Children’s Right to Health through the Principles of Protection, Promotion, and Participation, from the Perspectives for Children, Parents, and Professionals: A Systematic Review

ABSTRACT

This systematic review aimed to identify how children’s right to health, connected to the principles of protection, promotion, and participation, and from the perspectives of children, parents, and professionals in preschool, school, and healthcare has been empirically demonstrated by international scholars between 1989 and 2021. Following the standards of PRISMA-P, two searches, in 2018 and 2020, were conducted in seven databases. In total, 561 studies were found and after the screening process, which entails reviewing titles, abstracts, and full text-versions, 49 studies were finally included. A deductive qualitative content analysis, proposed by Elo and Kyngäs, was performed. According to the findings, protection was demonstrated as Being protected from harmful acts and practices and being entitled to special care and assistance. Promotion was demonstrated as Possessing of resources and Receiving of services, and participation as Being heard and listened to and Being involved in matters of concern. Conforming to the findings, although presented separately, protection, promotion, and participation could be understood as interrelated concepts. In summary, children’s right to health was demonstrated within two major fields: as the use of their own resources, and trust and as aspects provided by adults as support and safety. This is the first review of studies, published 1989–2021, identifying children's right to health through the perspectives of protection, promotion, and participation. During this period, children’s right to health has mainly been demonstrated in studies from a healthcare context. All researchers, policymakers, health workers, and politicians should include children in all decisions that concern them, to increase their participation. As children’s health is closely linked to their physical, social, and cognitive development there is a need for more studies exploring children’s right to health in preschool and school contexts in which children spend their everyday life.

KEYWORDS:

• Children’s rights
• protection, promotion and participation
• health
• school
• systematic review

Introduction

For children, the right to health depends on their own opinions and actions, as well as how the people encounter them, and in what way parents and professionals view their rights. In all encounters involving children and adults, acknowledging the child’s perspective and the child's perspective is important (Sommer et al., 2010; Söderbäck et al., 2011). According to the United Nations Convention on the Rights of the Child [UNCRC], every child is entitled to the highest attainable health (United Nations, 1989). Therefore, children need responsible adults who can claim and defend this right for them.

During the last few decades, to a large extent thanks to the adaptation of the UNCRC (United Nations, 1989), children’s rights have attracted significant interest among researchers in various disciplines. However, the UNCRC offers little guidance on how to carry out the responsibilities stated in the articles. One way to clarify the context could be by interpreting the UNCRC articles as principles of protection, promotion, and participation (Alderson, 2008). In this paper, protection is defined as the child’s right to special care and assistance, as well as the right to be protected from harmful acts and practices. Promotion refers to the possessing and receiving of and having access to resources and services from healthcare and education. Participation is defined as the child being heard, listened to, and involved in decision-making and in everyday activities.

In this systematic review, the focus is on children’s right to health in the contexts of healthcare, preschools, and schools. Preschools and schools form part of children’s everyday life. Related to their extended hours in these settings, issues of health and right to health need to be an integrated part of all activities performed. During childhood, most children occasionally encounter healthcare contexts, although for some, living with long-term or chronic illnesses, these encounters become regular occurrences. Accordingly, issues of health and the right to health are of equal importance for children in healthcare contexts. Since the ratification of the UNCRC in 1989, there has been no systematic review mapping research on children’s right to health in these contexts. Hence, this systematic review aimed to identify how children’s right to health, connected to the principles of protection, promotion, and participation, and from the perspectives of children, parents, and professionals, has been empirically demonstrated by international scholars between 1989 and 2021.

Method

The process of this systematic review follows the standards of PRISMA-P, Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (Moher et al., 2015) and is registered in PROSPERO 2018 with the ID: CRD42019128810. The process described includes identification, screening, and eligibility assessment before the final inclusion and further analysis of the included records (Moher et al., 2009).

Identification

Initially, in the identification phase, the main search term—children’s right to health—was constructed and the generic concepts (protection, promotion, and participation) were defined. Additionally, search terms such as population (children, parents, and professionals) and contexts (healthcare, preschool, and school), including synonyms, were established (see Table 1) and inclusion criteria were set regarding peer-review, language, and publication date. Based on the language skills within the research group, research in Danish, English, German, Norwegian, Portuguese, Spanish and Swedish was included. Publication dates were set from 1989 until 2021. The introduction phase also included the distinguishing of databases (see Tables 2–4). When searching the databases, the main search term—children’s right to health—was combined with each generic concept, population, and context into nine various search strings (see Tables 2–4). Research librarians facilitated the construction of search strings and database searches. Two searches were conducted, in September 2018 and September 2020. The nine search strings rendered 559 records in total. Among those, the systematic reviews were scrutinised for additional records and two more were identified. These 561 records were subjected to further screening and eligibility assessment but before that, reasons for exclusion were identified (see Table 5).

Table 1. Definitions of research terms, generic concepts, population, and contexts.

Constructed main search term	Definition
Children’s rights to health	Rights are claims that are justifiable on legal or moral grounds to have or obtain something e.g. health or to act in a certain way e.g. reach health as by promotion, protection, and participation. Health is both a goal and a resource in children’s everyday life. It is a positive concept that emphasises social and personal resources as well as physical abilities. For the concept health the synonyms wellbeing or well-being, or quality of life was used
Generic concepts	Definition	Synonyms
Protection	Entitle the childhood to special care and assistance as well as protection from harmful acts and practice.	keep safe, to support, to guard, to secure, to safeguard, to shelter
Promotion	Refers to possess, receive, and have access to resources and services for both health care and education.	to encourage, to progress, to facilitate, to enable, to raise
Participation	Imply that children shall be heard and listened to in matters that concern them and being involved in their own everyday life	to take part, to attend, to be engaged, engagement, to be involved, involvement, to join, to join in
Population^1	Synonyms
Child (0–18 years)	newborn, neonate, infant, toddler, adolescent, youth, young people
Parents	caregivers, guardian, father, mother
Healthcare/educational professionals	pediatric nurse, children’s nurse, midwife, public health nurse, district nurse, school health care nurse, child health care nurse, nurse, health professionals, health (care) staff preschool teachers, teachers, preschool staff, child minder, health visitors
Context	Synonyms
Healthcare Preschool School	preschool, childcare, school, children’s hospital, child health care centres, child health centre, school health care, youth clinics, antenatal clinics, hospital, health centre, primary health care, early intervention centre, habilitation, home visits, family centre

Table 2. The main search term combined with the generic concept of protection and the various populations.

Search string 4 Children’s right AND Health AND Protection AND Child N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (protect* OR (keep n3 safe) OR support* OR guard* OR “safe guard” OR safeguard* OR shelter*) AND ((child* OR newborn OR “new born” OR neonate* OR preterm OR premature OR infant* OR baby OR toddler* OR adolescen* OR juvenil* OR teen* OR youth* or young*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school health care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	286
Search string 5 Children’s right AND Health AND Protection AND Parents N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (protect* OR (keep n3 safe) OR support* OR guard* OR “safe guard” OR safeguard* OR shelter*) AND ((parent* OR caregiver* OR “care giver*” OR father* OR mother* OR paternal* OR maternal* OR guardian*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	91
Search string 6 Children’s right AND Health AND Protection AND Professionals N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (protect* OR (keep n3 safe) OR support* OR guard* OR “safe guard” OR safeguard* OR shelter*) AND ((“pediatric nurs*” OR “paediatric nurs*” OR “child* nurs*” OR midwi* OR “public health nurs*” OR “district nurs*” OR “community nurs*” OR “preschool teach*” OR “pre-school teach*” OR teacher* OR “child minder*” OR childminder* OR “child health nurs*” OR “school health nurs*” OR “preschool staff*” OR “pre-school staff*” OR nurs* OR “health staff*” OR “health care staff*” OR “health profession*” OR “health care profession*” OR “health visitor*” OR physiotherapist* OR “physical therapist*”) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	29

Table 3. The main search term combined with the generic concept promotion and the various populations.

Search string 7 Children’s right AND Health AND Promotion AND Child N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (promot* OR encourag* OR progress* OR facilitat* OR enabl* OR rais*) AND ((child* OR newborn OR “new born” OR neonate* OR preterm OR premature OR infant* OR baby OR toddler* OR adolescen* OR juvenil* OR teen* OR youth* or young*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school health care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	252
Search string 8 Children’s right AND Health AND Promotion AND Parents N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (promot* OR encourag* OR progress* OR facilitat* OR enabl* OR rais*) AND ((parent* OR caregiver* OR “care giver*” OR father* OR mother* OR paternal* OR maternal* OR guardian*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	79
Search string 9 Children’s right AND Health AND Promotion AND Professionals N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (promot* OR encourag* OR progress* OR facilitat* OR enabl* OR rais*) AND ((“pediatric nurs*” OR “paediatric nurs*” OR “child* nurs*” OR midwi* OR “public health nurs*” OR “district nurs*” OR “community nurs*” OR “preschool teach*” OR “pre-school teach*” OR teacher* OR “child minder*” OR childminder* OR “child health nurs*” OR “school health nurs*” OR “preschool staff*” OR “pre-school staff*” OR nurs* OR “health staff*” OR “health care staff*” OR “health profession*” OR “health care profession*” OR “health visitor*” OR physiotherapist* OR “physical therapist*”) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	21

Table 4. The main search term combined with the generic concept of participation and the various populations.

Search string 1 Children’s right AND Health AND Participation AND Child N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (participat* OR “take part” OR attend* OR engage* OR involve* OR join*) AND ((child* OR newborn OR “new born” OR neonate* OR preterm OR premature OR infant* OR baby OR toddler* OR adolescen* OR juvenil* OR teen* OR youth* or young*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school health care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	288
Search string 2 Children’s right AND Health AND Participation AND Parents N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (participat* OR “take part” OR attend* OR engage* OR involve* OR join*) AND ((parent* OR caregiver* OR “care giver*” OR father* OR mother* OR paternal* OR maternal* OR guardian*) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	71
Search string 3 Children’s right AND Health AND Participation AND Professionals N3 Perspective AND Context	Databases	Identified studies (n)
(child* N3 right*) AND (health* OR wellbeing OR well-being OR “wellbeing” OR “quality of life”) AND (participat* OR “take part” OR attend* OR engage* OR involve* OR join*) AND ((“pediatric nurs*” OR “paediatric nurs*” OR “child* nurs*” OR midwi* OR “public health nurs*” OR “district nurs*” OR “community nurs*” OR “preschool teach*” OR “pre-school teach*” OR teacher* OR “child minder*” OR childminder* OR “child health nurs*” OR “school health nurs*” OR “preschool staff*” OR “pre-school staff*” OR nurs* OR “health staff*” OR “health care staff*” OR “health profession*” OR “health care profession*” OR “health visitor*” OR physiotherapist* OR “physical therapist*”) N3 (perspective* OR view* OR perception* OR experience*)) AND (preschool OR “pre-school” OR kindergarten OR childcare OR “child care” OR daycare OR “day care” OR school* OR “child* hospital” OR “child* health cent*” OR “child* health care cent*” OR hospital* OR “school health” OR “school heath care*” OR “youth clinic*” OR “antenatal clinic*” OR “health cent*” OR “health care cent*” OR “primary health care cent*” OR “early intervention cent*” OR habilitation or “habilitation cent*” OR “habilitation service*” OR “family cent*”)	Academic Seach Elite, Cinahl Plus, ERIC, MedLine, PsycARTICLES, PsycINFO, Teacher Reference Center	27

Table 5. Overview of the reasons for exclusion.

Code	Reason for exclusion
A1	Language other than the included
A2	Non-empirical study
A3	Lack of relation to children's right to health related to promotion, protection, and/or participation Lack of perspectives of children, parents, and or professionals
A4	The population does not meet study requirements
A5	The context does not meet the study requirements

Screening process and eligibility assessment

The outcome of the identification phase and the further screening process as well as the eligibility assessment are outlined in the PRISMA flow diagram (see Figure 1). The screening process was initiated by reviewing titles and abstracts of the identified records regarding reasons for exclusion (see Table 5). Records meeting one of these reasons were excluded. For this process, as well as the eligibility assessment, the research team was divided into pairs working in parallel with the screening. From this phase, 267 records were excluded, and 123 records identified as duplicates were removed. Records included for eligibility assessment were reviewed in the full text in relation to the exclusion criteria (Table 5). Subsequently, the remaining records (n = 172) were reviewed using the Critical Appraisal Skills Programme. During the screening process and eligibility assessment, the researchers had regular discussions to reach a consensus about which records to include. Eventually, 49 records were included in the final analysis (see Table 6) of which 37 represented healthcare contexts and 12 school contexts. Preschool contexts were not represented. A semi-global representation of the records was shown: Europe = 31, Africa = 6, Asia = 5, Oceania = 5 and North America = 4. Of these 49 records, 37 studies were published during the latter part of the search period (see Table 7).

Figure 1. The PRISMA flow chart.

Table 6. A summary of the included articles.

Authors, title, country, year	Aim and objective	Study design	Sample	Data analysis	Major findings relevant to the review
Anderson & Graham Improving student wellbeing: having a say at school Australia, 2015	Links between student voice and wellbeing	Mixed methods	Focus groups: n = 606 students, principals, teachers, and other staff Semi-structured interviews: n = 89 principals and teachers Surveys: n = 9975 students and staff	Descriptive and thematically coded qualitative data	Students understood wellbeing in multifaceted ways, including having a say, being listened to, having rights, and being respected. Both students and staff identified positive associations between having a say at school, being recognised (cared for, respected, and valued), and well-being.
Bhana Sex and the right to HIV/AIDS education in early childhood South Africa, 2008	How early childhood teachers and young children in two primary schools constructed and interpreted the right to HIV/AIDS education.	Thematic analysis	n = 5 early childhood teachers and young children (n = 174) (age range 7–8 years; males = 81; females = 93)	Individual interviews	Teachers operated within discourses which upheld the image of the child as innocent requiring protection from sexual knowledge. Children's perceptions of their rights to knowledge of sex in HIV/AIDS education showed ambiguity. Some accepted the right to know whilst others felt that knowledge about HIV/AIDS was inconsistent with childhood innocence.
Bray et al. A qualitative study of health professionals’ views on the holding of children for clinical procedures: Constructing a balanced approach UK, 2019	Capture an international perspective of how health professionals report they would act if a child was upset and resisted a procedure.	Content analysis	n = 712 professionals	Online surveys open text responses	Many professionals would use distraction and spend time informing and engaging children in making choices about their procedure. However, most professionals indicated that if a child became uncooperative, they would hold or instruct the holding of the child to get the procedure done “as quickly as possible”. Professionals have trouble balancing the different agendas, rights, and priorities within the momentum often resulting in the child’s voice and rights being undermined.
Collings Professional services for child rape survivors: A child-centred perspective on helpful and harmful experiences. South Africa, 2011	To explore child rape survivors’ perceptions of helpful and harmful experiences at the hands of professional service providers.	Thematic analysis	n = 20 child rape survivors	Interviews	The professional services provided to some child rape survivors fail too adequately address the child's basic needs and rights, with there being an associated need for improved codes of practice designed to better serve the interests of child rape survivors
Collins & Coughlan Experiences of mothers in Romania after hearing from medical professionals that their child has a disability. Romania, 2016	To examine the parental experiences of caring for a child with an intellectual disability following this experience.	Exploratory qualitative	n = 8 mothers	Interviews	The results revealed gaps in the disclosure process of an intellectual disability that led to uncertainty among the mothers toward professionals. The disempowering bureaucracy connected to the local Disability Commission impeded mothers’ access to community support and contributed to a lack of understanding of the needs of their children.
Coyne Consultation with children in hospital: children, parents’, and nurses’ perspectives UK, 2006	To explore children's, parents’, and nurses’ views on participation in care in the healthcare setting.	Grounded theory	n = 11 children, 10 parents, and 12 nurses	Interviews, surveys, and observation	Nurses faced with workforce pressures may encounter considerable challenges in facilitating children's involvement in decisions about their care. Hence nurses must examine the basis of their decisions and use more explicit criteria for determining children's involvement.
Coyne & Kirwan Ascertaining children’s wishes and feelings about hospital life. Ireland, 2012	To report on children’s views and wishes about hospitals and healthcare professionals.	Content analysis	n = 55 children aged 7–18 years	Interviews	Children were dissatisfied caused of insufficient information, lack of involvement, and inadequate play facilities. Their wishes were mainly the need for more information and involvement in communication interactions with doctors and nurses. They wished to express their opinions, ask questions, and receive information about care and procedures. They recommended that healthcare professionals make a better effort to listen and to take account of their views.
Eklund et al. Children’s self-reports about illness-related Information and family communication when a parent has a life-threatening Illness. Sweden, 2020	To explore children’s illness-related information and family communication when living with a parent with a life-threatening illness.	Quantitative	n = 48 children 7–19 years recruited from four specialised palliative home care units	Baseline survey data	All but one child reported that someone had told them about the parent’s life-threatening illness; however, two-thirds wanted more information. A quarter of the teenagers reported that they had questions about the illness that they did not dare to ask. Half of the children aged 8–12, reported that they felt partially or completely unable to talk about how they felt or show their feelings to someone in the family. Interventions are needed that promote greater family communication and family–professional communication.
Funkquist et al. Consulting on feeding and sleeping problems in child health care: what is at the bottom of advice to parents? Sweden, 2005	To investigate and interpret ideas inherent in sleep and diet consultations concerning infants in Swedish child health services.	Phenomenological approach	n = 7 professionals at CHC	Semi-structured interviews	An underlying theoretical view may be that parents’ time can be saved if the child becomes independent of the parents at as early an age as possible.
Gallagher et al. Establishing premises for inter-professional collaborative practice in school: inclusion, difference, and influence. Ireland, 2021	To ascertain stakeholders’ agreement and disagreement about inter-professional collaboration (IPC) when supporting children with a developmental language disorder (DLD) in school.	Content analysis	n = 26 (researchers, practitioners, and parents)	Online Delphi survey	We propose that IPC should be viewed as a means of ensuring the inclusion of the child in school. A shift in focus from remediating perceived deficits of the child, to affecting change in classroom practice, is also indicated. The need to reinforce the unconditional right of the child to have influence in decisions about support is highlighted. Implications for IPC when meeting the needs of children with developmental disabilities in school are outlined.
Geiger Sixth graders in Israel recount their experience of verbal abuse by teachers in the classroom. Israel, 2017	To adopt a children’s rights perspective stated in Articles 3, 12, 19, and 28 of the UNCRC (1989) to listen to Israeli children articulate their experience of verbal abuse by teachers in 6th-grade classrooms.	Content analysis	n = 60 students (40 males, 20 females) 12–13 years	Individually interviews	Stresses the importance of gaining insight into the world of children by having them articulate their experiences and denounce any form of abuse by teachers in the classroom. A child-safe school culture that listens to children’s view and makes them feel safe when reporting any form of abuse in the classroom are preconditions to serving children’s best interests and wellbeing in schools.
Gilljam et al. Promoting participation in healthcare situations for children with JIA: a grounded theory study. Sweden, 2016	To explore the experiences and preferences for participation in healthcare situations among children with juvenile idiopathic arthritis (JIA) as a foundation for creating strategies to promote their participation in paediatric healthcare	Constructivist grounded theory	n = 20 children 8–17 years	Individually interviews and focus group interviews	Offers new insights from the perspective of children themselves and can constitute a valuable contribution to the understanding of necessary conditions for the development of specific interventions that promote participation among children in healthcare situations.
Harder et al. Undergoing an immunization is effortlessly, manageable, or difficult according to five-year-old children. Sweden, 2015	To describe children's perceptions of undergoing an immunization.	Inquiry, discourse analysis, and grounded theory	n = 21 5 years old	Interviews	Children's and adults’ perceptions of medical procedures may differ, and children need guidance, time, and space to deal with them. Recognising children's perceptions of undergoing an immunization contributes to the promotion of their right to be involved in their health care and towards the development of child-centred care.
Hewitt-Taylor Children who have complex health needs: parents’ experiences of their child's education. UK, 2009	To describe parents whose children, have complex needs’ experiences of their children's education.	Content analysis	n = 14 parents to children from 18 months–18 years	Interviews	Children who have complex health needs may have to make a greater effort than their peers to achieve educational goals and may miss considerable school time. This can impact their leisure time. Accessing preschool education can be difficult for children who have complex health needs.
Huus et al. The awareness of primary caregivers in South Africa of the human rights of their children with intellectual disabilities. South Africa, 2016	To explore the awareness of primary caregivers in South Africa of the human rights of their children with intellectual disabilities.	Quantitative	n = 219 caregivers of children with intellectual disabilities	Surveys	Primary caregivers in both rural and urban areas are aware of the rights of their children with disabilities, although there are significant differences between them.
Häggman-Laitila & Euramaa Finnish Families’ Need for Special Support as Evaluated by Public Health Nurses Working in Maternity and Child Welfare Clinics. Finland, 2003	To describe public health nurses’ views of the everyday problems of families and their needs for special support.	Mixed methods Content analysis	n = 74 nurses	Surveys	Approximately one-third of the families were considered to have a pressing need for support. More than half of families (54%) had difficulties coping with parenthood and family structure, almost one-third (30%) with raising their children and with childcare, and nearly one-third (27%) with their social network.
Irving Australian students’ perceptions of the Importance and existence of their rights. Australia, 2001	To rate the importance and existence of 40 rights, based on the themes of the UN Convention on the Rights of the Child, in their homes and public schools.	Quantitative	n = 519 early adolescents	Surveys	Students in educational programmes felt that their rights to advocacy, privacy, and fair treatment received little or no support in schools.
Jenholt Nolbris & Ahlström Siblings of children with cancer—Their experiences of participating in a person-centred support intervention combining education, learning, and reflection: pre-and post-intervention interviews. Sweden, 2014	To evaluate a person-centred intervention, directed to siblings with a brother or sister newly diagnosed with cancer that combines education, learning, and reflection about cancer.	Contentanalysis	n = 14 siblings 9–22 years	Semi-structured interviews	Person-centred intervention helps siblings to be more knowledgeable about the sick child's cancer, leading to a more realistic view of treatments and consequences. Further studies of person-centred interventions for siblings are important.
John-Akinola et al. Taking part in school life: Views of children Ireland, 2014	To facilitate a three-phase participatory research process (PRP) to document the views of children about participation in school.	Quantitative	n = 248 primary school pupils 9- 13 years	Surveys	The paper illustrates children's understanding of what taking part in school means to them. The PRP encouraged pupils to have control of the three-phase research process and demonstrated the ability of children to work together in groups while having fun at the same time.
Kajubi et al. Spaces for talking: Communication patterns of children on antiretroviral therapy. Uganda, 2014	To describe how different social settings facilitate or constrain HIV + children's communication regarding their health and medicines.	Qualitative ethnographic	n = 35 HIV + children 8–17 years	In-depth interviews	Children were active in using the different spaces, and in seeking information about their health and treatment. The Convention on the Rights of the Child and Ugandan National Guidelines on HIV Counselling and Testing encourage more open communication than is currently the case. Adults need support to achieve this goal.
Kangasniemi et al. Nurses’ perceptions of the use of restraint in paediatric somatic care. Finland, 2014	To describe nurses’ perceptions of the use of restraint in somatic paediatric care.	Content analysis	n = 8 nurses	Individual interviews	Restraint is part of somatic paediatric nursing, described as the last, but in some cases, the only resort for carrying out care or treatment. Restraint is not a goal, but an instrumental tool and procedure in carrying out care. In the future, more information about nurses’ roles and the use of restraint in paediatric nursing is still needed.
Kleiderman et al. Returning incidental findings from genetic research to children: views of parents of children affected by rare diseases. Canada, 2014	To explore parental per-ceptions and experiences regarding the return of genomic incidental research findings in children with rare diseases.	Thematic analyses	n = 15 parents of children with various rare diseases	Focus group interviews + individual telephone interviews	Parents believed they should be made aware of all results pertaining to their child's health status, and that they are responsible for transmitting this information to their child, irrespective of disease severity. Despite potential negative consequences, respondents generally perceived a favourable risk-benefit ratio in receiving all incidental findings.
Koller & Espin Views of children, parents, and health-care providers on paediatric disclosure of medical errors. Canada, 2018	To capture diverse perspectives on paediatric disclosure, and to identify gaps in our knowledge for best practices and policy uptake.	Thematic analysis	n = 5 parents to children with chronic medical conditions n = 27 health-care providers including physicians, nurses, and patient safety professionals	Semi-structured surveys + Focus group interviews	Children acknowledged various disclosure approaches while citing the importance of children’s right to know about errors. Parents generally identified the need for full disclosure and the uncovering of hidden errors. Health-care providers were concerned about the process of disclosure and whether it always served the the best interest of the child or family. While some health-care providers addressed the need for more clarity in paediatric policies, most stakeholders agreed that a case-by-case approach was necessary for supporting variations in how medical errors are disclosed.
Koller et al. Paediatric pandemic planning: children’s perspectives and recommendations. Canada, 2010	To examine the perspectives and recommendations of children hospitalised during SARS in a large paediatric hospital in Canada.	Grounded theory	n = 21 (child and adolescent participants	Semi-structured interviews	The authors call for greater youth participation in healthcare decision-making and pandemic planning. Key recommendations included specific policies and guidelines concerning psychosocial care, infection control, communication strategies and the management of various resources.
Lambert et al. Young children’s perspectives of ideal physical design features for hospital-built environments Ireland 2014	To explore young children’s (5–8 years) perspective of hospital environments.	Thematic content analysis	n = 55 child participants	Interviews	Findings revealed three themes: personal space, physical environment, and access.
Larsson et al. Parents’ experiences of an e-health intervention implemented in paediatric healthcare: a qualitative study. Sweden, 2019	To explore parents’ perspectives on the outcomes of an e-health solution, Sisom, used by children during healthcare appointments.	Grounded theory	n = 16 parents	Interviews	Sisom orientated communication about healthcare towards the voice of the child instead of the parents as well as including the child in the dialogue with the healthcare professional and thus increasing the child’s participation and human rights.
Lightfoot & Sloper Having a say in health: involving young people with a chronic illness or physical disability in local health services development England, 2003	To highlight the contribution young people can make and the methods they prefer for listening to their views.	Qualitative	n = 23 (15 girls and 8 boys) 13–20 years	Interview, single or in groups Thematic analysis	There are differences in how young people view their participation—from a positive experience to a situation of little meaning. The motivation to be involved primarily came from altruism. To contribute to improvements for young patients in the future. Due to not routinely being involved, the youths needed reassurance that their participation and contributions would be taken seriously. According to the youths, different methods for participation were required as “one method does not fit all”.
Machado et al. Informed Consent—Vision and Perspectives of Adolescents, Parents and Professionals: Multicentric Study in Six Hospitals. Portugal, 2019	To identify the dynamics of the implementation of assent and informed consent in hospital settings.	Mixed methods	n = 194 adolescents and parents n = 46 physicians and heads of department	Surveys + interviews	This pioneering study in Portugal enabled the identification of areas that can be optimised, through health education programmes for parents and adolescents, written information that is adequate to the different age groups, training in undergraduate education for medical students, and education in health institutions for professionals.
Migone et al. Are we following the European charter? Children, parents, and staff perceptions. Ireland, 2008	To establish how well the EACH Charter is adhering to and perceived by children, parents, and hospital staff.	Quantitative	n = 111 parents n = 50 children n = 61 nurses n = 41 doctors	Surveys	This paper highlights patients’ and staff's perceptions regarding children's rights in hospitals and discusses the changes needed to fully conform to the EACH Charter.
Munford et al. Components of effective social work practice in mental health for young people who are users of multiple services. New Zeeland, 2015	To describe young people’s experiences with mental health services.	Mixed methods	n = 605 surveys n = 109 interviews 13–17 years	Surveys + interviews	The youth had clear ideas about the types of services that worked for them and the barriers to successful engagement with services. Three thematic clusters emerged: ecological approaches to support, impediments to service engagement, and moving beyond stigma.
Mutambo et al. User-provider experiences of the implementation of KidzAlive-driven child-friendly spaces in KwaZulu-Natal. South Africa, 2020	To describe the user-provider experiences of KidzAlive-driven child-friendly spaces in HIV care in KwaZulu-Natal.	Thematic analysis	n = 30 children n = 30 primary caregivers n = 20 KidzAlive trained healthcare workers	Interviews	Child-friendly spaces promote HIV-positive children’s right to participation and agency in accessing care. However, a more rigorous quantitative evaluation is required to determine their impact on children’s HIV-related health outcomes.
Noghabi et al. Exploring children's dignity: A qualitative approach. Iran, 2019	To explores school-age children’s and parent's perceptions of children’s, dignity.	Content analysis	n = 12 children n = 8 parents	Unstructured interviews	Hospitalized children’s and parents stated that healthcare services should respect the child and protect their privacy. Also, they should communicate with the child and their parents to provide dignity.
Noyes Enabling young “ventilator-dependent” people to express their views and experiences Iran, 2000	To describe experiences of young “ventilator-dependent” children, regarding health and social care, education, and aspirations for the future.	Conventional qualitative content analysis	n = 18 young people 6–18 years n = 25 family members of 15 young people	Interviews	A significant number of Articles in the United Nations (UN) Convention on the Rights of the Child were not respected or upheld. Young “ventilator-dependent” people were discriminated against when trying to access health services because of their need for assisted ventilation. They were particularly excluded from making important decisions about their lives. Some were not able to maintain adequate contact with their families, first language, culture, nationality, and religion.
Obong’o et al. Suffering whether You Tell or Don’t Tell: Perceived Re-Victimization as a Barrier to Disclosing Child Sexual Abuse. Zimbabwe, 2020	To explore and describe perceived barriers to disclosing child sexual abuse in Zimbabwe.	Thematic analysis	n = 40 children aged 10–14 years n = 40 parents/caregivers 20–62 years	Focus group interviews	Addressing social and cultural norms related to sex and strengthening legal protection for CSA survivors and their families could encourage CSA disclosure and could help end this violence. Our findings also highlight a need to increase children’s awareness of their rights and to create safe systems for disclosure of sexual abuse.
Norena Peña et al. Ethical aspects of children’s perceptions of information-giving in care. Spain, 2014	To identify key aspects in the exchange of information and  to determine how nurses communicate news to hospita-lised children.	Critical incident technique	n = 30 children 8 - 14 years	Observation and semi-structured interviews	This article emphasises the need to promote children’s consent and participation in nursing interventions. An analysis of these aspects will verify whether children’s rights are being respected and considered to promote children’s well-being and adaptation to hospitalisation.
Persson et al. School satisfaction and social relations: Swedish schoolchildren’s improvement suggestions. Sweden, 2016	To explore schoolchildren’s views on how to increase school satisfaction and improve social relations among peers at school.	Content analysis	n = 92 school children 10–12 years	Feedback model	Examining children’s opinions is requested and promoted by the UNCRC. The findings contribute to the field by showing how school satisfaction and social relations might be improved, if the child's perspective is considered in the planning of health promotion activities in school. Children reported that a psychosocial climate and good social relations among peers, including adults’ roles and responsibilities and classmates’ norms and values; and influence including changes in the physical environment and flexible learning as views.
Powell et al. Wellbeing in schools: what do students tell us? Australia, 2018	To gain an understanding of how student wellbeing is conceptualised and approached in schools.	Content analysis	n = 606 primary and secondary school students	67 focus group interviews	Students provided rich accounts of how they view their wellbeing, conceptualised across three interconnected themes of “being”, “having”, and “doing”. They identified relationships with self, teachers, friends, peers, and significant others, as central to their wellbeing. The findings point to immense potential in accessing and utilising children and young people’s views for change and reform in schools in student wellbeing.
Przybylska et al. Delivery of the UN Convention on the Rights of the Child in an acute paediatric setting: an audit of information available and service gap analysis. The UK, Australian, and US, 2019	To describe resources available to acutely admitted medical paediatric patients.	Qualitative feedback	n = 2 play specialists n = 30 families n = 9 children 3 - 15 years	Interviews	At the study site, no child-specific information resources were available for acute admissions, whereas planned admissions were offered significant information face-to-face with supplemental resources. Child, parent, and play specialist interviews highlighted gaps in information provision regarding hospital practicalities and processes. Twelve external child-specific resources were identified, for 4–14-year-olds, explaining key care information: medical procedures, equipment, and staff.
Quaye et al. Children's active participation in decision-making processes during hospitalisation: An observational study. Sweden, 2019	To explore and describe the child's active participation in the daily healthcare practice at a children's hospital.	Content analysis	n = 32 children and their parents. children aged 2 and 17 years and Healthcare professionals.	Observations	Children demonstrated both verbal and nonverbal ways of communication during decision-making. Children's, parents’, and healthcare professional's actions influenced children's active participation in decision-making processes involving healthcare. Health-care professionals specialised in paediatrics need to embrace both a child perspective and a child's perspective, plan care incorporating key elements of a child-centred care approach, to ensure children's active participation at a level of their choosing.
Runeson et al. Children´s needs during hospitalization: An observational study of hospitalized boys. Sweden, 2002	To describe children’s needs during hospitalization as expressed by their body language and verbal expressions when interacting with parents and staff members.	Content analysis	n = 21 boys 5 months–16 years	Observations	Those involved in the care of children should be alert to the fact that as circumstances change, different needs must be met. During non-threatening situations efforts should be made to inform children and to allow them to continue with their everyday lives. During threatening situations, the children should be assisted and supported in keeping the situation under control.
Sahlberg et al. Children’s rights as law in Sweden—every health-care encounter needs to meet the child’s needs. Sweden, 2020	To investigate children's experiences and paediatric nurses’ experiences of caring in accordance with the United Nations Convention on the Rights of the Child.	Content analysis	n = 10 children 4–7 years n = 13 nurses	Interviews	Health-care encounters without the necessary time or competence can affect children and future encounters negatively. Instruments to safeguard children’s rights in health care need to be developed and implemented, such as a documentation system to make children’s rights visible and/or UNCRC certification. Implementation of UNCRC principles in all health-care situations for children as standardised care requires competence, involvement, strong leadership, and economic support. Children’s voices in research can assist in guiding care.
Schalkers et al. Health professionals’ perspectives on children’s and young people’s participation in health care: a qualitative multihospital study. Netherland, 2016	To investigate healthcare professionals’ perspectives on child participation in paediatric hospital care and their opinions on improving participation.	Content analysis	n = 32 healthcare professionals	Interviews	Children do not currently participate in the assessment of hospital services. Creative methods that support the role of children in evaluating and improving the quality of paediatric hospital care and services should be developed. Hospital-wide policies could help to promote understanding of child participation among all professionals caring for children in hospitals
Sjöberg et al. The perspective of children on factors influencing their participation in perioperative care. Sweden, 2015	To describe the experiences of participation in perioperative care of 8—to 11-year-old children.	Content analysis	n = 10 children 8–11 years	Interviews	Receiving preparatory information, lack of information regarding postoperative care, and wanting to have detailed information are important factors for influencing children’s participation. Efforts should be made to improve children’s opportunities for participation in the context of perioperative care and further research is needed to establish international standards for information strategies and a care environment that promotes children’s participation in perioperative care.
Sloper & Lightfoot Involving disabled and chronically ill children and young people in health service development UK, 2003	To investigate the extent and nature of involvement of physically disabled or chronically ill children and young people in local health service development.	Quantitative	n = 99 health authorities n = 410 NHS Trusts	Surveys	The involvement of this group of children and young people in service development in the NHS is at an early stage. The failure of policy documents on user involvement to identify children and young people as a group for whom methods of consultation need to be developed, and the lack of people with designated responsibility for developing children's involvement may be a reason for slow progress in this area. Such involvement is possible and can have a positive impact on services.
Srithanaviboonchai et al. Thai health care provider knowledge of neonatal male circumcision in reducing transmission of HIV and other STIs Thailand, 2015	To assess Thai health care provider knowledge of benefits implementing NMC in Thailand.	Quantitative	n = 133 physician administrators, practicing physicians, and nurses	Surveys	Physicians and nurses who had previous experience with circumcising patients of all ages were more reluctant to have NMC performed in their hospital. A clear policy advocating NMC, thorough preparation of health facilities, and staff training is needed before NMC could be used in Thailand as prevention strategy for HIV and other STIs.
Stålberg et al. Curious, thoughtful, and affirmative young children’s meanings of participation in healthcare situations when using an interactive communication tool. Sweden, 2018	To describe young children’s demonstrated participation in healthcare situations while using an interactive communication tool.	Hermeneutic analysis	n = 13 boys n = 7 girls 39–70 months old	Video observations	An interactive communication tool used in healthcare situations can promote young children’s understanding and facilitate their situated participation, which potentially reduces feelings of distress or anxiety. This innovative use of interactive technology within paediatric health care provides new ways of revealing the child’s perspective on the situation.
Thunberg et al. Strategies that assist children with a communicative disability during hospital stay: Parents’ perceptions and ideas. Sweden, 2016	To investigate parents’ experiences of the hospital visits with their children with communicative disabilities and to collect their ideas about how to optimise communication in this situation.	Content analysis	n = 10 mothers to children with disability	Focus group interviews	Enabling direct communication between the child and the staff during the hospital stay is important. Parents of children with communication difficulties highlighted the importance of listening to their children and understanding their needs during hospital care and that hospital staff need more knowledge in communicative disability and AAC. Training programmes for healthcare professionals should be established to facilitate these requirements and connect to the United Nations conventions.
Yıldız & Yıldız Attitudes of the nurses working in pediatric clinics toward children’s rights Turkey, 2019	To determine the attitudes of nurses working in pediatric service towards children’s rights.	Quantitative	n = 104 nurses	Survey	Pediatric nurses toward children’s rights are positive. This study contributes to the nurses working in pediatric clinics paying attention to children’s rights in the practices of treatment and care for children.
Åkerström et al. Intra- and Inter-generational Perspectives on Youth Participation in Sweden: A Study with Young People as Research Partners. Sweden, 2015	To explore young people’s experiences of participation in school with a methodology designed to combine and compare intra- and inter-	Qualitative and quantitative	Research circle n = 8 girls Surveys n = 100 students 15–19 years	Research circles with 15 meetings + Surveys	Young people’s opportunities and abilities to communicate are critical for their participation. Political definitions of participation should include young people in the communi-cative context and the enabling of sharing responsibility and experiences. Young people can take responsibility if adults offer the right opportunities and are willing to listen.

Table 7. Publishing years of the included articles.

Data analysis

A deductive qualitative content analysis as proposed by Elo and Kyngäs (2008) was performed. The constructed main search term, children’s right to health, constituted the domain from which the analysis emanated. The definitions of the generic concepts were used when identifying the meaning units. Additionally, the perspectives of each population (x 3) in each context (x 3) were identified. Initially, to ensure trustworthiness, the authors jointly identified meaning units in one record. Thereafter, the authors individually identified meaning units in the records they had previously reviewed through both the screening process and eligibility assessment. Any discrepancies in the identification were rectified by discussion and mutual agreement. Consequently, a matrix was constructed for each generic concept, and the meaning units were scrutinised and positioned into the predetermined generic category, context, and population perspective to which they belonged. When needed, the placement of the meaning units was discussed among the authors until a consensus was reached. Thereafter, one of the authors (MS) coded the meaning units and finally, the codes were deduced into subcategories according to the definition of each generic concept. Following that process, discussions among the authors were made during the analysis to verify the choice of categories and subcategories.

Findings

This section presents a synthesis of how children’s right to health, related to the definitions of the generic concepts of protection, promotion, and participation, was demonstrated in the reviewed studies, from the perspective of the children (patients or pupils), families (mostly parents) and professionals in healthcare (henceforth hospital as this was the only healthcare context present in the included studies) and school contexts. As illustrated in the text below, the right to health was either distinctly or scarcely demonstrated, and occasionally it was lacking.

Children’s right to health by protection

Children’s right to health by protection was demonstrated as the child Being protected from harmful acts and practices and Being entitled to special care and assistance.

Being protected from harmful acts and practices

According to the studies, non-discriminating actions were demonstrated by children in both hospital and school contexts as essential to improve bonding (Gallagher et al., 2021; John-Akinola et al., 2014; Kajubi et al., 2014). Professionals viewed non-discrimination against children as a rights issue (Huus et al., 2016). In hospitals, children demonstrated a connectedness to and chatted easily with someone suffering from the same disease, since the children shared similar experiences. However, when socialising with healthy children, feelings of stigmatisation and discrimination were demonstrated, feelings that were especially emphasised by children in low-income countries who suffered from HIV/Aids (Kajubi et al., 2014; Obong’o et al., 2020). In schools, parents stressed the need to implement non-discriminating actions and guarantee equal rights for all pupils (Gallagher et al., 2021). Children with special needs demonstrated that they felt discriminated against by peers and teachers, for instance in situations where teachers assumed a direct link between disability and poor learning abilities (Åkerström et al., 2015). Although parents and professionals in both contexts stressed the importance of non-discriminating actions, they partially failed to fulfil their obligations. For instance, they withheld information regarding a diagnosis or sexual information, as they considered children as innocent and too young to deal with certain matters (Bhana, 2008; Kajubi et al., 2014).

In both contexts, the studies identified risks that could negatively influence children’s right to health. Being afraid and feeling pain were two major themes demonstrated by children in hospital contexts. Needle procedures, restraint, and being left alone were factors that were specifically targeted (Coyne & Kirwan, 2012; Harder et al., 2015; Munford & Sanders, 2015). A polarised situation was demonstrated regarding how parents dealt with these situations. Either they tried to avoid potential exposure to fear or pain, or they were demonstrated as non-supportive, not requesting alternative solutions for painful procedures (Quaye et al., 2019). Although aware that harmful experiences, such as restraint, could cause hospital-related fear, in some situations professionals described restraint as the sole way of providing good quality care (Kangasniemi et al., 2014). Apart from that, professionals described male circumcision as a risk and a violation of children’s rights (Srithanaviboonchai et al., 2015). Additionally, professionals in both contexts identified family-related factors, such as domestic violence, limited social relations, and work/family-related problems, as risks that could negatively impact parenting abilities and given that, the child’s position in the family (Häggman-Laitila & Euramaa, 2003). In schools, fear was the most pressing harmful element. Children, specifically those with special needs, associate fear with verbal attacks or being exposed by peers or teachers. Although teachers were abusive, the children kept silent due to fear of being expelled (Geiger, 2017).

In hospital contexts distraction, such as being close to a parent, chatting with a nurse or a doctor, playing, music, or watching TV, was demonstrated as a way for children to manage identified risks such as fear and pain (Eklund et al., 2020; Gilljam et al., 2016; Harder et al., 2015; Sjöberg et al., 2015). Furthermore, from a parental perspective, play, and especially the child being able to bring toys from home, was considered an important distraction method (Thunberg et al., 2016).

Being entitled to special care and assistance

In hospitals, the provision of safety was demonstrated when children met skilled professionals who treated them well (Mutambo et al., 2020; Sahlberg et al., 2020). According to parents, their safety provision was related to being close to the child (Migone et al., 2008). From a professional perspective, child-centred care was stressed as a key factor in safety provision and if it was not being performed, professionals demonstrated an awareness that negative consequences for the child could occur (Runeson et al., 2002; Sjöberg et al., 2015). In schools, children related safety to their physical safety, although they stressed the importance of social and emotional safety regarding bullying (Powell et al., 2018). Parents demonstrated safety issues in relation to pupils being unable to raise their voices. For these children to be safe, parents stressed the importance of school personnel taking good care of them (Hewitt-Taylor, 2009).

Children in both contexts demonstrated how they cherished their privacy and tried to create private spaces (Lambert et al., 2014; Obong’o et al., 2020; Powell et al., 2018). In hospitals, children identified that their privacy, and body integrity, were threatened when they were touched by professionals without consent or by being half-dressed for extensive periods during examinations (Noghabi et al., 2019).

Children’s right to health by promotion

Children’s right to health by promotion was demonstrated as Possessing resources and Receiving services.

Possessing resources

Children demonstrated hospital and school contexts as encouraging environments (Irving, 2001; John-Akinola et al., 2014; Kajubi et al., 2014; Persson et al., 2016; Powell et al., 2018), and they identified professionals as co-creating these environments by being there to help and support (Irving, 2001; Munford & Sanders, 2015) and—in school contexts—by paying attention to children’s rights and acknowledging them as individuals (Åkerström et al., 2015). According to parents, professionals created an encouraging environment by striving to find ways for individualised and adequate child encounters, an approach of paramount importance for children with special needs (Hewitt-Taylor, 2009; Przybylska et al., 2019; Thunberg et al., 2016). However, children in both contexts demonstrated that distress and anxiety contributed to transforming both hospitals and schools into discouraging environments (Powell et al., 2018). Additionally, in hospitals, scarce school activities and having to stay there due to advanced medical treatment not being provided elsewhere enhanced children’s feeling that hospitals were discouraging environments (Noyes, 2000).

Age-relevant environments were demonstrated by both children and professionals as designated places where the children could be at ease and have fun (John-Akinola et al., 2014; Mutambo et al., 2020; Sahlberg et al., 2020). Child-friendly communication, for instance, the use of pictures, sometimes interactive, and drawings added to this understanding and were agreed upon also by professionals (Larsson et al., 2019; Thunberg et al., 2016). However, in hospitals, the studies demonstrated that older children lacked these designated environments, which meant they were unable to meet with same-aged peers, (Coyne & Kirwan, 2012; Migone et al., 2008).

The trust in hospitals helped children, although reluctant to go there, to realise that spending time in the hospital would make them feel better. The professional’s personality was understood as a resource for creating feelings of trust (Koller et al., 2010; Sahlberg et al., 2020). Parents and professionals uniformly demonstrated that children’s trust was built on being in safe and familiar environments (Mutambo et al., 2020; Quaye et al., 2019).

Receiving services

Relationships with professionals were demonstrated by children in both contexts, building on their reliance on professionals being kind, respecting, and supporting them (Coyne, 2006; Gilljam et al., 2016; Noghabi et al., 2019; Powell et al., 2018; Sahlberg et al., 2020; Yıldız & Yıldız, 2019), an understanding also agreed upon by professionals (Anderson & Graham, 2015). Parents in hospital contexts described child-professional continuity as essential as that provided a mutual relation and understanding (Thunberg et al., 2016). It also provided adequate support from the healthcare sector (Collins & Coughlan, 2016). However, long stays in hospital without proper reasons resulted in children and parents feeling deprived of prosperous professional relations (Noyes, 2000). In schools, children demonstrated bad child-professional relationships as the result of professionals disrespecting children’s rights (Powell et al., 2018).

In both contexts, social/family support was demonstrated by children as being with friends and siblings, being safe, and having fun (Eklund et al., 2020; John-Akinola et al., 2014). In schools, social support was equal to inclusion which was of definite importance for children with special needs (John-Akinola et al., 2014; Powell et al., 2018), although children with communication difficulties more often had problems finding friends (Åkerström et al., 2015). In hospital, professional social support mostly targeted parents, teaching and helping them to care for their children (Eklund et al., 2020; Funkquist et al., 2005). In hospital contexts, reduced family support was demonstrated by children when not being listened to or comforted in adequate ways by their parents. Extensive periods away from home risked increasing feelings of exclusion and loneliness (Eklund et al., 2020).

Children’s right to health by participation

Children’s right to health by participation was demonstrated as Being heard and listened to and Being involved in matters of concern.

Being heard and listened to

Being noticed and involved was demonstrated by children in both contexts as essential for their well-being and participation (Anderson & Graham, 2015; Gilljam et al., 2016; Koller & Espin, 2018; Larsson et al., 2019; Sloper & Lightfoot, 2003). The children preferred to decide for themselves when to disclose their perspective, for instance regarding daily activities and did not wish to do so only when asked (Lightfoot & Sloper, 2003). They also demonstrated preferences regarding whom they confided in (Kajubi et al., 2014; Lightfoot & Sloper, 2003). Children with disabilities were demonstrated as requiring special arrangements, such as pictures and interactive devices, to allow them to speak (Thunberg et al., 2016), although such arrangements could be beneficial communication tools for all children. These tools allowed the children’s voices, although sometimes non-verbal, to be heard and helped to target the conversation to areas of importance for the child (Larsson et al., 2019). However, in situations of opposite opinions or protesting something, the children found themselves not being routinely listened to (Anderson & Graham, 2015; Sjöberg et al., 2015). In conversations, when professionals exclusively turned to the parents, the children described frustration and anger, perceiving their opinions as being of less importance (Quaye et al., 2019). In both contexts, parents emphasised that positive child-professional relations enabled the child’s voice to be heard (Gallagher et al., 2021). A child-professional power imbalance or professionals lacking proper communication skills and abilities to listen to and understand the child adequately, risked jeopardising the child being listened to (Kleiderman et al., 2014). Likewise, parents viewed professional disbelief in the child’s abilities, especially regarding children with disabilities or children having communication difficulties, as posing a risk of muting the child’s voice (Thunberg et al., 2016). Professionals demonstrated a will, and need, for acquiring adequate communication skills regarding talking to children and correctly interpreting their non-verbal expressions (Gallagher et al., 2021; Jenholt Nolbris & Ahlström, 2014; Lightfoot & Sloper, 2003; Mutambo et al., 2020; Noghabi et al., 2019). Like the children, professionals had a positive attitude to the use of interactive devices, both for enhancing communication and respecting the child’s rights by providing time and space (Larsson et al., 2019). In school contexts, the studies demonstrated that parents and professionals unanimously agreed upon all children’s right to express themselves. However, the studies demonstrated that in reality not all children were allowed to express their opinions as professionals let maturity and disability affect who could enjoy that right (Gallagher et al., 2021).

Being involved in matters of concern

For children, including siblings, in hospitals, preparation and information worked reassuringly to help them know what to expect (Jenholt Nolbris & Ahlström, 2014; Sjöberg et al., 2015), a view also agreed upon by parents and professionals (Bray et al., 2019; Kleiderman et al., 2014; Larsson et al., 2019; Przybylska et al., 2019; Thunberg et al., 2016). Lack of preparation and information resulted in feelings of worry and disbelief (Collings, 2011; Gilljam et al., 2016; Sjöberg et al., 2015). There was a difference in how children preferred to be informed. Some children favoured information from professionals, others from their parents (Migone et al., 2008). Children with communication difficulties preferred information provision through images, either interactive or traditional (Larsson et al., 2019). Yet another group of children preferred not to be informed as the information could remind them of earlier negative experiences (Koller & Espin, 2018; Norena Peña & Rojas, 2014; Sjöberg et al., 2015). Despite children’s demonstrated wish of being informed, they perceived professionals as taking minimal measures to ensure child understanding. This perception contrasted with the view of professionals who, in school and healthcare contexts, were demonstrated as emphasising use of age-relevant approaches (Eklund et al., 2020; Sahlberg et al., 2020; Thunberg et al., 2016) and allocating enough time for adequate preparation and information (Quaye et al., 2019). However, according to professionals, it could happen that children were not asked if they want to be informed or that the information provision was from an adult perspective only (Runeson et al., 2002).

Children in both contexts demonstrated that participating in decision-making influenced their situation (Eklund et al., 2020; Stålberg et al., 2018). However, they realised that not all decisions were for them to make, an opinion agreed upon by parents who believed children did not have enough competence to make decisions on their own (Coyne, 2006). Some parents even believed their children were mature enough to make their own decisions only when they reached adulthood (Kleiderman et al., 2014). In hospital contexts, parents and professionals demonstrated child decision-making as a child’s rights issue (Larsson et al., 2019; Sahlberg et al., 2020; Schalkers et al., 2016) for which age alone could not be used to determine whether the child should be allowed to participate (Coyne, 2006). Professionals found child decision-making was enhanced by adequate preparation and information. However, although informed, professionals mostly allowed children to have a say concerning “minor” decisions (Sahlberg et al., 2020; Schalkers et al., 2015). Children with chronic diseases could enjoy greater freedom to make their own decisions (Schalkers et al., 2015).

Children in hospital wished to be the main actor in the situation as they perceived themselves as having enough knowledge and skills to handle a situation (Koller & Espin, 2018; Machado et al., 2019). However, they sometimes admitted an occasional need for additional information from professionals. Parents said that the introduction of additional interactive technology in healthcare encounters transformed the child from a bystander to the main actor, a transformation that was understood as simultaneously diminishing the role and involvement of the parent (Larsson et al., 2019).

Discussion

This review aimed to identify how children’s right to health, connected to the principles of protection, promotion, and participation, was empirically demonstrated by international scholars between 1989 and 2021. These three concepts were chosen as they are often used to briefly summarise the content of the UNCRC as well as mentioned in the preamble of the convention (United Nations, 1989). However, during the analysis, it became obvious that these concepts are not isolated islands; instead, they are interrelated. From our point of view, as authors and representatives of professionals in school and healthcare contexts, we argue that protection is facilitated by participation as children, by being involved, either by themselves or with adult assistance, are enabled to highlight the need for protection from harmful acts and practices. Additionally, we view promotion and participation as interrelated as the possessing and receiving of resources are necessary prerequisites for being noticed and involved. Another way to describe this interconnectedness is borrowed from Quaye (2022), who demonstrates that the principles of protection, promotion, and participation are interrelated and nested in a rather complex way. The child’s right to health is context-dependent, situational, flexible, and dependent on all actors involved. Nevertheless, our analysis was performed in line with the definition of each generic concept, and the findings section was presented accordingly.

The UNCRC, passed in November 1989, was preceded by extensive child’s rights work starting with the Geneva Declaration of the Rights of the Child in 1924, and emanated from the Universal Declaration of Human Rights in 1948 (although the universality of the human rights is not always, or fully, applicable for children) and the Declaration of the Rights of the Child in 1959 (United Nations, 1989). Accordingly, the passing of the UNCRC cannot be viewed as ground-breaking news; children’s rights had been in the news for a long time. It is remarkable that most studies included in this review (range 1989–2021) were produced during the latter part of the period, i.e. from 2011 onwards (see Table 7). Although the UNCRC is a significant child’s rights document, now ratified by 196 countries, it takes time to implement the convention. Perhaps 20 years were needed for the world to be ready to adopt, and adapt, to children’s right to health.

This review showed that children’s right to health, through the perspectives of protection, promotion, and participation, was demonstrated within two major fields. Firstly, this right was related to children’s use of their resources, such as trust, distraction, and creation of privacy. These results, mostly stemming from the children’s own perspective, show evidence of a child who wishes to be a main actor, participating in and influencing in what way the situation develops (James et al., 1998; Wyness, 2014). However, there is a risk that the adult-centric perspective negates the principle of child agency. The second main field that elicited children’s right to health through aspects provided by others (parents and/or professionals), such as support, safety, and preparation/information. This second field, less dichotomous compared to the first, described relations and positive encounters, being bi-directional and sometimes even tri-directional, i.e. child–parent, child-professional, child–child, and child–parent-professional, as contributing to support and understanding. Receiving peer support, for instance from someone suffering from the same disease, was demonstrated as valuable and helpful and could also work as protection from other groups of children, where fear of being discriminated against or stigmatised could arise. The importance of multidimensional support is not a revolutionary finding. Instead, our findings confirm the results of former research (Lygnegård et al., 2019; Møller Christensen et al., 2019). Yet another field emerging from the findings, partly an angle of what is discussed above, was that children and adults seemed to focus differently in relation to the right to health. Feelings and experiences were predominantly demonstrated in studies targeting children, whereas studies including parents and/or professionals seemed to focus on what should be done in each situation. This variation probably stems from a difference in the research questions posited in each respective study. Regardless of a potential variation in aims and/or research questions, these findings indicate the importance of focusing on both the child and the child’s perspective when working with children (Sommer et al., 2010; Söderbäck et al., 2011), to get as much knowledge as possible and to target aspects of relevance for all parties involved.

The findings indicated that relations and positive encounters enabled children to participate in communication and decision-making in both contexts. From the child’s perspective, being involved was a matter of respect. However, professionals allowing children to “have a say” is not just a way to show respect for them as individuals, but also a way to respect their human rights (United Nations, 1989). Child participation is essential but depends on professionals adjusting their way of working (Shier, 2001) and finding flexible ways for communication aligned with age, maturity, and language skills (Ford et al., 2018). Some of these flexible ways of communication have been described in this review, such as interactive technology, pictures, and drawings.

In this systematic review, three contexts were of interest: healthcare, preschool, and school. Preschools and schools are part of children’s everyday life, but healthcare contexts are not, at least not for most children. According to the WHO, children’s health is vital and linked to their physical, social, and cognitive development which puts focus on the importance for professionals to reflect on and acknowledge children’s rights according to the UNCRC (United Nations, 1989). It is meaningful to study the topic of children’s right to health within these contexts. Although an extensive search process (see Tables 2–4) was implemented, including several search terms, no studies describing preschool contexts were identified. School and healthcare contexts were represented; still, the number of studies in school contexts was strongly underrepresented compared to healthcare contexts. This distribution is surprising as children’s right to health is of equal importance regardless of context. Perhaps health-related issues are still predominantly viewed as relevant for healthcare contexts, while pedagogy is the most relevant for preschools and schools. Another possibility is that, within preschools and schools, other variables than those targeted in this study are used to examine health-related issues. Apart from this, the findings indicated that studies within school contexts, from all three perspectives, more often targeted children with special needs. In healthcare contexts, a broader mix of children was included in the studies, although most of whom were seven years of age or older. The perspective of the younger children was therefore lost.

Children’s right to health, as demonstrated in international studies, has been described in this paper.

However, the findings section reveals opposite scenarios as well, i.e. scenarios where the rights’ perspective was not emphasised, or missing. In summary, these scenarios concerned discrimination, lack of support, exposure and denied participation (Kajubi et al., 2014; Noghabi et al., 2019; Obong’o et al., 2020; Quaye et al., 2019). Although all included studies emphasised a child’s right perspective, some studies demonstrated that parents and professionals discriminated against children, for instance regarding age and disability (Bhana, 2008; Geiger, 2017; Kajubi et al., 2014; Åkerström et al., 2015). From the children’s perspective, the violation of the right to health was demonstrated by a lack of parental and professional support. Likewise, being ignored in conversations, and not being properly prepared and informed hindered the child from being adequately involved in a situation.

Finally, related to the geographical residence of the included studies, attention should be drawn to the fact that a variety of countries and continents were represented. However, a strong emphasis on the Western world, especially on Europe, was shown, although 196 countries worldwide have signed the UNCRC, indicating an intention of emphasising children’s rights. This review includes too few studies to state statistical assumptions. Regardless of that, we as authors would like, rhetorically, to point at a controversial question: are child issues, and more pressingly child rights issues, more noticed and emphasised within the Western world?

Methodological considerations

The trustworthiness of this review (Lincoln & Guba, 1985) derives from a thorough search process when identifying studies for inclusion. To further strengthen the quality of the performed searches, two research librarians were engaged throughout the entire search process. However, although multiple synonyms of relevant search terms were used, perhaps other search terms, including synonyms, could have targeted even more relevant studies, especially within preschool and school contexts. One weakness of the study could be the prolonged period used for finalising the manuscript. However, due to this extensive period, a second database search was conducted that allowed us to include more, and more recently published, studies for analysis. The credibility of the study was further strengthened by our analysis process which was characterised by a mix of joint and individual work.

Conclusion

Since the declaration of the Convention on the Rights of the Child in 1989, a growing body of studies has explored children’s right to health. We found children’s right to health to be demonstrated by the principles of protection, promotion, and participation as interrelated concepts. From the children’s perspective, the right to health is related to their resources, such as being an actor, having trust in and claiming support from others, and thus being able to participate. From the adults´ perspective, children’s right to health is related to them providing support and safety to the child. While studies with a child’s perspective focus on feelings and experiences, studies with an adult’s perspective focus on what should be done in a situation.

This systematic review identified studies related to children´s right to health mainly from the healthcare context. As children’s health is linked to their physical, social, and cognitive development, there is a need for more studies exploring children’s right to health in preschool and school, contexts that are especially important as these settings are where children spend their everyday life. However, many of the studies describing school contexts focused on children with disabilities, a subject scarcely used in healthcare-related studies. Accordingly, the right to health for children with disabilities in healthcare contexts could be of interest to further research, as well as putting a similar interest on the youngest children, a group that was invisible, in both contexts, in the reviewed studies. Furthermore, as all policymakers, health workers, and politicians should include children in all decisions that concern them, it would be interesting to consider the influence of state and community contexts in upholding/ facilitating/ negating children’s rights.

Acknowledgments

The authors wish to thank the research librarians Per Nyström and Sara Landerdahl Stridsberg, Mälardalen University, for their excellent support and guidance in the preparation for and execution of the database searches conducted for this review.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Anna Stålberg

Anna Stålberg, PhD, affiliated to the Karolinska Institute, Stockholm, and a paediatric nurse specialist at the PED, Astrid Lindgren's Children's Hospital, Stockholm. Her main research area concerns children's rights within healthcare and child participation in healthcare is an area of specific interest.

Maja Söderbäck

Maja Söderbäck has a PhD and is a Senior researcher and Associate professor at School of Health, Care and Social Sciences at Mälardalen university, Sweden. She has international experiences in children's health and paediatric nursing.

Birgitta Kerstis

Birgitta Kerstis has a PhD, paediatric nurse, and an associate professor in Nursing at Mälardalen University. Kerstis latest research focuses on the mental health of COVID-19 effects on the population, but also the mental health among older men and new parents.

Maria Harder

Maria Harder is an Associate Professor in Caring Science and Director of Research at the School of Health Care and Social Welfare, Mälardalens University, Sweden. Her individual research interest includes, to contribute to the right to health and participation among children and young people by involving them, their parents, and professionals in research, foremost in the context of child health services, preschool and psychiatric care.

Margareta Widarsson

Margareta Widarsson is a midwife, pediatric nurse, and associate professor in reproductive, perinatal, and sexual health at Mälardalen University. She has a PhD and has researched how newly graduated nurses can develop their professional competence through an introduction development program. She has also researched parental stress and support.

Lena Almqvist

Lena Almqvist is a professor of psychology at Mälardalen University, where she leads the ChiP research group. This group focuses on studying and promoting children's health and participation rights. She also works with the CHILD research program at Jönköping University. Her main research interest lies in the mental health of young children, especially those in challenging situations. Lena is keen on participatory research methods, particularly involving children as informants to better understand their participation and everyday functioning.

Marianne Velandia

Marianne Velandia is a Senior Lecturer at the School of Health, Care and Social Welfare, Division of Caring Sciences and Health Care Pedagogics, Mälardalen University.

Anna Karin Andersson

Anna Karin Andersson, PhD and physiotherapist, is a reseacher in ChiP research group at Mälardalen University and n CHILD research group at Jönköping University. Her main research interest lies in health, participation and everyday functioning in children, with a special focus on children with disabilities.