In this study that qualitatively explored the perspectives of community-based workers in vulnerable settings, 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), 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 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. This, combined with their experience of working with young children and caregivers in these communities, lends 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, this framing 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 (Williams et al., In review), 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, Mabena, et al., 2022). 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., 2018). 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 vulnerable 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., 2018). 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 vulnerable communities, and especially the intergenerational transmission of trauma. Given the limited number of published interventions in South Africa targeting social emotional development and mental health of young children, the Mazi Umntanakho tool has the potential to contribute valuable evidence and insights into ‘what works’ for digital interventions addressing these outcomes in a way that supports caregivers and links them with community-based services, as has been recommended (Tomlinson et al., 2022).