Study setting

This cross-sectional study was conducted from June to November 2016 at the primary care and mobile health clinics located in 7 out of 10 districts in Perak, Malaysia. These clinics consist of Primary Health Clinics (Klinik Kesihatan), Rural Clinics (Klinik Desa), Mother-and-Child Health Clinics (Klinik Kesihaan Ibu dan Anak), and Orang Asli Mobile Clinics (Klinik Bergerak Orang Asli) which are frequently visited by the Orang Asli community for primary care, dental care, maternal and child’s health care [23].

Standard care of growth assessment

The maternal and child health monitoring programmes have been started since the 1950’s in all health clinics distributed across Malaysia, and this service has been expanded progressively to meet the current needs [23]. Children aged 0 to 6 years old have access to free child health care services in all government-funded health clinics in Malaysia. All newborns and children, that attend the clinics, undergo continuous growth assessment monitoring and health screening. Their details are recorded in the registry at government-funded health clinics nearest to them. The children’s caregivers (usually the parents) are given a ‘Parent Child Health Record Book’ that also contains growth and monitoring details [24].

At each appointment visit to the clinic, the attendance of the children is recorded in the clinic registry. The ‘Parent Child Health Record Book’ is obtained from the caregivers, and the ‘Clinic Child Health Record’ kept in the clinic is traced. The children’s anthropometric measurements were conducted and charted on the intended growth charts (weight-for-age, length/height-for-age, weight-for-length, and BMI-for-age). The measurements are recorded in the ‘Parent Child Health Record Book’ as well as ‘Clinic Child Health Record’ in the clinic. The growth status is evaluated, determined, and documented. Caregivers are interviewed by the healthcare providers (HCPs) for the children’s nutrition intake, immunisation status, growth and development, and current health and social problems, if any. HCPs will then perform a physical examination and evaluate the general children’s response and development.

If there are any growth problems discovered during the routine health screening, the child will be referred to a medical officer by the nurse. Subsequently, a referral will be made by the medical officer to other HCPs including a dietitian, nutritionist, paediatrician, or family medicine specialist, if necessary, for further treatment. If a growth problem is detected by the medical officer, the child will be referred directly to the respective HCPs for further action.

In addition, home visits (if required) and counselling for the family of the affected child will be conducted to explore the home environment as well as teach the caregivers proper feeding techniques for the child. The next appointment is then given to the caregivers at a closer date for more frequent growth monitoring of the affected child.

If there is no growth problem, the child will receive immunization appropriate for age. All mothers will be given health education on children’s growth (Fig. 1) [20, 24].

Fig. 1
figure 1

A summary of the standard care flow chart for assessing child growth and development in government-funded health clinics

Audit standard and criteria

A meeting with stakeholders, which included the state Deputy Director of Public Health, Senior Paediatrician, State Head Matron, Medical Officers, and Nutritionist, was conducted to obtain a consensus in regard to the audit criteria and standards before the commencement of the audit. The audit criteria were set based on current growth management guidelines that all growth charts must be correctly and completely plotted. Children detected as underweight should be managed with appropriate growth management [24]. For this audit, we decided to audit only the growth status of the children; the children’s developmental status was not audited.

Given the high prevalence of underweight Orang Asli children [25], and the aim of ‘weight-for-age’ growth charts is to assess underweight or severely underweight young children [19], the stakeholders agreed to only audit ‘weight-for-age’ growth charts of all Orang Asli children less than 2 years of age for correctness and completeness of growth chart plotting, and the appropriateness of growth management for Orang Asli children who were underweight.

Instruments and training for data collections

An audit form was created to collect information about the children’s age and to assess growth chart plotting and appropriateness of growth management of children with underweight problem. A total of 29 senior nurses who have been working at the mother-and-child health unit in the primary care health clinics located in Perak State were identified as auditors. They were invited for a training session to learn the auditing procedure. Simulated ‘Clinic Child Health Record’ and growth charts were used for training. In addition, an audit instruction guide was created to instruct auditors on the audit method and audit form completion.

Sampling Method & Subject Population

To minimize measurement bias, auditors were assigned to conduct cross-district auditing; as such they were not auditing the clinics they worked at. A formal letter to inform the health district officers about this audit was issued a week before the audit began. On the day of the audit, after excluding the growth charts of children with intellectual impairment, developmental delay, children born prematurely (less than 37 weeks), and children with other disabilities (cerebral palsy, dysmorphism, spina bifida) and chronic diseases (e.g., thalassemia, congenital heart disease), ‘weight-for-age’ growth charts of Orang Asli children aged 24 months or less and their ‘Clinic Child Health Record’ were all sampled for the audit. All growth charts obtained were compared with a registry of Orang Asli children to ensure that the number of children audited tallied.

Method of data collection

The number of children’s visits to the clinic for growth monitoring that were documented in the ‘Clinic Child Health Record’ was compared against the registry to ensure that the measurements in the records tallied with the number of visits. The correctness and completeness of the ‘weight-for-age’ growth charts plotted were cross-checked with the anthropometry measurements stated in the ‘Clinic Child Health Record’ at the clinic. Operational definitions were as follows: –

  1. a.

    ‘Correctness’ of plotting was defined as the weight measurements in kilograms (kg), up to one decimal place, plotted accurately for the age and on the right chart (male or female growth chart respectively).

  2. b.

    ‘Completeness’ of plotting a chart was considered when all weight measurements were plotted on the growth chart without any missing points. For instance, ten measurements corresponded to ten points plotted on the growth chart. A missing point is defined as a measurement that was performed and documented in the ‘Child Health Record’ but was not plotted on the growth chart. Any missing point detected will be considered a growth chart that was ‘incompletely plotted’.

  3. c.

    ‘Completely not plotted’ is defined as the situation where all the measurements were not plotted on the growth chart.

The growth charts were examined for normal growth trend or underweight problem (crossing a − 2 z-score line, sharp incline or decline in the growth line, or flat growth line). Simulations of “weight-for-age” of a girl (Fig. 2) and a boy (Fig. 3) with normal growth and underweight problems were prepared for the auditors during the training session so as to standardize auditing for data collection. In the following situations, a decision was made about the growth chart according to the data available: –

  1. i.

    Missing of one point or incorrectly plotted but a measurement of anthropometry was documented in ‘Clinic Child Health Record’, the auditors were allowed to correct and complete the growth chart. The auditors, therefore, could determine the growth status of the child.

  2. ii.

    Completely not plotted or has many missing points or incorrectly plotted that disallow the determination of growth status, the auditors would state those cases as ‘uncertain status’.

Fig. 2
figure 2

Simulation of ‘weight-for-age’ growth chart of a girl with underweight problem for training purpose. Point A indicates normal growth, point B indicates flat growth line even it is within ±2 z-score, and point C indicates crossing a − 2 z-score line

Fig. 3
figure 3

Simulation of ‘weight-for-age’ growth chart of a boy with underweight problem. Point D indicates sharp decline

In the case where a child was identified as having an underweight problem, the child’s health record was checked for appropriateness of growth management. Appropriate growth management is defined as HCPs provide suitable managements according to the children’s condition. The type of management included HCPs giving caregivers an earlier follow-up appointment dates (2 to 4 weeks), making referrals to the related health care providers (medical officer, nutritionist, paediatrician, or family medicine specialist), making a home visit to the family of the affected child, and/or providing them with health education. The types of management for underweight included more than one of these interventions above, depending on the child condition. If a child is detected with an underweight problem without any of these appropriate management, the case would be considered inappropriate management. The auditor would inform the health clinic manager to conduct a follow-up action for the child. The completed audit forms were then returned for data analysis.

Data analysis

The data collected was entered into the Statistical Package for Social Sciences version 20.0. The achievements of audit standards were determined by performing descriptive analysis on the number of growth charts that were not plotted, incompletely or incorrectly plotted, children with normal growth, underweight, and those underweight cases managed with inappropriate growth management in all circumstances. Audit standards were considered not met if there were any episodes of incorrect or incompletely plotting of growth charts or inappropriate management of children who were underweight. The prevalence of underweight children was analysed by identifying the proportion of growth charts with underweight problems.

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