art-WOO-SSM

Social Science & Medicine 61 (2005) 1711–1722
The potential of schoolchildren as health change agents
in rural western Kenya
W. Onyango-Oumaa,Ã, J. Aagaard-Hansenb
, B.B. Jensenc
a
Institute of African Studies, University of Nairobi, P.O. Box 30197, Nairobi, Kenya
b
DBL–Institute for Health Research and Development, Jaegersborg Alle´ 1 D, DK-2920 Charlottenlund, Denmark
c
Research Programme for Environmental and Health Education, Danish University of Education, Emdrupvej 101,
DK-2400 Copenhagen NV, Denmark
Available online 20 June 2005
Abstract
A prospective, quasi-experimental study was carried out in Bondo district in western Kenya to determine the
potential of schoolchildren as health change agents in a rural community. A group of 40 schoolchildren were given
health education using action-oriented and participatory approaches and their knowledge and practices as well as the
influence on recipient groups consisting of peers at school and parents/guardians at home, were studied.
The study, which used questionnaire surveys, involved a pre-test of knowledge about malaria, diarrhea and hygiene
among the recipient groups. After the baseline surveys they underwent health communication training conducted by the
40 schoolchildren. An identical post-test questionnaire was administered to all participants at 4 and 14 months. Health-
related practices were studied regularly through observation in schools and homes over 14 months.
Significant improvement in knowledge was detected in all recipient groups. Behavioral changes were more evident
among the children than among the adults. The impact of the project was reflected in concrete changes in the school
environment as well as the home environments. The implications of the findings for health education projects and
public health programs are outlined.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: Behavioral change; Health education; Kenya; Public health; Schoolchildren
Introduction
Public health workers generally agree that a multi-
faceted approach involving biomedical interventions,
behavioral change and improvement of living conditions
would significantly reduce the spread of major diseases
in developing countries (e.g., malaria, schistosomiasis,
HIV) (Kloos, 1995; Lansdown et al., 2002; Mitchell,
Nakamanya, Kamali, & Whitworth, 2001). However,
while biomedical interventions and living condition
interventions seem to be well defined, achieving beha-
vioral change through health education remains to be
explored and developed further (Krumiech, Weijts,
Reddy, & Meijer-Weitz, 2001; Onyango-Ouma, 2003).
In Kenya, an estimated 7.2 million children are
enrolled in primary schools (Republic of Kenya, 2003).
From a public health perspective, primary schools offer
an extraordinary opportunity to improve the health of
students, their families and members of the community
in a cost-effective way (Kalnins et al., 1994). Children
are generally receptive to learning, and because many
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ÃCorresponding author. Tel.: +254 20 4449004x2029;
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E-mail address: onyaouma@yahoo.com
(W. Onyango-Ouma).

attend school, school-based programs are potentially
cost-effective (WHO, 1992). When children acquire
health-related knowledge and skills, they become well
placed to pursue a healthy life and to work for the
improved health of their families and communities (Patil
et al., 1996).
Different approaches to health promotion and health
education should be explored, and the present study aims
to help fill this gap. The study examined the potential of
children as health change agents within the school and
home environments following action-oriented health
education intervention in schools in rural Kenya.
Children as health change agents
A broader view of children as health change agents
captures children as individuals who make things
happen in different social environments (Onyango-
Ouma, 2000). As agents, children are capable of
strategizing and finding space to maneuver in situations
they face as well as manipulating resources and
constraints. Children can engage with health knowledge
and skills in their own right and are not merely passive
recipients of other people’s care and interventions.
Children’s health agency has been reported in the
literature (Christensen, 1998; Mayall, 1996; Prout &
Christensen, 1996). More recently, Christensen (2004)
has advanced the idea of the child as a health-promoting
actor in the family context.
A growing body of empirical data suggests that in
African countries, children are increasingly taking an
active role in their health care and that of other family
members (Geissler et al., 2000; Meinert, 2004; Onyango-
Ouma, 2003). A study by Geissler et al. (2001), e.g.,
concluded that given the state’s inability to provide
health care in both Kenya and Uganda, children might
be able to take a greater share in improving community
health. There is also evidence that in pluralistic medical
settings children engage in self-treatment of their every-
day illness episodes, thus becoming more or less
autonomous health agents (Geissler et al., 2000).
However, the potential of children as health agents
should be seen in the context of their social environ-
ments (e.g., school and home). As social actors, children
are embedded in larger societal structures, including
power and knowledge hierarchies, which enable or
constrain their ability to act as change agents (Onyan-
go-Ouma, 2003). It is important to recognize children as
both restricted and encapsulated by social structures and
as persons acting within or toward the structure (James
& Prout, 1990).
Action-oriented and participatory health education
Action-oriented and participatory health education is
a well-defined educational approach (Jensen, 1997, 2000;
Simovska, 2004), which differs considerably from the
traditional approaches to health education such as the
health belief model. It aims to strengthen children’s
desire and ability to influence the conditions that impact
on their health. It is an integrated part of this teaching
approach that the students should take action aimed at
influencing ‘real life’ conditions as part of their learning
processes (Onyango-Ouma, Aagaard-Hansen, & Jensen,
2004). These conditions could be health issues related to
the school, their family, the local community as well as
their own behavior.
The main concepts within this approach are ‘action’
and ‘participation’. The concept of action has two key
characteristics: it is targeted at change and it should be
decided upon by those carrying out the action.
Participation refers to the active involvement of students
in the learning process and is considered to be the most
important pre-condition for developing ownership
among students (Hart, 1992). Children’s genuine parti-
cipation enables them to acquire action-competence by
taking action and trying to influence ‘real life’ as part of
their education (Jensen, 2004). The genuine participa-
tion of children does not imply that teachers play a
passive role. Teachers need to take responsibility and
assume an active role as facilitators who promote
dialogue, suggest action strategies, and put barriers into
perspective.
The child-to-child (CtC) approach to health education
(Hawes, 1988) belongs to the family of action-oriented
and participatory approaches. It represents a departure
from traditional health education approaches that aim
at changing people’s behaviors based on the health
expert’s model. Like the investigation, visions, action
and change (IVAC) approach (Jensen, 1997), CtC is an
approach to health education based on participation
and active learning, which relate knowledge to everyday
life situations and experiences.
The concept of child-to-child
The concept of CtC is based on the philosophy of
valuing, trusting and respecting the child as an agent of
change (Hawes, Bonati, Hanbury, & Scotchmer, 1992).
Although originally used to refer to the communication
between children, the concept has been widened to
include Child-to-Community and Child-to-Family,
whereby children influence health change at the com-
munity level and in the family. As an activity-based
approach it aims to raise schoolchildren’s consciousness
of local health problems; to equip them to communicate
health messages to their peers, family and community; to
enable them to practice simple preventive measures; and
to prepare them as basic health workers (Patil et al.,
1996). The approach has been applied in school health
education programs in many countries and research
conducted in India (Patil et al., 1996), Botswana
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(Pridmore, 1997) and Kenya (Onyango-Ouma, 2003) to
assess its impact.
The concept of CtC promotes the understanding that
children can work together with others in their commu-
nities to solve health problems. It is assumed that
parents will be willing to learn from children and in-
clude them in family decision-making (Pridmore, 2003).
Most CtC reports are devoid of sufficient infor-
mation on the social, economic or environmental
conditions into which CtC activities are initiated. A
review of the literature by Lansdown (1995), e.g.,
identified an absence of in-depth ethnographically based
accounts. More often than not, CtC success stories are
presented without due consideration for contextual
issues. However, much depends on the context within
which children are expected to communicate about
health, and children may succeed in some situations but
not in others.
Methodology
Study area and population
The study was carried out in Nyang’oma sub-
location, Bondo district, in rural western Kenya between
January 1998 and June 1999. Water is a scarce resource
and most villagers have no access to clean and safe
water. The most prevalent diseases in Bondo district are
malaria, respiratory infections, diarrheal diseases, ane-
mia, intestinal worms and HIV/AIDS (Republic of
Kenya, 1997).
The population is predominantly Luo ethnic group
who practice a mixed economy; family members
combine subsistence farming, livestock and fishing
with labor migration (Cohen & Odhiambo, 1989).
The kinship system is traditionally patrilineal and
virilocal, and polygyny makes extended families com-
mon (Parkin, 1978). Childhood socialization puts a
strong emphasis on practical aspects, with children
being introduced to work tasks including infant care,
fetching water and preparing food at a young age
(Ominde, 1952). Customary education and learning
among the Luo occur in practical situations of everyday
life and are embedded in social relations (Prince &
Geissler, 2001).
In Kenya, children attend primary school for 8 years
(from grade 1–8) before joining secondary school. On
average, children start formal education at the age of 6
years. Universal primary education was reintroduced in
2003, and this has led to an increased number of primary
schoolchildren with negative consequences for effective
teaching and learning. Although health education is
taught in subjects like science, it is given low emphasis as
it is a non-examinable subject.
Intervention and study design
A quasi-experimental design was adopted in which a
health education intervention was set up in two schools.
The study population consisted of 80 schoolchildren and
40 adults (parents/guardians) living in two villages
surrounding the schools. Everybody gave verbal consent
to participate in the study. The selection of the two study
schools and villages as well as the study population
therein was done using purposive sampling. The schools
were ‘typical’, rural schools that expressed their interest
in the project when approached.
The schoolchildren were drawn from two classes—
grade/standard three and five. The class fives became the
health communicators (HCs) and each selected two
recipients—a student in class three and an adult (parent/
guardian) they were living with. The need to situate the
health communication process in children’s existing
social relationships necessitated the use of non-prob-
ability sampling methods.
The age range for schoolchildren was 9–15 years and
adults 24–68 years. There was proportional gender
representation among schoolchildren as compared to
adults where only three out of 34 were males.
The intervention was inspired by the CtC and IVAC
approaches to health education. It consisted of action-
oriented and participatory health education as well as a
follow-up phase, in which students worked as HCs in the
school, in the local community and in their families (see
Fig. 1).
A 2-day training workshop was held during which
teachers were introduced to action-oriented methodol-
ogies, including the CtC approach, by a group of local
resource persons. The output of the workshop attended
by 28 teachers was the formulation of a doable action
plan for the implementation of CtC activities. A 1-
month follow-up training to clarify methods and
modalities of implementation as well as field visits to
schools implementing CtC activities were organized for
study teachers. The initial intervention ‘teaching pack-
age’ was administered by teachers to the HCs only while
the follow-up phase involved the spread through health
communication in everyday settings.
The overall teaching period, which lasted 2 months,
was participatory and student-centered and involved the
use of drawings, role-plays, drama, songs and poems.
The HCs investigated issues related to malaria, diarrhea
and hygiene in the community; took actions individually
and together; and discussed the results of their actions as
part of learning. Students’ active participation was
considered a necessary element for taking actions in
health-related ways.
The intervention focused on two prevalent health
problems—malaria and diarrhea—and related hygiene
issues. Malaria and diarrhea were chosen because they
were the leading causes of childhood mortality and
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morbidity in the area. Although HIV/AIDS is a serious
problem, sex education was not permitted in primary
schools at the time of the study. The content taught
included preventive issues, aspects of etiology and
recognition of symptoms. Hygiene was based on every-
day practices about body and clothing care, household
maintenance, food preparation, sanitation, refuse dis-
posal, water safety and how they impact on people’s
health. The course content was adapted from ‘Children
for Health’ (Hawes & Scotchmer, 1993), a generic set of
health messages and actions developed for teaching
children health education.
The follow-up phase of 14 months involved the health
communication activities of HCs targeting recipient
groups and the wider settings of schools, homes and the
common spaces in the community (see Fig. 1). After the
initial exposure by their teachers, the HCs engaged in
knowledge dissemination and encouraging health-re-
lated actions at school and at home. Throughout the
health communication period, teachers played the role
of consultants who facilitated the HCs’ activities,
addressing their concerns and fears.
The design involved surveys at baseline (T1), in the
short-term (4 months into the intervention, T2) and
finally in the long-term 14 months later (T3), to assess
changes in knowledge among the study population. T2
was conducted 4 months after the HCs had undergone
the teaching activity and after they had also been
participating in health communication activities (follow-
up phase) for the same period. Alongside this, a system
of follow-up was put in place for monitoring behavioral
changes that could be related to the intervention.
Methods of data collection
Individual levels of knowledge on the intervention
topics were determined before and after exposure to the
intervention through a questionnaire survey. The ques-
tionnaire was developed and translated into the local
language (Dholuo), back translated into English, pre-
tested and administered by a team of trained field
assistants in the local language. Questions were both
open- and closed-ended and dealt with topics covered in
the intervention relating to malaria, diarrhea and
hygiene. Identical questionnaires were administered to
all the study participants three times (T1, T2 and T3).
School-based observations were done to gather
information on school routines, sanitation and hygiene
practices before and during the intervention. The
personal hygiene index was one of the most discrete
indicators of whether the children were taking action or
not at the individual level. Hygiene of nails, hair, body
and clothing were the parameters observed and recorded
twice during the school week. The nails and hair were
observed whether short and clean or dirty. The body was
observed for cleanliness, wounds and skin infections like
scabies; and clothing whether it was dirty or clean.
Compound hygiene index parameters were cutting grass,
cleaning classrooms and lawns, and appropriate refuse
disposal. Sanitation index parameters included the state
of hygiene in latrines and presence of hand-wash
facilities.
Structured observations were made in homes of study
participants on a fortnightly basis for a period of 14
months to monitor changes in everyday practices
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SCHOOL COMMUNITY
RRR
Teaching activity (Intervention phase 1)
KEY:
CRs – Child recipients
HCs – Health communicators
Direct influence of HCs
Indirect influence of HCs or CRs
Phase 1 of the intervention conducted by teachers
CRs
HCs
Rest of school
population
Families
Rest of community
members
Fig. 1. Flow of health communication and derived changes. The figure shows the flow of teaching as it spread from one group of
people to another first within the school environment and later in the community.

through actions taken by children, parents or other
people. The health practice index parameters included
presence and sanitary state of latrines, use of hand-wash
facilities, utensil hygiene and boiling/filtering water. The
environmental hygiene index comprised compound
hygiene, mainly cutting grass and appropriate refuse
disposal. Baseline observations were done, and subse-
quently observations were conducted as a continuous
assessment and not a comparison based on T1, T2 and
T3 as has been done with levels of knowledge.
Field assistants trained on observation methods
conducted the observations. To avoid bias, the assistants
were routinely assigned different study children and
were guided by a structured checklist specifying what to
observe and record. As a matter of routine, a system of
quality check was enforced whereby the principal
investigator (PI) crosschecked the data collected.
Semi-structured, in-depth interviews were conducted
with parents and schoolchildren as a process evaluation
on their participation and perceived changes and
difficulties. The PI conducted these interviews and
parents were interviewed on their views about children
communicating to adults and the actions they under-
took. Children were interviewed on their experiences of
communicating to their peers and parents, and the
actions they took.
The PI lived in the study community in order to study
the processes involved in the intervention. Whilst the
assistants engaged in the structured aspects of the study
the PI concentrated on the open-ended aspects. The
presence of the research team could have played a role in
some changes that took place initially although such
changes lasted a shorter period. With time the interven-
tion process took its own course and the study
population decided on the changes undertaken; that is
why some were reported 14 months later.
Data management and analysis
The survey data were coded and entered twice in the
computer and later the two similar files were compared
and corrected for mistakes using EPI INFO. In order to
gain an overview of the trends of knowledge change, the
scores were divided into three categories where
wrong ¼ 0, poor ¼ 1 and correct ¼ 2. On the scale from
zero (minimum) to 46 (maximum), 25 or below was
considered ‘wrong’, 26–35 ‘poor’ and 36–46 ‘correct’. A
response was considered wrong if it was completely
irrelevant, poor if unclear and correct if in line with the
intervention content. The cut-off point was determined
based on the distribution of scores from 23 questions
among the study population.
Respondents whose records were not available for the
whole study period (on all the occasions) were excluded
in the final analysis leaving only 101 complete records
out of the initial 120. The statistical tests performed are
the simple student t-test and chi-square (w2
) test-for
trend. The single tailed t-test was chosen because we did
not expect the intervention exposure to make our study
population less knowledgeable. The test was also paired
in the sense that we compared different intervals. The w2
test-for trend was applied to show changes in the level of
knowledge over time.
The data from structured observations conducted at
school and home were categorized and analyzed in the
form of indices, which grouped together the various
index parameters. School observations were grouped as
the health situation in primary schools indices including
students’ hygiene index, sanitation index and compound
hygiene index. Home observations were categorized as
household health practice indices, which included the
health practice index and environmental hygiene index.
Observations (Tables 3 and 4) were rated as good/
consistent action (those who were perfect 71–100% of
the time), poor/inconsistent action (those who were
perfect 41–70% of the time) or bad/no action (those who
were perfect o40% of the time or took no action).
These categories were developed at the analysis stage.
The interview data were transcribed and translated,
relevant categories developed and summarized along
common themes. The data were triangulated with the
survey and observation data providing explanations
where relevant.
Results and discussion
Changes in knowledge during the intervention
Table 1 describes the changes in knowledge at various
stages of the intervention. The communication of health
knowledge comprised two main stages.
The first stage was the communication during phase 1
(i.e., between T1 and T2), when the main activity was the
teachers’ health education to the HCs and the subse-
quent communication of the knowledge from the HCs to
the child recipients (CRs) and parents/guardians. The
second stage was the continued long-term communica-
tion from the HCs to the other two groups as indicated
by the difference between T2 and T3. All three groups
had a significant increase in knowledge levels. Between
T1 and T2, when most changes took place, the HCs had
a mean increase of knowledge score (8.25) that was
significantly higher than that of the CRs (6.09, p ¼ 0:02)
and parents/guardians (2.35, p ¼ 0:00), respectively.
Table 1 further shows that there were generally no
significant changes between T2 and T3. This signifies
that the achievements obtained during the first phase of
the intervention were maintained during the 14-month
follow-up phase.
Table 2 also shows changes in the level of knowledge
over time. Looking at the proportion of individuals in
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the category ‘correct’, there is a highly significant
increasing trend (p ¼ 0:00) during the intervention. In
addition, the 14 (13.9%) individuals scoring ‘wrong’ at
T1 all improved to higher levels of either ‘poor’ or
‘correct’ at T3.
Another interesting observation is that there are direct
links between the performance of the HCs and that of
their recipients, which suggests that a decline in the level
of knowledge of the recipients was associated with the
level of knowledge of the HCs. During T3, 37
respondents (36.6%) scored lower than they had at T2,
17 of them being parents/guardians, 10 HCs, and 10
CRs. Among the 37, in three cases the HCs and both
their recipients (CRs and parents/guardians) had lower
scores; in four cases both the HCs and their CRs had a
decrease; and in two cases there was a decline by both
the HCs and their parents/guardians. Thus, 21 out of the
37 individuals whose knowledge score decreased were
linked together within nine out of 40 ‘chains of
communication’.
The study revealed the potential of children as health
change agents with regard to conveying knowledge and
competence to act to the CRs and parents/guardians.
There was a significant increase in knowledge between
T1 and T2 (Table 1). The increase affected not only the
HCs (as could be expected because of their intensive
exposure) but also the CRs and parents/guardians even
within this short time frame. More remarkably, the long-
term effects were sustained. This can be seen from the
fact that T2–T3 mean changes are not statistically
different from the T1–T2 mean changes. Furthermore,
none of the recipients were found to possess what was
considered as ‘wrong knowledge’ at T3 (Table 2). The
finding that a low level of knowledge by the HCs directly
influenced the performance of their recipients attests to
the fact that the improvement in knowledge was not due
to other external factors.
There maybe several reasons for this. Maybe the HCs
did not grasp the health concepts properly and commu-
nicated wrongly formulated messages to their recipients.
Or maybe the HCs lost motivation and did not continue
to reinforce the health information. Whatever the
explanation, it further strengthens the case that chil-
dren’s health communication actually has an impact.
Our findings are consistent with those reported by
other scholars. Patil et al. (1996) found highly signi-
ficant differences in knowledge and reported practices
among the study children as opposed to the control
group in India 5 years later. In a controlled study of the
CtC approach among lower primary schoolchildren and
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Table 2
Changes in levels of knowledge among the study population
Knowledge level T1 T2 T3 w2
test-for trend
n (%) n (%) n (%)
Correct 18 (17.8) 59 (58.4) 69 (68.3) 51.40 (p ¼ 0:00)
Poor 69 (68.3) 40 (39.6) 32 (31.7)
Wrong 14 (13.9) 2 (2.0) 0 (0.0)
Total 101 (100.0) 101 (100.0) 101 (100.0)
Note: The table shows the number of individuals scoring ‘correct’, ‘poor’ and ‘wrong’, respectively, at T1, T2 and T3. The health
communicators (HCs), child recipients (CRs) and parents/guardians are here merged. The three score categories are based on a division
of the range of points (0–46) into three intervals. Chi-square (w2
) test-for trend shows a significant increase in the proportion of people
with correct knowledge. N ¼ 101.
Table 1
Mean change in knowledge test scores over the study period
Mean T2–T1 change SD p-Value Mean T3–T2 change SD p-Value
HCs (n ¼ 32) 8.25 3.45 po0:001 0.78 2.76 n.s.
CRs (n ¼ 35) 6.09 4.00 po0:001 1.11 4.03 n.s.
Parents/guardians (n ¼ 34) 2.35 4.14 po0:005 0.53 3.64 n.s.
All groups (n ¼ 101) 5.51 4.55 po0:001 0.81 3.5 n.s.
Note: The table shows changes in mean score (on the scale 0–46) of the health communicators (HCs), child recipients (CRs) and
parents/guardians over time as well as total of all. A simple Student’s t-test (single tailed) shows clearly significant increases in levels of
knowledge from T1 to T2, whereas changes for the three groups between T2 and T3 are not significant (n.s.). N ¼ 101.

pre-schoolers in Botswana, Pridmore (1997) found a
significantly greater knowledge gain in the experimental
group than the control group. As shown and confirmed
by our study, long-term change effects in knowledge are
sustainable.
Behavioral and physical changes in the school environment
Children’s health practices at school were studied to
determine whether changes occurred as a result of taking
appropriate health actions. Some of the actions were
related to personal hygiene whereas others pertained to
the school environment. Some were instituted directly by
the study children whereas others were undertaken by
the entire school population (see Table 3).
Observations before the intervention revealed that
there was lack of consistent actions. Most students were
found to have poor standards of hygiene, and the
schools were in a pathetic sanitary state.
During the follow-up phase, both HCs and CRs took
the necessary actions relevant to their personal hygiene
(upper part of Table 3); none of the study children was
observed to be consistently untidy. Seventy percent of
HCs performed well on the observed indicators
throughout the 14 months. Sixty-five percent of the
CRs maintained the improved level of change while 35%
performed well initially but their level of hygiene
dropped toward the end. Bodily cleanliness and clothing
also improved—though less consistently.
The children consistently kept their hair and nails in
good condition during the study period, but problems
arose with the state of their bodies and clothing.
Infections and wounds on the body required parental
intervention for treatment, but this was contingent upon
them having the necessary means to act. Clothes were
found to be clean at the beginning of the week, but
became unclean as the week progressed, partly due to
play and routine manual work at school. Children had
no control over school routines, which made them
susceptible to dirt, while at home, some of them lacked
soap to clean their sole school uniform often—poverty
being an underlying factor. Thus, while HCs were able
to communicate to their peers about how to maintain
body and clothing hygiene, the knowledge could not be
successfully turned into actions due to things beyond the
control of children. Such barriers prevent health
education from resulting into actions and change in
the long run.
The intervention influenced daily environmental
hygiene routines as shown in the lower part of Table
3. Prior to the HCs’ activities in school, sanitation and
hygiene practices were inadequate because the students
did not know what to do or lacked the motivation to do
it properly. The intervention increased the level of health
awareness and continuously exposed the school popula-
tion to health information and relevant protective
actions. Sanitary practices were improved by putting in
place hand-wash facilities (also known as ‘leaky tins’)
outside latrines. Burning grass around the pit hole in the
absence of disinfectants was used to kill the germs in
latrines, and a routine practice of washing them was
effected. Initially these activities were done by HCs but
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Table 3
Actions taken by children in the school environment before and after the intervention
Study children Rest of school population
Before After Before After
Personal hygiene measures
Cutting/cleaning nails / + / +
Cutting hair / + / +
Body cleanliness À / À /
Clean clothing À / À /
Sanitary measures
Making leaky tins À + À À
Use of leaky tins after toilet À + À +
Cleaning latrines / + / +
Disinfecting latrines À + À /
Appropriate refuse disposal À + À +
Cutting grass / + / +
Cleaning classrooms + + + +
Note: Partly the figure distinguishes between personal hygiene measures and environmental sanitary measures. Partly it is arranged
according to whether the actions were taken by the study children or non-study children.
+, Consistent action; /, inconsistent action; À, no action.

were later integrated into the school routines. Six
months into the follow-up phase, students in the two
schools took health protective actions including washing
hands after going to the latrine, maintaining compound
hygiene and sanitary state of latrines. However, hand-
wash facilities often run short of water during the dry
season, as a result disrupting the practice.
The results suggest that children took the necessary
actions required for maintaining their personal and
environmental hygiene following the intervention. This
is not to imply that they did not take such actions
before. They did under teachers’ supervision—but with
varying degrees of success and consistency due to an
apparent lack of commitment on the part of children.
The intervention led to the development of commitment
to healthy conditions which eventually made school-
children change their hygiene practices through health
protective actions. These actions became routine during
the study period so as to qualify as behavior change in
the study population.
Behavioral and physical changes in the home environment
Over a period of 14 months, fortnightly observations
were made on a number of parameters where we
expected changes in practice instituted by either the
children or adults in the households (see Table 4).
The most wide spread change was the state of
compound hygiene as people cut grass and cleared the
bushes in their environment. This change was realized 1
month into the follow-up phase, and the new standard
remained throughout the study period. Observations
confirmed that efforts were made to cut grass and clear
footpaths in the homes of study children more
frequently than other homes in the village. It seemed
that the study informants associated the state of
compound hygiene with health risks and this made
them take action faster than others.
Before the intervention, latrine coverage was found to
be 41% (29 out of the 70 homes) and some of those
available had poor sanitary conditions, including lack of
pit lids. During the follow-up phase, the state of hygiene
in the available latrines improved. There was evidence of
regular cleaning and sweeping, and in four homes pit
lids were put in place. But latrine coverage remained
low; only five new latrines were built. Of the five latrines,
four were built by parents under children’s influence,
while two boys rebuilt one. In seven other homes, boys
and male adults made attempts to construct latrines but
abandoned them, citing lack of money to buy materials
or lack of time.
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Table 4
Actions taken by children and adults in the home environment before and after the intervention
Children Adults
Before After Before After
Sanitary measures
Making leaky tins À + À À
Use of leaky tins after toilet À + À +
Cleaning latrines / + / +
Disinfecting latrines À + À À
Making pit latrine lids À + À À
Building pit latrines À / À +
Compound hygiene
Appropriate refuse disposal À + À +
Cutting grass / + / +
Sweeping the lawn / + / +
Utensil hygiene
Washing dishes + + + +
Building dish racks À + À +
Use of dish racks À + À +
Other measures
Cleaning the house / + / +
Washing fruits À + / +
Boiling/filtering water À + À +
Preparation of homemade ORS À + À /
Use of homemade ORS À + À +
Note: The behavioral changes were monitored in the areas of compound hygiene, sanitary measures, utensil hygiene and other
measures.
+, Consistent action; /, inconsistent action; À, no action.

Hand-wash facilities were reported in 50 (71%) homes
2 months into the follow-up phase. This was something
new introduced by the children which hitherto had not
been part of sanitary practices but was now widely used
by all, including adults. Hand-wash facilities were
observed even at homes without latrines, where they
were also used for cleaning hands for reasons other than
defecation. However, 6 months into the follow-up phase
the use of leaky tins was found to experience problems:
only 15 (14%) homes had operational leaky tins by the
end of the study.
The provision of hand-wash facilities was a remark-
able innovation which improved sanitary practices at
home. Adults found this to be a very important change
coming from children and easily adopted the practice.
Nevertheless, the technology was too fragile and that is
why their use experienced problems 6 months later.
Children who made them became discouraged from
making others in cases where they were stolen or broke
down due to over use. But the observation that this
simple idea could be implemented by children and used
by everyone in the homestead was a very important step
in children’s ability to introduce change.
Before the study, it was the practice in 57% of the
homes to put dirty utensils outside for some time before
cleaning and, if washed, set them to dry on the grass.
Household refuse was disposed of near the house. And
there was no evidence of filtering or boiling water before
use by most of the households. Interview data with
adults and children showed that children played a
leading role in changing these practices. Parents
reported children’s role in ensuring that households,
utensils and water were clean. Boiling and filtering of
drinking water was introduced in 50 (71%) homes while
dish racks for drying utensils were recorded in 22 (31%)
homes. In 12 homes, the racks were built directly by
children and in 10 homes by adults under the influence
of children. Another way of influencing adults is
illustrated by a case where a girl transcended the
gendered roles to construct a dish rack. However, she
did not make it strong enough and after a few weeks it
collapsed, but thereafter the father took it upon himself
to make a strong one.
Generally, gender considerations seemed to influence
changes in practice among adults. Women took a
leading role in boiling water, improving utensil hygiene
and food preparation, all of which are traditionally
female roles. Men took action in those areas that are
traditionally male domains, such as building dish racks
and latrines.
Children succeeded in involving adults in the changes
they introduced in everyday practices at home (Table 4).
Where adults did not take any action it was not always
because they were unwilling to be participants in
children’s projects as such. For some of them, it was
because they foresaw no immediate benefit. For others
the prevailing living conditions such as lack of resources
frustrated their efforts to effect change. Thus, a
considerable majority undertook only actions that did
not require resources in terms of money, e.g., cutting
grass and building dish racks. Similar findings have been
reported by Lansdown et al. (2002), who found that
there was very little opportunity for children to influence
food practices at home given that parents’ choices were
restricted due to economic reasons. Evidently, the
different resources available to a family and how it
makes use of them will determine their health practices
(Christensen, 2004).
The fact that children could change things at home,
even though many were not under their control as in the
school environment, was a sign of motivation to change
things. In spite of the existence of hierarchies of
authority, knowledge and legitimacy based on age
(Onyango-Ouma, 2003), we found that children did
have possibilities to change adults’ conditions at home.
But such possibilities and changes depended on the
extent to which adults accepted children’s new role in
the family. This finding addresses the skepticism of
various scholars on the potential of children as change
agents in developing countries (see Pridmore & Ste-
phens, 2000, p. 150).
The findings suggest that the HCs were relatively
more effective change agents among their peers than
among adults. This could explain the significantly
greater knowledge gain and behavior change among
the CRs as compared to the parents/guardians (Tables 1
and 4). The findings support the assumptions underlying
the concept of CtC that children can learn health
messages and in turn pass them on to other children
(Lansdown, 1995).
Study limitations
Our study has obvious limitations. The sample is
limited to two schools. The possibility of bias in the
study design also needs to be considered. The study
population voluntarily chose to join the project and
could have been especially motivated to learn about
the health topics taught by both teachers and the HCs.
A Hawthorne effect (Abramson, 1990) resulting from
the presence of the research team that monitored the
project could also have increased the motivation to
change.
No control schools were included in the design. We
acknowledge the limitations of this design, but we also
share the developing concern with regard to the use of
control groups (let alone randomized control trials) in
understanding the process and impact of health educa-
tion and promotion initiatives (see WHO, 1998; Tones &
Green, 2004). The costs of establishing and following a
control group were considered not to be worthwhile in
the present study. As pointed out by the WHO
ARTICLE IN PRESS

European Working Group on Health Promotion
Evaluation, ‘‘yThe use of randomized control trials
to evaluate health promotion initiatives is, in most cases,
inappropriate, misleading and unnecessarily expensive’’
(WHO, 1998, p. 11). Consequently, the available
resources in the present study were used to include a
wide range of qualitative and quantitative methods to
make an analysis of pre- and post-intervention situa-
tions.
Age could be another factor for change, but as most
changes took place within the first 4 months (T1–T2),
age is not an issue. Furthermore, there are no age-
related differences between the HCs and CRs even at
T1–T2.
Conclusions and recommendations
The present study demonstrates children can be
empowered to be health change agents in the commu-
nity. Action-oriented and participatory health education
intervention approaches have the potential to enable
schoolchildren to assist their peers and parents to
acquire health-related knowledge and changed practices.
As health change agents in schools, children collabo-
rated with other students to introduce and maintain
changes in the school environment. In the home settings,
they communicated health messages and introduced
relevant health practices through which their parents/
guardians improved their knowledge and changed their
behavior through their participation. The findings imply
that despite several constraints children can be health
change agents for their peers and parents/guardians in
school and home environments.
The study highlights children’s agency and poses a
number of challenges to traditional assumptions about
children as passive individuals in society. This study has
deconstructed the frequent generalization that is often
voiced in relation to the role of schools as entry points
for community development implying that children
cannot teach and influence adults. The study suggests
that it is possible in sub-Saharan Africa, though a
number of contextual factors lead to many barriers and
constraints, to use schools and schoolchildren in
community development.
This study has also contributed to our understanding
of the applicability of action-oriented and participatory
approaches to health education in different contexts. In
highlighting how children communicated about health
in different contexts, this study points to the structural
and environmental barriers to behavior change in terms
of inter-generational relations, gender balance and
poverty. Future studies using such approaches should
carefully consider the contexts within which they are
applied.
Our findings have a number of implications for policy,
practice and research:
Public health programs should incorporate partici-
patory, action-oriented methods which encourage
individuals’ full participation in the learning process
since they produce more benefits with regard to
improved knowledge and change of practice. Our
findings suggest that public health programs can be
more effective than they currently are if they work
with both knowledge and action perspectives of their
study populations. Further research is needed to
clarify and document how centrally planned pro-
grams can be developed to include ‘‘built in’’
approaches which encourage children to work as
change agents in the health area.
Teachers and education policy makers should con-
sider whether more didactic approaches should be
replaced with participatory and action-oriented ap-
proaches in future health education projects. How-
ever, such approaches may require additional costs in
terms of time, money and manpower. Where classes
are big and teachers demoralized, effective imple-
mentation of action-oriented methods may have
limited possibilities for success. Research is needed
to identify the high-quality skills, health-related
knowledge and pedagogical competencies teachers
need to support and stimulate students to develop
ownership and competence to take action in the
health area.
Fostering school–community links is essential for the
success of school health programs. A consequence of
health education programs should be the establish-
ment of good links between schools and communities.
The sustainability of such programs will depend on
the extent to which the two environments are
conducive to children’s actions and facilitate their
ability to act. Pre- and in-service training of teachers
on action-oriented methods will enhance the broad
application and sustainability of such programs.
Research is needed to clarify the potential roles and
attitudes the local community might have in support-
ing and stimulating children’s health-promoting
actions.
Acknowledgements
Professor Susan Reynolds Whyte provided invaluable
support in the formulation of ideas that finally produced
this manuscript. Drs. Henry Madsen and Sian Clarke
provided assistance in statistical analysis. We are grate-
ful to the students and teachers in two primary schools
in Bondo district who devoted their time to the study.
Finally, we would like to express our gratitude to the
ARTICLE IN PRESS
W. Onyango-Ouma et al. / Social Science Medicine 61 (2005) 1711–17221720

field research team at Nyang’oma Research Training
Site who participated in the data collection process. This
study was funded by the Danish Bilharziasis Laboratory
(DBL)—Institute for Health Research and Develop-
ment. Thanks to the anonymous reviewers for valuable
comments.
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