health Care Issues, series 1, no 3, American Public Health

Association, October, 1981.7. The children’s revolution: The Asian picture. UNICEF (Bangkok), 1984.8. A situation analysis of growth charts in the Philippines. UNICEF (Manila), 1983.9. Lakhani AD, Avery A, Gordon A, Tait N Evaluation of a home based health record

booklet Arch Dis Child 1984; 59: 1076-81.1. Laing W. Private health care London: Office of Health Economics, 1985: 27-34, 38