This is the fourth module in a course of five modules designed to provide a comprehensive introduction to children’s rights for health workers. 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 in 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 4 provides three study sessions for health care practitioners in relation to some of the broader issues in 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 with your own answer before continuing. We have provided you with space to write your notes after an activity, however if you wish, you can use a notebook.
How do social determinants of health impact on children’s rights?
Key words: health disparities, health inequity, social determinants of health, social justice
This session introduces you to the idea that health is not simply a medical issue based on biological factors and medical interventions. Health is also a result of how and where you live. For example, poverty, bad housing, stress, lack of access to clean water, and unemployment all contribute to how healthy you are. The social conditions in which people live have a dramatic impact on their health. These social conditions are known as the ‘social determinants of health’. Health is a product of the interaction between our biological makeup and the conditions in which we live and act.
This session will help you to understand what the social determinants of health are, and how they affect the health of children. It will also explore the way in which you, as a health worker, can support the right to the best possible health of children by taking action to address these social determinants.
When you have studied this session, you should be able to:
When we talk about someone ‘who is in good health’, what do we mean? The answer can depend very much on the context. A 60-year-old man who is physically frail but mentally strong and alert may be described as in good health, whereas we would not describe a 20-year-old pregnant woman as being in ‘good health’ if she was physically frail yet mentally strong.
Health can be defined as: a state of complete physical, mental and social well-being, and not simply the absence of disease or illness.
If we asked people in a poor community for their definition of good health, how do you think that would differ to the response we would get asking the same question in a wealthy community?
The social determinants of health are the circumstances in which people are born, grow up, live, work and age:
These circumstances are shaped by how money, power and resources are distributed at global, national and local levels. They can cause unfair and avoidable differences in health. These differences are known as health inequities between and within communities. For the majority of people, poor health arises from social and economic factors.
The World Health Organisation (WHO), a global body set up to promote the right to health, has published research to say that ‘this unequal distribution of health-damaging experiences is not in any sense a “natural” experience but is the result of a deadly combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer], and bad politics.’
The WHO developed a Commission on Social Determinants of Health, which in 2008 published a report entitled ‘Closing the gap in a generation’. This report identified two broad areas of social determinants of health that needed to be addressed. The first area was daily living conditions, which included:
The second major area was distribution of power, money and resources, including:
As a health worker, you need to understand how social determinants impact on the health and child rights issues in your community. In the activity below, you will take time to reflect and think of experiences that impact on children’s living conditions and thus their health in your community.
Answer the following questions:
Your answers to these questions will be dependent on the circumstances that you are familiar with in your own community.
You may have a very clear picture of how these conditions have developed in your own community, perhaps as a result of conflict, natural disaster or long-term policy decisions made by the local or national governing bodies – maybe even some combination of all three. You may just feel that the situation has been like this for so long that it is very difficult or impossible to describe how it came about. What is unlikely is that the people who live in poor living conditions have created them for themselves. Individuals are rarely able to exert direct control over the social determinants of their own health.
Living in these circumstances is hard for any adult, and children raised in such communities are likely to have very low expectations of what life has to offer. They will have a limited understanding of human rights and no way of knowing what their own rights are or how to claim them.
For ease in reading the text, from hereon we will be referring to the UN Convention and the African Charter.
In an earlier session in Module 2 you learned about the right to health. Here is a reminder of Article 24 on the UN Convention.
How do you think the social determinants of health affect the rights of children in your community to the best possible health, as well as other rights?
It will be clear to you that the social determinants in a child’s life will have a significant effect on their right to health. For example, if they are unable to access clean water or have a nutritious diet, they will not achieve the best possible health. They will be vulnerable to disease, blindness and stunting. Social determinants such as discrimination against girls, can lead to situations where they have less priority for food within the family, or may be less likely to have access to health care. This too will compromise their right to health. These social determinants may also lead to children not being able to realise their right to education or to optimum development. Poverty and lack of employment can lead to children being required to participate in work from a very young age. Girls may be forced into early marriage and other forms of sexual exploitation.
A socially just society is one that is based on principles of equality and fairness for all. An understanding and recognition of human rights is particularly important. The four principles of social justice are: equity, access, participation and rights.
Social justice means that the rights of all people in the community – particularly the groups that are marginalised and disadvantaged – are treated in a fair and equitable manner. Public policies should ensure that all people have equal access to health care services. For example:
Social justice is what faces you in the morning. It is waking up in a house with an adequate water supply, cooking facilities and sanitation. It is the ability to nourish your children and send them to a school where their education not only equips them for employment, but reinforces their knowledge and understanding of their cultural inheritance. It is the prospect of genuine employment and good health: a life of choices and opportunity, free from discrimination.Source: Mick Dodson, Annual Report of the Aboriginal and Torres Strait Islander, Social Justice Commissioner, Australian Museum, 1993.
In reality, as you will know from your own experience, many people do not experience social justice. There are huge differences in health between different groups in society. These differences affect groups who are marginalised because of poverty, race/ethnicity, gender, disability, or where they live, or some combination of these. People in these groups not only experience worse health but also tend to have less access to the things that support health. For example, healthy food, good housing, good education, safe neighbourhoods, freedom from gender and other forms of discrimination. As we discussed, these are called the social determinants.
These disparities or differences in health are described as health inequities when they are the result of the systematic and unjust distribution of these social determinants. Health equity is when everyone has the opportunity to reach the best possible health, and no one is prevented from being healthy just because of their social situation.
This activity is an option for those students who are studying the module with a group and not just as an individual. If you are not studying with a group you can still think about how the exercise would play out. You may even be able to try it with some willing friends or colleagues.
Please refer to Resource 1 on page 63, we have provided the activity template for you to print or draw and allow you to cut out each box. Each of the boxes represents a card. Hand out one card to each participant. Ten participants should be asked to study the information about the child on the card. Participants should not share which child they have been given and should line up in a row with backs against a wall or (imaginary) line on the floor.
Process for the exercise
The facilitator reads out the statements below. Considering the information on their card, each person should take a step forward each time they believe that the statement applies to the child they have chosen. If the statement does not apply then they should not move.
At the end of the exercise, other participants might like to guess at the general conditions for each of those who were in the line up, based on their final position. When all the conditions are revealed, you can explore:
At the end of the activity some people will be a long way from the starting line whilst others may not have moved from the start position. You can ask each participant to explain who their child was and why they are positioned where they are at the end of the game. This activity makes it apparent, very visibly, that children’s different life chances create inequalities between them and shows how some children get left behind. You can use this activity to explore the factors that lead to those inequalities and to think about which children lose out and how.
In every region of the world, the survival of a child past the age of five is shaped, to a large extent, by the wealth of their household, the region in which he or she lives, and the education of his or her parents. Children born in rural areas or urban slums, children born to mothers with lower levels of education, and children born to families with lower incomes do worse than others. For example, from a selection of countries where data is available in Africa, Asia and the Americas, a child born to the wealthiest 20 per cent of households is more than twice as likely to reach the age of five compared with children born to the poorest 20 per cent of households in urban areas. In Europe, it is the same: under-five mortality rates are at least 1.9 times higher among the poorest 20 per cent of households than among the richest 20 per cent.
Statistics like those above illustrate the need for measures to address the inequalities that are affected by the social determinants of health. Every child counts and every stakeholder has a responsibility to do what he or she can to support their right to health. Action to address the social determinants that lead to health inequities for children needs to take place at all levels of society – from the family up to the national and even international level (Figure 1.1).
It is important as a health worker that you understand the very powerful effect of social conditions on a child’s health. It can affect how you treat and advise children and their families. In the following module, you will have the opportunity to learn about how to use advocacy and community mobilisation to try and change some of the underlying conditions that prevent children from realising their right to the best possible health. However, at the individual level you can:
Think about the many children that you meet every day to provide health services at your facility:
Children will often arrive at your clinic or hospital with illnesses or conditions that are the result of the social determinants in the child’s life. Many children experience health inequities as a result of their backgrounds and their parents’ situation. It is important when treating these children that you are aware of their background and social and economic situation, as this could affect the advice or information you provide. For example, if a child is suffering from malnutrition, it is important to understand the reasons why before suggesting a solution. It may be that the mother needs help and guidance on good nutrition for her child. However, there is little point in providing such advice if the real problem is poverty rather than ignorance. In such circumstances, you might need to think about how to help the mother access the food she needs for her child. Obviously it is important that you treat children with the same respect, irrespective of their social backgrounds and status of their parents/care givers. However, sometimes the response to a situation may require interventions that go beyond the medical, where you see an opportunity to address some of the social determinants that are critical to their prevailing condition. For example, it is little use just providing a child with treatment to address illness caused by drinking polluted water if the child is going to return to a situation where she or he is forced into using the same water supply. You could use your role as a health professional to make sure the parents are aware of the risks, to encourage action to clean up the water supply or help the family find an alternative source of drinking water.
In Study Session 1, you have learned that:
What do you understand by the term ‘social determinants of health’? Give three examples.
Give two examples of how social determinants of health impact on children’s right to health.
What are the four principles of social justice and health equity in respect to children's rights?
Provide an example of health inequities that you have in your community as a result of social determinants. What action could you take to address it?
What is the role of a health professional in advocating for children's rights?
Key words: advocacy, advocate, loud advocacy, quiet advocacy
This session will introduce you to advocacy. It will explore how the work you do with individual children can be strengthened if you are able to advocate for changes that improve the situation of children. The session will provide you with an understanding of what advocacy is and why it is important for you as a health worker. It will also explore how you can get involved in advocating for children’s rights to bring about changes in their lives. This will include how you can support children themselves to be involved in advocacy for their own rights.
When you have studied this session, you should be able to:
Advocacy is the act of pleading or arguing in favour of something, such as a cause, idea or policy. An advocate can also serve as a ‘change agent’ by influencing practice and public policies that benefit all people particularly those who are under-represented or have less power in society. In this session we are focusing on understanding advocacy and the role it can play in enabling children to achieve their rights. Advocacy on children’s rights is a means to ‘speak up for children’. Basically, it involves a set of activities designed to influence the practices, attitudes and policies of others to achieve positive and lasting changes for children’s lives. It can be done by adults on behalf of children. But children themselves can also be empowered to advocate for their own rights.
There is no one subject that advocacy is suitable for: the principles of advocacy can be applied to the health care of an individual child the quality of health services, or issues like child labour and corporal punishment. Take, for example, a community where there are many girls being forced into early marriage. As a health worker, you are very aware of the damaging health implications for girls who are very young brides and mothers. You might decide that you want to take action to address the problem. This process of active engagement in tackling a problem involves advocacy.
Hospitals may be scary places for children.
Children have a right to information about their own health.
Children may be upset if they don’t understand what is happening to them.
Children have a right to information about their own treatment.
Children will always feel safe around an adult who is a health worker.
Compare your answers to those at the end of the study session.
Children’s rights in the UN Convention and the African Charter have been ratified in Kenya, Tanzania, Uganda and Ethiopia and are reinforced by the national laws of those countries. However, children continue to experience violations of many of their rights – within the family, at the community level, and through policies and laws at the level of local and national government. There is, therefore, a role for advocacy at all these levels. By doing effective advocacy, you can bring about key changes in local practice but also sometimes at the higher levels of policy and legislation that will have a lasting impact on children’s lives. It is possible to apply a child rights approach to advocacy on any local or international issues that affect children, such as education, health, protection or livelihoods.
Children often lack powerful advocates. They cannot vote, and have little influence with policy makers. It is important, therefore, that those people who work with and for children, and those who understand their lives, take responsibility to advocate for changes to improve children's lives.
You may already have performed an advocacy role in your work but if not can you think of an example from your experience where you could have taken up an issue raised by a child to act as an advocate?
Anyone can play a key role in supporting children, their families and communities to claim their rights. Often those people who have most contact with children in the course of their ordinary practice are best placed to advocate on their behalf. Any advocacy work that is undertaken will depend on the circumstances and the resources available, but does not necessarily need to involve significant resources. It does not necessarily need to be a special ‘added on’ activity but can be built into your day-to-day work of practical support to children.
Health workers, whatever their role, are particularly well placed to advocate for children. You are in a strong position to identify unfair or unhealthy environments and practices that are harmful for children or that violate their rights. For example, if services that children need are not available, you can play an important role in highlighting the gaps. You can then make the case for why these services are important. You can be a natural and powerful advocate on behalf of children’s health. Consider the following reasons why you are uniquely suited for advocacy:
How did that feel and how did they do it?
If you are working in a group discuss which skills are most important to fill in the boxes in Figure 2.1.
This is not a comprehensive list: you may have identified many others. For example, it is difficult to fairly represent the views of children without putting our own interpretation on what they have said or feeling that we know what they should have said. Good advocates are also often passionate about achieving change for the better. It is a skilled role but as you can see some of these skills will be ones that you should have anyway, as a result of your work as a health practitioner, also basic attitudes and values are equally important.
- take the time to listen
- remain neutral
- have a friendly, informal approach and not be too rigid about things
- be good at working with young people and give information in a way that suits them
- take time to get to know them and their needs
- do not speak down to them
- only share information with others when they agree that it’s OK
- do not jump to conclusions
- consult them on all things.
You can see that there is some overlap with our adult views but children also raise some issues that adults may not have in their list: for example their concerns about confidentiality – that passing on information they give to an advocate will not just be shared with everyone without their permission. You will be aware of this issue from Module 3.
There are lots of different approaches for effective advocacy. One way of grouping them together is to think of them as ‘quiet’ and ‘loud’ advocacy.
Quiet advocacy involves intimate discussions and personal persuasion in bringing an issue to people’s attention. This usually happens on a one-on-one basis between an advocate and the target audience of the advocacy. This usually employs interpersonal techniques in raising people’s awareness. Quiet advocacy could also happen between and among small groups of people such as in schools, women’s group meetings, or in other community settings. Techniques like sketches and drama may be considered relevant to this form of advocacy. Lastly, quiet advocacy could involve a network of like-minded individuals and organisations involved in cooperative work. Types of quiet advocacy therefore include:
Loud advocacy aims to create more of a ‘fanfare’ and involves strategies and activities that are used to try and reach a wider audience than quiet advocacy. Loud advocacy may employ media and press campaigns, lobbying and political pressure, grassroots organising, and other similar tactics. These strategies aim to raise awareness about issues and can be cost-effective considering the number of people that are reached. Types of loud advocacy are listed below:
In the following case study can you identify examples of quiet and loud examples of advocacy undertaken by the workers?
Martha, Rahel and Aman are workers in a children’s organisation in a city suburb.
They are active in promoting children’s rights and issues in their community. Recently, the rising number of cases of physical violence against children in their community came to their attention. This inspired them to act. They started out on their own by identifying who these children were by speaking with and befriending the children and their family members when they went to school, the shop or church. Some of the children were referred to them by other children who had been victims of violence.
After they have gained their friendship and trust, Martha, Rahel and Aman started listening to these children’s stories and what they would like to happen, and they also spoke to them about their rights. In time, the workers raised the issue with community members during a community meeting. They brought the issue to their children’s organisation and argued for it to take on the issue of child physical violence as part of their flagship programs. Soon, the children’s organisation engaged in bigger activities such as distributing flyers about violence against children. They also encourage politicians in their community to pass local ordinances protecting abused and neglected children. They worked with children to present a drama about child violence during a community festival and began forming networks with other children’s organisations in neighbouring communities.
Compare your answers to those at the end of the study session.
As you know from your study of this curriculum it is a guiding principle of both the UN Convention and the African Charter that children have the right to be heard and have their views taken seriously. However, generally, it is adults who have the power to decide how things are run. In practice it can be difficult for children to express their views or have their voices heard. Sometimes what is required to make sure this happens is advocacy with them and not just for them. Health workers provide support to children who come into health centres, clinics and hospitals. Advocating for child rights in health involves making this idea part of everyday health care practice. Health workers who care for children must be able to listen to children, respect their right to be heard and help them express their views to others.
Children can be involved in advocacy that is led by adults on issues concerning children, or they can be empowered to be advocates themselves. Organisations that work on issues affecting children need to move from talking on behalf of children to giving children opportunities to speak and empowering them to speak for themselves and their peers. Girls and boys in many different situations around the world have organised themselves to take collective actions and to promote and support their rights. Children will still need help to achieve this but rather than speaking for children, an advocate can be a facilitator. For example they could encourage and support their efforts with information and explanations about the way systems or bureaucracies work or with finance and technical assistance, such as helping them to produce a poster. It is children and young people who are taking the lead.
Example from a pilot project involving World Vision Zambia in monitoring and evaluating children’s participation
A 12-year-old boy was sexually abused by a 26-year-old woman. In this community, there had been a project to run an advocacy campaign by children and young people to raise awareness of the prevalence of sexual abuse and children’s rights to protection. Local men, women and children had been provided with knowledge on protective legislation; they learned that under the laws of Zambia, defilement was a serious crime punishable by imprisonment. Upon hearing of the incident of defilement involving the 12-year-old boy, the community was concerned, and mobilised themselves to take action. They involved the police, and the boy received psychosocial counselling and, in his best interests, was removed from the abusive environment and sent to live with his aunt in another town to enable him to recover. The alleged perpetrator had run away by the time the police got involved. Nonetheless a search for her was launched. This incident illustrates both that children can be effective advocates in raising awareness of the need for action within their local communities, and also the power of communities to protect children as a consequence of that advocacy. They were empowered with knowledge on protective legislation for children that they acquired through this project. Had the incident occurred in the previous years prior to the start of the programme, it is possible that perhaps the community’s attitude towards the incident could have been one of showing very little concern.
Some of the benefits of child-led advocacy are:
What is the problem you feel children are experiencing – early marriage, violence in the home, discrimination against girls or children with disabilities, failure to ensure birth registration, failure to design child-friendly health services? For effective advocacy you must know what it is the children themselves are saying – listen and take their views seriously.
What would need to change to address the problem – changes in laws, policies, attitudes, more resources? It is important to be clear about the cause of the problem, so that you can target your advocacy as effectively as possible. For example, if the problem is excessive physical punishment of children in the home, you need to be aware of what the law currently says about physical punishment. If the law already protects children, then the problem lies in its implementation, and that is where you need to put your energies. It is always useful to provide a very concrete proposal of what you want to happen – not just to criticise the current situation.
You need to be sure about your facts before you undertake your advocacy. What is the scale of the problem? What is its impact? What evidence do you have of the problem? For example, if you wanted to advocate to make your clinic child-friendly, as you learned in Module 3, you could undertake consultations with children, and possibly their parents, to find out how they experience the clinic. If you find consistent evidence that children are frightened of nurses, or that they do not feel safe in the clinic, you can use this evidence to begin to advocate for changes.
You need to be very clear about what you are asking for. It is helpful to keep your message as simple, clear and focused as possible. You need to think about how to get your concerns across to others, and to try and engage with their concerns. Use evidence wherever possible, as facts will carry more weight than anecdotal information.
It is very important to be clear about who you need to influence and what opportunities exist for influencing things. You need to understand how and where policy decisions are made. If you want to improve the delivery of health services, you may need to target the health administrators or doctors. If you are trying to influence community attitudes toward children, then your focus of attention will be, for example, community leaders, parents groups, or religious leaders. If you are trying to get the law changed, you need to target policy makers, government ministers, parliamentarians. Once you are clear about who you need to focus on, you can then design your advocacy strategy.
You will need partners and alliances to build as much support as you can get to help you make your case. You might be able to get the support of all the other health professionals you work with. There might be local or national NGOs who would be willing to be a part of it. The media at local or national level can be important in raising awareness on all issues. You may also want to involve children directly as part of the campaign. The more support you can get the stronger your advocacy. Not only does it provide you with more people to engage in the advocacy, but it demonstrates the breadth of support for the case you are arguing.
You may need different strategies to reach out to different agencies or organisations. For example:
You should regularly take stock of what you have achieved. Are there tactics that are not working? Then review and revise them. You need to communicate consistently with all your partners and alliances to ensure they are all working together. Remember that change can take time – you often need to be patient and prepared to stay committed for the long term. You can learn more about having a plan and checking how it is progressing in Module 5.
It comes to your attention that there is a rising number of cases of physical violence against children in your community.
If you are working in a group try to come up with at least three ideas for each question.
In order to take the issue forward, it helps to do some research into how many cases of violence there actually are, and the children could help to collect this information. You might also want to find out from parents what they thought about the issue and whether they were also concerned. You would need to find out what the law currently does to protect children from violence and whether the problem is inadequate legislation or poor implementation of the laws that do exist. Once you have done your research, you can then decide what needs to change and where you need to focus your advocacy.
There are many ways health practitioners can use their expertise and knowledge of what happens to children as a consequence of public policy. The issues of primary concern vary across localities within countries and from country to country, but there are invariably more issues than there are time and resources available to commit. When determining priorities for change, you might consider the following issues:
Give two reasons why advocacy is needed for children’s rights?
Identify three factors that make advocacy strategies successful/effective?
Identify three reasons why health professionals should get involved in advocacy on behalf of or with children?
Why is it important to engage in advocacy with children?
The first four statements are true, but the last one is not. A child may have had a difficult previous encounter with a health worker, or they might just be overwhelmed by the unfamiliarity of a medical environment. It is up to the health worker to recognise that the child needs reassurance in order to feel safe and that part of that reassurance is in making sure that the child is kept informed, in a way that is appropriate to their age, about what is happening to them. Taking into account the rights of children is good practice, but advocacy takes things a stage further.
In responding to the first statement, you can respond to an individual child who is scared by trying to reassure them. That would be part of your day-to-day role in working with children. But advocacy involves a different approach – rather than dealing with each individual child, you would try and identify the source of the problem and do something to change it. This might involve the following steps:
You might recognise that issues, such as the one discussed above, are problems but feel that in some health facilities it would be impossible to address because of lack of time, staff or resources. However, investment of time in advocacy to improve children’s experiences of their health care can lead to fewer demands on health professionals’ time in the longer term. For example, it is easier to treat children who are relaxed and confident than those who are frightened, crying and anxious.
These workers used a mix of different methods to try and advocate for these children. Discussing the issue with the children individually or in a small group and then raising their concerns with the community are examples of quiet advocacy. The workers then moved on to trying to get more attention for the issue by using ‘loud’ techniques such as leafleting and lobbying.
Being part of a specialist organisation Martha, Rahel and Aman probably had much more time and resource available to them than many health workers will. But it will not be appropriate in all cases to try and use many different forms of advocacy. You will need to choose which is likely to be most effective or which you can realistically achieve. Return to the same example and think about how you might be able to respond.
What are the practical strategies for effective community mobilisation in the promotion of child rights?
Key words: community, community dialogue, community mobilisation, participation
This study session will help you understand community mobilisation. Community mobilisation is an important strategy that health workers can use to help ensure that children’s rights are realised. It builds on many of the approaches explored in the advocacy study session, but looks at how to involve the wider community to come together to create changes to improve children’s lives. The session will explore how to identify issues in your community that are having a harmful effect on children’s health and work to mobilise the community to address the problem. It will provide you with guidance on the steps involved in mobilising local communities, as well as on different approaches that can be taken to achieve change through community action.
When you have studied this session, you should be able to:
A community is usually defined as a group of people who live within a geographically defined area and who share a common language, culture or values (Figure 3.1). In short, it is an area or a village with families who are dependent on one another in their day-to-day lives and activities, and who all benefit from that inter-dependency. However, sometimes a group of people who do not live together but have something in common like a special interest or job role are also referred to as a community.
To mobilise is to get something or someone ‘on the move’. It follows then that community mobilisation is about organising and motivating the community to move them towards achieving a certain goal. Community mobilisation is defined as a process through which individuals, groups and families, as well as organisations, plan, carry out and evaluate activities on a participatory basis to achieve an agreed goal. This might be on their own initiative, or for a goal suggested or initiated by others – like a health worker.
What do you observe from Figure 3.1? Can one person manage moving this big item they are struggling with? How do you get people to come together to moving this ‘BIG’ item?
This illustrates the idea of community mobilisation. Just as the community might need to come together to achieve any big task, so this can be the case with children’s rights and health issues. In an earlier session you looked at advocacy and explored how sometimes bigger (‘louder’) strategies are needed when supporting individuals. Sometimes to achieve a big change we need to find ways of motivating a whole community to take action.
Through community involvement, local communities and professional people can identify health problems, pool their knowledge and experience, and develop ways and means of solving them (Figure 3.2). Your role is to help the community organise itself so that learning will take place and action follows. The health worker cannot achieve wider health goals without involving the community. For example, a health worker might be facing regular cases of children with illnesses arising from drinking contaminated water. While you can treat each child, the only long-term answer is to address the source of the problem and try and improve the water supply. However, you cannot achieve this goal on your own. Only by mobilising the community might you be able to build the momentum necessary to take action to improve the water supply. This can only be achieved by building on the community’s knowledge and beliefs, not by anyone dictating to them what they should do (Figure 3.3).
Working with the whole community – women and men, young people, and children
Seeking to encourage individuals and the community to embark on a process of change
Using strategies over time to build a critical mass of individuals supportive of child rights
Supporting people to face the fact that issues such as violence against children and rights issues are not something ‘out there’: it is something we all grapple with in our communities
Inspiring and creating activism among a cross-section of community members.
Only raising awareness
Working with one sector, group or sex
A series of one-off activities
Pointing fingers, blaming or assigning fault
Top-down programme implementation by an NGO to a community
Completed within short time frames.
Look at UN Convention and African Charter in the resources, read what it says about birth registration and then answer the following questions:
Compare your answers to those at the end of the study session.
Now think of two other issues related to children’s rights in health care in the community where you work.
Community mobilisation will be more effective if you are able to encourage participation by as many community members as possible. To achieve this you really need to know your community well.
Think about the community that you live or work in. Imagine a co-worker from another area is coming to join you. What do you want to say right at the beginning about your community? Use the chart below to provide some of this information to the co-worker. If you have not yet started to work as a qualified health worker think about the community in which you live.
Write the following information about your community below:
|Name of your area / village:|
|Beliefs and values held:|
|The particular health problems in this community are:|
|The main health inequities are:|
|The people who are influential are:|
Your answers will be individual to you and your community. You may need much more detail than just these questions, such as, who are the most significant people in the community who could help you find out more or who will need to be involved because of their influence. The point of this question is that the more you know about the community, the more likely you will be to design children-related projects that fit the individual needs of that community.
There are many tools and techniques for collecting information that will help you to know more about your community. You can find this out through direct observation, group interviews, sketching maps, listening to stories and proverbs, and holding workshops. To find out about the history of the community, you can create a ‘historic profile’. This allows you to become familiar with the history of the village. A village history will include the significance of its name, the people who founded it, and the major events that have marked it through time.
Now look back at the initial information you have written about your community. You may have identified a health problem or problems. But is the community aware of these? If you asked them, would they also identify the same problem? A community will only mobilise if they are convinced there is an important issue to mobilise around.
Once you are familiar with the community, you can explore the health issues and child rights issues and why any specific problems are occurring. You should look for helpful or harmful health practices, beliefs, attitudes and knowledge within that community that are related to the health problem under consideration. Once the health issues are fully explored, you can set priorities, develop a more detailed plan of work and carry out the plan. During implementation of the programme, you should monitor and finally evaluate your activities (Module 5 has more information on monitoring and evaluation). Before starting a community mobilisation strategy, it can be helpful to think of the required activities in the form of a cycle (Figure 3.4). This is because as a health provider, you should start the mobilisation process by clearly setting the goal of the action and the steps to achieve it in your mind, then organise and plan the work with the community.
Here is an example of community mobilisation:
Step 1 Identify a significant health problem, for example, early marriage. You might already have ideas from your own experience as a health worker, or you might want to work with other members of the community, including children, to explore ideas.
Step 2 Plan and select a strategy to solve the problem. You will need to think about the causes of the problem and try to develop a plan to tackle those causes. You might do this by organising a workshop with key local people to explore what needs to change and how you might go about it.
Step 3 Identify key people and stakeholders. You need to involve as many people as possible from the community who are likely to be interested in the issue. But you also need to think about who are the influential people in the community who have the power to make change happen – for example, the local council chairperson, MP, cultural and religious leaders.
Step 4 Mobilise these key people and stakeholders for action. Engage them in discussions about possible activities and get agreement from everyone as to the commitments they are prepared to make.
Step 5 Implement activities to work towards a solution. You will need to follow up the commitments with action and have regular meetings to see what progress is being made.
Step 6 Assess the results of the activities carried out to solve the problem.
Step 7 Improve activities, based on the findings of the assessment. Following any community health activities, you should always get community members to participate in checking how well the activity went. Discuss the results with the community and in that way you can help them to learn. If they know why progress was achieved, or an action succeeded or failed, they will be able to make better efforts next time. If the programme seems successful, you should think about how you could scale up that method to a larger number of households. In this way, the action continues.
Overall, children’s health is going to be improved far more by the daily decisions and actions made by individuals and families in their own homes, rather than by health workers. So in order to make these daily decisions become healthy decisions, you should equip your community with appropriate skills and knowledge, and empower them through community participation. The greatest resources you have in your community are good relationships with individuals and groups; therefore, you should mobilise them to pool the resources available in the community (Figure 3.5).
Community participation is one of the key community mobilisation techniques. It is the involvement of people in activities of common interest to achieve common goals, working for a joint cause intended for the welfare or development of the people.
Local people have a great amount of experience and insight into what works for them, what does not work for them, and why. So they contribute to the success of any health intervention. Involving local people in planning can increase their commitment to the programme and it can help them to develop appropriate skills and knowledge to identify and solve their problems on their own. Involving local people helps to increase the resources available for the programme, promotes self-help and self-reliance, and improves trust and partnership between the community and health workers. It is also a way to bring about ‘social learning’ for both health workers and local people. Therefore, if you involve the local community in a programme that is developed for them, you will find they will gain from these benefits.
Community dialogue is a process that draws community participants from as many parts of the community as possible to exchange information, views, ideas, share personal stories and experiences. This allows participants to develop solutions to community concerns. Its value as a process is that:
The key characteristics of a dialogue with the local community will involve the following:
As a health professional the following tips can enable you to organise and conduct a successful community dialogue. Remember the nature of the community dialogue process can motivate people to work towards change. Effective dialogues do the following:
Below are some basic questions to help you as a health professional in organising a successful community dialogue.
It is helpful to start off with some key statements or questions as the starting point. For example:
Statements such as those above could explain the basis for which you, as a health professional, are planning to have a community dialogue. Depending on the focus of the issue at hand, you could then consider the following other steps:
A significant percentage of children in all societies are denied the right to the best health and development. This results either from cultural practices at community level, poor public policies that directly or indirectly influence their lives, or a lack of action to provide healthy and safe environments for children. As a health worker you can play an important role in mobilising communities to promote respect and realisation for children’s rights. The following are some examples:
It is important to note the following:
Putting together what you have learned above, read the following short case study and answer the following questions. You may find it helpful to look back at the cycle of mobilisation.
There has been an increase in HIV-infected street children in a trading centre near your health facility. Although most of them have not yet become very ill, you know it is only a matter of time before they contract infections. Unfortunately, you are aware that discrimination against street children in this trading centre exists in the community and that often requests for improved access to health services have been met with a lot of resistance. As a health worker, you want to use this opportunity of high HIV infection among street children to mobilise the community stakeholders to support improved access to health services.
Compare your answers to those at the end of the study session.
In Study Session 3, you have learned that:
What is meant by community mobilisation?
List three ways in which community mobilisation can be an effective strategy for promoting children’s rights.
What are the key steps that need to be taken in a community mobilisation process?
Give three reasons for health workers to be involved in community mobilisation processes.
Think of an example from your own community where community mobilisation might be used to promote children’s rights. How might you go about this process?
If this is an issue where you work, then as a health worker you may be in a position to influence this because you work with pregnant women and parents of young children. You can raise awareness of the importance of birth registration with individual mothers, but you can have far more effect if you get involved in making the wider community aware of the importance of the issue and mobilising their resources. In this way, universal registration is much more likely to be achieved.
In fact, successful birth registration campaigns have been run in many communities through a strong community mobilisation strategy. It is important to understand why registration numbers are so low to begin with and research shows that it can be for a variety of reasons, such as, the cost of registration and long distances to the Registry Office. But it can also be a lack of knowledge about the importance of birth registration and you can play a role here in raising public awareness in the community.
The support of community leadership and the involvement of community committees was crucial to ensuring the increase in demand for birth registration.
Because this is an issue of discrimination and prejudice, it is likely that there will be some resistance for you to overcome. You will probably already know this because of your work on ‘Knowing your community’. The most important issue here might be opening up a sensitive discussion about HIV in general and the stigma that surrounds it.
Strategies you could use might include involving members of the community, as early as possible, in discussing the problem to try and encourage participation, and perhaps organising a meeting to explain why you think the community should respond to the children’s needs. Knowing your community will also help in identifying the key people who need to be involved or influenced to enable an effective community plan.
Social determinants of health are the economic and social conditions that influence individual and group differences in health status. They are risk factors found in one's living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual factors (such as behavioural risk factors or genetics) that influence the risk for a disease, or vulnerability to disease or injury. They include early childhood development, education, economic status, employment and decent work, housing environment, and effective prevention and treatment of health problems.
The social conditions in which people live have a dramatic impact on their health. In fact, circumstances such as poverty, poor schooling, food insecurity, exclusion, social discrimination, bad housing conditions, and deficient sanitation in early childhood and poor occupational skills in adulthood, are all major determining factors of inequality both among and within communities in terms of health, disease and mortality rates.
Social justice means that the rights of all people in our community are considered in a fair and equitable manner. A focus on social justice aims to reduce the level of health inequities in communities. The four principles of social justice are equity, access, participation and rights.
You might identify, for example, poverty, poor housing, lack of clean water and sanitation, high unemployment, low wages or discrimination against girls. Action you could take might include raising awareness with families of the impact of these factors on children’s health, ensuring that you do not compound health inequities by discriminating against any group of children, trying to remove the source of the problem, such as encouraging the local community to take action to improve the quality of the water supply, or bring an end to activities that cause it to be polluted.
Factors that make advocacy successful and effective include:
Children have a unique contribution to make towards any understanding of their lives. They can therefore contribute value to advocacy. In particular, their involvement:
Community mobilisation can be defined as a process through which individuals, groups and families, as well as organisations, plan, carry out and evaluate activities on a participatory basis to achieve an agreed goal. This might be on their own initiative, or for a goal suggested or initiated by others – like a health worker.
Some of the benefits of community mobilisation include:
The key steps in a process of community mobilisation are:
Step 1: Identify a significant health problem affecting children.
Step 2: Plan and select a strategy to solve the problem.
Step 3: Identify key people and stakeholders who need to be involved.
Step 4: Engage the key people and stakeholders in discussions and agreement on the action needed.
Step 5: Implement activities to work towards a solution.
Step 6: Assess the results of the activities carried out to solve the problem.
Step 7: Improve activities, based on the findings of the assessment.
Reasons for health practitioners to get involved in community mobilisation include the following:
The answer to this question will be different for each person. But it is important you have been able to identify at least one issue related to health and chidren's rights where community mobilisation could be used.
For Activity 1.3
Brennan Ramirez, L.K., Baker, E.A. and Metzler, M. (2008) Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health, United States Centres for Disease Control and Prevention. Available at www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/SDOH-workbook.pdf (Accessed 18 April 2014).
Camacho, A.Z.V., Balanon, F.G. and Trinidad, A.C. (2005) RAISING One VOICE Training Manual for Advocates on the Rights of Child Domestic Workers, Child Workers in Asia, pp. 40–70. Available at http://resourcecentre.savethechildren.se/library/raising-onevoice-training-manual-advocates-rights-child-domestic-workers (Accessed 29 April 2014).
Childinfo (2013) Under Five Mortality Dashboard. Available at www.childinfo.org/mortality_underfive_dashboard.html (Accessed 27 February 2014).
Commission on Social Determinants of Health (2008), Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, World Health Organization. Available at http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf (Accessed 18 April 2014).
Nicholson, S. and Clarke, A. (2007) Child Friendly Health Care: A Manual for Health Workers Burr, S. and Southall, D. (eds). Abridged by Ross, A. and O. MCAI & Community Fund, pp. 24–79. Available at www.cfhiuk.org/publications/cfhi_manual.htm (Accessed 29 April 2014).
National Society for the Prevention of Cruelty to Children (NSPCC) and VOICE (2005) Speaking Out: A Guide for Advocates for Children and Young People with Learning Disabilities, London, NSPCC and VOICE.
Save the Children (2007) Advocacy Matters: Helping Children Change Their World, An International Save the Children Alliance Guide to Advocacy. Available at www.savethechildren.org.uk/sites/default/files/docs/Advocacy-Matters-Participants-Manual.pdf (Accessed 18 April 2014).
Whitehead, M. (1992) ‘The concepts and principles of equity in health’, International Journal: Health Service, vol. 22, pp. 429–45.
WHO and PHAC (2008) Improving Health Equity Through Intersectoral Action, World Health Organization and Public Health Agency of Canada Collaborative Project.
Wilkins, R. and Marmot, M. (eds) (2003) The Social Determinants of Health: The Solid Facts, 2nd edition, World Health Organization Europe. Available at www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf (Accessed 18 April 2014).
World Conference on Social Determinants of Health (2011) Rio Political Declaration on Social Determinants of Health, World Health Organization. Available at www.who.int/sdhconference/declaration/en/ (Accessed 18 April 2014).
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:
The contributors of original material are:
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:
The CREATE Team are:
Photographs and illustrations:
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: Tanzania, Kunke Village, Brian Sokol/IDRC/Panos.
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.