Growth monitoring and promotion practices among health workers may be suboptimal despite high knowledge scores

Malnutrition constitutes a major public health concern worldwide and serves as an indicator for assessing overall health [1]. Recent estimates indicate that 165 million of all children under 5 years worldwide are stunted and a further 52 million are wasted with Africa and Asia recording the highest burden [2]. Whereas 14% of the global population is estimated to be undernourished, the prevalence of undernutrition is about 33% in sub-Saharan Africa [3].

In Ghana, reports on child under nutrition are not much different from the prevalence of sub-Saharan Africa. Among Ghanaian children under five years, 19% are stunted, 5% are wasted and 11% underweight [4]. In comparative view, Northern Ghana presents highest prevalence of under-five malnutrition as against the southern part [4].

The compounding effects of all forms of malnutrition are devastating to the individual, family, community and the nation as a whole. Nutrition plays a critical role in promoting and maintaining optimal health throughout the life cycle [5].

The child health record booklet (CHRB) is a forty-four paged document that combines essential health information on the growth monitoring of a child, immunization, vitamin A supplementation, deworming medicine and other illnesses [6] with the ultimate aim of having healthy thriving children with good nutritional status. A larger proportion of the CHRB is comprised of health messages on infant and young child feeding practices and family planning (48%), information about expanded programme on immunization makes up about 7%, the growth charts form about 2% of the CHRB, whilst child personal data and nurses progress notes make up the rest of the booklet. The CHRB assists in the screening of children at risk of malnutrition and provides a simple, practical, cost-effective and convenient method of monitoring a child’s health [6]. The CHRB also helps to improve health through vaccination compliance and early identification of growth patterns. It serves as a mobile health data bank and a source of useful reference for both caregivers at home and healthcare professionals during consultations [7].The CHRB has been used for a number of years in many countries to help track health risks, vaccinations and other preventive health measures performed [8]. The booklet is a document capturing necessary health information about children and their families. The content of the booklet has been found effective in assessing the overall health status of children worldwide [9].

Growth monitoring component of CHRB is a preventive strategy which when implemented properly helps in early detection of any growth faltering [10]. Growth monitoring can suggest an entry point to preventive and curative health care and serves as a constituent of programmes in line with significant reductions in malnutrition and mortality. Child growth monitoring and promotion (GMP) is key in caring for children. This involves measurement of growth in children, recording and interpreting in order to provide counselling, therapy and follow up [10]. The booklet also presents a milestone for routine health management information system data, utilization and coverage of preventive health services over time [11].

Over the last two decades, the CHRB used in Ghana has undergone several changes in both content and presentation of the health messages; changes of name from “Road to Health Chart” to CHRB, inclusion of nutrition counseling, sex appropriate colour coded growth charts, parent’s pledge, structured communication and a certificate for rewarding mothers who regularly attend CWC. These changes seem to increase the volume of the booklet which can engage the time of health workers and may not lead to its full utilization.

Little is known of the utility level by mothers and health workers providing GMP in Ghana. Such data could be useful in improving growth monitoring and promotion in Ghana. The present study, therefore, aimed to assess the knowledge and utilization level of CHRB as a growth monitoring and promotion tool in northern Ghana.

This study sought to assess the knowledge and utilization of growth monitoring and promotion among mothers and health workers in Northern Ghana. The main findings of the present study are that: most of the health workers exhibited high knowledge on the interpretation of the essential components of the CHRB but that did not translate into skills in filling the growth chart. Majority of the mothers were also knowledgeable on the essential components of the CHRB. While a greater proportion of the growth charts were correctly plotted, there was poor level of completeness of the growth chart among health workers. These results could indicate a threat to the GMP programme as correctness and completeness are essential for GMP to be effective in identifying cases that require attention [13]. GMP is one of the important activities undertaken by health workers, therefore, a sound knowledge of it is paramount to reducing the burden of malnutrition among children under five years. It is mostly the first point for the monitoring, screening and management of childhood illnesses [13]. Ashworth et al. [14] reported that correct recording and charting of a child’s data on the growth chart allows for proper comparison of the child’s growth to the reference and could ensure early detection of growth problems for appropriate action. This important role may be compromised as the current study revealed only a smaller proportion of the charts were completed.

The finding in this study relating to large proportion of inappropriate charting is not consistent with that of Brownlee [15] who reported appropriate charting and understanding of the growth chart by health workers. One would expect health workers who play a pivotal role in providing health information for mothers on the usage of the child health record booklet to be equipped with the necessary knowledge to impart and influence practice. Even though knowledge on the booklet was high and consistent with existing data from Ghana [16], unfortunately, translation into practice was problematic. A systematic review by Roberfroid et al. [17] reported nearly a third of health workers in developing countries having poor understanding of the growth chart. The high knowledge level of health workers in the present study may be due in part to periodic trainings provided by non-governmental organizations in the area. The Ghana Health Service also provides periodic workshops on GMP which could explain the knowledge level observed. Knowledge level of the health workers appeared to be high on vaccines and vaccine routines and were higher than those reported from South Africa [6] but were less prominent on growth indicators. This could be explained by the caliber of health workers engaged in GMP. The common providers of GMP in health outlets in Ghana are general nurses and community health nurses who might not have much training on growth indicators compared to other cadre of health workers such as registered nutritionists who normally do not operate at this level.

Mothers had good perceptions on the CHRB concerning the monthly routines. This perception may motivate caregivers to make regular attendance for GMP at the health facilities. Similar results are reported by Gyampoh [16] whose study in the Greater Accra region of Ghana showed mothers placed importance on having their children weighed monthly. In this current study, mother’s ability to interpret the growth charts was similar to the health workers educating them about the nature of the growth curve during weighing session as a standard guideline for GMP (49.3%). This is similar to a study in Belgium where health workers made efforts to educate caregivers on growth charts, which led to improvement of mothers’ comprehension of the chart despite lags in formal education [18]. This may mean increasing the time for interaction with caregivers during GMP could improve their knowledge on interpretation of the chart [19, 20]. Our finding highlights the importance of nutrition counseling in achieving the objectives of GMP. The success of GMP depends on the knowledge, dedication and cooperation of the mothers and health workers. However, health workers identified uncooperativeness among caregivers as a challenge to GMP activities and indicated mothers being in a hurry to attend to other responsibilities at the household. This challenge could be tackled by involving the partners/husbands and household heads in GMP activities to understand the benefits of the programme and hence allow their women more time for GMP. In addition, addressing issues of work overload [21] of health workers and logistics [22] could be important at improving GMP activities in northern Ghana.

This study considered the overall sample as a combination of health workers and mothers and not separate even though we have performed sub-group analysis. As majority of the health facilities engaged in CWC also render the service through outreach to neighbouring villages, it is common not to find most mothers at the facility level for CWC which resulted in the inclusion of few mothers in the study. Data collection at the facility level was necessary because we needed a well representation of health workers which could suitably be gotten at the facilities. As many mothers are involved in CWC than health workers, we find that our sample may well represent health workers in the Municipality than mothers/caregivers. Our data on caregivers could therefore, be limited to this sample but may be useful in understanding their perceptions and knowledge on the CHRB. In spite of these limitations, the present study has provided ample information on the GMP programme in the East Mamprusi Municipal.

Knowledge scores on the child health record booklets among health workers and mothers in this part of northern Ghana were high but charting of growth of children was sub-optimal among health workers. There is a need for increased education of mothers on the CHRB and its correct usage among health workers engaged in GMP in northern Ghana.