Primary caregivers perceptions of the role of fathers in the provision of nutritional care in a resource constrained environment in Cape Town, South Africa

Background : The role of fathers has traditionally been defined as a breadwinner or provider, with men generally having lower levels of engagement in childcare tasks, especially with young children. The involvement of fathers has important consequences for child well-being, especially with regards to issues of diet/nutrition, exercise, play, and parenting behaviours. This paper seeks to explore the perceptions and limitations that primary caregivers have on fathers’ provision of care in a resource constrained community in South Africa. Methods : Data was collected through in-depth face to face interviews, with a sample of 10 primary caregivers in a resource constrained community in Cape Town, South Africa. Results : The findings reveal that there is a lack of involvement from fathers in the provision of nutritional care and that this affects mothers and grandmothers who then need to provide both the physical and emotional care to their children. These findings are based on the perspective of mothers and grandmothers and their perceived roles in the family. Conclusion : The level of lack of financial involvement from fathers has dramatically affected the participating family’s food security due to only one member in the household earning below minimum wage. This has therefore meant that the dietary needs of the family are not being met with nutritional foods, but instead by high fat and high sugar content foods. The findings also highlighted that primary caregivers want to be taught about health and nutritional food choices for a limited budget.


Introduction
Traditionally the role of fathers has been defined as breadwinner or provider with men being less involved in tasks with their younger children. (1). Father involvement has many needed consequences for the well-being of children specifically with regards to issues of diet/nutrition, exercise, play, and parenting behaviours (eg, reading, discipline) 3 (2).
Family studies have concentrated on the influences of maternal responsibilities or combined data of both parents (3). However, there is a lack of studies on the influence of fathers to inform an understanding of the independent effects of fathers on young children's health behaviours (3). This scenario is likely the result of older and traditional ideas of parental roles where mothers are considered caretakers with fathers seen as the breadwinners and head of the house (3). The involvement of fathers in parenting has been associated with greater positive outcomes in child development on a cognitive and sociobehaviour level. As a result there is a positive improvement in preterm infants weight, breastfeeding rates, higher receptive language skills and higher academic achievement (4). It is important to note the global increase in the lack of involvement of fathers in children's lives and the effect it has on them (1).
In 2013 South Africa's an estimated 14 Numerous reasons have been reported which affect where fathers are able to stay and why they do not live with their family such as Unemployment, poverty, income inequality, gender power, consequences of intimate partner violence, masculinity ideologies, migration and abandonment (6). Globally, it is estimated that the average time women spend daily in caring for the home and children is three times what men spend, but this varies dramatically across settings (7). An analysis of data from around the world found that the ratio of women's time spent on unpaid work (family caregiving) to men's is much greater in low-and lower-middle income countries. This difference shows that poverty exacerbates gender inequalities in unpaid care, with the poorest women who spend the most time on unpaid care (7). The provision of care from fathers needs to be seen in the context of unpaid care as well.
The provision of childcare in South Africa has been described quantitatively using data collected in Time Use Surveys (TUS). To date, two Time Use Surveys have been conducted, in 2000 and 2010. In both surveys it showed that women spent considerably more time on childcare than men. The 2000 TUS found that among adults (aged 21-55) who live with at least one child, women spend an average of 5.9 hours per week on childcare compared with 0.6 hours by men (8). Similar gender differences are identified in the more recent 2010 survey, where the average amount of time that women spend on childcare is more than eight-times greater than the time spent by men (9).
In South Africa there are low rates of parental maintenance for children and alarming rates of gender-based violence especially that of neglect and abuse of children by men (10). South Africa has one of the highest rates of violence against women in the world, second highest rate of father abuse in Africa, with its neighbouring country Namibia being the highest (11).
There are also racial dynamics when it comes to the presence of fathers in the household.
Across South Africa, Black African fathers have the highest rate of absence from their households at 41.92% (9). In the Western Cape specifically, Coloured fathers are most affected (due to the higher Coloured population), with 20.91% of fathers not being present , or living in in their household (10). Black African fathers were second followed by White fathers with 14.46% and 2.21% fathers not present and not living in the household (10).
Absent fathers create problems ranging from broken families, aggressive behaviour among children, economic and social problems and in some cases extreme poverty (5). The 5 absence of fathers results in most households being run by single mothers and grandparents (11), who are often reliant on the state's social security system. South Africa's extensive social security system includes a monthly Child Support Grant (12) with the number social grants increasing exponentially over the past twenty three years: from an estimated 4 million in 1994 to 17,4 million by October 2017 (13).
Socioeconomic inequalities in childhood are linked to both childhood and adult health inequalities (14). These inequalities are particularly closely associated with deficiencies in nutritional and health status based on diet quality (15). Diet quality is consistently associated with health problems such as obesity, type II diabetes, cardiovascular disease and several cancers (16). Recent research highlights the high cost of nutrient-rich foods and the low cost of nutrient-poor foods, which impacts diet quality and health. Parents end up having to negotiate food purchases on a limited budget (15). This in turn lays the foundation for the feeding practices parents then adopt.
The relationship between parental feeding practices and children's eating patterns described in the literature largely pertains to the practices and attitudes of mothers as the primary caregiver, with minimal focus on fathers (17). Mothers usually have a greater impact on the development of children's eating behaviour as they tend to be more involved in food-related decisions and the preparation of meals (17). Unhealthy food preferences by mothers (e.g., consuming fast foods, sweets and higher-energy fluids)as well as the availability of non-nutritional foods at home, were found to be responsible for children's preferences when it came to the consumption of these types of foods (17). Such indicates that maternal obesity is a substantial predictor of childhood obesity. It is crucial to acknowledge that fathers' attitudes and practices may also contribute to a child's health and the development of eating habits, although mothers and fathers may differ in their strategies (17). 6 Approaches to feeding used by mothers and fathers vary depending on a variety of factors., Personal weight-related experiences, perception of their child's BMI, or the parent's beliefs about gender differences regarding dieting and physical attractiveness are some of these factors (17). Child obesity research shows greater focus being made on the role of mothers and mothering, with less attention placed on the influence, roles and responsibilities of fathers in the provision of the family's food availability and choices (18). Data from the South African National Health and Nutrition Examination Survey (SANHANES) indicated that 28% of South African households were at risk of hunger and 26% experienced hunger in 2012. Undernutrition among children was high, with the prevalence of stunting being 27% of children under three years. Around 6% of children under 14 were recorded as being underweight and of these children about one in a hundred severely underweight (19). On the other end of the scale, 19% of children aged between two to five were classified as overweight and 5% were classified as obese in 2012. At six to nine years these results dropped slightly, but at ten to 14 years 17% of children in the survey were overweight and nearly 6% were obese (19). Pivotal to this research, the SANHANES study found that it is mostly women who shop for groceries and that the most important factor for women when purchasing food was the price as well as distance for travel to shop. Health was a lesser consideration for most shoppers, especially when men shop (19). The current research study therefore focused on the perceptions of mothers and grandmothers on the provision of nutritional care provided by fathers to their children in a resource constrained community.

Methodology
This research aimed to develop parental nutritional guidelines to improve nutritional knowledge and feeding practices for children. In this study we selected a qualitative approach to gain a deeper insight into the lives of our target group. This study used a 7 qualitative interpretivist research method (20) to explore how the mothers and primary caregivers experience fathers' provision of nutritional care in a resource constrained environment. This allowing for understanding and interpretation, with which the researcher's personal experiences and knowledge could be applied. The interpretations of the researcher were vital to bring "such objectivity to the fore as well as quality of arguments instead of statistical exactness" (1).

Study participants were mothers and primary caregivers in Manenberg, in the Western
Cape Province, South Africa, who care for children between the ages of 3 -18 years old.
The township of Manenberg was chosen because it was a resource constrained environment. It was established in 1966 at the height of the apartheid regime's forced removal programme. Located 20km from Cape Town city centre, Manenberg struggles with gangs, drugs and high unemployment (21). The 2011 census shows its population at over 61 000, of whom 85% were identified as Coloured and 10% as African. Of this population, 40 452 are 'working age' . Amongst this working age group, 35% (13 962) were classified as employed, 20% (7 923) as unemployed, and 46% (18 567) as 'not economically active.' 61% of households have a monthly income of less than R3200, and 38% a monthly income of R1600 or less (22). With regards to Coloured men, who were the target population of this study due to the mothers and grandmothers interviewed, there is limited contemporary research. Research that has been undertaken has focused on Coloured masculinity as violent, uncaring, and absent (23-26).
In order to recruit participants for the study, letters were sent to three local schools, regarded as safe zones by the community, with less likelihood of gang related violence. Of these, one school reported back in the required time period that mothers and caregivers 8 were willing to attend interviews. On the day, 15 mothers/ caregivers (grandmothers) arrived, however, five participants had to leave early, and three mothers that had confirmed did not participate due to gang violence the night before. A total of six grandmothers and two mothers where interviewed. Table 1

Data collection
Interviews included open-ended questions about respondents' perception of care, difficulties and barriers to parenting, grocery shopping and meal patterns, foodprovisioning priorities, fathers constraints and ideals; and the role of fathers in their children's lives. Questions focused on, but were not limited to, the children in the target age range (3-18 years old). If children fell outside this range, questions centred on the child closest to it (this happened 3 times). An interview schedule was used to guide the interview process. The questionnaire included a set of questions on parent/caregiver-child relationships and parental/caregiver involvement in personal matters and saturation was reached. The interviews were conducted in a mix of English and Afrikaans and were recorded and later transcribed verbatim by the interviewer.

Data analysis
A thematic analysis was carried out on the transcribed interviews to identify patterns or themes (27), with the findings sorted according to their themes. A table was used for the grouping of main themes and the sub -sequent breakdown of sub -themes. Additional information was presented using direct quotes from the participants and from supporting literature.

Results
The results in this study focus on mothers and grandmothers' perceptions of fathers' provision of care in relation to nutritional care. There were five themes identified, with each having either two to three sub-themes. Key parts of these findings focused on parental care in general -how mothers perceived care by fathers, healthy diets, as well as resources for nutritional support for mothers. The participants were vocal in the interviews, with some highlighting the effect of gangsterism and drugs on their family environment. Through their participation in the current study, two primary caregivers received information for social services in the area that could provide support to the families.

The perception of care
The results show that all 10 participants were able to provide a

Father's involvement in care and nutritional provision
Participants reported that fathers' involvement in providing nutritional care and support for their children was limited. This is due to many of the fathers being unemployed or not living with the children. When this occurred, they did not make any provisions for financial support. This lack of financial support often means that mothers and grandmothers need to borrow money or go to bed hungry, which had occurred more than once in the last 6 months of the interviews being conducted. Some participants highlighted food insecurity in the communities as an everyday reality. Other participants became emotional and angry when speaking of the lack of support from the fathers. "There is no money at times, he is not working so we have gone to other family members or somebody, we try and make a plan. Sometimes if there is not enough, we will go without as long as the children eat something and not go to bed hungry. But there were times when we had nothing to eat because we did not have any work and we couldn't ask any more people. I felt bad. The children eat at school in the morning at the feeding scheme. I just eat what I get, or eat a packet of cheap biscuits with tea, as long as the children eat a meal.
But everyone is suffering and always saying there is no food or just a little in the house, there are so many people in the area borrowing money and food that at the end of the month you have to pay so much back to those you borrowed you have to borrow again. I do not even know where some of the children's fathers are. So maybe they do not care." (Grandmother: age 57, diabetic, Participant 10, seven children -ages 7, 10, 12, 15 , 17 and 21 years old.) One mother noted that her husband, although unemployed, cooked and did the household shopping while she went to work as a street cleaner.
"My husband is not working so it is almost like he is standing in for me at home. I feel like I need to emotionally support everyone in the house, as they all come to me for everything. He takes care of the house work and cleaning while I go to work so it is like we changed roles for the last few months but you can see it is taking its effect on him, as he always used to provide for the family. Now my husband buys the food, but not really a big shop, not a monthly shop. Just when there is something that is needed at the corner shop.
There is not really money for a big shop." (Mother: age 39, Participant 6, three children -ages 7, 10 and 16 years old. ) Another mother noted that the father was unemployed but did make an effort to find food and care for them if the monthly contribution she brought home was not enough for their 13 basic nutritional needs.
"Their father is in the house, but he does not work now. And so I am the only one who is working. I make about R750 a month which does not stretch very far into the month. The father makes sure that if there is no food in the house that he goes out and looks to borrow or ask somebody else so that the children can eat. He enforces the discipline in the house. He is caring to the needs of the family and I think at this point he is a little depressed as he has been trying to find work." (Mother: age 39, diabetic, Participant 2 , seven children -ages 3, 6, 10, 13, 19, and 22 years old, all living at home. )

Father's present but not involved
The notion that fathers need to be supportive and discipline their children in order to instil work ethic and provide encouragement for their children to function well at school was commonly highlighted by mothers and grandmothers.
"Not really supportive fathering or loving at times. Don't recall the father sitting with his son many times, as he would get very angry with him for not being able to grasp things quickly. My husband is at home, he is a father but, provides the money for physical things.
He just orders the children around to do things he wants them to do. Our son is forever in trouble at school and then I always have to go." "How to feed children, because you can make the food but then they do not want to eat what is healthy. I am diabetic and the hospital they gave me a list of what to eat. I cannot buy all those things. It will be too expensive so I try to buy some of the things, then we can all eat healthy but they do not want to eat a lot of veg. They say it doesn't taste nice.
Maybe I need to know how to make it differently. Classes where you learn, not just pieces of paper that you throw away. How do I as a diabetic buy good food if it is so expensive." (Grandmother: age 57, diabetic, Participant 10, seven children -ages 7, 10, 12, 15 , 17 and 21 years old.) "How to make good healthy food choices and why. But also a course for everyone in the family so the children also understand why they are being given the food they are given.
It is maybe important to know when to buy foods in season and the quantity of food to buy for a family and how then to make sure they are eating enough or too little" (Mother: age 30, Participant 4, two children -ages 5 and 10 years old).
"Yes, I dish the food and also say they can have a little first and if they finish it and want more, they can have so that we do not waste. I eat whatever there is left or just a lot of white bread and coffee, but I take my medication for my diabetes.
Given that women are the primary managers of children's diets, health and weight, their articulations of men's contributions to food provision offer crucial insights into the power dynamics that produce and sustain the gendered responsibilities of nutritional care work in the family (28).

Discussion
Many parents in South Africa face considerable barriers to fulfil the tasks of parenting.
Poverty increases parents' difficulties in providing for and protecting their children, and makes emotionally distant, harsh and inconsistent parenting more likely. Parents living in poverty are likely to be less educated and therefore making them limited in being able to support their children's educational development and in some cases demanding nutritional needs (15). This is the case with the participants in this study where the highest qualification held by parents in the group was Grade 11.
Poverty also reduces the ability of parents to provide sufficient and appropriate nutrition as well as access to good educational opportunities for children, on a consistent basis necessary for healthy development (15). Low education levels paired with the presence of food insecurity may impact not only the quantity of available food but also diet intake patterns as people chose not to eat as regularly in an attempt to save meals (29).
According to Global nutrition report (30), note the number of people who suffer from hunger has increased over the past three years, returning to levels from a decade ago .
The number of people in the world affected by undernourishment, or chronic food deprivation, is estimated to have increased by 2.1% from around 804 million in 2016 to nearly 821 million in 2017 (31). Many food insecure communities have been found to eat less nutritious food, to limit portion sizes, to skip meals sometimes days at a time to deal with food shortages in the household (32). A psychosocial link between food insecurity, obesity and malnutrition along with further metabolic diseases such as diabetes has been found. A report by the Food & Agricultural Organization (FAO) noted the presence of physiological adaptations in response to "feast-and-famine" cycles. These adaptations have been associated with an increase in body fat, decrease in lean muscle mass and more rapid weight gain when food becomes plentiful (33). For many in impoverished communities, the experience of not having certain or adequate access to food often causes feelings of anxiety, stress and depression. This in turn leads to behaviours that increase the risk of becoming overweight and obese. Inherent in these behaviours are patterns of bingeing or overeating when food is available (as continued availability is uncertain), or choosing low-cost, energy-dense "comfort foods" rich in fat, sugar and salt (34). This is evident in the current study, with primary caregivers filling up on high sugar snacks, white bread and black coffee so their children and grandchildren have enough to eat. Some of these primary caregivers are already diabetic and on medication to control their blood sugar. This finding aligns with previous studies by showing how low income contributes to low dietary diversity, which in turn leads to poor dietary intake and micronutrient deficiencies (32,35).
The women's perception of fathers provision for their children's dietary needs were significantly similar -either the father was not present or present but unemployed.
Mothers also stated that they were responsible for everyone's care in the house. Yet, despite women being breadwinners, the provision of emotional support to children remained the women's responsibility. Emotional support was an area where the men had very little involvement to no involvement, thereby reconfirming women's role as caregivers (5). If fathers were not present, mothers provided for the nutrition and dietary needs both financially and physically.
Mothers' descriptions of their daily routines of nutritional care reflected an ethic of care imbued with a very strong 'morality of responsibility' that starkly contrasted with descriptions of fathers' approaches (28). The findings align with what is already known about the gendered division of family food work in Western societies, where 'the purchase and preparation of food for the family is the major responsibility of women' (28). Domestic involvement in children's diets and health remains more peripheral to contemporary fatherhood (36). Men's fulfilments of fatherhood does not necessitate participation in either feeding the family or managing children's routines, and broad conventional masculinity norms discourage fathers from engaging in healthy behaviours, including healthy eating (37,38).
The benefit of parental nutrition education in improving children's health outcomes has been demonstrated (39). Information on healthy eating practices can support communities to alleviate poor health and fight against household food and nutrition insecurity in South Africa (40). Members of the community involved in this study needed specific guidance regarding food-related practices, which could be provided through workshops or practical demonstrations. Existing literature notes that workshops and demonstrations can benefit communities in pursuit of healthy diets (41). Additionally, such communities require guidance in understanding how to provide healthy meals on a budget, and ways to encourage children to eat the healthy meals provided.

Ethics approval and consent to participate
Ethical clearance was received for this study from the University of the Western Cape, Senate ethics committee with clearance number 14/10/34. Informed written consent was obtained from all participants in the study.

Consent for publication
Not applicable

Availability of data and materials
All data generated or analysed during this study are included in this published article