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Research
Nutrition Project), Madagascar, and Senegal
showed that children whose growth is monitored
and whose mothers receive nutrition and
health education and have access to basic child
health services have a better nutritional status
and/or survival than children who do not.
The debate about GMP has remained ongoing.
In 2003, a report by Save the Children UK
questioned the evidence behind community
nutrition projects in Bangladesh, Ethiopia, and
Uganda. It also stated that “growth monitoring
and promotion interventions are bound to fail
unless they are explicitly linked to efforts to
address the underlying causes of malnutrition.”
A systematic review of the evidence for the
impact of GMP in 2007 provided a comprehensive
view of various programmes worldwide
and provided evidence that significant
reductions in malnutrition can be
achieved through intensive health and
nutrition education and basic healthcare
without GM.
After the launch of the new growth
standards by WHO in 2006, a momentum
was created to revisit GM activities
and rethink the best use of the years of
experience. As countries have begun to
adopt the new standards, many questions
have been raised concerning the
programmatic uncertainties of GM at
the community level.
Many countries face a challenge in
dealing with the question of whether or
not to implement GM and GMP.
Despite all the developments in nutrition
programming in the past 10 years,
GM still seems to be a convenient delivery
mechanism for community
interventions. However, national planners
need better guidance on
transitioning to alternative options that
are not based on monitoring growth in
the communities, if GM has not proven
to be effective in contributing to
programmes for prevention of undernutrition.
Part of the confusion about the place
of GM in nutrition programmes
appears to be due to lack of agreement
on the definition and expected
outcomes of GM and GMP. The authors
of this review suggest the following
clarifications:
Growth monitoring is a process of following
the growth of a child compared with a standard
by periodic, frequent anthropometric measurements
and assessments. The main purpose of
GM is to assess growth adequacy and identify
faltering at early stages before the child reaches
the status of undernutrition.
Community based growth monitoring is not
itself an intervention that can treat growth
faltering when it is identified. It is rather an
activity which, in addition to making a child’s
growth visible, may become an important point
of contact with the caregiver and stimulate
discussions at the community level. If implemented
as a stand-alone activity, GM does not
provide any benefits apart from knowledge
about a child’s growth status.
GMP is defined as tailored counselling based
on the GM results and follow-up problem solv-
The decision to include GM and promotion
sessions in community-based programmes
needs to be made at the national and subnational
levels after careful consideration of
priorities, available resources, and the feasibiling
with caregivers. This allows looking into
growth monitoring-specific outcomes and
benefits, as compared with general counselling
and other interventions that could be delivered
outside the GM session as well.
A community-based programme should
include a number of interventions such as
general counselling to caregivers (either individually
or in groups) and delivery of different
services within the context of the communitybased
programme. These interventions and
services could be delivered during the same
GMP session, using the opportunity of the
contact with caregivers. These services,
however, are not dependent on measuring the
growth of children and can also be delivered
outside the GM context.
Growth monitoring
Combining GMP and additional interventions
needs to be planned carefully to ensure
that the quality of both is maintained. In some
settings, workers may become overburdened by
additional tasks and focus most of their attention
on delivery of services rather than effective
counselling and problem-solving with mothers.
Evidence is accumulating on the types of
community interventions that are effective,
practical, and sustainable. These interventions
are not necessarily linked to GM, which raises
the question of whether there is a need for this
activity if the community-based programmes
can be designed and implemented successfully
without monitoring the growth of each child.
ity of reaching a high quality of GMP activities.
In many settings where a concrete nutritional
problem is affecting most of the population,
such as micronutrient deficiencies or low
breastfeeding rates, a targeted intervention may
be a first priority for reaching quick improvements
before deciding on more comprehensive
community-based programmes, which could
include GMP.
Although it is not strictly necessary for inclusion
in any community-based programme,
under certain conditions having quality GMP
can add desirable aspects to these programmes.
The approach of regular monitoring of child
growth provides the opportunity for better
community actions to prevent undernutrition.
High quality GM can:
• Provide an opportunity to prevent
undernutrition before it occurs. GMP
helps community workers identify
infants and children who have
growth faltering (or are at risk for
faltering) and promotes timely actions
to improve the situation within a
short time frame
• Assist in focusing attention and
resources on children at risk.
• Motivate families and caregivers to
change and improve practices.
• Help target and tailor counselling
messages.
• Produce ancillary benefits. GM
sessions provide opportunities for
immunisation, screening and treatment
for diarrhoea, malaria, and pneumonia,
counselling on various health and
nutrition topics and the provision of
other community-level health or
preventive services as needed.
These additional benefits that are pertinent
to GMP do not receive enough
attention during most of the evaluations
of community-based programmes.
In general, the level of commitment
from the health system required for
successful implementation of GM and
GMP has proven difficult to maintain at
a large scale, with the exception of few
well-supported and well-supervised
national programmes. Supportive
supervision of community health workers
requires ample allotment of time and
funding, which may not be realistic
within a strained healthcare system.
UNICEF/NYHQ2011-0273/Dormino
Appropriate implementation of GMP is
dependent on the motivation of health workers.
Experience shows that community workers can
be effectively motivated to accurately measure,
plot, and diagnose growth faltering but are
often undervalued, under supervised, and
poorly paid. The ratio of trained staff to the
target population may also be inadequate.
The quality of training of community workers
requires significant resources and efforts. In
an evaluation of nine projects (governmentally
and non-governmentally implemented) in
Africa and Asia that included GM, most of the
settings had adequate infrastructure to support
GM but training was incomplete, leaving only a
small proportion of the staff able to adequately
take weight measurements.
In addition, the low educational level of
community workers in some settings impedes
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