INNOVATIONS AND TOOLS IN CHILD GROWTH MEASUREMENT AND DATA VISUALIZATION 1 Despite global efforts to address malnutrition, the numbers of children under five who are not growing properly are alarming: 150.8 million (22.2%) are stunted (too short for their age), 50.5 million (7.5%) WHY ARE are wasted (too thin for their height), INNOVATIONS and 38.3 million (5.6%) are overweight AND TOOLS (too heavy for their height). Children NEEDED FOR living in lower-middle income countries (LMIC) are particularly affected. At these CHILD GROWTH rates, the world is off course to reach MEASUREMENT the World Health Assembly targets for AND DATA 2025 and the Sustainable Development VISUALIZATION? Goals for 2030.1 1 between growth, illness, and feeding.10 Ending malnutrition is critical: faltering or excess and, with adequately trained young children under age three because they and supported health workers, help caregivers often do not stay still or resist measurement.7 Many caregivers have difficulty Childhood stunting has life-long consequences understand and address the underlying causes Also, cultural or geographic factors can come understanding growth charts and healthy including negative impacts on health, cognitive of unhealthy growth and nutrition. into play. In some cultures, parents fear height child growth, especially those with lower development, educational attainment, and boards and don’t want their children measured, education and literacy, and as a result are income, and makes children less likely to There are, however, many challenges to thinking of them as coffins. In some countries not able to take concrete care-seeking escape poverty as adults.2,3 Children suffering conducting reliable and accurate measurement such as China, Mongolia, and Afghanistan, or nutrition actions.5,6,11 from wasting have lower immunity, are more prone to long term developmental delays, as part of GMP, using those measurements during the cold season children are weighed and are at increased risk of death, especially to counsel caregivers on the results and wearing their clothes, making weight difficult those that are “severely” wasted. Children future actions to be taken, and drawing on to interpret. who are overweight – the emerging form of the data collected for decision-making at all CHALLENGE 4 malnutrition – are likely to remain overweight levels. Section 2 discusses innovative tools DATA USE or obese as adults and at risk for developing that are being developed to address some diet-related noncommunicable diseases of these challenges; Table 1 summarizes the CHALLENGE 2 advantages and disadvantages of each tool. HEALTH In addition to using growth data for visualizing, later in life. 1 communicating and counseling on child COMMUNICATION growth, child growth data can and should be In the context of this double burden of AND COUNSELING used for decision-making and accountability malnutrition, measuring the weight and height of infants and children, especially CHALLENGE 1 The quality of health counseling and at the individual, community, district, and ACCURATE MEASUREMENT provider-client communication during GMP national level. When growth data from all before a child’s second birthday, is particularly is generally weak. Counseling messages children living in a community are aggregated, important. Regular assessment of growth AND DATA during GMP are often too generic: they may potential problems become more visible and development combined with behavior High quality, accurate anthropometric not be tied to the growth outcome, may and can be better understood, thereby change counseling, or growth monitoring and data is core to the viability of GMP and is not be age-specific, or do not emphasize stimulating community nutrition and health promotion (GMP), can help identify early growth critical for users (parents, caregivers, health follow-up actions that need to be taken. 8,9 programming that addresses the underlying workers, communities, and decision-makers) And if counseling is not based on accurate determinants influencing child growth and to determine how to respond effectively. measurements, the resulting information nutrition.12 For example, in a nutrition program However, many health workers – especially told to caregivers may be wrong. in India, community charts for nutritional at the community level – have problems with status of children registered in Anganwadi measurement, plotting, and interpreting Centres have been used as community growth monitoring data.4,5 These difficulties mobilization tools and are intended to help can be related to lack of appropriate and CHALLENGE 3 the communities understand the nutritional user-friendly job aids, low educational CARETAKERS’ UNDERSTANDING status of their children, underlying causes of levels or literacy, poor training, high OF GROWTH CHARTS undernutrition and what should be done to caseloads, poor remuneration, inadequate improve them.13 This type of work could more supportive supervision, and anthropometric AND HEALTHY CHILD GROWTH easily and accurately be done with reliable equipment that is not functional.4–6 Errors The interpretation and use of growth chart growth measurements that can quickly be in measurement are especially common in data is not always straightforward due to consolidated within communities and across the chart design or the skill, ability, and different government levels and sectors. 150.8 MILLION (22.2%) motivation of the health worker to help CHILDREN UNDER FIVE caregivers understand the meaning of the ARE STUNTED growth curves. A well-designed growth chart should ensure that caregivers can see the changes in weight or height, visualize their child’s growth pattern relative to the reference growth pattern, increase their awareness of why growth is important, and 50.5 MILLION (7.5%) 38.3 MILLION (5.6%) help them understand the relationship CHILDREN UNDER FIVE CHILDREN UNDER FIVE ARE WASTED ARE OVERWEIGHT 1 1 2 2 feedback messages ensure that supervisory and that poor growth influences children’s visits include high quality mentoring and health and development. Health workers coaching of the health worker and reinforce reported increased use of health services static training. The mobile app also makes a and requests from caregivers for weight and subjective process more objective. The plan length measures during health center visits.19 PROMISING TECHNOLOGICAL is to have the data from the mobile checklists INTERVENTIONS TO HELP feed into a dashboard in the district health ADDRESS CHALLENGES WITH information system that provides the Ministry GROWTH MONITORING AND of Health with an overview of health worker DIGITAL HEIGHT BOARD DATA VISUALIZATION performance in each health facility.16 A large-scale roll-out of a mobile phone This device is currently being developed application for low-literate Anganwadi by UNICEF and is similar to current CHILD LENGTH MAT Workers (AWWs) (CHWs) is currently being height boards but with digital output that implemented in India to track clients, provide addresses, among other challenges, reading timely service delivery, improve plotting and The Child Length Mat was developed by The errors that commonly arise from height interpretation of growth monitoring data, and Manoff Group as an inexpensive, easy-to- measurements. The digital height board can facilitate counseling on maternal and child use tool that helps families and communities also process and transfer data electronically health and nutrition. With the mobile app, the focus attention on linear growth and timely to a mobile phone or tablet for rapid data data can be entered in real time, offline and action. As a non-clinical tool for community capture and analysis. A prototype of the online, is spot checked by a supervisor, and use, it helps to identify if a child under two board is being field tested and potential MOBILE PHONES then consolidated in a web-based dashboard is at risk of becoming stunted or is stunted. improvements to the board are being so that all levels of government can access it The mat has separate sides for boys and communicated to the supplier. Mobile phones have been widely implemented and determine how best to improve and target girls. Countries determine the periodicity of in programs to improve maternal and child services. For GMP, the application automatically measurement, but commonly children are plots the child’s data, interprets it and provides measured every three months, starting from health. More recently mobile phones are being multi-media counseling messaging for the three months of age. The mat clearly shows ANTHROIMAGING used in nutrition programs to facilitate tracking and follow up with target populations, improve AWW and caregiver. The application has been whether a child’s length, while lying on the plotting and interpretation of child growth piloted, is currently being used by over 80,000 mat, is <-2SD of the current WHO standard The 3-D imaging uses a tablet, phone, or and counseling, and streamline information AWWs across six states and will be rolled out for the child’s age. Validation in Cambodia a special camera to measure height, head, systems.14,15 While few studies have looked at nationally to 1.4 million AWWs in the country and Guatemala showed high sensitivity and and arm circumference. Scans can then the impact of these interventions, or do not use through funding from the Government of India specificity in identifying stunting compared be uploaded to provide individual and rigorous evaluation methodologies, small scale and the World Bank. An external evaluation is to results when a height board was used.17,18 population-based growth data. Controlled research and pilot studies show promising underway in Madhya Pradesh and Bihar.15 Following implementation in Bolivia in 2008, studies have shown that this technique is findings. A cross-sectional study in 14 health programs in Cambodia, Guatemala, and highly accurate and as reliable as a posts in Indonesia found that the use of the Mobile phones are also starting to be used to Indonesia currently use the mat to be joined gold-standard manual measurement.20 It is mobile phone by community health workers improve, digitize, and streamline supportive soon by Rwanda. In each country, specific currently being field tested in Guatemala for (CHWs) significantly improved the accuracy supervision practices for the delivery of adaptations in the mat design, the training accuracy and acceptability (results pending). of the classification of children’s growth status nutrition services. In Ghana, the Northern package, and the guidelines for family and by 80% on average, especially for children Regional Health Directorate of the Ghana community actions are tailored to the local who were mildly underweight and thus were Health Service with funding from USAID/ context. Health services, communities, and classified as normal. The phones also improved Resiliency in Northern Ghana project is piloting families find positive benefits. For example, the timeliness of data submission from the a mobile application to digitize supervision in Cambodia, the mat is integrated into village to sub-district levels. Moreover, CHWs checklists at specific contact points where community GMP services to trigger referrals with a phone were more likely to provide nutrition services are critical, incorporates and counseling. A review in 41 villages found feedback and arrange follow-up GMP real-time feedback to health workers on their that the mat helped both village health counseling sessions and referrals than strengths and weaknesses, and provides workers and caregivers visualize linear those without a phone. 14 targeted multimedia content/refresher training growth, understand that height and weight to improve health worker performance. The gains are important for children’s growth, 3 3 4 4 TABLE 1: A D VA N TA G E S A N D D I S A D VA N TA G E S O F T O O L S T O M E A S U R E C H I L D G R O W T H TOOLS ADVANTAGES DISADVANTAGES MOBILE APPLICATIONS: • Can potentially improve calculation and interpretation of • Costs: Procurement of devices, training, help desk, Digitize, standardize, and growth charts, patient registration, provider counseling, development of software, training vs. cost savings from streamline the work of data entry, consolidation of data across sectors and levels implementation in terms of time and impact community health workers, of government14,15 • Limited battery life of mobile phones, lack of electricity including child growth • Can reduce the workload of CHWs by accelerating the plotting to recharge the phone, low confidence by CHWs to monitoring and promotion of child data and providing timely feedback to mothers14 use apps21 Improve supportive • Some caretakers find that they can trust the results from • Health workers may use mobile phones for their personal supervision of health a mobile phone app more, and find them less judgmental, use, which can affect data security and confidentiality care workers than those of CHWs14 • Can improve supportive supervision and health worker performance for nutrition services ANTHROIMAGING: • Low-cost, portable system • Technique is still being field tested for accuracy The 3-D imaging uses a • Scans can be uploaded to not only provide individual but also and acceptability tablet, phone or a special population-based growth data • Scanning and processing software need camera to measure further development before routine use of height, head, and • Highly accurate measurements as shown by controlled studies 3-D anthroimaging20 arm circumference • Same as “mobile applications” (above) CHILD LENGTH MAT: • Inexpensive, durable, easy to use, and intuitive for communities • Currently, does not sufficiently capture growth faltering, Poly-vinyl mat that employs • Easy to adapt to country context, by tailoring the age groups, but adaptations are being made in several countries to visual cues to assess if a colors, graphics, and format to reflect the national stunting profile add one or two more markers so that trends between child (3-24 months) is at and local preferences measures are easier to assess to determine faltering risk for becoming stunted • Not a clinical measure; for community awareness or is stunted • Helps providers, community leaders and families visualize stunting and appreciate linear growth raising and promotion of action • Integrates well with on-going community GMP: offers straight-forward training and use and involves the caregiver in measurement • Can help drive demand for clinical measures at health centers • Heightens accountability for action on stunting by giving parents the information on their child; allowing leaders and health providers to know if stunting is increasing or decreasing in their jurisdiction DIGITAL HEIGHT BOARD: • Easier to read the measurement value than when using a • Still under development Similar to current height board with measuring tape for readings, thereby increasing • Needs to be field tested on a wider scale boards but with the likelihood of accurate reading digital output • Currently twice the price of a regular • Digital output can potentially reduce reading errors and height board measure, process and transfer data electronically to a mobile phone or tablet • Much lighter than current height board 5 5 6 3 New tools to measure child growth have great potential to REFERENCES improve anthropometric diagnostic accuracy and data quality, improve the classification and value of routine nutritional 1. UNICEF/WHO/World Bank Group. Levels and trends in child malnutrition 2018 [Internet]. 2018. Available from: assessments, and increase needed referrals. Some of the http://www.who.int/nutgrowthdb/estimates2017/en/ new tools under development can help caregivers visualize 2. Galasso E, Wagstaff A, Naudeau S, Shekar M. The Economic Costs of Stunting and How to Reduce Them. CONCLUSIONS their children’s growth, provide tailored communication World Bank Policy Res Notes [Internet] 2016;Available from: http://pubdocs.worldbank.org/en/ AND NEXT STEPS messages, enhance their trust of health workers, and facilitate 536661487971403516/PRN05-March2017-Economic-Costs-of-Stunting.pdf changing nutrition behaviors and taking necessary follow-up 3. Shekar M, Kakietek J, Dayton EJ, Walters D. An Investment Framework for Nutrition: Executive Sunmary actions. Mobile phones that standardize nutrition supportive [Internet]. 2016. Available from: http://elibrary.worldbank.org/doi/book/10.1596/25292 supervision can improve health worker performance. Reliable, 4. Ashworth A, Shrimpton R, Jamil K. Review Article Growth monitoring and promotion : review of evidence easily aggregated data can be used by the community or of impact. Growth Monit Promot Rev Evid impact 2008;86–117. different government levels to detect problems and develop 5. Mangasaryan N, Arabi M, Schultink W. Revisiting the concept of growth monitoring and its possible role in potential responses. The development of these tools is a community-based nutrition programs. Food Nutr Bull 2011;32(1):42–53. turning point for GMP, which in the past has been criticized for measurement errors, poor health worker performance, and 6. Bilal SM, Moser A, Blanco R, Spigt M, Dinant GJ. Practices and challenges of growth monitoring and promotion in Ethiopia: A qualitative study. J Heal Popul Nutr 2014;32(3):441–51. inadequate provider-caregiver counseling. 7. Conkle J, Martorell R. Perspective: Are We Ready to Measure Child Nutritional Status with Lasers? Adv Nutr Of course, implementation and use of these tools should not 2019;10(1):S10–6. be undertaken without implementation research in a health 8. Gyampoh S, Otoo GE, Aryeetey RNO. Child feeding knowledge and practices among women participating facility and community settings that analyzes the tools’ impact, in growth monitoring and promotion in Accra, Ghana. BMC Pregnancy Childbirth 2014;14(1):1–7. cost-effectiveness, ability to improve quality data, and barriers 9. Schaetzel T, Griffiths M, Miller Del Rosso J, Plowman B. Evaluation of the AIN-C Program in Honduras. to use. It is also important to evaluate the impact of programs 2008;69–79. Available from: https://www.manoffgroup.com/AIN-CEvaluation.pdf/ and tools for consolidating data, tracking data, and using child 10. Griffiths M, Dickin K, Favin M. Promoting the Growth of Children: What Works Rationale and Guidance for growth data for accountability and decision-making as a means Programs. Washington DC: 1996. of improving child growth. 11. Roberfroid D, Pelto GH, Kolsteren P. Plot and see! Maternal comprehension of growth charts worldwide. Trop Med Int Heal 2007;12(9):1074–86. 12. Report of the Technical Consultation on Growth Monitoring and Promotion. Revisiting Growth Monitoring and its Evolution to Promoting Growth as a Strategic Program Approach: Building Consensus for Future Pho Program Guidance. 2007;1–19. Available from: https://www.unicef.org/nutrition/files/Report_of_Technical_ to: ©2 01 6G Consultation_on_GMP-2007.pdf i rd h ari Bor a /m 13. Programme Evaluation Organization. Evaluation Report on Integrated Child Development Scheme (ICDS) Seh at , Co Jammu & Kashmir. Gov India [Internet] 2009;1–73. Available from: http://planningcommission.nic.in/reports/ urte sy o f Ph peoreport/peo/peo_icds.pdf ot osh a re 14. Barnett I, Yosellina, Sulistyo S, et al. Mixed-method impact evaluation of a mobile phone application for nutrition monitoring in Indonesia. 2016;(July):46 p. Available from: http://opendocs.ids.ac.uk/opendocs/ bitstream/123456789/12077/1/ER200_MixedMethodImpactEvaluationofaMobilePhoneApplication forNutritionMonitoringinIndonesia.pdf 15. Global Financing Facility. Summary Report of the Convening on “Rethinking Growth Promotion: New Approaches for Results in the SDG Era.” Washington DC: unpublished; 2019. 16. John Snow Inc. Digital Supportive Supervision. Boston, MA: 17. Nutri-Salud Project. Nota Tecnica: La Manta de Crecimiento: Una herrimienta comunitaria para la deteccion oportuna de la desnutricion cronica, Resultados de la Validacion en Guatemala. 2017. 18. NOURISH PROJECT. Validation of the Child Length Mat. 2016. 19. Save the Children. Child Length Mat Pilot in Pursat. 2017. 20. Flores-Ayala R, Suchdev PS, Martorell R, Ramakrishnan U, Alexander E, Conkle J. Accuracy and reliability of a low-cost, handheld 3D imaging system for child anthropometry. PLoS One 2018;13(10):e0205320. 21. Louw J, Richter L, Sen D, Desmond C, van Heerden A. App-Supported Promotion of Child Growth and Development by Community Health Workers in Kenya: Feasibility and Acceptability Study. JMIR mHealth uHealth 2017;5(12):e182. 7 7 8 8 Photo: © 2015 Dominic Chavez/World Bank. Freetown, Sierra Leone. Photo: © 2018 Sarah Cunningham, USAID-funded Resiliency in Northern Ghana project “ re o tos ha NEW TOOLS TO MEASURE CHILD Ph urt esy o f GROWTH HAVE GREAT POTENTIAL Co A2 0 20 , TO IMPROVE ANTHROPOMETRIC M rm a n/P DIAGNOSTIC ACCURACY AND DATA me ne aZ im QUALITY, IMPROVE THE CLASSIFICATION Lin :© 2 01 6 AND VALUE OF ROUTINE NUTRITIONAL oto Ph ASSESSMENTS, AND INCREASE 9 Photo: © 2019 Bo Sorensen, UNICEF Product Innovation Photo: @2018 USAID-funded NOURISH Project NEEDED REFERRALS. 10 This work is a product of the staff of the RIGHTS AND PERMISSIONS Global Financing Facility (GFF) Secretariat The material in this work is subject to at the World Bank with contributions from copyright. Because The World Bank the Bill & Melinda Gates Foundation, The encourages dissemination of its knowledge, Manoff Group, and UNICEF. 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