Date: Mon, 20 Apr 1998 19:48:05 +0100

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: Ngonut: growth monitoring: hookworm: financing

I have been asked to send these questions by a member working in South East Asia.

I know Fitzroy Henry wrote a stimulating article with Ed Coper on Growth monitoring and Don Bundy could guide us on mass deworming. I will enjoy the responses to nutrition financing.

I would like you to raise the following issues for comments or

sharing experience (anonymously!):

1. GM/P is considered as one of the most important components of the

PEM control? How do you think the real value of this activity based on

the experience from different countries?

2. Hookworm is recognised as one important cause of IDA. Which group

will be the target one for deworming? Is there any harm if we carry

out mass deworming to all women in productive age as we will not

certainly know who is becoming pregnant?

3. One of the interesting issues is nutrition financing which is now

more relevant when we try to advocate for nutrition. Up to now, we

always consider nutrition as charity??? In order to advocate for

nutrition, we are trying to change behaviour of our counterpart from

charity to economic benefit. Whoever can share experience?

Prof. Michael H.N.Golden

Dept of Medicine and Therapeutics, Univ of Aberdeen

Foresterhill, AB9 2ZD. Scotland, (UK)

Tel +44 (1224) 681 818 ext 52793/53014 Tel(direct) +44 (1224) 663 123 527 93

Fax +44 (1224) 699 884 INTERNET m.goldenatabdn.ac.uk

Date: Mon, 20 Apr 1998 21:10:00 +0100

From: Ted Greiner <Ted.Greineratich.uu.se>

Subject: Re: Ngonut: growth monitoring: hookworm: financing

>I have been asked to send these questions by a member working in South East

>Asia.

>I know Fitzroy Henry wrote a stimulating article with Ed Coper on Growth

>monitoring and Don Bundy could guide us on mass deworming. I will enjoy

>the responses to nutrition financing.

> I would like you to raise the following issues for comments or

> sharing experience (anonymously!):

> 1. GM/P is considered as one of the most important components of the

> PEM control? How do you think the real value of this activity based on

> the experience from different countries?

Two workshops were held in Kenya in May 1992 and resulted in rather

negative evaluations of the value of implementing GM, at least without the

P (promotion of growth). UNICEF did a 7 country study in 1994 published by

Roger Pearson as No. 2 in their Evaluation & Research Working paper series

that provided some interesting insights in when and why it does not work.

But no matter how poorly it is done, GM remains a tool to focus and

maintain interest in nutrition and does so to some extent at every level

when it is the basis for monitoring systems. Its potential is enormous and

almost unexplored, for example, in providing feedback to health workers

about what kinds of feeding advice works and does not work in their patient

population/catchment area. One of my favorite articles pointing out this

potential is "Ten pitfalls of growth monitoring and promotion" by L

Hendrata and JE Rohde, Indian Journal of Pediatrics 55(1):S9-15, 1988. (The

whole issue is about GM.)

> 2. Hookworm is recognised as one important cause of IDA. Which group

> will be the target one for deworming? Is there any harm if we carry

> out mass deworming to all women in productive age as we will not

> certainly know who is becoming pregnant?

From what I have heard, WHO is almost certain that mabendazole at least

(having been around much longer than albenazole) is safe in pregnancy. I

think they were even conducting a study on this recently but have not heard

the results.

> 3. One of the interesting issues is nutrition financing which is now

> more relevant when we try to advocate for nutrition. Up to now, we

> always consider nutrition as charity??? In order to advocate for

> nutrition, we are trying to change behaviour of our counterpart from

> charity to economic benefit. Whoever can share experience?

It continues to surprise me how seldom the basic arguments raised by Alan

Berg in The Nutrition Factor in 1973 are used in advocating for nutrition.

It is now popular to treat the poor as the key actors in the struggle

against poverty. But it is cruel and foolish to expect people who are

suffering from energy deficiency, hypothyroidism secondary to iodine

deficiency, and reduced work capacity due to iron deficiency to pull

themselves up by their own bootstraps. Similarly, I have yet to come across

a ministry of education that recognized it would be in their own interests

to invest at least something in ensuring that the children who attend

school are not greatly reduced in their active learning capacity due to

deficiencies of calories, iron and iodine through different mechanisms.

Unit for International Child Health, Entrance 11

Uppsala University Medical School, 75185 Uppsala, Sweden

phone: +46 18 511598, fax 515380 or 508013

email: Ted.Greineratich.uu.se (when in Sweden), ted_greinerathotmail.com (when out of Sweden)

website: http://www.geocities.com/HotSprings/Spa/3156

Date: Tue, 21 Apr 1998 10:11:32 +0200 (METDST)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: Ngonut: growth monitoring

The anonymous mail to NGO nut re: grwoth monitoring prompts me to a few comments based on my previous work on the topic.

A while ago, I examined how monthly growth monitoring compares with other approaches to meet the following goals:

a) to detect children with a high risk of dying in the community

b) to detect at an early stage children who are to become malnourished.

The conclusion was that growth monitoring was less effective than cross sectional measure of nutritoinal status (and much less effective than measure of arm circumference) to assess the risk of dying. Growth monitoring was less effective than a measure of weight at 6 month to predict future malnutrition.

This work was published in 2 papers :

Briend A, Bari A. Critical assessment of the use of growxth monitoring for identifying high risk children in primary health care programmes. Brit Med J 1989; 298: 1607-11.

Henry F, Briend A, Cooper E. Targeting nutritional interventions: is there a role in growth monitoring ? Health Policy Planning 1989; 4: 295-300. (I guess Mike is refering to this one)

When I exposed these findings to advocates of growth monitoring, I was told many times that growth monitoring is much more than detecting high risk children, and that the education component should not be neglected. Fair enough. The problems is that we are now talking about difficult to measure benefits / outcomes.

These ref are now getting old. I don't know whether new work / data came out in favour of growth monitoring. Anyhow, I remain skeptical, and believe that time consuming techniques to detect malnourished children diverts attention from the main problem: what will you do once you find a child with poor growth ?

Other comment: I believe that growth monitoring which results in gathering of big numbers of children should NEVER be promoted in absence of excellent measles immunisation coverage.

Regards,

Dr. Andre' Briend

Date: Tue, 21 Apr 1998 19:19:19 +0000 (GMT)

From: "Judith McGuire, Nutrition" <jmcguireatworldbank.org>

Subject: RE: Ngonut: growth monitoring

Andre misinterprets the use of growth "monitoring". The purpose

of weighing the child is to target and tailor the counselling

messages to that child's recent growth performance (after some

diagnostic DIALOGUE has taken place between the growth promoter

and the parent of the child). The promoter negotiates some

behavioral improvements with the parent/care provider based on

further dialogue and sets a timetable for checking progress

(reminders are sometimes necessary in the form of a wall chart).

Only as a last resort (if the child is sick or if persistent

growth faltering does not respond to family-controlled solutions)

is referral to health personnel part of growth PROMOTION. I am

sending him a copy of the "tool" developed for the World Bank on

Growth PROMOTION. Experience has not reached the Peer-reviewed

journals but we know an awful lot about what works and what

doesn't.

Date: Tue, 12 May 1998 15:22:08 -0400

From: Festo_Kavishe_at_PO116A01atsmtplink.unicef.org (Festo Kavishe)

Subject: Re: Ngonut: growth monitoring

I am one of those proponents of growth monitoring and promotion, not

so much for purposes of measuring risk but as a powerful tool to

improve the nutrition-relevant decisions taken by families,

communities, governments, NGOs and other agencies, through a cyclic

process of assessment, analysis and action (triple A process).

My experience in Tanzania (for more than 10 years) and in Cambodia

(for one and half years) with integrated community actions for social

development shows that regular (we do it quarterly) assessments of

child nutrition status provides a poweful tool for communities to (a)

assess the extent of the malnutrition problem (b) discuss the causes

of the problem (immediate, underlying and basic)(c) design actions to

address the problem by themselves and (d) monitor and evaluate the

actions taken. Thus nutritional status is used as the outcome/proxy

indicator for various processes in society which lead to malnutrition.

The triple A process which uses nutrition status as the entry point,

builds up human and institutional capacity and is empowering. It helps

initiate discussions about nutrition across sectors and disciplines.

If properly done, it also ensures sustainability of interventions as

it is more likely to lead to changes in understanding and perception

and in many cases to positive changes in behaviour. By using an

explicit conceptual framework about the causes of malnutrition, the

results of nutrition assessment and growth monitoring are used to ask

the two fundamental questions:(a) "Why is there high levels of

malnutrition (or why is the nutrition situation not improving) in this

community? (b) What can be done to address the situation?

There are several publications on the Tanzanian experience e.g.

(1) Kavishe F.P and Mushi S.S (1993). Nutrition Relevant Actions in

Tanzania. UN ACC/SCN country case study supported by UNICEF. Copies

can be obtained from ACC/SCN, c/o WHO, 20 Avenue Appia, 1211 Geneva

27, Switzerland, fax [41 22] 798 8891, Email: ACCSCNatWHO.CH There are

several other references by UNICEF which can be obtained from this

publication.

(2) Kavishe F.P. (1995). Investing in nutrition at the national

level. An African perspective. In: Proceedings of the Nutrition

Society (1995), 54; 367-378.

We shall document the Cambodian experience after getting enough impact

data.

However, I agree with Dr. Andre Briend that many of the current types

of growth monitoring and promotion done through the Health system are

ineffective in addressing the problem of malnutrition. I have seen

some which monitor the child from being normal to being hospitalized

by malnutrition! In all the instances, it was not that the risk was

not identified, but action (a decision ) was not taken! Growth

monitoring is useful not as a measure against malnutrition, but as a

tool to assist in deciding when measures are to be taken.

Festo P. Kavishe

UNICEF, Cambodia.

Date: Tue, 12 May 1998 11:39:00 +0200

From: "Egal, Florence (ESNP)" <Florence.Egalatfao.org>

Subject: Re: Ngonut: growth monitoring

What about using alternative tools for promoting the same awareness

(e.g. MUAC), as they are much simpler to use and can be appropriated by

the community? Identifying community indicators for malnutrition as

perceived by a given community could also be useful...

In my previous professional lives as NGO health staff and public health

consultant, I also developed serious doubts about the appropriateness

(feasibility, cost, effectiveness, replicability, and sustainability) of

the growth chart approach...

Florence Egal

Date: Tue, 12 May 1998 15:53:37 -0400

From: Festo_Kavishe_at_PO116A01atsmtplink.unicef.org (Festo Kavishe)

Subject: Re: Ngonut: growth monitoring: hookworm: financing

On the question of financing, we have some experience in ASIA where

through a UNICEF/AsDB collaboration Initiative called the Regional

Technical Assistance (RETA) study, seven countries have developed

Nutrition Investment Plans. These countries are Bangladesh, Cambodia,

China, India, Pakistan, Sri Lanka and Vietnam. The premise for the

development of these plans is that good nutrition is essential for

economic growth, socio-development and a human right. The coutries are

expected to take a loan from AsDB to finance their nutrition

investment plans.

For example, the Cambodian Nutrition Investment Plan (CNIP), which I

have supported its development, seeks to invest about US$ 90 million

over the next ten years (starting from 1999). The main strategy is

community-based (80% of the funds) supported by a national strategy

which includes support to policy development, training, research and

to micronutrient control.

At the country level, the development of these investment plans were

done through a wide consultative multi-sectoral national steering

committee over the last two years. In Cambodia, consultations included

UN agencies (UNICEF took the lead role), and several NGOs. I would be

happy to provide more information on request.

Regards

Festo P. Kavishe

UNICEF, Cambodia.

From: Remi Sogunro <rembascsatzamnet.zm>

Subject: RE: growth monitoring

Date: Mon, 25 May 1998 15:30:46 +0200

It is pointless to discuss the effectiveness of the GMP. It is a known fact that it is very effective. However, I agree with all authors that GMP as practised today is perhaps ineffective. The question we should begin to ask ourselves is how best can we assist health workers in developing appropriate skills, attitude and confidence to promote growth.

In Zambia, we are developing a manual for re-training health workers and community volunteers in "how to" set up a GMP session; what is needed; How to do counselling; etc. This manual has been pretested among targetted clients.

From: avivaatnetnam.org.vn

Date: Tue, 2 Jun 1998 07:58:18 -0700

Subject: Re: growth monitoring: hookworm: financing: (2)

Dr Festo Kavishe wrote from Phnom Penh on May 15:

On the question of financing, we have some experience in ASIA where

through a UNICEF/AsDB collaboration Initiative called the Regional

Technical Assistance (RETA) study, seven countries have developed

Nutrition Investment Plans. These countries are Bangladesh, Cambodia,

China, India, Pakistan, Sri Lanka and Vietnam. The coutries are

expected to take a loan from AsDB to finance their nutrition investment

plans. I would be happy to provide more information on request......

I would like to add that I collaborated in the preparation

of the Vietnam RETA report and I will also be happy to provide more

info on it.

Claudio Schuftan

avivaatnetnam.org.vn

PS: Dr Golden, I think the real value of growth monitoring (clinic based) based

on the experience from different countries is rather poor. Every

nutritionist would agree with me (Dr Briend certainly did already). At

best, it "chronicles" what is happening to malnutrition for historians

to keep records. Not much successful prevention/promotion is done. Only

community based GM has a chance ...and that is a whole other ballgame as

Dr Kavishe noted in his second note. Will we be bold enough to cut the

expensive 'ritual' of clinic based GM and invest that money in much more

meaningful CBGM? I'm afraid even 'good manuals', sensitization and

training of PHC staff will not do it for clinic based approaches despite

the note from our friend from Zambia on May 25.

From: Paul Garner <pgarneratliverpool.ac.uk>

Subject: Re: Ngonut, growth monitoring

Date: Tue, 2 Jun 1998 16:43:38 +0100 (British Summer Time)

We are just completing a first draft of the cochrane

systematic review of growth monitoring.

We have searched extensively for randomised trials and

only two meet the inclusion criteria (George; Ruel).

If anyone knows of any trials where participants were

randomised to two different groups, or some other method of

allocation relatively free of bias was used eg alternate

allocation, please can you let us know. We have

identified one in press from North UK but no

others!

Thankyou.

Paul Garner

Cochrane Infectious Diseases Group and The Effective Health Care in Developing Countries Project (DFID supported)

Date: Mon, 01 Jun 1998 08:14:54 +0100

From: "Judith McGuire, Nutrition" <jmcguireatworldbank.org>

Subject: RE: Ngonut: Re: Ngonut, growth monitoring

I seriously question WHAT you are reviewing as "randomized"

trials. You say "growth monitoring" (most of us in the nutrition

program business prefer to call it growth promotion because

monitoring growth doesn't do anything without action taken on the

basis of growth performance). There's weighing babies and

there's counselling mothers and there's referral. Without

assessing the composition of the services provided and the

quality of the services (particularly the content of the

counselling and the style of counselling but also the reality of

the referral, whether nutrition status or growth trajectory was

used to identify problems, the accuracy of the weighing, the

quality of the interaction between the weigher and the weighee,

and WHO is doing the weighing (I'd say, by and large, doctors and

nurses do the worst on growth PROMOTION even though they may

weigh more accurately)), you can't compare growth "monitoring"

with growth "monitoring" because it's not a single thing. The

Sabu George study is a perfect example of comparing apples and

oranges without taking into account interpersonal communications.

The illusion of science with meta analysis done by the Cochrane

group needs to be examined. These are programs not drugs so

methods to evaluate them need to take into account the human

element in delivery of programs not just the efficacy of some

consistent uniform independent variable (like a drug), which growth

promotion is not.

From: Paul Garner <pgarneratliverpool.ac.uk>

Subject: RE: Ngonut: Re: Ngonut, growth monitoring

Date: Fri, 5 Jun 1998 13:21:01 +0100 (

RE GROWTH MONITORING

Judith, thanks for your comments here. Please do send me your address/room in the World Bank so that we can send you a copy of the draft review for comment.

You ask what we are reviewing as "randomized" trials. We use a standard definition of an RCT, but the inclusion criteria also specified trials using alternate allocation would be acceptable.

You raise some important points about definitions of growth monitoring that we struggled with in consultation with our referees at the protocol stage of the review.

We define "monitoring" as measuring with remedial action taken where required. As you say, it doesn't make any sense otherwise. The remedial action will vary with context and condition.

To assess effectiveness, you need to define the outcomes against which these can then be measured. This has been most troublesome because it appears rather muddled in what people actually what growth monitoring to achieve.

I rather like the "illusion of science with metanalysis needs to be examined". Certainly anyone who statistically combines data inappropriately should be chastised, wherever they are or wherever the come from; or puts numbers to things that don't make any sense, as some cost-utility measures such as DALYs have been criticised on.

It would be helpful if Judith could outline some specific examples, or, even better, would be to go to the Cochrane Library with its 600 or more systematic reviews and use the "comments and criticisms" button to email her comments to the authors.

In addition, you might like to look at the reviews of organisational interventions in the Professional Practice Group which are working hard in synthesising research evidence around complex interventions.

With best wishes

Paul Garner

Liverpool School of Tropical Medicine

Pembroke Place, Liverpool L3 5QA; UK

Fax: 0151 707 1702, Tel: 0151 708 9393, MT: 0498 866193

Email: pgarneratliverpool.ac.uk

Date: Fri, 5 Jun 1998 17:42:37 +0100 (BST)

From: RA Carr-Hill <irss23atyork.ac.uk>

Subject: RE: Ngonut: Re: Ngonut, growth monitoring

You also might like to look at the many critiques of meta analysis and systematic reviews that have now been published.

Best of luck

Roy Carr-Hill

Date: Mon, 28 Sep 1998 18:26:39 +0100

From: David Morley <Davidatmorleydc.demon.co.uk>

Subject: Growth Monitoring

A new approach to Growth Monitoring involving the Direct Recording Scale.

Just as Paulo Freire used words important to people to teach literacy, so we can use child growth to teach numeracy. Research among the Maasai of Kenya suggests that at the same time we can improve the nutrition of the children being measured.

Growth monitoring is difficult because it involves the creation and decision making from a line graph,considered by Piaget to be one of the more difficult concepts to teach in education. It needs to be taught in a highly practical manner. One successful method involves measuring known quantities of water into a bucket hanging below the Direct Recording Scale.

For this a plastic bottle cut to hold 400cc at one end and 200cc at the other end is required. As the water is poured into the bucket below the spring the mothers see the spring stretch and themselves with a ball pen create successive points on the growth curve. A more detailed description of this method of teaching is available from TALC*.

The following are results from a large controlled study of the scale among the Maasai in Kenya:

1. Mothers appreciate being involved. They understand what weighing and plotting a growth curve means. When shown several charts they can select the most appropriate growth curve.

2. After 2 years the grandmothers experience with the scale, who are the decision makers, and their grand-daughters, the future mothers, also understood the growth curve. Even 50% of the fathers and older sons understood it well.

3. Once a mother understands, that the vertical lines on the chart indicate months, she can more easily understand the timing of other sections of the chart (e.g. Immunisations). She may be put more in the 'driving seat' of her child's PHC.

4. An unexpected finding from the recent Maasai study by Meegan (To be published in "Tropical Doctor", to be published Jan'99) was a difference in growth faltering. Faltering was defined as no gain in weight for two months, or a loss of 200 grams in children under 2. Among 339 children weighed by their mothers on the Direct Recording Scale only 8% faltered compared with 30% among 127 children weighed by CHWs on dial scales.

[Subsequent questions to mothers, weighing their children on Direct Recording Scales in 20 homesteads, showed that the mothers themselves had noticed growth failure early and had given extra feeds of goat, or cow's milk to the infant. Whether we can find equivalent improvement in other communities that do not have ready access to milk is still not known]

*Copies of the scientific papers giving more details of these studies and the scales , available

from :

TALC, POB 49. St Albans, AL1 5TX. UK.

Ph' 44 (0) 727 853869. Fax. 44 (0) 727 863845.

E-mail: talcukatbtinternet.com ..........................

I badly need those willing & with the resources to either confirm of refute these finding. If you can point me in the direction of any one who can I should be most grateful.

Yours David Morley

David Morley

Davidatmorleydc.demon.co.uk