Understanding Childcare Choices amongst Low-Income Employed Mothers in Urban and Rural KwaZulu-Natal

This study explains how low-income employed mothers navigate care strategies for their young children (0-4 years). The study considers the constraints within which they make ‘choices' about caring for their children using the market, kin and state. In addition, the study argues that these ‘choices' are immensely constrained and that the low-income employed mothers have no real choice. For many women, the ‘feminisation of the workforce' – the growing number of women in paid work – has entailed enormous stress and pressure, as they combine strenuous paid work with the demands of mothering. Low-income employed mothers must balance paid with unpaid work, in ways that are different to women who have more resources. This study analyses how women do this within households where gendered roles and a gender hierarchy continue to prevail. In some cases, low-income employed mothers must take on not only do the ‘work' of managing the household but also the additional ‘work' of soliciting the fathers for financial support and involvement in at least some aspects of their children's lives. This is a phenomenon that existing literature has not captured. The work performed by low-income employed mothers is shaped by changes in the family structure and kinship relations. The family structure in South Africa has been described as disintegrating and in crisis. I argue that the presence of paternal kin had traditionally been a pertinent one in the life of a child (specifically in KwaZulu-Natal, the study site) based on patrilineal belonging. This has significantly shifted and has implications for low-income employed mothers already stretched thin balancing work and childcare with limited support. The ‘choices' made by working women are also framed by their understanding of motherhood, which are in turn framed by cultural and societal expectations and perceptions. Having engaged with the balance between paid and unpaid work (and other forms of work – cognitive work and the work of chasing money and involvement) that the mothers must do (mothering practices), the thesis makes sense of Zulu ideals about motherhood, and how these have shaped and informed the experiences of the mothers, in the present context of the changing position of women. Mothers are nearly always the gatekeepers for the provision of care for children. This study uses the lived experiences of low-income employed mothers to show that they cannot exercise much choice in determining how to provide care for their preschool children. Most of the institutional options – both through the market and the supposed state – are constrained by their inability to afford to look for better options and by their lack of time to travel to better options. Familial or kin options are constrained by the ambivalence of kin and mothers' own expectations and understandings of their own roles. The result is that employed mothers are often on their own, piecing together a combination of childcare arrangements that is very far from the ideal childcare they would like to provide for their children. Low-income employed mothers need to be supported in their roles as employed mothers; this would be possible through subsidized public provision of quality early childhood services. However, policy implications of this would need to be considered. For instance, what would quality childcare provision cost the state? Is it feasible in a country still working on undoing the policy implications of the apartheid state? It could be that the state might not have the capacity to organize this. The South African state has a very poor track record in converting public expenditure into high quality public services. Lessons from this can be drawn from a few examples, for instance health care, education and housing (which are problematic). This thesis adds to the literature in using the lived experiences of employed mothers to show that neither the state nor the market nor kin provide an adequate safety net for the care of the children of low-income employed mothers

Understanding policy making and policy implementation with reference to land redistribution in South Africa : case studies form the Eastern Cape

This thesis focuses on land reform in post-apartheid South Africa and specifically on land redistribution, as one of the main pillars of land reform. There have been many studies undertaken on land redistribution in South Africa and these studies offer deep criticisms of the prevailing land redistribution model (a market-led, but state-assisted model) and the ways in which this model has failed to meaningfully address colonial dispossession of land. Further, studies have focused on post-redistribution livelihoods of farmers and the many challenges they face. One significant gap in the prevailing literature is a sustained focus on the state itself, and particularly questions around policy formation and implementation processes pertaining to land redistribution. Delving into policy processes is invariably a difficult task because outsider access to intra-state processes is fraught with problems. But a full account of land redistribution in South Africa demands sensitivity to processes internal to the state. Because of this, it is hoped that this thesis makes a contribution to the existing South African land redistribution literature. In pursuing the thesis objective, I undertook research amongst farmers on selected redistributed farms outside Grahamstown in the Eastern Cape, as well as engaging with both current and former state land officials. Based on the evidence, it is clear that the policy process around land in South Africa is a complex and convoluted process marked not only by consensus-making and combined activities but also by tensions and conflicts. This, I would argue, is the norm with regard to what states do and how they work

Using qualitative study designs to understand treatment burden and capacity for self-care among patients with HIV/NCD multimorbidity in South Africa: a methods paper

Background: Low- and middle-income countries (LMICs), including South Africa, are currently experiencing multiple epidemics: HIV and the rising burden of non-communicable diseases (NCDs), leading to different patterns of multimorbidity (the occurrence of two or more chronic conditions) than experienced in high income settings. These adversely affect health outcomes, increase patients’ perceived burden of treatment, and impact the workload of self-management. This paper outlines the methods used in a qualitative study exploring burden of treatment among people living with HIV/NCD multimorbidity in South Africa. Methods: We undertook a comparative qualitative study to examine the interaction between individuals’ treatment burden (self-management workload) and their capacity to take on this workload, using the dual lenses of Burden of Treatment Theory (BoTT) and Cumulative Complexity Model (CuCoM) to aid conceptualisation of the data. We interviewed 30 people with multimorbidity and 16 carers in rural Eastern Cape and urban Cape Town between February-April 2021. Data was analysed through framework analysis. Findings: This paper discusses the methodological procedures considered when conducting qualitative research among people with multimorbidity in low-income settings in South Africa. We highlight the decisions made when developing the research design, recruiting participants, and selecting field-sites. We also explore data analysis processes and reflect on the positionality of the research project and researchers. Conclusion: This paper illustrates the decision-making processes conducting this qualitative research and may be helpful in informing future research aiming to qualitatively investigate treatment burden among patients in LMICs

The impact of persistent precarity on patients’ capacity to manage their treatment burden: A comparative qualitative study between urban and rural patients with multimorbidity in South Africa

BackgroundPeople living with multimorbidity in low-and middle-income countries (LMICs) experience a high workload trying to meet the demands of self-management. In an unequal society like South Africa, many people face continuous economic uncertainty, which can impact on their capacity to manage their illnesses and lead to poor health outcomes. Using precariousness – the real and perceived impact of uncertainty – as a lens, this paper aims to identify, characterise, and understand the workload and capacity associated with self-management amongst people with multimorbidity living in precarious circumstances in urban and rural South Africa.MethodsWe conducted qualitative semi-structured interviews with 30 patients with HIV and co-morbidities between February and April 2021. Patients were attending public clinics in Cape Town (Western Cape) and Bulungula (Eastern Cape). Interviews were transcribed and data analysed using qualitative framework analysis. Burden of Treatment Theory (BoTT) and the Cumulative Complexity Model (CuCoM) were used as theoretical lenses through which to conceptualise the data.ResultsPeople with multimorbidity in rural and urban South Africa experienced multi-faceted precariousness, including financial and housing insecurity, dangerous living circumstances and exposure to violence. Women felt unsafe in their communities and sometimes their homes, whilst men struggled with substance use and a lack of social support. Older patients relied on small income grants often shared with others, whilst younger patients struggled to find stable employment and combine self-management with family responsibilities. Precariousness impacted access to health services and information and peoples’ ability to buy healthy foods and out-of-pocket medication, thus increasing their treatment burden and reducing their capacity.ConclusionThis study highlights that precariousness reduces the capacity and increases treatment burden for patients with multimorbidity in low-income settings in South Africa. Precariousness is both accumulative and cyclic, as financial insecurity impacts every aspect of peoples’ daily lives. Findings emphasise that current models examining treatment burden need to be adapted to accommodate patients’ experiences in low-income settings and address cumulative precariousness. Understanding treatment burden and capacity for patients in LMICs is a crucial first step to redesign health systems which aim to improve self-management and offer comprehensive person-centred care

Ubuntu as a mediator in coping with multimorbidity treatment burden in a disadvantaged rural and urban setting in South Africa

Background: People living with multimorbidity in economically precarious circumstances in low- and middle-income countries (LMICs) experience a high workload trying to meet self-management demands. However, in countries such as South Africa, the availability of social networks and support structures may improve patient capacity, especially when networks are governed by cultural patterns linked to the Pan-African philosophy of Ubuntu, which promotes solidarity through humanness and human dignity. We explore the mediating role Ubuntu plays in people's ability to self-manage HIV/NCD multimorbidity in underprivileged settings in urban and rural South Africa. Methods: We conducted semi-structured interviews with 30 patients living with HIV/NCD multimorbidity between February–April 2022. Patients attended public health clinics in Gugulethu, Cape Town and Bulungula, Eastern Cape. We analysed interviews using framework analysis, using the Cumulative Complexity Model (CuCoM) and Burden of Treatment Theory (BoTT) as frameworks through which to conceptualise the data. Results: Despite facing economic hardship, people with multimorbidity in South Africa were able to cope with their workload. They actively used and mobilized family relations and external networks that supported them financially, practically, and emotionally, allowing them to better self-manage their chronic conditions. Embedded in their everyday life, patients, often unconsciously, embraced Ubuntu and its core values, including togetherness, solidarity, and receiving Imbeko (respect) from health workers. This enabled participants to share their treatment workload and increase self-management capacity. Conclusion: Ubuntu is an important mediator for people living with multimorbidity in South Africa, as it allows them to navigate their treatment workload and increase their social capital and structural resilience, which is key to self-management capacity. Incorporating Ubuntu and linked African support theories into current treatment burden models will enable better understandings of patients’ collective support and can inform the development of context-specific social health interventions that fit the needs of people living with chronic conditions in African settings

Intervention development of ‘Diabetes Together’ using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

Objectives Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.Design We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.Setting We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020–2021.Participants The 38 participants were couples where one person had T2D.Intervention We developed the ‘Diabetes Together’ intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.Results Our guiding principles included: providing equal information on T2D to partners; improving couples’ communication; shared goal-setting; discussion of diabetes fears; discussing couples’ roles in diabetes self-management; and supporting couples’ autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.Conclusions Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops’ feasibility and acceptability

The impact of persistent precarity on patients’ capacity to manage their treatment burden: a comparative study between urban and rural patients with multimorbidity in South Africa

Background: People living with multimorbidity in low- and middle-income countries (LMICs) experience a high workload trying to meet the demands of self-management. In an unequal society like South Africa, many people face continuous economic uncertainty, which can impact on their capacity to manage their illnesses and lead to poor health outcomes. Using precariousness – the real and perceived impact of uncertainty – as a lens, this paper aims to identify, characterize, and understand the workload and capacity associated with self-management among people with multimorbidity living in precarious circumstances in urban and rural South Africa. Methods: We conducted qualitative semi-structured interviews with 30 patients with HIV and co-morbidities between February and April 2021. Patients were attending public clinics in Cape Town (Western Cape) and Bulungula (Eastern Cape). Interviews were transcribed and data analysed using qualitative framework analysis. Burden of Treatment Theory (BoTT) and the Cumulative Complexity Model (CuCoM) were used as theoretical lenses through which to conceptualise the data. Results: People with multimorbidity in rural and urban South Africa experienced multi-faceted precariousness, including financial and housing insecurity, dangerous living circumstances and exposure to violence. Women felt unsafe in their communities and sometimes their homes, whilst men struggled with substance use and a lack of social support. Older patients relied on small income grants often shared with others, whilst younger patients struggled to find stable employment and combine self-management with family responsibilities. Precariousness impacted access to health services and information and peoples’ ability to buy healthy foods and out-of-pocket medication, thus increasing their treatment burden and reducing their capacity. Conclusion: This study highlights that precariousness reduces the capacity and increases treatment burden for patients with multimorbidity in low-income settings in South Africa. Precariousness is both accumulative and cyclic, as financial insecurity impacts every aspect of peoples’ daily lives. Findings emphasise that current models examining treatment burden need to be adapted to accommodate patients’ experiences in low-income settings and address cumulative precariousness. Understanding treatment burden and capacity for patients in LMICs is a crucial first step to redesign health systems which aim to improve self-management and offer comprehensive person-centred care

Intervention development of ‘Diabetes Together’ using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

Objectives: Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.Design: We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.Setting: We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020-2021.Participants: The 38 participants were couples where one person had T2D.Intervention: We developed the 'Diabetes Together' intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.Results: Our guiding principles included: providing equal information on T2D to partners; improving couples' communication; shared goal-setting; discussion of diabetes fears; discussing couples' roles in diabetes self-management; and supporting couples' autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.Conclusions: Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops' feasibility and acceptability