Socio-cultural factors influencing preschool enrolment in a rural cohort exposed to early parenting interventions in Pakistan: A qualitative study

Abstract

Early parenting interventions have shown to be effective for changing parenting behaviours to provide stimulation at home. However, evidence about the effect on decision to timely enrol the child in preschool and the related pathways is scarce. A follow-up study of a rural cohort exposed to early parenting interventions in the first 2 years of life in Pakistan though indicated benefits for children’s cognitive skills and learning environment at home but did not improve preschool enrolment rates. The aim of this study was to explore stakeholder knowledge, attitudes and perceptions about preschool education that may influence parent’s decision of enrolment. A qualitative study using a phenomenological approach was conducted. Data collection methods included focus group discussion and in-depth interviews with the parents and the teachers and observations of selected preschools. An emergent thematic analysis was followed. Findings showed that community attitudes related to their role in children’s preschool education (e.g. lack of parental involvement), and their perceptions of stakeholders’ responsibilities and accountability (child being responsible for own motivation and interest to learn) were barriers to preschool enrolment. Facilitators included quality of preschools and older siblings enrolled in the school. Early parenting interventions may be insufficient to change community perceptions of preschool education in disadvantaged contexts with dysfunctional education systems. Targeted strategies addressing socio-cultural barriers for early learning are needed.

Keywords

Early parenting interventions Pakistan preschool enrolment qualitative study sociocultural factors

Introduction

In 2013, 59 million children of primary-school age were out of school worldwide. An estimated 20 percent of these children had dropped out of primary school indicating that schools fail to retain these children. Data on learning achievement suggest that between 40 percent and 90 percent of children fail to achieve even minimum levels of proficiency in reading alluding to poor quality of education which is also a major barrier to retention (United Nations, 2016). When schools fail to provide quality education as indicated by poor learning, parents are less likely to enrol children in school (Wiegerová & Gavora, 2018). Experts have recommended that for countries to meet the goal of universal primary education, they need to work on the following two strategies: getting out-of-school children into school through addressing demand and supply side barriers while also retaining them by implementing solutions to improve quality of education (Birdsall et al., 2006). One proven strategy to increase enrolment and retention in pri-mary school has been investment in quality early learning or pre-primary education (UNESCO, 2016).

In Pakistan, an estimated 22.8 million children aged 5–16 were not attending school representing 44 percent of the total population in this age group, which was the world’s second-highest number of out-of-school children (National Education Management Information System & Academy of Educational Planning and Management, 2018). Similar to the global data, in Pakistan too much of the drop out is early, and every sixth child in the first grade does not transfer to the second grade (UNICEF Pakistan, 2013). A report on Education for All (UNESCO, 2014) suggested that the likelihood of children reaching the primary enrolment target of at least 95 percent enrolment in pre-primary school by 2015 is unlikely. Pakistan is also 1 of the 10 countries that account for 72 percent illiterate adults in the world. Pakistan dedicates less than 3 percent of gross national product (GNP) to education, cutting spending on education from 2.6 percent of GNP in 1999 to 2.3 percent in 2010 (UNESCO, 2014). Despite policy provisions for preschools since the 1970s, education indicators for preschool age children are still very disappointing with only 24 percent attending preschool, 25.1 percent attending primary school and 51.2 percent out-of-school (UNICEF Pakistan, 2013). Out-of-school preschool aged children are more likely to be girls than boys; to be rural than urban; to be from poorer households than richer households further enhancing inequities (Sindh Education Foundation, 2007).

Literature suggests that a host of complex and varied factors affect preschool enrolment ranging from national commitment to socio-cultural factors. Several aspects surrounding the family can play a major role in affecting the preschool enrolment of a child. According to Becker’s (1973) Model, family maximizing their income is what defines the likelihood of a child to receive preschool education. Another reason that impacts children’s preschool enrolment is the parent’s own educational levels and value (Okantey, 2008). Indicators such as household composition (Marjoribanks, 1996) and parental occupation (Hanushek & Ludger, 1992) play a role in decreasing the enrolment rates whereas, other parental sociodemographic factors are also crucial when it comes to getting their children enrolled for preschool education. Moreover, parental commitment to ensuring timely enrolment for young children is also an important aspect of successful school transition. A characteristic of supportive families is the learning environment provided in the home, including parents’ engagement with their children in learning activities such as singing, reading books, telling stories and playing games (Bradley & Corwyn, 2005). Responsive relationships within the family are the building blocks of children’s social and emotional development, which are required for success in school. Children of responsive mothers have better developmental outcomes forming the foundation of early learning (Eshel, Daelmans, Mello et al., 2006; Richter, 2004).

Supportive parenting and stimulating home environments have also been shown to be among the strongest predictors of school performance during primary school (Belsky et al., 2007; Bradley & Corwyn, 2005; Downer & Pianta, 2006). Parents’ educational goals, beliefs, attitudes and commitment are considered crucial for school success. Families knowledge about how to support their young child’s early learning, development and transition to school, enables them to foster stimulating home environments, have educational goals for their children, and ensure timely school enrolment for young children (Arnold et al., 2007; Black et al., 2016; Britto, 2012; Downer & Pianta, 2006). Early parenting interventions and preschool programmes are two broad closely connected areas of evidence-based interventions to improve caregiving skills of parents to promote children’s preschool attainment (Black et al., 2016). Early parenting interventions, in the first 3 years of life, are typically designed to improve family’s readiness to support their young child’s early learning by enhancing parent–child responsive interactions, and parenting behaviours, knowledge and practices that support the provision of a stimulating early learning environment at home (Britto et al., 2016; Eshel et al., 2006). Recent meta-analyses of parenting interventions implemented in low- and middle-income countries (LMICs) reported short-term benefits for children’s cognitive, motor, and psychosocial development (Aboud & Yousafzai, 2015; Britto et al., 2016; Naudeau et al., 2011). Few studies have longitudinally followed cohorts exposed to early parenting interventions into adulthood. One exception is the ‘Jamaica Study’, which found that children who were enrolled in an early parenting and stimulation programme had higher cognitive outcomes, school enrolment rates and academic attainment, and reduced risky behaviours in young adulthood than the comparison groups (Walker et al., 2005, 2011). While transition to preschool was not studied in the Jamaican population, it can be speculated that one factor contributing to the long-term success of the early parenting intervention was that young children were able to take advantage of subsequent early learning opportunities in a context with high preschool enrolment rates (Aboud & Yousafzai, 2015)

Parenting interventions when followed by access to preschools benefits children’s school readiness and school performance (Britto et al., 2016; Rao et al., 2014). Using data from 133 countries, Mingat and Jaramillo (2003) found that 80 percent of children completed primary school following exposure to a preschool programme compared to a 50 percent completion rate in the absence of a preschool programme. However, continuity of quality learning environments may influence the long-term impacts of preschool participation. The effectiveness of preschool interventions is mediated through structural features of quality (e.g. lower teacher-to-child ratios, availability of developmentally appropriate learning resources) and process features of quality (e.g. interactions between teachers and young children) (Arnold et al., 2013; Britto et al., 2016; Engle et al., 2011; Rao et al., 2014). Zhai et al. (2012) examined data from the Chicago School Readiness Project (CSRP) in the United States and found that exposure to the CSRP intervention had longer term significant effects on academic and behavioural outcomes for children who subsequently attended high-performing primary schools, but no significant effects on children who attended low-performing primary schools. In other words, maximum developmental gains from early intervention programmes for children is more likely if there is continuity in high-quality early childhood services from birth to school age especially in contexts of higher risks to child development and learning. This bundle of early life interventions is also reflected in the Sustainable Development Goal (SDG), target 4.2, which highlights school readiness achievement through access to programmes that promote early care and development as well as preschool services (Arnold et al., 2007; Rao et al., 2014; Richter et al., 2017).

There is an emerging body of research in early childhood development (ECD) and learning in Pakistan that can inform strategies for promoting preschool enrolment and participation. The Pakistan Early Development Scale-up (PEDS) trial, a cluster randomized factorial trial evaluated the effectiveness and feasibility of community health workers (CHWs) of a national programme to deliver early parenting, stimulation intervention integrated within their curriculum of child health and nutrition intervention for children in the first 2 years of life. The CHWs were trained as part of the trial to coach mothers to engage the child in developmentally appropriate play activities while responding to the child’s cue strengthening responsive interactions. The early parenting and stimulation intervention significantly benefitted children’s cognitive, language and motor development (Yousafzai et al., 2014) and enriched the home learning environment (Yousafzai et al., 2015) when children were 2 years old. A follow-up study found sustained effects on children’s cognitive capacities and prosocial behaviours and learning environment at home at 4 years of age. However, only 25 percent of the cohort was enrolled in preschool and there was no significant difference in enrolment rates between children exposed to the early parenting interventions and the comparison groups (Yousafzai et al., 2016). The PEDS trial setting provided a unique opportunity to explore the reasons for low rates of preschool enrolment despite gains from exposure to an early parenting intervention. The finding could inform future parenting intervention of specific strategies to promote preschool participation and enhance children’s readiness for school. The objective of this study was to identify socio-cultural factors that can be barriers or facilitators to preschool enrolment in a rural cohort exposed to early parenting and stimulation intervention in Pakistan.

Methods

We followed the recommendations of the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007) when reporting the methods, results and discussion of this study.

Study site and population

The study was conducted in district Naushahro Feroze, Sindh, Pakistan in the same communities that had participated in the PEDS trial. Naushahro Feroze is a predominantly rural district. The average monthly household income is PKR 9000 (approximately US$100). As reported by Yousafzai et al. (2016), on average, women had completed 2 years of education, and men had completed 7 years of education, and rates of childhood stunting (retarded linear growth) were high with 60 percent of children stunted by 24 months of age. In Sindh province, the net enrolment rate in primary schools is 52 percent. Gender disparity in the province is high with only 66 percent of girls completing primary education compared to 77 percent boys (UNICEF Pakistan, 2013). The drop-out rate from primary school is as high as 45 percent and attributed to the inaccessibility of schools and the poor infrastructure of government schools (Sindh Education Foundation, 2007).

Ethical approval for the study was received from the Ethics Review Committee of the affiliated university. Informed consent was read aloud by a trained research assistant. Stakeholders provided written consent or thumb print. They were allowed to leave the interview if they felt uncomfortable. Refreshments were provided after each interview for the participants. Since, the study was part of a longitudinal follow-up of a cohort, the team had established a relationship with the community. Another facilitator for the qualitative interviews was the fact that the data collection team belonged to the same community and spoke the same language.

Study design

The study adopted a qualitative approach with a phenomenological design defined as ‘the study of lived experiences of people’ which attempts to interpret the essence [core meaning/s mutually understood] of the experience’ (Creswell, 2013). This qualitative study design facilitates exploration of the personal meaning underpinning the actions of the community in their specific social environment. The inductive nature of qualitative research methods enabled an exploration of the issues relating to behaviours which influence the period of school readiness (transition from home to school) in Naushahro Feroze that were actually experienced, or perceived as important by the stakeholders in this setting.

Sample selection

Participants, identified in advance of interviews, were selected using a purposive sampling strategy (Table 1). Representation of participants and schools was selected from each of the four intervention arms of the original PEDS trial setting: Responsive Stimulation (RS); Enhanced Nutrition (EN); Combined Interventions (RS+EN); Standard Care (SC) as described in an earlier publication of the work, (Yousafzai, Rasheed, Rizvi et al, 2014). Inclusion criteria included being resident of the trial arm and having a child between 3 years and 5 years of age (eligible for preschool enrolment). In the trial, lady health workers (LHWs) delivered parenting interventions for children less than 2 years old and their caregivers. They were included as an important stakeholder to share reflections from their perspective about the factors that affect parental decision to enrol their child in preschool. Since, at follow-up, no significant differences in the preschool enrolment rates between the four intervention arms were found, respondents from all four trial arms were selected.

Table 1.

Study sample for qualitative interviews.

Original intervention groups	Mothers	Fathers	Teachers	LHWs	Total
Responsive stimulation	1	1	1	5	8
Enhanced Nutrition	1	1	1	5	8
Combined interventions	1	1	1	4	7
Standard care	1	1	1	5	8

Combined intervention means Responsive Stimulation and Enhanced Nutrition.

LHWs: Lady Health Workers.

Six to eight parents participated in each focus group discussion (FGD) and the groups were homogeneous with separate discussions for fathers and mothers. For the in-depth interviews (IDIs), teachers were identified from government primary schools, and 19 LHWs were selected from the 80 who were part of the original PEDS trial. A total of 17 schools were observed ensuring representation of private and government schools across the study groups to assure a complete picture of the preschools is available (Table 2). To cover the larger representation of government schools and largely rural population, the sample was selected using stratified purposeful sampling on 25:75 ratio for private:government from a list of schools available for the research site.

Table 2.

Study sample of observed schools.

Original intervention groups	Government	Private	Total
Responsive stimulation	3	2	5
Nutrition education	3	1	4
Combined interventions	3	1	4
Standard care	3	1	4
Total	12	5	17

Combined intervention means Responsive Stimulation and Enhanced Nutrition. In total, 2 girls’ schools and 15 mixed schools were observed, but boys were also formally enrolled in girls’ schools.

Data collection

FGD, IDIs and school observations were conducted from September to December 2012. Qualitative data were collected in Sindhi (the local language). Interview guides were developed by the research team, and were informed by the study objectives and the available literature from Pakistan and other LMICs on barriers and facilitators to preschool and school enrolment in similar rural contexts. The topics explored in the interviews were the following: intent of sending child to school, choice of school, factors influencing enrolment choices (including exposure to early childhood interventions), perceived significance of early childhood education. The interview guides were piloted prior to data collection. Pilot data were reviewed and modifications were made to topics where needed to enhance clarity, reduce redundancies, and fill gaps. The pilot interviews were not included in the main analysis.

The data collection team was provided with a 3-day qualitative data collection and management training led by the first and second authors. The training topics were understanding the study objectives, principles of qualitative research and the management of qualitative data. The training also included practice of moderating FGDs and IDIs, note taking and transcription. Practice interviews were observed by the trainer and feedback provided. Observation of data collection and feedback by senior members continued during pilot data collection.

The FGDs and IDIs were audio recorded with consent from participants. The duration of the FGDs was between 40 minutes and 50 minutes and for the IDIs between 30 minutes and 40 minutes. Data collection was stopped once a point of saturation was reached (i.e. no new information emerged). For school observations, data were collected through direct observations of government and private primary schools by a trained research assistant and data were recorded on a structured observational form. The form contained both types of data: quantitative and qualitative notes to explore maximum aspects of a primary school environment. During this observation, short semi-structured interviews were done with teachers and students. The data of the learning process in preschool and grade 1 classes were also collected through direct classroom observation. Data were collected on the quality of the infrastructure and the learning environment for preschool and first grade students, which may have been a multi-grade setting. The domains observed included teacher-to-child ratio, availability of clean water, availability of learning resources, access to learning resources, availability of space for physical play and teacher–child interactions. Observational notes were supplemented with photographs.

Data management, quality assurance and analysis

Transcription was supported by eight members of the field data collection team, which consisted two interviewers, two note-takers and four research assistants to support transcription.

Dropbox was used to support data management. Folders contained topic guides (drafts and comments), audio-recordings, raw transcripts and coded transcripts. Data were recorded, translated and directly transcribed (transliterated) from Sindhi to Urdu (the national language). Back translations of transcripts were completed to ensure validity of meaning was retained. The translated transcripts were entered to MS Word for analysis and Atlas TI (version 6) supported data management. Only the research team had access to the team Dropbox and the files removed after the close of data collection.

The iterative nature of qualitative approaches allowed for continued review of data collected (audio-recordings) and discussions with the data collection team to inform any modifications to interview guides and to provide feedback to moderators and note-takers for quality assurance. The data collection team participated in daily debriefings led by the field-based supervisor (who also led data collection for observation of school) and regular Skype meetings with the analysis team, who were not field-based, were conducted to support the iterative process.

The analysis (generation of themes and coding) was managed together by two senior members, ensuring quality, enhancing objectivity and reducing bias. Analysis was completed in Urdu. A systematic analysis process was followed. Each researcher familiarized herself with the raw data and noted her reflections from the nascent transcripts of the first four interviews transcribed. In the next step, both researchers met and discussed their themes and reflections to agree on the parent and sub-themes that were identified using an emergent approach. A ‘Thematic Coding Dictionary’ was developed describing the scope of each main theme and sub-theme. The thematic coding dictionary was placed in the Dropbox folder. The remaining transcripts (n = 27) were divided between the two researchers and coded independently. During this process, any new parent theme or sub-theme was added to the thematic coding dictionary. After the completion of thematic coding of transcripts, two random transcripts coded by each researcher were selected for review by the second researcher. Any disagreements on themes were discussed and coding updated. Transcripts were then entered into Atlas TI (Version 6.0) by the first author to facilitate the organization of data. A coding report was generated for each theme

A narrative on each theme was then prepared summarizing the quotes into a meaningful summary. All narratives were reviewed by the team. Feedback was provided on each narrative to reduce subjectivity. Additional perspectives or disagreements on the narratives were discussed and incorporated in the narrative summaries. The analysis team (first and last author) then compared and contrasted thematic narratives for further analysis to understand interconnections and linkages between themes in several meetings. Linkages were drawn on charts for clarity. Data were triangulated from multiple sources and stakeholders, verifying the repeatability of an observation or interpretation and also highlighting distinct differences. A preliminary report of the findings was shared with the data collection team for their feedback, who represented a greater closeness to the community perspective of the phenomena being explored.

Research team and reflexivity

The field data collection and analysis team comprised 11 persons. The data collection team members (n = 9) including the team for interviews and school observations was bilingual (Urdu and Sindhi). The interviews were completed by two interviewers/moderators assisted by two note-takers. All four women were from the local community with 14 years of formal education. They were not part of the original PEDS trial and were hired for this study reducing the likelihood of bias about the potential influencing role of exposure to early childhood parenting and stimulation interventions. The data transcription team comprised four research assistants, all from the local community, with a minimum of 14 years of formal education.

The analysis team included two authors who had been involved in training and overseeing the original trial and while they had minimal direct interaction with the community, their closeness to the study phenomenon helped identify nuanced themes which might otherwise have been missed. The analysis was completed in Urdu because the analytical team had only basic–moderate knowledge of Sindhi, but was fluent in Urdu. Sindhi is close to Urdu and this property supports a reliable translation.

Results

The section depicts the findings of 31 interviews conducted and 17 schools observed. The total sample consisted of 70 percent government schools and 30 percent private primary schools. The demographic characteristics of the schools observed are presented in Table 3.

Table 3.

Demographic characteristics of schools observed.

Indicator	Source of data: O, I, V	Private schools: n = 5	Government schools: n = 12	Total:n = 17
Total teachers median (range)	V	18 (9–24)	6 (1–22)	9 (1–24)
Male teachers median (range)	V	6 (0–9)	3.5 (0–16)	4 (0–16
Female teachers median (range)	V	12 ( 0–24)	0 (0–22)	0 (0–24)
Education level of teachers (years) Min–Max	I	12–16	10–16	10–16
Number of classrooms median (range)	V, O	8 (6–29)	4 (1–13)	6 ( 1–29)
Number of girls:boys	V	1:1.6	1:1.5	1:1.6
* Number of students with disabilities	V, O	3	1	4
Number of schools with a management committee	V	4	14	15
Preschool classroom
Number of schools with separate classrooms	O	5	2	7
Number of schools with multi-grade classrooms	V, O	0	8	8
**Number of schools with other spaces	O	0	2	2
Number of teachers median (range)	V	1 (1–2)	1 (1–2)	1 (1–2)
Number of girls:boys	V	1:1.5	1:1.4	1:1.4
Average teacher:child ratio	V	1:52	1:46	1:46

I: Interview; O: Observed; V: Verified by administrative records.

Child had weak eyesight.

Under a tree, in the corridor.

Along with providing free of cost education and having no tuition fees, the Government primary schools (100%) also provided academic books for free. The families had to pay for uniforms and lunch for their child.

The private schools were divided as per the monthly fees charges for children enrolled in their schools. The definitions were decided by the research team, based on the available fee database of schools in the study district. About 40 percent of private schools charged a low monthly fee which is Rs. 100–Rs. 300¹ and the rest of the schools charged a moderate monthly fee, Rs. 350–Rs. 600. While there was no school charging a high monthly fee, that is, Rs. 650 and onward and the cost of private education in Pakistan can exceed more than Rs150,000 per month on fees alone elsewhere in the country.

According to the analyses, several themes were identified from the interview transcriptions (Table 4). Furthermore, the findings indicate certain socio-cultural factors influencing parents’ decision of preschool enrolment being identified at multiple levels: child-related (e.g. motivation, self-care abilities, health and nutrition), parent-related (e.g. involvement, affordability), teacher-related (e.g. ability to use learning materials, attendance), school-related (e.g. infrastructure), community-related (e.g. poverty) socioeconomic class-related ECD programme-related (Table 5). Along with the socio-cultural indicators, this section also presents a brief discussion and recommendations for future intervention strategies.

Table 4.

List of ‘main themes’ derived from the qualitative analysis process.

General education themes
Aspirations for children Perceived benefits of early childhood development programme Perceived benefits of education Perceived benefits of preschool Challenges for providing an education School expenses School dropout Facilitators for providing an education Attitudes about education of girls Perceptions about school quality The perceived differences between public and private schools
Early childhood development themes
Knowledge of early childhood development Lady health workers’ sustained delivery of early childhood development programme
Preschools and school readiness themes
Motivation to teach Parents’ role in school readiness Challenges experienced by preschools Preschool curriculum Preschool enrolment age Preschool learning resources Preschool teaching approaches

Table 5.

Factors that influence parent’s decision of preschool enrolment.

Factor	Quote
Child-related
Motivation	It has been long [since he left school] there was no interest. (Mother, FGD, RS + EN group) Child had no interest [in going to school] that is why we left the decision on him [to not attend school]. (Father, FGD, RS + EN group)
Child health and nutritional status	The community observes their children that who is healthy, or unhealthy, stays sick and does not go to school. When the child is restless or unhealthy they do notice that and whenever they are asked they tell you that the child cannot go to the school because he is not healthy enough. (LHW, IDI 5, EN group) If the child would be healthy then he would develop properly and stay active. (LHW, IDI 1, RS group)
Parent/family-related
Parental involvement	Their parents pay less attention to those children. They say that a certain person has studied but has gained no benefit. Therefore it is better that we rear cattle and cows. (Teacher, IDI, SC group) This is the problem of the community. They would talk to you and then they would not take interest. (Teacher, IDI, Standard Care group)
Knowledge of ECD	When he learns how to talk, he starts taking instructions from mother and father, recognizes siblings, tells only by looking that if they are going to the school then I will be going too and then consequently eats khichri [local dish made from rice and lentils] and also eats with other children. This would build interest in the child that he will also go to study. (Mother, FGD, RS group) We first check children whether they can sit, stand or walk independently and are he able to go to the toilet independently. If the child doesn’t perform toileting process without any assistance, then how would the child attend school as it would be unhygienic which wouldn’t be right. (Father, FGD, EN group) This is how it [early learning] happens here. Parents teach their child so that when they grow up to become an adult they will know how to respect their elders and how to behave with children. When we perform household chores or observe someone doing household chores we get to learn it. Secondly we have games . . . when games are played according to the rules or we watch dramas, we also get to learn how to do a lot of things. [Father, FGD, EN group] Some things will be taught by parents, some things will be taught by teachers, some things he [the child] will learn through reading. Some children learn to perform the task just by observation, which is a positive thing. (Father, FGD, RS + EN group) Firstly, they [children] will learn on their own gradually in their childhood. If they don’t learn then the parent will teach them [children]. (Mother, FGD, RS + EN group)
Affordability	We provide the child with whatever they need: uniform, books, pen and slate. The poor cannot send their child to school. (Mother, FGD, EN group) They don’t go to the school due to extreme poverty. They are a lot of people who work along with going to the school. (Father, FGD, EN group)
Aspirations	It is important and necessary for children to learn. Without education, children will not learn to respect [their] elders or learn morals. Neither would they gain education or religious knowledge, which would result in them being disadvantaged and ignorant. (Father, FGD, RS + EN group) We will support our son to be educated as much as we would like to. We will bear the expenses, we will send them to the city for higher education. [Father, FGD, RS + EN group] We want them to study and work and even if they don’t work they should at least gain education so that they are better able to take care of their in-laws and husband. (Father, FGD, RS + EN group)
Older sibling enrolled in school	School is near, and we can send our children from an early age, around three years old, only with the older children. (LHW, IDI 1, EN group) A four-year-old child is not able to take care of himself. [Hence sending with an older sibling is helpful]. (LHW, IDI 1, EN group)
Social capital	Teachers are from our own village and the school is near to our house. We send the child to the school after bathing them by carrying them in our arms to cross the road and drop them at the gate. This makes me satisfied. (Mother, FGD, RS group)
Community-related
Community norms	But now the circumstances have changed and the girls have become independent. Now that can act on their own will. This is becoming a big problem for the villagers as they have been doing court marriages. (Teacher, IDI, Standard Care group) We want them (girls) to attain higher education and if God wills can pursue a job. Regardless of a job, they should serve their in-laws. (Father, FGD, EN group) I wanted to study and secondly there was no teacher (female) in my village. I always wanted to start a school in my village once I complete my education. Teachers who were appointed would stay for a week. Children would be in the school without a teacher and hence I decided to be a teacher. (Teacher (female), IDI, RS group) Children of the land lord in the village pursue education and we use the as role models to motivate out children. I am a farmer, I plough the field but I motivate my children to study and find a better job. (Father, IDI, SC group)
Teacher-related
Absenteeism	There is no teacher in the school. (Father, FGD, SC group) We will request the government to provide whatever limited amount of teachers we have with the training. The training they used to give once a month would be fine if they do it once every three months where they would train the teachers and provide them with the lectures on PTC. (Teacher, IDI, RS + EN group)
Teacher–student ratio	The reason is that there are a lot of children and very few teachers. At times they are able to handle them, at times they cannot and they don’t hit the child if he refuses to go to the school. (Father, FGD, SC group)
Lack of teacher training	Teachers do not teach and if we complain then they provide our boys with the lessons to read but do not review it in the morning and move directly to the next topic and the same pattern is followed for the next lesson too. Why do they provide them with the next lesson [when the first one is not clear yet]? (Father, FGD, SC group)
School-related
Infrastructure	The government doesn’t spend on the school. Now you see, the ceiling is broken even after the enrolment of 300-400 children. (Teacher, IDI, EN group) Now we have rooms in our school but at this moment if you see, the ceiling has fallen which has injured a few of our students. (Teacher, IDI, EN group) We do not have separate classes here nor do we have any separate teacher’s office. A teacher teaches 2-3 grades at a time and this is how it is taught in every class. (Teacher, IDI, SC group)
Poor hygiene	At the moment there are no problems but when it rains it creates a lot of problems. School’s ground gets filled up with the water, drinking water becomes unavailable. So when children need to drink water during school to have to go to the village to get the water. (Father, FGD, RS + EN group)
Insufficient resources	In our school, the children are taught through rote learning which is not the most effective at this age. (Teacher, IDI, EN group)
Distance	There are some villagers who talk about how children used to get kidnapped. Girls used to be blackmailed and kidnapped when schools were far away. Now they are provided with the facility of girl’s education. Previously they used to walk 1 km. (Teacher, IDI, SC group) Let us talk about our school. The school is located in the village only therefore there are no traffic problems or calling of strike that could result in parents saying that they cannot send their children due to unstable conditions. Furthermore, our teachers are the natives of the same village as the children and school is very near for them. (Father, FGD, EN group) There should be schools for higher education in every village. There is a school in this village till 8th grade. So the children of this village will study till 8th grade. Those who are poor tell their child that being an 8th grader is enough and they should quit because they do not have money for the bus fare. There should be school till at least 12 grades here. (Mother, FGD, RS group)
Registration of preschool children	First of all, in pre-primary classes, we do not complete a formal registration [enrolment] of the children. We give admission without registration. (Teacher, IDI, SC group)
Socioeconomic class-related
Inability to meet expenses	Even though there is free education in government schools, it is still very problematic for a poor person who does not have any means to earn. Hence, he will try harder to indulge his child, whether the child is five or eight years old, to find a job in order to cover household expenses. (Teacher, IDI, RS+EN group) The expenses are that firstly, monthly fees for every child in nursery is Rs. 350. Apart from this, when the child goes to school, we give him/ her Rs. 10 to buy and eat lunch in halftime, and the young children also tear books, hence we have to buy new ones either on the next, third, fourth or fifth day. We also pay the transportation fee. (Father, FGD, RS group) The main expense is their fees. He (the child) is now studying in third grade so the fees is Rs. 500 and the tuition fee is Rs. 200. We buy good books and things for them. The private schools’ books are good but expensive. We also give them Rs. 10 or 20 to spend, and also send roti (bread). (Mother, FGD, Standard Care group)
ECD programme-related
	(Research) team has provided us with immense knowledge and motivation which we would have never thought of. They advised us about nutrition of the child, to feed him on time. Also about growth and developmental monitoring. Nobody has ever advised us before in the same way. (Mother, FGD, RS group)After your program a lot of people are aware now. (LHW, IDI 1, EN group)Now they play with them on their own with the children and after the program we go with them and ask them about it. Now after the ECD program, they have started to note what the child has learnt and if the child is able to do one thing then what will the child learn if the child is made to do a bit of a different game. (LHW, IDI 1, RS group)Previously we did not provide the children with the books. The children have started showing interest and want to go to the school since they are provided with the books and now they also tell us that this is a dog, this is a cat and do everything with interest because they have now gotten their books. (LHW, IDI 3, RS group)The difference that came up is that the child who used to talk pointlessly and use slangs has gotten smarter since they have been sent outside to study in KG. The children now stay neat and clean and do not use slang. This pilot has benefited ECD a lot. (LHW, IDI 4, EN group)

ECD: early childhood development; EN: enhanced nutrition; FGD: focus group discussion; IDI: in-depth interviews; LHW: lady health worker; RS: responsive stimulation; KG: kindergarten; PTC: primary teaching certificate; SC: standard care.

Child-related factors

This portion explores the challenges faced by the parents and children that act as a barrier and prevent from school enrolment and attendance. In spite of being aware of the hurdles, there was a striking finding where parents held the child responsible for her own school performance and drop out. Another child-related barrier identified by LHWs was children’s health and nutrition as important factors that can affect a child’s attendance and performance at school.

He’ll go to the school once he is healthy. (LHW, IDI 1, SC group)

Parent/family-related factors

The majority of teachers shared that to improve the provision of preschool and primary education, there should be a strong cooperation between teachers and parents. They also showed concern on the child’s age by saying that young children get fatigued easily and their attention span is less. However, they further added that the curriculum and learning material does not seem to be designed for children as it was unable to enhance their attention and motivation.

Moreover, the responses revealed that the facilities available in the schools and teachers’ or government support was not enough for parents to earn their involvement to promote preschool education. According to the teachers, the biggest challenge was parents’ attitude towards school. It was clearly evident from the child’s irregular attendance at preschool level. The parents took least interest in their child’s progress. The teachers further suggested that if parents were being called, then the parents should come to discuss any challenges or issues that are being faced by the family. However, the parents express that their attitude towards preschool was linked to the significance emphasized by the school management. Since these children are not even registered, the parents tended to care less.

Another factor that altered parents’ mind-set was the child’s age and their aspirations. As per the teachers, the parents hold this belief that older children require more attention at school. This causes them to divert attention from children who are in their early years. The parents believed that as the child ages, he/she becomes more attentive towards studies. However, once the child is enrolled in higher grades then they realize that he/she requires proper attention since early years of education.

Interestingly, a trend was observed whereby the stakeholders held each other responsible with teachers believing parents could be more involved in their child’s education and parents laying responsibility on teachers’ attendance. This seemed like an ongoing debate which could only be resolved if each party was aware of its responsibilities.

Teacher-related factors

Several teacher-level challenges emerged of which the most common one, as expressed by all the participants, was the teacher–student ratio, teacher absenteeism and lack of training.

Through school observations, it was revealed that in one of the schools, the teacher used to reach late to classes and the students used to wait for him outside the school. Moreover, as per the students, he was often absent as well. The students expressed their love for school but also complained that they were not receiving a proper education. Moreover, in a school in a rural community, it was observed that a boy was hired by a teacher of the government school to teach the class on his behalf. After inquiring the reason behind this, it was known that the actual teacher was running a shop in a nearby town and since there was no concept of extra shifts in the schools (i.e. morning and afternoon sessions for different groups of enrolled students), he had to hire a responsible student to avoid the compromise of students’ time and studies.

In addition to this, during observations, teachers also demonstrated certain inappropriate behaviours that were not conducive to learning and also had disturbed interaction with the young kids. Comparatively, teaching in a loud tone and shouting was more common among young teachers. The teachers also used verbal threats during the teaching sessions for example, they would prohibit students from taking a break or threaten to call the principal if the students would not read correctly or stop talking. However, a few teachers still depicted positive behaviours such as encouraging students in various activities while the older teachers preferred and used affectionate teaching methods. The overall interaction of teachers with their students was poor which was categorized as being less responsive to students’ request, infrequent praise and encouragement and less initiation in affectionate talks. Even though there was no significant difference between the interaction of private and government school teachers, however, it was observed that private school teachers displayed more negative behaviours as compared to the government schools. Moreover, the schools face the issue of limited learning material, however, the teachers still do not utilize the limited resources available for example, picture charts only.

Another key challenge noted by a few fathers was a low teacher to child ratio with multi-grade classrooms further added to the complexity, making it a barrier to individual attention or child-friendly discipline strategies. One of the participants shared similar views by asking the following question:

How can a single teacher manage all the students of a village? (Father, FGD, RS group)

While few teachers also mentioned that teaching young kids is by itself a big challenge. Similarly, a participant stated that despite having 10 teachers or 20 students, they still cannot handle them because of the disturbances created by the students:

If the students are sitting together, how can they study properly? The teacher keeps trying to calm the loud noises. Whether there are ten teachers and twenty students, the teachers still can’t handle them. (Teacher, IDI, SC group)

Another issue that hindered preschool education was most of the teachers being untrained in the private schools. The teachers stated in the interviews that most of them were newly appointed and were mostly given the responsibility of the preschool/lower grades. There are very few teachers who were given training on teaching methods last year. The private schools had less educated teachers for pre-primary and grade 1, as compared to the Government schools. The teachers of Government schools have received bachelors and masters level professional training (e.g. bachelors ‘BEd’ and masters ‘MEd’ in education), and recently, most teachers also attended training on teaching methods. However, the issue of lack of trainings still persisted as one of the participants stated the school management had requested the government that even with less teachers, training should be arranged for them highlighting the need for continual trainings.

Finally, according to the observations, the number of teachers on the day of observation was less than recorded in government schools. In a government school, half of the teachers were absent on the day of visit, while the students sat in classes with nothing to do. While, in another government girls school, only a single academic activity was observed during the whole visit. Furthermore, the female teachers were not present in classrooms but were instead spending their time chatting in the staff room (not during a break time).

School-related factors

This aspect deals with the challenges posed by the school that hampered children from receiving preschool education. These challenges are categorized into the following three main factors: infrastructure glitches, lack of resources and hygiene.

Infrastructure problems

According to some respondents, it was found out that a few government schools had weak building structures and teachers had to teach under trees due to threat of collapse that too under extreme weather conditions. One participant stated something similar to the above-mentioned condition:

Our children are sitting in the heat. The teachers are teaching under the trees as the students can’t sit in the classrooms. We have to fulfil this responsibility by giving them education and hence the needs should be fulfilled. (Teacher, IDI, EN group)

In most schools, students belonging to preschool and grade 1 study in combined (multi-grade) classes. Furthermore, one of the participants complained about the infrastructure of the school and also stated that a few students were injured:

The students should have spaces in different classrooms. The roofs of all the rooms in our schools are broken and slowly falling down, due to which few students have been injured. (Teacher, IDI, RS group)

In fact, one of the private schools also had a very weak building structure. According to the observations, about half of the private schools had very small classrooms with inadequate space for children. The students were not able to sit in their classrooms and were instead taught in the open courtyard due to the poor infrastructure. The quality of schools with respect to the physical environment was so poor as both the government and private schools did not create enough space for sleep or keeping lunch boxes for younger children in pre-primary grade and grade 1.

However, there were certain attributes in private and government schools that were different. For instance, some private schools were more likely to possess a well-built structure, functional electricity and appropriate furniture, while the government schools generally had good ventilated classrooms with enough space and light.

Insufficient resources

The second category of challenges was the limited resources or unavailability of learning material for preschool students. Overall, there were very limited learning materials available in both private and government schools. In the IDI and FGDs, the teachers recognized the importance of learning materials for early education, however, they did not have access to such materials.

Furthermore, even during observation, it was confirmed that material was insufficient to meet the needs of children and even when it was available, it was not appropriately utilized. This could be due to less or inadequate teacher training as highlighted in the earlier sections. Another reason for this could be the fear of resources being depleted that did not allow the teachers to use the materials when essentially needed. Despite most of the teachers expressing that they have not faced any challenges in teaching, there were still a few government teachers who admitted lack of resources and attention by the government as the biggest challenge in teaching. Another private teacher shared less salary is a difficult problem as they, teachers, have to earn well enough to meet their needs. The participant stated,

Despite having BEd, MEd, MA and other degrees, teachers still don’t get promoted and due to increasing expenses, they give tuitions in their free time. Hence, they either start focusing on giving tuitions or starting a side business, after their teaching time. If the teacher has no problems and is fit then why will he/ she go tutor or have a side business instead of teaching. (Teacher, IDI, SC group)

Poor hygiene

According to the School Survey Report (Table 6), numerous factors related to hygiene and sanitation were observed in both private and government schools. As per the observations, it seemed that the facilities provided by the private schools were far better than the ones provided at the government schools. The observations stated that facilities such as access to a functional toilet, running water and soaps in the washroom, sanitation, access to drinking water was 100 percent in the private schools. Despite the statistics, the observations revealed that less attention was given to health and hygiene (hand washing, first aid kit, access to functional washrooms for all students), but this trend was higher in government schools.

Table 6.

Data of observed schools on ECD indicators.

Indicator	Source of data: O, V	Private schools(n = 5)	Government schools(n = 12)	Overall(n = 17)
		Yes (%)	Yes (%)	Yes (%)
School building has sound structure (e.g. no broken wall or leaking roof) and good condition (e.g. no peeling paint)	O	60	66.7	64.7
School has good structural compound wall	O	100	66.7	76.5
Good functional electricity supply, fans are visible	O	80	58.3	64.7
School has appropriate comfortable furniture	O	80	33.3	47
Class rooms are ventilated	O	40	91.7	76.5
Class rooms have enough light	O	60	91.7	82.4
There was enough space in classrooms for children	O	40	50	47.1
School has space for outdoor play	O	80	91.7	88.3
Kaachi class creates space for sleep time	V	0	0	0
Kaachi class has clean space for children to put their lunch/snacks	V	0	0	0
Learning materials
Materials for learning are available (charts, pictures, blocks, colours, plastic cards)	O	40	8.3	17.6
Access to material was observed	O	0	0	0
Children have access to picture books/reading books	O	80	25	41.2
Is a class timetable visible?	O	0	0	0
Is timetable appropriate (e.g. free time, play time, snack time, nap time)	O	0	0	0
Which activity was observed (e.g. academic, play, break time)	O	100	66.7	76.5
Were all children included during session	O	80	41.6	52.9
Teacher helps students to understand	O	40	50	47.1
Teacher sits at same level	O	40	33.3	35.3
Teacher responds to students’ questions or request	O	80	25	41.2
Teacher asks questions	O	60	33.3	41.2
Teacher allowed students to respond	O	80	41.6	52.9
Interaction of teacher with children was friendly	O	80	58	64.5
Teacher used students’ mother tongue as language of instruction	O	80	66.7	70.6
Teacher did not show negative effect in class room	O	80	66.7	70.6
Teacher was generally responsive, happy and comfortable with visitor	O	100	58	70.4
Children were generally content	O	80	66.7	70.6
Hygiene
Students are protected from access by unauthorized adults or being bullied by older students while at school	V	100	100	100
Students are not permitted to leave school grounds without the knowledge and permission of school staff	V	100	100	100
The school grounds are kept free of unwanted animals and animal waste or any toxic material (e.g. stray dogs). Any school pets are kept in sanitary conditions	O	80	75	76.5
The school grounds are kept free of litter and garbage, except in designated containers	O	100	42	59.1
Schools with one first aid kit	V	60	8.3	23.5
Students and staff have ongoing, easy access to drinking water	O	100	58.3	70.6
Children have access to a toilet	O	100	66.7	76.5
The toilet is functional	O	100	58.3	70.6
There is running water in the toilet	O	100	50	64.7
There is soap in latrines	O	0	0	0
Students and staff wash their hands prior to eating or handling food	V	20	8.3	11.7

ECD: early child development; O: observed; V: verified from records.

When it came to government schools, access to clean drinking water was about 58.3 percent. Moreover, the other facilities such as sanitation, availability of soaps and running water in functional toilets were hardly half the percentage available.

As per the observations notes, it was noticed that in the rural schools for both girls and boys, the girls were not allowed to use the toilets. They had to go to their homes for toilets. This is due to the social norms regarding female modesty and privacy persisting in the society and hence discouraging the use of mixed access to washroom facilities.

Community-related factors

The rural and urban communities in Pakistan are very closely knitted and decisions are very much influenced by community factors too. Hence, this theme identifies responses and observations that socially influences the parents’ decision on the enrolment of schools. Social capital played a facilitating role, and a personal relationship with the teacher was likely to ensure that the child was taken care of in school. One of the participants admitted to this by stating,

Teachers are from our own village and the school is near to our house. We send the child to the school after bathing them by carrying them in our arms to cross the road and drop them at the gate. This makes me satisfied. (Mother, FGD, RS group)

Accessible schools were defined by the presence of a school in the same village where the child lived or within a comfortable walking distance. Close distance of the local school influenced enrolment for girls more than boys, and for preschool children more than older children:

Schools are all government schools, and the children will get admission to the school nearest to them. (Teacher, IDI, RS+EN group)

Facilitators specific to preschool were local access and having an elder sibling enrolled in the same primary school. An elder sibling in the same school was helpful because she could care for the younger child.

In general, Sindh comprises segregated government primary schools for girls and boys. However, there are a few schools in the district, as evident from the interviews and observations, where co-education enrolment exists and the parents did not show any concern over it. This might be because of community-level acceptance of mixed schools which act as a factor for parental decision-making. As for the private schools, the primary school and preschool has a co-education system.

A review of the policy to allow government preschools and primary schools to be co-educational could potentially increase the enrolment of girls where access to a local school may be inhibited because it is restricted for the education of boys.

Socioeconomic class-related factors

The socioeconomic class has created huge differences among people in terms of lifestyle and even fulfilling the basic necessities of families. The lower class has faced a major barrier that is, poverty, even when it comes to enrolling their kids for preschool education. However, one must realize that the enrolment alone is not a challenge for the parents, it is also the daily expenses that burdens them. The participants were satisfied with the government providing free books and uniforms along with free education at the government schools. However, the daily expenses that come with it such as the cost of the washing powder to wash uniforms, providing pocket money for children to buy snacks, or purchasing stationary, is something that they cannot cover on a daily basis. Hence, since the parents cannot afford their daily living, they prefer to have their child contribute to the household income rather than go to school. One of the participants stated,

In Sindh, there is extreme poverty. Therefore, children are taught to work in the farms and take care of the cattle. This is to help their children survive. (Teacher, IDI, SC group)

However, recently there has been a shift in demographics, socioeconomic aspects and cultural dynamics which has led to the emergence of new opportunities for women specifically (UN, 2011), improving the living conditions by altering household divisions of labour across LMICs. Although no such thing was expressed in the interviews of FGDs.

ECD programme-related factors

This section incorporates parents’, teachers’ and LHWs’ views on the ECD programme in terms of perceived benefits and challenges faced. Triangulation of sources of evidence found that child-related factors (e.g. child health) was expressed by the parents and LHWs. The early parenting and stimulation programme was mentioned by the mothers and LHWs, who were directly exposed to the original interventions instead of by other participants.

The participants revealed that the programme has increased awareness among many individuals. The programme has been very informative in terms of growth and development monitoring, nurturing and feeding the child. Furthermore, LHWs stated that after the programme, they have augmented parental involvement through participating in various activities with their children and also taking interest in their progress.

It was believed that the perceived benefits of ECD programmes with collective community attitudes influenced the value placed on education. First, the programme led to community acceptance of girls’ education and being employed to support families during hard times. It will also lead to increased social standing in the community, however, it is more appreciated if a male child is educated. Finally, parents perceive financial benefits for them as the children are being educated and hence will help in household duties. Although, as per the cultural norm, the male child is likely to play this role. Such realizations led to a higher community motivation for boys’ education coupled with unfavourable community attitudes that hinder aspirations and motivation for girls’ education.

The programme though beneficial to change parent’s perception about early learning may not be enough to influence their decision of timely preschool enrolment given the grave challenges related to school systems which resulted in poor educational achievement and early dropouts from schools. Catering to these will require multi-sectoral coordinated interventions leading to improved outcomes. The challenges came from numerous parties such as lack of parental involvement, teachers being less, absent, untrained or exhibiting harsh disciplines, lack of community acceptance for girls’ education and less emphasis on pre-primary grades. Interventions such as teachers training in mentorship ECD practices or appropriate discipline practices, helping community value’s girls’ and preschool education and linkage between 0 and 3 pre-primary programmes can be considered (Figure 1).

Figure 1.

Challenges, outcomes and potential points of intervention leading to improved outcomes.

The parents perceived themselves to be an important element in such interventions for example by helping children be ready for school, but they also rightly felt that the next stage of learning and development was a shared responsibility with the teachers and schools. Comparatively, fathers spoke more about school (e.g. physical structure) and teacher-related (e.g. absenteeism) factors as the mothers were generally less-educated and seldom visited the school. Therefore, it was concluded that fathers need to be a key target in a school readiness intervention (Table7).

Table 7.

The common and distinct perceived challenges and facilitators to receiving an education across stakeholders.

	Mother	Father	Teacher	LHW
Child-related	Child’s motivation and interest			Health and nutritional wellbeing
Parent-related	AspirationsKnowledge of early learning		Parent involvement	Elder sibling enrolled in the preschool
Community-related		Social norms about girls’ education
Teacher-related	Social capital	Teacher absenteeism	Teacher trainingTeacher–student ratio
School-related		Poor physical environment	Poor physical environmentInadequate and unsuitable learning materials
Wider issues	Inability to provide snacks, wash uniforms competing with keeping the child at home to help with chores or earn money
ECD programmes	Perceptions about early learning			Perceptions about early learning

ECD: early child development; LHW: lady health workers.

It is clear that with respect to the school environment, less emphasis was placed on the quality of preschool classrooms with respect to dedicated teachers for preschool teaching, resources available and classroom space. An intervention designed to promote school readiness can intervene at several point; for example, building parent–teacher relationships to enhance parental involvement (which may need to be suited to local social norms to engage mothers as traditional parent–teacher committees or meetings in school may not engage mothers in this setting), provide teachers with training and on-the-job mentorship on early childhood education and managing the behaviours of young children, and creating a wider community acceptance and value on girls’ education.

Conclusions and implications

This study explored parental and teachers’ attitude and perception along with direct observations of schools to understand factors that may have influenced preschool enrolment of young children. The study found that the socio-cultural context shaped parent’s decision of enrolling their child into preschool and an intervention targeting parenting alone in a disadvantaged community is unlikely to be sufficient to help children succeed in formal education. The findings revealed that the LHW had sustained knowledge about ECD from the original parenting and stimulation intervention she had been trained to deliver 2 years earlier; however, given the disadvantaged context, there are numerous risk factors including poor quality of preschools and lack of value on preschool education, which threaten early developmental gains. The following recommendations based on the study findings are suggested for the design of future ECD interventions for preschool children.

First, a life course approach needs to be adopted and early childhood services should be continued until at least 8 years of age for optimal development (Black et al., 2016). Sensitive windows for intervention opportunity include periods of vulnerability in transition from home to preschool and preschool to primary school. As different age groups are catered for by different sectors (i.e. health and education), enhancing multi-sector coordination between stakeholders for consistency of messaging and continuity of service uptake (e.g. the LHW cannot only promote early stimulation, but she can also advocate timely preschool enrolment in the households that she visits).

Second, early parenting and stimulation interventions might be bolstered with messaging on how to support school readiness by guiding parents on scaffolding parenting skills for infants and toddlers for preschoolers, and by providing information about local preschool services.

Third, in this specific context, fathers should be an integral recipient of interventions to promote school readiness. As seen in this study, men are more likely to be the parent who enrols their child in school and have contact with the teachers.

Fourth, the promotion of demand for preschools should target the wider community with behavioural change communication strategies. Parents are influenced by the collective social and cultural norms of their communities (e.g. whether they invest in their girl’s educations); therefore, addressing collective attitudes and norms in the social setting are essential. Fifth, quality improvements for existing preschools are critical and should take into consideration the perceptions of poor quality that parents report as barriers to preschool enrolment.

Finally, these data suggest preschool enrolments may not be formally completed. Preschool data should be tracked to enhance the value of learning in the formal education system. Unless these data are available, the gravity of the situation may go unnoticed by governments and concerned stakeholders. These data will also inform early childhood care, development and education policies, which are crucial in achieving SDG target 4.2.

The strength of this study includes the opportunity to qualitatively explore a lack of transition to preschool from a large cohort exposed to an early parenting intervention which allowed us to explore the role of risk factors in shaping the readiness of child, family and community at large. The study followed a qualitative design to explore the nature of experiences; however, these results likely represent the social milieu of a rural community and cannot be generalized to urban settings in Pakistan where different factors may influence preschool participation including a larger low-cost private sector. Future research should explore how demand for preschool participation in communities can be effectively promoted in communities in partnership with the education sector.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Grand Challenges Canada (Grant No. 0061-03). Grand Challenges Canada is funded by the Government of Canada and is dedicated to supporting Bold Ideas with Big Impact in global health.

Notes

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