INTRODUCTION

The creation of the Colombian Institute of Family Welfare in 1968 strengthened the policy of supporting Colombian families in improving child care. Many assistance programmes for poor families were introduced: Traditional Community Homes and FAMI Homes (Familia, Mujer, e Infancia, FAMI) were explicitly designed to support child rearing by providing food and education. In 2012, the National Strategy for Comprehensive Early Childhood Care, named From Zero to Forever (Cero a Siempre), ¹ was developed to establish a series of intersectoral initiatives for early childhood treatment, also, some programmes include child rearing as one of their central topics. The health sector participation in this policy focuses essentially on caring for pregnant women through the Early Detection of Pregnancy alterations Programme² and a programme aimed at children under the age of ten called Early Detection of Growth and Development alterations in Children under the age of Ten³. As their names indicate, both programmes are focused on disease prevention and health care in these populations, from a biomedical perspective. A thorough review of their technical guidelines shows that child rearing is not explicitly included, although there is an important educational process in this regard. Child rearing is not identified as a priority topic for public health in the various public health plans developed in recent years, including the Ten-Year Public Health Plan 2012 - 2021 ⁴.

Education in the health sector programmes mentioned above takes a traditional and transmissionist approach, which imposes the knowledge and meanings of child rearing derived from scientific discourse ⁵, especially from the discourse of children’s rights ⁶. Based on this knowledge and their own cultural values, health professionals have the power to determine which meanings are ‘true’ ^7,8 and thereby pass judgement on the quality and appropriateness of popular knowledge and practices with regard to child rearing ^5,9.

But is there such a thing as correct child rearing? What does that child rearing consist of? Starting from the hypothesis that child rearing is a historically, sociologically and ontologically complex process ¹⁰, there is clearly no single version of ‘correct child rearing.’ Moreover, it would be problematic to define this, especially unilaterally by an expert; one should at least ask the sort of child rearing valued and feasible for the people involved.

Another question that arises from inquiries about caregivers in these programmes is: What are the opportunities(that is, what social, material and personal support do caregivers have to carry out the type of child rearing they value? Health professionals often make requests with regard to child rearing without understanding what this means for caregivers nor knowing the material conditions in which child rearing takes place ^5,11. This question arises from a concern for social justice, but given that there are multiple views on this subject, one must also ask, ‘What sort of justice are we talking about?’

This article presents the partial results of a research project aimed at understanding how child rearing takes place among families living in a settlement made up mostly of forcibly displaced people by the armed conflict in Colombia. The project sought to undertake a process of research and education that would strengthen social mobilization and create better opportunities for people flourishing and child rearing. It focuses on the meanings that child rearing has for caregivers who participated in the thematic investigation circles in order to develop more pertinent health education activities with regard to child rearing.

METHODS

An action research project designed to gain knowledge useful for those involved was developed, with the objective of seeking new ways to understand reality as a crucial step towards transforming the participants and their realities. This work of research became a driving force for praxis, in a process of reflecting on practice in the light of theory, as a dialectical relationship between them ¹². The emerging process is based on a problematizing and dialogic educational dynamic: ‘Every thematic investigation which deepens historical awareness is thus really educational, while all authentic education investigates thinking’ ¹³.

The project was conducted in the most isolated sector of a settlement on the outskirts of a municipality near the city of Medellín, Colombia, as a component of a primary health care project conducted by the School of Medicine of the University of Antioquia. With almost 20,000 inhabitants, this is the largest settlement of displaced people fleeing the armed conflict and violence in Colombia. Approximately 70% of the inhabitants are displaced people and the rest are ‘homeless’ because their economic circumstances make it impossible for them to afford rent and utilities ¹⁴. The sector is home to approximately 300 families.

The proposed methodology is an adaptation of the work of Paulo Freire ¹³, Lola Cendales ¹⁵ and the guidelines for participatory action research projects produced by the Pan American Health Organization ¹⁶. The research-education-action processes are completely intertwined and based, in turn, on three sub-processes that interact simultaneously and continuously ¹³:

The project was evaluated by the National School of Public Health’s technical committee on research and by the ethics committee of the institution (Act No. 2014-1722 of 22 January 2015).

Two settings were established to conduct the research and education processes. One of them was in the settlement and called ‘Thematic Investigation Circles’ ¹³, it consisted of the formation and consolidation of two groups between 10 and 16 caregivers interested in participating, after an invitation and presentation of the project to the 33 families with children under the age of five through a home visit. Written informed consent forms were handed out, and the participants had an opportunity to discuss this consent with their families. Participants were told they could withdraw at any time without any consequence and they were informed about the procedures for ensuring the confidentiality of their identities and what happened in the meetings. They also made an internal promise of confidentiality. The groups remained open during the study period, and some caregivers left while others joined; the criteria of informed consent, confidentiality and voluntary participation were always met.

In the groups, which met every two weeks for 24 months, the participants presented and discussed their own upbringing and lives as children, their experiences with child rearing before coming to the refugee settlement (for those who had become mothers before their arrival), and their current approach to raising their children. The topics addressed arose from the group discussions (in accordance with the concept of thematic investigation).

The other setting consisted of the research team meeting to reflect on their findings regarding child rearing and the educational practices carried out in the circles (the educator as a researcher of his or her own educational practice). Meetings were held in weeks alternating with the meetings of the thematic investigation circles and they served as spaces for continuous analysis and preparation, in an emergent process of research and education. The processes of analysis and reflection were also carried out in the thematic investigation circles. The team consisted of an epidemiologist physician and two paediatricians from the School of Medicine (one of them with a master degree in collective health), a public health paediatric dentist from the School of Dentistry, a public health sociologist from the Department of Social Sciences, a social sciences doctor from the National School of Public Health and two doctoral students of Public Health (a nurse and a physician). Six participants of the circles were invited to be part of the research team.

The information was recorded in field diaries that were coded and categorized according to the topics that emerged, at the same time the thematic investigation circles were being developed. A story that integrated the findings into a vision of totality was written and discussed with the participating women, which that contributed to the process of collective analysis. We understood data analysis form a praxis perspective, considering coding as a crucial process to reflect collectively about child rearing beyond the technical aspects of data management.

RESULTS

The childhood experiences of the women in the settlement occurred in expelled displaced families, the consequences of poverty that allowed meeting only the most basic needs. Besides, the armed conflict left death and displacement in their teenage years, in both rural and urban contexts. They lost their homesteads, and with them, their social and family ties, customs, cultural roots and few possessions, which infringed their rights. Violence was frequent within their families, including physical abuse, punishment, sexual abuse, child labour and serious verbal and emotional abuse, which made them expeller families. Many of these women ran away from home and established relationships with boyfriends or husbands at a very young age, only to become mothers abused by men, living in severe poverty, often worse off than in the families they had fled.

I remember my mother used to beat me very hard with sticks, whips and belts. Once, she threw me to the ground and put her foot on my neck so I couldn’t move and she could hit me. She punished my sister in the same way. We did not die because our neighbours defended us from those punishments.

These women arrived at the settlement with their families, seeing it as a final refuge where they could obtain a lot to build their house, and hoped to rebuild their lives in a less violent environment. Since the settlement is a marginal illegal land encroachment, these women cannot count on any help from the State regarding solutions to supply basic needs such as drinking water, education, health care or roads. Moreover, criminal gangs control the public order and impose their own social rules, including extortion, violence and drugdealing, among others. Despite the adverse circumstances, these conditions are often better than the conditions in the places from which they fled; for this reason, they say the settlement ‘takes everything from them and gives them everything.’

Here I don’t live fearing a stray bullet. Where I lived, there were shootings every time and my mother, scared to death, shouted at us: ‘Go and lock yourself in a room, close all the doors!.’

We did not have a home before. I love the shanty I have now. I love my stove, even though it has only one burner that is working.

I lived in a hole, getting here helped me get out of my in-laws’ house and my husband’s mistreatment. I changed my life!

The settlement has programmes run by state institutions and by national and international NGOs. However, these restricted programmes are unable to recognize the women’s limited circumstances and particular needs or to provide sufficient support to carry out the type of child rearing they value, such as providing a ‘good road’ that would make it easier for women to get a job, health care and education. The difficulties are worsened by mistrust among the women, who come from different regions of the country and have complicated histories of displacement and violence, making them fearful of forming bonds and creating support networks for child rearing.

These women are responsible for the care and education of their children because of the instability of the relationships with their partners or because, according to them, those partners were irresponsible and now they have to raise their children alone. In other cases, even when they live with their partner, the prevailing male-dominant culture assigns women the role of raising the children. Some of the women report that their partners have affectionate contact with their children, although they still delegate much of the responsibility for their children’s care and discipline to the mother.

When one has to raise them alone, it’s very difficult. That’s hard! I think I will not be able to cope because I have to take responsibility for everything. Everything! Everything! Everything! If they lack money, if they get sick, if they brush their teeth, if they go to school, if there is food…

In this context, the constraints create a conflict between searching for better alternatives and resignation, which takes a paradoxical form in the women: they do not lose hope in ‘moving forward’ with productive initiatives or community projects, among other things, but they still feel frustrated by the difficulty of finding more options for themselves and their children. Very few of them have employment opportunities due to their low level of education; also, the transportation conditions between the settlement and the downtown area presents a challenge. Those who do work must leave their children in the care of grandmothers, sisters or neighbours. Many of the women decided to take care of their children rather than looking for a job as they considered it would not be worthwhile to have a low-paying job without access to social security benefits -many times in conditions of exploitation- if that meant leaving home very early in the morning and returning late at night. Besides, they considered it dangerous to leave their children alone because of the violence in the settlement.

Additionally, some women have problems with the fathers of their children, who provide no financial support for the children’s care, sometimes to such an extent that the children do not have any food. The feelings of anguish and worry grow when they have to care for several children in overcrowded conditions, overburdened by work and the challenges of disciplining the children. Some women recognize that they end up ‘blowing up,’ shouting at and mistreating their children, which they later regret. Their worries and problems put them on an emotional rollercoaster that makes it difficult to express their love for their children.

The economic situation overwhelms me. Sometimes I am very angry and I explode with them. I am going crazy! I don’t want to live! I don’t know why I am in this world. I would like to change, but I feel my mind tight with so many problems. I am very tough with them.

There are times I say, ‘I want to run and give these children away.’ Then I say, ‘no! I can’t leave them! I would die before leaving them because I love them’.

Without the support of fathers or others in their child rearing, some of the mothers walk a great distance on difficult and steep paths to take their children to the child development centres (CDCs) or schools, where children receive food and care. Some of these women have informal jobs in the settlement, others get by with state aid, and some even resort to strategies such as selling their hair or gathering leftovers to feed their children. This is an indicator of the effort they make to get ahead in a setting where opportunities are so scarce, and it is an expression of the love they bear for their children.

Mothers and grandmothers recognize that they have some family or institutional support for their child rearing, including people who help them with child care; some mothers even resort to leaving their children in institutional care as an option to protect their children and keep them out of the hostile environment that surrounds them. The state-run programmes generally provide assistance on specified conditions, such as demonstrating that one is poor or someone in a displacement situation, or they must attend other programmes (for example, the Growth and Development Programme). They also have other types of pressure, for example, those from the Colombian Institute of Family Welfare (CIFW) that question how the women care for and discipline their children, there is an imposition of standards for child rearing, children’s diets and ‘appropriate’ expressions of affection, such as touching and hugging.

They teach us guidelines for rich people. They say I have to give her fruit, vegetables, lots of fish and meat. However, if I give her an apple of $600 pesos she stays hungry. Instead, with $1,000 pesos, I can buy a tortilla with egg and hot chocolate that satisfies her.

This imposition occurs through a verticallyoriented and biomedical-based education that judges their forms of child rearing. Pressure from the CIFW becomes even stronger because they have the power to assume guardianship of the children and take them away from their mothers if they deem the children’s rights have been violated. This creates great fear among the mothers, who are afraid of punishing their children or taking them to the Growth and Development Programme because they may be accused of violence or negligence and may lose their children if the children do not have the expected weight and height. These fears are a product of the stories told by neighbours and relatives who have lived traumatic experiences with this institution. Moreover, these programmes, which are childfocused in nature and designed to consider the treatment of children, ignore the needs and experiences of these women.

When I look at the calendar where I have the appointment written down I get stressed. One goes there forcedly, because they threaten you with the CIFW; if the child is very thin or very fat, they put you on a report list. They always concentrate on the bad.

The last time I went, I was told I was under surveillance by the ICBF. I’m afraid they’ll take my child away from me. I didn’t come back.

Moving beyond these problems, through an alternative learning process, the women of the settlement were able to reflect on their child rearing, finding greater love for themselves and recognizing that ‘for our children to be okay, we have to be okay.’ During the discussions, they identified the weaknesses in their child rearing practices constrained by the difficult material circumstances, but they also recognized that they are strong and tenacious women in spite of the adverse circumstances they face in their lives. Within the framework of this process of dialogue and collective reflection, they have sought to correct their ways of disciplining their children, and although they are aware of the difficulty of doing so, they have made specific changes in their relationships with their children and their partners.

I talked to my husband and told him that he was very cold in his treatment with the children and me. Since then, he cares more about us and goes out with us on the weekends.

My world changed, before I wasn’t even able to speak in public. I feel better, more relieved.

As with most caregivers, they want their children to be happy and they want to be able to care for them. They want better economic conditions in their lives and more support for their child rearing in order to dedicate more time to their children and better express their love for them. In a context of such limited opportunities, the women consider their children to be the ‘motivating force’ of their lives, seemingly almost their only way to realize their human potential, an expression of the injustice they experience.

Before, I was kept confined to my home. I felt empty, I didn’t care about anything. I wasn’t happy. My life made sense when I got pregnant.

Thanks to my children, I am alive. I have moved away from bad company. Now I work and live for them.

DISCUSSION

All care givers have an ideal of child rearing that stands at odds with external social and cultural demands as well as with internal demands of a subjective and emotional nature ¹⁷. But what are the chances that the mothers in this context be able to provide the kind of child rearing they would like to? This question refers to a concern for social justice, which in this case entails three dimensions: the structuralmaterial, the symbolic and the cognitive. The analysis will take into consideration that there are diverse theoretical, ethical and political concepts of social justice and incorporate some elements of different theories of justice to advance the discussion.

First, one can speak of a structural-material justice, adopting some elements of Rawls’ ¹⁸ and Sen’s theories ¹⁹, as well as some of the criticisms that have been levelled against them. According to Rawls ¹⁸, one must count on just institutions that shape a well-ordered society and guarantee everyone sufficient primary goods to carry out the life projects they value. These primary goods include income and wealth, power, rights and duties, employment and the social bases of self-respect ¹⁸. One must also consider the way these rights are defined ²⁰ and decisionmaking processes ²¹. According to Sen ¹⁹, the equality that is promoted should focus on the capabilities of the individuals rather than only on the nature of institutions; with these capabilities seen as opportunities to fulfil the life a person values, which requires not only primary goods but also certain personal abilities or functioning. One must then consider the concrete individual in a specific socio-culturally and politically situation. But one must go beyond an individualist and voluntary view (rational choice) because the triad of liberty, agency and responsibility has been employed by the neoliberal discourse to release the state from its social responsibility, thereby shifting responsibility for poverty to the individual him- or herself ²². Similarly, Marxist critiques ²³ show how injustices, rather than being a flaw in the social institutions of capitalism, are the product of a historical process that sustain privileges and oppression precisely by means of capitalism.

From a structural-material perspective, the conditions of insoluble extreme poverty, the various types of violence these women had suffered, and their forced displacement by the armed conflict, constitute a flagrant violation of their human rights that have drastically limited opportunities to satisfy their needs, develop their potential, flourish as humans, lead a dignified life and raise their children on their own terms.

The policies and programmes of caring for children and poor families, based on neoliberal conceptions tied to late capitalism and designed to fight poverty, maintain the unjust status quo because of the persistent conditions that produce poverty rather than diminishing it ²⁴. These policies and programmes are based on strategies of targeting on poor people and made up of minimal biological packages that require the recipient to accredit the condition of being poor and meet other requirements (negative rights, ^22,25), such as registering the child in the public records office, attending the Growth and Development Programme, and vaccinating the children, which themselves become barriers to accessing social welfare assistance. They are also based on theoretical concepts such as social risk management and human capital ²², which entail a fragmented, causalistic and functionalist idea of social reality ^26,27; this prevents the social and cultural determinants of human behaviour to be faced ²⁸. In this way, a neoconservative conception of justice is consolidated, grounded in utilitarian and radical liberal assumptions (distant of an egalitarian perspective), which ends up making individuals responsible for their own circumstances and releasing the state of its social responsibility (each to his own fate) ^22,29. This situation is exacerbated by the growing corruption and problems associated with the governments’ representative democracy ²⁴.

This structural-material injustice is leveraged by a symbolic injustice accomplished through various means. First, one must consider the power the state exercises over the population to guide individuals’ behaviour, a process Foucault calls ‘governmentality’, which produces a modelled liberty where the individual ends up acting in accordance with one of several models of possible action ^22,30. In this way, by means of symbolic power, a limited conception is imposed on human needs and poverty, as well as on the social responsibilities of the state, by which they take on a connotation of service instead of rights. The ‘discursive front’ made up by state initiatives, the media, NGOs and transnational organizations to impose certain meanings on the rights of children ⁶ based on northern-hemisphere views of childhood and child rearing, that are accepted as almost naturally superior, with very little criticism ⁶, together with the disciplinary biomedical discourse, as well as knowledge, practices and values held by the dominant classes (and specifically by the professionals working in social welfare programmes), form the parameter by which child rearing in subaltern communities is judged. The child rearing that takes place in these subaltern groups is deemed insufficient, inappropriate or harmful ^5,9 and is, thus, stigmatised and devalued. The education that takes place in the social welfare programmes must be understood not only as the dissemination of knowledge that the women lack, but also as tools for controlling and imposing meanings on child rearing ^5,8,31. Taken to the extreme, these discourses create pressure (including, even the threat of removing the children from the mother) that become new barriers to accessing public services. In this way, the dichotomy between the public aspect of child rearing (the control) and its private aspect (the responsibility of the family, specifically of the woman) ³² is consolidated and delves deeper into the stigmatization and exclusion that affect the self-recognition of these women ⁹. The struggle for justice is also one for recognition, not only for material rights ³³.

A particular type of symbolic injustice is cognitive injustice ²⁴ meaning that popular knowledge, arising from these groups’ tradition and experience of child rearing, is invalidated in the view of Western scientific knowledge ⁵. The fact that these mothers are able to raise their children ‘the way they can’, rather than the way they ‘wish to’, in very challenging socioeconomic conditions of extreme injustice, constitutes valuable knowledge that professionals involved in social programmes, especially within the health sector, disregard or simply cannot perceive because it is judged based on scientific-disciplinary discourses ³⁴.

CONCLUSION

This research shows how actions in health education should not be separated from the analysis of social justice. Ignoring the conditions in which these women are living their lives, (and in this case, raise their children), the meaning of it for them, and the ways in which scientific knowledge imposes practices, knowledge and values, without considering common-sense truth, experience and traditions, results in compounding the stigmatization and exclusion of these subjects and groups. Therefore, it is necessary to analyse how the actions proposed in health education and social welfare programmes from a biomedical point of view and marked by a neoconservative trend of justice, functional to neoliberal perspectives, can perpetuate injustice.

The development of policies and programmes in the field of public health should move beyond the biomedical model and a traditional approach to education to pave the way for proposals that recognize the knowledge, practices and values of communities and individuals living in circumstances of extreme injustice. While it is true that they need to have their rights protected from violation and need just conditions to flourish as human beings, it is also necessary to recognize them as worthy and capable people. In addition to developing relations based on cognitive justice, taking an ethical stance in this sense is key to promoting an education based on dialogue within the framework of a problematizing dynamic that can strengthen critical thinking ³⁵. In that way, both, participants and health professionals, can arrive at a better understanding of the social, cultural and political conditions that constitute injustice. Hence, health professionals do not miss the opportunity to learn from those with whom they interact to provide a relevant education that promotes the transformation of the individual to advance social change.

Finally, child rearing can be addressed as a key category on health education theory and practice. Viewing child rearing as an ontological, social, cultural and historical complex, drives the development of a transdisciplinary perspective and promotes an approach that goes beyond the biomedical model’s focus on disease. As the mothers who participated in this study pointed out, they need to ‘be okay’ and strengthen their ‘love for themselves’ to engage in the kind of child rearing they value, which implies going beyond child-centred approaches. Child rearing therefore requires addressing health in terms of the human being, society and culture to ensure a good life, the life they value.

FUNDING

This work was supported by the University of Antioquia [“Convocatoria Pública Programática 2014: Área de Ciencias Sociales, Humanidades y Artes”]; and the Research Development Committee of the University of Antioquia [Proyecto No. 20141722 in accordance with Rector’s Resolution 39827 of 24 February 2015 of the University of Antioquia].

COLLABORATIONS

FP coordinated the research, the text writing and review. DB participated in research, analysis, text writing and review. All researchers participated in research, analysis and review.