Comparative study of stunting measurement in children using WHO procedure and stunting mat in Ghana

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Forfoe, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1582047/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective : Height data is not useful immediately without further processing. The Stunting mat was designed to stunting. However, the mat has not been validated for use in Ghana. This study compared stunting measured with the mat and stunting measured following the WHO recommended procedure. We sampled 163 children aged 6-24-m in the Bono region of Ghana. We compared stunting prevalence measured with the mat and WHO recommended procedure. We also explored the acceptability and interpretability of the two procedures among mothers and healthcare givers. Results: The prevalence of stunting was 3.7% and 11.7% using the Stunting mat and WHO procedures respectively. However, in younger aged children, the Stunting mat was more accurate in detecting stunting: Both healthcare workers and caregivers found it easy to interpret the stunting status of children using the Stunting mat. Therefore, we can conclude that the Stunting mat was less sensitive at detecting child stunting compared to the current gold way of measuring stunting in younger children. There are possibilities to improve the accuracy and utility of the Stunting mat for measuring stunting in low-resource settings by re-designing the mat to be more age appropriate. Height young children anthropometry stunting stunting mat Figures Figure 1 Introduction A child is classified as stunted when it is too short for their age [ 1 ]. Based on international agreement, children are considered stunted if their length/height-for-age is less than − 2 SDs from the World Health Organization (WHO) Child Growth Standards median for the same age and sex [ 2 , 3 ]. Poor health conditions coupled with nutritional inadequacy often result in stunted growth which negatively affects overall health outcomes [ 4 – 6 ]. Stunted children are more likely to suffer irreversible cognitive and physical health damages that could be lifelong and even be passed on to the next generation [ 7 ]. Stunting also has negative long-term educational and economic consequences [ 1 , 7 ]. Stunting usually goes unnoticed in most community settings particularly among populations where short stature is common. Stunting may also go unnoticed because height is not routinely measured as part of growth monitoring [ 4 ]. The prevalence of stunting in under five children in Ghana decreased from 35.5–17.5% from 2003 to 2017 [ 8 ] respectively. Similarly, the prevalence in the Bono Ahafo region of Ghana decreased from 25.2–17.2% within the same time frame [ 6 , 9 ]. The WHO procedure is widely used when measuring the height/length of children during nutritional status assessment in demographic surveys. However, these measurements require further processing in reference to age to determine the degree of stunting [ 10 ]. The Stunting mat also is known as the “Length Mat” is an innovative tool developed in Cambodia to support community and health workers to detect stunting and rapidly identify children who may need attention. The mat seeks to address the challenge of special skill and processing needed to use the WHO procedure in determining child stunting [ 11 ]. The WHO procedure normally involves using a calibrated wooden/plastic board with a headpiece and a movable foot piece which is used for measuring height or length of children (0–59 months of age). Its foot piece can also serve as a headpiece when measuring the standing height of children and compared with WHO standard growth charts [ 12 ]. The Stunting mat on the other hand is 96 cm long and 50 cm wide [ 11 ]. It is made with a flexible and foldable material and relatively light to carry. The mat is colour coded to indicate the status of a child (normal or stunted) when placed on it depending on the sex and age and measures child stunting directly. The objective of this study was to compare the use of the WHO procedure and Stunting mat in assessing stunting in children 6–24 months in one of the districts of the Bono region of Ghana. Materials And Methods Study design, population and sampling The study design was cross-sectional and both WHO procedure and Stunting mat were used to measure the stunting status of children. It was conducted in the Tain District of Bono region of Ghana. The study participants were sampled from Tain District Hospital and other CHIP zones under the hospital. Simple random and convenient sampling methods were adopted to select facilities and respondents for the study respectively. Primary targets were with children aged 6–24 months. The study sampled 163 participants, consisting of mothers/cargivers with children between the ages of 6 to 24 months of age who were attending child welfare clinic (CWC). Child health record books were used to determine the children who qualified to be part of the study at each of the health facility visited. Mothers were shown how both an infantometer and Stunting mat are used, and health workers were given detailed training as to how to use the tools and the conversion heights/lengths in reference to age to generate z-scores. We also administered a short semi-structured questionnaire which elicited data on socio-demographic information, the ease of using the WHO procedure and the Stunting mat. Finally, we asked health care providers about their experiences and challenges with using both procedures in determining child stunting. Measurement Of Stunting Using The Stunting Mat Stunting status with Stunting mat was measured using the mat designed by SPRING USAID Ghana in collaboration with GHS. The Stunting mat has two color codes (red indicating stunted and green indicating normal) with age ranges 6, 12, and 18 months for both sexes (See illustration in Supplementary Figure S1). Children were measured by laying the mat (according to their age and sex) in a recumbent position with minimal clothing acceptable by local culture. Measurements were done by two assessors together assisted by mothers/caregivers when requires with the child’s eye looking straight up similar to measuring standard length [ 3 ]. Measurement Of Stunting Following Who Procedure Recumbent length was measured with a wooden board. Wooden board was placed on flat surface and measurements were taken similar. While the Stunting mat was used to determine the stunting status of children on the field, the WHO procedure was used to measure the length (cm) of children and later on converted to height-for-age Z-scores (HAZ) using WHO-anthro software. Data analysis Data collected from the field was entered and analyzed using Stata 16 (Stata Corp, USA). Study results were presented in tables. The WHO-anthro was used to generate length-for-age Z-scores (HAZ) of children. The Z-scores were transformed into stunting status. Stunting was defined as HAZ <-2. Results A slightly higher number of children included in our analysis were male (58.3%) with a good age distribution (Table 1 ). Table 1 Background characteristics and stunting status of children sampled Characteristic Frequency Percent Sex Male 95 58.3 Female 68 41.7 Age group (months) 6–9 48 29.4 10–12 37 22.7 13–15 25 15.3 16–18 26 16.0 19–24 27 16.6 Overall, using the WHO existing gold standard for classifying child stunting, 12% of the children were stunted compared to 4% detected using the Stunting mat (Fig. 1 ). The Stunting mat tended to be more effective at detecting stunting in younger children (6-9months) than older children beyond 9months. The mat also performed better at detecting stunting in female children than in male children (Table 2 ). Only 4 children were severely stunted by WHO procedure (2.5%), 2 of these were detected by the Stunting mat (1.2%) (Data not shown). Table 2 Distribution of stunting prevalence by age group between WHO procedure and the Stunting mat Age group (months) WHO procedure Stunting mat Stunted Stunted n(%) n(%) 6–9 5 (10.4) 4 (8.3) 10–12 3 (8.1) 0 (0.0) 13–15 3 (12.0) 0 (0.0) 16–18 4 (15.4 2 (7.7) 19–24 4 (14.8) 0 (0.0) Total 19 (11.7) 6 (3.7) Sex of child Male 14 (14.7) 3 (3.2) Female 5 (7.3) 3 (4.4) Total 19 (11.7) 6 (3.7) The measurement of the stunting status of children using the Stunting mat came with several challenges. Among which were difficulty correctly positioning children on the mat and reading values on the mat but both health workers and caregivers widely accepted the mat and found the colour codes depicting stunting status easy to interpret. Comparatively, health workers expressed more difficulty measuring stunting status following the WHO procedure. Most health workers (50%) agreed it was cumbersome to measure the length or height of children using the height board which requires special skills and at least two assessors. The combination of age and height to generate z-scores to determine stunting status using special software such as WHO-anthro was also a challenge (Supplementary Table S1). Discussion The Stunting mat was designed to measure the stunting status of children under two years of age directly, unlike the WHO procedure that involves a combination of processes and multiple measurements. The Stunting mat was designed in Cambodia to help screen for children who are suffering chronic malnutrition. However, in Ghana, this tool was adopted by the Strengthening Partnership, Results, and Innovations in Nutrition Globally (SPRING) project to serve the same purpose. 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 25.2–17.2 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 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 Stunting mat is made with a flexy material with sex of children, color coding, and age ranges indicated on mat just like the Mid Upper Arm Circumference (MUAC) tape. 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 were all measured on the 6-months and children 12–17 months old were all measured on the 12months section according to their sex and so on. Therefore, a wide range of ages are compared at the same side of the mat. This may explain the tendency of the mat to detect stunting in the younger ones than the older ones measured on the same side of the mat. that more younger stunted children compared to older children measured on the same section on the mat. The mat also lacks a color coding for moderate stunting which limits its ability to differentiate between severe and mild forms of stunting in children. While the idea for a simple and easy tool to measure stunting is warranted, the Stunting mat will need substantial improvements in its design to improve its accuracy in detecting stunting in children before being adopted. One way to improve the sensitivity of the mat is to develop age-specific mats with narrow age ranges to measure stunting in more similar groups. Therefore, we can conclude that the current design of the Stunting mat 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 Stunting mat for measuring stunting in low-resource settings by re-designing narrower age appropriate mats. Limitations 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 Stunting mat. Abbreviations CWC Child Welfare Clinic GDHS Ghana Demographic and Health Survey MUAC Mid-Upper-Arm Circumference SPRING Strengthening Partnership, Results, and Innovations in Nutrition Globally Declarations Ethics approval and consent to participate Ethical clearance was given from the Joint Medical and School of Allied Health Sciences Institutional Review Board of the University for Development Studies. We also sought the permission of the Ghana Health Service to conduct the study in their health facilities and engage staff. Written informed consent was sought from mothers and health workers before participation in the study which was voluntary. Availability of data and material All data supporting the conclusions of this study are included in the manuscript. Funding There was no external source of funding. Author’s contributions All authors contributed significantly towards the development, design and conception of the study. NB, AD and AM were involved in the field training of participants and collecting and analyzing data. ZA contributed to data analysis and interpretation of results. ZA, AG and WWF contributed to manuscript drafting, reviewed it for intellectual content and supervised the study. All authors read and approved the final manuscript for publication. Acknowledgements We wish to acknowledge the contributions of late Professor Abdul-Razak Abizari for his supervisory role on this project before his passing. Consent for Publication Not applicable Conflicts of interest The authors declare no conflicts of interest. References UNICEF / WHO / World Bank Group. Levels and trends in child malnutrition. Joint Child Malnutrition Estimates. UNICEF, WHO and the World Bank Group; 2019. De Onis M. The WHO Child Growth Standards , in Pediatric Nutrition in Practice. World Rev Nutr Diet , P.M. Koletzko B Cooper, M. Garza, C. Uauy, R. Wang, W., Editor. 2008, Basel, Karger. p. 254–269. De Onis M, et al., The W orld H ealth O rganization's global target for reducing childhood stunting by 2025: rationale and proposed actions. Maternal child nutrition 2013. 9 : p. 6–26. De Onis M, Branca F. Childhood stunting: a global perspective . Maternal child nutrition2016. 12: p. 12–26. WHO. Training Course on Child Growth Assessment. WHO Child Growth Standards C. Interpreting Growth Indicators. World Health Organization: Geneva; 2008. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana.Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, and ICF International. Dewey KGB. Khadija Long-term consequences of stunting in early life . Maternal child nutrition. 2011;7:5–18. World Bank. Joint child malnutrition estimates [4]. Aggregation is based on UNICEF, WHO, and the World Bank harmonized dataset (adjusted, comparable data) and methodology. In: Prevalence of stunting, height for age (% of children under 5) - Ghana. UNICEF, WHO, and the World Bank; 2020. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. 2009. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro. Blossner M, De Onis, Prüss-Üstün A. Malnutrition: quantifying the health impact at national and local levels. World Health Organization; 2005. Bauman A, Ernst K, Taren D. Assessing community health: Innovation in anthropometric tool for measuring height and length . Annals of Global Health. 2015. 81 [5]. WHO. Training Course on Child Growth Assessment: WHO Child Growth Standard. B Measuring a Child's Growth. World Heealth Orgarnization: Geneva; 2008. Cheikh Ismail L, et al. Anthropometric protocols for the construction of new international fetal and newborn growth standards: the INTERGROWTH-21st Project. International Fetal Newborn Growth Consortium for the 21st Century %J. BJOG: An International Journal of Obstetrics Gynaecology. 2013;120:42–7. De Onis M, et al., Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference . Food nutrition bulletin 2004. 25(1_suppl_1): p. S27-S36. Altobelli LC, et al. A Cluster-Randomized Trial to Test Sharing Histories as a Training Method for Community Health Workers in Peru. Global Health: Science Practice. 2020;8(4):732–58. WHO. Training course on child growth assessment. World Health Organization. Geneva: World Health Organization; 2008. Blackwell N, et al., Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years. Archives of public health 2015. 73 [5]: p. 26. Supplementary Files SupplementalMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 30 Aug, 2022 Reviewers agreed at journal 27 Jun, 2022 Reviewers invited by journal 24 May, 2022 Editor invited by journal 04 May, 2022 Editor assigned by journal 27 Apr, 2022 First submitted to journal 21 Apr, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1582047","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":108487894,"identity":"3f517e24-f7dd-45e9-a644-6231c4ef0f6c","order_by":0,"name":"Nafisatu Bukari","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-0377-0540","institution":"McGill University School of Human Nutrition","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Nafisatu","middleName":"","lastName":"Bukari","suffix":""},{"id":108487895,"identity":"7f20b2f4-5726-4188-b85f-eb697d48e65f","order_by":1,"name":"Alhassan Danaa","email":"","orcid":"","institution":"Ghana Health Service, Tain District Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alhassan","middleName":"","lastName":"Danaa","suffix":""},{"id":108487896,"identity":"bca4716a-6fdc-40e5-84ac-030e7b8d177d","order_by":2,"name":"Abdullai Mubarak","email":"","orcid":"","institution":"University for Development Studies School of Allied Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abdullai","middleName":"","lastName":"Mubarak","suffix":""},{"id":108487897,"identity":"031b502e-b9f8-490d-a435-19cb59794ea9","order_by":3,"name":"Wilfred W. 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Based on international agreement, children are considered stunted if their length/height-for-age is less than \u0026minus;\u0026thinsp;2 SDs from the World Health Organization (WHO) Child Growth Standards median for the same age and sex [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Poor health conditions coupled with nutritional inadequacy often result in stunted growth which negatively affects overall health outcomes [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Stunted children are more likely to suffer irreversible cognitive and physical health damages that could be lifelong and even be passed on to the next generation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Stunting also has negative long-term educational and economic consequences [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Stunting usually goes unnoticed in most community settings particularly among populations where short stature is common. Stunting may also go unnoticed because height is not routinely measured as part of growth monitoring [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The prevalence of stunting in under five children in Ghana decreased from 35.5\u0026ndash;17.5% from 2003 to 2017 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] respectively. Similarly, the prevalence in the Bono Ahafo region of Ghana decreased from 25.2\u0026ndash;17.2% within the same time frame [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe WHO procedure is widely used when measuring the height/length of children during nutritional status assessment in demographic surveys. However, these measurements require further processing in reference to age to determine the degree of stunting [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The Stunting mat also is known as the \u0026ldquo;Length Mat\u0026rdquo; is an innovative tool developed in Cambodia to support community and health workers to detect stunting and rapidly identify children who may need attention. The mat seeks to address the challenge of special skill and processing needed to use the WHO procedure in determining child stunting [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe WHO procedure normally involves using a calibrated wooden/plastic board with a headpiece and a movable foot piece which is used for measuring height or length of children (0\u0026ndash;59 months of age). Its foot piece can also serve as a headpiece when measuring the standing height of children and compared with WHO standard growth charts [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Stunting mat on the other hand is 96 cm long and 50 cm wide [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is made with a flexible and foldable material and relatively light to carry. The mat is colour coded to indicate the status of a child (normal or stunted) when placed on it depending on the sex and age and measures child stunting directly.\u003c/p\u003e \u003cp\u003eThe objective of this study was to compare the use of the WHO procedure and Stunting mat in assessing stunting in children 6\u0026ndash;24 months in one of the districts of the Bono region of Ghana.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, population and sampling\u003c/h2\u003e \u003cp\u003eThe study design was cross-sectional and both WHO procedure and Stunting mat were used to measure the stunting status of children. It was conducted in the Tain District of Bono region of Ghana. The study participants were sampled from Tain District Hospital and other CHIP zones under the hospital. Simple random and convenient sampling methods were adopted to select facilities and respondents for the study respectively. Primary targets were with children aged 6\u0026ndash;24 months. The study sampled 163 participants, consisting of mothers/cargivers with children between the ages of 6 to 24 months of age who were attending child welfare clinic (CWC). Child health record books were used to determine the children who qualified to be part of the study at each of the health facility visited. Mothers were shown how both an infantometer and Stunting mat are used, and health workers were given detailed training as to how to use the tools and the conversion heights/lengths in reference to age to generate z-scores. We also administered a short semi-structured questionnaire which elicited data on socio-demographic information, the ease of using the WHO procedure and the Stunting mat. Finally, we asked health care providers about their experiences and challenges with using both procedures in determining child stunting.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eMeasurement Of Stunting Using The Stunting Mat\u003c/h2\u003e\u003cp\u003eStunting status with Stunting mat was measured using the mat designed by SPRING USAID Ghana in collaboration with GHS. The Stunting mat has two color codes (red indicating stunted and green indicating normal) with age ranges 6, 12, and 18 months for both sexes (See illustration in Supplementary Figure S1). Children were measured by laying the mat (according to their age and sex) in a recumbent position with minimal clothing acceptable by local culture. Measurements were done by two assessors together assisted by mothers/caregivers when requires with the child\u0026rsquo;s eye looking straight up similar to measuring standard length [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\n\u003ch2\u003eMeasurement Of Stunting Following Who Procedure\u003c/h2\u003e\u003cp\u003eRecumbent length was measured with a wooden board. Wooden board was placed on flat surface and measurements were taken similar. While the Stunting mat was used to determine the stunting status of children on the field, the WHO procedure was used to measure the length (cm) of children and later on converted to height-for-age Z-scores (HAZ) using WHO-anthro software.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData collected from the field was entered and analyzed using Stata 16 (Stata Corp, USA). Study results were presented in tables. The WHO-anthro was used to generate length-for-age Z-scores (HAZ) of children. The Z-scores were transformed into stunting status. Stunting was defined as HAZ \u0026lt;-2.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA slightly higher number of children included in our analysis were male (58.3%) with a good age distribution (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBackground characteristics and stunting status of children sampled\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, using the WHO existing gold standard for classifying child stunting, 12% of the children were stunted compared to 4% detected using the Stunting mat (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The Stunting mat tended to be more effective at detecting stunting in younger children (6-9months) than older children beyond 9months. The mat also performed better at detecting stunting in female children than in male children (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only 4 children were severely stunted by WHO procedure (2.5%), 2 of these were detected by the Stunting mat (1.2%) (Data not shown).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of stunting prevalence by age group between WHO procedure and the Stunting mat\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge group (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO procedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStunting mat\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStunted\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStunted\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex of child\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe measurement of the stunting status of children using the Stunting mat came with several challenges. Among which were difficulty correctly positioning children on the mat and reading values on the mat but both health workers and caregivers widely accepted the mat and found the colour codes depicting stunting status easy to interpret. Comparatively, health workers expressed more difficulty measuring stunting status following the WHO procedure. Most health workers (50%) agreed it was cumbersome to measure the length or height of children using the height board which requires special skills and at least two assessors. The combination of age and height to generate z-scores to determine stunting status using special software such as WHO-anthro was also a challenge (Supplementary Table S1).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe Stunting mat was designed to measure the stunting status of children under two years of age directly, unlike the WHO procedure that involves a combination of processes and multiple measurements. The Stunting mat was designed in Cambodia to help screen for children who are suffering chronic malnutrition. However, in Ghana, this tool was adopted by the Strengthening Partnership, Results, and Innovations in Nutrition Globally (SPRING) project to serve the same purpose. 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\u0026thinsp;\u0026minus;\u0026thinsp;19% nationwide and the prevalence in the Bono region declined from 25.2\u0026ndash;17.2 between 2008 and 2014. Our results show that the prevalence of stunting in children 6\u0026ndash;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 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\u0026rsquo;s age to calculate z-scores to determine the stunting status of children. The Stunting mat is made with a flexy material with sex of children, color coding, and age ranges indicated on mat just like the Mid Upper Arm Circumference (MUAC) tape. 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.\u003c/p\u003e \u003cp\u003eThe mat has 6 months age range that is 6, 12, and 18-months sections. For example, 6\u0026ndash;11 months old children were all measured on the 6-months and children 12\u0026ndash;17 months old were all measured on the 12months section according to their sex and so on. Therefore, a wide range of ages are compared at the same side of the mat. This may explain the tendency of the mat to detect stunting in the younger ones than the older ones measured on the same side of the mat. that more younger stunted children compared to older children measured on the same section on the mat. The mat also lacks a color coding for moderate stunting which limits its ability to differentiate between severe and mild forms of stunting in children. While the idea for a simple and easy tool to measure stunting is warranted, the Stunting mat will need substantial improvements in its design to improve its accuracy in detecting stunting in children before being adopted. One way to improve the sensitivity of the mat is to develop age-specific mats with narrow age ranges to measure stunting in more similar groups. Therefore, we can conclude that the current design of the Stunting mat 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 Stunting mat for measuring stunting in low-resource settings by re-designing narrower age appropriate mats.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDespite 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 Stunting mat.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCWC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChild Welfare Clinic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGDHS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGhana Demographic and Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMUAC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMid-Upper-Arm Circumference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPRING\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening Partnership, Results, and Innovations in Nutrition Globally\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical clearance was given from the Joint Medical and School of Allied Health Sciences Institutional Review Board of the University for Development Studies. We also sought the permission of the Ghana Health Service to conduct the study in their health facilities and engage staff. Written informed consent was sought from mothers and health workers before participation in the study which was voluntary.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material\u003c/h2\u003e\n\u003cp\u003eAll data supporting the conclusions of this study are included in the manuscript.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThere was no external source of funding.\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eAll authors contributed significantly towards the development, design and conception of the study. NB, AD and AM were involved in the field training of participants and collecting and analyzing data. ZA contributed to data analysis and interpretation of results. ZA, AG and WWF contributed to manuscript drafting, reviewed it for intellectual content and supervised the study. All authors read and approved the final manuscript for publication.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe wish to acknowledge the contributions of late Professor Abdul-Razak Abizari for his supervisory role on this project before his passing.\u003c/p\u003e\n\u003ch2\u003eConsent for Publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eConflicts of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF / WHO / World Bank Group. Levels and trends in child malnutrition. Joint Child Malnutrition Estimates. UNICEF, WHO and the World Bank Group; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Onis M. \u003cem\u003eThe WHO Child Growth Standards\u003c/em\u003e, in \u003cem\u003ePediatric Nutrition in Practice. World Rev Nutr Diet\u003c/em\u003e, P.M. Koletzko B Cooper, M. Garza, C. Uauy, R. Wang, W., Editor. 2008, Basel, Karger. p.\u0026nbsp;254\u0026ndash;269.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Onis M, et al., \u003cem\u003eThe W orld H ealth O rganization's global target for reducing childhood stunting by 2025: rationale and proposed actions.\u003c/em\u003e Maternal child nutrition 2013. \u003cb\u003e9\u003c/b\u003e: p.\u0026nbsp;6\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Onis M, Branca F. \u003cem\u003eChildhood stunting: a global perspective\u003c/em\u003e. Maternal child nutrition2016. 12: p.\u0026nbsp;12\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Training Course on Child Growth Assessment. WHO Child Growth Standards C. Interpreting Growth Indicators. World Health Organization: Geneva; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. \u003cem\u003eGhana.Demographic and Health Survey 2014.\u003c/em\u003e Rockville, Maryland, USA: GSS, GHS, and ICF International.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey KGB. Khadija \u003cem\u003eLong-term consequences of stunting in early life\u003c/em\u003e. Maternal child nutrition. 2011;7:5\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Bank. Joint child malnutrition estimates [4]. Aggregation is based on UNICEF, WHO, and the World Bank harmonized dataset (adjusted, comparable data) and methodology. In: Prevalence of stunting, height for age (% of children under 5) - Ghana. UNICEF, WHO, and the World Bank; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro. 2009. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlossner M, De Onis, Pr\u0026uuml;ss-\u0026Uuml;st\u0026uuml;n A. Malnutrition: quantifying the health impact at national and local levels. World Health Organization; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauman A, Ernst K, Taren D. \u003cem\u003eAssessing community health: Innovation in anthropometric tool for measuring height and length\u003c/em\u003e. Annals of Global Health. 2015. \u003cb\u003e81\u003c/b\u003e[5].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Training Course on Child Growth Assessment: WHO Child Growth Standard. B Measuring a Child's Growth. 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Global Health: Science Practice. 2020;8(4):732\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Training course on child growth assessment. World Health Organization. Geneva: World Health Organization; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackwell N, et al., \u003cem\u003eMothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years.\u003c/em\u003e Archives of public health 2015. \u003cb\u003e73\u003c/b\u003e[5]: p.\u0026nbsp;26.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Height, young children, anthropometry, stunting, stunting mat","lastPublishedDoi":"10.21203/rs.3.rs-1582047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1582047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: Height data is not useful immediately without further processing. The Stunting mat was designed to stunting. However, the mat has not been validated for use in Ghana. This study compared stunting measured with the mat and stunting measured following the WHO recommended procedure. We sampled 163 children aged 6-24-m in the Bono region of Ghana. We compared stunting prevalence measured with the mat and WHO recommended procedure. We also explored the acceptability and interpretability of the two procedures among mothers and healthcare givers.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u0026nbsp;The prevalence of stunting was 3.7% and 11.7% using the Stunting mat and WHO procedures respectively. However, in younger aged children, the Stunting mat was more accurate in detecting stunting: Both healthcare workers and caregivers \u0026nbsp;found it easy to interpret the stunting status of children using the Stunting mat. Therefore, we can conclude that the Stunting mat was less sensitive at detecting child stunting compared to the current gold way of measuring stunting in younger children. There are possibilities to improve the accuracy and utility of the Stunting mat for measuring stunting in low-resource settings by\u0026nbsp;re-designing the mat to be more age appropriate.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Comparative study of stunting measurement in children using WHO procedure and stunting mat in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-26 16:03:18","doi":"10.21203/rs.3.rs-1582047/v1","editorialEvents":[{"type":"communityComments","content":1},{"type":"decision","content":"Major revision","date":"2022-08-30T08:35:03+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2022-06-27T12:51:34+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-24T16:19:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"BMC Research Notes","date":"2022-05-04T13:55:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-04-27T22:10:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2022-04-21T16:27:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"37693553-63c2-4d47-8eb9-da5669ba0d10","owner":[],"postedDate":"May 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-11-29T09:11:45+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-26 16:03:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1582047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1582047","identity":"rs-1582047","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}