ABSTRACT
Background: The ‘Child health card’ (CHC) is integral to monitoring a child’s growth and assessing development to support the early detection of malnutrition and prompt intervention. CHC is also valuable in keeping track of a child’s vaccinations. There are limited studies on knowledge and utilization of CHC in Oyo state, Nigeria. We therefore aimed to assess caregiver’s knowledge, retention, and utilization of child health cards in Ibadan, Oyo State, Nigeria.
Method: A community-based mixed-method study using a parallel convergent design was employed. Quantitative data were collected from 617 caregivers at their compounds in the selected communities using an interviewer-administered questionnaire. Qualitative data were collected by interviewing caregivers and healthcare workers at health facilities. Bivariate analysis of quantitative indicators and thematic analysis of qualitative interviews were conducted.
Result: Caregiver knowledge of the CHC, including the contents of the CHC and growth charts, was poor, but retention was relatively high (69.6%). Retention of the CHC was higher among caregivers whose index child was <12 months (p=0.011) and among those with good knowledge of the CHC (p<0.001). Being employed (p=0.016), having tertiary education (p=0.027), having good knowledge (p<0.001), and good perception of the CHC (p=0.001) were positively associated with the utilization of CHC. We found that when caregivers failed to present the card at immunization clinics, they often faced verbal reprimands from healthcare workers, and in some cases, their child’s vaccination was denied.
Conclusion: CHC retention was high despite low utilization by caregivers. Therefore, interventions designed to improve community awareness of the CHC could provide an opportunity to improve the use of child health cards in this setting.
Keywords: Vaccine card, Home-based record, Under-five children, Card holding, Growth monitoring
BACKGROUND
The growth and physical development of children are important indicators of community health.1,2 Therefore, high-quality child health services are needed for children to reach their full potential, especially in their early years when they are most vulnerable to infectious diseases, nutritional deficiencies and other environmental influences.3,4 As a result, child growth monitoring has been embedded in primary healthcare in most countries to provide regular developmental assessment to detect children in need of early intervention.5
Studies from low- and middle-income countries (LMICs) suggest healthcare providers and caregivers
I have inadequate knowledge about early childhood development and the need for growth monitoring instruments.6,7 Without regular monitoring, some children may miss out on referrals to specialized health services and developmental support that could help them fulfil their potential.3 To promote early, appropriate, and regular monitoring of growth and development in children, child health cards (CHC) or child welfare cards (CWC)—a home-based record usually maintained in the household by caregivers and brought to the health facilities at each visit to be completed by health workers, have been introduced.8,9 CHCs are affordable, easily stored, and retrievable.
They contain a child’s vital health information, such as birth data, pattern of growth in weight, immunization, including adverse events, vaccination appointment visits, and episodes of illness of the child.10 CHCs also include vital information required for safe childhood, such as preparation of oral rehydration solution, and administration of zinc tablets. The card serves as a guide for healthcare providers in making objective clinical decision as well as reference material for child survival strategies for caregivers.8,9
Despite the integration of CHCs in healthcare, a gap still exists in the knowledge, retention, and utilization of child health cards among caregivers, especially in LMICs.9 Kaphle et al., in their cross-sectional study among women in the Kaski district of Nepal, found that only 25.2% of the mothers were adequately aware of different aspects of the CHC.11 Similarly, 38.2% of caregivers in Amritsar district, India, had adequate awareness of growth charting.12 A study in South-West Nigeria also found that only 21.8% of the caregivers had good knowledge of the intervention contents of the CHCs, which was associated with the underutilization of the card.9 Low retention of CHCs has been reported in sub-Saharan Africa, ranging from 20.7% in the Democratic Republic of the Congo to 69.2% in South Africa.13 In South-West Nigeria retention is 49.1% and 40.7% among caregivers of children aged 12-23 months and 24-35 months old, respectively.14
Sub-optimal knowledge, retention and utilization have been linked to a range of health system and caregiver factors. Caregivers with a poor understanding of the CHC and do not appreciate its role as a long-term
vaccination record, alongside inadequate counselling of caregivers on the use and safekeeping of CHCs by health workers, have been associated with low utilization. Poor paper quality of the cards themselves, resulting in damage, also hinders retention.11,15 Studies have identified delivery place, mother experiencing complications during pregnancy and utilization of health facilities as important factors affecting the utilization and retention of child health cards.16,17
Caregiver’s retention of child health card has been linked to vaccine uptake.13 In Oyo state, CHC retention is 57.4% for children aged 12-23 months and 51.9% for children aged 24-35 months, according to the 2021 Multiple Indicator Cluster Survey,18 but data on knowledge and utilization of the CHC in the state are limited. Assessing retention, knowledge and utilization of CHC among caregivers of children under-five is therefore important, given the sub-optimal uptake of childhood immunization in Oyo state.18 We therefore sought to assess caregivers’ knowledge, retention, and utilization of CHCs in Lagelu Local Government Area (LGA), Ibadan, Oyo State. This evidence should support the government, policy makers and other stakeholders in the Ministry of Health with improved data for policies related to child health card utilization.