Module 3: Module 3 - Children’s rights and health practice

Introduction to Module 3

This is the third module in a course of five modules designed to provide health workers with a comprehensive introduction to children’s rights. While the modules can be studied separately, they are designed to build on each other in order.

Module 1: Childhood and children’s rights

Module 2: Children’s rights and the law

Module 3: Children’s rights and health practice

Module 4: Children's rights in the wider environment: the role of the health worker

Module 5: Children’s rights: planning, monitoring and evaluation

Module 3 provides four crucially important study sessions for health care practitioners in relation to ensuring children’s rights in health care settings. Each of these sessions is designed to take approximately two hours to complete. The sessions provide you with an introduction to these topics and are supported by a range of different activities to help you develop your understanding and knowledge. The activities are usually followed by a discussion of the topic, but in some cases there will be answers at the end of the study session for you to compare your own answer to before continuing. We have provided you with space to write your notes after an activity, however if you wish, you can use a notebook.

• Study Session 1 stresses the importance of children being actively involved in their own health care. In the session you will explore the implications of listening to children and taking their views seriously. You will also learn about the importance of recognising children’s evolving capacities. By the end of the session you will have a better understanding of why the participation of children is so important and what are the main difficulties and challenges.
• Study Session 2 will introduce you to two important principles: the right of children not to be discriminated against and the need for adults to think about the best interests of children when they are making decisions on their behalf. It will help you explore the different forms of discrimination and the importance of treating children equally in a health care setting. The session will question how can we act to ensure the best interests of children and prevent discrimination? And how are the best interests of children to be determined and balanced against any other considerations?
• Study Session 3 is devoted to the topic of violence against children. It looks at how you can support the right of children to be free from violence and abuse. In this study session you will question your own views and attitudes towards violence, recognise the signs of abuse and understand the impact it has on children. By the end of the session you will have explored the important role of health practitioners in identifying and reporting violence against children.
• Study Session 4 focuses on an issue important to any health worker, which is how to make their practice environment ‘child-friendly’. You will consider what is meant by being child-friendly and the role that standards and charters can have in promoting a positive environment. By the end of the session you will have had the opportunity to reflect on your own health facility and plan how it can be improved to support the rights of children.

1 The child as an active participant

Key words: competence; confidentiality, decision-making, participation

1.1 Introduction

In this session you will learn about one of the fundamental rights contained in the United Nations (UN) Convention on the Rights of the Child. Article 12 of the UN Convention gives children the right to express their views and have them taken seriously. This means that children are entitled to be involved in decisions that affect them. It is commonly described as the right to participation. It challenges assumptions in East Africa that children are not expected to question or challenge adults or to contribute to decisions adults make on their behalf. Article 12 does not encourage children to be disrespectful or disobedient. It seeks to promote respect for children to be more actively involved in their own lives and to be able to influence the things that happen to them. Children are not just passive recipients of adult care and protection – they can also contribute to the exercise of their rights and participate in decisions that affect them.

This session will help you to explore your own views about child participation, to appreciate the capacity of children to influence decisions about their health. You will also think about why this is important for health workers to understand.

1.2 Learning outcomes

When you have studied this session, you will be able to:

• explain correctly the meaning of the above key words
• understand the right that children have to participate in their own health care
• discuss the benefits of involving children in decisions that concern their health
• identify situations in your practice where children should be involved in decision making.

1.3 Your own childhood experience

1.4 What is child participation?

Participation is a process of being involved in decisions and actions that affect you. Children traditionally are denied this opportunity. However, this right to be heard and taken seriously is one of the fundamental values of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child. Of course, children have always participated in many ways within societies – for example, at the community level, through play and art, and in their economic contribution to their families. In the context of children’s rights, however, the term participation is now very widely used as a short-hand to describe the process of children expressing their views and having them taken seriously.

It is important to understand that this does not mean that children should always have their own way, or that adults can no longer make decisions on behalf of children. What it does mean is that children can and should be involved in those decisions and have their views taken seriously, even if they cannot always be complied with.

Children can form and express views from the earliest age, but the way they participate, and the range of decisions in which they are involved, will necessarily increase as they grow older and more able. Young children’s participation will be largely limited to issues relating to their immediate environment within the family, care facilities and their local community. However, as they grow older and their capacities evolve, they are entitled to be involved in issues that affect them in the immediate family, in their community, their country, and even at the international level.

1.5 Four rights that promote children’s participation

Some of the key rights that need to be understood in relation to the child as an active participant in their own health care are contained in Articles 5, 12, 16 and 17 of the UN Convention. Figure 1.1 below shows the relationship between the four articles and children’s involvement in their own health care. We will now move on to explain these four Articles in a little more detail.

Figure 1.1 Children’s participation in their own health care

Article 5: Acknowledging children’s evolving capacities

Article 5 recognises that parents have rights and responsibilities to provide guidance and direction to children. However, it also introduces boundaries on how those responsibilities are exercised. For example:

• Parents’ rights exist in order to protect children’s rights. For example, a child has a right to a name, so parents have the authority to give a child a name because a small baby cannot exercise that right for him or herself. Parents can give consent to medical treatment while the child is too young to do that for him or herself.
• Any guidance or discipline must respect children’s rights. For example, parents cannot impose punishments on a child that causes them physical, emotional or psychological harm. This means they should not punish a child by denying them food because this would abuse the child’s right to be as healthy as possible. Beating a child is also an abuse of their right to protection from violence.
• Parents should recognise that as children are able to exercise their own rights, then they should be increasingly allowed to do so. They should respect their child's evolving capacities (you studied evolving capacities in Module 1). In other words, parental rights exist until a child can exercise those rights for him or herself. After that, children should be allowed to take decisions for themselves. Children are not the property of the parents. The level of guidance and direction provided by parents should reduce as children acquire greater competence.

Children learn through experience and observation of what is going on around them. They develop their capacities to think and make decisions through guidance by the adults and other children around them. Constant mentoring and guidance as they grow through childhood enables them to develop their capacities.

Article 12: Listening to children and taking their views seriously

Article 12 of the UN Convention states that children have the right to be involved in all matters that affect them and to have their views taken seriously in accordance with their age and maturity. This applies to individual decisions such as their own health care. It also means that children as a group should be involved in matters that affect them, for example, how and what health care services are provided in their local community. The Committee on the Rights of the Child has identified Article 12 as a general principle that must be considered in the way all other rights are implemented. For example, in order to ensure that children’s right to health is fully realised, it is necessary that children are listened to and involved in their own health care. In order to ensure children’s right to protection from violence, they need to be listened to and taken seriously.

Children are entitled to make choices about whether or not they want to participate and to what extent. In relation to health care, for example, some children will want their parents to retain full responsibility for taking decisions. Some will want to share it with their parents. Others may feel that as it is their life and future at stake, it should be their responsibility to make choices for themselves.

Article 16: Respecting confidentiality and the right to privacy

Article 16 of the UN Convention states that children have a right to privacy. This means that children are entitled to respect for privacy and confidentiality, for example, in getting advice and counselling on health matters, depending, of course, on their age and understanding. Governments are expected to introduce laws and regulations to ensure that older children are able to seek medical help in confidence. As a health worker, you need to know what the law says about keeping the medical information of older children confidential, and to protect that confidentiality as far as possible.

Respect for confidentiality is important as young people are likely to avoid seeking medical help if they fear either that they will not be seen without their parents or, that if seen alone, their parents will be notified. Clear and well-publicised policies that confidentiality will be respected will encourage children to approach a nurse or doctor. They should then feel free to discuss their situation more frankly and explicitly than might otherwise be the case. The outcome will certainly be better access to health care and earlier interventions to promote good health. There are many circumstances where the principle of respecting confidentiality is of crucial importance to children’s safety, well-being and dignity.

Article 17: Ensuring that the child has access to age appropriate information

Children can only make meaningful decisions if they have access to relevant information. As a health worker, you can play a key role by ensuring that children have appropriate information to help them make healthy choices in their lives. For example, information on how to keep healthy, how to avoid risks, information about sexual and reproductive health and HIV/AIDS, illegal drugs and alcohol, diet and nutrition. You could be involved, in collaboration with young people, in developing preventive and promotional materials on health to disseminate within your local community. If children are ill, you need to provide them with information about the nature of the condition, the symptoms, the treatments needed, the implications of those treatments, and how to avoid further problems. Such information enables them to appreciate the importance of the decisions they make and empowers them to make safe choices in the future.

1.6 Why is child participation important?

Participation is not only a right of every child, but it also brings with it many positive benefits for children themselves, including to their health and well-being. It can also make the work of the health worker easier:

• Involving children in their own health care makes children feel more respected. And when children feel that they are respected, listened to and that their views are valued and taken seriously, this helps reduce the vulnerability associated with being ill, in pain and dependent on others.
• If you listen to children, it will help you understand the child’s condition better, and this will help you treat them more effectively.
• Being listened to helps relieve anxiety and enables children to cope better with treatment.
• If children have information about their condition, they are better able to understand and address what is happening to their bodies and why things are happening the way they are.
• It gives them confidence. If children are involved in the process of treatment, they will not have fears that actions will be taken without their knowledge or understanding.
• It encourages co-operation. If children lack information, they are likely to be more frightened and therefore less willing or able to co-operate in treatment which, in turn, makes interventions more painful and distressing.
• It avoids unnecessary distress. When information is withheld, children may worry unnecessarily about what is going to happen to them.
• Often the imagined risks are far worse than reality. If they have information, children can prepare appropriately for what is happening and receive necessary counselling, comfort and support.
• Children develop a better understanding of their own health care needs.
• It encourages them to take more responsibility for their own health because they develop a better sense of the causes and consequences of their actions or inactions.

1.7 What are the challenges to participation and how can we address them?

There are a number of challenges to making sure children are listened to by health professionals. As we discussed earlier, in many countries and cultures, including in Africa, there is a considerable resistance to the idea that children and young adults have to be consulted and listened to. It runs counter to the assumption that adults know best and that children lack the experience and competence to take responsibility for decision-making. Many parents and professionals are also concerned that providing children with information about their medical condition might be painful for them to accept. They argue it is better to protect children from such information and choices. The following discussion looks at five particular challenges and provides some ideas on how to address these.

1.8 Capacity to participate

Even very small children can tell you what they like or dislike about being in hospital and can produce ideas for making their stay less frightening and distressing. Provided they are given support, adequate information and allowed to express themselves in ways that are meaningful to them, all children can participate in issues that are important to them. This can be through pictures, poems, drama, photographs, as well as more conventional discussions, interviews and group work.

In the case of babies, their lack of speech should not be an obstacle to considering and respecting their point of view and feelings. For example, they can express their feelings of distress, fear, distrust, or comfort through facial expressions, body language, crying and smiling. A health worker can use this information to identify needs such as the need for a nap or a feeding, responding to whether or not they are in pain. It is important for health professionals to establish a positive relationship with a baby and his or her parents and involve them during the consultation or treatment.

Some children with disabilities, such as children who are hearing or visually impaired, or those that have autism, may experience difficulties in communicating verbally. It is equally important to explore approaches that allow them to express their views. Parents and caregivers will often be able to advise on how to communicate effectively with disabled children.

All children have the capability of expressing their views. Therefore it is necessary for health professionals to explore the many ways that enable the child to articulate these views, concerns and opinions.

1.9 Assessing competency

Obviously children at different stages of development will have differing capacities to take responsibility for their own health care, although these capacities are not necessarily defined just by age. Children’s capacities are highly dependent on the experiences they have had. For example, young children who have experienced major surgery or frequent medical interventions may have a profound understanding of life or death and how decisions will affect them. There are two distinct issues to consider here.

1. All children can be involved in decisions about their health care, even though the actual decisions will be taken by adults. For example, while five-year-old children may lack the competence to decide that they need to go to hospital for an operation, they can indicate if and why they feel comfortable at the hospital, and provide suggestions to improve their stay.
2. Some children will have the capacity to give formal consent to their treatment or to refuse treatment, although the legal rights to do so will be determined by the legislation in any given country. You need to know what the law says in your country. Considerations to take into account in assessing children’s capacities to give or refuse consent can include:
   • Is the child able to understand and communicate relevant information? The child needs to be able to understand the alternatives available, express a preference, express concerns and ask relevant questions.
   • Is the child able to think and choose with some degree of independence? The child needs to be able to exercise a choice without coercion or manipulation and to think through the issues for themselves.
   • Is the child able to assess the potential for benefit, risk and harm? The child must be able to understand the consequences of different courses of action, the risks involved and the immediate and long-term implications.

In general, health professionals need to listen to children, provide appropriate information and give them time to articulate their concerns, so that children can develop the confidence and ability to contribute effectively to their own health care.

1.10 Child participation: obligation or burden?

Neither the UN Convention nor the African Charter imposes obligations on children to express their views. Rather, they provide a right for the child to do so. Children should be given the opportunity to participate and express their views if they so choose, and be helped to do so.

The assumption that children will be burdened unnecessarily is rooted in a view of childhood that imagines children and adolescents do not take decisions or responsibilities at very early ages. However, even small children can act responsibly, for example, in caring for younger siblings, coping with parents in conflict, deciding on what games to play, and negotiating rules. Listening to the views of children, and supporting their participation in a way that respects their evolving capacities teaches children to listen and respect the opinions of others, clarify their own opinions and make decisions about their lives.

1.11 The right to protection versus the right to privacy

All rights are inter-dependent. However, at times there can be a tension between different rights. For example, it may be the case that in order to protect a child from serious risk of abuse, it is necessary to override their right to privacy. Depending on the laws and regulations in your country, health care professionals may have an obligation to report cases of abuse and neglect, even where the child is adamant that he or she does not want the information to be taken further. In such circumstances, it is important to be clear with the child about the boundaries of confidentiality, what the law says, and to involve the child as far as possible in deciding how and when the information will be reported. It is important to remember that violence and abuse of children disempowers them. The strategies adopted to protect them should not further disempower them. Any action must take account of the child’s individual circumstances and contexts. A ‘one size fits all’ approach should never be adopted.

1.12 Lack of respect for parents

Listening to children is about respecting them and helping them learn to value the importance of respecting others. It is not about teaching them to ignore their parents. Indeed, the UN Convention states that education should teach children respect for their parents. Listening is a way of resolving conflict, finding solutions and promoting understanding – these can only be beneficial for family life. It can be difficult for some parents to respect children’s rights to participate when they feel that they, themselves, have never been respected as subjects of rights. This does not imply the need to retreat from encouraging children to participate but, rather, the need to be sensitive in doing so. Children should not be led to believe they alone have a right to have a voice; wherever possible, their families should be involved too.

1.13 Summary

The aim of this study session was to introduce you to the right of children to be active participants in decisions and actions that affect their lives. The key points it addresses are as follows:

• Participation is a process of being involved in decisions and actions that affect you. Despite historical traditional practices that encourage children’s participation, children are often denied this opportunity. However, this right to be heard and taken seriously is one of the fundamental principles in the UN Convention and the African Charter.
• In the field of health care, the right to participate is addressed in four key articles in the Convention: the right to respect for evolving capacities, the right to information, the right to express views and have them taken seriously, and the right to privacy and confidentiality.
• Participation is not only a right but also carries significant benefits for children. It leads to better decisions, it builds their confidence, it reduces fears and anxieties, and it helps children to take on the responsibilities they will have in later years. The health worker benefits too, as children will be more likely to communicate more effectively with the health worker and to cooperate in treatment.
• Many adults have concerns about letting children participate. For example, they worry that children lack capacity or that it will erode parental authority. On the contrary, participation serves to enhance children’s lives and can strengthen relationships between adults and children. Of course, children should never be forced to participate against their will. It is a right not an obligation.

1.14 Self-assessment questions

1.15 Answers to activities

2 Best interests of the child and non-discrimination

Key words: best interests, competing interests, direct discrimination, inclusive services, indirect discrimination

2.1 Introduction

In the first study session of this module, we discussed the principle of children as active participants. Children have a right to be involved in the decisions made by adults on their behalf. In this session, we explore the right of children to have their best interests given consideration when adults are making decisions about them, as well as the right not to be discriminated against.

Both the UN Convention and the African Charter emphasise the importance of best interests and non-discrimination. These are two of the guiding principles you studied in Module 2. This session will explain what these two rights mean, their implications for you as a health worker, and will provide guidance on how to apply them in your day-to-day practice

2.2 Learning outcomes

At the end of this study session, you will be able to:

• define and use correctly the key words above
• explain the principle of best interests of the child as it applies to the provision of health services to children
• explain the principle of non-discrimination as it applies to the provision of health services to children
• understand how to make decisions that are in children’s best interests in your practice.

2.3 What is meant by ‘best interests of the child’?

The concept of the ‘best interests of the child’ is a central building block and a guiding principle of both the UN Convention and the African Charter. It means that when any decision or action is being taken that will affect a child, you need to think about whether it is in the best interests of that child.

The Committee on the Rights of the Child has interpreted Article 3 as applying both to children as individuals and as a group. For example it applies to a child’s specific health condition and care, and it applies to decisions affecting groups of children, for example, policies on health or welfare. To give an example, if you are deciding to give a child a particular treatment, you must be sure it is in their best interests to do so. Equally, the way in which your clinic or hospital ward is organised should take account of the best interests of children rather than the convenience of the administrators or doctors.

It is important to understand the weight that should be given to the best interest principle. Article 3 of the UN Convention and Article 4 of the African Charter require that the best interests of the child is a primary consideration. This recognises that other interests can be considered, but that the child’s interests are the most important interests. The scope of the article is extremely wide, covering all actions concerning the child or children.

2.4 How to determine the best interests of a child

There are four aspects you can consider in determining the best interests of a child. These are shown in Figure 2.1 below.

Figure 2.1 Deciding the best interests of the child

These aspects are interlinked and can be used in any situation where you want to determine the best interest of a child or children.

Rights in the UN Convention and the African Charter

The overall goal of the UN Convention and the African Charter is to promote children’s best interests. The starting point in defining the best interests of the child, therefore, must be to make sure that all their rights are fully realised. Both treaties also make clear what is not in children’s best interests, for example, exposure to all forms of violence, sexual and economic exploitation, harmful traditional practices, and discriminatory laws, policies and practices. Together they provide an important guide to help you assess whether a decision or action may be harmful to a child’s best interests.

Views of the child

The views of the child must be taken into account in determining what is in their best interests. A child’s age, maturity and capabilities are important factors in the weight given to the child’s views, but children of all ages and abilities should have an opportunity to have their views considered. Too often, adults decide what is best for a child without any reference to the child’s experiences or concerns.

Balancing different rights

Determining the best interests of the child also requires you to think about the different rights children have and how they are taken into account with each other. For example, a child requires a stable family environment, but if the child is experiencing harm or neglect in the family home, it may not be in their best interests to stay with their own family. The disruption to the child's life may be necessary in order to protect them. Situations can arise where rights appear to conflict. For example, a competent teenager may exercise his right to refuse treatment, whereas medical opinion considers that the treatment is vital for his long-term health and well-being.

The child’s immediate and long-term interests

Consideration must always be given to both short- and long-term best interests of the child. A child that is at risk of harm or neglect may need to experience temporary disruption to their lives while they are moved to a safe location. However, in the long term this may prevent them from further harm and improve their opportunities in life.

There are no easy answers to such complex dilemmas, but a commitment to the best interests of the child provides a mechanism to help determine how to reconcile tensions, and ensure the realisation of children’s rights.

2.5 Competing rights and interests

So far, we have considered how children’s rights law, children’s views, children’s holistic needs and children’s short- and long-term interests help to determine what is in a child’s best interests. Sometimes, the rights and interests of other children, of parents and families, and of wider society, also need to be balanced with the rights and best interests of a child (see Figure 2.2).

Figure 2.2 Balancing competing interests

Balancing the interests of a child with other children

Situations will arise when ensuring the best interests of one child or a group of children may not be in the interests of other children, and vice versa. For example, health workers might need to respond to a particular epidemic, which might affect other children and adults. They cannot decide to use a particular child for experiments so they can get a remedy to treat the disease and save many other children. Instead they have to identify other strategies that do not compromise the best interest of the child. By contrast, even though an individual child has a right to education, if she or he is continuously disruptive and behaving badly, they may need to be excluded from school for a while so that other children can learn.

Balancing the interests of a child with parents and family

Most parents will have their children’s best interests at heart. However, it cannot be assumed that this will always be the case. There are times when the interests of children and parents can be in conflict. For example, a parent may wish to arrange for a teenage girl to be given a contraceptive injection to prevent her getting pregnant. However, the girl may strongly object to having the injection, perhaps because she is frightened of injections or because she feels it is a sign of her parents not trusting her.

Although the UN Convention and the African Charter fully recognise the importance of parents in children’s lives, and respect their rights and responsibilities towards their children, it also stresses that children have rights and that it cannot simply be assumed that parents will always act in the best interests of children. Where children’s rights are placed at risk by their parents, the best interests of the child must always come first. Where parents abuse or neglect their children, for example, or discriminate against girls. Health professionals need to ensure that this principle underpins all services, procedures or policies, which they are responsible for implementing.

Balancing the interests of a child with wider society

It is sometimes proposed that the interests of the community or the society must take precedence over those of an individual child. For example, where the maintenance of traditional cultures is sometimes seen to be more important than the rights of an individual child who may be harmed within that culture. However, these arguments cannot be used to override the rights of a child. Nor can it be argued that children’s best interests are served by cultural practices, which deny rights that are now guaranteed in law. For example, it is not acceptable to claim that because a particular culture has always beaten children to instil discipline, their best interests are served by its continuation. Similarly, female genital mutilation cannot be defended as a traditional practice serving girls’ best interests by enhancing their marriage prospects, or maintaining the values of the wider community. It clearly represents a rights violation, and is contrary to the child’s interests in terms of health, survival, emotional well-being, dignity, and protection from violence and harm.

A commitment to the best interests of the child demands that health services adopt explicit policies to protect and promote the rights of children above those of their communities when those rights are in conflict. Of course, the way in which this is done needs to be sensitive to the concerns of that community and, wherever possible, explore approaches, which can be accepted by the majority of its members.

No easy answers can be provided when there are legitimate competing claims. When assessing the best interests of the child and children generally, it is a case of sensitively assessing and comparing different views and different degrees of actual or potential benefit and harm.

2.6 Assessing best interests and competing interests in practice

2.7 What is meant by ‘non-discrimination’?

Human rights apply equally to every child. No child must be discriminated against on any grounds. For example, it is not acceptable to say that the right to education for children with disabilities is less important than for other children. It is also not acceptable to allow different levels of funding for services for one ethnic group over another. Children who are stateless or refugees or asylum seekers have exactly the same rights as any other child – the right to food, shelter, education, and protection, for example.

The articles in the UN Convention and the African Charter place a clear obligation on governments to respect and ensure the realisation of all rights to all children without discrimination on any grounds.

2.8 Different types of discrimination

Discrimination can occur at any level in a society. It can be practiced by governments, by adults against children, by one community against another, or one group of children against another. It can arise from active, direct and deliberate actions, or it can take place unconsciously through insensitivity, ignorance or indifference. These two types of discrimination that arise from either deliberate action or indifference are called direct and indirect discrimination (Figure 2.3). It is important that you understand the difference because they need to be tackled in different ways.

Indirect discrimination

This occurs when an action, law or policy has the consequence of excluding or harming particular groups of children, even if that was not its intention. For example, holding clinics in areas where there is no public transport may result in discriminating against poorer children. A health facility would discriminate indirectly against some children with disabilities if it was based in a building that they find difficult to get into. Young people in Tanzania described examples of children with disabilities being removed from health care lists, and a total lack of any attempt to provide accessible facilities, such as ramps or adapted toilets. Without these adaptations, children with disabilities are indirectly discriminated against in their right to health care.

Figure 2.3 Understanding direct and indirect discrimination

2.9 Treating children according to their needs

The principle that children should not be treated differently does not mean that all children must be treated the same. This may seem like a contradiction, but it simply means it is acceptable and appropriate to provide different responses to different children if they have different circumstances and needs. For example, a child with a disability may require a particular service or may require extra time to assess their condition during a medical examination, particularly if they are unable to communicate their needs as well as other children. It would not be appropriate to give all children this extra time because they do not need it. This difference in treatment is very similar to the principle we discussed earlier – the best interests of the child. Different treatment is appropriate when it is in the child’s best interests.

2.10 Who is protected from discrimination?

If you look back at the box that contains the Articles from the UN Convention and the African Charter, you will see that in the Articles on discrimination there is a list of categories of children who are entitled to protection from discrimination. Children are often discriminated against because of their own or their parents’ or guardians’ race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, disability, fortune or birth status. That is why these categories are specifically listed in the UN Convention and the African Charter.

However, it is important to note that both the UN Convention and the African Charter include ‘or other status’ at the end of the list of categories. Human nature is such that people will continue to find ways of including or excluding groups of people based on distinctions in how we look or sound, our history and how we behave. The Convention and Charter are clear that no category of distinction permits the denial of any child’s human rights.

2.11 Applying the principle of non-discrimination in health care

It is important to go beyond an approach that relies on an absence of direct discrimination towards any particular group of children. Ensuring that a service is not discriminatory requires a pro-active analysis of what the service does, how it does it, and who it does and does not include. Consideration can also be given to targeting services towards the most marginalised or vulnerable children. This means designing programmes that explicitly tackle under-representation or exclusion.

The approach shown in Figure 2.4 may help you to review your existing practice or practices in your place of work. It goes beyond preventing discrimination and encourages a pro-active approach to creating an inclusive service that meets different needs, ensuring that all children can realise their rights.

Figure 2.4 Action to tackle discrimination in health care

By taking action to prevent unfavourable treatment, to challenge discrimination and to meet different needs, you will be creating an inclusive health service.

Discrimination against children on the grounds of, for example, disability, gender and colour exist in all societies to varying degrees. Some types of discrimination have been identified as particularly serious issues in East Africa. Girls are discriminated against in many ways; for example, if a girl gets pregnant, is the attitude to her the same as it is to the boy who is the prospective father? Also, do girls get the same access to reproductive health care advice as boys?

As you reflected on your work place, you could no doubt identify many examples of discrimination that you have seen. In your health care practice, you may have seen children with disabilities getting a much poorer response from parents or fellow practitioners because they do not feel that their life is of equal value to other children. Perhaps a child with a disability has been refused services on the grounds that their quality of life does not justify intervention. The physical structure of the building or the toilets may prevent some children with disabilities from using the health facility in the first place.

As a health worker, now that you are becoming familiar with the UN Convention and the African Charter, part of your role needs to be in countering this discrimination in the workplace. You can work to ensure that children with disabilities get the same treatment as other children. You could also challenge attitudes and behaviour that are directed towards girls and make sure your own practice is informed by a commitment to children’s rights and non-discrimination.

2.12 Summary

1. In all actions concerning a child or children, the best interests of the child is a primary consideration, meaning that it has added weight when weighing the interests of the child against other interests.
2. Four different aspects can be actively considered to help you to assess what is in a child’s best interests:
   • implementing all children’s rights
   • taking account of the views of the child
   • balancing different rights
   • looking at the short- and long-term interests of the child.
   It is also important to take into account the best interests of others – other children, family members or the wider community.
3. Children have a right to experience their lives free from discrimination on any grounds.
4. There are two main types of discrimination. Direct discrimination arises from active, direct or deliberate action, and indirect discrimination arises from indifference to the needs of particular groups in society.
5. In applying the principle of non-discrimination, it is essential to go beyond an approach that simply aims to avoid direct discrimination. Consideration can be given to ensuring the most vulnerable children in the community have access to services and that specific services are set up to meet the needs of particular groups of children.

2.13 Self-assessment questions

2.14 Answers to activities

3 Addressing violence against children

Key words: emotional abuse, neglect, physical abuse, sexual abuse, violence

3.1 Introduction

Many children face violence in their homes, at schools and in their communities. The impact of neglect, physical, sexual and emotional violence and abuse on children is significant. It can damage their health, well-being, growth and ultimately their development into adults able to create strong family and community units. It is important for health practitioners to have an understanding about the factors that are likely to place children at risk of violence, and to recognise key signs and indicators of abuse. In this session you will explore the various forms of violence that may be inflicted on children and consider the impact of such behaviour. You will also learn about the strategies that may be used to prevent and respond to violence in the communities where children live.

3.2 Learning outcomes

At the end of this study session, you will be able to:

• define and use correctly the key words and terms above
• explain the right for children to be safe from all forms of violence
• identify the risk factors for violence against children
• describe the effects of violence on children
• recognise the key symptoms of a child who is a victim of violence
• understand how to conduct an appropriate professional response.

3.3 The right to protection from violence

The legal right to protection

Violence against children happens regardless of where they live, and regardless of their race, class, religion or culture. It is never justifiable. You will know from your study of Module 2 that both national and international law and conventions recognise children’s right to protection from all forms of violence.

The box below contains a quote from the UNICEF Fact Sheet A summary of the rights under the United Nations Convention on the Rights of the Child, and specifically refers to Article 19: The right to protection from all forms of violence.

The significance of the right to protection from violence is also reflected in Article 16 of the African Charter, as below:

It is clearly agreed that children have rights to be protected from all forms of violence. Therefore there is an important role for those responsible for health care provision in recognising and challenging the abuse of these rights. In the next section Activity 3.1 will help you to think about your own experiences of witnessing violence against children, and to help you understand more about what is meant by violence, and how and where it happens.

3.4 Defining violence

For many children some form of violence is a part of everyday life, and wide cultural acceptance of certain violent practices means that this is often unchallenged. While, for example, rape is universally recognised as a violent and abusive act, opinions on corporal punishment or child labour might vary significantly according to region and/or culture. As a health worker it is vital that your definitions of violence recognise all forms of child abuse.

The discussion section for the activity above gave a number of examples of violence. Did any of them challenge your own definitions? Do you agree that they all show evidence of abuse? If not, why not? These are important questions because your own views on violence and abuse will effect on how you respond to incidents of violence and abuse to children. Activity 3.2 will get you to look at this in more detail.

In the box below are the examples that were described in Activity 3.1: What do you know about violence against children, may be easier to recognise as abuse if we think about them under the four key headings that are generally used to categorise violence:

Key points to remember:

• Not all abuse involves physical violence.
• Not all abuse involves the victim exhibiting obvious or immediate distress.
• Most abuse is inflicted by someone the child knows.

3.5 Risk factors for violence

Since ancient times there have been records showing that children have suffered abandonment, cruel and humiliating punishment, sexual abuse, neglect, and even murder and other violence from adults. This has occurred in every country in the world in a whole range of forms and settings. All children, everywhere, are vulnerable to abuse of any kind but research finds that certain conditions increase the risk factors.

Figure 3.1 below shows a model that demonstrates the layered nature of the risk factors for violence. This is known as an ‘ecological model’ which shows how an individual person is influenced by lots of other factors in their family, the community and the wider society.

(Krug et al., 2002)

Figure 3.1 Ecological model for understanding risk factors and protective forms of violence

We can perhaps understand this diagram in relation to risk better by grouping some of the most commonly recognised risk factors within each of the layers of the model (Figure 3.2). You might want to adapt the model to take account of your particular community and context. Obviously the specific risks will vary in different situations.

Figure 3.2 Ecological model with added risk factors

By looking at this model, you can begin to see the factors that expose children to risk of violence can take place at many levels. For example, a child may be more vulnerable because he or she has a disability (individual level). However, the risks will be much greater if the family is very poor (relationship level), the community has negative views towards disability (community level) and the government has failed to provide any protective laws and services to ensure that families with a disabled child are properly supported (society level).

The most powerful factors in the protection of children are:

• the development of strong bonds of attachment between parents and children
• the building of positive relationships within loving, safe and stable family units

These need to be supported by:

• communities that recognise and nurture the rights of their children within positive cultural norms
• societies that have a strong legal framework to reject all forms of abuse.

Together these conditions provide the wider layers of protection that help minimise the risks for violence.

Activity 3.3 will help you see the connections between the layers in deciding how much a child is at risk.

3.6 Effects of violence

Children and adolescents feel the effects of violence and neglect in ways that range from mild symptoms to debilitating and life-threatening conditions. In the same way that the risk of violence comes from a combination of influences, so the child's circumstances (both negative and positive) will affect their vulnerability or resilience to the effects of violence. Factors that influence the effects of abuse include:

• the age and developmental status of the child when the violence occurs
• the severity of the abuse
• the frequency and duration of the abuse
• the relationship between the child and the perpetrator
• the type(s) of violence and neglect.

You might remember these definitions from Module 1 Session 1:

In the first section of this session we identified four groupings for violence against children. Let us return to those grouping to consider the effects that children may suffer from each sort of violence.

You will see there is some overlap between the effects of different forms of violence and abuse. This is because they are all forms of trauma to the child. The extent of the impact of violence may also be affected by the length of time for which it has been experienced by the child.

3.7 Responding to violence

Recognising violence

Cultural norms around abuse vary significantly between countries and regions, but as with all issues relating to child rights it is the right of the child (in this case to protection from violence) that should be considered first and foremost. For example the line between physical abuse and corporal punishment or discipline is often considered hard to define, however, the UN Committee on the Rights of the Child has stated that the right to protection from violence covers the issue of corporal punishment for children and therefore all corporal punishment is unacceptable.

Professionals who support the cultural norms that sanction physical punishment, or indeed any other form of culturally sanctioned abuse such as harmful child labour or early marriage, are effectively approving or condoning child abuse. Protecting children from violence is not only an issue of rights, but research shows that it has the potential to reduce all forms of violence in society. This makes sense when we reflect on the previous section and what it tells us about the long-term effects of all forms of abuse including the impact on the behaviour of adult survivors of childhood violence.

Health workers and teachers are the two professional groups of adults that most children are likely to encounter regularly. This makes you the front line of defence beyond the adults within the child’s family. A parent or carer may have experienced violence or abuse in their own childhood and may not know about their own rights or the rights of their children. They may know that violence or abuse is happening to their child, but assume that this is a normal part of growing up. Even if they believe that the violence or abuse is wrong, they may not know how to protect their child. Sometimes they will be the actual perpetrators of abuse. Children themselves may not have the information they need to know how to protect themselves or how to report or challenge abuse. So it is vital that you as a health worker recognise your responsibility and duty to act in order that the appropriate agencies can investigate and take any necessary action to protect a child.

As part of this process it is helpful if you are alert to the possible signs of abuse. Sometimes it may be obvious, but often children will be reluctant to say anything and it is up to practitioners like health workers to notice the signs. Every case of abuse is individual and unique and there is no definitive list of signs or indicators. However, there are many generally recognised indicators that should alert you to the possibility of violence and abuse. There is a list of these as a resource for you to consult at the end of the session.

Look back at the examples of violence that you studied in Activity 3.1. You can look at each of these and use the resource list combined with your own experience to think about the likely signs of each type of abuse. In the table below there are three of these examples: one of physical abuse, one of sexual abuse and one of emotional abuse with some of the potential signs of violence alongside.

Responding to violence

Some professionals such as doctors and nurses may be legally obliged to report suspected child abuse. It is essential that you find out what your own responsibilities are within your specific role as a health worker. If you have studied Module 2 you will already have found out this information. If not you need to know:

• Is there a procedure for reporting?
• Is there a child protection committee?
• Which other colleagues can you consult with?
• Are there other appropriate services or people in the community who should be consulted?

If you believe there are signs of violence and abuse to a child then any response you make should prioritise the child’s safety and well-being. In a situation where a child is in immediate physical danger then your response should be equally immediate in acting to separate the child from the situation.

You should respond sympathetically and listen to what the child is saying. Do this sensitively and with respect for the child’s or young person’s need for privacy and confidentiality. They may have important information that may help decide what happens next. It may be appropriate to talk to the parent or parents, but only if you believe it will not jeopardise the safety of the child or young person. In most cases it is logical to gather information and facts according to what you know and have observed.

Ultimately the action that you take will be dependent on the many variables and the practical options that are available to you, but it should always be driven by the child’s right to be protected from being hurt and mistreated, physically or mentally.

A proactive approach to violence

Finally in this section it is important to think briefly about what you can do to prevent violence against children. Much of this approach is about education – for example the fact that you are working through this study session indicates that you are taking a proactive stance in the prevention of violence against children. You can now share that education by working with your patients and their communities as an advocate to raise awareness and promote non-violent values in their everyday lives. There are many opportunities to share your learning, for example in the way that you talk one-to-one with a parent about how they discipline their child, or you may run a campaign or other wider awareness-raising activity. You could work with your organisation and with other professionals (for example in law and/or education) to create accessible and child-friendly reporting systems and services. You should consider a child protection charter for your own health facility. (This is discussed in Study Session 4 of this module.) You could include children in the consultation for any education and measures of prevention so they are educated in their own rights, and not solely dependent on adults to advocate on their behalf. Try to develop and promote health services and systems that are accessible, child-sensitive and accountable. Where possible implement or support research efforts and the collection of systematic data that can contribute to a bigger picture of education about violence against children. (More information on how to do this can be found in Module 5.)

3.8 Summary

• Violence and abuse towards children is widespread but it is a fundamental right for children to be protected from violence and abuse.
• For health workers to be effective in contributing to the protection of children you need to be aware of the risk factors, the signs and the effects of violence and abuse.
• It is important that children are listened to and their views are taken into consideration in finding a solution.
• It is vital to know how to report concerns you have about children and know the system for reporting.

3.9 Self-assessment questions

3.10 Answers to activities

4 Child-friendly health facilities and standards

Key words: children’s charter, child-friendly, child protection, standards

4.1 Introduction

Creating a child-friendly environment is a very important part of promoting children’s right to have the best possible health and well-being. Health facilities can be designed to promote children’s rights to express their views, support their best interests and be non-discriminatory. As a health worker you can address barriers that obstruct children’s access to effective health services in the environment in which you work.

In this session you will learn about the value of a child-friendly environment in health service delivery. Such an environment can be created by training staff to be child-friendly, providing facilities, such as play rooms where feasible, and promoting child-friendly attitudes. This session will explore how establishing protocols and standards can also help to create the right environment.

Not all measures to establish a child-friendly service require resources – sometimes all it takes is a change of attitude and personal commitment.

4.2 Learning outcomes

By the end of this session you will be able to:

• explain the meanings of the above key words
• describe a child-friendly environment in relation to health service delivery
• list ways in which you could make your facility child-friendly
• understand the importance of standards in delivering a child-friendly health service

4.3 What does the term ‘child-friendly health services’ mean?

A child-friendly health service provides an environment for children where they feel safe and respected rather than threatened or unnecessarily worried. Health care providers, organisations and individual health care workers, share a responsibility to reduce the anxiety and suffering of children and their families. The services should be accessible, free or easily affordable, and should be guided by procedures that specifically address the needs and rights of children. They should allow children to participate in diagnosis, treatment and prevention of situations that might put them at risk. Child-friendly health services should provide appropriate information for children to be able to know how to access the service and give feedback on their experiences.

Trying to create a child friendly ward entrance

What do children say?

Research undertaken in Tanzania with children and young people for this module clearly revealed that many children experience unfriendly and unhelpful responses when they visit health facilities. The older boys in the research said they go on their own to get medical attention but the doctors disregard them. They can stay for a long time without being seen by anyone and are called truants if they turn up in school uniform. The following quotes are real examples of their experiences.

It is clear that some children and young people suffer very poor experiences at health facilities (which in turn can actually endanger their health). It may be that you think the two young people would not have this experience where you work. If they would then now that you understand children’s rights and their importance, you can adapt your own practice and challenge the practice of others where necessary.

Many health facilities are very busy and under-resourced but being child-friendly is not just about resources. Research that was done in many countries around the world concluded that:

A well-resourced city hospital may be very frightening for children because of the environment and attitudes of the staff. A poorly resourced rural facility could be a model of supporting the rights of children if staff have made efforts to make children feel safe and at ease.

4.4 What is your own health facility like?

This session is an opportunity for you to review your own service and consider how it might be improved to give children a better and more valuable experience of health care. This means that you need to see your workplace in a different way – from the point of view of a child. Also you can draw on the work you have done in the previous sessions in this module about a child’s right to express their view, not to be discriminated against and to be safe. Putting all of these issues together can make a big difference to the quality of health care for children.

Now that you have spent time thinking about this issue it is important that you translate your views into action. Activity 4.3 asks you to identify some specific changes you could make where you work.

4.5 What are child-friendly health standards?

A good way to ensure the development of child-friendly heath care is to develop child-friendly health standards. This should be done with the participation of everyone at the health facility and ideally also with members of the community, including children. This will help to ensure that the standards are accepted by everyone.

Creating standards and protocols in your facilities that promote respect for children, is a way to support improving the well-being of children. Health workers can ensure that guidelines and standards for promoting respect for children in the health facilities are established and followed. There are both international and national standards in health care systems that can be used to develop your facility-based standards for children. In the next section we will explore different standards and guidelines that can be established to improve the experience of children in health facilities.

Child-friendly standards are the minimum requirements necessary for enabling a child to access services in a health facility without discrimination and in a safe and friendly environment. They help to ensure that through awareness, good practice and robust systems and procedures, staff and other representatives are able to keep children safe and can access health services without any inhibitions. Child-friendly standards can work hand-in-hand with a child protection policy and, as you will see later, with a children’s charter.

Why should you implement child-friendly health standards?

• To ensure that children can access health services in safety.
• To protect and advocate for children’s rights.
• To ensure that staff and other representatives are competent and committed to protecting the best interest of the child while accessing health services.
• To maintain the reputation and credibility of your individual facility.

The Child-Friendly Healthcare Initiative developed a set of standards for health care facilities. They can be used as standards against which health facilities can identify positives, gaps and improvements. The standards below are all supported by articles in the UN Convention and the African Charter.

Activity 4.4: Using standards

You could consider reviewing all 12 of these standards and apply them to your workplace but for this activity, take just three: standards 4, 5 and 9.

What examples or evidence do you have of how your environment currently meets these standards?

What might need to be done to improve?

Record your answers in the table.

Take the ideas into your workplace to discuss with colleagues.

Standard	What happens now?	What needs to be done to improve?
Giving child-centred health care
Sharing information and keeping parents and children consistently and fully informed and involved in all decisions
Enabling play and learning

Discussion

Using these standards is another way of promoting change in health care practice. You may think you are already good at some of these areas but some of the others could be improved. There are no right or wrong answers to how you can improve but some suggestions include:

Giving child-centred health care:

• a welcoming attitude to children
• allowing parents to stay with children in hospital
• named nurses – in other words, when a child goes into hospital, they are given the name of a nurse who will have special responsibility for them.

Mother staying with her child in hospital

Sharing information and keeping parents and children consistently and fully informed and involved in all decisions:

• involving children and parents in explanations about their health problems and treatment
• helping children and families understand what to expect. This should help reduce fear and anxiety
• explain how the child or the parents can provide feedback on how they felt about their care, or make a complaint if there were problems.

Enabling play and learning:

This recognises children’s right to play (Article 31) but can also contribute to a reduction in fear and play an important role in helping children recover.

• Where there is space, have a separate clean area for children to play.
• If children are in hospital and missing school, provide the opportunity to read or have access to educational materials.

Play area in a Ugandan hospital

4.6 Protecting children

Another important standard from the list above is number 10: protecting and supporting vulnerable or abused children. In the session on violence and child protection you covered your role in identifying violence and abuse in the community and in reporting. Here you are continuing the theme by considering protection for children within health facilities.

Children are not always safe in health facilities as this quote from a child participating in the Tanzania study indicates:

While the majority of health workers will act appropriately towards children, clear and agreed standards will help protect children and young people from exploitation or harm. There may also be many other people who are not health workers who are able to come in and have contact children and young people. Many workplaces have a child protection policy which lays out the procedure staff should follow in some detail.

What is the purpose of child protection standards?

• To raise awareness of the problem of child abuse and the risks children may be exposed to.
• To provide a framework for everyone working with children to effectively protect them from abuse.
• To outline clear actions to be taken when abuse is suspected.

What are the advantages of implementing child protection standards?

• Children are protected, which minimises risks of abuse and exploitation.
• Agency representatives are protected – clarity on expected behavior with children and what to do if there are concerns about the safety of a child.
• The organisation is protected – commitment to keep children safe deters potential abusers from joining it.

An example of a list of standards is provided below. You could use it to help you develop or improve the child protection standards of your own facility.

Example of child protection standards

The following standards are adapted from: Keeping Children Safe: A Toolkit for Child Protection, Keeping Children Safe, 2011.

In our health facility we will ensure that we:

Standard 1 Have a written policy on keeping children safe.

Standard 2 Have clear procedures for putting the policy into practice.

Standard 3 Do everything we can to prevent harm to children.

Standard 4 Follow the written guidelines on how we behave towards children.

Standard 5 Meet the standards in allocations where we work.

Standard 6 Protect children equally, regardless of any differences they have.

Standard 7 Actively communicate ‘Keep Children Safe’ message.

Standard 8 Educate and train our staff on child protection.

Standard 9 Provide children with access to advice and support.

Standard 10 Monitor the implementation of these standards.

Standard 11 Promote these standards with the partners we work with.

4.7 A children’s charter

Standards are important to measure how a hospital or health centre is achieving appropriate rights-based child-friendly care. Sometimes standards are not written in very simple language and it may be helpful to convert the key principles behind a list of standards into a more specific and easily understood ‘charter’ suitable for your location. This can make the standards easily understood by children themselves and make a clear link to children’s rights. For such a charter to be successful it is important to create one that is agreed on by practitioners and members of the community, including children.

4.8 Summary

• Making health settings child friendly is a vital part of helping to ensure that children are treated in accordance with their rights.
• Sometimes extra resources are needed but mainly it is a matter of reorganising the physical environment and changing attitudes.
• Achieving a child-friendly environment can be supported by using standards and charters.

• You can use the information in this study session to think about your own health environment and plan changes to make it more child-friendly.

4.9 Self-assessment questions

5 Answers to self-assessment questions

Study session 1

Study session 2

Study session 3

Study session 4

Bibliography

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Hall, D. and Elliman, D. (eds) (2003) Health for All Children, 4th edn, Oxford, Oxford University Press.

Krug, E.G. et al (eds) (2002) World Report on Violence and Health, Geneva, World Health Organisation.

Lansdown, G. (2011) Every Child’s Right to be Heard, Save the Children, UK. Available at www.savethechildren.org.uk/resources/online-library/every-childs-right-be-heard (Accessed 19 February 2014).

Ministry of Gender, Labour and Social Development (2008) The National Child Participation Guide for Uganda: Creating an Environment for Children to be Heard, Ministry of Gender, Labour and Social Development , Uganda, Child Rights Network, and UNICEF Uganda. Available at http://toolkit.ineesite.org/toolkit/INEEcms/uploads/1033/The_National_Child_Participation_Guide_Uganda.pdf (Accessed 12 May 2014).

Naker, D. (2004) ‘Raising Voices Uganda’, cited in Derib, A. (2005), Regional Report on Physical and Humiliating Punishment Against Children, Save the Children.

Nicholson, S. and Clarke, A. (2007) Child Friendly Healthcare: A Manual for Health Workers in Burr, S. and Southall, D. (eds) Abridged by Alice and Oliver Ross. MCAI & Community Fund, pp. 24–79. Available at www.cfhiuk.org/publications/cfhi_manual.htm (Accessed 19 February 2014).

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Acknowledgements

This is one of five modules in the CREATE curriculum on children’s rights education for health care workers in Ethiopia, Kenya, Tanzania and Uganda. It has been developed through a partnership between the MS Training Centre for Development Cooperation based in Arusha in Tanzania, The Open University in the UK and Child Rights Education for Professionals (CRED-PRO), an international programme committed to strengthening the understanding and application of children’s rights in professional practice.

We would like to thank the Oak Foundation in Geneva for its generous funding for the development of this programme and OPITO for additional funding to support advocacy and engagement activities.

CREATE was produced by a team of experts from the four participating countries, including representatives from government, academia, professional practice and the NGO sector. They were led in Child Rights Advocacy by Gerison Lansdown from CRED-PRO and trained and supported by experts in blended learning pedagogy from the CREATE team at The Open University. Many thanks to the governments and agencies who enabled them to participate. The authors are:

• Humphrey Onyango Wandeo, Children Services, Government of Kenya
• Kellen Karanu, Deputy Director of Children’s Services, Government of Kenya
• Kabanda Obed, MD, Executive Director, Action for Community Development (ACODEV), Uganda
• James Kaboggoza Ssembatya, Assistant Commissioner/Children’s Affairs, Ministry of Gender, Labour and Social Development, Uganda
• Hajat Safinah Kisu Museene, Principal, Jinja School of Nursing and Midwifery, Uganda
• Sarah Bunoti, PhD, Lecturer Department of Psychology, Faculty of Education, Kyambogo University, Uganda
• Stella Ayo-Odongo, Executive Director, Uganda Child Rights NGO Network (UCRNN), Uganda
• Yodit Tesfaye, Child Protection and Promotion Officer, Ministry of Health, Ethiopia
• Samrawit Tassew Mekuria, MD, Medical Education Team Coordinator, Ministry of Health, Ethiopia
• Stephen Ataro Ayella, MD, Save the Children, Tanzania.

The contributors of original material are:

• Gerison Lansdown, Co-Director, Child Rights Education for Professionals
• Andy Rixon, Lecturer in Faculty of Health and Social Care, The Open University, UK
• Tony O’Shea-Poon, Head of Equality and Information Rights, The Open University, UK
• Anna Peachey, Deputy Director (Academic) for International Development, The Open University, UK.

We would like to particularly acknowledge the additional material for this curriculum that was produced by TAMASHA in collaboration with District Youth Networks in Temeke (Dar es Salaam), Arusha and Magu. This was research conducted with young people by young people in Tanzania on their experiences of health care.

We would also like to thank those who acted as critical readers for the CREATE curriculum:

• Kate McAlpine, Freelance Consultant, Caucus for Children’s Rights, Tanzania.
• Els Heijnen-Maathuis, Technical Adviser Education, Save the Children International (Uganda)
• Richard Mabala, Director, Tamasha
• Dr Terry DiPaolo, Freelance Consultant
• Dr Helen Yanacopulos, Senior Lecturer in International Development, The Open University, UK.

The CREATE Team are:

• Gerison Lansdown, Co-Director, Child Rights Education for Professionals
• Andy Rixon, Lecturer in Faculty of Health and Social Care, The Open University, UK
• Tony O’Shea-Poon, Head of Equality and Information Rights, The Open University, UK
• Lindsay O’Dell, Senior Lecturer in Faculty of Health and Social Care, The Open University, UK
• Lesley-Anne Long, Deputy Director (Academic) for International Development (until April 2013), The Open University, UK
• Anna Peachey, Deputy Director (Academic) for International Development (after April 2013), The Open University, UK
• Ellen Scott, Senior Project Manager for International Development, The Open University, UK
• Alison Robinson, Senior Operations Manager for International Development, The Open University, UK
• Gail Vardy, Projects Coordinator for International Development, The Open University, UK
• Delphine Mugisha, Training Coordinator, MS-TCDC, Tanzania
• Steven Ndosi, Manager for Cross Cultural Department, MS-TCDC, Tanzania
• Anna Mbwambo, Programme Assistant, MS-TCDC, Tanzania.

Photographs and illustrations:

• Courtesy of Action for Community Development (ACODEV)
• Child-to-Child in collaboration with Unicef Ethiopia, March 2010.

All editing by Learning and Teaching Solutions at The Open University.

The opinions expressed in the CREATE materials are those of the authors and do not necessarily reflect the views of the donor organisations whose generous support made the production of this material possible.

Grateful acknowledgement is made to the following sources:

Cover image: African Child Getting a Vaccine, ©iStockphoto.com/ranplett.

Illustrations

Page 67: Child friendly health facilities; Page 74: Mother using mosquito net; Page 75: Play area in Ugandan hospital. Taken from Nicholson, S, Clarke, A. Child Friendly Healthcare: A Manual for Health Workers, Child Friendly Healthcare Initiative.

Every effort has been made to contact copyright holders. If any have been inadvertently overlooked the publishers will be pleased to make the necessary arrangements at the first opportunity.