Problems and Purpose

The community of El Recreo in Duran District, is located in the suburbs of Guayaquil, the largest city in Ecuador. As a lower-income community, it lacks resources to provide adequate services such as paved roads, water and sewer systems, garbage collection, and infrastructure maintenance. Water is a particularly major issue, as it is provided only three times per week and has to be boiled to make it drinkable because of damaged piping infrastructure. In some areas, water is delivered only once or twice a week, and some of the schools have cisterns that require regular cleaning. At the same time, low levels of education in the community translate to poor health and nutrition practices, including in the schools.

Within this context, in 2015 the Pan American Health Organization (PAHO) developed a specific program to intervene in the schools of El Recreo. The purpose was to give students an opportunity to apply what they have learned in the classroom related to health and nutrition to their lived experience and to influence the type and quality of food and services they receive at school. The project, called Watchdog Clubs, centered on the creation of student clubs whose members are responsible for monitoring and reporting on water, food, and health conditions inside the schools. Clubs members from Grades 5 to 7 assess whether their school complied with what they have studied in class and make recommendations for improvement when they consider it necessary.

More specifically, the intervention was focused on the following objectives:

• Sensitize school children and train them as watchdogs for healthy eating, physical activity, sanitary conditions, and monitoring of water quality;
• Promote participation in the monitoring of water quality;
• Empower and motivate students to adopt healthy eating habits;
• Identify positive leaders to act as watchdog club leaders and school health promoters;
• Promote healthy food practices, safe water consumption, and physical activity, framed as community organization and participation; and
• Involve the broader school community in healthy practices.

Background History and Context

The Government of Ecuador has prioritized certain districts based on their level of poverty, sanitary conditions, malnutrition, and adverse health conditions, among other factors. Over the last decade, priority districts have had a history of socio-economic interventions especially aimed at addressing the unmet needs of the poorest populations. Located in Duran District, a significant segment of the population of El Recreo lives in poverty, lacks sanitary infrastructure, and suffers from poor health conditions. Concerned with meeting their basic needs and livelihoods, few residents are aware of their rights and duties as enshrined in the Political Constitution of Ecuador.

In 2015–2016, the Watchdog Clubs program began using as a baseline the National Nutrition Survey ENSANUT ECU-2012, which showed an increasing number of health problems. These included an obesity rate of 30% among school children, which is strongly related to non-communicable diseases (NCD). Watchdog Clubs were thus seen as way to engage citizens (student) through awareness raising around health rights, and ongoing action to monitor and promote those rights at the school level.

The Second Phase (2017–2019) is now underway, the Global School Survey (2018) showed that the same obesity rate among children is of 30%. Also, results showed deteriorating sanitary conditions, especially regarding safe water in households and schools. This phase has an emphasis on applying a Health Promotion Strategy, which is applied in schools, households, and community organizations and includes the following components: 

• actions to promote healthy lifestyles to influence the determinants of health;
• preventative and remedial actions to compensate for the lack of safe water in schools; and
• actions to reduce risk factors for cardiovascular diseases and NCDs.

Organizing, Supporting, and Funding Entities

The Watchdog Clubs program originated in 2015 in response to the Ministry of Public Health’s request for technical cooperation with the Pan-American Health Organization/World Health Organization (PAHO/WHO), and with the financial support of the Korean Agency for International Cooperation (KOICA).

A multi-sectorial committee was created with the participation of the Ministry of Public Health, the Ministry of Education, the Municipality of Duran, KOICA, and PAHO/WHO to support the coordination of multiple projects within a program called Strengthening Primary Health Care MSP-KOICA-PAHO 2017-2019 (SPHC). This Committee coordinates actions, allocates resources, and advocates to apply health promotion policies in El Recreo.

Participant Recruitment and Selection

Selecting schools

The community of El Recreo was selected because of its poverty indicators and adverse health factors affecting a large majority of the population. Within El Recreo, the Watchdog Clubs project was implemented in nine schools participating in the SPHC program. A diverse set of schools was selected, based on their different sizes, infrastructure quality, and student populations. As a criteria for selection, students in these schools attended specific classes on healthy eating, physical activity, sanitary conditions, and water quality. The Clubs would be formed to provide an opportunity for these students to apply the learning to their lived experience and to promote their participation in a democratic process driven entirely by students, with the support of a supervising teacher in each school.

Selecting students

Participation in the Watchdog Clubs was open to students aged 9 to 12 years and from Grades 5, 6, and 7. One club was organized in each of the nine schools, based on the voluntary participation of up to 18 students (for a total number of approximately 162 students across El Recreo schools). Boys and girls interested in the clubs were selected with the authorization of their parents and the recommendation of their teachers. As participation was voluntary, it was difficult to ensure equity and inclusion of diverse students in the clubs. Because of the gender norms and the structure of the educational system in Ecuador, girls attend schools in larger numbers than boys. This was reflected in the composition of Watchdog Clubs, where girls made up approximately 70% of participants.

Methods and Tools Used

The Watchdog Clubs used a participatory approach called community-based monitoring to engage the members of the community—in this case, the respective schools—interested in solving a specific problem—in this case, health outcomes. The active participation of school children was key to accomplish the objectives and outcomes, involving both the oversight and reporting of service quality, efficiency, and efficacy. 

The children also used an Oversight Checklist to collect data and comments on school services such as water supply, sanitation, healthy food availability, and physical activity. As part of this process, the children made recommendations based on the Oversight Checklist survey results and presented those to decision makers—in this case, the respective school principal. 

What Went On: Process, Interaction, and Participation

To organize and prepare students to lead the service delivery oversight, interact effectively with stakeholders, and provide actionable recommendations, the following steps were followed in each of the participating schools.

Step 1. Developing an Oversight Protocol for Watchdog Clubs

Each Watchdog Club comprised 18 students, divided voluntarily into three groups of six students. Each group focused on one of the major topics discussed in class: healthy eating, water quality, physical activity, and sanitary conditions. With the support of a facilitator, each club discussed and agreed on their internal dynamics and operations through a participatory process. The students also defined and adapted the three checklists to be used during the process. 

Once the internal processes, roles, and tools were developed and clear, the clubs followed four additional steps to execute the oversight process.

Step 2. Initial Verification 

At a defined location inside the school, the students make an initial review to verify that they have all the necessary elements to perform Watchdog Clubs duties. In doing so, they verify:

• Member attendance: All the members are present and know in which of the three groups they belong;
• Member roles: That each member knows the role he or she will play; and
• Materials: All the necessary materials, such as checklists and survey instruments, are available.

Step 3. Route Mapping 

The route, or focus of the activities to be carried out, is defined. This route can be done by the three groups together or separately, depending on the characteristics of the educational center. The objective is for each of the students to know which route they should follow and their role in it.

Step 4. Observation Tour

At this stage, the observation tour is executed and survey instruments are filled out. Members observe and collect quantitative and qualitative data on their topic (service) of focus, taking the necessary notes according to their oversight role. Specific sites and locations observed within the schools vary according to each educational institution. To guide this step, they fill out the checklist in their group of six. 

Step 5. Final Review 

Once the tour has been completed, a final review is made to conclude the oversight activity. The students discuss what recommendations they can make based on what they have found and write them down on the checklist. Then, they collect and review all the instruments to make sure there are no omissions. If information is missing, the necessary procedure is repeated.

At the end of the intervention, in each school, a teacher supporting the Club sets up a meeting with the school principal. The children share their findings and recommendations and can ask for an action plan to follow up on to improve service delivery in their school.

Because most problems were due to a lack of resources and, therefore, outside the control of school principals, the school administrations did not feel threatened by the students’ findings and critiques. They were able to respond to the extent possible, with each school developing an action plan that was communicated to the children. 

In the weeks following, the Clubs repeated the oversight process, monitoring progress on these action plans and verifying that the measures are implemented. 

Influence, Outcomes, and Effects

One of the aims of the SPHC program and the Watchdog Clubs was to apply new knowledge to improve the determinants of health in their school settings. This model provided a fast and enduring reflection of the current situation of health, food, nutrition, environment, and clean water in schools and stimulated the implementation of an action plan by the school principal—the main decision maker in the school setting. 

In most cases, the oversight process led to positive results. The reports and recommendations from the children had a great impact on the decision makers, with improvements in the indicators around the determinants of health and the school environment. These result were noted not only by the school administration, but also by the local education authorities, the international organizations supporting the program, and the student population.

Overall, the main areas of impact were:

Increased availability of healthy food options

The participatory approach used within the Clubs had a positive effect on some determinants of healthy eating in the school setting. The school principal informed managers at the cafeteria and in certain cases, at food stands, about the need to improve the supply of healthy products and reduce unhealthy foods and snacks. Specifically, requests were made to:

• Decrease the sale of processed juices and beverages;
• Decrease the supply of processed foods;
• Decrease the supply of candy on offer;
• Increase the supply of natural juices;
• Increase the offer of homemade food; and 
• Increase the supply of fresh fruit.

Increased access to clean water

Findings from the oversight and follow-up surveys showed an important qualitative improvement in the availability of clean water for cleaning and washing (increasing from 3 to 5 of the 9 schools) and in the availability of water in the bathrooms (doubling from 2.5 to 5 of the 9 schools). This showed that there was an interest and commitment to address and resolve the suggestions and issues raised by the Watchdogs Clubs. 

Increase in physical activity

The results obtained through the oversight showed increases in the time dedicated to, and spaces provided for, physical activity, which confirmed that school authorities took into account the recommendations from schoolchildren. All nine schools now have physical education classes (up from five before the initiative) and have increased their supplies of sports equipment.

Improved sanitation

As a result of the intervention, several improvement were noted with regards to clean restrooms, the availability of faucets, and working basins (increasing from 2 to 5 of the 9 schools). 

Analysis and Lessons Learned

Students as active citizens

The Watchdogs Clubs had an important impact on the motivation of girls and boys to play an active part in school governance. As a way to deepen their civic values ​​from early stages of life, using tools such as the checklist, the Clubs were promoted as a means of building awareness about their responsibility over their right to a healthy environment. Watchdog Clubs represented spaces where children have become committed actors in the process of social responsibility that every democracy must enable for citizens. 

While each school is a community composed of school children, teachers, administrative staff, principals, and parents, traditionally, participation has been minimal in school affairs in Ecuador. Yet, schools are an important space to transmit values, to form citizenship, and to learn to live in a democracy.

By placing students at the center of a democratic process within their educational institution, the Watchdog Clubs fostered a sense of citizenship in children and increased their confidence and agency to participate in school governance and decision-making. Such opportunities to participate and to exercise citizenship are clearly established in the Convention on the Rights of the Child, of which Ecuador is a signatory.

The value of participatory approaches in learning democracy

Given their participatory, student-led nature, the activities undertaken by the Clubs created a safe environment where schoolchildren were able to reflect on their own realities. In carrying out a reflective participatory research process, they developed a deeper understanding of their own needs, as well as the existing resources and conditions. Further, this allowed them to understand and exercise their rights and responsibilities and to realize the scope of their actions within a responsible democracy. 

Building accountability relationships for mutual benefit

Because the process involved the creation of oversight instruments designed by the children themselves, they were effectively able to understand and use the data to engage decision makers in constructive, evidence-based conversations. Their findings and opinions served as a credible foundation for increased accountability and improvements in the quality and health of their school environment. Their participation as service users informed decisions that resulted in improvements for both students and school staff and administration. Of note, school authorities were generally open to this process from the beginning, as they were sensitized and engaged from the outset and understood the potential benefits for all involved.

Enhancing rights awareness

By achieving a healthier school environment through student participation, Watchdog Clubs contributed to the broader community’s recognition of the importance of a culture of healthy living, of health as a constitutional right, and of citizen participation as a civic right. Further, by actively monitoring the determinants of health in their educational establishment, students gained knowledge about their right to healthy food, to safe water, to health, and to physical activity.

Lessons on Watchdog Club sustainability

To improve the results and sustainability of oversight processes such as Watchdog Clubs, several lessons have emerged from this experience. 

First, the sustainability of Watchdogs Clubs can be affected if there is no effective support from authorities or external actors. Establishing partnerships and support from community organizations such as NGOs, community watchdogs associations, and parents' associations can be a solution to this challenge. 

Second, the motivation of school children may decrease as time progresses, especially if they do not receive positive feedback from the project or decision-making authorities. It is important to give students ongoing and positive feedback and encouragement on their participation. 

Third, to maintain a high level of motivation for student participation, it is important to plan activities in a participatory manner and make the work visible to the broader community, for example, organizing a photo exhibit, a video contest, or community reports on the health situation in the environment. This would also extend the reach of the project outside the schools and into the community. The participatory nature of the work meant that students understood the benefits of the oversight and used part of their play time to do it, without any compensation or benefit other than feeling that their voices have been heard.

Lastly, learning about health and nutrition is effective when using a participatory and experiential approach and involving schoolchildren in the process from the beginning. 

See Also

Community-based monitoring

References

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World Health Organization. (2018). Global School Survey, PAHO. Retrieved from https://www.paho.org/ecu/index.php?option=com_content&view=article&id=2001:encuesta-global-escolar-realizada-en-el-recreo-evidencia-un-alto-consumo-de-productos-ultraprocesados-y-sedentarismo&Itemid=969

External Links

Pan American Health Organization: https://www.paho.org/hq/index.php?lang=en

Notes

This case was produced and submitted by a graduate of the Coady International Institute at St. Francis Xavier University with the support of J. Landry and R. Garbary.