The research involved 26 mothers of infants aged between six and ten months, recruited from participants in the ongoing Bukhali randomised controlled trial, a complex continuum-of-care intervention in Soweto that begins before conception and continues through early childhood. Between 1 and 5 May 2023, the team conducted four focus group discussions lasting between 80 and 114 minutes, each involving five to eight mothers. The participants ranged from 20 to 29 years of age, and for 17 of them the study child was their first. Only four mothers were employed at the time. The most common home languages were isiZulu and Sesotho, and discussions were facilitated in English with explanation in local languages where needed, allowing participants to express themselves freely in their home tongue.

Methodologically, the team used reflexive thematic analysis, a widely applied qualitative approach developed by Braun and Clarke that treats coding and theme development as inherently subjective processes. The analysis proceeded in two stages. First, transcripts were indexed deductively against the World Health Organization’s Nurturing Care Framework, the dominant global roadmap for early childhood development, which identifies five components of nurturing care: good health, adequate nutrition, responsive caregiving, safety and security, and opportunities for early learning. In the second stage, refined analytic subcodes were generated inductively from the data itself, allowing themes to emerge from the mothers’ own words rather than from the framework’s definitions. The authors acknowledge that anchoring the initial analysis to the framework risked confirmation bias, but argue that the two-stage design preserved space for genuinely new findings while keeping the work connected to the broader evidence base.

The first major theme concerned mothers’ goals and their sense of their own role. Far from viewing infants as passive recipients of care, the mothers described themselves as active agents in their children’s learning from the earliest months. “It’s folded while it’s still wet mama. You train them now,” one mother said, invoking a proverb about shaping cloth before it dries. “Every day you are teaching your child something new,” another added. During infancy, the most frequently cited markers of healthy development were weight gain and physical growth, with mothers describing genuine excitement when the scale went up at clinic visits. A good appetite was a central goal, and feeding difficulties were a notable source of stress. Alongside this, mothers repeatedly used the word “active” as a broader indicator of wellbeing, encompassing motor, socioemotional and cognitive development in a single everyday concept that went beyond the narrow metric of weight.

Looking further ahead, the mothers’ aspirations shifted in revealing ways. Very few mentioned wanting their child to be intelligent. Instead, they emphasised social adjustment: liking, respecting and accepting other people, fitting in, and being “normal” or “like other children.” One mother put it vividly: “I want my child to like people. I want them to accept people, who they are and their situations. If they visit someone and they find that at that place they are eating cabbage, they should eat cabbage with them, they should not be judgemental.” Others spoke of calmness, self-knowledge and independence, qualities the researchers interpret as a broader vision of self-mastery rather than a narrow focus on cognitive attainment. Yet when asked directly about school readiness, mothers readily acknowledged their role as first teachers, pointing to basic numeracy and literacy, naming colours and shapes, and the knowledge children should carry with them into the classroom.

The second theme may prove the study’s most consequential contribution: the idea that nurturing care is bidirectional. Rather than a one-way delivery of services from caregiver to child, the mothers described a relationship in which both parties shape and benefit from each other. They spoke of the joy of watching first noises and small developmental leaps, of bonds that made hard circumstances bearable. “Being a mother is a really wonderful thing, seeing your child’s development as they get older, that bond,” one said. Several described talking to their babies as a form of emotional release, with one recounting a friend’s advice that “your child is your therapist.” The mothers also described routines responsive to their infants’ individual preferences for food and sleep, and stressed the importance of being calm, patient and loving. This is not to say caregiving was effortless: many reported stress, insecurity, feeding struggles and inconsolable crying, along with a near-total loss of personal time and sleep.

This emphasis on maternal enjoyment stands in deliberate contrast to the Nurturing Care Framework, which the authors describe as fundamentally outcome-oriented, framing improvements in child development in terms of benefits to the child and to society through future economic returns. The framework acknowledges the emotional bond created by mutually enjoyable interactions only briefly. Yet behavioural science suggests that enjoyment associated with an activity motivates its repetition, and that positive emotion during caregiving is associated with greater responsiveness and cognitive stimulation, while negative emotion predicts reduced sensitivity. The authors point back to John Bowlby, the pioneer of attachment theory, who argued as early as 1951 that what matters for mental health is a warm, intimate and continuous relationship in which both infant and mother find satisfaction and enjoyment. On that logic, parenting interventions that emphasise immediate affective rewards, such as joy, rather than long-term developmental outcomes, may be more likely to succeed in changing behaviour.

The third theme mapped the external forces shaping caregiving, and the picture is one of layered, sometimes contradictory influences. Many participants lived in single-parent households with fathers largely absent, though some described supportive partners contributing financially, emotionally and physically. Where fathers were absent, maternal grandmothers often stepped in, and advice from elders was generally welcomed, even when it clashed with modern conveniences. One mother contrasted her own generation’s reliance on branded instant baby cereals with the older generation’s home-cooked pap and stews. Commercial products, from Purity and Nestum foods to walking rings, the wheeled frames that let infants move upright, featured prominently in daily routines. Community attitudes were ambivalent: some mothers appreciated strangers’ interest in their babies, while others, citing dangerous environments and even fears related to witchcraft, trusted no one, including mothers-in-law, with their child.

Screens emerged as a pervasive and largely unexamined presence. Most mothers reported regular use of phones and cartoons such as Cocomelon, typically to keep infants occupied while they completed domestic tasks, though some also cited educational benefits. Only one mother mentioned reading books with her child, and her account, in which her own mother dismissed the practice as “white people things,” suggests how culturally loaded such activities can be. A few mothers worried about dependence, with one deliberately limiting phone use after noticing how instantly it silenced her crying baby. The authors note that South African evidence suggests children’s screen time likely exceeds national guideline levels, and that passive screen use may displace the interactive, responsive caregiving that drives development. Notably, the Nurturing Care Framework does not mention screens at all, focusing its early learning guidance on books and toys. The authors argue future revisions should confront the reality that screens dominate many children’s daily experience, and point to emerging international guidance that offers practical advice on content quality and boundaries rather than simple prohibition.

The study’s implications are tempered by its limitations, which the authors state candidly. All participants were drawn from an ongoing trial and were engaged with health services, and many had already received the infancy component of the Bukhali intervention, which addresses responsive caregiving, so their awareness of nurturing care may exceed that of the general population. The hospital-based setting of the discussions may have shaped responses, and the views of fathers and other caregivers were not captured. Social desirability bias, a standard hazard of focus groups, cannot be excluded, though the authors note that participants freely shared critical views on crèches, screen time and absent fathers, suggesting candour prevailed. Even so, the findings align with a growing body of qualitative work across urban Africa showing that caregivers recognise their influence on development and value loving bonds, while challenging assumptions of developmental universalism embedded in many parenting interventions. The message from Soweto is deceptively simple: mothers already know they are their children’s first teachers, they already enjoy the relationship, and interventions that build on that joy, rather than lecturing about outcomes, may be the ones that finally stick.

Subject of Research: Caregiving practices, beliefs and nurturing care during infancy in Soweto, South Africa

Article Title: “A Baby is Like an Empty USB. Whatever You Do, They Store It”: A Qualitative Study of Caregiving Practices and Beliefs in Soweto, South Africa

Article References: Palmer, T., Nkosi, N., Motlhatlhedi, M., Prost, A., Skordis, J., Gram, L., Norris, S. A., Batura, N., & Draper, C. E. (2026). “A Baby is Like an Empty USB. Whatever You Do, They Store It”: A Qualitative Study of Caregiving Practices and Beliefs in Soweto, South Africa. Journal of Child and Family Studies. https://doi.org/10.1007/s10826-026-03392-0

Image Credits: AI Generated

DOI: 10.1007/s10826-026-03392-0

Keywords: early childhood development, nurturing care, Soweto, South Africa, infancy, caregiving, responsive caregiving, Nurturing Care Framework, qualitative research, screen time, maternal wellbeing, parenting interventions

The study, published in the Journal of Clinical Sleep Medicine, set out to answer a deceptively simple question: does a questionnaire validated largely in high-income, Western settings measure sleep the same way among young, predominantly low-income women in urban South Africa? The answer, according to the research team led by Stephanie Alcock of the University of the Witwatersrand, is a qualified no. When the researchers subjected the data to confirmatory factor analysis, the statistical technique used to test whether a set of questionnaire items hangs together as a single underlying construct, the original one-factor model of the PSQI performed poorly. The model produced a Comparative Fit Index of just 0.65 and a Tucker-Lewis Index of 0.48, both far below the accepted threshold of 0.90, with a Root Mean Square Error of Approximation of 0.13, more than double the 0.06 cutoff that signals good fit.

In plain terms, the numbers mean that treating the seven components of the PSQI, which cover subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction, as reflections of one single latent trait called sleep quality does not describe how these women actually experience their sleep. When the researchers instead tested multidimensional alternatives, the picture changed dramatically. A two-factor model, which grouped sleep duration and habitual sleep efficiency under one latent factor and the remaining components under another, achieved a Comparative Fit Index of 0.94 and an RMSEA of 0.05, comfortably within the range considered good. A three-factor model performed nearly as well, but with a caveat: the correlation between its sleep latency and sleep quality factors exceeded one, a statistical red flag indicating those two constructs could not be reliably distinguished in this sample.

The internal consistency figures tell a similar story of an instrument under strain. Cronbach’s alpha and McDonald’s omega, the two standard measures of how coherently a scale’s items hang together, both came in at 0.57, well below the conventional benchmark of 0.70, though some methodologists accept values of 0.50 or higher. Item-total correlations ranged from 0.33 for the sleep medication component to 0.65 for sleep duration, and the sleep medication item showed the weakest relationship with the rest of the scale at just 0.15. The researchers note that removing the medication component barely changed the overall reliability, a pattern likely rooted in context: prescription sleep aids are often unavailable or unaffordable in this setting, and many women may not view poor sleep as a condition that warrants treatment at all.

Perhaps the most striking finding is not statistical but epidemiological. On average, the women in the study spent 9.5 hours in bed and reported sleeping 7.8 hours, figures that would suggest ample sleep opportunity by almost any standard. Yet 42.6 percent of the sample scored above the PSQI’s global cutoff of 5, classifying them as poor sleepers, a prevalence that exceeds estimates from Germany but sits in line with figures from Spain and South Korea. The median bedtime was 22:00 and the median wake time 07:00, but median sleep onset latency stretched to 20 minutes and fragmentation scores pointed to frequent nocturnal disruptions. The data paint a picture in which the problem is not too little time for sleep but too little continuous sleep, a continuity crisis rather than an opportunity shortage.

This distinction matters because it reframes what poor sleep means in this population. The researchers found that longer time in bed was moderately associated with longer sleep duration, meaning that extra opportunity did translate into more sleep, but greater fragmentation was linked to shorter sleep duration. In other words, women were getting enough hours in bed, yet nocturnal interruptions, whether from noise, crowding, caregiving, or hypervigilance related to safety concerns, were eroding the restorative value of that time. The authors suggest that in urban South African townships, environmental and psychosocial stressors such as material deprivation, overcrowded households, caregiving demands, and fear-driven alertness may disrupt sleep onset, reduce efficiency, and normalize fatigue, causing women to experience disturbed sleep, daytime tiredness, and negative evaluations of their sleep as one blended phenomenon rather than separate problems.

The sociodemographic correlates add another layer of intrigue. Poor sleep quality was associated with higher household socioeconomic status measured by an asset score, higher educational attainment, and single relationship status, while age made no difference in this young cohort. The authors caution that these associations, drawn from a global cutoff score that the study itself undermines, should be interpreted carefully. Still, they speculate that educational and employment pressures, stressors accompanying low socioeconomic conditions, and reduced social support among single women may combine to shape sleep in ways that defy simple assumptions about poverty and rest. The finding that higher asset scores tracked with worse sleep is counterintuitive and underscores how context-specific sleep research must be.

The implications for measurement science are considerable. The PSQI’s factor structure has been contested for years, with studies reporting one-, two-, and three-factor solutions across populations as varied as Canadian adults, Sri Lankan patients, Portuguese older adults, Iranian students, Peruvian pregnant women, and New Zealand female workers during COVID-19 lockdowns. Even within a single multinational student study, the factor structure shifted between countries. The new South African results reinforce a growing consensus that sleep quality is not a universal, monolithic construct but a context-sensitive one, and that exporting a scoring scheme developed in Pittsburgh to a township in Johannesburg without local validation risks misclassification and misinterpretation. The authors recommend the two-factor model for this population because it is more parsimonious, fits slightly better, and avoids the discriminant validity problems that plagued the three-factor alternative.

Clinically, the message is that screening and intervention should target specific PSQI components, particularly nocturnal disruptions and the environmental factors that drive them, rather than relying on a global score that conflates distinct experiences. For young South African women, the authors argue, interventions may need to address stress-related sleep disturbance, environmental noise and crowding, and perceived sleep quality rather than simply exhorting people to spend more hours in bed. The study also positions sleep as a social determinant of health, shaped by safety, housing conditions, caregiving burdens, and financial stress, and calls for sleep health to be integrated into community health, women’s health, and public policy initiatives.

The researchers are candid about the limitations of their work. The cross-sectional design cannot capture how sleep patterns change over time, the sample of young urban women limits generalizability to men, older adults, and rural populations, and self-report measures carry the risk of reporting bias and misinterpreted items. Because no qualitative interviews accompanied the survey, the team cannot say how respondents actually understood phrases like sleep quality, and the data violated assumptions of multivariate normality, which may affect some parameter estimates. Future research, they write, should test whether the PSQI measures sleep equivalently across different groups within South Africa, deploy longitudinal designs to untangle the relationships between sleep domains and mental health, caregiving burden, and socioeconomic stress, and use qualitative methods to learn how women in Soweto define good sleep on their own terms. Until then, the study stands as a warning to global health researchers: a questionnaire is only as good as the evidence that it means the same thing everywhere it is used.

Subject of Research: Psychometric validation of the Pittsburgh Sleep Quality Index among young South African women

Article Title: Psychometric evaluation of the Pittsburgh Sleep Quality Index among South African women participating in the Bukhali trial: Healthy Life Trajectories Initiative

Article References: Psychometric evaluation of the Pittsburgh Sleep Quality Index among South African women participating in the Bukhali trial: Healthy Life Trajectories Initiative. (n.d.). https://doi.org/10.1007/s44470-026-00146-z

Image Credits: AI Generated

DOI: 10.1007/s44470-026-00146-z

Keywords: Pittsburgh Sleep Quality Index, sleep quality, psychometrics, confirmatory factor analysis, South Africa, Soweto, women's health, sleep fragmentation, Bukhali trial, Healthy Life Trajectories Initiative, public health, measurement invariance

MGUS is a precursor state in which a small clone of plasma cells in the bone marrow secretes identical copies of immunoglobulins or free light chains, known as M-proteins, into the bloodstream. The condition itself causes no symptoms, but it is the obligatory first step on the path to multiple myeloma, a malignancy that can trigger kidney failure, destructive bone lesions, anaemia and dangerously elevated calcium levels. Despite major therapeutic advances, myeloma remains incurable, which is why identifying who carries the precursor condition has become a central question in cancer epidemiology. In the United States, Black individuals are diagnosed with myeloma at roughly twice the rate of White individuals and at younger ages, and screening studies have shown correspondingly elevated MGUS prevalence, with the disparities most pronounced in younger age groups.

Whether Black populations in sub-Saharan Africa share this elevated risk has been far less clear. Only a handful of screening studies had been conducted in the region, and their results were mixed. Studies of 917 men in Ghana and 386 men in Johannesburg each found roughly a two-fold higher MGUS prevalence compared with a White reference population from Olmsted County, Minnesota. Yet a study of 515 individuals in Eswatini reported a heavy-chain MGUS prevalence similar to the Olmsted County figure, while simultaneously reporting a strikingly high light-chain MGUS prevalence of 12.3 percent, a discrepancy speculated to reflect overdiagnosis caused by free light chain reference ranges that may not be valid for racially diverse populations. These methodological uncertainties left the true burden of monoclonal gammopathies in Africa unresolved.

To close this gap, the PROMISE South Africa team enrolled 2,004 Black South Africans aged 40 to 75 at a community screening site in Soweto, an urban settlement of more than one million people in southwestern Johannesburg. Between January 2021 and August 2023, every participant provided a blood sample and completed an interview-guided survey covering sociodemographic background, comorbidities and lifestyle exposures. Samples were processed at the Sydney Brenner Institute for Molecular Bioscience at the University of the Witwatersrand and shipped to the Dana-Farber Cancer Institute, where they were analysed with the EXENT platform, which uses matrix-assisted laser desorption ionisation-time of flight mass spectrometry to identify and quantify M-proteins. This technique detects proteins at concentrations far below the threshold of conventional serum protein electrophoresis, and prior calibration work established that M-proteins quantified by mass spectrometry at 0.2 grams per litre or above correspond to the detection level of conventional assays.

The results were striking. Heavy-chain MGUS was detected in 12 percent of participants, with a median M-protein concentration of 0.76 grams per litre, and the great majority of these proteins were immunoglobulin G, accounting for 85 percent of cases, followed by IgA and IgM. Light-chain MGUS was found in a further 3 percent, most commonly involving kappa light chains. Combined, roughly 15 percent of this middle-aged Soweto cohort carried detectable monoclonal proteins. Prevalence rose with age, and participants living with HIV, who made up 26 percent of the cohort, were significantly more likely to have MGUS than those without the virus. In multivariable models adjusted for age, sex, education, poverty and ethnic-linguistic group, each additional decade of life was associated with 22 percent higher odds of MGUS, while HIV infection was associated with 67 percent higher odds, an association that persisted in sensitivity analyses.

The international comparison placed these numbers in context. The investigators pooled their Soweto data with two US cohorts screened with identical methods: the PROMISE US study of Black Americans and non-Black individuals with a family history of haematological malignancy, and the Mass General Brigham Biobank. Among 3,726 Black individuals aged 40 to 75 across both countries, the adjusted predicted prevalence of MGUS was 17 percent for Black South Africans, compared with 13 percent for Black Americans and 10 percent for non-Black Americans with a positive family history. The differences were most dramatic in the youngest age band: among participants aged 40 to 49, Black South Africans had a markedly higher prevalence than Black Americans, while at older ages the two groups converged. Against the family-history group, Black South Africans showed higher prevalence across every age category.

The study also probed which modifiable exposures might shape this risk, yielding several unexpected signals. Obesity, often considered a myeloma risk factor, was associated with 41 percent lower odds of MGUS in this population, a counterintuitive result the authors attribute to the difficulty of interpreting body mass index in a community experiencing a double burden of malnutrition, where undernutrition and overnutrition coexist and childhood stunting remains common. By contrast, high physical activity, equivalent to running or jogging 30 to 45 minutes daily, was associated with 57 percent lower odds of MGUS, consistent with prior US findings and with the anti-inflammatory and metabolic effects of exercise. Smoking emerged as a clear risk factor: past or current smokers had 61 percent higher odds of MGUS than never smokers, with risk rising from light-to-moderate to heavy smoking histories, plausibly reflecting chronic antigenic stimulation of the immune system.

Alcohol told a more complicated story. Heavy consumption of 15 grams or more per day was associated with 40 percent higher odds of MGUS in models adjusted for sociodemographic factors, and notably, 84 percent of the heavy drinkers reported binge or high-intensity drinking patterns in a typical month. However, when the analysis additionally adjusted for smoking pack-years, the alcohol association weakened and lost statistical significance, suggesting that it may partly reflect correlated smoking behaviours and other shared lifestyle exposures rather than a direct effect of alcohol itself. The authors caution that alcohol is not currently considered a myeloma risk factor and that the drinking patterns captured in prior studies have often been too crude to distinguish moderate consumption from the heavy episodic drinking prevalent in some urban, low-income settings.

A crucial methodological choice underpinned the light-chain findings. Rather than applying standard free light chain reference ranges, which were derived from a small cohort of blood donors and have been shown to overdiagnose light-chain MGUS in Black populations, the team used ranges optimised for racially diverse populations including people of African descent from the United States and South Africa. Earlier work showed this approach reduces light-chain MGUS overdiagnosis by 91 percent, cutting estimated prevalence from 10.7 percent to under 1 percent in pooled international cohorts. Data from the large Icelandic iStopMM screening study have similarly demonstrated that standard ranges lead to substantial overdiagnosis. Applying the refined ranges here likely yields a more realistic picture of the true light-chain disease burden, though the authors note it could modestly underestimate prevalence and call for validation in other African populations.

The study’s limitations include its cross-sectional design, which cannot establish whether the measured exposures preceded the development of MGUS, its reliance on convenience sampling at a single community site, and the absence of serial M-protein measurements to track changes over time. Residual confounding and limited generalisability to rural South Africa are further caveats. Nevertheless, the authors argue the evidence is strong enough to reframe thinking about global myeloma risk: Black South Africans appear to be a high-risk population, plausibly shaped by African ancestry, high HIV prevalence and specific lifestyle factors. If validated, these findings could justify targeted screening strategies in South Africa and open prevention avenues, including long-term virologic control of HIV, smoking cessation and promotion of physical activity, that might ultimately reduce the global burden of multiple myeloma.

Subject of Research: Prevalence and risk factors of monoclonal gammopathy of undetermined significance among Black South Africans screened by mass spectrometry

Article Title: MGUS in Black individuals in Soweto, South Africa screened by mass spectrometry: results of the PROMISE South Africa study

Article References: Lee, D. J., Chen, W. C., Bertamini, L., El-Khoury, H., Allam, S., Fleming, G., Alberge, J.-B., Perry, J., Davis, M. I., Lightbody, E., Goqwana, L. N., Philip, V., Pentz BRad, A., Dip Tchg, T. H., Redd, R., Sakrikar, D., Barnidge, D., Perkins, M. C., Harding, S., … Marinac, C. R. (2026). MGUS in Black individuals in Soweto, South Africa screened by mass spectrometry: results of the PROMISE South Africa study. eClinicalMedicine, 100, Article 104208. https://doi.org/10.1016/j.eclinm.2026.104208

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104208

Keywords: MGUS, multiple myeloma, Soweto, South Africa, mass spectrometry, HIV, health disparities, plasma cell disorders, smoking, physical activity, cancer screening, epidemiology