The Growth Length Mat was designed to measure the stunting status of children under 2 years of age directly, without the more complicated WHO procedures that involve considerable training, a combination of processes, and multiple measurements. The mat was initially designed in Bolivia and a validated prototype adapted for use in Cambodia by the NOURISH project to help screen children for stunting. The initial validation work in Cambodia produced similar results to our current study [13]. However, our study found far less sensitivity of the mat compared to Cambodia (21.0% vs. 57.0% for Ghana and Cambodia respectively) [13]. In Ghana, this tool was adopted by the Strengthening Partnership, Results, and Innovations in Nutrition Globally (SPRING) project for stunting screening without validation. Hence this research was conducted to evaluate the level of accuracy of the mat in detecting stunting compared to the standard WHO procedure. According to the recent demographic and health survey of Ghana, the prevalence of stunting decreased from 23–19% nationwide and the prevalence in the Bono region declined from 25.2 to 17.2 between 2008 and 2014. Our results show that the prevalence of stunting in children 6–23 months in the Tain district of Bono region is 11.7% which is consistent with the regional average. Like weight measurements, measuring heights/lengths is an important part of growth monitoring of children but is less utilized by health workers in Ghana due to difficulties associated with measuring height which also requires two people to measure. Altobelli et al. 2020 [14] demonstrated that community health workers with trainings on height/length measurement felt motivated and positive and demonstrated a high level of knowledge in performing tasks compared to the control group. The infantometer is made with wooden material with both movable head and foot pieces with graduations indicated. The tool measures the length/height of children and compared them with the child’s age to calculate z-scores to determine the stunting status of children. The Growth Length Mat is made with a flexy material with colour-coding indicated on mat for the sex of children and their age ranges. This design is similar to the Mid Upper Arm Circumference (MUAC) tape developed by UNICEF [15]. Hence, it is easier to read by caregivers as there is no need to compare with any variable before determining the stunting status of the child.
The mat has 6 months age range that is 6, 12, and 18 months sections. For example, 6–11 months old children are grouped and children 12–17 months old also measured together as a group according to sex. Therefore, stunted, but relatively older children within a group are more likely to touch the “normal line”, while normal but younger children of in a group are less likely to touch the “normal line”. Overall, the mat was very poor in detecting stunting in children over 12 months old. While the idea for a simple and easy tool to measure stunting is warranted, the mat will need substantial improvements in its design to improve its accuracy in detecting stunting in children before widespread adoption across populations. One way to improve upon the design of the version of the mat used in Ghana could be a simple inclusion of the profile of the infant/child to make sure the child is correctly positioned.
We can conclude that the current design of the Growth Length Mat used in Ghana is less sensitive in detecting child stunting compared to the WHO gold standard of measuring stunting in children. There are possibilities to improve the accuracy and utility of the Growth Length Mat for measuring stunting in low-resource settings by re-designing with positioning illustrations or building narrower age-appropriate mats.
Limitations
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Due to lack of repeated values of measurements made, we could not compute reliability measures of the tests.
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Despite training of our field staff and engaging two assessors per measure, it is still likely that some measurements of length of children were less accurate due to difficulty in placing younger children on the infantometer or Growth Length Mat which can affect the validity of our results.