Promoting health education through children in primary schools is a valuable tool for spreading good health practices in local communities. In this article Dr. Shabnam Ahmed explores the benefits of this approach and the contextual limitations it faces in a traditional society such as Pakistan.

Children?s participation in initiating change is as important as that of adults. Health is an important component of development and just as adults have rights and duties towards health, so do children.

Following the World Conference on Education for All it was recognised that primary schools are the most efficient way to introduce basic health education to children. A school provides opportunities to interact with a large population of children and school health activities provide opportunities for children?s participation and social development. Adults play an important role in facilitating such activities for children.

Health promotion in schools and the Child-to-Child movement

In order to understand why we need parental participation and involvement in the health promotion activities targeted to their children, it is important to understand health promotion and Health Promoting Schools and learn about a rights-based participatory method called the Child-to-Child (CtC) approach. This approach makes the children partners in promoting health in their community.

Health Promotion has been a goal of World Health Organization (WHO) for the last forty years. WHO defines health promotion as ?a process of enabling people to increase control over and to improve their health. It has identified strategies to help people maintain and improve their health and has changed the location from a more general one to a specific setting such as the school.

The school has long been recognised as an important setting to promote health and the wellbeing of children. In the 1960s and 1970s efforts were made to bring health and education together in most of the schools in the West. Traditionally, the education sector has viewed health as part of a number of key learning areas in school; however the concept of a Health Promoting School (HPS) was first defined in the 1980s. This has been used since to promote children?s health and wellbeing in school settings around the world. Hawes states that ?School health promotion includes all the means a school uses to become healthier and to spread health to those who attend and work in it and to their families and communities?.

In HPSs, health is defined broadly as comprising of physical, mental and social health. HPS initiative takes advantage of the presence of children and staff for long hours at school, at a stage in their lives when they are open to long-term influences on their health and lifestyle.

The single, most important determining factor in a child?s health is the mother?s level of education. According to a World Bank report mothers who have attended even one year of schooling are more likely to have their children immunised. A survey report conducted in 25 developing countries shows that 1-3 years of schooling reduces child mortality by 15%.

The number of children enrolled in primary schools worldwide is constantly growing and rose by more than 40 million between 1999 and 2007. Hence the drive to promote health through schools can go a long way in meeting the twin goals of Health for All and Education for All through the Global School Health Initiative. The CtC approach which is guided by the UNCRC principles of inclusion, non-discrimination, protection and participation could form the basis for intensified and joint action to make schools healthier for children.

What is the Child-to-Child approach?

An all-encompassing definition of health goes beyond the physical state of the body, and includes the social and cultural aspect. Children all over the world have been participating in health activities for a long time. In many cultures older siblings take care of younger siblings. They cook, feed and bathe them. Playing and teaching songs and stories is another common interaction between siblings. These activities develop care and concern for others in young children. For most parents and communities especially in developing countries, this is a way of life.

In childhood theory, children and young people are treated as equal citizens to adults. They have a voice and specific points of view about their own wellbeing and that of the social group that they interact with.

Building on the belief that children can be agents of change, an approach to health education was introduced in 1978 called the Child-to-Child (CtC) approach. The CtC Trust based in the Institute of Education at the University of London emphasises that it is founded on the belief that children have the skills and the motivation to educate and assist others. Since then the trust has developed seventy active health promotion and community development programmes around the world, using a skill-based participatory approach to health education. Adult participation and facilitation is also seen to be very important in enabling children to participate successfully in health promotion activities in their schools.

Hawes (2005) says that CtC ?represents a movement which believes this approach is vitally important to health and development?. This is an approach in which children are able to take responsibility for their own health, and that of their families and communities. Through participating in CtC activities, the personal, physical, social, emotional, moral and intellectual development of children is enhanced. This approach to health education seems to help children understand, find out more and take action for their own health and the health of their families.

The CtC approach involves children in three ways;
? through helping their younger brothers and sisters
? through assisting children in their own age group,
? through working together to spread health messages and improve health practices at home as well as in their community.

However, health education is much more than just conveying health messages. It is about ?learning, relearning and unlearning? as they challenge the cultural and traditional beliefs and practices. Through this approach, children not only learn educational facts but also develop important life skills of creative thinking, problem solving, communication, decision-making and empathy. This approach to health education promotes ideas and methods that are integral to achieving the goals outlined in the 1989 Convention on the Rights of the Child.

The CtC approach can sometimes be erroneously seen as child exploitation, and so it is important to understand what CtC is, and also what it is not.

Child-to-Child is MUCH MORE THAN
? One child helping another child
? Older children passing on health messages to younger children
? An approach to Peer Education
? A one time activity

Child-to-Child IS NOT about
? Children being asked to act as loudspeakers for adults
? Children being used to do things adults do not want to or should do
? Richer children helping poorer ones
? A few children being put into positions of authority over their peers (e.g. as ?little teachers?)

However, it is evident through various evaluations that this child-based approach could only succeed in communities where cultural expectations do not diminish or marginalise children especially girls. In some countries such as Pakistan children are not expected to initiate conversation Therefore at times in its initial stages this approach may create apprehensions and so it has to be contextualised to be successful. Adults need to be flexible, willing to trust children, and work along with them. The real challenge for parents would be to let go of the central control traditionally exercised over children and learn to work with them as partners.

It is yet to be seen how far CtC will be able to overcome traditional resistance in developing countries to involving children in the decision-making process. This approach builds on the traditional role of children helping each other and their families, but rejects the low status given to children in most hierarchical societies. This balancing act between the traditional values of society and the role of children in health promotion activities can create strains. There has been a growing critique of the name, as this approach is not CtC in the true sense. Hawes (2000:1) rightly points out that the name CtC ?confuses those who don?t understand?. Nevertheless the name is catchy and is associated with success and therefore it is commonly used.

Barriers to children?s participation in health and development

The UNCRC (1989) clearly states that children like adults have a right to be consulted and to express their views. The major barrier towards children participation is the myth that young children cannot perform and cannot be trusted. Although when adults mutually consult and listen to young children they build their confidence and increase their self-esteem. However, it is increasingly accepted that children?s capacity for participation is determined by many factors. Some common factors identified in literature, which act as barriers to children?s participation are:

Adult?s attitudes towards the social and emotional development of children
The factor that plays the most important role in a child?s development is the attitude of the adults (mostly parents). A child?s status in the society and his or her parent/guardian?s attitude affects a child?s self esteem. Hart states that ?a child who is troubled or who has low self esteem is less likely to demonstrate his/her competence to think or to work in a group?a child?s ability to participate in development varies greatly according to the culture and the individual characteristics of a child?.

Social Pressure
One reason for parents? reluctance to allow their children to participate in health promotion activities is the influence of other people around them. There are few people who can make decisions or perform actions without considering the opinions and views of those around them. For instance a traditional Pakistani mother will have to consider the opinion of an elder in the family, mostly a mother-in-law or a grandmother or her husband before taking any action regarding her children?s or her own health. Therefore any action a person takes is due to the interplay between one?s self and the environment he or she lives in. It is the people?s belief about the world around them, which affects their decisions and actions.

It is widely believed that culture has an important influence on people?s attitude towards various issues in society. There are three overlapping features that all cultures consist of : shared characteristics, traditions and belief systems.

Shared characteristics are a belief shared by a group of people, the whole community or even the whole country, and this can influence the decision an individual takes. Traditions are practices held for a long time, which are passed on from one generation to the other. The transfer of these practices takes place through informal instructions or by copying the actions of adults. Traditional practices put parents under great pressure and often restrain them from taking any decisions that are different from the general norms of the society.

Beliefs could exist on their own or could be the part of wider system of beliefs such as religion or traditional medicines. In Pakistani culture, religious beliefs are the most difficult to change and they are the ones which greatly influence the decisions of the adults.

Poverty diminishes opportunities for poor children to participate and being a girl further worsens the situation. A girl child between the ages of ten to twelve years usually starts looking after her younger siblings and participating in household chores, helping her mother to wash, clean and cook. Hart (1992) points out that while male child labour can be seen on streets and factories, girls work out of sight, in kitchens or backyard. It is important to clarify that when a child participates in development, he or she is not being used to do things that adults do not want to do. Children?s participation in development urges an attitude of respect for the capacity of children, whether a boy or a girl, to contribute to decisions that affect them, and avoids excessive responsibilities or workloads in the guise of participation.

In societies such as Pakistan, children are participating in economic and household activities all the time, but there is a need to find ways to bring these children into the fold of the development process and help them participate for the right purpose and be able to take decisions for themselves.

Socio-economic factors
Various comparative studies in many countries show that the middle class gives more independence to their children than those from low socio-economic classes. The latter expect their children to be obedient. Here class refers to all those people who share the same class situation, that is, the same set of life chances and opportunities. As poverty hinders spontaneous children?s activities, only the voice of the middle class is being heard. Not surprisingly the main participation in development is by children from the middle class, whereas poor children remain marginalised.

Benefits of children?s participation in Health Promotion

Children?s participation in health promotion has a long-term benefit, the impact of which is not immediately obvious. Participation helps children grow up as competent and confident members of the society. It also helps them develop skills which help them to be an agent of change for themselves and for their communities.

Adults must listen to children in order to learn about their experiences and this is only possible if children are given the right to express themselves. When adults routinely listen to children and consult and reflect with them, they help to increase children?s competencies, mutual trust and confidence. The greatest benefit is delivered to children who take part in health promoting activities.

These children are provided with knowledge, skills, attitudes and values such as respect for others, denial of violence, and care for the environment, which benefits them now and in future, when they become parents and citizens. Through participation in health promotion, it is also suggested that children may improve family relations characterised by increased parental support. This could be due to the knowledge acquired which enables them to contribute more effectively to the wellbeing of their households. This method of actively involving children may act as a catalyst to motivate the local community as whole.

Dr. Shabnam Ahmed has a Masters degree in Education, Health Promotion and International Development from the Institute of Education, University of London, UK and a Bachelor?s degree in Medicine. She is a regional consultant for the Child-to-Child Trust UK. She has worked as faculty member at the AKU-IED and is currently working as a Senior Manager and is part of the Training and Development Team at TRC.


– WCEFA (1990) ?World Declaration on Education for All and Frame work for Action New York:http// (accessed on 12th June 2009)
– (WHO 1996). WHO (1996) ?The Status of School Health?. Report from the WHO Expert Committee on Comprehensive School Health Education and Promotion, Geneva
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– World Bank Report (1993) World Bank (1993) World Development Report: Investing in Health, Oxford: Oxford University Press
– WHO (1996) ?The Status of School Health?. Report from the WHO Expert Committee on Comprehensive School Health Education and Promotion, Geneva: WHO
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– UNCRC (1989) Convention on the Rights of the Child New York:United Nations).
– Hart,R.(1992) Innocent Essays No.4 :Children?s Participation: from tokenism to citizenship. Florence: UNICEF
– Mayall,B., Zeiher ,H.(2003) Childhood in Generational Perspective. London: Bedford way papers,University of London

October 2011