Introduction

The COVID-19 pandemic has caused the largest global health crisis of the past century and has raised many concerns for people’s livelihoods and survival [1]. As of July 2022, in Africa, there were a cumulative total of more than 12 million COVID-19 cases and more than 250,000 COVID-19-related deaths [2].

Amidst the spread of COVID-19 globally, governments across the world enforced countrywide lockdowns to curb the spread of COVID-19 and to minimise the loss of life [3]. The first COVID-19 case in South Africa was reported on the 5^th of March 2020 and the country went into strict national lockdown on the 26^th of March 2020 –which was scaled down over time with less severe restrictions. South Africa initially implemented one of the most stringent lockdowns as compared globally, causing substantial disruption in the labour markets, with already disadvantaged workers bearing the heaviest burden [4–7]. Over 2 million jobs were lost during the second quarter of 2020 [8]. Low-income earners working in the informal sector were disproportionately affected [9], requiring people to rely on their families for material and financial support [4, 10, 11].

As a means of mitigating these challenges, vulnerable communities in many high-income countries (HICs) were given economic assistance packages [10, 12]. The South African government established the temporary 6-month COVID-19 Social Relief of Distress grant, as well as food assistance and child support grants [13]. However, the monetary value (R350/€20,14/$21,91 per grant per month) was insufficient to cover the most basic needs of families. Many families in South Africa experienced difficulties in accessing grants, difficulties withdrawing money, long queues, and unclear payment dates [10]. The standard of living in South Africa in 2020 was (R7541/ €440, $448.30 per person per month) demonstrating that the grant provided was insufficient to cover the basic needs of families [14].

Food insecurity increased from 6% to a staggering 22% during the COVID-19 pandemic [15].

School closures in South Africa resulted in a loss of learning which further widened the existing educational disparities [16–18]. Economically advantaged schools (approximately 10% of all schooling in South Africa) were able to provide students with online learning resources [19]. While children from disadvantaged schools (±90%) residing in LMICs households lacked a quiet workspace, a computer, internet access, or caregivers with the time and capacity to take on the role of homeschoolers.

The COVID-19 lockdown had far-reaching implications for the health system and other public services. Tuberculosis (TB) testing and TB notifications have been significantly affected by the COVID-19 pandemic [20]. The under-five pneumonia mortality rate is significantly higher in LMICs compared to HICs, additionally, the effect of underlying co-morbidities such as TB, HIV, malnutrition and now the impact of COVID-19 disease and pandemic with restrains on health care system could have significant implications [21].

Children most severely affected by respiratory illnesses, especially Tuberculosis, in South Africa are often already from socio-economically marginalised homes. Further, COVID-19-related changes to health services delivery and access may disproportionately affect these families. However, limited data is available on the impact of COVID-19 on the social and economic context of families of children with respiratory illnesses in LMICs. We aimed to fill this gap by describing the experiences of families providing care to a child diagnosed with a respiratory illness (including COVID-19 and Tuberculosis (TB)) in Cape Town, South Africa. Specifically, we explored 1) the economic impact of COVID-19 on these families, and 2) the socio-psychological contexts for these children through which to understand the economic impact of COVID-19.

Methods

Sample

We enrolled a purposive sub-sample of 21 caregivers of 20 children (⩽10-years-old) enrolled in the COVID-kids study (total cohort = 124) with unclear pre-enrolment diagnosis (refer to Fig 1 for inclusion and exclusion criteria). We recruited participants between November 2020 and March 2021 for this sub-study. Participants were selected for diversity in child age, sex and respiratory illness diagnosis. Five of the 20 children had confirmed SARS-CoV-2, while 15 children had other respiratory illnesses (e.g. pneumonia, respiratory syncytial virus (RSV), pulmonary tuberculosis (PTB)). We recruited participants when the child was initially hospitalised but conducted the interviews once they were receiving outpatient care. We stopped recruiting when we had reached saturation which we determined through iterative analysis of case descriptions written as field note summaries and discussed between MA, MvdZ and GH.

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Fig 1. Inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pgph.0003020.g001

Findings

Discussion

We found that the indirect effects of the COVID-19 epidemic (and associated non-pharmaceutical responses) introduced new stressors and exacerbated existing strains for caregivers of children with respiratory illnesses in LMICs. These stressors included the experience of financial and food insecurity, loss of individual and family livelihoods as well as emotional and psychological impacts. The indirect effects of the COVID-19 lockdown in our study went beyond immediate health concerns, encompassing economic, social, and psychological dimensions. Economically, business closures and job losses led to financial instability for many families. Socially, the lockdown induced isolation, disrupted education, and strained social support networks, while psychologically, uncertainties and prolonged restrictions increased stress and anxiety, particularly for families with children having respiratory illnesses. Furthermore, the lockdown exposed and intensified existing inequalities, disproportionately impacting vulnerable populations. Most of the participants described financial hardships, with a focus on job loss and limited financial opportunities. In high-burden, low- and middle-income settings, childhood respiratory illnesses disproportionately affect families who are economically on the margins. We show how these already very vulnerable families have been further negatively impacted by the socioeconomic costs of COVID-19.

Our findings revealed that the COVID-19 lockdown had a ripple effect on families who were already struggling before the COVID-19 pandemic. These effects impacted their finances e.g., job loss resulted in the lack of providing basic necessities such as food and shelter to their families is similar to a study conducted by [28]. The ripple effect described in our study refers to the cascading repercussions of the COVID-19 lockdown on the families in our study are indicative of a sequential series of events. Notably, instances include the progression from job loss to income deprivation, subsequently resulting in food insecurity, potential loss of shelter, or heightened vulnerability to instances of violence. Illustratively, within a specific household in our study, the principal income earner (breadwinner) experienced unemployment, precipitating intra-household conflict. This finding is similar to the study by [29] that found 48.8% of families from LMIC households experienced changes in their employment for example reduced work hours, reduced pay, loss of employment and fewer leave days. The worsening economic situation of families cannot solely be attributed to the COVID-19 lockdown measures as these disparities were already existing before the pandemic. Studies have found that people globally feared that the lockdown would cause damage to the economy and ultimately cause and/or worsen poverty and hunger among many families [30]. These sentiments particularly applied to individuals working on a contract basis and/or the informal sector that offered no protection to employees. Families in HICs received a lot of support from the government such as food assistance (food stamps, meal programmes), direct financial pay-outs of $ 1400 (R 21 779,18) to all earning below $75 000 annually (National Associations of Counties, 2021). Families in HICs also had built up financial reserves while families in our setting before the lockdown were living day to day to survive. In addition, families in South Africa only received (R350/€20,14/$21,91 per grant per month) if the recipient was unemployed from the government. A decent standard of living found that in 2020 the amount for a decent standard of living was R 7541 per person per month [14]. Thus, the R350 social relief of distress grant was insufficient for families.

South Africa has a high unemployment rate even though it is classified as an upper-middle-income country with significant inequalities and has one of the highest Gini indexes [30]. These existing inequalities worsened during the COVID-19 pandemic. The primary source of income for many South Africans is through the informal economy such as casual work which was not allowed during the hard lockdown [10, 30, 31]. This finding aligns with the sentiments echoed by the participants in our study in which many families worked in the informal sector. Domestic workers and gardeners have experienced a vast number of impacts resulting from the pandemic and related restrictions. One of the main consequences of these restrictions resulted in the loss of jobs and reduced working hours. In some instances, employers stopped paying domestic workers as a result of their financial difficulties.

The impact of the COVID-19 pandemic in South Africa as in many other countries resulted in the loss of learning due to school closures, mainly in the already disadvantaged schools leading to further widening of pre-existing education disparities [16–18]. Satisfactory online learning is nearly impossible for many disadvantaged schools and learners due to insufficient infrastructure and resources both at learners’ homes as well as in schools [19]. A survey conducted by the South African Democratic Teacher Union found that nearly two-thirds of children did not communicate with their teachers during school closures [32, 33]. However, children in our study regularly communicated with their teachers and peers via social media (WhatsApp). Disadvantaged and vulnerable learners have been disproportionately affected by the impact of COVID-19 on education as they were unable to access the resources of the education system. The COVID-19 pandemic highlighted inequalities in both the provision of resources for continued learning from home for vulnerable learners such as digital devices, data, adequate nutrition and funds as well as the disparity in how well educators, caregivers and children were equipped to do so [33].

We found that families experienced increased stress due to not being able to provide the basic necessities to their families which largely stemmed from financial losses due to unemployment, reduced income and limited job opportunities [34]. Financial insecurities (including financial difficulties, perceived job insecurity and unemployment) are associated with mental health challenges [35–38]. We found that families experienced increased stress as they were unable to provide their families with the basic necessities e.g. food, shelter etc. that directly stemmed from the financial losses due to unemployment, reduced income and limited job opportunities [30, 34]. A study among families in Nepal found that families did not have enough money to arrange meals for their families due to job losses [28]. Similarly, families in our study had to depend on external family members for basic necessities and in some cases cut on meals and ration food. Another study conducted by [39] found that families that had savings managed to sustain their families but those who did not have any savings were placed in a difficult position. Similarly, we found only one family had savings that they could tap into during the pandemic while many others did not. Interestingly, two of the families in our study started their businesses to generate income to provide for their families.

Households from lower-income households were disproportionately affected by the pandemic due to compounding the effects of already high gender-based violence, rising unemployment, inequality and poverty [40]. Young parents especially those working experienced difficulties in coping with the COVID-19-related effects. Similarly, caregivers in our study experienced mental health difficulties such as stress, anxiety, worry, fear etc. especially those who lost their jobs [31]. Caregivers’ emotional and psychological impact of COVID-19 in terms of their employment and described feeling ‘held back’, ‘big adjustments and dreams being put ‘on hold’. These sentiments were accompanied by feelings of frustration, stress, worry and anxiety. Our study suggests two recurring stressors experienced by caregivers (1) finding employment and 2) the ability to provide necessities which directly impacted on the mental well-being of caregivers. These findings show the need for mental health interventions that specifically focus on coping with the indirect impact (e.g. mental health) of pandemics are required and needs to be prioritised [31, 41–43].

Studies conducted in South Africa found a strong correlation between food insecurity and psychological distress [40]. Similarly, many of the caregivers in our study experienced emotional and psychological difficulties. However, despite these challenges, caregivers in our study remained resilient and accepted the ‘new normal’. Economic hardship, food insecurity and parenting stress increase the risk of violence such as GBV [44–47]. Many South Africans experience financial hardships and food insecurity during the pandemic due to reduced working hours and job loss, which may worsen an already stressful household situation. Similarly in our study, two caregivers reported experiencing GBV due to the job loss of their partners and the frustration of being confined [44]. The experiences of violence increased during the COVID-19 pandemic and the most common forms were verbal abuse followed by sexual harassment [48].

A strength of the study is that it explored the experiences of families caring for children with respiratory illnesses residing in an LMIC. Another strength of this study is that it led to a further understanding of the impact of the COVID-19 pandemic on families and provides insight into the effects of the lockdown measures on South African families. Limitations of this study include the small sample size and the fact that the study was only conducted in Cape Town, South Africa, limiting generalizability. Our study does not represent the experiences of children with respiratory illnesses who either did not seek care at all or who sought care at only primary or secondary care facilities. However, we believe that the core ideas that a pandemic and its responses have multiple, compounding impacts on children and their families is robust. Our data can be used to explore this further in future studies. Lastly, we did not explore the ability of participants to access the unemployment insurance fund (UIF), which was an option to get monetary government support and which could have partially mitigated some income loss.

This study provides insight into the gaps in the government’s response to the COVID-19 pandemic and how families that were already struggling financially from South Africa were disproportionately affected by the pandemic. This study can assist policymakers and the government in working on strategies to support families from South Africa and other LMICs when faced with a pandemic. In addition, this study highlights the gaps in mental health service provision for families in crisis. Mental health interventions as well as support services are required as they could assist in providing individuals and their families with coping skills. These services will not solve the problems related to job loss and unemployment but they could help individuals cope while they embark on a journey to secure employment. This study revealed some gaps in the government’s strategy to support vulnerable families during an outbreak like the COVID-19 pandemic. Further research is needed about the emotional and psychological impacts of pandemics on families and there is a need to develop strategies to enhance family’s well-being. The indirect impact of a future pandemic should be more carefully considered including global support for relief packages to support families living in South Africa and other LMICs. These interventions are not only relevant to the COVID-19 pandemic but also more generally, in the context of South Africa with persistently high rates of unemployment and social ills such as GBV. Policymakers are advised to consider the interconnected cascade of effects from our study when addressing future pandemics, acknowledging the catalytic role of job loss in triggering adversities such as income loss, food insecurity, potential homelessness, and increased household violence. Formulating comprehensive responses is essential, incorporating targeted measures like social support mechanisms, employment retention initiatives, financial assistance programs, and conflict prevention measures. Tailored policies should be informed by a nuanced understanding of specific vulnerabilities within households, as demonstrated by the experiences of primary income earners in our study, necessitating a holistic approach to effectively mitigate these indirect effects across diverse sectors while simultaneously addressing the direct health impacts of pandemics.

Acknowledgments

We would like to thank all the study participants and their families who were willing to participate in our study. We would also like to acknowledge the study staff and the support staff at Stellenbosch University, Desmond Tutu TB Centre for their dedication and assistance throughout the study.