Good health and health matters of babies.
Lesotho, like many developing countries, experiences challenges in providing quality early childhood services for children below 3 years of age. No formal education programme for children aged below 3 years exists yet, except the informal daycare centres run by inexperienced child-minders. At this tender age, the focus for child development and care must focus on child protection, healthy stimulation nutrition and health. Realizing the need for quality child services for the age cohort, Catholic Relief Services Lesotho introduced a programme named Whose Child is This? (WCIT) that focuses on provision of quality services for the children. This chapter shares Lesotho’s experiences in addressing delivery of quality informal early learning environments. A case study of one daycare centre in the Maseru Industrial settlement was undertaken focusing on practices and services rendered to children aged below 3. New lessons learned were the need for partnerships among agencies serving children’s needs, and collaboration with parents strong advocacy for implementation of the Nurturing Care Framework is critical for all ECCD service providers. Institutions of higher learning need to step forward to produce research evidence on importance of strong foundations for children aged below 3 years.
Global initiatives, among them,
1.1 Nurturing care framework
The Framework is a new initiative that was launched at the 71st World Health Academy to address recognition of the importance of, and research evidence on investments in early childhood development. The Framework addresses five main components of care which are;
The quality of care and nurturing could however differ in different contexts depending on each family’s socio-economic background. For instance, where families are poor, infants and children become vulnerable and they face many threats that affect their quality of life, such as infant and childhood diseases like diarrhea, and exposure to poor nutrition due to families’ inability to provide food and other livelihood needs.
As the world journeys to 2030, countries have committed to “leave no one behind” hence the SDGs require urgent action in order to implement actions and programmes that will ensure all children are included in the global development agenda.
2. The context
The Kingdom of Lesotho is a small landlocked mountainous country located in Southern Africa and it is completely surrounded by the Republic of South Africa. The country has four distinct ecological zones; the mountains, foothills and Senqu River Valley which altogether occupy almost three quarters of the total land area in the eastern parts, and lastly, the remaining one quarter of the land is the western lowlands area. Lesotho’s population is estimated at 2.2 million people . Children aged between 0 and 5 years are reported to form 13.5 percent of Lesotho’s total population . The 0-5 years old children are served in early childhood development programmes and the parents who afford to pay the fees charged in the ECD and daycare centres enroll their children . The Government of Lesotho regards education as key to the country’s economic development and; early childhood development and education (ECDE) is recognized as the foundation level for lifelong learning. The Lesotho government is therefore committed to supporting programmes for the 0 to 5 year old children  and for government, setting up quality programmes that offer integrated and holistic early childhood services are the hallmark of child development.
Lesotho, like many developing countries, experiences challenges in providing quality early childhood services for children below 3 years of age. Despite research on neuroscience informing that the first three years of life are critically important for ensuring good child development, many countries still face challenges in improving children’s developmental outcomes. The Lesotho National Policy for Integrated Early Childhood Care and Development (IECCD) 2013 , calls for individualized and intensive home visiting services for Lesotho’s most vulnerable children who, if they are not identified and served between 0 – 36 months of age, shall cost society and result in provision of costly remedial services to children later.
In Lesotho, one of the strategic goals for Early Childhood Care and Development (ECCD) is “Improved access to comprehensive early childhood care and education, especially for the most vulnerable and disadvantaged children . As it is currently, there is yet no formal early childcare and education programme for children below 3 years of age in Lesotho, except for the informal daycare centres run by inexperienced child-minders who provide a much needed service by the working parents while they go to earn income for their families. Realizing the gap in child services for the children below 3 years of age, in April 2015, Catholic Relief Services Lesotho, one of the partners and a member of the IECCD Multi sectoral team, embarked on a project for this age group, named
This chapter presents a case of a specific daycare centre in Thetsane industrial area in Maseru and shares experiences of Lesotho regarding the extent to which the care practices implemented by the caregiver seemingly address the five components of the Nurturing Care Framework. A combination of care and nurture attributes that are: trained caregiver, childcare facility, child care guidelines and early stimulation, health and nutrition, safety and protection, are likely to enhance the quality of care of infants who could otherwise be vulnerable and disadvantaged if they never received such care.
Until recently, early childhood education in Lesotho was offered through three approaches: the Early Childhood Care and Development (ECCD) centres for children aged 3–5 years, the Home base centres (2-5 year old children) and the preschool/reception class phase for 5 years old children who will enroll in primary schooling at age 6. The newest approach is the daycare service that provides childcare services for toddlers and infants below 3 years of age.
A number of stakeholders such as ECCD service providers, line ministries, non-governmental organizations and individuals in the country have, over the years expressed concern over the plight of children aged below 3 years. This age cohort is generally serviced in uncoordinated services that present poor health conditions, poor nutrition, inadequate social welfare and protection. As a result, the development of these children is compromised. Lesotho’s population is approximately 2.2 million people and of that about 227,000 are children aged between 2 and 4 years.
The Lesotho Demographic Health Survey  presents the situation of children in Lesotho. Statistics below depict a depressing picture of the children. The under 5 mortality is 85 deaths per 1000 live births, while infant mortality is 59 deaths per 1000 live births. Breastfeeding stands at 95 percent with 67 percent babies exclusively breastfed while maternal mortality stands at 1,024 deaths per 100,000 live births. Immunization coverage is 68 percent, stunting stands at 33 percent while birth registration at national level is 68 percent and lastly, hand washing with soap and water stands at 46.2 percent. This situation calls for concerted effort of all stakeholders to engage in actions that provide care aimed at addressing the overall well-being of children below 3 years of age.
In Lesotho, because of an increasing number of women engaged in paid employment, particularly young women in urban areas living around the textile factories, infants and toddlers of some of the working mothers are cared for in paid daycare facilities that offer child minding services in the absence of better options for child care in the family. The facilities are usually private family homes where the caregiver uses her house for both child care services and own household activities. Caregivers who are providing the service are volunteers. They charge a monthly fee amounting to about US$18 - US$22 which is deemed rather steep by many parents. While the day care service is critical for families that access it, the caregivers are mostly untrained and have quite limited information about child development and child care for that age cohort.
Catholic Relief Services (CRS) attests to this situation as they highlight that “delivery of quality IECCD services to all children in Lesotho under the age of 5, regardless of their social or household economic status, is not currently a reality. Poorly trained teachers are working in sub-standard teaching environments with little support from the community; parental training programmes for the stimulation of children are not provided…” . Due to lack of training, the caregivers have limited knowledge of how to run a daycare service while others regard the service as mainly income generation opportunity. In these circumstances, the lives of the children are in danger. Therefore, in a country that is concerned about its young, quality and well-structured early child care programmes are a requirement and must ensure holistic development of the children. The Lesotho National IECCD policy expresses the need to pay attention to the critical ages of early childhood however the government of Lesotho is not yet formally committed to support the daycare programme where children aged below 3 years are cared for. Although legislation such as policies, guidelines and protocols for children exist within different ministries that address children’s matters, (particularly Ministry of Education and Training, Ministry of Social Development, Ministry of Health and Ministry of Home Affairs), what remains is the need for strengthened collaboration between these ministries to agree on cost sharing of activities and services for young children.
2.1 Retšepile Jesu Daycare Centre
Retšepile Jesu Daycare centre was started in 2009 as a voluntary service of child care provided by a young woman aged about 30 years. The daycare facility is located in the Thetsane industrial area which is inhabited largely by families comprised of single mothers who are employed in the textile factories in the area. The caregiver was prompted to open the daycare centre after realizing that the women factory workers with babies and young children did not have a place to leave their children while they were at work. She started the centre with only three (3) children; a boy aged 3 months, a girl aged 5 months and another girl aged fifteen months. The caregiver used her two-roomed rented house and particularly her kitchen was used for all activities with the children. She provided child care services of feeding and changing nappies only. There was no schedule for daily routine or any organized child activity. A monthly fee ranging between US$4.4 (for toddlers who were toilet trained) and US$6.9 (for toddlers who were not toilet trained) was charged for the child care service. With time, other women also brought their young children. The centre grew and more children were enrolled. There was no feeding programme as a result the parents who could afford, provided meals for their children. In many cases, the food was not nutritious and it comprised mainly of soft porridge and one vegetable or soft porridge with beef stock. The caregiver had no training in child care except the experience she had from raising her own children. She was not aware of what quality child care meant and why it was important. However, there was concern from some ECCD teachers in the area that since the caregiver cared for infants; she had to inform the community chief about the daycare centre. Infants and young children need special care offered by a knowledgeable or trained adult who would be able to monitor their safety and general wellbeing. Similar conditions in many other surrounding daycare facilities in the area were experienced. The situation of the young children cared for in those facilities called for immediate attention and intervention that would save their lives.
2.2 Description of intervention
In 2015, the Catholic Relief Services (CRS) Lesotho, a partner with Ministry of Education and Training, the Early Childhood Care and Development (ECCD) Unit, started a project,
S.O 1. “Children in targeted communities access higher quality and inclusive IECCD services.
S.O 2. Key stakeholders in Lesotho take ownership of IECCD services in targeted communities.
S.O 3. Improved development outcomes are monitored and improved” .
One of the interventions made was the design of “one stop service delivery centres” that offered critical services needed by children and families and the services were provided by specialist agencies such as nutrition sector, immunization and health checks to detect any malfunctions and disabilities among the children, protection and education services. Activities days named
Achievements were realized due to the intervention. First, the training of caregivers including their willingness to participate in the project was realized. In the particular daycare centre, the caregiver went further to enroll for a 2-year training programme in early childhood education with the Lesotho College of Education. She reported that she completed her studies and now holds a certificate in early childhood education (CECE). She further explained that she took the decision to enroll because she felt it was important for the children to receive proper care provided by a knowledgeable person. She alluded that she was aware that children had the right to
Secondly, the project was successful in introducing well-being days (WBDs) since the services that were offered attracted a lot of parents who under normal circumstances rarely had time to take their children to access some of the services, particularly in the health centres. In her words, the caregiver said, “
Lastly, the project has helped to improve child development outcomes through parents’ better understanding of child nutrition, health, protection and stimulation by parents and families. In this regard, parents provide children with adequate and proper nutrition.
3. Lessons learned
In discussing the lessons learned by the caregiver, the Nurturing Care Framework (NCF) is used to form the basis of the discussion. The Framework  promotes a holistic approach in early childhood development. It asserts that for a child to grow up well it must be healthy, have good nutrition, responsive care, stimulation, safety and security. There are five components of the NFC. However, in this paper, specific focus is on components 1, 2 and 3. Components 4 and 5 were not specifically highlighted in the study because issues of safety and security including early learning surfaced in the care practices discussed in the three components researched on. The components are presented as individual themes that guide the discussion and are accompanied by questions that were posed to the caregiver and the observations that were made. In that regard, it is hoped that the study would inform how the caregiver’s care practices linked with the Framework.
3.1 Component 1: good health
The nurture and care surrounding this component relates to monitoring of children’s physical and emotional condition; giving affectionate and appropriate responses to child’s daily needs, protecting child from household and environmental hazards, practicing hygiene which minimizes infections, use promotive and preventive health services and seeking appropriate treatment for children’s illnesses.
In Table 1below, the caregiver commented on good health and related health matters of babies in her centre.
|Questions asked||Caregiver response||Finding/result|
|Why must improvement of health and child wellbeing begin from pregnancy to 3 yrs. of age (0-3)?||Wellbeing of a child begins during pregnancy, health and nutrition status of the expecting mother affects the development of the child.||Caregiver has knowledge of the requirements for preparing for a healthy start for a new-born baby.|
|How are you as caregiver, able to influence that?||I have no influence because I do not know much about the pregnancy of the mothers. I only see the children when they are enrolled at my daycare centre.||Caregiver does not seem to have direct influence over what the condition of the mothers is during pregnancy.|
Here there is a gap in knowledge of the caregiver regarding a mother’s status during pregnancy and the subsequent transition of a child from home to daycare.
|But then what interventions do you as the caregiver undertake to ensure babies under your care are fed appropriately?||Caregiver informed that she discusses with the mother the importance of good nutrition in the first 2-weeks of the life of the infant.|
I advise the mothers to visit health centres and to abide by the requirements for mixed feeding.
|Caregiver has knowledge of disadvantages of mixed feeding but that if the mother is unable to provide breastmilk for the child at the daycare centre, then she has to follow proper feeding practices as advised at the health centre.|
|How do you ensure children in your centre are protected and safe in the environment they are cared for?||I am renting a room where I have established the centre. I do not keep dangerous objects that can harm children, example sharp objects, buckets of uncovered water and paraffin.||Caregiver is aware of safety issues for children. She has taken care to ensure the environment is safe. The children are however mostly kept indoors where most of the activities are undertaken such as sleeping, eating indoor play and stimulation activities.|
|What do you do when a child cries consistently?||I know it is a sign of illness or the child is telling me something. Children cry when they want to talk to us. I therefore check if they are wet, or they have a high temperature. These are the skills I have always practiced with my own children.||Caregiver has some skills she learned as a mother and she applies them with the children to attend to their needs. It is good that she knows that babies cry to communicate with adults.|
|What do you do when a child falls sick while in your care?||There is a clinic nearby. I have entered into some agreement with the parents to allow me to take children to the clinic when they are sick and then call to inform them afterwards. I have their mobile numbers. From the fees they pay, I use some of the money to buy airtime to talk with them.||Caregiver knows she has to seek immediate medical attention to address the sick children’s ailments. She seems knowledgeable about health and wellbeing of the children in her care and she takes responsibility to safeguard the children’s health.|
|Do you know the kind of immunisations babies and young children need to ensure they stay healthy and develop appropriately?||The parents are required to bring children’s Health Record Books “Bukana” to the daycare centre and when the nurses or health workers visit the centre, they check the immunization history of the child and inform me if the parent has not taken the child for the required immunization injection.|
I know of some the immunizations but not all, particularly I do not know the times when those immunisations have to be administered.
|Caregiver does not seem to have clear knowledge of the immunization schedules. However, she relies on the clinic nurses when they visit and they are able to detect which immunization the children have skipped.|
|How do you interact with the child during feeding and, or nappy change?||I talk with the children, during such activities. I engage in baby play motions, sooth the baby who cries, and generally engage with the baby to calm him. However, when the child cries continually I check his nappy and sometimes I discover that the nappy is wet or is soiled.|
3.2 Component 2: adequate nutrition
The component relates to a baby’s nutrition right from when a mother is pregnant and eats well in order to supply micronutrients and supplements that help baby to develop. Brain development is critical in the first three years of a child’s birth hence breastfeeding, particularly exclusive breastfeeding, is critical from immediately after baby’s birth. Complementary feeding must be introduced from 6 months hence food safety and family food security are essential for adequate nutrition.
Below in Table 2, the caregiver commented on the issue of nutrition of the babies in her centre.
|Question asked||Caregiver response||Finding/result|
|How do you think nutrition affects children’s development?||I believe that good nutrition is important for children to develop. Lack of proper nutrition can affect all areas of development.||The caregiver recognizes the importance of good nutrition in the development of children.|
|Are children provided with balanced and nutritious food at the centre?||Initially parents were providing lunch boxes for the children, but some of them were not providing children with balanced meals. Due to insufficient funds, they would provide only porridge or rice which are starch food.||The caregiver is aware that children need to eat all the three types of food – energy giving, body building and protective foods.|
|How did you address the problem of children not being provided balanced food?||I talked to parents to make sure that they provide children with balanced food, and also to include fruits in the lunch boxes. Many parents failed to oblige because they said they had no extra funds to buy other “extras” for the children.|
I was concerned with this situation because some children had started to show signs of malnutrition. The visits by the clinic nurses raised the same concern,
|The caregiver realized that the poor nutrition of children had a negative impact on their healthy development. A strategy she devised to address the children’s nutritional needs was to introduce feeding at the centre.|
Caregiver held meetings with individual parents when they came to collect their babies and she raised concerns about the child’s nutrition. Parents were requested to ask parents to pay some money for feeding so that caregiver could provide some nutritious and adequate meals at the centre.
|How did you decide on the menu for the children’s feeding?||CRS training had impact on the children’s feeding at the centre.|
3.3 Component 3: responsive caregiving
Responsive caregiving entails observing and responding to babies’ and children’s needs and their movements. This caregiving practice is the basis for protection of baby against injury; recognition of baby’s illness or discomfort, learning and building of social relationships and trust.
The caregiver was surveyed on how she provided responsive caregiving to babies and toddlers in her centre (Table 3).
|Question asked||Caregiver response||Finding/result|
|What kind of stimulating activities did you do with children when you first started the centre?||Initially I used to think that all I needed to do was to see that the children are fed and their nappies were changed.||The caregiver had not received any training regarding young children’s development.|
|After receiving training from CRS and Certification in Early Childhood Education from Lesotho College of Education I now know that children need to be stimulated in order for them to develop to their full potential.||The caregiver has acquired knowledge and skills of stimulating young children.|
|What kind of activities do you do with children?||Reading stories and playing games with the toddlers mostly.|
The 0-1 year old children needed one-to-one attention when doing the stimulation activities. However, sometimes I could not attend to a single baby if more than one were awake. That was a challenge because sometimes I would have to soothe one who is crying and somehow ignore to provide necessary attention to the others.
As children become toddlers, I started to make sure that I stimulated them in at least three learning areas each day but that the activities were short in duration. There are some toys and manipulatives, bright objects to dangle and teddy bears to play with.
|The caregiver seems to have knowledge of the importance of play in young children’s development, and in developing their communication skills and early learning.|
|Why should the activities be of short duration?||I know that babies cannot engage in the same activity for a long time, I have to give them time to rest but ensure that at the same time they develop their muscles. I learned this in my studies at the College.||The caregiver is aware of the role of play in child development and she keeps play materials that stimulate learning of children.|
The Nurturing Care Framework provides the importance of why care and nurture must be accorded the children in order that they can “survive and thrive”. The critical attention we need to pay to the earliest moments of a child’s life cannot be understated. A child’s foundation to survive and thrive is nested in the nurturing environment in order for a child to develop socially, physically, cognitively, emotionally and spiritually . The role of nutrition, good health, early stimulation, protection and safety of both the mother and child can ensure that children have a chance to develop holistically.
In the case study centre, the caregiver seems to be familiar with some of the critical actions and requirements for child development and wellbeing. She further applies some of the knowledge she had when she was bringing up her own children and she applies that appropriately. However, being unsure of the immunization schedule and proper injections children require at a specific time might compromise the health of the child and put children at risk. Nonetheless, she seems to rely on the services she gets from scheduled visits of clinic nurses in the area to undertake health checks of the children. One critical finding from the daycare centre was that the caregiver had no knowledge of the pregnancy history of the mother. That lack of knowledge would possibly deny the baby proper attention it required in the event the mother herself had had a difficult pregnancy period that might have affected the baby’s healthy development. It would seem the caregiver needs to conduct one-to-one interviews with the mothers of the babies in her care in order to learn more about the history of the baby from conception. Such additional information would then be documented in the baby’s health book and when necessary it would be shared with the health facility when need arose.
On the other hand, some serious challenge the caregiver had was that of parents who did not provide balanced and nutritious food for the children’s meals. The fact that some children had only starch-based foods compromised their nutrition. Nevertheless, the caregiver with consent from the parents introduced feeding at the centre and parents had to pay increased fees and that practice allowed children to be provided with good nutrition. Through the CRS training that the caregiver had attended, she was able to design an appropriate menu for the children. Adequate nutrition throughout the early years from pre-natal to eight years cannot be over-emphasized. Inadequate nutrition before birth and in the first years of life can seriously interfere with brain development and lead to such neurological and behavioral disorders as learning disabilities and mental disorders . Therefore, when children do not feed well, they become vulnerable to diseases that could otherwise have been curbed through good nutrition.
At the beginning, Retšepile Jesu Day Care centre was neither registered nor formally known to the Ministry of Education and Training. Resultantly, the daycare centre was not receiving any support in terms of training of the caregiver and advice or guidance on baby care. After the Day Care centre and others in the area were known to the Ministry and other partners in ECCD, the caregivers in the area were exposed to basic training on child development and care. The caregiver’s enthusiasm and desire to provide improved and quality child care service, prompted her later to enroll for a Certificate in Early Childhood Education (CECE) course at the Lesotho College of Education. She qualified in 2018 and currently she strives to improve her practice at the centre. In a study conducted in Kenya in 2000, mothers of children below 3 years of age reported that they ensured their babies were happy by singing lullabies to them or feeding them (p. 132, ). On the other hand, Dodge and Phinney  highlight the importance of play in early childhood. They inform that “play provides the foundation for academic or “school learning”. It is the preparation children need before they learn…play is the work of young children”, (p. 3). The issue of care and nurture is one of the critical ingredients to a healthy start for young children and where parents engage in such care practices, as stimulation and play, the children are likely to benefit.
5. Conclusions and recommendations
As mentioned earlier, this study was undertaken to establish how far the care practices offered by the caregiver were aligned to some of the components of the Nurturing Care Framework. The Framework is relatively a new innovation and as such, had never been introduced to the caregiver, let alone to a number of ECCD stakeholders in the country. The extent of the quality of care and nurture that the caregiver has been sensitized about may be sufficient to ensure children benefit extensively from how she interacts and handles them. If the caregiver had been knowledgeable about the Framework, it would be expected that her care and nurture practices would be adequate. It is therefore concluded that some aspects of components 1, 2 and 3 of the NCF are practiced by the caregiver although the quality of care and nurture may still remain inadequate given that the caregiver is still learning how to implement some of the practices in the Framework.
To ensure nurturing and care are entrenched in care practices for young children, it is recommended that:
First, at national policy level where decisions are taken, attention should be made on enforcement of policies and other legal instruments that support ECCD providers and other stakeholders with knowledge on how to provide an enabling environment to cater for the needs of children. Such environment should raise issues of resource allocation, both physical and financial, in support of the endeavor.
Second, the lead ministry, in collaboration with the IECCD multi-sectoral team and with support from partners (UNICEF, World Bank, World Health Organization) must ensure that training in the application of the Framework is offered and guidelines for its implementation are availed. Advocacy for implementation of the Framework must be set as a priority in all efforts undertaken to improve the wellbeing of children, and particularly children aged below 3.
Third, lessons learned from the practices of the caregiver at the daycare centre could form a platform for other caregivers in the area regarding how child care can be improved for the benefit of children’s wellbeing. Furthermore, experiences that have been uncovered in the case study centre could be used as a basis for designing a study with wide coverage to investigate the care and nurture practices as outlined in the Nurturing Care Framework, among the different caregivers in various settings in the country.
In summary, quality child care is a partnership between day care settings and a child’s parents (family). Caregivers, as providers of the valuable service of child minding, play a critical role in the healthy development of children. Therefore, the ability to nurture children to optimal growth and development depends on the quality of skills, knowledge and attitudes that caregivers learn from training. The Nurturing Care Framework offers support to how caregivers are guided to provide good health, good nutrition, responsive caregiving, stimulation, safety and protection of the children. Therefore, strong foundations must be built right from the start. The above sentiment is represented graphically below.
The authors wish to acknowledge the Retšepile Jesu Daycare centre for allowing us to use their centre as a case study. The caregiver and her staff willingly allowed us to observe their work in practice and also to be interviewed. Without their cooperation, the study would not have materialized.
Conflict of interest
The authors declare that the contents herein are entirely their own work, except where other sources have been acknowledged and furthermore the chapter has not been previously submitted for publication elsewhere.
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