All children deserve equal rights and opportunities to grow and develop to their potential. The Declaration of the Rights of the Child 1924 stated that “the child, by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth.” Children's rights at the international level have been enshrined in the Convention on the Rights of the Child (CRC) 1989, which >196 states agreed upon (Tobin, 2019).

Afghanistan ratified the CRC in 1994 and recognized children's rights in its national laws. According to Article 52 of Afghanistan's Constitution, “the state shall provide free preventative healthcare and treatment of diseases as well as medical facilities to all citizens under the provisions of the law .” Align with CRC, this country has adopted a law on children's rights and the responsibilities of the state, society, and parents about children. The law has recognized children's rights to life, health, food, education, nationality, identity, non-discrimination, and care. The right to health entails access to health and rehabilitation services, vaccination, social assistance, the prohibition of selling and the use of drugs by children, and protecting children from violence, exploitation, and neglect (Afghanistan Parliament, 2019).

Poor economy, widespread poverty, unstable political system, poor public governance, pervasive violence, insecurity, lack of infrastructure, internal conflict, and displacement are the main challenges in Afghanistan. The poor public health system suffers a shortage of trained healthcare providers, particularly women (Rashed, 2023). This system is fragile because domestic healthcare spending is low and dependent on foreign funding. According to the World Health Organization (WHO), many health indicators, including child mortality, are highly worrisome in this country. (World Health Organization, 2019).

Children constitute half of the population of Afghanistan (UNICEF, 2023) and have been disproportionally affected by the country's socio-economic conditions. Child poverty has led to the deprivation of basic needs, such as healthcare, food, and welfare. UNICEF indicated that 13.1 million Afghan children required humanitarian assistance in 2022, while 1.1 million under-5 children are malnourished (UNICEF, 2021a, UNICEF, 2021b). Afghan children are experiencing physical violence, malnutrition, displacement, poverty, the loss of family members, hazardous labor, and harmful social norms and practices.(Shoib et al., 2022) Notably, children living in rural areas, girls and younger children are deprived the most.(Cousins, 2022b) The combination of global economic sanctions, lack of sustained donor support for health, and economic collapse severely decreased children's access to quality healthcare in recent years.(Cousins, 2022a) Restrictions on women's movement and work contribute to less access of children to healthcare.(Narain et al., 2022) Today, more children are out of school and at risk of early forced marriage.(Cousins, 2022a; Neto et al., 2022).

Based on national and international laws, children's rights must be realized in all children-related settings, such as hospitals (United Nations, 1991). In recent years, this issue has received increasing attention. Child and Family Centered Care (CFCC), as a healthcare philosophy, acknowledges children as rights holders with their perspectives, experiences, and needs. They should be allowed to participate in decisions affecting their health and well-being. Children's voices as healthcare consumers are critical to improving health outcomes and quality of care (Foster et al., 2023). Some healthcare providers, particularly nurses, play pivotal roles in fulfilling children's rights as they are the primary point of contact for patients and have the opportunity to build relationships, allocate resources, advocate children's rights, and educate and support others to respect the rights. Foster and Blamires believe that “healthcare providers' attitudes and beliefs, time constraints, organizational culture, communication channels, and lack of training are some of the barriers that can prevent the full implementation of CFCC” (Foster & Blamires, 2023).

The European Regional Office of WHO provided a manual supporting countries in fulfilling children's rights in hospitals. The manual covers the main aspects of children's rights and is used as an assessment tool to translate the rights into practical principles and action plans (WHO Regional Office for Europe, 2017a, WHO Regional Office for Europe, 2017b). Little is known about children's rights in the hospitals of Afghanistan This study aimed to assess the situation of children's rights in one of the largest public hospitals in this country and to draw recommendations for improvement.

For assessing children's rights in the studied hospital, a cross-sectional survey was carried out in 2021. The hospital is a regional and non-military hospital with 490 beds and is located in Herat City. Herat is the largest city in Afghanistan, with an estimated population of about 636,000 (Macro Trends, 2021). The study population comprised hospital managers, physicians, and nurses in the mentioned hospital. A randomly selected sample of 142 participated in the study. The inclusion criteria were having two years of work experience in the health system, particularly pediatric facilities, and being willing to participate in the study.

The assessment was done using a manual and questionnaire developed by the European Regional Office of the WHO to assess children's rights in hospitals. The questionnaire consists of seven primary rights categories with several sub-categories (WHO Regional Office for Europe, 2017a, WHO Regional Office for Europe, 2017b). They include quality services for children, equality and non-discrimination, play and learning, information and participation, safety and environment, child protection, pain management, and palliative care. The tool was initially designed for self-assessment through discussion groups with parents, children, health professionals, and hospital managers and for filling out checklists . In this study, minor changes were made to the checklists to make them self-administered. So, a structured multiple-choice questionnaire was prepared on the track of the original work of WHO (WHO Regional Office for Europe, 2017a, WHO Regional Office for Europe, 2017b) that consisted of 90 questions. The assessment tool was available in English but translated into the local language for implementation in Afghanistan, and its validity and reliability were evaluated and peer-reviewed. Five Afghan health experts Assessed the content validity of the questionnaire. Ambiguous words and sentences were corrected, and finally, there was a consensus on the latest version. The internal consistency of the questionnaire was assessed using the opinions of 30 healthcare professionals. The stability, balance, and homogeneity of the questions were measured based on the results obtained from the two test stages and retest with similar individuals and by calculating Cronbach's alpha. The Cronbach's alpha value in this study was 0.87, which is an acceptable value and indicates the instrument's reliability.

In the study, the questions were scored with five option Likert Scale (including very high, high, medium, low, and very low) in addition to none and “I have no idea”. The mean score of each dimension was calculated to analyze the data. The final scores were presented in 4 categories, including significant progress (3.75–5), meaningful progress (2.5–3.75), some action (1.25–2.5), and no action (<1.25). Independent t-test or Mann-Whitney was used to compare the total scores of two-dimensional variables such as gender according to the normality of data. Analysis of variance was used to compare the total scores of multivariate variables (such as education level, age. and work experience).

This study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Iran (reference number IR.MUMS.REC.1400.094). Informed consent was acquired from all participants after the purpose of the research was explained to them and their probable questions were answered. They could withdraw from participating in the research at any time. The principles of confidentiality and research ethics were followed.