In the clinics where Precious Madzimbe works as a paediatric physiotherapist in Bulawayo, Zimbabwe, it is almost always the same figure who brings a child with cerebral palsy through the door: a mother, alone. His PhD, completed through the University of Cape Town's (UCT) Division of Physiotherapy, set out to understand why - and what it costs the families involved.
Precious will graduate from UCT's Faculty of Health Sciences (FHS) on 9 September, four years after he began the degree while working full-time as a clinician in Zimbabwe. His thesis, "Father and sibling participation in home rehabilitation programmes for children with neuro-developmental delay in an African context", is based on what he was seeing at the clinic.
"So many times we see mothers bringing children to the clinic," he said. "And fathers are invisible. They rarely come, and they seem not well involved in the care of their children. And so are siblings. They are rarely involved." Left to manage the household and the rehabilitation programme on their own, Precious noted that mothers were "abandoned when caring" for a child with a neurological condition. The question remains: Why are fathers and siblings not coming on board to share that load?
Four phases, one pattern
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His thesis moved through four connected studies. The first was a scoping review of the global literature on family participation in childhood rehabilitation. The second was a qualitative study with rehabilitation professionals, probing how they understood - and, often, unintentionally excluded - fathers and siblings from a child's care. The third turned to fathers themselves, using questionnaires to understand what stood between them and greater involvement.
"So many times we see mothers bringing children to the clinic, and fathers are invisible."
The pattern that emerged was consistent: participation by fathers and siblings sat below 20%. Yet when fathers were asked directly, many said they wanted to be involved - they simply were not being invited into the conversation. The barriers they described are practical rather than personal: work commitments, and the difficulty of securing leave to attend a child's appointments compared with what mothers were routinely granted.
The final and largest study was a longitudinal comparison. Precious enrolled 480 mothers and, despite the demands of following families over time, retained 450. Children's development was tracked using the Bayley Scales of Infant and Toddler Development - a rigorous, internationally recognised tool that assesses a child across five developmental domains. Families fell into three naturally occurring groups: home programmes run by mothers alone; by mothers and fathers together; and by mothers, fathers and siblings as a triad.
The differences were clear. Children in the triad group showed markedly better developmental trajectories than those supported by a father and mother alone, who in turn did better than children supported by mothers alone. Mothers' own mental health outcomes followed the same pattern, improving as the circle of family involvement widened.
"The study finally concluded that including fathers and siblings has ... a positive trajectory in the reaction of children with disabilities," he explained. His recommendation is that rehabilitation programmes for children with disabilities be family-centred, not an afterthought left to individual clinicians.
From thesis to practice
That recommendation is already being applied in the hospitals where Precious works, including Bulawayo's Mpilo Central Hospital, where clinicians are encouraged to involve fathers from a family's first appointment. Siblings, too, are being drawn in deliberately. "Sometimes they don't understand what is troubling their sibling; what's their diagnosis; what's their condition," he said. "So, emotionally, they get drained, because they are not actually involved." Precious is now working to influence policymakers in Zimbabwe to shift rehabilitation programmes away from a mother-and-child model toward one built around the whole family.
"Including fathers and siblings has a positive impact on the developmental trajectory of children with disabilities."
The hardest stretch of the PhD, he said, was the longitudinal study itself: the cost and logistics of assessing 450 families with a demanding, five-domain testing tool, and the constant risk of losing participants. The fact that he didn't was because of dedicated research assistants Dr Ronnie Matsweruka and Rumbi Mapfumo, who kept in regular contact with families. He also thanked his supervisor, Professor Soraya Maart (UCT) and co-supervisors, Dr Lieselotte Corten (University of Brighton) and Dr Jermaine Dambi (University of Zimbabwe). Support also came from UCT Libraries, a biostatistician who helped shape his analysis plan early on, as well as funding from the Department of Physiotherapy and an international scholarship that covered part of his research costs and tuition. His family filled the gaps the funding couldn't close and a network of peers helped him proofread and review papers before submission. By the time his results came, four papers from the thesis had already been published, with a book chapter accepted since.
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Precious is now applying for postdoctoral fellowships that would let him extend the work in a specific direction: gathering data directly from siblings themselves - rather than relying on what mothers and fathers report about them - to understand how caring for a brother or sister with a disability shapes their own mental health and quality of life over time.
With his flights and accommodation booked well in advance, Precious is ready to graduate at one of UCT's spring graduation ceremonies. It is a smaller milestone than the one he has spent four years working toward: a shift, still under way in the clinics he works in, from a room where only a mother stands beside a child, to one where a father waits his turn to ask a question, and a sibling, finally, is told what is wrong.
