Coetzee, D.J.

Ferrinho, P.

English

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Nutritional status ofchildren in AlexandratownshipClinic-based data and a communitysurveyD. J. Coetzee, P. FerrinhoA community-based survey of the nutritional status ofchildren aged 12 - 23 months was conducted. A clustersampling technique was used. The weight and height of426 children were measured.Compared with clinic-based growth-monitoring data,which showed that 5,5% of the children were below the3rd percentile of weight for age, this survey revealed that17,7% of boys and 9,3% of girls were below the 3rdpercentile of weight for age. This may indicate that thehealth centre is not reaching those in greatest need.In respect of height for age, 44,3% of boys and 44,1 %of girls were below the 3rd percentile while less than 4%of boys arid girls were below the 3rd percentile of weightfor height; this indicated a high percentage of stunting butno acute malnutrition.Growth monitoring may be an important component of achild health programme. However, unless growth ismeasured accurately and appropriate action implemented,growth monitoring alone is of little value.Thus before continuing with the programme of growthmonitoring, the Alexandra Health Centre should ensurethat health workers are adequately trained and thatappropriate interventions are implemented to reduce therisks associated with children who fail to gain weight atthe expected rate. Once implemented, a regular evaluationof all aspects should be undertaken.S Atr Med J 1994; 84: '413-415'.In its efforts to provide comprehensive primary health careto the community of Alexandra, the Alexandra Health Centre(AHC) and University Clinic is attempting to create a modelfor health care for the urban poor.'The AHC conducts well-baby clinics both at the healthcentre and as part of the Child Health Outreach . .Programme! All children under 5 years of age are weighedand their growth monitored on Road-to-Health cards. AsDepartment of Community Health, University of the Witwatersrand,JohannesburgD. J. Coetzee. BA. M.B. B.CH.• D.T.M. & H.• D.f'H.Alexandra Health'Centre and University Clinic, Centre forEpidemiological Research in Southern Africa, JohannesburgP. Ferrinho, M.B. CH.B.• D.T.M. & H.. M.SC. (MED.)SAMJARTICLESpart of a health information system, all weights are plottedon a master card and data are summarised and reported ona monthly basis.3Anthropometric data collected by the AHC are limited tothe measurement of weight and have a number of biases.The degree to which routinely collected clinic-based dataare representative of the nutritional status of the communityis also not clear.The object of this study, therefore, was to evaluate thenutritional status of children in Alexandra by means of acommunity-based survey. The survey was conducted inApril 1990 on children 12 - 23 months of age at the sametime as a vaccination coverage survey'Data from the health information system as well as thecommunity survey will be presented in order to compare the.survey's findings with routine clinic-based data.Population and methodsHealth information system dataAll master cards used to record nutritional data at AHC'swell-baby clinic (June 1989 to December 1990) wereretrieved. The weight for age was analysed for each of 3 agecategories.Children are weighed with minimal clothing on a 25 kghanging Salter scale if under 2 years of age and onbathroom scales if older tban 2 years. There are no checkson the accuracy of measurement.Community surveyThe study population included all children aged 12 - 23months. The sample consisted of 450 children and thesampling unit was a dwelling with a child in the required agegroup. A cluster sampling technique was used. Forty-fiveclusters were randomly selected from the 108 clustersdefined on field research! The initial dwelling in each clusterwas randomly selected. Interviewers moved to the adjacentdwelling according to well-defined rules until 10 children ofthe required age were found.The names of all mothers of children aged 12 - 23 monthswho were identified, but who were not present, wereobtained from other members of the family or fromneighbours, and 2 further attempts were made to interviewthem at their convenience. If a mother had 2 children in thisage group, only the first-born child was included in thestudy, If the interviewer was unable to find 10 mothers withchildren of appropriate age in a particular cluster, thedifference was not made up from another cluster.The weight of children was measured to the nearest0,1 kg. Children were weighed in underclothes only. Scaleswere checked with standard weights before the surveycommenced and calibrated to zero before each child wasweighed.Length was measured to the nearest 0,1 cm with the childin the recumbent position according to standard WorldHealth Organisation methods!The date of birth was taken' from the Road-to-Health card.Where not available, the date of birth was obtained from themother. The duration of the period of breast-feeding wasalso recorded.SAMJ Volllme 84 No.7 July 1994DiscussionTable 11. The distribution of children in the community surveybelow the 3rd percentile (%)Table 11 summarises the distribution of children below the3rd percentile of weight and height for age and weight forheight.Significantly more children from informal dwellings(79,2%; 95% Cl 71,7 - 84,8) had weights below the 50thpercentile for age than those from formal dwellings (67!6%;95% Cl 64,4 - 70,8).Similarly 53,2% (95% Cl 46,6 - 59,2) of children from.-informal dwellings and 39,5% (95% Cl 36,3 - 42,9) fromformal dwellings had heights below the 3rd percentile forage. There was no significant difference in respect of weightfor height.When children who were no longer breast-fed werecompared with children who were still breast-fed, 78,0%(95% Cl 72,4 - 81,9) as opposed to 65,3% (95% Cl 61,6 -68,6) had weights below the 50th percentile for age. Therewas no significant difference when comparing height for ageor weight for height.(12,5; 23,1)(5,3; 12,9)(37,5; 51,3). (38,8; 49,9)(1,2; 7,0)(1,6; 6,9)95% confidenceintervals17,79,344,344,13,53,9GenderBoysGirlsBoysGirlsBoysGirlsWeight for heightWeight for ageHeight for ageThe health information system data have a number ofbiases. The data are biased in favour of children under 12months of age (68% of attenders). A percentage of the datawill be duplicated as no distinction was made between firstand repeat attenders. Other possible biases relate tomeasurement errors, rounding off of decimal points and thelack of regular calibration of scales.9 Children (especiallyinfants) are often not completely undressed, particularly oncold days, as weight assessment is generally done in theopen.A limitation of the community survey is the narrow agegroup. However, the health information system data suggestthat the highest prevalence of children with weights belowthe 3rd percentile is in this age group.The poor inter-observer reliability, especially with regard toheight, is a cause for concern. The measurement of heightof children 12 - 23 months of age is a difficult procedure,particularly under adverse conditions such as in informalsettlements. The exercise has to be done in the open andeven with reassurance and calming, the child is excited andirritable and has to be restrained while the height ismeasured. In the younger child weight is more prone tochange, depending on whether it is measured before or aftermeals or if the child has passed urine or stool.Both data sets confirm the clinical experience at AHC thatsevere protein energy malnutrition is rare in Alexandra.However, the percentage of underweight children wassignificant and an extremely high percentage of children wasAge (months)Percentile < 12 12 - 23 > 23 All ages> 97 12,8 3,5 1,9 9,03 - 97 84,7 91,0 93,2 87,0<3 2,5 5,5 4,9 4,0Health information system dataData were available for 24 489 patient contacts: 68,1% wereless than 12 months old, 23,8% were 12 - 23 months oldand 8,1% were over 23 months of age. The weight profilefor each age group is presented ,in Table I.Table I. Distribution of children attending well-baby clinicsaccording to weight for age by age group (%)ResultsTwelve interviewers were selected from the AHC staff,most of them experienced in field surveys. Weights andheights were measured by 4 team leaders. A field pilot studywas conducted in a cluster not selected for the survey.A residence was assessed as an informal dwelling if thestructure was not built primarily of permanent materials.Repeatability checks were performed-on 1 mother andchild, randomly selected from each of the 45 clusters. Arepeatability coefficient (twice the standard deviation of themean difference between 2 repeat measurements) wascalculated to assess agreement of continuous data....Because of the cluster sampling method a bootstrapprocedure was used to establish confidence intervals andto identify variables associated with nutritional status.'Gender-specific WHO reference standards were used.· Alldata were analysed on the SAS statistical package (SASInstitute, Cary, NC).Data from the community surveyA total of 426 children was examined. In 4 clusters, less than10 children in the required age group were identified. Fiveinterviews had to be excluded: in 2 cases the full birth datewas not known and in 3 cases the age of the child was notwithin the required range. Thus the denominator for thestudy was 421 children.The Kappa statistic for the repeatability study comparinganswers to questions put to mothers on the periodof breast-feeding was 0,8 (95% Cl 0,6 - 1,0) and on theassessment of type of dwelling 0,9 (95% Cl 0,7 - 1,0). Therepeatability coefficient for weights was 1 500 g (mean + 2SO = 600 g, mean - 2 SO = 900 g) and 12 cm (mean + 2 SO= 7 cm, mean - 2 SO = -5 cm) for heights.Thirty-two per cent of dwellings were informal and 51 % ofthe children were boys.Mothers or guardians produced Road-to-Health cards for88% of children (82% of mothers from informal dwellingsand 92% from formal dwellings).Three per cent of mothers reported that they had neverbreast-fed their babies, 17% breast-fed for less than 3months, 9% breast-fed for 4 - 11 months while 71 %reported that they breast-fed for more than 12 months.Forty-four per cent of mothers were still breast-feeding theirbabies.- 414 Volume 84 No. 7 fuly 1994 SAMJstunted. The results are similar to those from othercommunities in the Cape'O.11 and Oukasie. 12A higher percentage of boys had weights below the 3rdpercentile for age but this differential was not observed withregard to height for age and weight for height.The lower prevalence of children 12 - 23 months of agebelow the 3rd percentile of weight for age at the well-babyclinic (5,5%) than in the community survey (13,8%) mayindicate that services are not reaching those in greatestneed. Data recently collected at AHC's paediatricoutpatients' department suggest that 15% of children12 - 23 months of age have weights below the 3rdpercentile, a better reflection of the community data.Forty-four per cent of children were below the 3rdpercentile of height for age, indicating that children arenutritionally stunted. Stunting is accepted as a reliableindicator of chronic malnutrition" and reflects the effects ofsocio-economic and environmental factors on growth; it isparticularly alarming at this early age. A 1981 review ofnutritional studies by Moosa and Coovadia14 suggests a 30 -60% range of chronic malnutrition in South Africa. A study inKhayelitsha showed a consistently high degree of stunting inall age groups, including 46,2% in the 12 - 23-month group.'oExposure to poor environmental conditions, with higherrates of infection, and the effects of socio-economic factorsmay explain the association between nutritional status andresidence in an informal dwelling.,5.,. A large number ofchildren in informal dwellings are recent immigrants fromrural areas and their nutritional status may reflect conditionsin the areas from which they came. A limitation of this studyis the lack of information on length of stay in Alexandra.Implications for programmedevelopmentSevere protein energy malnutrition is unlikely to be a majordirect cause of mortality in Alexandra. However, the healthinformation system data for the paediatric outpatients'department and casualty underline the fact that muchpaediatric morbidity is associated with low weight for age.A second major and equally important concern isthe extremely high prevalence of stunting. Theconsequences of chronic malnutrition are usually notaddressed as these effects are difficult to assess in terms ofmortality and morbidity. The evidence shows that stuntingdoes have a major medium- and long-term impact on thequality of life of children and adults,17.'8 and points to theneed for programmes that address this problem.Reasons for the differences between the routinelycollected clinic data and those from the community surveymust be examined.Whom do the well-baby clinics serve? If an interventionprogramme was introduced would it reach those in greatestneed? An evaluation to determine who attends the servicesand how to attract those in greatest need is beingconducted at present.Is growth monitoring adequately performed at well-babyclinics? A number of studies have shown that weights aremeasured inaccurately and that the plotting andinterpretation are inadequate.9,'9,20 An evaluation of thesefunctions is essential.SAMJARTICLESIn order to address the problem of stunting, height shouldalso be measured as part of the growth-monitoringprogramme. However, even with extensive training, height isdifficult to measure accurately in children under 2 years ofage.What action should be taken if a child who fails to gainweight at the expected rate is identified? The causes ofgrowth faltering are complex and the answers are oftenoversimplified.'9 However, unless appropriate action is taken,growth monitoring alone is of little value.Growth monitoring may be an important component of achild health programme but before continuing with theprogramme, the AHC should ensure that: (I) health workersare adequately trained to measure, plot and interpretweights accurately; (il) appropriate interventions areimplemented to reduce the risks associated with childrenwho fail to gain weight at the expected rate; and (iil) onceimplemented, a regular evaluation of all aspects isperformed.In addition the AHC should continue to conductcommunity-based nutrition surveys as routine clinic-baseddata may not reflect the true nutritional status of thecommunity.The authors wish to thank Ms G. Phakathi, who managesthe health information system at the clinic, Ms L. Vena whocoded the data, Drs D. Yach and M. Zwarenstein forcomments on an earlier draft, the Centre for EpidemiologicalResearch in Southern Africa for generously funding thisresearch and all the interviewers who participated in thesurvey.REFERENCES1. Ferrinho PdeLGM, Wilson TO. Alexandra Health Centre and University Clinic - amodel for urban primary health care (Opinion). S Afr Med J 1991; 80: 368-369.2. Coetzee DJ, Ferrinho P, Reinach SG. A vaccination survey using the EPImethodology to evaluate the impact of a child health outreach programme in anurban area of South Africa. Bull World Health Organ 1993; 71: 33-39.3. Phakathi RN, Ferrinho P, Aobb 0, et al. Problems identified and lessons learnt duringthe development of a health information system for a primary health care centre inAlexandra township. CHASA 1993; 4: 16-20.4. Jelliffe DB. The Assessment of the Nutritional Status of the Community. Geneva:World Health Organisation, 1966.5. Bland JM, Altman DG. Statistical methods for assessing agreement between twomethods of clinical measurement. Lancet 1986; 1: 307-310.6. Fleiss JL. Statistical Methods tor Rates and Proportions. New York: John Wiley &Sons,1988.7. Effron B, Tibshirani R. Bootstrap methods for slandard errors, confidence intervals,and other measures of statistical accuracy. Statistics in Science 1986; 1: 54-57.8. National Centers of Health Statistics. Gro....lth Charts (HRS 76-1120, 25,3). Rockville,Md.: United States Public Health Service, Health Resources Administration, 1976.9. Kuhn L, Zwarenstein M. Weight information on the 'Road-to-Heatth' card - inadequatefor growth monitoring? (Correspondence). S Atr Med J 1990; 78: 495-496.10. Hugo-Hamman CT, Kibel MA, Michie CA, Yach D. Nutrition status of preschoolchildren in a Cape Town township. S Afr Med J 1987; 72: 353-356.11. Yach D, Coetzee N, Hugo-Hamman CT, Fisher SA, Kibel MA. Identifying children atrisk in peri-urban Cape Town. S Atr J Epidemiollnt 1990; 5: 6-8.12. Barron PM, Ferrinho PdeLGM, et al. Community health survey of Oukasie, 1987. SAir Med J 1991; 79: 32-34.13. Waterfow JC, Buzina R, Keller W, Lane JM, Nichaman NZ, Tanner JM. Thepresentation of use of height and weight data for comparing the nutritional status ofgroups of children under the age of 10 years. Bull World Health Organ 1977; 55: 489-498.14. Moosa A, Coovadia HM. The problem of malnutrition in South Africa(Correspondence). S Air Med J 1981; 59: 888-889.15. Martorell R, Sharma R. Trends in nutrition, food supply and infant mortality rates. In:Halstead SB, Walsh JA, Warren K, eds. Good Health at Low Cost (Proceedings of aconference of the Rockefeller Foundation held at Belagio, Italy, 1985). New York:Rockefeller Foundation, 1987.16. Beisel WR. Magnitude of the host nutritional response to infection. Am J CUn Nutr1977; 30: 1236-1247.17. Scrimshaw NS. Individual, Social and Political Consequences ot Malnutrition. Paperpresented at Nutrition and Dietetics Congress, Cape Town, 1990.18. Dabbing J. Infant nutrition and later achievement. Am J Clin Nutr 1985; 41: 477-484.19. Nabarro D, Chinnock P. Growth monitoring - inappropriate promotion of anappropriate technology. Soc Sci Med 1988: 26: 941-948.20. Kuhn L, Zwarenstein M, Thomas Tt et al. Village health workers and GOBI-FFF:evaluation of a rural programme. S Afr Med J 1990; 77: 471-475.Accepted 28 Jul 1993.SAMJ Volllme 84 No.7 JlIly 1994

Nutritional status of children in Alexandra township

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Nutritional status of children in Alexandra township

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