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The recognition of children’s voices in health care and research within Nigerian child protection legislation: A normative analysis

January 2021
International Journal of Africa Nursing Sciences 14(4):100284

DOI:10.1016/j.ijans.2021.100284

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There is a growing body of knowledge about children as moral agents and their capacity and interest to participate in healthcare and research discussions/decisions that affect them. Although this has led to some research and practice improvements that have better-recognized children’s voices, this trend has not been globally embraced, especially within Sub-Saharan Africa. Objective This study examines and analyzes the rights of children to participate in healthcare and research discussions and decisions within the normative discourse of child protection laws in Nigeria. Method We conducted a normative documentary analysis based on five of the principal Nigerian child protection legislative documents enacted from 1999 to 2019. Results Findings demonstrated that Nigerian legislation acknowledges the participation rights of children in healthcare and research. However, the normative document also emphasized children’s obligation to the given privileges in the form of respect to parents/guardians, superiors, and elders. Conclusion Norms regulating the rights of children are in existence in Nigeria. Nevertheless, legal guidance to ethical practice in healthcare have been generalized and has not upheld the idea of dignity and liberty of children. We recommend that Nigeria should reconsider the code of ethical practices in the fields of health and research to give children the participatory authority that could provide active involvement and compliance.

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The recognition of children’s voices in health care and research within Niger‐

ian child protection legislation: A normative analysis

Shilni J. Liberty, Franco A. Carnevale

PII: S2214-1391(21)00007-X

DOI: https://doi.org/10.1016/j.ijans.2021.100284

Reference: IJANS 100284

To appear in: International Journal of Africa Nursing Sciences

Received Date: 30 January 2020

Revised Date: 18 November 2020

Accepted Date: 14 January 2021

Please cite this article as: S.J. Liberty, F.A. Carnevale, The recognition of children’s voices in health care and

research within Nigerian child protection legislation: A normative analysis, International Journal of Africa

Nursing Sciences (2021), doi: https://doi.org/10.1016/j.ijans.2021.100284

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The recognition of children’s voices in health care and research within Nigerian child

protection legislation: A normative analysis

Shilni J. Liberty, Franco A. Carnevale

McGill University, Ingram School of Nursing. Montreal, Quebec, Canada

Email addresses: shinipukuma@gmail.com, franco.carnevale@mcgill.ca

Funding

The study was funded by the authors with support from VOICE (Views On Interdisciplinary

Childhood Ethics) research team

Conflict of interest

The authors declare that there was no conflict of interest.

Acknowledgment

We are grateful to our research team VOICE (Views On Interdisciplinary Childhood Ethics) for

their valuable information that was useful in the preparation of this article.

The recognition of children’s voices in health care and research within Nigerian child

protection legislation: A normative analysis

ABSTRACT

There is a growing body of knowledge about children as moral agents and their capacity and

interest to participate in healthcare and research discussions/decisions that affect them. Although

this has led to some research and practice improvements that have better-recognized children’s

voices, this trend has not been globally embraced, especially within Sub-Saharan Africa.

Objective: This study examines and analyzes the rights of children to participate in healthcare and

research discussions and decisions within the normative discourse of child protection laws in

Nigeria.

Method: We conducted a normative documentary analysis based on five of the principal Nigerian

child protection legislative documents enacted from 1999 to 2019.

Results: Findings demonstrated that Nigerian legislation acknowledges the participation rights of

children in healthcare and research. However, the normative document also emphasized children’s

obligation to the given privileges in the form of respect to parents/guardians, superiors, and elders.

Conclusion: Norms regulating the rights of children are in existence in Nigeria. Nevertheless,

legal guidance to ethical practice in healthcare have been generalized and has not upheld the idea

of dignity and liberty of children. We recommend that Nigeria should reconsider the code of ethical

practices in the fields of health and research to give children the participatory authority that could

provide active involvement and compliance.

Keywords: Children’s rights; Discussion, Decision-making; Informed consent; Normative

analysis; Voice of the Child

1. Introductions

Under the prevalent protective model practiced in Nigerian healthcare and some counties

considered in this study, adults customarily stand in the gap to protect the interests of vulnerable

children and adolescents. Therefore, decisions regarding their care are commonly made

exclusively by parents or legal guardians and healthcare professionals (Agu, Obi, Eze, & Okenwa,

2014; Douglas & Walsh, 2010; Folayan, Haire, Harrison., Odetoyingbo, Fatusi, & Brown, 2015;

Bubadué, Cabral, Carnevale, & Asensi, 2017; Carnevale, 1997, 2002, 2008; Glass & Carnevale,

2006). Nevertheless, national and international studies have progressively suggested the

importance of involving children in their healthcare and research (Agu et al., 2014; Bubadué et al.,

2017; Carnevale & Manjavidze, 2016; Cashmore & neglect, 2002; Coyne, Amory, Kiernan, &

Gibson, 2014; Coyne & Gallagher, 2011). These recommendations are not practiced, which results

in children and adolescents often silenced with regards to exercising their rights. They are seldom

allowed to express their views on issues related to their health care and research (Agu et al., 2014;

Adejumo & Adejumo, 2009; Bubadué et al., 2017). Similarly, their participation in healthcare or

research is inadequately applied globally (Adejumo & Adejumo, 2009; Adi, Abdu, Khan, Rashid,

Ebri, Cockcroft, & Andersson, 2015; Agu et al., 2014; Akinwumi, 2010; Coyne, 2008; Gilljam,

Arvidsson, Nygren, & Svedberg, 2016).

In Nigeria, children are commonly silenced from participating in discussions and decisions

regarding their healthcare, as enshrined in the country’s laws. Often children are treated as passive

rather than active participants in health-related issues that concern them (Agu et al., 2014;

Ogundiran & Adebamowo, 2012; Adejumo & Adejumo 2009). According to the Child’s Right

Act Section 19, Article 2a of the Nigerian Child’s Right Act No. 26, 2003, ‘a child is subject to

respect his or her parents, superiors and elders at all times...’ (Nigerian Child’s Rights Act No.

26, 2003). This wording implies that the child must, at all times, consider and follow decisions

made by adults without dissent. For instance, situations such as invasive and non-invasive medical

procedures, duration and nature of the treatment. There are cases where children in other countries,

such as Canada and Australia, have been encouraged to express their preference according to

knowledge and options available (Cashmore & neglect, 2002; Coyne, 2008; Ruiz-Casares, Collins,

Tisdall, & Grover, 2017; Grace, Knight, Baird, Ng, Shier, Wise, Fattore, McClean, Bonser, Judd-

Lam, Kemp 2019; Marsh, Mwangome, Jao, Wright, Molyneux, & Davies, 2019). However, such

has not been the practice in Nigerian healthcare or research as children are subject to whatever

decision taken on their behalf by parents, guardian or healthcare professionals (Adejumo &

Adejumo, 2009; Adi et al., 2015; Agu et al., 2014; Akinwumi, 2010). Examples of this include the

alleged involvement of nurses in the unethical treatment of children recruited in

Pfizer’s clinical trial of Trovan for cerebrospinal meningitis in northern Nigeria (Adejumo &

Adejumo, 2009). According to Adejumo & Adejumo (2009), nurses, patients and their families

were not given sufficient information to accord ethical decision making which resulted to lawsuit

between the families and Pfizer company. Also, a study conducted to examine the attitudes of

people towards informed consent in developing countries indicated that the educational level of

individuals affects their views regarding informed consent with children. Approximately 70% of

those who had tertiary education noted that informed consent was necessary for procedures on

children, while the more significant number of those with primary (64.4%) and no formal

education (76.4%) indicated that informed consent was not necessary for procedures on children

(Agu et al., 2014)

Furthermore, Nigeria makes health care decisions on children based on the Nigerian

Child’s Rights Act: “the best interest of the child as the paramount consideration in all action,”

(Section 1 Article 1) and “to give protection and care necessary for his or her well-being” (Section

2 Article 1 and 2). Section 19, Article 1 and 2 of the Nigerian Child’s Rights Act No. 26 2003

state that: “Every child has responsibilities towards his family and society, the Federal Republic

of Nigeria and other legally recognized communities, nationally and internationally” therefore,

“A child shall in the subject to his age and ability and such other limitations as may be contained

in this Act and any other law, to (a) work towards the cohesion of his family and community; (b)

respect his parents, superiors, and elders at all times and assist them in case of need (Nigerian

Child’s Rights Act No. 26, 2003). As declared by the law, the adult’s judgement determines the

best interest of the child as further explained in Section 19, Article 1 and 2 of the Nigerian Child’s

Right Act No. 26 2003. Although these legal codes protect children, in the same vein, it silences

them, especially in an instance where they may need to have their voices heard in the promotion

of their quality of life and healthcare.

Emerging studies on children’s health have revealed that the voices of children can be

relevant in health-related discussions and decision-making, especially those relating to them.

Stressed by these studies, such practices will help them develop self-confidence, reduce fear,

improve adherence to treatment and recognize their agency (Coyne, 2008; Grace et al., 2019;

Marsh et al., 2019; Bubadué et al., 2017; Carnevale, 2012; Committee on Bioethics, 2016;

Gaudreault & Carnevale, 2012). Some African countries, such as Ghana, South Africa, Tanzania,

including Nigeria, have made efforts to revamp the medical system. They established a universal

health care system where children’s rights would be protected by law and recognize children’s

voices, but none of the mentioned countries have yet achieved (Ajayi & Dibosa-Osadolor, 2013;

Adegbehingbe, Oginni, Ogundele, Ariyibi, Abiola, & Ojo, 2010; Amodu, Olumese, Gbadegesin,

Ayoola, & Adeyemo, 2006; Renne, 2010).

Countries with universal health care systems such as Canada and Australia, have

recognized the voices of children in healthcare practice irrespective of social class, sex, age, or

race (Coyne, Amory, Gibson, & Kiernan, 2016; Montreuil & Carnevale, 2016). Pediatric

healthcare professionals often encounter moral and ethical problems that require legal/court

intervention (Coyne & Gallagher, 2011; Cureton & Silvers, 2017; Francis & Silvers, 2013; Koller,

2017; Marsh et al., 2019; Mercurio, Murray, & Gross, 2014). Health policies, programs, and

materials provided by the countries named above have been instrumental in overseeing the

protection of the rights of the child as well as their inclusion in health decisions according to the

child’s capacities (Cashmore & Neglect, 2002; Bubadué et al.; 2017; Canada Department of

National & Welfare, 1981; Federal-Provincial Working Group on & Family Services, 1994). These

have acknowledged the voices of children and enhanced the quality of healthcare practices with

children.

For instance, Australia has integrated children in discussions and decision-making

regarding healthcare and protection within its legislation. For example, in Queensland, a ‘Charter

of Rights for Child in Care’ is included in the Child Protection Act 1999, New South Wales (NSW)

(Cashmore & Neglect, 2002). Similarly, in Canada, the voice of the child in healthcare decision-

making that relates to them has been recognized with age considerations Canada Department of

National & Welfare, 1981; Federal-Provincial Working Group on & Family Services, 1994 (Ruiz-

Casares, Collins, Tisdall, & Grover, 2017). Both in Canada and Australia, policies promote child

inclusion in healthcare discussions and decisions. Noteworthy children’s capacity to participate

has also been regulated both legally and ethically.

In contrast, since 2003, Nigeria has passed a bill to protect the rights of children but has

failed to implement the Act nationally. According to research reports by Olayinka (2010) and

Daniel (2018), only nineteen States out of the thirty-six states in the country support the legal

protection of the rights of the child. Efforts to adopt the Child’s Rights Act nationally have not

been successful because of political, socio-cultural, and religious considerations (Olayinka 2010;

Daniel 2018).

The Nigerian Child’s Right Act 2003 provides guidelines for all professional codes of

conduct involving Nigerian children. Hence, a normative analysis of Nigerian laws and standards

seemed warranted at this time, shedding light on the state of children’s rights while promoting the

protection of children in healthcare practices. Healthcare practices were considered an essential

focus for this study because of their importance in protection, promotion, and improvement of

children’s quality of life. A second reason for this inquiry is grounded in a review of the existing

literature, which identified knowledge gaps regarding existing norms on the rights of children in

healthcare and research in Nigeria. These gaps exist in Sub-Saharan Africa as well, but we have

narrowed the focus of this article solely on Nigeria.

This article examines the recognition of children’s voices – or not - in healthcare and

research discussions and decision-making that pertains to them, through a normative analysis of

child protection laws in Nigeria. With a focus on normative and regulatory child protection

documents, the authors assayed children’s participation in healthcare practices, given

understanding the limitations and strengths of the laws and regulations guiding pediatric practices.

Through this investigation, we aim to assess whether these normative standards adequately support

the participation of children in discussions and decision-making in healthcare and research in

Nigeria.

1.1 Research Objectives

To examine and analyze the voices of children in healthcare and research through a normative

discourse analysis of child protection laws in Nigeria.

1.2 Research Questions

Are children entitled to any participation rights in healthcare and research within child protection

laws in Nigeria?

2. Methods

In health research, normative analysis is yet to be popular. However, a few studies have postulated

on its significance and adaptation (Bubadué et al., 2017; Omura, Stone, Maguire, & Levett-Jones,

2018; Zanotti & Chiffi, 2016). An example of a normative study considered in the present work

undertaken in Brazil studied contextually the legal conduct applied to children’s participation in

health care and research. The normative analysis prescribed for normative child protection treatise

to grant children a voice, though with restrictions and operates under the authority of an adult or

parental authority (Bubadué et al., 2017). The second study examined was a research work that

investigates behavioral and control beliefs concerning assertive communication among Japanese

nurses in a pediatric department. A normative analysis was used together with other studies to

explore the number and type of expressions applied by children to express pain. Normative

analysis specified the importance of understanding the child’s self-reported pain based on the

child’s ability to relate (Omura et al., 2018).

The present article involves a documentary analysis of legislative norms that guide the

practices of health professionals in healthcare and research in Nigeria. The primary data utilized

in the report were considered according to the relevance of the preliminary data from normative

documents that relate to the Nigerian child protection legislation. A content analysis approach was

used to examine the documents, and Baron’s (2004) normative analysis method for ‘normative

models of judgment and decision making’ (as described in Blackwell Handbook of Judgment and

Decision Making) was used for understanding and interpretation of the documents.

National and health databases were explored to identify relevant literature for this article.

Searches included the terms “rights, children, law, act, code of ethical conduct, discussion,

decision-making, informed consent, normative analysis, the voice of the child.” To ensure

comprehensiveness, we searched for synonyms of keywords, “legislation, code of ethical practice,

privilege.” Databases examined involved: Scopus, CINAHL, Pubmed, and Google Scholar.

Results were limited to Nigerian legislation, national code of ethical conduct for healthcare

professionals, and health research documents within 1999 – 2019. The review of documents - the

pre-analysis stage – involved the selection of national normative documents that address children’s

voices within the papers. Documents were organized to form the basis for analysis utilizing the

following principles of content analysis (a) Thoroughness: all documented sections related to the

child’s voice were considered; (b) Representativeness: documents that addressed children’s

participation; (c) Homogeneity: normative documents that made reference to children’s right to

active involvement; lastly, (d) Pertinence: the relevance and ability of normative documents to

address the objective of this analysis. Documents reviewed and selected from national normative

documents were based on the following inclusion criteria: 1) Articles on children’s rights in

healthcare and research, laws, decrees, and resolutions that relate to children as acknowledged by

the Nigerian constitution; and 2) Covering the 1999 to 2019 period. Exclusion criteria included:

1) Articles on children that did not address the rights of children in healthcare or research; and 2)

Articles that are neither laws, decrees, or resolutions and did not cover the 1999 to 2019 period.

The documents considered were used to form the body of analysis. This resulted in the

selection of five documents for inclusion, as presented in Table 1, and five documents were

excluded based on the criteria considered in the study as mentioned above, as shown in Table 2

below.

Table 1: Normative texts included in the corpus of analysis. Nigeria 1999 to 2019

Nigerian Child’s Right Act, No. 26 (NCRA) 2003.

National Code of Health Research Ethics (NCHRE) 2007.

Version 1.0 of the Policy Statement Regarding Enrollment of Children in Research in Nigeria

(PS2.1016) 2016.

Code of Ethics for Nursing and Midwifery Practice Nigeria 2004.

Medical and Dental Council of Nigerian Code of Ethics. (2004).

Table 2: Normative texts excluded from the text corpus of analysis. Nigeria, 1999 to 2019

Constitution of the Federal Republic of Nigeria 1999

Children and Young People’s Act (CYPA) 1943

The Integrated Maternal, Newborn and Child Health (IMNCH) Strategy of 2007

National Health Act, 2014 Federal Republic of Nigeria.

National Adolescent Health Policy 1995

Exploration of material-meta-analysis is the second stage, which includes understanding,

interpretation, and inscription of the corpus of the analysis. The texts were classified into

categories to constitute the description of study attributes, that is, children’s voices as represented

in the texts. The last stage explored the core meaning of the characteristics of children’s voices. A

descriptive model generates a suitable prescriptive model, which makes up an excellent normative

analysis. Therefore, the researchers explored descriptive articles and prescriptive articles. The

descriptive model expounded the legal documents as presented in statutory texts and moral

principles of the law. At the same time, the prescriptive model states how standards and legal

principles should be incorporated into practice. Grounded within this normative framework, we

analyzed texts from documents regarding critical ethical codes, such as autonomy (dignity,

informed consent, and confidentiality) beneficence, non-maleficence and justice (liberty and

freedom).

A normative analysis of the law is not an attempt to oppose the prevailing legal standards

but rather an effort to incorporate legal standards into healthcare practice to protect the rights of

healthcare recipients if possible, in this case, the children. Consequently, normative analysis is

considered suitable for comprehending legislative context and conduct rather than regulating that

which is accepted and followed. An example can be a prescriptive model of legal conduct applied

to healthcare practice and research with children, where children’s rights will be incorporated and

empowered by law in healthcare and research with children.

In this article, we used normative analysis to interpret the legal principles that are justifiable

and could form the basis of supporting children’s participation in healthcare and research.

3. Results

The analysis resulted in two categories and five sub-categories for each of the two groups.

Category 1. the rights of children in healthcare; 1.1. right to dignity; 1.2. right to information, 1.3

right to protection. 1.4 right to confidentiality 1.5 right to informed consent. Category 2. the rights

of children in scientific research; 2.1. right to dignity 2.2. right to liberty, 2.3. right to information,

2.4 right to consent; 2.5 right to confidentiality.

3.1 The rights of the child in healthcare

The Nigerian Child’s Right Act No. 26 2003 provides expected conduct for every organization in

the management of the child. It covers both governmental, non-governmental institutions or

individuals and provides guidelines to uphold the best interests of the child. Consequentially, it is

pertinent that health care professionals and researchers should seek the best interest of the child as

it is the child’s right according to the Child’s Rights Act.

“In every action concerning a child, whether undertaken by an individual, public or private body,

institutions or service, court of law, or administrative or legislative authority, the best interest of

the child shall be the primary consideration,” Section 1 of the Nigerian Child’s Right Act No. 26.

(NCRA) 2003

The Nursing and Midwifery Council of Nigeria 2004 stated it clearly in the code of conduct for

Nigerian Nurses and Midwives that they should provide care without prejudice to age among other

clients. As a result of this rule, the age of children should not deprive them of acceptable healthcare

services.

“Provide care to all members of the public without prejudice to their age, religion, ethnicity, race,

nationality, gender, political inclination, health or social-economic status,” Nursing and

Midwifery Council of Nigeria (NMCN) 2004.

According to the nursing and medical code of practice, the right to consent to medical or nursing

treatment should be ensured by the parents, or legal guardians, in consultation with the most senior

in the healthcare team or the law. Consequently, children in Nigeria are, by this law, expected to

receive healthcare interventions according to the consent of an adult.

“Ensure that the client/patient of the legal age of 18 years and above gives informed consent for

Nursing intervention. In case the health consumer is underaged, the next of kin or the parents can

give informed consent on his behalf the Nursing and Midwifery Council of Nigeria (NMCN) 2004.

Where the patient is underage (below eighteen years (18) by Nigerian law), or is unconscious, or

is in a state of confusion mental impairment, a next-of-kin should stand-in. In the absence of a

next-of-kin, the most senior doctor in the institution can give an appropriate directive to preserve

life. In special situations, a court order may need to be procured to enable life-saving procedures

to be carried out.” Article 19, Medical and Dental Council of Nigeria (MDCN) 2004.

Exceptions seem to exist as it relates to the right to consent regarding a religious belief for or

against adherence to treatment according to the Medical and Dental Council of Nigerian code of

conduct 2004. This statutory guide categorizes at what age a child can consent during a

contradictory religious treatment, but notwithstanding his right, the parents’ decision takes

precedence over that of the child.

“Article 39 Section C subsection (a) those within ages of 16 to 18 years have a statutory right of

their own to consent to procedures, and this takes precedence over parental objections but does

not invalidate the right of others to consent on their behalf. However, where the child of this age

group objects and parental consent obtained in an emergency, appropriate treatment or procedure

can be given. Section C subsection (ii) children younger than 16 but not below 13, though

considered as minors, but of clear mind and can grasp the benefits and consequences of accepting

or rejecting a proposed treatment, “Gillick-competence,” can give an acceptable consent. Section

C subsection (iii) in respect of children under 13, but the well-being of the child is paramount. If,

after full parental consultation, treatment is refused, the practitioner should make use of the law

by obtaining an order from the court to protect the child’s health interest. A child who needs blood

transfusion or procedures in an emergency should be so given. A practitioner who stands by and

allows his minor patient to die in circumstances which might be avoidable may be charged with

negligence and is also vulnerable to criminal prosecution.” Article 39, Medical and Dental

Council of Nigeria (MDCN) 2004.

As part of the right to human dignity, this necessitates that the agency of the child should be

recognized. It is pertinent to grant children the power to express their wishes, views, and opinions

in healthcare discussions and decision-making. Also, children should be confident that their

opinions will be valued and respected. Children should have the assurance that their conversation

is protected and treated ethically. According to the Nigerian Child’s Right Act No. 26, 2003, the

law forbids medical professionals from disclosing professional information shared to them by

children. The child is entitled to privacy except where non-disclosure could cause harm to the child

or society. Therefore, health professionals should be responsible for assuring confidentiality during

therapeutic discussions (The Nigerian Child’s Right Act No. 26 (NRCA) 2003).

“Every child is entitled to his privacy, family life, home, correspondence, telephone conversation,

and telegraphic communication, with the regulation of the parent.” Section 8 article 1 of the

Nigerian Child’s Right Act No. 26 (NCRA) 2003.

Respect for liberty and dignity governed by this Act encompasses the autonomous right of children

to reason and decide on issues that relate to them without coercion. The child should be free to

consent, assent, or reject an intervention as his or her thoughts and conscience permits, as stated

in the Nigerian Child’s Right Act No. 26. Therefore, health professionals ought to respect the

choices made by children and give due recognition to their cognitive ability.

“Every child has the right to freedom of thought, conscience, and religion.” Section 7 article 1 of

the Nigerian Child’s Right Act No. 26 (NCRA) 2003.

One element of the child’s right to dignity falls under the child’s right to liberty. For example, this

would involve the freedom of movement around after admission within the healthcare facility.

Children should be at liberty to be involved in recreational activities after admitted and to receive

some form of education to keep them up to date with their academic work. It is the right of the

child to be visited by friends and family and to choose visitors’ (section 6 of the Nigerian Child’s

Right Act No. 26 2003). Therefore, keeping children for any reason and depriving the child of

their freedom of movement is a form of slavery and violation of the child’s rights and dignity,

which may even predispose him or her to suicide. It is essential to provide favourable conditions

to children that allow them to live and interact as freely as possible. Likewise, in the absence of a

family member, the child should be provided with a suitable representative as per section 11 of the

Nigerian Child’s Right Act No. 26. (Nigerian Child’s Right Act No. 26. 2003).

“Every child is entitled to respect for the ‘dignity of his person, and accordingly no child should

be (a) subjected to physical mental or emotional injury, abuse, neglect or maltreatment, including

sexual abuse (b) subjected to torture, inhuman or degrading treatment or punishment; (e)

subjected to attacks upon his honour or reputation; Or (d) held in slavery or servitude, while in

the care of a parent, legal guardian or school authority or any other person or authority having

the care of the child.” Section 11 of the NCRA No. 26. 2003.

3.2 The rights of the child in research

Authority to consent to participation in health research is the responsibility of the parents or legal

guardian of the child, according to the National Health Research Ethics Committee (NHREC)

2007. A parent ought to have precise information before approving a documental consent by

writing or voice recording (Policy Statement Regarding Enrollment of Children in Research in

Nigeria, 2016).

Section B article 1, Version 1.0 of the Policy Statement Regarding Enrollment of Children in

Research in Nigeria 2016, (PS2.1016). “Enrollment of children below the age of 12 years requires

the consent of both parents or the parent that has primary responsibility for the child at the time

of research or the legal guardian” (NHREC) 2007.

In the case of older children (between the ages of twelve and eighteen), the Act provides them with

authority to assent to research. Parents or legal guardians also need to consent to validate the

decision made by the older child. Notwithstanding the age of the child, the authority to consent

remains with the parents or legal guardian, according to the National Health Research Ethics

Committee of Nigeria (NHREC) 2007.

“For children between 12 and less than 18 years, the child must give assent while the relevant

parent as described in B.1 above, and appropriate to each specific research scenario gives

consent”. Section B articles 2 and 3, Version 1.0 of the Policy Statement Regarding Enrollment of

Children in Research in Nigeria 2016 (PS2.1016).

A particular group of children who are between the ages of thirteen and eighteen called

emancipated minors (have petitioned the courts to assume adult responsibilities) can give consent

(NHREC) 2007. Consequently, according to the Nigerian Child’s Right Act No 26, 2003, they can

consent in research according to their level of knowledge and understanding.

“Emancipated minors (in case of children younger than 18 years) can give consent in their

cognizance”. Section B article 4, Version 1.0 of the Policy Statement Regarding Enrollment of

Children in Research in Nigeria 2016, (PS2.1016).

As regulated by the prescriptive norm in the Nigerian Child’s Right Act No. 26, this provides a

practical approach based on the principle of bioethics ‘nonmaleficence and beneficence’ that the

child is not to be harmed in the research setting. The researcher should respect the dignity of the

subject-child and ensure safety throughout the research. The researcher should ensure that the child

suffers no harm even after the study. It states that it is wrong for the researcher to abuse the child

during research or even after the investigation. Also, there should always be measures in place to

protect the child from current harm or future damage to the child’s integrity and dignity. The child

should be treated with respect and should have the liberty to decide what is best for them and in

their interest without coercion.

“No Nigerian child shall be subjected to physical, mental or emotional injury, abuse or neglect,

maltreatment, torture, inhuman or degrading punishment, attacks on his/her honour or

reputation.” Section 11 of the Nigerian Child’s Right Act 2003.

4. Discussion

Children’s rights, as supported in the normative documents examined in this study, recognized

children’s right to liberty, protection, and dignity when consenting to informed care or research

and confidentiality. We analyzed the voice of children normatively according to the prescriptive

text - the Nigerian Child’s Right Act No. 26, (NCRA) 2003 - the supra-legal regulations and

descriptive texts; The Medical and Dental Code of Conduct (MDCC) 2004, the Nursing and

Midwifery Code of Practice (NMCP) 2004 and the National Code of Health Research Ethics

(NCHRE) 2007 -the infra-legal standards. According to the prescriptive text, legal conduct in

health care and research with children should respect the “best interest of the child” (Section 1 of

the Nigerian Child’s Right Act No. 26 2003). However, it encouraged comprehensive health care

and research with children where children voluntarily participate according to their decision-

making capacity under adult guidance (Article 39 MDCN 2004; Section 11 of the NCRA No. 26.

2003; NHREC 2007). The descriptive text-infra-legal norm; encouraged the responsibilities of

health professionals and researchers to conduct their duties with less regard to the child’s liberty

or autonomy, if the care is in the “best interest” of the child and society.

Noteworthy, the NCRA 2003 is the national legal document that protects rights, privileges,

dignity, and liberty of the child and the MDCC 2004 and NMCP 2004 are the documents guiding

the conduct of medical doctors and nurses/midwives in Nigeria regardless of the age, sex, race,

culture or religion of the patient. Similarly, the NCHRE 2007 regulates the activities of Nigerian

health researchers. Although Version 1.0 of the Policy Statement regarding enrollment of children

in research in Nigeria, PS2.1016 (2016) is standing legislation to protect children in health

research, this document is dependant on the NCHRE 2007.

In the present article, we explored the Nigerian Child’s privileges through the standpoint

of normative and regulatory child protection documents. We assessed children’s rights in

healthcare and research from the view of determining the representation of children’s liberty,

protection, consent, confidentiality, and dignity in practice. Informing this search are works of

literature that postulates the benefits of involving children in healthcare and research. (Agu et al.,

2014; Bubadué et al., 2017; Carnevale, 2008; Carnevale, Campbell, Collin-Vézina, & Macdonald,

2015; Committee On BIoethics, 2016; Coyne et al., 2014; Folayan et al., 2015; Montreuil &

Carnevale, 2016). According to the pieces of international literature, the participation of children

in their healthcare and research has disclosed that children are moral agents with the capacity to

provide critical suggestions when given the opportunity. Recommended ways in which children

could be involved according to the studies included but are not limited to, seeking children’s

consent and protecting their information (Adejumo & Adejumo, 2009; Agu et al., 2014; Bubadué

et al., 2017; Carnevale & Manjavidze, 2016; Cashmore & neglect, 2002; Committee on Bioethics

2016; Fadare & Porteri, 2010; Kelly & Mackay-Lyons, 2010; Montreuil & Carnevale, 2016;

Coyne & Gallagher, 2011; Grace et al., 2019).

Informed consent involves a contractual ethical, and legal commitment that is established

and shared among all participants without ambiguity in a therapeutic or research setting regarding

a procedure or study. Consequentially, this established agreement between the health professional

or the researcher and the client in the form of signing the consent document containing the agreed

information (Agu et al., 2014; Committee on Bioethics, 2016; Fadare & Porteri, 2010; Katz, Webb,

& Committee On Bioethics, 2016). Informed consent in pediatrics should integrate two essential

obligations: relating explicit information to the child and his parents or legal guardian and

obtaining legal authorization on given information before any healthcare intervention or research

(Agu et al., 2014; Annas, 2009; Goldie, Schwartz, McConnachie, & Morrison, 2002; Katz et al.,

2016). The prescriptive norm identified the principle of dignity and justice to necessitate respect

for “the best interests of the child” (Section 1 of the Nigerian Child’s Rights Act No. 26, 2003),

which may be related to the right to protection for the child. Nevertheless, this is not the prevalent

practice in Nigeria, where parents or legal guardians or the most senior officer in a health care

team makes decisions (Ogunrin, Daniel, & Ansa, 2016; Ajayi & Dibosa-Osadolor, 2013; Agu et

al.,2014; Ogundiran & Adebamowo, 2012; Adejumo & Adejumo, 2009; Adi et al., 2015;

Akinwumi, 2010).

Although informed consent has been the standard practice in the health care system but

from this article, we found out that there is a need to expound on its meaning and practice within

the context of children’s health in Nigeria. This action should give a clear guide to healthcare

providers and researchers regarding the promotion and protection of children’s rights in Nigeria

and Africa at large. Similarly, it is vital to keep in confidence any consent obtained to ensure trust

between health professionals and clients for quality health delivery, but to what extent has been a

dilemma in healthcare and research with children in Nigeria.

Confidentiality implies that children and adolescents can exercise their rights by expressing

personal views according to their capacity and remain optimistic about the safety of their

commitment without fear of prejudice from the health professional or researcher (Carnevale, 2012;

Montreuil & Carnevale, 2016; Carnevale et al., 2015). As such, a medical professional or

researcher should not disclose information in therapeutic or research situations. The Nigerian

Child’s Right Act has recognized the child’s right to freedom of thought, as stated in the Nigerian

Child’s Right Act Section 7, Article 1, “Every child has the right to freedom of thought,

conscience, and religion” (Nigerian Child’s Rights Act No. 26, 2003). Nevertheless, the same law

also states in Section 19 Article 2a that “a child is subject to respect his or her parents, superiors

and elders at all times…”. This law makes it difficult for health professionals and researchers to

keep private therapeutic or research information provided by the child.

Confidentiality may also be affected when the healthcare professional or the researcher

doubts the information provided by the child according to observable evidence in the situation.

Studies showed that children and adolescents, if given the privilege, can understand, discern and

judge but are constrained by several factors that militate their active participation (Agu et al., 2014;

Cashmore & neglect, 2002; Kelly et al., 2010; Adejumo & Adejumo, 2009; Bubadué et al., 2017).

According to studies, factors that affect children’s participation include fear of causing ‘trouble’

by disclosing the origin of a problem, difficulty understanding medical terms, and fear of asking

questions to elucidate the meaning of what is needed. Others include lack of confidence in the

safety of the given information because they are not familiar with the health professional or the

researcher; lack of adequate amount of time with health professionals; having a fear of being

disbelieved; inattentive health professionals or researchers; and fear of parents’ reactions

(Adejumo & Adejumo, 2009; Agu et al., 2014; Kelly et al., 2010; Melo, Ferreira, Lima, & Mello,

2014; Ogunrin et al., 2016).

The privileges of the child as buttressed in the normative texts respect the right of the child

to dignity and liberty, as realized in the right of the child to guided judgment and voluntary

participation in healthcare interventions or research (Adejumo & Adejumo, 2009; Adi et al., 2015;

Ajayi & Dibosa-Osadolor, 2013; Carnevale & Manjavidze, 2016; Renne, 2010). Therefore,

children are supposed to have the privilege to make choices and healthcare professionals or

researchers should not influence the child’s decision or participation. Children should be able to

get involved in research or healthcare interventions voluntarily by understanding according to their

developmental capacity. Besides, children’s right to be protected should be from the collective

responsibility of the family, society, and the child. Consequently, since the Nigerian law

acknowledges the rights of the child, it should similarly inculcate that in practice. This practice,

we presume, should be enforced by law overtly in all healthcare practices and research with

Nigerian children.

The explicit inclusion of children’s voices in Regional, Provincial, and Federal laws is

principal in actualizing the children’s rights. Countries like Canada and Australia have achieved

the inclusion of the child by representative inclusion of children’s voices in child promotion and

protection programs, thereby giving children a platform to exercise their rights. Likewise, they

encourage children to relate information with regards to their health from their perspectives

(Carnevale & Manjavidze, 2016; Cashmore & neglect, 2002; Committee on Bioethics 2016; Katz

et al., 2016; Montreuil & Carnevale, 2016; Grace et al., 2019). These practices have improved

healthcare and health research activities with children in the countries, as mentioned earlier, that

are worth emulating.

This article revealed that, notwithstanding the existence of legal documents regarding the

rights of the Nigerian Child, the code of conduct for healthcare professionals and research in

Nigeria does not encourage the participation of children in discussion or decision-making within

healthcare or research settings. Also, there are very few studies on the inclusion of the Nigerian

Child in healthcare and research (Adejumo & Adejumo, 2009; Agu et al., 2014; Ogunrin et al.,

2016). A study conducted to assess the knowledge of Nigerian biomedical researchers comprising

of doctors and nurses on the “code of health research ethics” revealed that there were inadequate

knowledge and limited application of the code of ethics in practice (Ogunrin et al., 2016; Ogunrin,

Ogundirans, & Adebamowo, 2013). Similarly, other studies posit that politics, culture, and

religious beliefs contend against the rights of the Nigerian Child (Akinwumi, 2010; Ogunniyi,

2018). Nevertheless, the recognition of children’s voices requires knowledge of the child’s

capacities and benefits of including children in their care as a crucial phenomenon to respect the

rights of the child. Consequently, there should be an interaction between the legislature and

relevant societal institutions in structuring laws that possess ethical regard and promotes moral and

legal standards appropriate for healthcare and research practices. Accordingly, emphasis on

statutes that recognize the voice of children in daily healthcare practices is essential.

5. Conclusion

This article described the rights of the child in the legal premise and the expected duties of

healthcare professionals and researchers within the existing laws. Studies show that norms

regulating healthcare delivery have been in existence in Nigeria, but there has not been a clear

guide to laws that are specific to the child in practice. Also, legal principles to ethical practice in

healthcare have been generalized with only passive statements regarding judicial conduct in case

of dealing with the child.

In the present article, we normatively analyzed the norms centred on the respect of the child’s

rights as upheld by the principle of dignity and justice. The principle of dignity is realized to

suggest that the right of the child to information, consent, liberty, and confidentiality must be

protected. According to the normative treatise, regulatory text expressed respect to the right of the

child to involve the freedom of the child to participate in research or healthcare intervention as a

result of information-knowledge and willingness-consent.

6. Recommendation

Recognition of a child’s voice is essential in healthcare promotion, and this right should help

respect and protect children’s dignity.

Hence, we recommend that the code of ethical practices in the fields of healthcare and research

in Nigeria and Africa at large should be reviewed to recognize children’s participation rights in

healthcare or research. The active involvement of children in discussions and decision-making to

promote voluntary cooperation in healthcare or research presents a constructive pathway to health

promotion with children.

We also suggest that an unambiguous legal protection document that is specific to the child

should be developed to address ethical conduct in pediatric healthcare practice and create improved

awareness among relevant parties.

Lastly, we recommend that research be conducted to explore and develop strategies for

recognizing children’s voices in Nigerian healthcare practice. We are optimistic that such work

can be conducted to help redress the barriers to the protection, promotion and improvement of the

wellbeing of Nigerian children – informed by their own particular experiences and voices.

7. Limitations

A limitation of this study is that data collection involved only nursing, medical, and health research

codes of ethical conduct, excluding other healthcare and research fields. Also, there are insufficient

individualized healthcare field-level documents related to the legal protection of children in the

Nigerian healthcare system to help further support this study.

Funding

The authors funded the study with support from VOICE (Views On Interdisciplinary Childhood

Ethics) research team.

Conflict of interest

The authors declare that there was no conflict of interest.

Acknowledgment

We are grateful to our research team, VOICE (Views On Interdisciplinary Childhood Ethics), for

their valuable information that was useful in the preparation of this article.

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