Health Promotion International Advance Access originally published online on December 16, 2007
Health Promotion International 2008 23(1):16-23; doi:10.1093/heapro/dam037
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School children as health change agents in Magu, Tanzania: a feasibility study
1 National Institute for Medical Research, PO Box 1462, Mwanza, Tanzania 2 Danish University of Education, Institute for Curriculum Research, Research Programme for Environmental and Health Education, Emdrupvej 101, DK-2400 Copenhagen NV, Denmark 3 DBL—Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen, Jaegersborg Allé 1D, DK-2920 Charlottenlund, Denmark
* Corresponding author. E-mail: jrmwanga{at}yahoo.co.uk
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SUMMARY |
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The feasibility of an action-oriented and participatory educational approach, where school children function as health change agents, in a rural community of (Magu district) Tanzania was explored. Observations, in-depth interviews and focus group discussions with pupils, teachers and parents were undertaken. Findings showed that study participants favoured an approach where school children played an active role as health change agents in a combined school and community health education project. This conclusion contradicts traditional views in many African cultures where power, status and wisdom are usually closely associated with old age. However, a number of barriers were found, including the curriculum, time constraints, class size, teaching materials and teachers' skills and working conditions. The idea that pupils act as health change agents in the community as part of an action-oriented and participatory health education approach in schools was supported. A list of factors to consider when planning an action-oriented health education project is provided and discussed.
Key words: action-oriented health education; change agents; Tanzania
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INTRODUCTION |
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Peer education has been successfully utilized in health projects seeking to reduce the incidence of smoking among young people (Klepp et al., 1986); substance misuse (Perry et al., 1989) and recently in HIV prevention and sexual health promotion (Ebreo et al., 2002). However, this methodology lacks a rigorous theoretical base (Turner and Shepherd, 1999) and focuses on the peers rather than on the impact of the programme on the peer educators themselves (Ebreo et al., 2002).
In the majority of peer education studies, little attention has been paid to the possibility of children being change agents as their participation and actions in health education are often not valued and usually pupils assume the role of passive recipients of information. In some studies (Onyango-Ouma et al., 2004; Simovska, 2004; Simovska and Jensen, 2003), pupils and schools are viewed as social agents for change. This study explored the idea of pupils as active dialogue partners in schools and as active change agents in the local community and the families in the Tanzanian context.
Theoretical and conceptual framework
The theoretical framework underlying the current study comprises the concepts of action, participation and action competence (Jensen, 2000; Schnack, 2000). An action is targeted at change, and those carrying out the action should decide and set the priorities. Actions aim at influencing ‘real life’ conditions as part of learning processes.
Action competence has been operationalized into an approach, which stands for (i) investigating health issues, (ii) developing visions and (iii) taking action to (iv) facilitating change (Jensen, 1997). These are perspectives that constitute a conceptual framework and steering tool in an action-oriented and participatory teaching. This implies close links between schools and their local communities, as pupils will often have to work in the community when they explore concrete health issues.
Participation is crucial as it is the main precondition for the development of ownership among pupils. Without ownership, health education will have no impact on pupils' practice and actions. From Hart's (Hart, 1997) and Simovska's (Simovska, 2000) work on children and participation, two different forms of participation, genuine and token participation are distinguished. Genuine participation is directed towards pupils' own critical reflections; token participation is related to a health behaviour modification approach, where pupils are encouraged to be active, but at the same time are expected to adopt predetermined practices and behaviours and pupils' own reflections and decisions are not in focus.
Children assume the role of change agents in an action-oriented and participatory teaching and learning approach aimed at ensuring the development of their genuine participation, ownership of educational process and action competence; and the facilitation of processes leading to concrete change. This is a fundamental departure from projects which use children as peer leaders.
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METHODS |
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Study area and population
A cross-sectional study was carried out in a rural part of Magu district, Tanzania. Participants were recruited purposively among pupils and teachers from four primary schools and parents from three surrounding villages of Nyanguge area. Most of the study participants belonged to the Sukuma tribe (a Bantu-speaking people who live in part of Sukumaland, located to the west and south of the Lake Victoria. Their economy is based on subsistence farming and livestock keeping. In this community, traditional sector of healthcare is composed of different categories of informal healers (bafumu) who claim to treat a number of illnesses. Self-treatment by both modern pharmaceuticals and traditional medicines is also very common (Mwanga et al., 2004).
Data collection
Data were collected in 1998 and 1999. There was no incentive for participation but soft drinks were served during the focus groups sessions. Forty-three sessions of focus group discussions were held with a total sample of 306 participants (Table 1). The composition of groups took into consideration homogeneity and related aspects emphasized in the literature on focus group discussions (Dawson et al., 1993). We interviewed 247 informants with almost equal gender balance (Table 2). Most of the informants were between 10 and 19 years of age and were primary school pupils. Majority of interviewees were Christians (Table 3). Focus group discussions and interviews were held in schools and households.
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The main research questions posed were: how did the pupils view an educational approach in schools where they have to play an active part? What were the pupils' own opinions about the approach? Do they see themselves as potential agents in the community and do the teachers see a participatory and action-oriented approach as a way forward in schools and where are the potential barriers? Will people from the local community accept to be taught by children? Furthermore, observations were noted down.
Data management and analysis
Recorded tapes from focus group discussions were transcribed and together with field notes from interviews and observations translated from Swahili into English (back-translation) and typed. Transcripts were organized using Ethnograph Version 3.0 (Qualis Research Associates, USA) software package for qualitative data analysis.
Content analysis was performed and verified by two investigators independently by comparing raw data and summaries repeatedly using the principles of grounded theory (Strauss and Corbin, 1994) and inter-coder variation was very minimal. Quotes were taken from transcripts to support findings by shifting between emic and etic perspectives (Miles and Huberman, 1994).
Where cases did not fit the emergent theories, these theories were re-examined and re-evaluated (Bernard, 1995). The two investigators assigned more or less the same meaning to the data (i.e. inter-investigator reliability was very high as data from focus group discussions and interviews validated each other). Hence, validation and trustworthiness of the findings was established as analysis of data used explicit, systematic and reproducible methods (Greenhalgh and Taylor, 1997).
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RESULTS |
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The pupils' perspective
Pupils expressed a high commitment to schools-based health education. More than three quarters of the interviewees agreed that there was a strong need for health education to children. Reasons related to health promotion (‘maintain good health’) and prevention (‘avoid various diseases’) were equally often mentioned.
Pupils preferred ‘learning by doing’ to theoretical teaching alone. For example, tooth brushing, washing and taking bath, general cleanliness of the school compound and latrines were among the issues mentioned frequently.
Great satisfaction with a programme called ‘Education on HIV/AIDS’ was expressed, because teachers left pupils alone during some of the sessions and this gave children more possibilities for having a say in health education.
Pupils expressed willingness to work as communicators and change agents as part of health education particularly if they are left alone with their peers. The following quotation illustrates this: ‘I can instruct my family and the entire community on how to adhere to hygiene practices such as taking bath, washing clothes and keeping the compound tidy’.
However, many pupils pointed out that all pupils should get a chance to become involved in the teaching process as they learn best when they are actively engaged rather than only passively listening. This mode of learning engaged every child, so that even the quiet or shy ones could not hide behind the performance of others.
Pupils expressed motivation and willingness to work with participatory processes which are not directed by teachers and a strong commitment to work as health change agents and ‘teachers’ for other peers and adults.
The teachers' perspective
All schoolteachers emphasized the importance of health education to children of school-going age as the first step towards controlling diseases. Once the pupils had basic knowledge of how diseases are caused, transmitted and prevented, then they could take initiatives to prevent ill health.
During interviews and focus group discussions, schoolteachers deliberated on ways of disseminating health education. All teachers regarded it as their responsibility and supported the idea of health education becoming a separate subject in the primary school curriculum. During one of the interviews, there was the following remark: ‘For school-going children, health education should be taught as a major subject in schools. Materials to be used should include books and demonstrations with real things, e.g. in keeping hair clean, things required would include a mirror, comb, water, towel, soap etc.’
Schoolteachers needed in-service training in health education in the form of seminars or refresher courses. They also demanded health education materials such as books, posters, booklets and real things for demonstration, e.g. using real items such as soap, basins and foodstuff, which will make children understand quickly as opposed to showing pictures alone. Furthermore, there were very few posters and scientific charts in the study schools, and these did not cover priority diseases in the area.
The following quotation underscores some of the problems involved in teaching health education: ‘Teachers prepare themselves according to the curriculum but they are forced to prepare teaching materials and real things for demonstration themselves. There are very few books and charts to be used’.
Moreover, teachers demanded a good teaching environment in order to be able to teach health education effectively. To attest to this view, one teacher stated: ‘The government should improve school buildings to provide many classrooms and adequate number of teachers. The average size of class should be 40 pupils. For the time being, the size of class can go up to 100 pupils. It is difficult to increase "streams" because that would require additional staff. The current situation is that one teacher teaches an average of 28 lessons per week. This is too much work and may lead to deterioration of teaching standards. An average of 20 lessons per week is desirable’.
Most teachers believed in participatory methods, but confessed that these are hard or almost impossible to practice with the big classes found in Tanzanian primary schools. It was also a concern that participatory methods could erode the teacher's authority. Schoolteachers unanimously agreed that children could communicate health messages to their families and communities in general, as shown by the following quotation: ‘Children can teach fellow children and adults on how to prevent diseases. If parents can give children opportunities to listen to what they have to offer in terms of health messages, then this strategy will succeed. Parents should note that even if they are educated, health messages from children can still be important to them’.
Concerning the possibility of children educating fellow children and adults on health education, one teacher said: ‘Yes, it is possible because children are among the community. It is easy for a child to meet others in play or another activity and advise/educate fellow children on various issues pertaining to health. If this education is also brought into the family, it would be very useful and a child can do the job of a teacher (a family teacher) on what is good or bad for the health. For instance, if a child find his mother preparing food without washing hands, or coming from latrine and does not wash hands, he can tell her to wash hands. This would be a very useful advice’.
Some teachers commented specifically on how to reach non-school-going children as follows: ‘It is possible for a few children to educate fellow children and adults. In schools, peer education has been a success. The same can be true for non-school going children. School going children mingles with non-school going ones more often. This can facilitate dissemination of health messages. Parents can also learn from children if they listen to them’.
Teachers observed that pupils' learning in the health field gain from participatory and ‘hands on’ approaches. But a number of factors hinder this process. Lack of teachers' skills, lack of adequate in-service training activities and school materials, too many pupils in the classrooms, too much work and an overloaded curriculum constitute barriers to a participatory approach. Teachers believed in the pupils working as health agents in the local community (including non-school-going children and family members).
The parents' perspective
The discussions focused on whether pupils should and could act as communicators and health agents in the local community and parents' willingness to listen and learn from their children. A very positive attitude was expressed with regard to learning from children. Very few informants had reservations in this respect. Most parents insisted that they have time (in most cases in the afternoons and evenings after work) to listen to children and would implement the health education messages brought by the children. The issue of ensuring time to be ‘educated’ is obvious in the following quotation: ‘We have all agreed that we can be educated by our children. In the old days, we could not accept, but nowadays we are progressive. We know the importance of cleanliness. One can find time to be educated by own child or neighbour's child. It will be nice after coming from farm work’.
The study revealed that adults respect children for their skills and knowledge acquired at school. They regarded children as quick learners and as resourceful and enlightened people. Furthermore, some parents saw children as role models and emphasized learning by doing rather than theoretically. A parent said: ‘Children should show actions in the course of educating their parents and fellow children. For example, they should wake up early in the mornings and clean the surroundings, boil drinking water so that parents and other children may follow suit’.
Only three of the 107 parents interviewed were not in favour of this approach. The majority of parents were willing to be taught by children because they realize that there are a number of disease problems that they cannot handle on their own. Children are resource persons who have something ‘new and important’ to say. Even though time is a scarce resource, they are willing to set aside time for children to communicate and teach them their messages.
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DISCUSSION |
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Pupils were of the opinion that participatory learning can only become a reality if their teachers were willing and committed to extend this approach to all teaching/learning scenarios in the schools. Teachers need to change their general attitudes towards children and become more democratic in their approach so as to encourage children's genuine participation. Pupils enjoyed being ‘left alone’ to plan and carry out teaching of others as it give them more freedom to participate and make their own decisions.
Teachers have been exposed to child-centered and participatory methods during their time at teacher training colleges. However, it is questionable to what extent they are able to substitute the traditional didactic teaching methods with the participatory approaches in daily reality of schools. Among the most important obstacles, teachers mentioned the lack of adequate materials, an overloaded curriculum, fear of loosing control and status, too many pupils in the classrooms, too much pressure on the single teacher and lack of continuous professional support and in-service training. At the same time, the prevailing strict punishment of pupils, which is against a more democratic school culture, is hard to get rid of.
Regarding pupils acting as health change agents in the community and in their families, pupils, teachers and parents expressed a positive attitude. Pupils believed in their own competence to carry out the task and they demonstrated commitment and confidence in relation to this challenge. Teachers also believed in their pupils' skills to take up the challenge and they emphasized the possibility and importance of reaching non-school-going children through this approach. Almost all parents expressed a very positive attitude towards the idea of children playing an active role as health change agents in the community.
This may be a surprising conclusion in an African context where power and status is usually closely associated with old age, an issue which from the outset give children little negotiating power. Nevertheless, the parents were not only willing to listen to children's health messages, they also strongly believed in children as resource persons who were needed in a fast changing society with new disease problems and resurgence of old ones.
The potential of children as active change agents was also found in a study in Upper Egypt (Al Khateeb, 1996), where children were prepared to teach parents what they learned, in school and during summer club activities, about how to prevent communicable diseases. An evaluation after 6 months showed a great increase in parents' knowledge about the importance of combating infectious diseases.
Studies in Kenya (Onyango-Ouma et al., 2004), Macedonia (Simovska, 2004) and Denmark (Simovska and Jensen, 2003) demonstrated positive outcomes of the use of children as change agents not only in hygiene and tropical diseases but also in reproductive health and substance abuse.
Although this study is mainly based on the statements of the participants about hypothetical situations, the use of triangulation (application of several data collection methods as well as involvement of several categories of informants) strengthens the findings.
Moreover, there were sufficient measures taken to guard against biases as the settings created during focus group discussions and interviews were natural and allowed for rapport, and interviewers and facilitators appeared sufficiently neutral to the informants to facilitate free and spontaneous responses.
Figure 1 gives an outline of the issues that came up during the interviews and focus group discussions regarding factors, which may have constraining or enabling effects on action-oriented, child-centered health education projects. The left part focuses on the implementation in the school environment per se. The right part describes the additional factors, which are at play when pupils are supposed to extend a school-based programme into the surrounding community.
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We have primarily been addressing the attitudes among pupils, teachers and parents. But a number of factors embedded in the school context, the community context or the societal context strongly influence these person-bound attitudes. Factors belonging to the school context, such as availability of staff quarters and timelines of monthly payment and the transfer policy may play a major motivating or de-motivating role for teachers.
Also, a school-based health education project is very dependent on the school manager's dedication and ability and projects of this nature should be seen in relation to the relevant parts of the national curriculum and the in-built incentive structures, e.g. whether a subject is examinable or whether the teachers get any credit career-wise when engaging themselves in extra-curricular health education activities.
Basically, a school-based project is based on the root assumption that children go to school. Hence, the local enrolment rate (the proportion of children of school-going age being enrolled) is a crucial parameter.
At the community level, there are a number of factors that will influence a participatory, action-oriented project like this. Thus, school/community relationships and the attitudes of the community leaders are crucial preconditions for success. This is closely related to the ability of the various community groups to collaborate and the extent to which the community has a sense of ownership of the health education project. At a more general but very concrete level, issues such as poverty, epidemics and draughts may have serious influence on projects.
Within the school as well as in relation to community directed initiatives, there are two kinds of factors (positive and negative), which are ‘rooted’ within the local environment—factors which may in principle be influenced by local initiatives. In the school, these factors are related to pupils, teachers and certain aspects of the school environment in general.
Regarding community initiatives they are related to pupils, parents and certain aspects of the community in general. However, it is important to note that there are certain general, contextual factors within the school environment (e.g. big class size or national curriculum) as well as the community (e.g. poverty or epidemics), which may be important for the outcome of the project. Although these contextual factors are outside the immediate influence of such a project, it is of crucial importance to take them into account when planning and carrying out a health promotion project.
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FUNDING |
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This study received financial support from the DBL-Centre for Health Research and Development, Faculty of Life Sciences, University of Copenhagen.
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ACKNOWLEDGEMENTS |
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We acknowledge study participants in Nyanguge ward, Magu district, Tanzania, as well as the field staff who devoted their time to the study. The National Institute for Medical Research, Mwanza, Tanzania; the Danish University of Education and DBL-Centre for Health Research and Development in Denmark are acknowledged for practical support. We are also grateful to the two anonymous reviewers for their time and constructive comments.
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