|Tool contents. Instituting a growth promotion program can be a highly effective means to avert the mild and moderate malnutrition that underlies the majority of child mortality. Drawing on program design and implementation experience from Latin America, South and Southeast Asia, and Africa, Tool #4 presents a comprehensive overview of the design and delivery of growth promotion services. Practical guidance includes criteria for adequate weight gain by age, sample growth curves, decision guides for targeting and integrating follow-up actions in response to growth faltering, examples of tailored counseling messages, sample counseling cards, best practices in nutrition negotiation, and regionally diverse case studies of successful growth promotion programs.
Growth promotion defined. Growth promotion is the targeting of counseling and other assistance to children and their families based on their monthly weight gain (or decline). Growth promotion includes growth monitoring of children (weighing and charting of weights), but goes beyond that to identify growth problems (in partnership with mother or caregiver), formulate actions in response to problems, and follow-up the effects of agreed-upon interventions. Although the families of growth faltering children may face severe economic constraints, they often are able to make small, but profoundly important changes in the way they feed their child. Even if the behavior changes do not achieve the internationally accepted feeding guidelines, they can maintain or improve the growth and nutrition status of a youngster. For example, feeding an extra tortilla twice a day, adding 2-3 spoonfuls of rice to each meal, or instituting exclusive breastfeeding can keep a child from faltering and thus on an adequate growth trajectory.
In health and nutrition programs at the central or community level, information on growth is compiled and analyzed for problem-solving and planning, to integrate and target services and resources, to motivate/enhance household-level actions, and to provide follow-up/feedback on the effects of actions taken. Growth information has been effective in rallying the community for action and as a trigger for increased attention to supervision of health and nutrition workers. A common error in growth promotion programs is an over-emphasis on the task of weighing and compiling, reporting, and sending data without using them locally. Programs need to focus attention on trends in growth (not on nutritional status) and on the use of this information to target counseling and referral plans for children.
The central tenets of effective growth promotion programs. Programs work most effectively when they are community- or neighborhood-based (not reliant on a health facility) and aim for universal coverage of children under two or three years. Growth monitoring should begin at birth, continue monthly for the first 18-24 months of life, and involve child caregivers in the monitoring process. Adequate growth (weight gain) rather than nutrition status is the best indicator for action. Growth promotion is well suited for programs with a preventive approach because it catches growth faltering early on before significant malnutrition has occurred, making it possible to correct the problem with home-based actions. Programs that work well record a child's growth on a growth chart making his/her growth status visible to the caregiver; analyze the causes of inadequate growth and formulate clear and feasible options for action based on the analysis; engage the family in negotiation on actions for improved nutrition practices using precise recommendations tailored to the individual child and her environment; follow-up with the family at the next weighing to assist with continuing problems and to provide encouragement and praise.
Tailor precise, individualized messages for action. Individual nutrition counseling is the cornerstone of an effective and efficient growth promotion program. The first step for programs is to develop a set of age- and condition-specific counseling materials that the worker can use to initiate the negotiation process with the mother. These counseling materials should be well tailored to the problems of the area and to what is known about what actions are feasible for mothers. A method, called trials of improved practices or TIPS, can be used to define the actions by age group. These actions can be discussed and negotiated between mothers and health workers in a process that leads to one or two actions being identified that the mother will try to implement. In this process of identifying key actions, local best practices from mothers with children who are growing well are used also.
Ensure the positive impact of growth promotion programs through good management. Programs need a dedicated worker(s) in each community for growth promotion. Workers' tasks must be limited and well defined. Formulate detailed, area-specific implementation plans, with allowance for local innovation. Ensure liaison between community workers and the health system, agricultural system, and social services to resolve persistent and difficult growth failure. The most effective training curricula are task-oriented and "hands on," covering the entire growth promotion process, with an emphasis on problem solving. Supervision needs to be supportive, continuing worker training and addressing problems directly as they arise (refer to Tool #1, "Incorporating Nutrition into Project Design," for more information on supervision). On-going monitoring alerts management about developing problems. Build commitment to the program among staff at all levels. Use growth as an indicator of program functioning.
The bottom line. Growth promotion works well in programs seeking to improve efficiency and effectiveness by responding to individual and local problems. Program experience shows that families will respond to identified growth deficits by improving feeding practices and sustaining change in nutrition behaviors. Similarly, growth promotion programs provide communities with the information to understand and take action to prevent the poor growth of their children. While cost data are limited, experience in India and Indonesia shows that targeting through growth promotion programs clearly increases the efficiency and cost-effectiveness of expensive interventions such as food supplementation. Growth status statistics have also become powerful tools for program monitoring and for advocacy with policy makers.
Assessing a growth promotion program: Hallmarks of excellence.
RESPONSE TO GROWTH FAILURE
IssueOptimal program design
|Participation of mothers and familiesMothers help weigh child, interpret growth pattern; with worker, choose actions to improve growth; mothers share experiences with other mothers; counseling materials developed for mothers as primary audience.|
|Guidelines for decision making based on child's progressCriteria for adequate and inadequate growth are combined with health status; used at all program levels, with clear guidelines for decisions and action.|
|Targeting, referral, and integration of program componentsClose coordination with program and community services for referral of children with growth failure; good targeting of referral services and follow-up after interventions are initiated.|
|Community awareness and decision makingCommunity compiles, discusses, and frequently bases decisions/actions on growth data; takes pride in having few under-nourished children and in children who grow adequately.|
|Individual nutrition counselingAdequacy of growth determines content and intensity of counseling; nutritional negotiation and targeted materials (based on results of TIPS) used.|
LEVEL OF OPERATIONAL MANAGEMENT
IssueOptimal program design
|Worker and workloadCommunity worker has help and will make home visits; percent of children gaining weight is part of job performance.|
|Training of workersIncludes weighing and charting, analysis of causes and how to target feeding, how to negotiate with mother; emphasis also on community motivation and counseling; task-oriented cases and practice sessions; self-assessment and community follow-up.|
|Supervision of nutrition worker and activities Supervisor observes weighing sessions, assesses targeting and decisions on actions based on growth data; uses growth faltering information to focus supervisory attention on difficult cases; initial visits are monthly, later quarterly; visits mothers and works with community; emphasis on improved performance and continued training.|
|Detailed operational planningFull set of operational guidelines with options and examples of local initiatives; materials respond to local needs; budget for local innovations.|
|Program-level monitoringData on growth used for program decisions (design, expansion) and advocacy at all levels.|
|Commitment to sustain programAdequate child growth is a national development objective; commitment to achieving this is seen at all levels; local resource allocation for growth promotion programs.|
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