EVALUATING INCOME GENERATION, NUTRITION, AND PARENTING PROGRAMS ON MATERNAL AND CHILD HEALTH OUTCOMES: A MULTI-PROGRAM CASE STUDY OF A COMMUNITY-BASED ORGANIZATION IN THE WESTERN CAPE, SOUTH AFRICA by SIMONE MARTIN A Dissertation submitted to the Graduate School-Newark Rutgers, The State University of New Jersey in partial fulfillment of the requirements for the degree of Doctor of Philosophy Graduate Program in Division of Global Affairs written under the direction of Dr. Jeffrey Backstrand, Rutgers University Chair and approved by Dr. Jeffrey Backstrand, Rutgers University Dr. Teri Lindgren, Rutgers University Dr. Andres Rengifo, Rutgers University Dr. Timothy Dye, University of Rochester Newark, New Jersey October, 2017 © 2017 SIMONE MARTIN ALL RIGHTS RESERVED ABSTRACT OF THE DISSERTATION EVALUATING INCOME GENERATION, NUTRITION, AND PARENTING PROGRAMS ON MATERNAL AND CHILD HEALTH OUTCOMES: A MULTI-PROGRAM CASE STUDY OF A COMMUNITY-BASED ORGANIZATION IN THE WESTERN CAPE, SOUTH AFRICA By SIMONE MARTIN Dissertation Director: Dr. Jeffrey Backstrand The Western Cape Province of South Africa captivates tourists from all over the world who flock to the region to visit the spectacular view from Table Mountain, take in the beauty of wildlife on a safari tour, and sip some of the best wines in the world at any one of the region’s stunning vineyards. However, while the Western Cape prides itself as a vacation destination for visitors, residents are faced with social and health problems on an everyday basis as a result of the country’s complex apartheid history. The province remains socially stratified by social class, gender, age, and race in which socio- economically disadvantaged groups, specifically Black and Coloured women and children, are treated differently and live under unfavorable conditions. Maternal poverty, poor maternal nutrition and health, and maternal alcohol abuse, the three risk factors explored in this study, have resulted in malnourished infants and children. One response to this is that community-based organizations have been developed throughout the province to provide at-risk, low-income Black and Coloured mothers with income generating programs in order to lessen poverty and maternal and child health disparities, II nutrition and health support groups, and early childhood development centers for young children in tandem with parenting workshops and counseling programs. Although there is significant research that indicates participating in evidence- based parenting programs can improve child health outcomes in high-income countries (Lachman et al., 2016), few studies have examined their impact in low-and middle- income countries and what constitutes effective implementation of parenting interventions in severely impoverished rural communities. This multi-program case study will examine how a community-based organization helps at-risk Black and Coloured mothers make better behavioral, nutritional, and parenting choices through a process evaluation using document analyses and 48 semi-structured qualitative interviews with staff and participants. Life Course Theory and the Social Determinants of Health are the guiding conceptual models to frame this research which stress that barriers to health, including economic disparities and health inequity in the early years of life, can have an impact on the health trajectories of children and that a mother’s social position is the main determinant of inequity, respectively. III Dedication This dissertation is dedicated to my family and close friends – Gloria Edwards, Gordon Martin, Frederick Clarke, Anthony Tait, Lisa-Marie Aird, Sue-Ann Banfield, and the Aird clan. A special thank you to my mother, Gloria Edwards, and my late father, Gordon Martin, who shaped me into the woman that I am today. A special thank you to my late cousin, Dr. Tony Martin, well-known Professor Emeritus and founding member of the Department of Africana Studies at Wellesley College, who told me to pursue my passion of obtaining a doctorate degree three months before suddenly passing away. Lastly, a special thank you to Jerry Howard II, whose love and support throughout my doctoral journey has been unfailing. IV Acknowledgements First, I thank the entire staff and mothers of Table Views Foundation for their kindness and warmth. This research was achievable because the staff embraced me into their organization and culture and the mothers shared their personal narratives with me. Second, I thank my translator Unathi Pityana for assisting me with the study which was critical in shaping the context of the women’s stories and assuring that I interpreted their responses clearly and accurately. Third, I thank the Community Chest of the Western Cape for hosting me as I completed my data collection, the United States Agency for International Development (USAID) and Rutgers University-Newark who provided me with the necessary funding to travel twice to Cape Town, South Africa, the Western Cape Provincial Government for their time, specifically MEC Albert Fritz and Ms. Esther Lewis of the Department of Social Development and Dr. Nomafrench Mbombo of the Department of Health, and Dr. Kyle Farmbry for bestowing advice and offering constant support to me during my doctoral journey. Finally, I thank my dissertation committee, Teri Lindgren, Andres Rengifo, and Timothy Dye, for guiding me through this process. I am especially appreciative for the assistance of Jeffrey Backstrand, who guided me throughout the dissertation process and whose expertise in the field was extremely valuable. V Table of Contents Page Chapter 1: Introduction .......................................................................................................1 Introduction to the Research Problem......................................................................1 Context and Background..........................................................................................3 Purpose and Significance of Study .........................................................................4 Research Questions ..................................................................................................5 The Researcher’s Background ................................................................................7 Chapter Overview ...................................................................................................9 Chapter 2: Theoretical Framework and Literature Review ..............................................13 Life Course Theory, the Social Determinants of Health and Health Disparities... 13 Size of the Global Maternal and Child Health Problem and Definitions .............21 Global Upstream Causes of Maternal and Child Health Problems ........................25 Global Downstream Causes of Maternal and Child Health Problems ...................27 Global Maternal and Child Health Programs and CBIs ........................................32 What Has Not Worked ...........................................................................................33 What Is Working ....................................................................................................38 Conclusion .............................................................................................................50 Chapter 3: Literature Review – South Africa and the Western Cape Province .................53 South Africa – General Background ......................................................................53 South Africa – Size of the Maternal and Child Health Problem............................56 Upstream Causes of Maternal and Child Health Problems in South Africa ..........58 Downstream Causes of Maternal and Child Health Problems in South Africa .....61 South Africa Maternal and Child Health Government Programs and CBIs ..........66 The Western Cape Province – General Background ............................................68 The Western Cape Province – Size of the Maternal and Child Health Problem ..70 Upstream Causes of Maternal and Child Health Problems in the WCP ................71 Downstream Causes of Maternal and Child Health Problems in the WCP ...........72 Western Cape Province – Maternal and Child Health Government Programs .... 75 Conclusion ............................................................................................................82 Chapter 4: Methodology ...................................................................................................86 Specific Research Objectives .................................................................................86 Overview of Research Design ..............................................................................88 Sampling Strategy ..................................................................................................94 Data Collection Procedures ....................................................................................95 Data Analysis ........................................................................................................96 Human Subjects ....................................................................................................98 Conclusion ...........................................................................................................100 Chapter 5: Provider Views of the Community ...............................................................103 Table Views Organization – General Background .............................................103 VI Barriers and Challenges to Organizational Goal Achievement