Introduction
Early childhood (generally referring to the period from birth up to the start of formal schooling) is a crucial period for development (Black et al., 2017), and children need to receive nurturing care in order to develop and thrive; nurturing care includes responsive caregiving, as well as health, nutrition, early learning, safety and security (Britto et al., 2017). Children in low- and middle-income countries (LMICs) experience multiple risks that negatively impact on their developmental and educational outcomes (Lu et al., 2020), and their ability meet their developmental potential (Black et al., 2017). In addition, it has recently been estimated that 181.9 million 3–4-year-old children are not receiving adequate nurturing care necessary to diminish these developmental risks in LMICs (McCoy et al., 2022).
A key component of development in early childhood is social emotional development, which typically refers to skills such as emotional awareness (of self and others’ emotions), social skills (particularly with peers), and self-awareness. These skills are not only an important component of young (3–5 years old) children’s readiness for school, but also relates to their mental health. Children not receiving adequate nurturing care (Britto et al., 2017) are at risk for poor social emotional development. In South Africa (SA), a Majority World country (Alam, 2019; Draper et al., 2022a; Khan et al., 2022), young children’s social emotional development is seen as a valuable component of school readiness (Goldschmidt & Pedro, 2020; Munnik & Smith, 2019), but there are areas for concern. In a recent national survey of 50–59-month-old children (Giese et al., 2022; Tredoux et al., 2023), 27.5% did not meet the standard (locally derived) for social relations with peers and adults, and 33.5% did not meet the standard for emotional readiness. These social emotional outcomes were found to have a large effect on learning outcomes in the sample (Giese et al., 2022; Tredoux et al., 2023), and more recently, social emotional functioning was found to be positively associated with ‘positive deviance’ (i.e. children from low-income settings who outperform their peers) in this sample (Henry & Giese, 2023).
Evidence also suggests that young children in low-income SA settings are not receiving the stimulation they need at home to promote these developmental outcomes (Dawes et al., 2020), and that there are numerous factors at the home and community levels that negatively impact on social emotional development of young children in SA (Munnik & Smith, 2019; Zondi, 2020). Many of these factors also have a detrimental effect on the mental health of young children in SA, along with the impacts of intergenerational trauma as a result of legacies of apartheid and colonialism (Gobodo-Madikizela, 2016; Kim et al., 2021). A national survey found that adverse childhood experiences were associated with mental health challenges in SA adults, which were related to poverty and a lack of access to services (Craig et al., 2022).
The South African Child Gauge 2021/2022 (Tomlinson et al., 2022) recently focussed on child and adolescent mental health, highlighting the numerous environmental and social ecological factors that influence child mental health, as well as the critical role of families and other social supports for mitigating risks to child mental health. This report argued for the need to invest early in child mental health, and advocated for viewing child mental health on a continuum from thriving, through to struggling, and experiencing severe mental health challenges. The implications of this for early investment in mental health is a more inclusive and preventive approach that does not wait for children to experience mental health challenges before receiving attention. This report brought attention to the limited evidence of what works for child mental health in Majority World countries, and proposed a system of child mental health support that links families and caregivers with community-based services (Tomlinson et al., 2022).
Despite the importance of social emotional development and mental health of young children in SA, there are few published interventions targeting these outcomes, using strategies such as dialogic book-sharing (Dowdall et al., 2021), and play (Dawes et al., 2023; Lunga et al., 2022), drawing on the known benefits of play for children’s social emotional development (Rauf & Bakar, 2019). Furthermore, the challenges and lack of child mental health services in SA are well documented, along with the stigma and discrimination associated with mental health challenges amongst children (Davids et al., 2019; Mokgaola et al., 2022; Mokitimi et al., 2018). A regional SA study (Mokitimi et al., 2019) identified weaknesses of child mental health services, including neglect of systems, limited capacity, workload challenges, insufficient and inequitable allocation of resources, and poor implementation of early detection and preventive policies. The consequence of this poor implementation is that children are referred only when their mental health challenges have become advanced and complicated, necessitating greater resources for intervention and solutions that are more complex and long-term. Ultimately this means that parents and families have to take on the burden of preventive work (Mokitimi et al., 2019).
Mazi Umntanakho – ‘Know your child’
Mazi Umntanakho is a project supported by the Connecting the Ed-tech Research Ecosystem network (https://ceres.uci.edu). The goal of the project is to co-design, pilot, and evaluate a digital tool to assess mental well-being (specifically, social emotional development and mental health) of young children in low-income settings. Digital tools can offer innovation solutions for promoting child development and health in Majority World countries, leveraging the affordances of technology for potentially cost-effective, accessible and scalable strategies (Till et al., 2023). However it is critical that communities are involved in the development of such solutions and strategies, using methods such as co-design (Till et al., 2023). There are many definitions of co-design in relation to the development of digital interventions, but there is agreement on the collective and empowering nature of co-design, and the notion of doing this work ‘with’ rather than ‘for’ or ‘on’ communities (Bevan Jones et al., 2020; Freire et al., 2022; King et al., 2022; Till et al., 2023). Co-design approaches bring together the strengths of researchers, community members and stakeholders to enable meaningful engagement that promotes dialogue and equal contribution, ultimately increasing the likelihood that an intervention will be used and benefit the community where it is being used (Till et al., 2023).
The Mazi Umntanakho tool was initially intended for use by community-based workers (e.g., home visitors, community health workers), and therefore this project is being conducted in partnership with community-based organisations (CBOs) and community health worker programmes working in low-income settings working to address various aspects of early childhood health and development. The importance of capturing community perspectives in the co-design process of contextually relevant digital health tools in LMICs has been emphasised (Till et al., 2023). Therefore, an essential component of the co-design process for Mazi Umntanakho was qualitatively exploring CBO home visitors and community health workers’ understandings of social emotional development and mental health of young children in their communities, including risks and protective factors for these outcomes.
Co-design considerations relating to CBO home visitors involved in the initial co-design phase of Mazi Umntanakho are being documented elsewhere in work that has explored the work processes, experiences, and preferences of home visitors. These considerations included the lack of community trust, home visitors’ work-life management, and social-economic inequalities, all of which present challenges for delivering a sustainable and scalable digital tool. Building on and further contextualising this work, the aim of this paper is to qualitatively describe community perspectives of risks and protective factors for young children’s social emotional development and mental health in low-income South African settings, through the lens of the nurturing care framework. The insights presented in this paper have contributed to the co-design process of the Mazi Umntanakho tool, which will primarily be used by community-based workers, and this co-design process is being reported elsewhere. In future work, we intend to further explore the greater care ecosystem around such tools, including perspectives from families.
Methods
Study Design
This qualitative study (see COREQ list provided) formed part of the broader Mazi Umntanakho project, and specifically the co-design process to develop the tool prototype that was piloted. Qualitative methods, including focus groups, are commonly used as part of co-design processes (Freire et al., 2022). For this study, group discussions were conducted with staff of CBOs and services to obtain their input on the development of the digital tool, understanding their working context, and priority issues for social emotional development and mental health of young children in their communities. This paper focuses on CBO home visitors and community health workers’ perspectives on these priority issues.
Study Settings, Participants and Recruitment
Participants of this study were staff (total n = 154; 97% female; >18 years old) of CBOs and community health worker programmes, which are listed in Table 1, including details of the programme offered. These included home-, community- and health facility-based programmes promoting early childhood development or maternal and child health. Participants were from three urban communities, two peri-urban communities, and five rural communities across four provinces in South Africa. Only three participants were male; the predominance of females in this sample is reflective of the reality of individuals working in community-based work in SA being mostly female. All programmes are delivered by community-based workers (e.g., home visitors, community health workers, or mentors), who are typically residing in the communities in which they work.
Table 1
Focus group details
Province | Programme offered by organisation | Group | Groups | na |
|---|---|---|---|---|
Round 1 | ||||
Western Cape | 1. Home-based programme for caregivers of children not attending early care and education services, to promote early childhood development | Urban 1 (U1) | 3 | 17 |
Urban 2 (U2) | 3 | 17 | ||
Rural 1 (R1) | 2 | 10 | ||
Rural 2 (R2) | 2 | 7b | ||
Round 2 | ||||
Gauteng | 2. Community-based programme to support pregnant mothers, and mothers of young children | Peri-urban 1 & 2 (PU1&2) | 1 | 10 |
3. Community-based programme to promote health and early childhood development with young women during pregnancy, infancy and early childhood | Urban 3 (U3) | 3 | 15 | |
KwaZulu-Natal | 4. Home-based stimulation programme to promote early childhood development, and other community-based activities to promote early literacy | Rural 3 (R3) | 1 | 19b |
5. Community-based programme to promote early childhood development, including play groups | Rural 4 (R4) | 2 | 9 | |
Limpopo | 6. Health facility-based community health worker programme to promote maternal and child health | Rural 5 (R5) | 3 | 50 |
Six CBOs and programmes were recruited based on existing contacts of the SA authors (and referrals from these contacts), or were already involved in early childhood development research with the SA authors. One CBO is located in the Western Cape province. Four of these communities were included in this study – two urban (City of Cape Town Metropolitan municipality), and two rural (Cape Winelands District Municipality). Two CBOs were included that are based in small towns, and implement their programme in rural communities in KwaZulu-Natal province. These rural settings are within or in close proximity to areas previously categorised as ‘homelands’ under apartheid. Community health workers were included from one sub-district in rural areas in Limpopo province, and an urban setting in Johannesburg, Gauteng province. One CBO in Gauteng province was involved that works in two peri-urban communities within the City of Tshwane municipality. All of the community-based workers from the recruited CBOs (and communities selected by the CBOs) were invited to participate in the focus groups; no specific inclusion or exclusion criteria were applied since recruitment was intended to be as inclusive as possible. No staff specifically refused participation, although staff availability on the day (e.g. due to sickness or a family matter) for the focus groups did affect attendance.
In SA, the communities where all these CBO or community health worker groups work are typically referred to as low-income due to the high prevalence of poverty, unemployment, food insecurity, as well as substandard housing, infrastructure and amenities. These economic challenges contribute to substance abuse in these communities (Ellis et al., 2013). Urban low-income communities are typically characterised by high housing density; rural communities (particularly those close to former homelands) are characterised by more limited access to services given their remote location.
Procedures
As outlined in Table 1, data were collected in two rounds as part of the co-design process. Round 1 was conducted to gain initial input for the co-design process from one CBO; round 2 was to obtain additional feedback for this process from a wider range of CBOs and community health worker programmes. For round 1, group discussions took place over two sessions, one week apart. Given the size of some groups, these could not be accurately described as focus groups. However, despite the large size of some groups, these were facilitated in a similar way to how focus groups would be facilitated, in terms of asking open-ended questions using a semi-structured discussion guide, and encouraging participation from all group members. These guides were developed by the authors to cover a range of topics relevant for the co-design process (e.g. challenges and priorities for young children in their community, feedback on tool prototypes). The discussion guides for the focus groups are provided as supplemental material. Each focus group was facilitated by one of the research team (LW, EA, CD, CC), with another team member taking notes and providing facilitation support. The duration of the focus groups ranged between 40 min and 1 h 40 min. Questions were posed in English, with the availability of a translator in each group to translate questions and responses from local languages into English where necessary. All group discussions were audio recorded, and translated and transcribed into English by a professional transcribing team.
Ethical approval for the study was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical). All participants gave written informed consent for their involvement. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Data Analysis
A codebook thematic approach was taken to the descriptive and exploratory process of data analysis (Braun & Clarke, 2019, 2021, 2023). This is a more structured coding approach to qualitative data analysis, with some or all themes determined prior to analysis, but coding reliability is not established. The choice of this approach for analysing the data for this study was influenced by our desire for this structure, but also to align to a qualitative paradigm and non-positivist approach, drawing on the exploratory, flexible and iterative nature of reflexive thematic analysis. Furthermore, we wanted to acknowledge our subjectivity and that a ‘correct’ interpretation of data is not possible, all of which are accommodated within the codebook approach (Braun & Clarke, 2019, 2021, 2023).
In terms of the analysis process, this began with the discussion guide, which informed the initial development of some themes, as mentioned above. In the discussion guide, participants were asked to comment on relevant considerations regarding social emotional development and mental health of young children in their communities. This provided a broad range of responses, and an inductive approach was taken to identify relevant issues that came up in the discussions. This started with data familiarisation, and the lead author then developed a conceptual outline of potential themes and sub-themes, which appeared to highlight a range of risk and protective factors for young children’s social emotional development and mental health. Using the key components of the nurturing care framework (further predetermination of some themes), these themes and sub-themes were then grouped according to these components: responsive caregiving, safety and security, good health, adequate nutrition, and opportunities for early learning. An additional theme of child challenges was also identified, since these challenges provide insights into the impact of risks in these contexts. Furthermore, child challenges were grouped into internalising challenges (social, emotional), and externalising challenges (hyperactivity, behavioural), since these have shown to be a helpful framing of mental health difficulties in South African children (Aarø et al., 2022).
An initial coding framework was developed based on these themes and sub-themes. After receiving input from the co-author team, the codebook was finalised and applied to the transcripts to identify relevant portions of the text that corresponded to these codes using MAXQDA data analysis software (MAXQDA code system available as supplementary material). The coding was done by the lead author (CD), and ‘checked’ by another co-author (CC). Coded sections were then exported and summarised, and illustrative quotes were selected. Consistent with the codebook thematic analysis approach, these can be more accurately described as topic summaries, rather than meaning-based interpretive story themes (Braun & Clarke, 2023).
Researchers’ Positionality
All four researchers who facilitated the group sessions have experience conducting community-based research and qualitative research. At the time of the study, two of the researchers were based at a university in South Africa and have expertise in child development and cross-cultural research; the lead author comes from a background in psychology and public health. They identify as cisgender, White and English-speaking. The two other researchers were based at a university in the United States, have expertise in human-computer interaction, and identify as cisgender, Black, and English-speaking.
Results
Table 2 summarises the themes and sub-themes, grouped by components of the nurturing care framework, with the additional theme relating to child challenges.
Table 2
Themes and sub-themes
Themes | Sub-themes | Illustrative quote |
|---|---|---|
Nurturing care framework components | ||
Responsive caregiving | Caregiver attitudes | “Sometimes, you find that the parent is not interested, even when you come to the house, they are not in the mood for you.” (R2) |
Sensitivity to challenges | “…the community out there have this thing that we are working with children so, for them, they think their grants will be taken away or we are going to have their children taken away…” (R1) | |
Lack of connection | “that happens a lot, almost like a gap between the parent and the child, like there is a lack of communication, almost like it is hard for the parent of the child to connect.” (U3) | |
Norms and beliefs | “And the way we were raised, our mothers used to shout at us a lot… with our parents, we didn’t even know they loved us because of how they were treating us.” (U1) | |
Caregiver and family challenges | “Kids are left with grannies, you find that the granny is too old, sometimes she sleeps the whole day, and the child ends up having to look for the granny.” (R3) | |
Safety and security | Protective factors | “There are those parents that you can see really enjoy this whole thing because like they’re doing this for their children, like they’re grateful for that mere fact that there’s someone that comes and helps their child with things relating to school” (U1) |
Substance abuse | “Most of our children, they are living in families that the mother or most of the people in the home they are drinking alcohol. So they don’t have time to notice what is happening to the children.” (R3) | |
Economic challenges | “The ones that are very poverty stricken, and because of that, they don’t actually help the child grow and they are more focused on the stressful side on their life.” (R4) | |
Neglect, abuse and violence | “Some children stay in what we call horror houses. There is no electricity in there and the windows are broken…you go into the house and you cannot see anything in that house.” (U2) | |
Adequate nutrition and good health | Basic needs not met | “When the mothers are using social grant money on alcohol, clothes, beauty, and drugs, kids suffer…not having food to eat and having any clothes to wear.” (PU1&2) |
System challenges | “Because even in our clinics, our local clinics…they have this thing of saying if the child is not developing well for that age, they are going to say ‘no give it time, she will come along’…I don’t even know that there are services where you can take the child.” (U3) | |
Opportunities for early learning | Limited resources | “Sometimes they say ‘we don’t have crayons for the children, or we don’t have pencils’.” (U2) |
Caregivers’ limited education and literacy | “The children are living with their grannies. Most of the grannies who are raising their grandchildren are illiterate.” (R3) | |
Child challenges | Internalising challenges | “But when you say tell me…Tell me how you are feeling, they can’t express themselves.” (R4) |
Externalising challenges | “…this one, he will believe that everything, you need to solve it with violence, maybe beating someone.” (PU1&2) | |
Responsive Caregiving
Primary caregiving roles were played not only by the biological mother, but often by a grandmother or other female caregiver (seldom the father or other male family member). The importance of engaging all these caregivers for the development of the child was highlighted by some participants. The most dominant theme identified from the discussions was risks associated with responsive caregiving, in the sense that participants perceived that caregivers’ attitudes, knowledge, beliefs, behaviours and challenges were not conducive to the provision of responsive caregiving for their young children in these settings.
Caregiver attitudes
While participants acknowledged that they interact with a range of caregiver attitudes, they frequently mentioned negative attitudes of caregivers, which ranged from being disinterested or indifferent, to being resistant, uncooperative, inattentive, “difficult”, “negative”, “stubborn, hard-headed, lazy”, moody, unwilling to change, uncaring, or even hostile. While these attitudes were often related to the provision of the programmes implemented by the organisations, participants perceived these attitudes could possibly be directed towards their children and hence negatively influence their responsiveness as caregivers. Some participants also spoke about caregivers who had refused to take steps to obtain the help her child needed, not wanting to act on information provided, or wanting someone else to take responsibility for their children. They also mentioned experiencing caregivers not making time for or prioritising their children’s development, or not thinking it is important.
“Sometimes get in and the caregiver is not in the mood for you. Sometimes you get in the caregiver is busy with the phone’s not even answering you. Sometimes you see the kid is not in the right situation, but you can’t say nothing. The caregiver is not in the mood to answer you. Sometimes it’s rude. Sometimes. You can’t even the caregiver is right is working with you. So, it depends, you go to different people.” (U1)
“a child grows up in a very poor household, parent is distant…they don’t even have interest in the child’s upbringing or education…we work with the parent, we try and redirect the parent’s mindset on how important it is for education at an early age.” (U2)
Numerous participants mentioned how some caregivers’ motivation for being part of their programmes seemed to be conditional on what tangible reward or incentive they would receive, beyond the benefit of promoting their child’s development. While these comments were mentioned in the context of poverty and food insecurity in these communities, this attitude was viewed by participants as unhelpful.
“Yes, even when you go for a visit, they will ask: “what am I going to get out of this?” and then you have to sit there and explain that it’s for the benefit of the child.” (R2)
Sensitivity to challenges
Related to caregiver attitudes, many participants mentioned caregivers’ sensitivity to hearing about or dealing with any challenges relating to their child’s development, beyond what could be considered a typical response of a caregiver to view their child in a positive light. Some mentioned caregivers’ concerns about being judged for the care they give their child. Participants thought that this could lead to them not being honest about their child’s challenges (or development in general), but also to being suspicious about being reported to government authorities. Some of this sensitivity could be linked to what participants mentioned about caregivers not understanding child development more generally, or more specifically to developmental challenges, social emotional development, and mental health.
“For me, I must say that in our communities, people have got those beliefs, so because you have been working with these communities for a long time, and we have tried to interact and some of them, they are very difficult to accept, maybe like, if the child has got the behaviour like bullying other children, if the people who are working with the child are trying to talk about it, the parent doesn’t receive it well, and then sometimes they just take their child out of the program and they say I will keep my child at home.” (R4)
“Do you know that when you ask the parents too many questions, they’ll tell you that you want to report them to the department of social development?” (R2)
Lack of connection
Some participants spoke about the lack of connection they observed between caregivers and children, which included caregivers not showing love, paying attention to, or spending time with their children, as well as not communicating (talking and listening) or connecting with their children. A few participants mentioned that in their setting, showing love to children was perceived to mean providing for their basic needs: “take them to school, to the clinic when she’s sick…” or “the child needs food and that is that. You have eaten, go to bed. You have bathed, go sleep…” Given the pervasive economic challenges within these communities, it is possible that the equating of love with meeting basic needs is seen as socially normative, and may be a response to the chronic (and intergenerational) trauma of living to survive in the context of food insecurity and safety concerns.
“These challenges that we are talking about, where children end up facing but are unable talk about them. Parents must give themselves time to spend with their children. They must give themselves time to talk to their children. When they see that something is upsetting their children, they must talk to them with love and find out what is the problem. In this way a child will be able to express themselves. When parents shout at their children instead of opening up and being comfortable, these children end up being scared and hold and unable to express their feelings because parents are always angry at their children. They should show love to their children, build a relationship and bond with them so that their children can be more comfortable and express themselves. If they don’t have a good relationship with them, children come across problems along the way but will not tell their parents because are not paying attention to them, they are always busy with other things.” (R5)
Norms and beliefs
Some participants’ comments indicated that harsh parenting was seen as a norm in these settings, and something passed on from previous generations. Linked to this, the norm of children being ‘seen and not heard’ in these settings was mentioned, suggesting that children may have limited agency.
“Maybe it has to do with the environment where they black community grows up in, that an adult is always an adult, and a child is always a child. So you can’t just say or feel like communicating what you want to communicate with the parent, because of that age gap. But then we have found a lot parents that find it weird that a child would ask certain questions where it is something that the child is curious about.” (U3)
“We don’t have inside us to care for children because even if the child comes with wanting to show you, if you are busy washing dishes you can say I’ll see that later and even later you don’t bother to say okay show me that paper…” (R3)
Other participants mentioned related norms in their communities, including limited emotional awareness or expressing emotions as being common amongst caregivers, and that they perceived caregivers in some settings do not consider emotions (and mental health) to be important. This too could be related to the intergenerational trauma common within these communities where the de-prioritisation of emotional awareness could be a way to survive in contexts where there are limited to no resources for help.
“…I can’t remember my mom saying to us I love you, so it wasn’t easy to say it to my child because I didn’t receive that as a child…I think even when we were young we were not allowed to express our feelings because if you try and express your feelings that you show that you are rude to the family, I think uh we grew up like that and now it’s just a shame to share feeling they think no this child is being rude now, you’re not supposed to say that to me because I am an adult…there’s not the luxury of expressing emotions or even the cultural appropriateness of doing that.” (R3)
Another cultural belief that came up was regarding certain conditions and disabilities being related to witchcraft, or being some kind of punishment. Related to norms and beliefs, many other participants spoke about the stigma attached to disabilities and developmental challenges, and also to mental health in their communities. Participants shared how they had observed this stigma led to some caregivers isolating their child if they had one of these challenges.
“There is a stigma…that is why they don’t want to stand up and find help for their children, probably you have been bewitched.” (U3)
Caregiver and family challenges
From the discussions, it was clear that participants perceived caregivers to be experiencing numerous risks to their own emotional wellbeing and mental health, including challenges with their family environment. Risks included a lack of awareness of the importance of mental health, stress, a lack of social support, and “social problems”. A number of participants mentioned caregivers experiencing depression.
“For them it’s nothing it’s not important and they are not aware that if their mental health is not okay that actually starts affecting their actual health. So most of the participants or people in [community name] as a whole are not really aware their emotions, they don’t know the importance of mental health, it’s nothing hectic to them, it’s nothing hectic to them.” (U3)
“Another challenge is that I would have problems at home, but I can’t share them with anyone because they get scared that you will tell everyone even though one can see that they are troubled, they keep quiet.” (U1)
Family challenges mentioned by participants included the absence of fathers, or fathers who are perceived as not wanting to be involved in their child’s caregiving. However, the ways in which female caregivers prevent fathers from being involved was also raised. Other challenges mentioned were frequent changes in caregivers (due to caregivers moving to other areas), the absence of biological parents, or very young parents. This can leave grandparents to take the caregiving responsibility, and sometimes these grandparents were not perceived to be well equipped for this role due to age. Participants experienced some grandparents as resistant to changing their parenting practices, or not keen to engage in the child’s development; some were reported to take over from the young parent if they felt they were not competent.
“I think one more thing I just remember is the lack of or totally non-existent participation of a male caregiver, so your daddies are rarely in the pictures, so it is really difficult, especially groups, to get the male caregivers to get them to join in. For them, it is more, I give the money, you know, I give me, that is my responsibility, and it stops there.” (R4)
“I think some of the challenges that are challenging the children with their mental wellbeing, it is some of them, they get, they live with the caregivers, their mothers are not around, and then they don’t get the special treatment that they should get from their real parents, actually, their biological parents, so their treatment from the caregiver and the biological parent is not the same, so they struggle with playing with other children and being comfortable with other children.” (PU1&2)
Protective factors
In relation to responsive caregiving, protective factors were mentioned far less frequently by participants; these related to participants’ own observations and experiences (e.g., as home visitors), as well as the responsive caregiving displayed by the caregivers with whom they work. Participants spoke about recognising the importance of the relationship and bond between parents and children, and how they can promote positive interactions between caregivers and their children. A few participants talked about caregivers who understood the importance of early stimulation, and of spending time with their child and showing an interest in their development. Some mentioned positive attitudes (“forthcoming”, “excited”), as well as changes that they had observed in caregivers’ attitudes and their increased enjoyment of activities with their children, as well as aspirations for the child’s future. A couple of participants noted that sharing their own experiences with caregivers and role modelling care for the children they work with helped to shift these attitudes through listening, observing, motivating, and learning.
“Parents who don’t use substances, they take more of an interest, they care about what we do where the child is concerned…the parent will go the extra mile and ask if there’s anything they can do to help…the mother spends time with the kid, sitting with the kid and explaining…if the mother maybe forgot or doesn’t understand in that moment, she will give you a call and say, ‘listen here, I am struggling with this thing, can you please explain it to me?’” (U2)
“No, with the positive parents, even if they are strict, you can find a way to change them…some of them they do listen and change their attitude towards the problem…even if financially they are not stable, they do become positive parents because you can motivate them. You can tell them your life story or explain briefly about the programme. And you’ll see that this person has a dream for her child, and she sees the vision behind this, and they cooperate with us.” (R2)
Safety and Security
Substance abuse
Participants discussed numerous risks to young children’s safety and security that could negatively impact their social emotional development and mental health. By far the most commonly perceived risk to young children’s safety and security discussed across all groups was substance abuse. This mostly referred to alcohol abuse, and seemed to be across a range of caregiver ages, from young mothers to grandparents. In one of the communities, drug abuse was mentioned to be particularly prevalent; a participant referred to “drug dens” and “drug houses” in their community. The main impact of this on children was perceived to be abuse and neglect of children, in terms of not providing for their basic needs, and not giving their children the love and attention they need for optimal social emotional development and mental health. Some participants described their perception of the reliance on substances as a way for mothers to cope without social support, or to deal with the stress of their lives, which when consumed in pregnancy, contributes to foetal alcohol syndrome and “drug babies” observed in some communities. They commented on how they see these risks contributing to a cycle of poor mental health between caregivers and children.
“I think our challenge is more like alcohol abuse, the parents are drinking a lot of alcohol, whereby they don’t take care of their kids because there are lot of taverns there, they want those sugar daddies to give them money, so they tend to leave their children with their grandmothers or maybe the caregivers.” (PU1&2)
“I would say it’s substance abuse and alcohol because uhm, since we live in the township, almost everyone drinks and parties, so, you’ll find that maybe when you visit a home on Monday, you can see that the child is really hungry. Maybe, they didn’t even bath for the whole weekend, they had no one looking after them. So, when you get there, you can tell that the situation is not well.” (R2)
“So that is where then those parents who have challenges end up drunk because they are trying to…calm the stress that they don’t know how to solve. They go to the shebeen looking for anything that they can get in order for them to forget the situation for the child, it’s not good.” (U1)
“We have our drug mothers and fathers, and they are just not there. Seriously speaking when we come there even after 11:00 those houses still look like a bomb hit the place. It is not swept, the carpets are still dirty, the dishes are still there, the children are still in their pyjamas, and they are so black when their pyjamas used to be pink, but it is now black.” (U2)
Economic Challenges
Economic challenges were frequently discussed in relation to risks to the safety and security of young children in these communities. These included poverty, high rates of unemployment, as well as seasonal employment in the Western Cape rural area, largely characterised by wine and fruit farming. Many families rely on social grants, but these are generally not seen to be sufficient to cover a child’s basic needs as well as the fees they need to pay for preschool or “creche”, which is not available for free in SA. As a result, in many of these low-income communities, children do not access these services. A further risk to accessing necessary services discussed in some groups was the lack of birth registration of many children. Apart from the impact of poverty on caregivers’ ability to provide for their children, one participant also spoke about the alienating effects of poverty on children, which would have a detrimental effect on their social emotional development. The contribution of poverty and unemployment was also mentioned as a factor contributing to substance abuse.
“Another factor is poverty. It makes the child to isolate themselves and feel out of place. It becomes difficult for them to interact with other children because when they compare their situation with that of their friends, theirs is not good and usually begs food or things from others.” (R5)
Part of the economic challenges in these low-income communities mentioned was the housing situation for families. This included high numbers of people living in a home, which they observed to put a strain on resources within the home; the cramped living conditions were also seen to expose children to safety risks. Other risks mentioned were the fires that can easily break out amongst less formal living structures (“shacks”), and the lack of basic amenities in homes within these communities.
“We have got families where, like in one room, you will get 14 staying in one room, the other day, she told me she found a family of 25 living in two rooms or something, it is just difficult, and then that is when all these problems come in.” (R4)
Neglect, abuse and violence
As mentioned above, participants maintained that substance abuse contributes to the neglect of children. Some participants also spoke about children being left alone without adult supervision, or placed in situations that are not safe. Abuse was mentioned often in discussions, and described by participants as a norm in some communities, also in relation to substance abuse. This included physical, verbal, mental, and sexual abuse, experienced by both children and caregivers. Harsh parenting came up often in discussions as well, specifically physically hitting children as punishment, and shouting at children, although some changes in these practices were mentioned.
“…children always play far from at home, they didn’t notice that the children they must be close from where they are. Sometimes the children came with that they are playing for the whole day without giving them something to eat and the children came late at home.” (R3)
“I think most children, they experience so much abuse in their communities, and sometimes at home. So I think the challenge is, they grow up with this, thing, knowing that this is what is around us, and they don’t really know how to express themselves because they get used to abuse, it becomes a norm in their lifestyles, so as they grow up, I think it affects their emotional wellbeing because they turn up to be those abusive children as well, or bullies, because that is what they are used to at home, that is what they see at home, most of the time.” (U3)
“Some of our clients were not aware that they are abusing the children, until we came and said you don’t hit your child…your child was born not knowing anything, so you need to redirect the child from wrong to right, in a nice way. But in a harsh way, the child won’t understand anything.” (PU1&2)
Participants also spoke about domestic and community violence as common in their communities, with the effects being seen by them in both caregivers and children’s mental health, apart from the obvious risks to their physical safety. These risks were relevant for participants who live and work in these communities as well. In some communities, this violence was described as more prevalent, with armed robberies and shooting being commonly reported. This can be linked to gangsterism, which was reported to start from a young age in some communities. In one of the particularly violent communities known for drug abuse and gangsterism, some of the participants in one group pointed out the intergenerational trauma experienced in these communities.
“This child witnessed the rape and murder of his sister. After his sister was killed, this child used to walk around the house looking for his sister. He got affected emotionally and was always crying. He could not express himself verbally, when there were people around the house and hungry, he would just hit and push them in order to get their attention.” (R5)
“a lot of our parents and grandparents had trauma previously, way back and it still affects them, so we are dealing with that as well…Like psychology of trauma and psychology of living in an environment like this, violence…especially PTSD…they shot somebody there by us and for the first time I saw what a person looks like dead, who has just been shot now…so a lot of people go through that trauma where maybe a mother and a child both get shot at the same time maybe they just knocked them with a bullet and so on. But still it’s a trauma or the gun just goes off while children are on their way to school and guns are going off, so that does affect them.” (U2)
Adequate Nutrition and Good Health
Basic needs not met
The main risk to young children’s health and development in these communities perceived by participants was the fact that their basic needs were often not being met, which is concerning in light of participants perceptions that some caregivers’ views that showing love was tied to meeting these basic needs. These needs include basic nutrition, clean water, hygiene, clothing, and access to decent health care. The main threat to nutrition discussed in all groups was food insecurity leading to hunger, which were reported to be highly prevalent in all communities represented. In some cases, this was seen to be exacerbated by substance abuse.
“Some parents do ask us, ‘don’t you give something because I’m not working and I have these children; there’s no food, there’s no porridge, there’s nothing’…sometimes you give from your own pocket because you can see the situation, so you give them porridge from your home.” (U1)
“We have children who are 2 years old and they are not bathed for the whole week, sometimes for a month. They walk the whole day just like that or the same nappy that is flapping at the back, or sometimes children under the age of 5 have to go to what we call, skarrel [hustle] they have to go and look for food.” (U2)
System Challenges
The prevailing view of participants from all groups was that there are insufficient services within the public health system to cater for children with developmental and/or mental health challenges. Or that the service received at health facilities was not helpful and did not prioritise early intervention. Some participants mentioned the referral system that did not work as intended in their communities, which meant that help was not obtained for children who need it. These were described as particularly challenging in rural locations, which were geographically further from available services.
“Say for instance my child that is in need of one of these that is not at our clinics and I need a referral letter to…hospital, I’m just not going to go because I don’t have the money, I don’t have the finances to take my child there, so then I don’t go and then obviously it’s going to influence my child negatively in the future because this is the help that she needs but I can’t afford to give to her.” (R1)
Opportunities for Early Learning
Limited resources
In light of the economic challenges mentioned previously, some participants highlighted caregivers’ lack of resources. These included electricity, internet and smart phones to stay in contact with their home visitor, and resources for their children’s early learning, such as books, toys, and crayons.
Caregivers’ limited education and literacy
A number of participants mentioned caregivers’ limited education levels (due to limited opportunities), which they perceived to have an impact on caregivers’ willingness to engage with the programmes, and hence with young children’s opportunities for early learning. In the rural communities, historical inequities have contributed to a legacy of illiteracy amongst older adults who were not afforded the opportunity to learn to read and write.
“We have very little parents who have matric…it is rural, it is poor, and education levels are low…within the communities that we work with, illiteracy is still a big issue.” (R4)
“Sometimes you do get parents who left school, maybe in grade 6 or an earlier grade and they do not have the experience that the children experience at school.” (R1)
Based on participants’ responses regarding caregivers’ understanding of the importance of early childhood development, it would seem that these inequities and the consequent levels of education and literacy have had a negative impact. While participants mentioned a few instances of caregivers understanding of the importance of early childhood development, it seemed more common for participants to perceive caregivers having limited awareness of how early childhood development lays the foundation for later learning, and of their role in their child’s early development. While financial constraints were the reasons cited by participants for many caregivers not sending their children to preschool, participants pointed out that it is just not a priority for some caregivers.
“And sometimes we have parents that say: “I want my child to go to the ECD [early childhood development], but I can’t afford it, but I appreciate the fact that you are willing to help”. So, you do get parents like that, parents who understand that this child needs a foundation for Grade R.” (R2)
“We have got parents who doesn’t understand the word ECD, they think that it should be at the preschool…last I was at a centre, you see parents don’t even care, they just drop off the kids and then come back and pick up.” (PU1&2)
Participants also voiced their perceptions of caregivers’ limited understanding about what helps to promote or harm this development. One of the harms mentioned by a few participants was excessive screen time, which was seen by some as another indication of caregivers’ lack of engagement in their child’s development.
“…the child is looking at the cartoon the whole day, just staring. They just stare, sometimes they’ll sing along as they watch, or they’ll sing the rhyme to you or whatever they hear…it also affects their vocabulary because they don’t know, it’s not like talking face-to-face. They just listen, watching, listening, watching and it keeps them calm, that’s what the parents think but here, in the mind-set, it doesn’t help them with anything for the mind, you see. There’s a point where their cognitive imagination is going haywire because now, they’re playing in a group, they can’t socialise with other children.” (U2)
Child Challenges
While the detrimental impact of the risks mentioned above of children’s social emotional development and mental health are mentioned or at least implied in the preceding sections, participants mentioned more explicitly some of the challenges they have observed in children as a result of these risks.
Internalising challenges
A few participants mentioned social challenges experienced by children in their communities, namely not wanting to share with others, not having friends, having difficulties making friends, not wanting to play with other children, not being able to play with other children, or not being able to interact with peers in a positive way. Far more participants mentioned children’s emotional challenges, and spoke of children in their community being “emotional”, “sad”, and “struggling”, and some highlighted how children had difficulties articulating their emotions. Participants noted that many children were quiet or “shy” to open up or speak about their feelings, but that they were able to pick up that these children were having emotional difficulties. This was because children were observed to be withdrawn, agitated, or sometimes had a physical reaction, e.g. shivering or shaking in the presence of a certain adult. Participants linked these internalising challenges to the way children were treated at home, in terms of a lack of attention, neglect, abuse, harsh parenting. The negative impact of maternal mental health was also mentioned as a contributing factor, along with the lack of stability experienced by some children, and their exposure to substance abuse.
“It is their upbringing, so it started at home, how the child is raised also affects the child, most of the children, they don’t open up, they don’t show emotions, not because they don’t feel, or they don’t get raised, sometimes it is because of how they were raised, that you are supposed to be strong, and you just carry on.” (U3)
“If you look at circumstances in and around houses then you can pick up. You can see for yourself something…mostly, in most houses there are parents that are drug addicts, and you can see what impact it has on the children because, there is that one house…you can see the children are neglected. So, they definitely are impacted and under emotional strain but because they were not talking, we will not know.” (R1)
Externalising challenges
Some participants spoke about children being hyperactive, which in some cases was believed to be linked to drug abuse during pregnancy. It was mentioned that some children do not listen, which could relate to hyperactivity. Behavioural challenges were mentioned more frequently, and included bullying, tantrums, fighting, and resorting to violence to solve problems or get what they want. Linked to these behaviours, some children were also described as rude, rebellious, unruly, angry, and “naughty.” In a couple of communities, it was mentioned that children resorted to stealing because of hunger at home.
“The child plays harshly with other children. When you reprimand the child, the child will be doing the same thing after 2 min. The child acts the way they want, they don’t listen to anyone and screams when they don’t get what they want.” (R5)
“Others who don’t have food at home, become thieves, because if they come to the house and see everything there, they are going to take something, in order to help their mothers.” (U1)
Children’s treatment at home was perceived to lead to these externalising challenges, and it was frequently mentioned how young children copy what they see at home, specifically shouting, fighting, swearing, and even imitating drinking and smoking. One participant pointed out how you can see what is happening at home by the way children engage in imaginary play.
“Another challenge could be because of the abuse that they may experience at home, it could be verbal or physical. This will make the child not to have friends or finds it difficult to make friends. Let’s say parents are constantly fighting at home and swearing at each other in front of the child, when he goes out to be with his peers, he hit other children and swear at them.” (R5)
“They will always ask ‘Why are you like this? Why are you so rude?’. And the child will tell the mother ‘Because you did it with me so why must I be nice to someone else?’. I do not know how to do that. I do not know love and respect because you never gave it to me. (R1)
Discussion
In this study that qualitatively explored the perspectives of community-based workers in a range of low-income SA settings, these community-based workers perceived risks to the social emotional development and mental health of young children appear to far outweigh protective factors for these critical aspects of their development and well-being. The only protective factor that was identified from the data related to responsive caregiving, which aligns with the emphasis on its importance in the provision of nurturing care (Britto et al., 2017). In this study, this included caregivers spending time and communicating with their child, showing engagement and warmth, enjoying their interactions, and being aspirational about their child’s future. The participants for this study clearly played a role in promoting and modelling responsive caregiving, drawing from their own lived experience.
In terms of the risks identified, participants reported seeing the impact of these on the well-being of the children with whom they work, particularly in terms of social, emotional and behavioural challenges. These findings align with global evidence of the multiple risks that children in Majority World countries such as South Africa experience that negatively impact on their development (Black et al., 2017; Lu et al., 2020; McCoy et al., 2022), and adds to local evidence on the numerous social ecological factors that are having a detrimental impact on the social emotional development and mental health of South African children (Munnik & Smith, 2019; Tomlinson et al., 2022; Zondi, 2020), as well as concerns about South African children’s social emotional development (Giese et al., 2022) and mental health (Mokitimi et al., 2019).
From the perspective of the participants of this study, there were risks experienced across all domains of nurturing care, which align with the social ecological factors identified in previous work in this context (Tomlinson et al., 2022). While substance abuse emerged as the most common issue perceived to be threatening the safety and security of young children, participants’ responses evidenced the ways in which this issue intersects with (and sometimes causes) other threats to safety and security, including the abuse and neglect of children, economic challenges such as poverty, unemployment, and housing challenges. Substance abuse is known to be particularly problematic in South Africa (Ellis et al., 2013; World Health Organization, 2018), and the interaction between substance abuse and other social and economic problems, along with the impacts on children’s development (e.g. from prenatal exposure to alcohol and/or drugs) are well documented (Ellis et al., 2013; Fontes Marx et al., 2021). These social and economic risks relate to the difficulty observed that many caregivers struggle to meet the basic needs of their young children, and hence limit their ability to provide adequate nutrition and promote good health. System challenges were also seen as a contributing factor for children with developmental and/or mental health challenges not accessing the help they need for good health, and the challenges and lack of appropriate services were previously highlighted (Davids et al., 2019; Mokgaola et al., 2022; Mokitimi et al., 2018, 2019).
The risks relating to responsive caregiving mentioned by participants are particularly complex, and at first glance, their perspectives paint a dismal picture of caregiving in these communities. Most of the participants (especially home visitors and community health workers) reside in the communities where they work and thus are very aware of the contextual realities and experience many of the same challenges experienced by the caregivers with whom they work. Given participants’ membership of the communities in which they work, it is extremely difficult to disentangle their own childhood experiences and their experiences working with caregivers and children in these communities. A ‘benefit’ of this entanglement is that they shared lived experiences with caregivers and children, and are uniquely placed to understand the challenges they face. This, combined with their experience of working with young children and caregivers in these communities, lends at least some legitimacy to their framing of the negative caregiver attitudes and sensitivity to challenges they experience with caregivers, the lack of connection between caregivers and children and caregiver and family challenges they observe, and the norms and beliefs they have noted and likely have experienced themselves.
However, it is possible that participants’ perceptions of risks relating to responsive caregiving may be due to a mismatch between the services provided by the participants and the CBOs they represent, and caregivers’ priorities and needs. Further research with caregivers is needed to explore this potential mismatch in greater depth. In addition to this, this framing of negative attitudes should consider that these individuals (community-based workers) have likely already undergone somewhat of a shift in perspective in terms of the importance of providing nurturing care (even if not specifically referring to the nurturing care framework), and of early childhood development. This could potentially make it difficult to work in home situations where caregivers are still in the process of making this shift, or where there are significant constraints that make this shift feel impossible (and potentially irrelevant in light of other challenges) for some caregivers. Such constraints highlighted in this study include caregivers’ education and literacy, and their understanding of the importance of early childhood development (or lack thereof); it is possible that these caregivers have never known a different way of caregiving, but have reproduced caregiving practices that they received as children and observe in their community, including harsh parenting; harsh parenting has been associated with exposure to community violence in previous work in these settings (Cook et al., 2022). These realities may also make it difficult for many caregivers to appreciate the benefit of promoting their young child’s development as a sufficient incentive for their participation in a programme, without something more tangible and material, particularly in light of their often-desperate economic circumstances. These considerations further underline the importance of the relationship of trust that is built between community-based workers and community members, which has already been emphasised in previous work on this project, in order to navigate these realities and shifts.
The relevance of intergenerational trauma in these South African contexts (Gobodo-Madikizela, 2016; Kim et al., 2021) has already been noted. Linked to this, the impact of trauma on behaviour change has been recognised, in that individuals battle to make changes that have long-term benefits when they are living to survive in the short-term (Marks et al., 2021), including in South African settings (Draper et al., 2022b). This has relevance for caregivers finding it difficult to change their behaviour to promote their child’s development in the longer term (although some short-term changes may well be apparent), when they are faced with the difficulties and trauma of everyday life in their communities. Furthermore, in this study, intergenerational trauma has been offered as a possible explanation for equating love with meeting basic needs and the de-prioritisation of emotional awareness, and was pointed out by a participant in relation to exposure to violence.
More specifically, the intergenerational transmission of trauma provides a helpful lens through which to further understand the issues mentioned above regarding caregivers. Many of the risks that came up in this study could be classified as relational trauma (e.g., substance abuse, neglect, abuse, caregiving disruptions, parental mental illness) (Isobel et al., 2019). The sociocultural model of trauma transmission provides some explanation of this study’s findings, as it maintains that the process of trauma transmission is through social norms that are passed down through social learning, including observation and imitation, as well as understandings that are learned about self and the world (Kellermann, 2001). This could help to explain some accounts of children copying the behaviour they see within their community, persisting norms, abuse and neglect, harsh parenting, and a lack of connection between caregivers and their children.
However, Isobel et al. (2019) argue that “intergenerational transmission of trauma is not an intentional, harmful act”, and that just as there can be transmission of trauma, there can also be transmission of strengths. This provides some hope for the contexts of this study, in that caregivers are, for the most part, not deliberately depriving their children of the nurturing care they need. And there was evidence presented of responsive caregiving that was observed, along with the recognition of the importance of early childhood development, showing that change is possible in these low-income contexts, with some insights into possible ways in which change could be accomplished, such as through maximising caregivers’ loving relationships and enjoyment of activities with their child, and aspirations for their future. This echoes findings from previous qualitative work in similar settings in South Africa (Draper et al., 2023). Isobel et al. (2019) also emphasise that prevention of transmission of trauma is key, and this has to involve resolving caregivers’ trauma, and supporting the caregiver-child relationship, while acknowledging the complexity of the social and systemic influences on prevention of trauma transmission (Isobel et al., 2019). The need to intervene early and preventively to address child mental health in South Africa was previously highlighted, particularly to reduce the burden on caregivers and families (Mokitimi et al., 2019; Tomlinson et al., 2022). These are critical considerations for intervening in the South African context to improve social emotional development and mental health outcomes in young children; this has to be done taking these intergenerational effects into account, but recognising the transmission of strengths as well. In South Africa, these strengths could include community support, as well as caregivers’ recognition of their role in their young child’s development, which has been identified in previous research in these contexts (Draper et al., 2023). In light of the systemic challenges faced by young children and their caregivers, and given the potential for promoting warm, positive caregiver/child relationships shown in this study, an emphasis on responsive caregiving could be an actional target with known positive effects (Britto et al., 2017) for early intervention in these settings.
The strengths of this study include the large sample from a range of diverse, urban and rural settings in South Africa, as well as the approach of partnering with CBOs to capture community perspectives. The fact that most participants were home visitors or community health workers could be viewed as a limitation of this study, as it presents perspectives from one sector of the broader range of voices on risks and protective factors for young children’s development and well-being. In addition, our focus on social emotional development and mental health could be viewed as narrow considering the other important components of early childhood development and health. However, given that these outcomes have received limited attention in South Africa, we believe the depth of this focus is a strength rather than a limitation.
In conclusion, there is an urgent need to mitigate risks and amplify protective factors for the social emotional development and mental health of young children in South Africa. It is critical that these risks and protective factors are considered within the contextual realities of low-income communities, and especially the intergenerational transmission of trauma. Further research to better articulate factors specific to the SA context influencing young children’s social emotional development and mental health would be valuable. This could include a more detailed exploration of equity issues, intergenerational trauma, and the contexts of colonialism, racism and other systems of oppression faced by children and families in low-income communities. The insights gained from this study in the SA context may have relevance for other Majority World country settings where similar risks and protective factors are present for young children, as well as in low-income contexts in Minority World countries.
Supplementary information
The online version contains supplementary material available at https://doi.org/10.1007/s10826-024-02929-5.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
Ethical Approval
Ethical approval for the study was obtained from the Human Research Ethics Committee (Medical) at the University of the Witwatersrand (Ref: M200104). All participants gave written informed consent for their involvement. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
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