Understanding why child welfare clinic attendance and growth of children in the nutrition surveillance programme is below target: lessons learnt from a mixed methods study in Ghana

Faith Agbozo, Esi Colecraft, Albrecht Jahn, Timothy Guetterman

Growth monitoring and promotion (GMP) programmes promote not only child health but serve as a service delivery strategy to enhance coverage for other crucial nutrition-specific interventions. This study compared community-based and facility-based GMP programme with respect to attendance rates, children's nutritional status, caregivers' satisfaction with services received and perceptions of service providers and users on factors influencing utilization. Explanatory sequential mixed methods study conducted in Ga West municipality, Ghana. It comprised 12-month secondary data analysis using growth monitoring registers of 220 infants aged 0-3 months enrolled in two community-based (CB = 104) and two facility-based (FB = 116) child welfare clinics; cross-sectional survey (exit interview) of 232 caregiver-child pairs accessing CB (n = 104) and FB services (n = 116); and in-depth interviews with 10 health workers and 15 mothers. Quantitative data were analyzed through Fisher's exact, unpaired t-tests, and logistic regression at 95% confidence interval (CI) using SPSS version 20. Qualitative data were analyzed by thematic content analysis using ATLAS.ti 7.0. Mean annual attendance to both programmes was similar with an average of six visits per year. Only 13.6% of caregiver-child pairs attained more than nine visits in the 12-months period. At least 60% of children in both programs had improved weight-for-age z-scores (WAZ) scores during participation. Predictors for improved WAZ were being underweight at baseline (AOR:11.1, 95%CI:4.0-31.0), annual attendance of at least six visits (AOR:2.2, 95%CI:1.1-4.1) and meeting the Ghana Health Service target of nine visits (AOR:4.65, 95%CI:1.4-15.1). Compared to 31.5% CB users, significant proportion of FB caregivers (57.4%) were visited at home. Half were dissatisfied with services received (CB:55.6% vs. FB:62.0%, p = 0.437) citing long waiting times, negative staff attitude and extortions of money. Regarding perceptions on factors hindering service utilization, emerged themes included extremes of maternal age, high parity, postpartum socio-cultural beliefs and practices, financial commitments, undue delays, unprofessional staff behaviours, high premium on vaccination and general misconceptions about the programme. The association of increased attendance with improved growth reaffirms the need to strengthen primary healthcare systems to improve service delivery; sensitize caregivers on contribution of growth monitoring and promotion to early child development; and increase contacts through home visits.