Why are children left out of ‘community’ strategies?

This opinion piece reflects upon how children and adolescents contribute towards their health, despite there being a general lack of acknowledgment, let alone engagement with young people. A Strategic Review of Child Health, published this year by the BMJ illustrates this gap. The question remains: why are adolescents and children’s capabilities (roles), still so often left out of children’s health strategies?

The Future of Child Health must include children’s own engagement

At Children for Health, we are deeply concerned, that almost 30 years on from the UN Convention on the Rights of the Child, which outlines the rights of children ‘to be heard’[1]– to participate in matters that concern them – that they remain side-lined in ‘community engagement’ strategies. This is apparent in Audrey Prost’s et al. ‘Strengthening the capabilities of families and communities to improve child health in low and middle income countries’ (Published 30 July 2018 in the BMJ).

This opinion piece explores the specific roles that adolescents and children can and should play as key ‘agents of influence’. This unfortunately was not identified in the above article on how to improve child health in the BMJ. We believe (based on experience), that children influence their parents and families; and that fundamentally they can help shift the identity of others and their family unit. But that they alone, cannot change an individual – that person (young or old) must eventually change themselves.[2]

This piece firstly challenges the use of ‘community’ in the article, before discussing child rights expert, Gerison Lansdown’s notion of ‘evolving capacities’ (a development of capabilities thinking to some extent). It then outlines two ways whereby children can influence other children’s health as well as their own mothers’ health, and discusses schools as a particular place of influence, whereby children can exercise their agency to influence other children’s health. Finally we show how children can go beyond service delivery in health care and be part of social accountability processes to check that quality is maintained.

The Challenge of using ‘community’

There is a problem for many practitioners and academics alike in using ‘community’ in development: several anthropologists of development have discussed how labelling can exclude/simplify/ devalue individuals and/or groups of people[3]. They often refer to Foucault’s work on ‘power and discourse’ to demonstrate this. An example of how development practice can overly simplify working with diverse people is acknowledged in this statement in Prost’s et al. article by a senior manager of a multilateral organisation: “The laundry list of components and behaviours was not an effective mechanism of communication. While we’ve paid lip service [to community engagement] we haven’t addressed it beyond distributing bed nets.” And whilst the article does start to break down who specific community members might consist of: ‘women’s groups’ and ‘husbands, partners, community leaders, and health committees’. It does not go far enough.[4]

The BMJ’s articles do not refer to the UN’s guiding framework for unpacking narrow development proclivities towards people – the ‘Leave No-One Behind’ agenda of the SDGs. This is a concerted attempt to strive to tackle social inclusion head on. There are rich primary accounts in the article regarding community engagement approaches in general: “you need somebody to be there in the village to have regular contact”, which is a reference to external health workers not always being effective….so the next logical question is who can be effective within the so called community? We would argue that children and adolescents are an integral part of solutions, and we will shortly provide a couple of examples, but if you wish to read more, you can also see this earlier article of ours on the Every Women, Every Child Strategy.

Discussion on ‘capabilities’: what can child health learn from child rights/participation?

Before we present some examples of how children are engaging in community child health practices we would like to acknowledge the seminal work of Gerison Lansdown on ‘evolving capacities’ of the child.  This is an important addition to the work on capabilities (started by Amartya Sen). Central to Landown’s arguments have been that: “Presumptions of children as immature learners have led to a failure to value or witness the behaviours they exhibit that testify to their active participation in shaping their own and others’ lives around them.” (p. 12: 2005). They are not passive recipients or empty vessels waiting to be moulded.

Ways in which child and adolescent engagement influences inter and intra generational health outcomes

The Child to Child ‘six step’ methodology developed back in the 1980s in consort with numerous field partners and programmes, shows how as individuals, pairs and groups children can influence familial health outcomes; linking children’s learning with actual child health problems and issues at a family level. Essentially these are different spheres of influence with families and neighbours.

The Integrated Management of Childhood Illnesses (IMCI) introduced by the World Health Organisation and Unicef as a global strategy to “reach all children” with prevention, diagnosis and treatment for common childhood illnesses, aiming at reducing child mortality and promoting child health has 16 (ideally integrated) areas for intervention. For the purposes of this short article we will refer to two as indicative examples:

1. “Promote mental and social development by responding to a child’s needs for care through talking, playing, and providing a stimulating environment”(4 out of 16). The work of Berger and Nuzzo (2008) shows that: “Older siblings provide developmentally more advanced models for younger siblings and help create a stimulating, enriched environment that seems to enhance younger siblings’ [motor] development.” And with regard to mental and social development, the work of Dunn (2007) shows that: “Through their conflicts, for example, siblings can develop skills in perspective taking, emotion understanding, negotiation, persuasion, and problem solving.”[5]
2. “Adopt and sustain behaviour for prevention of HIV/AIDS and care of people affected, including orphans”(8 out of 16). There is a large amount of literature regarding how older siblings, that are orphans due to HIV/AIDs, care for younger siblings[6]. As well as how peer education approaches are used amongst children and adolescents towards the prevention of HIV/AIDs. For one example see the Ace Child to Child Clubs in Tanzania promoted by the Child to Child Trust.

Whilst peer education is a whole subject matter in itself, it is worth mentioning that it can be an instrumental preventative and promotive aspect of child health ‘community’ engagement strategies, that don’t necessarily have to be in the school (and my early work with youth focused NGOs are a testament to this, as well as work by agencies such as UNFPA). There is some debate over the extent to which, and the lack of scale with much evidence, but in the main it is agreed that: “Research suggests that adolescents are more likely to modify their behaviours and attitudes if they receive health messages from peers who face similar concerns and pressures”[7].

The school as a place and site of influence[8]

Children for Health’s Rapid Sift of ‘Children as Agents of Change Children’s role in influencing health and nutritional practices’ by Lisa Davis & Clare Hanbury (July 2016) also demonstrates that schools can be a place and site of influence for children and adolescents. I mention two examples here; the firstfocuses on how children can be agents of influence upon their mothers’ health, and the second on malaria prevention amongst themselves and their peers.

Gunawardena et al (2016) used a 12-month cluster randomised trial to measure the impact of School-based intervention to enable school children to act as change agents on weight, physical activity and diet of their mothers. Participants were mothers with grade 8 students, aged around 13 years, of 20 schools in Homagama, Sri Lanka. Students of the intervention group were trained by facilitators to acquire the ability to assess non communicable disease risk factors in their homes and take action to address them, whereas those of the comparison group received no intervention. Body weight, step count and lifestyle of their mothers were assessed at baseline and post-intervention. Multi-level multivariable linear regression and logistic regression were used to assess the effects of intervention on continuous and binary outcomes, respectively. The study concluded by stating that a program to motivate students to act as change agents of family’s lifestyle was effective in decreasing weight and increasing physical activity of their mothers.

A Save the Children (2012) project supporting malaria prevention combined school-based education with the distribution of Long Lasting Insecticide Treated Nets (LLINs). The school-based malaria prevention education included children’s “malaria clubs”. These were formed in every school to assess and promote mosquito net use at the household level. A ‘School Malaria Day’ was organised to coincide with the LLIN distribution. The entire community was invited and children performed sketches, poems, songs and demonstrations on how to hang and use the mosquito nets. Each school child also received two LLINs (for himself and for his siblings). The study was evaluated using a Cluster Randomised Control trail (this approach is described later in the evaluation methodology section). Following the school-based and national universal community-based distribution of LLINs the percent of children reporting sleeping under a mosquito net the previous night increased in both the intervention and comparison schools. However, the use of nets improved significantly more amongst children from the intervention schools and this improvement was sustained for longer. Children’s knowledge of malaria, how it is transmitted, and how to prevent it was also significantly higher in the intervention group.

Children’s for Health’s own work with Government schools in Mozambique demonstrates that young adolescents can profoundly influence their family’s nutrition and hygiene behaviours.

Adolescent social accountability of health services

It’s important to go beyond children and adolescents’ contribution to preventive health programmes, and also acknowledge their contribution to holding local and national governments to account on their health service provision. One way of doing this (and I draw from some of my own experiences here), is via social accountability tools, such as the use of score cards. This is widely documented amongst NGOs such as ActionAid and for the Global Strategy on Women and Adolescents Health. This is also an important form of citizenship education-building capacity and strengthening young people’s ‘evolving capacities’ as community health workers, in their own terms.

The practical application of ‘adolescent empowerment’ is not easy. It is much easier to talk about it, than to create the enabling environment for children and adolescents to effect change. Children for Health is however doing just this: we are increasingly employed by governments and the larger international agencies to construct practical ways of ensuring that adolescents are a part of ‘community solutions’.

Conclusion

So here at Children for Health, we agree with the recommendation from ‘Strengthening the capabilities of families and communities to improve child health in low and middle income countries’, that there is a need for evidence of community engagementto be further strengthened. After all this echoes our Rapid Sift, but it needs to go much further: to discuss community engagement without acknowledging children and adolescents as vital agents of influence, and an integral part of these processes, is ignoring what many teachers, parents and health workers see on a daily basis[9].

[1]https://resourcecentre.savethechildren.net/sites/default/files/documents/5259.pdf

[2]This is a slightly different position, on an overused and often under articulated concept; ‘agents of change’. Based on our experience at Children for Health, the structures and enabling environment around children rarely exist for them to really be able to reach/ attain sustained social change at a community/ national level. We plan to explore our concept of ‘Agents of influence’ in our next opinion piece.

[3]See http://eprints.lse.ac.uk/253/1/Anthropology_and_development_a_brief_overview.pdffor an example.

[4]At Children for Health, ‘community’ is inherently concerned with the diverse children and people we have connections with. Therefore if a child goes into a community of connections/ relationships – they are poised to be influenced or be influencers.

[5]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956653/

[6]See for example the work of Sonja Merton (2016): https://www.tandfonline.com/doi/full/10.1080/09540121.2016.1195483

[7]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499060/

[8]We are not saying that schools are the only places of influence, but rather that they are an important and significant place.

[9]See the previous article for a discussion on Who nurtures the adolescent care givers?