Abstract
Home programmes are a core component of early childhood intervention, where speech-language therapists provide take-home, structured activities for caregivers to support children's speech-language development between sessions. Limited research exists on home programmes within South Africa's public healthcare system, where resources and access challenges impact delivery. This study explored caregiver perceptions on the usefulness and challenges of these programmes in a South African public healthcare context. A descriptive cross-sectional survey was conducted with 60 purposively selected caregivers of children aged 0–6 years attending speech-language therapy at public clinics. Data was collected via a structured questionnaire. Descriptive and non-parametric inferential statistics were used to analyse quantitative data on demographics, therapy history, home programme experiences and environmental factors. Open-ended responses were examined quantitatively through frequency analysis to highlight common responses. While 46.7% of participants rated home programmes as ‘extremely helpful and exceeding expectations’, 51.7% reported challenges, including limited time, unconducive home environments, limited finances and unclear instructions. The reported benefits of home programmes clustered around several themes. Caregivers most frequently identified increased opportunities for practice at home, alongside improved confidence in their ability to support their children. Many also highlighted visible progress in their children's development as a key benefit. Practical elements were particularly valued, with caregivers emphasising the usefulness of clear and simple instructions as well as activities that could be carried out using common household items. Findings support the development of contextually responsive, flexible, low-cost home programmes that are integrated into daily routines, particularly in socio-economically diverse, multilingual settings. Further research is needed to explore strategies across broader populations and settings.
Keywords
Introduction and background
In South Africa, the public healthcare system serves the majority of the population, with approximately 83% relying on public healthcare services due to limited access to private medical insurance (Ngobeni et al., 2020). Within this context, early childhood intervention (ECI) services are delivered through public healthcare facilities to support children from birth to 6 years with developmental delays or disabilities (Kyarkanaye et al., 2017; Storbeck, 2024). Within interprofessional teams, speech-language therapists (SLTs) play an important role in supporting early communication and language development. One commonly used intervention strategy is the implementation of speech-language therapy home programmes, which involve structured activities that caregivers complete with their children between therapy sessions (Bornman et al., 2020).
Home programmes aim to integrate therapeutic strategies into children's daily routines, promoting consistent practice, skill generalisation and improved developmental outcomes (Clare et al., 2023; Ingersoll et al., 2024; Sandbank et al., 2020). These programmes may be delivered through written instructions, verbal coaching, video demonstrations or digital platforms (Gonzalez et al., 2023; Hoek et al., 2020; Sulku et al., 2021) and are typically adapted to caregiver needs, preferences and available resources (Qu et al., 2022; Vikberg et al., 2022). In South African public healthcare settings, where therapy sessions are often infrequent, home programmes rely heavily on caregivers to carry out intervention activities at home (Bornman et al., 2020).
The importance of caregiver involvement in children's development is supported by several theoretical frameworks. Bronfenbrenner's Ecological Systems Theory (1979) and Vygotsky's Sociocultural Theory (1978) highlights how children's learning and development occurs through interactions within their social and environmental contexts (Mustafa et al., 2023; Saracho, 2023). Similarly, the International Classification of Functioning, Disability and Health (ICF) (Borges et al., 2021; WHO, 2007) emphasises the interaction between biological, environmental and social factors. Guralnick's Developmental Systems Approach (2011) recognises the critical role of caregiver engagement and contextual supports in shaping developmental outcomes. These frameworks reinforce the importance of understanding how caregivers experience and implement home programmes.
Research suggests that caregiver-led home programmes can support language development, promote caregiver engagement and increase flexibility in intervention delivery (Gibson et al., 2021; Saeedi et al., 2022; Sone et al., 2021). Such programmes are valuable in low-resource contexts where regular clinic attendance is difficult (Shahouzaie & Gholamiyan Arefi, 2024; Tar-Mahomed & Kater, 2022). However, successful implementation depends on caregivers’ understanding of therapy strategies and their ability to incorporate activities into everyday routines. Factors such as limited access to resources, varying levels of health literacy and challenging home environments may influence caregivers’ ability to implement home programmes effectively (Easterbrook et al., 2023; Prabarini et al., 2024; Torres et al., 2024; Villaluna & Dolby, 2024).
Communication between therapists and caregivers may also influence the success of home programmes. Language mismatches, use of technical terminology and limited caregiver training can affect caregivers’ confidence and self-efficacy in implementing therapeutic strategies (Cycyk et al., 2021; Donoso Brown et al., 2021; Marshall et al., 2023; Mdlalo et al., 2019; Shady et al., 2024). Research shows that culturally and linguistically responsive interventions may improve caregiver engagement and programme outcomes (Khoza-Shangase & Mophosho, 2021; Parker et al., 2023).
The COVID-19 pandemic further increased reliance on caregiver-implemented intervention approaches. When face-to-face services were limited, many South African SLTs turned to home programmes and teletherapy to continue providing services (Bruder et al., 2021; Tar-Mahomed & Kater, 2022). International research indicates that while some caregivers adapted well to this increased role, others reported feeling unprepared or overwhelmed (Barton-Hulsey et al., 2023; Pinkerton et al., 2023). Although these findings highlight the importance of caregiver involvement in intervention delivery, most available evidence comes from high-income settings.
Despite the central role caregivers play in home programmes, limited research has explored how caregivers perceive and experience these interventions within South Africa's public healthcare system. Existing local studies have largely focused on SLTs’ perspectives or were conducted in higher-resourced contexts (Omidire et al., 2015; Porter, 2015). As reliance on caregiver-implemented home programmes and telehealth approaches increases, understanding caregivers’ perspectives becomes essential to ensure interventions are feasible, acceptable, and responsive to family contexts.
Exploring caregiver perspectives can also complement existing research on SLT experiences by providing insight into how home programmes are understood and implemented within everyday family environments. This may help inform more contextually appropriate, family-centred intervention practices in South African public healthcare settings, aligning with the broader principles of early childhood intervention that emphasise the importance of context in supporting young children and their families. This study therefore examines caregiver perceptions of speech-language therapy home programmes, exploring both the perceived benefits and challenges to inform more responsive and effective family-centred intervention.
The current study
This study aimed to explore caregiver perceptions of home programmes provided by SLTs to children aged 0–6 years in South Africa's public healthcare system. It focused on understanding both the perceived benefits and the challenges of implementing these programmes in home environments.
The study was guided by three research questions:
How do caregivers perceive the usefulness of home programmes? What challenges do caregivers face in implementing them? How do environmental factors such as socio-economic status, technology access, language and home environment affect participation?
By addressing these questions, the study seeks to inform the development of more accessible, culturally responsive and practical home programmes that align with caregivers’ real-life circumstances.
Method
Ethical approval
Ethical clearance was obtained from the institutional ethics committee and district health research authority. The study adhered to professional health council guidelines. Written informed consent was obtained from all participants in English or the local dialect of Setswana. Participation was voluntary, with the right to withdraw at any stage without consequence. Participant confidentiality was protected by using non-identifying codes and data collection in private spaces.
Study design
A descriptive, quantitative cross-sectional survey design was employed (Creswell and Creswell, 2017) to investigate caregiver perceptions of speech-language therapy home programmes. Descriptive analyses were employed, and inferential statistics were used to explore associations and further data interpretations. This approach aligns with previous research on caregiver experiences in early intervention and home-based therapy contexts (O’Toole et al., 2021; Klatte et al., 2018).
Participants and setting
The study was conducted at nine public health facilities offering SLT services in the City of Tshwane, Gauteng Province, South Africa. Tshwane, a metropolitan municipality comprising both urban and informal settlements, currently operates 24 public primary healthcare clinics (City of Tshwane, 2023). Despite improvements in service quality, only 66.3% of residents report having access to a public healthcare facility within their area, according to a recent population-based survey conducted across the municipality (Moeti et al., 2023). Of these facilities, nine provide SLT early communication intervention services and were included.
The target population comprised primary caregivers of children aged 0–6 years receiving ECI services at the facilities. Following South African definitions, a ‘primary caregiver’ refers to biological parents, relatives or non-related individuals such as family friends or neighbours responsible for the child's care (Schlebusch et al., 2016). Caregivers were excluded if children were receiving only audiology services, did not meet age or consent criteria, or were attending initial assessments or their first therapy session. All caregivers had attended at least one prior therapy session. Although no minimum duration was required for inclusion, the questionnaire captured how long children had attended therapy to provide context information on therapy engagement.
Sampling strategy
Purposive consecutive sampling was used to recruit caregivers with direct experience of home programmes, as this sampling approach enabled the selection of participants who could provide information relevant to the aims of the study (Campbell et al., 2020b). A sample size of 81 was calculated using the Raosoft Sample Size Calculator (2004) with a 5% margin of error and 95% confidence level, based on an estimated population of 102 eligible participants. Due to recruitment challenges, the final sample comprised 60 participants, representing 74% of the projected sample size. This sample was deemed sufficient for the aims of the study (Daniel, 2011).
Participant recruitment
SLTs identified eligible caregivers using predefined inclusion criteria provided by the researcher. These included caregivers of children aged 0–6 years who were receiving speech-language therapy, had been issued a home programme and were attending scheduled ECI appointments during the data collection period. Caregivers also had to be over 18 years to participate. To support consistent recruitment and reduce bias, the SLTs received a briefing outlining the study procedures and inclusion criteria. The researcher approached all caregivers who met the inclusion criteria during the data collection period and followed up with non-respondents to maximise response rates and minimise potential differences between participants and non-participants. On appointment days, the researcher was introduced to participants after therapy sessions and provided a verbal explanation of the study. Written consent was obtained from willing participants. Data collection occurred on the same day or at a follow-up appointment. No caregivers had more than one eligible child, therefore caregivers responded regarding one child. No incentives were provided.
Materials
A structured questionnaire (Supplementary material 1) was used to gather data, developed by the researcher based on relevant literature and adapted from validated tools used in similar studies (Alighieri et al., 2021; Meerschman et al., 2019). The questionnaire included seven sections: caregiver demographics, child profile, speech therapy history, home programme use and perceptions, environmental factors, financial considerations and caregiver preferences and suggestions. It comprised 54 quantitative and five open-ended qualitative questions. A 10-point Likert scale was used to capture nuanced differences in agreement or frequency and improve discrimination between response options when measuring subjective perceptions (Coelho & Esteves, 2007). Responses were treated as ordinal data and analysed accordingly, without collapsing categories, to preserve the full range of participants’ perceptions, as longer Likert-type scales have been shown to capture greater variability and reduce clustering of responses compared with shorter scales (Sun et al., 2025; Wu and Leung, 2017). The questionnaire was translated into Setswana by the primary researcher, a fluent speaker familiar with the local dialect. Online resources supported accurate phrasing. Although no formal process (e.g., back-translation or expert review) was used, the translation was tested during the pilot study, which revealed no issues with clarity or understanding. The lack of a formal validation process is noted as a limitation, and future studies should consider more structured translation methods.
Pilot study
A pilot study was conducted with eight participants (10% of the intended sample) to assess clarity, layout, and content relevance of the questionnaire. Participants met the same inclusion criteria as the main study and were recruited from the same sites as those in the main study. A total of six interviews were conducted in English and two in Setswana. This distribution occurred on a convenience basis, as the study did not intentionally aim to achieve an equal number of interviews in each language. Responses were used for piloting purposes and were excluded from the final study data analysis. Based on feedback, revisions were made to improve clarity, including adjustments to phrasing and use of abbreviations. The pilot study confirmed the questionnaire's feasibility and appropriateness of procedures. Psychometric properties such as face validity, content validity and internal consistency were not formally assessed due to the small pilot sample size and the exploratory nature of the study.
Data collection
Data were collected from November 2023 to April 2024 at the SLT departments of the selected facilities. Each session lasted approximately 45 min. Literate participants responded independently. An interview-administered format with the researcher or the child's treating SLT who received prior training on administration was used when participants required support. Data was collected in English or Setswana, based on participant preference (53 in English and seven in Setswana). Responses provided during interviews were confirmed and rephrased where necessary to ensure clarity and accuracy. Participants were given the opportunity to review and correct their responses during the interview process.
Data analysis
Quantitative data were entered into Excel and analysed using SPSS Version 26. Descriptive statistics (frequencies and percentages) provided a general overview. Inferential analysis was conducted using non-parametric methods due to the ordinal nature of the Likert-scale data and small sample size, to identify meaningful associations beyond descriptive trends (Pallant, 2020; Field, 2024). Point-biserial and Spearman correlations, Phi coefficients and two-proportion z-tests were used to explore internal associations within the sample. Analyses were exploratory, and no formal adjustments for multiple testing were applied. All statistical tests were conducted at a 5% level of significance. The dataset contained only a negligible number of missing values and because the proportion of missing data was minimal and unlikely to influence the overall results, no data imputation or replacement was performed.
Open-ended responses were examined quantitatively through frequency analysis by grouping similar responses into categories. These categories were then summarised using frequency counts to highlight common responses. The categorisation process was reviewed by three co-researchers to ensure consistency and agreement in the grouping of responses.
Reliability, validity and objectivity
Content validity was ensured by consulting validated instruments (Alighieri et al., 2021; Meerschman et al., 2019), reviewing relevant literature and refining the tool based on pilot study feedback. Reliability was strengthened through consistent administration procedures and established survey formats. The researcher's role was strictly that of observer, reader (where participants could not read) and analyst. Objectivity was maintained by grounding interpretations in the data, engaging an independent reviewer for the analysis and maintaining a clear audit trail.
Results
Participants’ demographic information
Sixty participants aged 18 years and above participated in the study. Table 1 presents the participants’ age, gender, race, monthly household income, their relationship with the child, whether they live with the child full-time, whether they can read and write and the languages they are literate in.
Demographic information of participants, n = 60.
According to the results, a majority of the participants lived with their children full-time (n = 55, 91.7%) and the majority were mothers (n = 47, 78.3%). Participants were generally young adults, with the largest group aged 25–35 years (n = 28, 46.7%) and relatively few younger than 25 (n = 6, 10.0%).
Caregiver perceptions of home programmes
In the closed-ended question, all participants (n = 60, 100%) answered ‘yes’ to home programmes being important. Furthermore, participants were asked if they think home programmes are helpful using a Likert scale (1–10), where 1 means ‘useless’ and 10 means ‘extremely helpful; exceeded expectations’. Figure 1 shows the results of the question about home programme helpfulness.
Rating of home programme helpfulness, n = 60.
Almost half of participants (n = 28, 46.7%) rated the home programmes as extremely helpful and exceeding expectations (10/10). The lowest rating was 5/10, reported by a small minority (n = 7, 11.7%). An open-ended follow-up question explored participants’ reasons for valuing the programmes, with the most common themes summarised in Table 2.
Reasons why participants felt home programmes are important, n = 60.
Challenges faced by participants
Just over half of participants (n = 31, 51.7%) reported challenges in implementing the programme. The most common personal barrier was limited time (n = 26, 43.3%), while others noted difficulties with understanding specific aspects of the programme (n = 14, 23.3%). Environmental challenges such as lack of resources or inconsistent family or community support were reported by 10.0% of participants (n = 6). Additional concerns centred on child-related factors such as disinterest, short attention span or non-compliance (n = 9, 15.0%). The personal challenges were further explored, and the following factors were determined: caregiver language, literacy and time (see Table 3).
Personal challenges reported by participants, n = 60.
Almost all participants (n = 59, 98.3%) reported that home programme instructions were clear. Instructions and implementation were predominantly in English, though a minority of participants used Setswana or Sepedi (n = 1, 1.7%). Most participants (n = 53, 88.3%) understood the key terms, with a small proportion noting difficulty with concepts such as ‘shared attention’ and ‘routine adjustment’.
Participants showed high literacy levels with almost all reporting the ability to read and write, often in more than one language (n = 58, 96.7%). No statistically significant correlations were found between caregiver age and literacy across the languages reported (all P > 0.05).
Time management was also a major challenge for participants. Almost half of participants (n = 27, 45.0%) reported that time constraints limited their ability to implement the home programme, and 3.3% (n = 2) missed scheduled appointments due to time conflicts. The frequency with which participants were required to implement the home programme and execute it was also examined. These findings are summarised in Table 4.
Frequency of required vs. actual time spent on home programme per week, n = 60.
Although 81.7% (n = 49) of participants were required to engage in the programme more than three times per week, only 65.0% (n = 39) achieved this. Among those expected to participate two to three times per week, only 23.3% (n = 14) met the target. Notably, 10.0% (n = 6) of participants only engaged once per week, despite just 1.7% (n = 1) being expected to follow that frequency.
Environmental factors were further explored in Table 5. The following factors were determined: caregiver resources, access and their environment.
Environmental challenges reported by participants, n = 60.
Financial challenges were evident, with nearly three-quarters of participants (n = 44, 73.3%) earning less than R10,000 per month. Just over half (n = 31, 51.7%) reported that the programme required additional purchases, and 40.0% (n = 24) could not carry out the home programme without these resources. Some 41.7% (n = 25) were able to adapt by using home-made toys as alternatives, though financial strain remained a common theme.
From Table 5, it is apparent that most participants reported being computer literate (n = 53, 88.3%) and the majority (n = 53, 88.3%) had access to a computer or smartphone, which enabled engagement with digital components of the programme. However, a minority (n = 7, 13.2%) lacked access to data or Wi-Fi, limiting their use of online resources.
Statistical analysis indicated that household income was not significantly associated with access to a computer or smartphone (r = −0.003, P = 0.980, n = 59) or the ability to purchase data or access Wi-Fi (r = 0.050, P = 0.709, n = 59). A statistically significant negative association was identified between age and computer literacy (point-biserial r = −0.358, P = 0.005, n = 59), indicating that younger participants were more likely to report being computer literate than older participants. No significant associations were observed between caregiver age and overall literacy (r = 0.085, P = 0.521).
At home, some participants experienced environmental challenges when implementing the programme. A third (n = 22, 36.7%) reported difficulties with privacy, as other people were often present during activities, while others noted issues such as excessive noise (n = 10, 16.7%) or limited space (n = 10, 16.7%). Almost half (n = 26, 43.3%) reported no interference, and a smaller group (n = 14, 23.3%) highlighted child-related barriers such as lack of attention or interest.
Transport was generally reliable for most participants (n = 52, 86.7%). A statistically significant positive association was identified between monthly household income and perceived transport reliability (point-biserial r = 0.289, P = 0.026, n = 59), indicating that participants with higher incomes were more likely to report reliable transport.
Further analysis of transport type showed that participants earning less than R5,000 used public transport significantly more frequently (72.0%) than those earning R5,000–R10,000 (38.9%; P = 0.030) and those earning more than R10,000 (25.0%; P = 0.003). Conversely, participants earning more than R10,000 were significantly more likely to use private cars (62.5%) compared to those earning less than R5,000 (16.0%; P = 0.002). Missed appointments were infrequent (n = 9, 15.0%) but, when they occurred, were often linked to transport difficulties (n = 4 out of 9, 44.4%).
Due to financial struggles, some participants were unable to purchase all the materials required for the home programme (40.0%, n = 24). As a result, they explored alternatives using items they could make at home.
Table 6 presents examples of home-made toys that participants reported they could create and use in the programme. When asked if they could use home-made toys as alternatives, 41.7% (n = 25) responded positively.
Home-made toys suggested by participants, n = 60.
Home programme modifications
Participants were asked through open-ended questions if they had any suggestions for modifications to their home programmes, including additions or removals. The responses are summarised in Table 7.
Suggestions for home programme modifications made by participants, n = 60.
Participants were also asked to rate their willingness to participate in the home programme if certain modifications were provided. Table 8 shows participants’ willingness to participate in the home programme, based on a Likert scale from 1 (not willing) to 5 (very willing).
Willingness to participate, n = 60.
An overwhelming 91.7% (n = 55) of participants expressed the highest level of willingness (rating of 5) for providing props and printed materials, while 96.7% (n = 58) were very willing to participate if the SLT practised the programme with them before they left. Ratings below 3 were rare across all modifications.
Discussion
Demographic information
The demographic profile of this sample highlights the interplay of gender, socio-economic status, and environmental conditions in caregiver participation. Most participants were women (80.0%), reflecting the feminised nature of caregiving shaped by cultural expectations and gendered economic roles (Kim et al., 2023). This pattern is consistent with existing international and local evidence that early childhood caregiving responsibilities are predominantly carried by women (Egan et al., 2022; Vanleeuw et al., 2024). However, given the small, urban sample in this study, these findings should be viewed as indicative rather than representative of all South African caregivers.
Participants largely resided in low- to middle-income, urban households, consistent with peri-urban South African communities that rely heavily on public healthcare, with majority earning less than R10,000 per month (Akande et al., 2023). These findings align with South African research suggesting that caregivers in low-income communities often work full-time while earning below minimum income thresholds, with 97% earning less than R10,000 per month (Yakubu & Schutte, 2018). Literacy levels were high (96.7%), comparable to findings by Yakubu and Schutte (2018), who reported that 89.5% of caregivers had completed secondary education. This suggests that written instructions are broadly accessible, although technical healthcare terminology may still pose a barrier for non-native English speakers (Oksiutycz and Azionya, 2022).
Most participants (88.3%) reported access to digital devices, primarily smartphones, with limited access to computers or Wi-Fi. Although recent South African research examining caregivers’ access to digital devices is limited, national data suggest that mobile phones are the most widely accessible technology, while access to computers and fixed internet remains lower (Statistics South Africa, 2023). This suggests that smartphones may play a central role in facilitating digital home programme delivery in low-resourced urban South African contexts. However, the coexistence of high smartphone access alongside financial constraints highlights the importance of low-data, mobile-based platforms. Given the exploratory urban sample, broader applicability requires further investigation.
In line with the ICF, these results underscore how personal and environmental factors, including gendered roles, financial constraints and digital access, shape caregiver participation in healthcare interventions (Nurjazuli et al., 2023). However, this cross-sectional, exploratory study involved a small urban sample, therefore, these findings should be interpreted with caution and may not be generalisable to rural or broader populations.
Caregiver perceptions of home programmes
Participants valued home programmes for reinforcing therapy at home (41.7%) and promoting empowerment (20.0%). Although direct percentage comparisons are limited in recent studies, dated studies from middle-income contexts such as India demonstrate high caregiver acceptability of structured home programmes (Dias et al., 2008), while more recent systematic reviews confirm that empowerment-focused interventions, including home programmes, reduce caregiver stress and burden thus creating a positive perspective among caregivers (Lin et al., 2025). International evidence also shows that home-based support models are consistently valued by caregivers for their ability to extend practice and strengthen caregiver roles (Leff et al., 2015). Empowerment emerged as a central theme in this study, with caregivers reporting a stronger sense of involvement in their child's development. This is consistent with Movahedazarhouligh (2021), who highlights the advantages of collaborative, family-centred models over clinician-led approaches. However, variation in perceived helpfulness indicates that not all caregivers benefit equally, echoing findings by Milliken et al. (2020), who argued for flexibility and context sensitivity in programme design. Tailoring interventions to match caregivers’ language, time, and available resources may therefore be critical to maximising impact and preventing inconsistency. As this was an exploratory cross-sectional study conducted in an urban setting, these perceptions may not reflect the experiences of caregivers in different cultural, geographic or service-delivery contexts.
Caregiver challenges
Participants reported both personal and environmental challenges, echoing Bronfenbrenner's Ecological Systems Theory (1979) and the Developmental Systems Approach (Guralnick, 2011), which highlight the interaction of multiple systemic factors in shaping child outcomes. These barriers align with recent South African research (Coetzee et al., 2023), showing that constraints compromise home programme implementation. The following sections outline these personal and environmental challenges in greater detail.
Personal challenges
Time emerged as the most frequent barrier, with 45% of participants reporting inconsistent implementation due to time constraints. Similar patterns have been observed in low-income South African households (Silaule et al., 2024) and internationally, where caregiver burden is widely reported (Malki et al., 2025). Gendered caregiving roles further compound these constraints in South Africa (Govender, 2024). Although no statistical relationship between income and time availability was observed in this sample, a study conducted in Japan found that lower-income caregivers were more likely to experience reduced time availability due to caregiving responsibilities (Saito et al., 2018). Contextual differences, such as national policies, social support systems and cultural expectations, may account for these contrasting findings, and no comparable local South African studies were identified.
Language also presented challenges for some participants. Although most participants were multilingual, 11.7% reported difficulty understanding English-only instructions, particularly when technical terms were used. This proportion aligns with other South African literature, which similarly found that 11.9% of caregivers required instructions in their home language, while the remainder were comfortable using bilingual resources or preferred English (De Leo et al., 2024). These findings highlight the importance of linguistically and culturally responsive interventions in South Africa (Khoza-Shangase & Mophosho, 2021). However, a notable finding of this study was that despite the multilingual context, most caregivers reported that the instructions were generally clear and understandable. This suggests that simplified written materials, supported by visual or multimodal strategies, may remain an effective communication approach for home programmes even within linguistically diverse South African settings. High literacy levels among participants may also serve as a protective factor (Guralnick, 2011), facilitating engagement with simplified, visual or multimodal supports.
Environmental challenges
Environmental constraints, including material shortages, noise and limited space, were prominent. About 51.7% of participants reported needing additional materials to carry out the programme, with 40.0% stating that they could not proceed without them. These findings are consistent with the 54% of caregivers in a South African village study reporting missing materials needed to carry out home programmes and 32% identifying resource shortages as barriers (Mashau et al., 2016). This finding aligns with Campbell et al. (2020a), who noted that cost barriers often prevent full participation in interventions. Some participants responded resourcefully by creating home-made toys when materials were unavailable. This represents an important context-specific finding of the present study, highlighting caregivers’ adaptability in resource-constrained environments. Similar approaches have been encouraged in early childhood intervention literature, with McCoy et al. (2020) and Bergen (2021) emphasising the developmental value of low-cost, play-based activities.
Environmental limitations also included crowding and noise. Around 93.3% reported difficulty establishing an appropriate learning space, echoing findings by Mahomed and Pretorius (2022). Such barriers may reflect broader systemic inequalities and highlight the need for adaptable, routine-based interventions that integrate into daily caregiving practices, particularly in similar urban low-resource settings.
Home programme modifications
Participants strongly supported modifications to the home programme, particularly increased therapist involvement (96.7%) and the provision of props (91.7%), reflecting a desire for programmes that are responsive to their specific home environments and needs. These findings align with previous research showing that 85% of caregivers prefer active collaboration with clinicians in decision-making (Tielemans et al., 2023), and that 88% value greater access to tailored services designed to meet their unique circumstances (Markoulakis et al., 2020).
In line with Bornman et al. (2020), these findings reinforce the importance of SLT follow-up and interprofessional collaboration in home programme success. Incorporating routine follow-ups, whether in person or via WhatsApp, can improve fidelity, build caregiver confidence and provide space to troubleshoot challenges. Even brief weekly or bi-weekly WhatsApp check-ins can boost caregiver motivation, offer timely feedback and help address challenges, thereby improving the effectiveness and consistency of home programmes (Barbosa and Fernandes, 2017; Bornman et al., 2020; Skeen et al., 2023).
Clinical implications
Grounded in Vygotsky's theory of the Zone of Proximal Development (ZPD), this study highlights the essential role of caregivers as co-facilitators in supporting children's developmental progress at home. While informative, findings are based on a cross-sectional, small, exploratory urban sample and should be applied with contextual consideration. By identifying both enablers and barriers to home programme participation, the findings inform strategies for designing more functional, feasible and family-centred interventions that SLTs can implement within the South African public health context.
Leveraging digital access and caregiver strengths
The high rate of literacy and smartphone access among participants presents a valuable opportunity for SLTs to use platforms like WhatsApp to deliver programme materials in user-friendly formats (Ajani & Khoalenyane, 2023). This includes short videos, voice notes and infographics, which reduce cognitive load and ensure accessibility across varying literacy levels (Tar-Mahomed & Kater, 2022). Such approaches are especially useful in resource-limited settings, offering cost-effective, asynchronous ways to provide support and follow-up.
Reducing material costs through functional design
Financial challenges emerged as a major barrier, with over half of participants reporting that they could not afford all required programme materials. In response, SLTs are encouraged to adopt a functionality-focused approach, designing home programme tasks that rely on common, low- or no-cost items already available in the home. For example, participants in this study used recycled bottles, cardboard, and fabric to create educational tools, demonstrating creativity and commitment despite financial constraints. Building on this resourcefulness, SLTs can co-develop home-based activities using familiar routines and household items, such as using laundry time for vocabulary naming or meal prep for sequencing skills (Bergen, 2021; Hatherly et al., 2025).
Where available, community-based resource lending such as toy libraries or clinic-based prop checkouts, may offer caregivers access to developmentally appropriate tools without the financial burden. SLTs can also collaborate with community organisations to extend resource-sharing networks that support sustainable programme delivery.
Enhancing feasibility and engagement
Given the significant time constraints reported, particularly by women balancing multiple roles, home programmes must be seamlessly integrated into participants’ daily lives. Activities that align with caregiving routines, such as storytelling during bath time or language modelling while shopping, reduce the need for additional time, which many caregivers lack (McCoy et al., 2020). Additionally, the use of culturally familiar examples and translated materials improves understanding and promotes inclusive participation (Khoza-Shangase & Mophosho, 2021).
Hands-on training methods, such as live demonstrations during clinic visits, brief role-play or video modelling, help ensure caregivers feel confident in carrying out activities. Ongoing engagement can be supported through brief, scheduled follow-ups via WhatsApp or in-person, where SLTs check in, address questions and celebrate progress (Bornman et al., 2020; Perillo et al., 2023).
Finally, conducting a needs assessment prior to home programme initiation can help SLTs tailor their support by identifying caregivers’ unique constraints, such as income, time, environmental setup and technology access (Zarzycki and Morrison, 2021). This individualised, problem-solving approach ensures that programmes are not only developmentally appropriate but also contextually realistic.
Research limitations and recommendations for future research
This study offers insight into caregiver perceptions of early intervention home programmes within an urban South African public healthcare context; however, several limitations must be considered. The smaller-than-intended sample size (n = 60), drawn from a single metropolitan region, limits the generalisability of the findings. South Africa's cultural, linguistic, and socio-economic diversity means that caregiver experiences are likely to vary across provinces and rural areas, where resources and services are often less accessible (Khoza-Shangase & Mophosho, 2021). Potentially, selection bias may limit generalisability of the findings, as caregivers who attend scheduled appointments and agree to participate may differ systematically from those who do not attend or are less engaged.
Additionally, the cross-sectional nature of the study captures a snapshot of caregiver experiences at a single point in time. As such, it does not account for changes in perceptions or practices that may emerge throughout long-term participation in intervention programmes. Longitudinal research is needed to explore how caregiver engagement evolves and how environmental factors, such as changing access to financial or technological resources, influence home programme implementation over time.
Although most caregivers in this urban sample were literate and had access to smartphones, financial strain and environmental limitations still emerged as key barriers. Future studies should explore how socio-economic status affects implementation across both urban and rural contexts and evaluate scalable, low-cost models of home programme delivery. Research into culturally relevant, language-accessible strategies as well as time-flexible designs may yield more inclusive and sustainable intervention models.
Data on whether participants were receiving concurrent therapies (e.g., occupational therapy, physiotherapy) was not collected in this study. This is acknowledged as a limitation, as involvement in multiple therapies may influence caregiver perceptions of home programmes. Future research should explore the impact of concurrent interventions on caregiver experiences and implementation.
This study did not formally assess the psychometric properties of the questionnaire, such as internal consistency or construct validity. Although the questionnaire was translated into Setswana to improve accessibility, the process did not include back-translation or expert panel review. These factors may affect the reliability, validity and cross-cultural equivalence of the findings. Future research should incorporate formal psychometric evaluation and rigorous cross-cultural validation procedures to strengthen measurement accuracy and interpretability.
Conclusion
This study explored the perceptions, strengths and challenges of caregivers implementing ECI home programmes in public health settings. While participants generally expressed positive attitudes and willingness to engage, several implementation barriers were reported, including time constraints, environmental limitations, financial strain and difficulties understanding instructions.
Nonetheless, participants demonstrated high levels of resourcefulness, literacy and motivation. These strengths provide a promising foundation upon which SLTs can build more accessible and responsive home programme models. Key strategies include simplifying materials, integrating therapy into daily routines, providing culturally and linguistically relevant support and making greater use of digital communication tools to sustain engagement.
By centering caregiver realities in programme design, SLTs can foster more equitable access to ECI services and enhance the developmental outcomes of children across diverse South African communities.
Supplemental Material
sj-docx-1-clt-10.1177_02656590261467406 - Supplemental material for Caregivers’ perceptions of speech and language home programmes for young children
Supplemental material, sj-docx-1-clt-10.1177_02656590261467406 for Caregivers’ perceptions of speech and language home programmes for young children by Ingrid Bodirwa, Casey Jane Eslick, Mavis Mohuba, Marien Alet Graham and Katerina Ehlert in Child Language Teaching and Therapy
Footnotes
Acknowledgements
The authors thank the caregivers who generously gave their time to participate. Gratitude is also extended to the speech-language therapists for their support with data collection and interview coordination.
Ethical considerations
The Sefako Makgatho University Research Ethics Committee (SMUREC) approved the research protocol (SMUREC/H/103/2023/PG) on 8 June 2023. Additional approval was obtained from the Tshwane District Health Research Committee (REF: GP_202307_047) on 11 September 2023. Respondents gave written consent before voluntary participation.
Consent to participate
Informed consent to participate was obtained from all individual participants included in the study. Consent was documented in written form and included agreement to complete a questionnaire and, where applicable, an interview.
Consent for publication
Written informed consent was obtained from legally authorised individuals for anonymised patient information to be published in this article.
Author contributions
Ingrid Bodirwa: conceptualisation, data collection, data interpretation, literature review and manuscript drafting. Casey Jane Eslick and Mavis Mohuba: co-supervision, methodological guidance and manuscript editing. Marien Alet Graham: Statistical analysis, interpretation of quantitative data and contribution to the results section. Katerina Ehlert: Provided overall supervision, academic guidance and critical feedback throughout the research process. All authors reviewed and approved the final manuscript.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Data availability statement
The data that support the findings of this study are not publicly available due to participant confidentiality but are available from the corresponding author upon reasonable request and with appropriate institutional and ethical approval.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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