https://doi.org/10.

1186/s13104-020-4910-z
BMC Research
Notes

RESEARCH NOTEOpen Access

Effect of maternal growth monitoring

knowledge on stunting, wasting
and underweight among children 0–18
months in Tamale metropolis of Ghana
Mohammed Bukari* , Muzamil Mohammed Abubakari, Mohammed Majeed, Abdul-Razak Abizari,
Anthony Wemakor and Ambrose Atosona

Abstract
Objective: This study sought to assess maternal growth monitoring knowledge and its effect on stunting, wasting and
underweight among children 0–18 months in the Tamale Metropolis. An analytical cross‑sectional study design, involving 340
mother–child pairs randomly selected from 4 health facilities in the Tamale Metropolis was used. A structured questionnaire was
used to collect information on socio‑demographic characteristics and maternal growth monitoring knowledge. Weight and length
of children were taken to assess nutritional status (stunting, underweight and wasting). Chi square/Fisher’s exact test was used
to determine the association between maternal growth moni‑ toring knowledge level and child nutritional status.
Results: The study revealed that 87.6% of mothers had good knowledge on growth monitoring. The prevalence of stunting,
underweight and wasting were 9.4%, 25.9% and 17.9% respectively. Bivariate analysis revealed that there is

no association between maternal growth monitoring knowledge and stunting (p = 0.781), wasting (p = 0.743) and
underweight (p = 0.529) among children 0–18 months in the Tamale Metropolis.
Keywords: Growth monitoring, Knowledge, Wasting, Stunting, Underweight, Tamale

Introduction
improve growth [3, 4]. Assessing growth allows captur-
Child growth monitoring is aimed at improving and
ing growth faltering before the child reaches the status
maintaining child health and nutrition [1]. It is so far
of under-nutrition thereby reducing the risk of death
the best strategy carried out worldwide to tackle mal-
[5]. According to Schwinger et al. [6], assessing a
nutrition [2]. It involves regular measurement and plot-
child’s growth trajectory provides a more accurate
ting of a child’s weight on a growth chart [3, 4].
prognosis of likely death than the use of static measures
Growth monitoring is a process of regularly following
of nutritional status. Sinaga et al. [7] also revealed that
the growth rate of a child in comparison to standard
growth moni- toring has a positive impact on infant
anthropomet- ric measurements [2]. It is usually
feeding practices and calorie intake.
coupled with pro- motional activities such as
Growth monitoring is practiced worldwide [8] and its
counselling and actions to improve growth, as
coverage in Ghana is 95.3% [9]. A79% coverage has also
weighing and charting alone cannot
been reported in the Tamale Metropolis [10]. Despite
its wide coverage, the prevalence of malnutrition is still
*Correspondence: mohammed.bukari@yahoo.com high, indicating that it may be poorly implemented.
Department of Nutritional Sciences, School of Allied Health
Sciences, University for Development Studies, P. O. Box TL 1883, Globally, approximately half of all deaths in under five
Tamale, Ghana

© The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits
use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The
images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the
copyright holder. To view a copy of this licence, visit http://creativeco mmons.org/licenses/by/4.0/. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article,
unless otherwise stated in a credit line to the data.
Bukari et al. BMC Res (2020) Page 2 of
Notes 13:45

children are link to malnutrition, translating into the

Data collection
loss of about 3 million lives a year [5].The prevalence
A pretested structured questionnaire was used to docu-
of stunting, wasting and underweight for children
ment information on participants’ demographic charac-
under 5 years are 19%, 5% and 11% respectively in
teristics (sex of child, age of mother and child,
Ghana and
mothers’ educational level, religion, occupation and
33.1%, 6.3% and 20% respectively in Northern region
marital sta- tus) and level of maternal knowledge on
[11]. Malnutrition puts children at greater risk of dying
growth moni- toring. Regarding growth monitoring
from common infections, increases the frequency and
knowledge, the questionnaire items were adapted from
severity of such infections, and delays recovery [5].
similar studies (9, 14). A composite score was on
It has been established in other settings that poor
mothers’ responses to the questions. A score of 1
knowledge on growth monitoring among mothers
(maximum score) was assigned to a correct response
is associated with poor implementation of growth
while a score of 0 (mini- mum score) was assigned to
monitoring [9, 12] which results in high malnutrition
an incorrect response. Mothers who scored 0–4 for the
rate. However, growth monitoring knowledge among
knowledge questions were considered to have poor
mothers and its relation to child nutritional status is
knowledge while those who scored 5–8 for the
unknown in the Tamale Metropolis. Hence this study
knowledge questions were considered to have good
sought to assess maternal growth monitoring knowl-
knowledge. Anthropomet- ric measurements (length
edge and its effect on nutritional status of children 0–
and weight) of the children were taken and nutritional
18 months in the Tamale Metropolis.
status (stunting, wasting and underweight) assessed in
accordance with WHO standards [14]. Length of
children was measured using an infantometre to the
Main text nearest 0.1 cm. Weight of chil- dren was measured
Methodology
using a digital electronic weighing scale (Seca 874) to
Study design, study setting and sampling
the nearest 0.1 kg. Height-for-age Z-score (HAZ),
An analytical cross-sectional study design was
weight-for-height Z-score (WHZ), and
employed and involved 340 mother–child pairs selected weight-for-age Z-score (WAZ)
(− 2SD) from the median of the< WHO
− 2 standard
Growthdevia- tions
Standards
from 4 health facilities (Tamale Central Hospital, were defined as stunting, wasting, and
Reproductive and Child Health Centre, Nyohini Health underweight respectively.
Centre and Bulpiela Health Centre) in the Tamale
Metropolis. The study was carried out from May 10 to
June 15, 2018. Simple random sampling method was Statistical analysis
used in selecting the 4 study health facilities from all Data entry and analysis was done using Statistical
(10) the public health facilities in the Tamale Metropo- Pack- age for Social Sciences (SPSS) (IBM, version
lis. Mothers with children aged 0–18 months attending 21) and WHO Anthro software. Chi square/Fisher’s
the child welfare clinics of the selected health facilities exact test was used to determine the association
were eligible for the study. Subjects who were very ill between maternal growth monitoring knowledge level
(unstable vital signs/mental status) were excluded from and child nutritional status (stunting, wasting and
the study. underweight). p < 0.05 was considered significant at
Sample size was determined using the formula [13]: two tailed tests. Percentages and cross tabulations were
2 used to show respondents’ responses.
= z p (1 − p)
N
M.E 2

where N is the sample size; z is the abscissa of the nor- Results

Socio–demographic characteristics of the study sample
mal curve that cut-off an area at the tail (1.96); P is the The mean age and
of mothers wasages
29.26
the minimum maximum of±17
5.64
andyears with
50 years
estimated proportion of an attribute (stunting) that is respec-
present in the study population, which is 33.1% [11] in tively. Most of the mothers (44.7%) had no formal educa-
(5% =
region; M.E is the desired 0.05). Northern
level of precision tion, with 96.8% being married. Moreover, majority of the
mothers were self-employed (71.8%), belonged to Dag-
(1.96)20.331(1 − 0.331) omba ethnic group (80.9%) and Islamic religion (93.8%).
The mean age of children was 5.7 ± 4.3 months, with
N = = 340
0.05 2
( )
majority of them in the age group 0–5 months (57.4%).
Therefore, sample size for the study was 340 respondents. Also, majority of the children were males (51.5%).
 Bukari et al. BMC Res (2020) Page 3 of
Notes 13:45

Table 1 Socio-demographic characteristics

Relationship between maternal growth monitoring
Characteristic Category Frequency (%)
knowledge and child nutritional status
It was revealed in the present study that the association
Age of mother
stunting (p = (years) underweight
0.781), 17–27 (p = 0.529) 146
and (42.9)
wast- between maternal growth monitoring knowledge and ing (p =
0.743) is statistically insignificant
28–37
as shown 158
in (46.5)
Table 3.
> 38 36 (10.6)
Education None 152 (44.7)
Primary 31 (9.1) Discussion
Middle/JHS 59 (17.4) With regards to knowledge level of mothers on growth
SHS/vocational training 51 (15) monitoring, the study revealed that majority (80.6%) of
Tertiary 47 (13.8) respondents chose weighing as the meaning of growth
Occupation Employed 38 (11.2) monitoring. This finding is comparable to that of
Self employed 244 (71.8) Debuo et al. [9] in Lawra District, Upper West Region
Unemployed 58 (17) of Ghana, where 70.3% of mothers chose weighing as
Ethnicity Dagomba 275 (80.9) the meaning of growth monitoring. This indicates that
Gonja 19 (5.6) there has been a lot of education on growth monitoring
Mamprusi 11 (3.2) among mothers in both districts. Apart from massive
Others 35 (10.3) education, it could also mean that the health person-
Religion Christianity 21 (6.2) nel used similar approaches in delivering information
Islam 319 (93.8) to mothers. The present study also revealed that 85.6%
Age of child (months) 0–5 195 (57.4) of mothers thought growth monitoring improves chil-
6–11 102 (30) dren’s nutritional status and subsequently growth. This
12–18 43 (12.6) finding is similar to findings of other studies [9, 15].
Sex of child Male 175 (51.5) In addition, 92.9% of participants in the current study
Female 165 (48.5) said that growth monitoring is provided every month.
Table 1 depicts the socio-demographic characteristics A similar study by Daniel et al. [15] in Ethiopia
of respondents. revealed that 32.1% of the respondents said growth
monitor- ing services is provided every month. The
difference in findings could be due to the fact that
Maternal growth monitoring knowledge level mothers in Ethiopia did not receive adequate education
Table 2 shows maternal growth monitoring knowl- on inter- val of growth monitoring visits as compared
edge level. Majority of the mothers referred to to mothers in Ghana. It could also be due to differences
weighing (80.6%) as the meaning of growth in health policy implementation between Ghana and
monitoring. A large section (85.6%) of the mothers said Ethiopia. Furthermore, 98.5% of the respondents know
growth monitoring is important as it determines the when growth monitoring services should begin. In a
child’s nutritional status. Also, majority (92.9%) said simi- lar study [15], a higher percentage (68.2%) of
every mother ought to attend growth monitoring mothers knew when growth monitoring services ought
sessions once every month. Some of the mothers to begin. If mothers know when growth monitoring is
(31.8%) said the growth chart represents the growth of supposed to begin then there is a high probability that
the child. With regards to overall knowledge level of mothers will start growth monitoring early and could
mothers, 12.4% had poor knowledge while 87.6% had reap the full benefits of growth monitoring services.
good knowledge. This study also uncovered that 32.1% of mothers felt
growth moni- toring was for children between the ages
Nutritional status of children of 0–5 years. This finding is also in consonance with
The mean HAZ, WHZ and WAZ were 0.1 ± 1.7, that of Daniel et al. [15].
Regarding the overall knowledge level of mothers on
− 1.08 ± 1.75 and − 0.78 ± 1.4 respectively (Additional growth monitoring, 87.6% of the mothers had good
file 1). The prevalence of stunting, wasting and under-
weight were 9.4%, 25.9% and 17.9% respectively (Addi- knowledge in the present study. Similarly, a good
tional file 2). It was also revealed in the present study knowl- edge level was also reported in studies
that stunting and underweight were significantly associ- conducted in Ghana [9, 16] and other parts of the world
ated with maternal education (p = 0.008) and age of child [17, 18]. Con- trarily, a study by Daniel et al. [15]
(p = 0.003) respectively (Additional file 3).
revealed that 53% of
Bukari et al. BMC Res (2020) Page 4 of
Notes 13:45

Table 2 Maternal growth monitoring knowledge

Characteristic Category Frequency (%)

When you hear growth monitoring, what comes to mind? Weighing 274 (80.6)
Immunization 62 (18.2)
Treatment of malnourished children 4 (1.2)
Importance of growth monitoring Determines child’s nutritional status 291 (85.6)
Educates about appropriate child feeding 44 (12.9)
Don’t know 4 (1.2)
Not important 1 (0.3)
Number of times one is supposed to go for growth monitoring sessions Once a month 316 (92.9)
Twice every month 15 (4.4)
Once every 6 months 4 (1.2)
Don’t know 5 (1.5)
When is one to start going forgrowth monitoring sessions? At birth 282 (82.9)
At 1 month of age 53 (15.6)
At 1 year of age 5 (1.5)
Age range for growth monitoring Children < 2 years of age 208 (61.2)
Children 0–5 years of age 110 (32.3)
Don’t know 22 (6.5)
One responsible for growthmonitoring provision Nurses 321 (94.4)
Midwives 10 (2.9)
Doctors 8 (2.4)
Teachers 1 (0.3)
Where growth monitoring services are provided? Hospitals 79 (23.2)
Health centers 248 (72.9)
Don’t know 13 (3.8)
What does a growth chart represent? It shows the age of child 63 (18.5)
It shows how the child is growing 107 (31.5)
It has no meaning 28 (8.2)
Don’t know 142 (41.8)
Knowledge level Poor knowledge 42 (12.4)
Good knowledge 298 (87.6)

mothers had poor knowledge on growth monitoring, present study. Moreover, the decreasing trend in stunt-
which could be due to inadequate education on growth ing prevalence in the Northern region since 2011 could
monitoring in this setting. also account for the low prevalence reported in the pre-
The prevalence of stunting in the sampled population sent study. The prevalence of stunting decreased from
was 9.4%. This result is much lower than the Northern 37.4% in 2011 [20] to 33.1% in 2014 [11]. Although
regional prevalence of 33.1% reported in the most the prevalence of stunting is on the decrease, the
recent Ghana Demographic Health Survey (GDHS) in finding of the present study shows that it is still a
2014 [11]. It is also lower than the national stunting public health concern in Northern region of Ghana. The
prevalence of 18.7% reported by WHO in 2014 [19]. prevalence rates of underweight and wasting were
The present study was conducted among children aged 25.9% and 17.9% respectively in the present study.
0–18 months while that of GDHS and WHO were Regarding underweight, the prevalence rate in the
among children under current study was higher than the prevalence rates in
5 years, this methodological difference could partly Northern region of Ghana (20%)
account for the lower prevalence recorded in the pre- [11] and Ghana as a whole (11.2%) [19]. Similarly, the
sent study. It is also worth noting that the prevalence prevalence of wasting in the present study was higher
rates reported by GDHS and WHO were average figures than the prevalence rates in Northern region (6.3%) [11]
for Northern region and Ghana respectively, suggesting and Ghana (5%) [19]. Again, the difference in methodolo-
that other places in the Northern region or Ghana could gies employed may partly explain the difference in find-
have lower prevalence rates, hence the finding of the ings between the present and previous studies. Also, the
Bukari et al. BMC Res (2020) Page 5 of
Notes 13:45

Table 3 Relationship between maternal growth monitoring knowledge and stunting, wasting and underweight
Characteristic Stunting
Stunted N = 32 (%) Not stunted N = 308 (%) Total N = 340 (%) p-value

Knowledge level
Poor knowledge 3 (7.1) 39 (92.9) 42 (100) 0.781
Good knowledge 29 (9.7) 269 (90.3) 298 (100)
Characteristic Underweight
Underweight N = 61 (%) Not underweight N = 279 Total N = 340 (%) p-value
(%)
Knowledge level
Poor knowledge 9 (21.4) 33 (78.6) 42 (100) 0.529
Good knowledge 52 (17.4) 246 (82.6) 298 (100)
Characteristic Wasting
Wasted N = 88 (%) Not wasted 252 (%) Total N = 340 (%) p-value

Knowledge level
Poor knowledge 10 (23.8) 32 (76.2) 42 (100) 0.743
Good knowledge 78 (26.2) 220 (73.8) 298 (100)

high prevalence rates of underweight and wasting in

exposure and outcome were assessed simultaneously.
the present study could be an indication that enough
Moreover, nutritional status of the mothers was not
empha- sis has not been laid on interventions geared
assessed. This notwithstanding, we trust the study shed
towards tackling underweight and wasting in the
some light on the effect of maternal growth monitor-
Metropolis. Although underweight among children
ing knowledge on child nutritional status in the Tamale
under five is not considered public health concern in
Metropolis.
Ghana [20] and Northern region [11], this study has
shown that under- weight should be considered a
Supplementary information
public health concern for children between 0–18
Supplementary information accompanies this paper at https://doi.
months in the Tamale Metropolis. Moreover, no org/10.1186/s13104-020-4910-z.
association was established between maternal growth
monitoring knowledge level and stunt- ing, Additional file 1. Nutritional status indicators.
underweight and wasting. On the other hand, a study Additional file 2. Nutritional status of children.
revealed a significant association between underweight
Additional file 3. Nutritional status by socio-demographic characteristics
of respondents.
(p = 0.02) and maternal growth monitoring knowledge
[21]. The variation in findings could be attributed to dif-
ferences in attitudes and practices of mothers in Abbreviations
relation to growth monitoring in both settings. The GDHS: Ghana Demographic Health Survey; HAZ: Height-for Age-Z-score; M. E:
finding of the present study shows that good maternal marginal error; WAZ: Weight-for-Age-Z-score; WHO: World Health Organiza-
tion; WHZ: Weight-for-Height-Z-score.
knowledge of growth monitoring does not
automatically translates to improved child nutritional Acknowledgements
status, unless it is coupled with good attitude and The authors would like to thank the mothers who willingly consented to par-
ticipate in this study. We also wish to thank all the staff of the health facilities
practices of growth monitoring. for their support during the study.

Authors’ contributions
Conclusion Authors MB, MMA, MM and AA designed the study. Author MB, MMA, MM
Growth monitoring knowledge level of the mothers is performed field data collection. Authors MB, MMA and AA analyzed the
high, but has no effect on stunting, wasting and under- study results. MB and AA wrote the first draft of the manuscript. Authors
A-RA and AW contributed to the writing of the manuscript. All authors read
weight among children 0–18 months in the Tamale and approved the final manuscript.
Metropolis.
Funding
We did not receive funding for this study.
Limitations
The cross-sectional nature of the study does not pro-
vide a good basis for determining causality as both
Bukari et al. BMC Res (2020) Page 6 of
Notes 13:45

Availability of data and materials

7. Sinaga HT, et al. Using scores in interpreting growth status
The datasets used and/or analyzed during the current study are available
effectively improved infant feeding practices and calorie intake of
from the corresponding author on reasonable request.
child aged 0–12 months. Int J Med Sci Public Health. 2016;5:1014–
20.
Ethics approval and consent to participate
8. De Onis M, Wijnhoven TM, Onyango AW. Worldwide practices in child
Approval to conduct the study was given by the Joint Ethical Review
growth monitoring. J Pediatr. 2004;144(4):461–5.
Commit- tee of the School of Medicine and Health Sciences and School of
9. Debuo TD, et al. Caregivers knowledge, attitude and practices on
Allied Health Sciences, University for Development Studies (Protocol
child growth monitoring and promotion activities in Lawra District,
Number 05-2018).
Upper West Region of Ghana. Sci J Public Health. 2017;5:20–30.
Permission was obtained from the Tamale Metropolitan Health Directorate
10. Service G.S. Population and housing census: district analytical
and the hospitals of study. Written informed consent was also obtained
report. Agotime Ziope District: Ghana statistical service; 2014.
from participants after providing them with sufficient information about the
11. Service, G.S. Ghana demographic and health survey, 2014. Maryland: GSS,
study. Regarding participants who were less than 18 years of age, written
GHS, and ICF International; 2015.
informed consent was obtained from their parents. Participants were also
12. Roberfroid D, et al. Perceptions of growth monitoring and promotion
assured of the confidentiality of the information provided.
among an international panel of district medical officers. J Health Popul
Nutr. 2005;23:207–14.
Consent for publication
13. Cochran WG. Sampling techniques. New York: Wiley; 2007.
Not applicable.
14. Organization, W.H. WHO child growth standards: length/height for age,
weight-for-age, weight-for-length, weight-for-height and body mass
Competing interests
index-for-age, methods and development. Geneva: World Health
The authors declare that they have no competing interests.
Organi- zation; 2006.
15. Daniel B, et al. Knowledge and attitude on growth monitoring and
Received: 17 October 2019 Accepted: 16 January 2020
its associated factors among mothers/guardians of children less than
2 Years in Areka Town, southern Ethiopia, 2017. J Nutr Disord Ther.
2017;7(216):2161–0509.1000216.
16. Gyampoh S, Otoo GE, Aryeetey RNO. Child feeding knowledge and prac-
tices among women participating in growth monitoring and promotion
References in Accra, Ghana. BMC Pregnancy Childbirth. 2014;14(1):180.
1. Griffiths M, Rosso JD. Growth monitoring and the promotion of healthy 17. Wamani H, et al. Infant and young child feeding in western Uganda:
young child growth: evidence of effectiveness and potential to prevent knowledge, practices and socio-economic correlates. J Trop Pediatr.
malnutrition. Washington, DC: Manoff Group; 2007. p. 36. 2005;51(6):356–61.
2. Österberg, M., Nursing staff´ s experiences of working with 18. Otoo GE, Lartey AA, Pérez-Escamilla R. Perceived incentives and
children’s growth monitoring and promotion in Zambia. 2016. barriers to exclusive breastfeeding among periurban Ghanaian women. J
3. Panpanich, R, Garner P. Growth monitoring in children. Cochrane Data- Hum Lactation. 2009;25(1):34–41.
base Syst Rev. 1999(4). 19. World Health Organisation. Global database on child growth and
4. Garner P, Panpanich R, Logan S. Is routine growth monitoring effective? A malnu- trition. 2019. https://www.who.int/nutgrowthdb/database/en/.
systematic review of trials. Arch Dis Child. 2000;82(3):197–201. Accessed 10 Oct 2019.
5. UNICEF. Revisiting growth monitoring and its evolution to 20. Ghana Statistical Service G. Ghana multiple indicator cluster survey
promoting growth as a strategic program approach: building with an enhanced malaria module and biomarker. Final Report. 2011.
consensus for future program guidance. Report of the technical 21. Ashworth A, Shrimpton R, Jamil K. Growth monitoring and promotion:
consultation on growth monitoring and promotion. Book revisiting review of evidence of impact. Matern Child Nutr. 2008;4:86–117.
growth monitoring and
its evolution to promoting growth as a strategic program approach:
building consensus for future program guidance. Report of the Publisher’s Note
technical consultation on growth monitoring and promotion. 2007. Springer Nature remains neutral with regard to jurisdictional claims in
6. Schwinger C, Fadnes LT, Van den Broeck J. Using growth velocity to pub- lished maps and institutional affiliations.
predict child mortality, 2. Am J Clin Nutr. 2016;103(3):801–7.