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

Introduction to Module 4

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.

• Study Session 1 builds on your knowledge of health and the right to health as a very broad issue. Health is not just about individual health and medical treatment but is influenced by a wide range of factors in society such as poverty, bad housing, and lack of access to clean water. By the end of the session you will have a better understanding of these challenging factors, their impact on health, and how they relate to the role of the health worker.
• Study Session 2 explains the important role of a person who listens to children and helps them express their views or argue for change. This role (called an advocate) and what they can do is discussed and explored. By the end of the session you will have an understanding of how health workers could and should be advocates for children’s rights.
• Study Session 3 builds on your learning about being an advocate and explains how whole communities can be mobilised to take action on children’s rights. The session will explore how to identify issues in your community that are having a harmful effect on children’s health and how to mobilise the community to address the problem. You will learn about practical techniques and strategies and the role that children themselves can play.

1 Understanding the social determinants of health in the context of children’s rights

Key words: health disparities, health inequity, social determinants of health, social justice

1.1 Introduction

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.

1.2 Learning outcomes

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

• define and use correctly all of the above key words
• explain the social determinants of health and their relationship to children’s rights
• identify the principles of social justice and health equity in respect to children’s rights
• understand the role of the health worker in addressing the social determinants of health in relation to children.

1.3 What are the social determinants of health?

The social determinants of health are the circumstances in which people are born, grow up, live, work and age:

• Social determinants of health are risk factors found in a person’s living and working conditions (such as the distribution of income, wealth, influence, status and power), that influence the risk for a disease, or vulnerability to disease or injury. They are not in the individual (such as behavioural risk factors or genetics).
• Social determinants of health include early childhood development, education, economic status, employment and work, housing environment, and effective prevention and treatment of health problems.

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.

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.

1.4 Understanding social justice and health inequities

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:

• Someone with a low income should receive equity in the same quality health services that a person with a higher income receives.
• Someone living in a geographically isolated community should have the same access to clean water and sanitation as a person living in an urban area.
• Information designed to educate the community must be provided in languages that the community can understand rather than the preferred language of the governing class, enabling them to participate in the learning.
• The right of a child to health is as important as the right of any adult.

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.

1.5 Taking action to address the social determinants of health

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).

Figure 1.1 Those responsible for a child's right to health

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:

• Use community health clinics and outreach to raise awareness of the socio-economic differences and how they impact on children’s health, for example, lack of knowledge about diet and nutrition, impact of poor housing, poverty, and lack of electricity on children's health.
• Ensure that there is no discrimination in the services you provide. The social or other circumstances of the child should not affect the treatment they receive. For example whatever the education status, religion, disability, or economic background of the child and their care givers.
• Take the social situation of each child into account when providing health advice and treatment.

1.6 Summary

In Study Session 1, you have learned that:

1. It is not just biological conditions and access to health care that affects children’s health. Social determinants of health are the economic and social conditions that influence individual and group differences in health status.
2. Social conditions in which people live have a dramatic impact on their health. 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 can all result in health inequalities between children.
3. Social justice means that the rights of all people in the community are considered in a fair and equitable manner. The four principles of social justice – equity, access, participation and rights – must all be promoted at all levels of the community. Failure to address social justice leads to health inequities. And in turn, this leads to the failure to realise children’s rights to health as well as to other rights.
4. Responsibility for addressing the social determinants of health that lead to health inequities lies at all levels of society – families, communities, local and national government and the international community.
5. There is action you can take as a health worker to address health inequalities: for example, community health outreach to increase awareness of health inequities, ensuring non-discrimination in service provision, and taking account of social determinants when treating children.

1.7 Self-assessment questions

2 Advocating for children’s rights

Key words: advocacy, advocate, loud advocacy, quiet advocacy

2.1 Introduction

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.

2.2 Learning outcomes

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

• define and use correctly all the key words
• understand advocacy in the context of children rights
• identify different approaches to and strategies for effective advocacy for children’s rights
• demonstrate that children can be advocates for their own rights
• discuss the reasons why health workers should be involved in advocating for children's rights.

2.3 What is advocacy?

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.

Advocay can bring about lasting change for children and they can be helped to play a part in advocay themselves

2.4 Why advocate for child rights?

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.

2.5 Who can be 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:

• You put a human face to the statistics. You care for children every day who are affected by the environments in which they live and work. When you tell your story, you can make people understand the issue of children’s health in a way that fact sheets or statistics alone cannot.
• You have credibility. By the nature of your role, education and training, people in your community respect and trust you. When you speak out on an issue, you bring credibility and relevance to that issue.
• You have influence. Because you instil trust in others and add credibility to your cause, your investment in the community can inspire others to do likewise. Moreover, your voice may be listened to when other voices are not.
• Your patients are depending on you. Children cannot vote. They need your help to tell their story. You have the power to not only advocate for children, but for their families. Through advocacy, you can help ensure that decision makers are not simply recognising children’s health and well-being as an important issue, but that they are actively working to improve their health and their lives.
• You have passion. Advocacy allows you to dig deeper into your interests and touches on why you originally became a health professional. Through advocacy, you can channel your passion for health and well-being into lasting change. Advocacy allows you to help improve the lives of children while at the same time strengthening the role of your profession within the community.
• You have well-suited skills. Health practitioners already have the skills of an advocate. The same skills you use every day to establish trust, develop relationships, provide solutions to your patients and clients can be applied in your community advocacy work.
• You are not alone. Through advocacy, you can join other health practitioners, school personnel, youth organisers, agricultural groups and others.

Activity 2.2: What makes a good advocate?

1. Think of a time when someone else helped you to get across your views or argued on your behalf.

   How did that feel and how did they do it?

2. What do you think are the skills and characteristics of a good advocate in working with children? Try to identify at least five things.

   If you are working in a group discuss which skills are most important to fill in the boxes in Figure 2.1.

Figure 2.1 The skills and characteristics of a good advocate

Discussion

1. Reflecting on personal experience can help us think about good and bad experiences we have had. This might be realising the importance of advocacy, when you wished someone had been able to speak up for you but no one did. If you have had a good experience, what was it that made it successful? What attitudes or skills did the person have who helped you? This should help you answer the second question.
2. Although there is no ‘correct’ list of skills, some of the following can be valuable for effective advocacy:
   • to be a good listener – so you really understand what the issue is
   • to be a good communicator – as you would need to be able to work with children and young people of different ages, and also explain the issues to other people
   • to value the opinions of children – you must accept that children have valid opinions and that their experience is important
   • to be assertive or persistent – some people might not be prepared to listen to the views of others, particularly those of children
   • to be creative – as there is usually not just one approach for every situation to address the issue of children
   • to be patient – as it might take a while to achieve change.

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.

Children themselves have ideas on ‘what makes a good advocate’

• 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.

(NSPCC/Voice, 2005)

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.

2.6 Approaches to advocacy

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

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:

• Individual advocacy – this involves someone who may not necessarily be connected to an advocacy organisation but who engages in advocacy work.
• Self-advocacy – this involves people who are directly affected by a particular issue speaking out for themselves.
• Peer advocacy – this involves people who were engaged in a particular issue in the past (i.e. child domestic workers), received services from an advocacy group, and are now themselves involved in the advocacy work.

Loud advocacy

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:

• Legal advocacy is a form of advocacy where lawyers or qualified advocates may engage in representing people in court or lobbying for changes in laws regarding a particular issue.
• People-centred advocacy is where the public are encouraged to participate in supporting a particular initiative. Such advocacy work is carried out in various ways including, but not limited to, public demonstrations, rallies, leafleting, canvassing, and protests to help bring important issues to the political arena.
• Media-advocacy gets people interested in an issue by using TV, newspapers, radio, the internet, etc. This is an important form of advocacy because media reaches a lot of people. Media advocacy does a lot to fuel public concern in a particular issue.
• Lobbying comes from the word ‘lobby’ which refers to an entrance area or meeting place. In the case of advocacy, it refers to conversations and meetings where people get access to and seek to persuade those in power. Lobbying involves direct communication with decision-makers and others who have influence over them. Lobbying is about educating and convincing them to support and advance your agenda. The primary targets of lobbying are the people with the power to influence a policy change on your issue.
• Alliances and coalitions are a form of advocacy where individuals, groups and individuals join together to form a stronger body promoting or advocating for a certain issue.

2.7 Advocacy with children

Empowering children to advocate for themselves – Uganda

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.

Some of the benefits of child-led advocacy are:

• Children have a unique voice – they talk about issues clearly and simply.
• They can cut through technical jargon. They just want things to change.
• Decision-makers do not usually come into contact with children so when they do, they often find it refreshing, and they take notice of what children say.
• It will bring ideas from children’s reality and adults will be able to see the problem and the solutions through the children’s eyes.
• Children and young people will have ownership of the solutions.
• The visibility of children promotes recognition that children can express their views and can be active citizens and have rights.
• Children will learn new skills, gain self-confidence, and begin to have a voice and exert influence.

2.8 Strategies for advocacy

Step one: Identify the problem

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.

Step two: Decide what you want to achieve

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.

Step three: Get the facts

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.

Step four: Design your message

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.

Step five: Decide who you need to influence

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.

Step six: Build alliances

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.

Step seven: Decide your strategy

You may need different strategies to reach out to different agencies or organisations. For example:

• To reach the media, you will need to write press releases, letters to the paper, find a story of local interest that they can publicise and emphasise the human interest side of the story.
• To reach politicians, policy makers and officials, you will need to write letters, get petitions signed by as many people as possible, ask to meet parliamentarians.
• To reach out to local communities, you will need to organise public meetings or meet local community leaders.

Step eight: Review progress

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.

2.9 Determining priorities to advocate for change

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:

• The scale and degree of harm. How many children are affected and with what degree of severity? Does it address all children or a selected few? What about children who are marginalised or suffer discrimination? How is it influencing child development? Which rights are not being respected?
• The degree of urgency. Is it an issue that should be addressed urgently to keep a greater number of children from being affected?
• The potential for enlisting support from others. A campaign is more likely to be successful if you can attract others to support the cause. Who is already on board, and who needs to be educated and/or convinced?
• The public sensitivity expressed for the issue. If the issue has attracted media attention or public interest, you can capitalise on this heightened sensitivity to promote the case from a children’s rights perspective.
• The current political environment. You can take advantage of windows of opportunity. Examples would include:
  • a.when a relevant bill is passing a legislative body that can be amended to introduce better protections for children or
  • b.a general election wherein you can lobby political parties or candidates to take your concerns or issues seriously.
• Cultural and religious context. What are the cultural and religious views? Will you be able to get support from religious communities?
• The scope of what needs to be done. What needs to be done and what resources will it require? Is it simply making a phone call, or a large-scale campaign spanning across systems?
• The level of resistance. Who is disinterested or in opposition? Why? How can their perceptions be changed?
• The likelihood of success. It may be a better investment of time to focus on policy issues that are attainable in the short-term, as well as other more challenging long-term goals.

2.10 Summary

1. Advocacy for children and their rights is about listening to their views and speaking out on their behalf.
2. Advocacy can raise consciousness among decision-makers and the general public about an issue or a disadvantaged group, with a view to bringing about changes in policy and improvements in their situation.
3. Advocacy can take different forms and use a range of different techniques.
4. Children can be supported to be very effective advocates for their own rights.
5. An advocacy strategy sets out the policies and actions that need to be changed, identifies who has the power to make those changes, and analyses how you can influence those decision-makers.

2.11 Self-assessment questions

2.12 Answers to activities

3 Community mobilisation: practical strategies

Key words: community, community dialogue, community mobilisation, participation

3.1 Introduction

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.

3.2 Learning outcomes

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

• define and use correctly all the key words
• define community mobilisation in the context of children's rights
• describe the techniques and strategies that are necessary for involving communities in child rights activities
• understand the benefits of involving children and community in community mobilisation
• demonstrate the role of health professionals in mobilising communities for children's rights.

3.3 The concept of community mobilisation

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.

A community is not just a collection of houses, although these are important as well.

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?

Figure 3.1 Moving a '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).

Figure 3.2 A community picture during a community mobilisation meeting for children's rights in rural Western Uganda

Figure 3.3 A quote from Nelson Mandela

3.4 Knowing your community

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.

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.

3.5 The action cycle of community mobilisation

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.

Figure 3.4 Action cycle of community mobilisation

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.

3.6 Issues to think about in undertaking community mobilisation

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).

Figure 3.5 All community activities are founded on good relationships with individuals (Photo: ACODEV)

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.

Figure 3.6Community participation helps in stakeholders understanding issues in detail including getting to the root causes of the problem and agreeing on solutions together for everyone to implement: (Photo; ACODEV achieves community participatory plan)

3.7 Engaging in community dialogue

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:

• It enables common values to be explored.
• It allows participants to express their own interests.
• It enables participants to grow in understanding and to decide to act together with common goals.
• It creates space for participants to question and re-evaluate their assumptions.
• It facilitates behaviour change.
• It can make unexpressed concerns visible.
• It encourages people to learn to work together to improve their situation.

Key characteristics of community dialogue

The key characteristics of a dialogue with the local community will involve the following:

• An emphasis on ensuring that the dialogue is targeted to individual behaviour as well as social change in the community.
• The community itself asks the questions and finds solutions, rather than looking to an external ‘expert’ to produce those solutions.
• A focus on resources that communities already have and building communities’ commitment to providing these resources.
• A move away from just giving messages and telling people how to behave and what to do, towards actively engaging the communities.
• A challenge to existing power relations, giving the weak and vulnerable a voice in any given community.
• Working through existing channels that are already well-organised and are using dialogue in various forms.

3.8 Practical questions to address in community dialogue

Below are some basic questions to help you as a health professional in organising a successful community dialogue.

1. Set the focus of the community dialogue

   It is helpful to start off with some key statements or questions as the starting point. For example:

   • There is a problem that I would like to understand better in discussion with the community members.
   • There is an issue in the community that people need to talk about. It could be an issue affecting children’s right to health, e.g. early marriage.
   • There are people in the community who could benefit from sharing their experiences on an existing community problem.
   • I would like to get the community to come together to tackle a common problem that is being faced in the community.
   • The time is ripe for change – people are ready to do something positive.
   • The ‘face’ of the community is changing, and people need to acknowledge and understand the changes in a more constructive light.

   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:

2. Ask yourself what the goals of the community dialogue would be. Some possible answers could include:
   • To improve the well-being of children in the community.
   • To influence attitudes of local law enforcement to address a community child rights problem.
   • To build partnerships across community structures handling children issues.
   • To use new innovations to solve a community problem.
   • To work on a community project together.
3. Think about who should be included. Who should be in the dialogue? For example:
   • Men, women, children and youth in a given community that are directly or indirectly affected by the issue at hand that the dialogue plans to address.
   • Members of different religions in the community.
   • The school community – parents, teachers, administrators, and students.
   • Police and community members.
   • Business owners as these might be interested in supporting some processes aimed at addressing the problem.
   • Elected officials and community leaders representing the community.
4. What format could you use? What type of discussion should we have? For example:
   • Small community groups meeting once or twice to discuss the issue.
   • A large public meeting with questions from the audience.
   • A year-long commitment among a group of key community leaders to study, reflect on and discuss community problems; this often is limiting as some of the key people in the community keep changing.

3.9 Role of health worker in community mobilisation

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:

1. Use your position as a respected and trained health worker to speak at gatherings, like church services, community group meetings, parent–teacher meetings, union meetings, business meetings, community fairs, and peasant group meetings, etc.
2. Conduct home visits and talk with families about children’s rights and health issues, how to prevent child abuse, and also what they can do to support those already facing abuse in their families or communities.
3. Find a way to talk with and involve the young people (children and youth). Adults usually do not talk to young people about issues that affect them like sex education and that leaves them without knowing some important things that matter to their lives. Youth can also organise dramas, songs and events to reach the youth in schools and communities. Youth have shown in many settings that they are interested, creative and hard working in issues that affect them.
4. Involve all kinds of community members in child rights promotion and abuse prevention efforts. Help different people and different groups, see what they can do to help. As a health worker, you can encourage people to:
   • Provide for children’s basic needs in their families and communities including, for example, food and housing.
   • Care for an orphan or vulnerable child in their neighbourhood.
   • Provide abused children with support.
   • Help organise a community event for child rights promotion.
   • Join in income-generating activities aimed at supporting children’s programs in families and communities.
   • Form a drama group and present plays with child abuse prevention messages.
   • Pool money to pay for health needs and school uniforms for children in vulnerable families.
   • Use their workplaces or their positions to talk with others about how to prevent and support, like business people and teachers.
5. Help communities to form child rights promotion support groups so they can ably respond to and act together on issues of children’s rights, including speaking openly about children’s issues and holding others accountable.
6. Work with the most vulnerable child groups in the community, e.g. street kids, children in conflict with the law, the orphaned and youth in separated families, to identify key stakeholders that can support their needs and provide appropriate referrals.

   It is important to note the following:

   • Health practitioners have insight and experience with children’s lives and how their right to the best possible health is affected by their community settings. They also know how the actions and inactions of communities contribute to the failure to protect children’s rights to health.
   • When health practitioners act as and collaborate with well-mobilised communities, they can tackle the barriers to children’s rights to the best possible health, rather than simply treating the consequences on a daily basis in their clinics, health centres and hospitals.
   • Children remain very powerful allies in community mobilisation. By working together with children, health practitioners will ensure that the change they are mobilising communities for, truly addresses children’s needs and they will be able to have a much stronger voice.

3.10 Summary

In Study Session 3, you have learned that:

1. Community mobilisation is a process through which you will be able to work with the community to identify and plan health activities, particularly in relation to children's rights.
2. Always think of undertaking community mobilisation when the problem affects the whole community and when local resources, as well as larger scale changes, are required to address the problem.
3. The greatest benefits of community mobilisation are to help the community identify and address its own needs.
4. In community mobilisation, the first step is to investigate the community problems, then develop an action plan based on the dialogue.
5. Community participation as part of community mobilisation is critical for success.
6. Participation enables local people to develop commitment, skills and knowledge, and it enhances the partnership with health workers.
7. You will need to understand the community well before you start work on mobilisation in the community.

3.11 Self-assessment questions

3.12 Answers to activities

4 Answers to self-assessment questions

Study Session 1

Study Session 2

Study session 3

Resource 1

For Activity 1.3

Bibliography

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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).

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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).

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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: 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.