"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
The Evidence: Officially or Unofficially, CHWs Already Address Violence Against Children | Last year I was working for World Vision’s Technical Services Organisation, which provides technical assistance and training to WV offices and partners. We received a request to analyse the results of a piece of research undertaken by World Vision Canada as part of the ENRICH Programme, funded by Global Affairs Canada. This research was conducted as part of the “It Takes a World” campaign that identified CHWs as the most promising channel to scale up action on violence against children. The study brief “It Takes Community Health Workers to End Violence Against Children” yielded some surprising results. A total of 412 CHWs from four countries were interviewed about their current experience of witnessing child abuse in the course of their duties, and what actions they take in response. It further explored how they are supported to respond through training and supervision, and existence of community-based child protection mechanisms.
The data were shocking and made clear the degree to which CHWs are already engaged in addressing violence against children, often without proper training or support (Figure 1).
Figure 1: Percentage of CHWs who reported providing violence-against-children-related services within the last three months.
Over 76% of the community health workers in the four countries (Bangladesh n=97, Kenya n=105, Myanmar n=105 and Tanzania n=105) reported witnessing violence against children (VAC) in the course of their duties over the last three months, most commonly neglect, child marriage, harsh physical discipline and verbal abuse. There was also a high rate of awareness of other forms of violence such as child labour, sexual violence against both boys and girls, and, to a lesser extent, child trafficking and female circumcision. However, regarding their preparedness for responding to abuse, only 23% had received recent training, roughly 20% had some form of community-based Child Protection mechanism to link to, and about half of them discussed the cases with their supervisors. In spite of this absence of adequate support, 60% reported taking action, mostly to counsel caregivers (87%) but about 30% of them were also making referrals.
In this CHW Central feature, we want to share the findings from this study and reach out to the broader community to solicit others’ experiences, documented or otherwise, on the issue of CHW involvement in addressing violence against children.
Can/Should CHWs Provide VAC Services?
Although CHWs are at the frontlines and are witnessing abuse, many governments and organizations remain hesitant about expanding their role to formally address VAC. During my tenure leading the development of World Vision’s CHW portfolio from 2012 to 2017, we proactively promoted the inclusion of messages about positive discipline and parent-child communication into our core project models: Timed and Targeted Counselling and its companion module Healthy Families. We included a module called “A Safe and Loving Home," which included tools for assessment, stories for counselling parents, and messages about types of abuse and violence. As these approaches were then adopted by Ministries of Health in five different countries, I was used to having the conversation with government health policymakers about including child protection issues in CHW programmes, met with varied responses. In Mauritania, the government, in partnership with the Council of Imams and World Vision, agreed to include family counselling on the prevention of child marriage in the CHW services. Lesotho and Ghana also included counselling materials and stories with messages about violence and child safety for parents. However, when it comes to identifying and reporting child protection issues in the community, there is clearly a diversity of opinions on the extent to which CHWs can or should take on this type of role. Many governments raised concerns that CHWs are under-skilled and over-tasked to take on additional complex and sensitive roles such as addressing violence against children.
Taking on a role in safeguarding through formalised reporting to police or government actors could have a big impact on how communities receive and perceive CHWs and how willing families would be to continue to allow CHWs access into their homes. In addition, although there is a shift towards professionalization of the CHW cadres, many are still lay volunteers and members of the community who may feel uncomfortable reporting other members of their own community to child protection services. The trust between CHWs and families is critical for open and frank conversations about caregivers’ skills, challenges and current behaviours. Knowing or fearing CHWs can report them might change that trust relationship. CHWs are at the forefront of efforts to scale up life-saving treatment and health promotion in LMICs. Thus, anything that compromises the trust they currently hold could reduce their impact.
Within World Vision, we also had multiple discussions about the personal safety of CHWs, particularly related to child protection interventions. In the literature review we conducted for the “It Takes CHWs” study, we found several reports of CHWs being victims of abuse or violence following their efforts to intervene in child protection and child marriage matters. Taking action on child abuse is a sensitive matter, and task shifting down to CHWs – frequently part of the voluntary unpaid workforce – might also be perceived as risk-shifting. If CHWs are operating without adequate support for their personal safety, or without the significant endorsement of community-based leadership and faith communities, it would be irresponsible to expect this of them.
If you are working in a developed country setting this debate might seem implausible. Police checks and safeguarding training is a prerequisite for working with children in any public, private or civil society organisation. For example, in the UK it would be unthinkable to send a health visitor or social worker into the household without adequate support, backup, and training to respond to suspected child abuse. But social welfare workers and programs, police and other resource persons are often in short supply in LMICs, and CHWs are frequently the main link between communities and health and social welfare systems. In recognition of CHWs’ role and in an effort to provide safeguards for CHWs and for the clients they serve, World Vision is rolling out safeguarding initiatives in its country programs to include community resource people and volunteers. Thus, we will need to return to this dialogue with the Ministries of Health to consider the options for reporting mechanisms for frontline health workers. The question remains as to whether CHWs are the right community workforce to carry out VAC interventions in depth, but at this point, for many countries they are the only community-based workforce available.
Preparing CHWs to Play a Larger Role in VAC Services
The data from this study underscore the importance of preparing and supporting CHWs to carry out VAC services. The findings changed my attitude; I now perceive a certain duty of care by organisations and governments supporting CHWs insofar as we are sending them into homes where they are likelyto witness extreme forms of child abuse, yet we are currently failing to equip them with guidelines on how to respond.
I believe that efforts need to be made to reinforce referral mechanisms and community-based responses to child protection, and this cannot be achieved by adding some roles to CHW job descriptions. The study demonstrates the value of CHWs being consulted in research and policy decisions, informing better estimates of the levels of VAC (typically underreported) given their proximity to families. Policies made from the top down, without adequate consideration of what community-based workers already face, cannot adequately address the needs of populations or the workforce that serves them. We suggest that actions taken against VAC need to be better supervised and monitored. In addition, we outline some proposed CHW roles in the prevention, protection and response of VAC (Table 1).
Table 1. Potential roles for CHWs in prevention, identification and response to child violence, based on World Vision’s existing work and normative guidance 4,5
Polyvalent /generalist cadres
Additional or specialised cadres
Conduct home visits to promote early child development and positive discipline, e.g. Timed and Targeted Counselling
Educate parents on harmful practices
Parenting groups and community education e.g. Go Baby Go
Mobilise communities on social norms change and to abandon harmful practices (harsh punishment, early marriage, forced labour, FGM)
Identify families and children with risk factors for abuse
Increased home visiting to families and children at risk
Identify children with special needs
Counsel families at risk on positive parenting
Observe parent-child interactions and attachment
Assess parenting competencies
Targeted home visiting
Refer suspected cases to supervisors
Inform social or health services
Treatment of injuries/first aid
Mobilise community resources to support families
Mobilise families to access health and social services support
Deliver parent-child interaction therapy
Sexual and gender-based violence interventions36
Psychological first aid
Although many programs are educating caregivers on early childhood development and positive discipline, some simple additional steps could also be considered to better prevent and address VAC in communities. Simply increasing the number of home visits to families of children at risk can also reduce the risk of violence as we have observed in domestic violence home visiting. Providing targeted support and education for those perpetrators is also a valid option.
A Call for More Information and Research
We need to better understand the current and prospective role of CHWs in addressing VAC. The academic literature provides precious little information on CHWs responding to violence. However, I feel sure that within the CHW community at large there is a wealth of experience, grey literature, experiments and tacit knowledge that can inform policy guidance on this issue. If you have a story, some research, or some experience in this area, we would love to hear from you and continue the discussion. Please send us your stories, technical briefs or research papers by contacting CHW Central.
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*Author Affiliation: Polly Walker is Knowledge Management and Capability Manager, Sustainable Health at World Vision International
TTC or Timed and Targeted Counselling is a family-inclusive psychosocial approach to home visiting for maternal and child health through to 100 days.
Go Baby Go is World Vision’s core Early Childhood Development approach, parenting course, https://www.wvi.org/maternal-newborn-and-child-health/go-baby-go
Care for Child Development Package includes training for CHWs to counsel in response to observing caregiver interactions with the child and can be done as a standalone package or integrated (21)
Caregiving-Reported Early Development Instrument, Harvard Public health, 2018. https://sites.sph.harvard.edu/credi/