Children Raising Children: A cross-sectional survey of parental perceptions and practices regarding sibling caretaking in rural Pakistan

Children Raising Children: A cross-sectional survey of parental perceptions and practices regarding sibling caretaking in rural Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Children Raising Children: A cross-sectional survey of parental perceptions and practices regarding sibling caretaking in rural Pakistan Shelina Bhamani, Waliyah Mughis, Amir Raza, Sheraz Ahmed, Fayaz Umrani, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3498453/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The phenomenon of children raising children, or older children caretaking for younger children is under-investigated and can significantly impact child development and family wellbeing outcomes. Methods The perceptions and practices of 150 parents towards sibling caretaking in rural Pakistan were explored through mixed methods surveys and interviews. Results 73% of parents assign sibling caretaking responsibilities to their daughters primarily, and 89% ask the eldest child to care for younger siblings, while only 2% reported never assigning this responsibility to a child. Caretaking responsibilities include feeding, bathing, disciplining, and putting the younger siblings to sleep. 95% reported assigning these responsibilities to their eldest child as their personal choice; 79% reported sibling caretaking is aligned with traditional practices/beliefs, although 89% agreed it is unrelated to religious obligations. Conclusions The findings hold implications for provision of nurturing care services for young children to support their health, education, childcare, social engagement in resource-constrained settings where children are expected to care for their siblings. siblings caretaking child-rearing early child development children raising children Figures Figure 1 Figure 2 Background Pakistan is the sixth most populous country in the world (UNDP, 2019), with approximately 27.84 births per 1000 people (World Bank, 2019). Most households in rural areas have an average of 5 children birthed by one mother (Pakistan Bureau of Statistics, 2016) and most children are born in poverty or resource-constrained settings, resulting in adversely affected developmental trajectories and unmet developmental potential (McCoy et al, 2016). The Nurturing Care Framework for Early Child Development (World Health Organization and UNICEF, 2018) guidelines identify a safe, secure, loving environment with appropriate nutrition, responsive care, and early learning activities as essential for optimal development and holistic well-being in a child’s life. This includes not just a healthy home environment, but also a safe, nurturing environment for childcare and early education. However, there is a dearth of affordable, accessible, quality services for childcare and development in resource-constrained settings such as Pakistan due to systemic challenges such as extreme poverty, limited funds, weak policies, and inadequate implementation (Kurji et al, 2016; Arshad & Zamir, 2018). Parents and caregivers who cannot afford early education or childcare for their young children may often rely on their older children for caretaking responsibilities while they are at work during the day. The phenomenon of children raising children, or older children caregiving for their younger siblings, has not been sufficiently investigated, particularly in the low- to middle-income country (LMIC) context. The question remains unanswered on how these practices emerged, how they impact the younger siblings and their development and how it influences the child caretaker. This also raises questions regarding the impact of children raising children on various biomarkers, psychosocial factors, and their holistic well-being (cognitive, physical, and socio-emotional development). The phenomenon of children raising children in this study is operationalized as young children aged under ten years either supporting, co-parenting, or supporting their younger siblings 25% or more (4 or more hours) during their daily routine time. Inquisition regarding this phenomenon is rooted in the ground-level experiences and core observations of the researchers during different field activities whereby young children under the age of 10 years were seen taking care of their younger siblings in the remote villages of Pakistan. Formative research and field observations reflect that these practices are prevalent in low-income, resource-constrained, and rural settings. There is a lack of data regarding its prevalence or impact on children’s development and socioeconomic status in Pakistan. It is imperative to explore the existing perceptions and practices pertinent to children raising children or sibling caretaking in rural Pakistan, in order to design appropriate education, health, social services and welfare interventions for the developing population of the country. In theory, children raising children can have a multidimensional impact on young children and their families at large. The children responsible for the caretaking of their younger siblings or children in the neighbourhood may have compromised formal learning time, playtime, and time to engage in constructive early childhood development activities. Moreover, there could be multiple impacts of their caregiving on the younger children and their developmental milestones. In the long run, it may contribute to early marriages as the community might think that these children are prepared to be parents due to their experiences with their siblings. In Pakistan, such occurrences of children caring for children are seen as very common in both remote and urban contexts, but its prevalence seems to be much higher in areas with resource constraints and poverty (Ali et al, 2004). However, there is a lack of availability of literature regarding this phenomenon in the region and these associations require further exploration in the Pakistani context. Consequently, it becomes fundamental to first conduct an exploratory mixed-methods study to understand the current prevalence, practices, and perceptions regarding sibling caretaking. Carrying this out on a national scale would be extremely time- and resource-intensive; hence, it is vital to focus on a subset of the population and conduct a province-wide statistical projections. Human experiences are universal. Social conditions could also be similar across cultures in different countries. Are children in rural Pakistan, particularly burdened with sibling caretaking or do other cultures and regions observe similar phenomena? Exploring the commonality of the phenomenon is essential to understand the impact sibling caretaking could have on the caregiving child, especially since research in Pakistan is non-existent on this topic. One study explored the burden on children’s personal and school success among Mexican American youth, revealing that excessive sibling caretaking could impact the caregiving child’s educational aspirations and prosocial tendencies, as there was a greater tendency for the caregiving youth to be absent from school (East & Hamill, 2013). While the experience could be a positive marker in the lives of some children, excessive caregiving that replaces the active role of parenting could have a negative impact and outcomes of the caregiving youth. It is important to note that this study too stated it lacked comprehensive evidence of the short- and long-term effects on caregiving children. Across the US, children as young as ten years old have assumed the roles of caregivers for their siblings; the situations and circumstances leading to each child’s role reversal as a caregiver stem from various issues such as deportation, absence of paternal and maternal roles (Allen, 2016), and poverty (NPR, 2012). Another study conducted in high-income countries highlights opportunities for research on the meaning and experiences of caregiving in young children’s lives (East, 2010). Children’s involvement in caregiving is rising in the global north due to increased divorce rates, single-parent families and less participation of adults in parenting (Garey et al, 2002; Chappell & Johnson, 2005). This study also provided terminology for this study in understanding sibling caregiving: exclusive caretaking and secondary caretaking, each having a significant impact on children’s lives (East, 2010). Compared with what is ‘visible’ in the Pakistani context, sibling caretaking mostly assumes the greater responsibility, bordering on or immerses in exclusive caretaking including household chores and absence from school. Caregiving and parenting are an adult’s responsibility (Evans, 2014). Caregiving children lose their childhood all too quickly due to poverty and household situations and circumstances. Where the youth demands education, companionship and interactions with similar age groups, sibling caregivers are rushing too soon into adulthood (Children Incorporated, 2018). The stresses of such a life could have a detrimental impact on children and young adults who miss out on a healthy transition from childhood to adolescence and adulthood. While some research reveals that caregiving could have a positive impact on children and youth to some extent (such as socio-emotional learning opportunities for the siblings involved), it could have a negative effect if the exclusive responsibility of caregiving rests mostly on a child (East, 2010). Research Questions The following research questions were investigated in the formative phase of the study: What are the perceptions of parents towards sibling caretaking in resource-constrained settings of district Matiari, Pakistan? What are the practices of parents towards sibling caretaking in resource-constrained settings of district Matiari, Pakistan? Methodology Design This is a sub-study of a larger study exploring the phenomenon of children raising children. For the quantitative front, a cross-sectional study design was chosen to explore the perceptions and practices of parents pertinent to the same. Research setting Four union councils of district Matiari were chosen as research sites. Matiari is a rural district of Sindh province, about 185 kilometers from Karachi, with a total population of 0.7 million as per the 2017-18 census and residing in 1,600 villages. Most of the adult population is engaged in agriculture-related activities. Matiari district is subdivided administratively into 18 Union Councils. Each union council has an average population of 35,000 and 5,000 households. The socio-economic demographics of the population in four union councils are comparable as stated below in Table 1. Matiari was selected as a rural site for this study as the Department of Paediatrics at the Aga Khan University has established a Demographic Surveillance System (DSS) and has been conducting multiple maternal and child health projects in the district for over a decade. ERC approval was obtained from Aga Khan University to ensure that all components of human bioethics research comply with this investigation. Informed consent from all the participants was sought. For children under 10, the parental informed consent/assent form was administered in the local language (Sindhi) to seek their consent. Sampling Triangulation was done, and convenient and purposive sampling with a predefined inclusion criterion was chosen as a sampling strategy for this study. A total of 150 parents and children from four districts were chosen considering the below inclusion criteria. A total number of 5 parents from each of the union councils were selected to be a part of the qualitative in-depth interview who have sibling caretaking occurring in their houses, the sample for which was driven from the quantitative subset. Inclusion Criteria for Parents Having more than 3 children and one child must be under 6 years of age Any work status i.e. Working or non-working Should not be a widow or widower Inclusion Criteria for Children Prevalence of sibling caretaking, as reported by parents. 2 or more children in the household Children aged between 8 – 14 years. Children, regardless of their parents working status i.e., Working or non-working parents. Data collection tools and instrumentation A survey questionnaire composite of demographic variables and prevalence and practices to capture the sibling caretaking items were designed and piloted before data collection. All data collection instrumentation was designed in Sindhi, the local language of the participants. The translation was done and reviewed by a trained research specialist whose first language is Sindhi. For quantitative data collection, a survey tool consisting of a demographic section, parental practices section and parental perceptions section was used. Overall, the tool consisted of 45 items with different response categories such as “always, sometimes, never” and “strongly agree, agree, disagree, strongly disagree”. For the qualitative interview guide, a semi-structured key informant interview guide consisting of open questions with probes was used. Questions included “What are your thoughts on sibling caretaking/an elder sibling taking care of their younger sibling”, with probes such as “How did it start, what are your family practices, how often is sibling caretaking done” and “Which gender do you think is most fit for sibling caretaking, and why?”. Data analysis All statistical analyses were performed using IBM SPSS 19.0 (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA). Frequency and percentage were computed for all categorical variables and responses of practice and perception of parents were assessed on the Likert scale in percentages. Mean and standard deviation were computed for quantitative variables. Results A total of 150 parents was surveyed from a rural district of Sindh, Pakistan. Only parents whose children were involved in sibling caregiving activities were included in the final sample. The socio-economic demographics of participants are presented in Table 1. 78% of the respondents revealed their household size between 5 to 10 family members, followed by 1 to 5 family members (16%) and 6% had more than 10 family members in the household. Around 57% (86) of the respondents reported living in a concrete house ( Pakki ), while 43% (64) were living in Katchi houses (mainly made of mud). Over half (80; 53%) did not own the house they were living in and were living in the house owned by the landowner, whereas 42% (63) of respondents resided in their own house. However, regardless of house status and type, all respondents reported living in small houses (i.e. having 1 to 3 rooms). Additionally, 66% of participants stated that they do not have toilet facilities inside the house and go outside for toilet purposes, whereas 34% reported the availability of toilet facilities inside their houses. Nearly 50% of the respondents reported their range of income as less than 10,000 Pakistani rupees (>US$35) per month, while a fraction of the respondents (N=10) mentioned an income of over PKR 15,000 per month. The monthly income of the remaining respondents (45%) was in the range of PKR 10,000 – 15,000 (US$35-55) per month. The respondents further reported that they spend a monthly average of PKR1801 on their medical treatments and PKR1033 on the educational activities of their children/families. The majority of the respondents have mobile phone access (85%) and electricity at home (83%), while 35% of them have a television in their house. Furthermore, a vast majority claimed the availability of toys for their children; in contrast, 93% reported the unavailability of non-academic books for their children at home. Overall, respondents – both husband and wife – were less or not educated, but there were considerably more uneducated females (82%) than uneducated males (52%). Only two female respondents had completed Matriculation/Intermediate level education, while only two male respondents recorded a Bachelor’s degree as the highest level of their education. Most of the male respondents (78%) were field workers/general labourers, whereas the rest were working as shopkeepers, mechanics or self-employed. On the other hand, more than half (58%) of female respondents reported doing manual labour in the fields or farms. Table 1: Demographics of participating parents Characteristics Description Frequency (percentage) House type Katchi (mud-based) 64 (43%) Pakki (concrete) 86 (57%) House ownership Owned 63 (42%) Rented 0 Joint family 2 (1%) Landowner’s property 80 (53%) Number of rooms in the house 1 – 3 150 (100%) 3 – 6 0 6 and above 0 Household income per month in Pakistani rupees Below 5000 2 (1%) 5000 – 10000 71 (47%) 10000 – 15000 67 (45%) 15000 and above 10 (7%) Medical expenses per month On average M=1801; S.D=1622 (Min.=200; Max. 10000) Educational expense per month On average M=1033; S.D=1549 (Min.=100; Max. 10000) Toilet Facilities Open inside house 26 (17%) Closed inside house 26 (17%) Outside 98 (66%) Mobile Phones Yes 127 (85%) No 23 (15%) Television Yes 53 (35%) No 97 (65%) Electricity Yes 125 (83%) No 25 (17%) Toys for children Yes 138 (92%) No 12 (8%) Non-academic books for kids Yes 10 (7%) No 140 (93%) Number of members in the household 1 – 5 24 (16%) 5 – 10 117 (78%) 10 and above 9 (6%) Father’s highest level of education No schooling 78 (52%) Below matric 53 (35%) Matriculate 5 (3%) Intermediate 12 (8%) Graduate 2 (1%) Graduate and above 0 Father’s profession Self-employed 6 (4%) Fieldworker/general labour 117 (78%) Shop worker 6 (4%) Other 21 (14%) Mother’s highest level of education No schooling 122 (81%) Below matric 25 (17%) Matriculate 0 Intermediate 1 (0.7) Graduate 1 (0.7) Graduate and above 0 Mother’s profession Self-employed 6 (4%) Fieldworker/general labour 87 (58%) Shop worker 0 Other 57 (38%) Parental Practices Regarding Sibling Caregiving Results presented in Figure 1 show parents’ practices regarding sibling caregiving. Parents assigned sibling caretaking responsibility to their daughters (109;73%) more than the sons (41; 27%). Parents usually ask their eldest child to care for their younger siblings: a majority of parents (134; 89%) always ask their elder children to play with younger siblings, followed by 9% who rarely ask and 2% who never ask. Furthermore, 75% of participants reported that they always ask their elder children to feed younger siblings, while 22% ask occasionally for feeding young siblings. Around 60% of the parents always ask their children to bathe and dress younger siblings. However, many parents (20%) reported that they never ask their children to bathe younger siblings. A considerable percentage of parents reported that they also ask their children to guard (70%) and discipline (62%) their younger siblings when they go out. Moreover, 66% and 29% of parents stated that they always and sometimes ask their children to get younger siblings to sleep, respectively. When asked if the children’s school attendance is affected by caretaking, some parents were of the opinion that “ if my daughter is at home and not going to school, then [sibling caretaking] is right… if she was going to school, then my mother or I or some other woman from the neighbourhood would take care of our children ”, while others reported that the eldest female child in their family attends school during the day and takes care of her siblings after school and that her caregiving responsibilities also include teaching the younger siblings and helping them with their schoolwork. Parental Perceptions of Sibling Caregiving The results presented in Figure 2 demonstrate parents’ perceptions of sibling caregiving. A vast majority of the respondents (95%) reported that they view assigning sibling caretaking responsibility to their elder children as their personal choice, while 75% of respondents reported that sibling caregiving is not a trend or common practice in their family. 79% of parents agreed that sibling caretaking is part of their cultural practice and tradition, with interview responses including “ This has happened since [the time of] our elders … if there is an older sister, she takes care of the younger brothers and sisters ” and “ Before it was more common, now [sibling caregiving] time has decreased [in this generation] ”. Most responses such as “ Our opinion is that if the elder girl doesn’t do it, she remains immature … if there is no one else to take care [of the younger children], then she must do it ” and “ If the mother is busy with work, then our daughters do take care of our babies … because they know more than boys do ” indicated that girls are expected to care for their younger siblings more than their male counterparts are. Interestingly, parental responses were equally distributed for the item ‘elder child caretaking is the right of the younger sibling’, where 50% agreed and 50% disagreed. Likewise, the same pattern was observed in response to sibling caretaking as the responsibility of elder children. 43% of the parents responded that assigning sibling caretaking responsibility is their right as parents. In contrast, a substantial number of respondents (89%) disagreed that sibling caregiving is related to any religious obligation. Discussion The present study aimed to explore parental perceptions and practices regarding sibling care-taking in resource-constrained settings of district Matiari. Two research questions were posed to guide the investigation: What are the perceptions, and what are the practices of parents with regard to sibling caretaking in such settings? The findings provide valuable insights into the dynamics of sibling caretaking in a setting where resources are limited, and familial support is critical. This is one of the first studies in a developing region to explore parental perceptions and practices pertinent to sibling caregiving. As for the parental perception, an overwhelming majority of respondents viewed assigning sibling caregiving responsibilities to their elder children as a personal choice, suggesting that parents may have a high degree of agency when it comes to determining their family's approach to childcare. Moreover, the finding that 79% of parents agreed that sibling caregiving is part of their cultural practices and tradition suggests that the expectations surrounding sibling caregiving may be deeply rooted in cultural norms and beliefs. The interviews revealed that girls are often expected to care for their younger siblings more than boys are, perpetuating gendered expectations and potentially limiting opportunities for girls to pursue other interests or activities. The finding that girls are expected to care for their younger siblings more than boys is consistent with previous research on gender caregiving expectations within families. These gendered expectations can have significant implications for girls' opportunities to pursue education and other lifestyle activities. These findings are also pertinent to research regarding girls and women taking up most roles in homemaking (Raza & Sohaib, 2010 ; Moyer, 2018 ; Human Rights Watch, 2018 ). Another significant finding was concerning that 43% of parents believed that assigning sibling caregiving responsibilities is their right. This suggests that some parents may view their children's caregiving responsibilities as an obligation or duty that they are entitled to assign. Research has shown that child caregiving can have negative consequences for children's academic achievement and psychological well-being. Additionally, studies have found that children who provide caregiving are at increased risk for physical and emotional abuse, which can have long-term adverse implications for their well-being and development (Toth & Manly, 2019 ). The second question was regarding parental practices; significant findings included that while they are at work during the day, parents usually ask their eldest children to take care of the younger sibling in terms of feeding, disciplining, guarding, playing with, dressing and bathing, and putting them to sleep. In rural Pakistan, the average family has 4 to 6 children (Pakistan Bureau of Statistics, 2016 ; World Bank, 2019 ). The enhanced burden of poverty and constrained resources result in both parents working, with women/mothers usually engaged in manual agricultural labour in the family fields. This leads to the older sibling taking charge of caretaking for their younger siblings during the day, when they could alternatively be going to school, socializing with age-appropriate peers or engaging in other developmentally appropriate activities. An explanation for the phenomenon of children raising children could be the parents’ personal beliefs and their cultural practices, wherein traditionally the parents, and their parents, have also been raised in similar circumstances. Additionally, there is a lack of formal outlets for play, socialization and education (parks, public libraries, daycare centers and quality schools) in rural areas such as Matiari, which results in children often staying home and helping their parents with manual labour in the fields, or tending to the younger children in the household, or assisting in other household errands/chores (Toor, 2001 ; Toor, 2005 ). The phenomenon of older children caretaking for their younger siblings is not limited to rural Pakistan. Children’s involvement in household chores and child caretaking have been documented in LMIC and HIC (Weisner et al, 1977 ; Morrow, 2008 ; Merten, 2016 ; Ruiz-Casares et al 2018 ). In higher-income countries, older siblings may be accountable for sibling caretaking in low-income single-parent households (Wikle et al, 2018 ; McReary et al, 2004), whereas, in the rural Pakistani context, most families usually expect and ask children to support their parents in multiple daily caretaking and household activities. However, from most of the interview responses, this appears to be a personal and cultural choice stemming from tradition, rather than one based on religious beliefs, and therefore sibling caretaking by children is viewed as an organic cultural element, rooted in tradition, and not so much an imposition on children’s rights. The findings from this survey indicate that parental perceptions and practices regarding sibling caretaking have trends similarities. Similarly, household income level and family practices regarding sibling caretaking are correlated, indicating that families with higher incomes may be more likely to provide additional resources and support for sibling caretaking. These findings highlight the importance of examining familial and socioeconomic factors when considering the role of sibling caretaking in child development and family dynamics. As per our findings, sibling caretaking appears to be more often a girl’s responsibility, and the phenomenon is mostly a result of parents’ personal choices and the wider cultural practices in Matiari. Older girls are seen as a natural substitute for their mothers who are working outside the home and therefore are assigned significant responsibilities including cooking, cleaning and caring for their siblings (Wiysahnyuy, 2018 ). These domestic responsibilities prevent a significant proportion of female children from attending school and pursuing a formal education in rural Pakistan. However, from the descriptive data of this study, it is not possible to establish a causal relationship between sibling caregiving and low school attendance rates, particularly of girls, since the interview findings indicated that girls, when at home, are expected to take care of their siblings, but they may not be going to school for other reasons such as lack of infrastructure and transport options, as well as safety and security concerns. Parents in rural areas of Pakistan may not send their daughters to school for the fear of defamation of the girl or potential harassment during long-distance travel or in school (Ali & Cheema, 2018 ). Furthermore, the investment in educating children is deemed more rewarding for a male child for want of gainful employment and family rearing (Purewal & Hashmi, 2015 ; Moyer, 2018 ). It is generally believed that the girl child is better suited for this role of caregiving (Howe & Rinaldi, 2004 ) as she is to prepare for marriage and motherhood (Wiysahnyuy, 2018 ). In Pakistan, much work is required for a multi-sectoral level (academia, education and child-related policy), ranging from daycare facilities for working parents and their young children, to safe, accessible, quality educational facilities for children. Furthermore, gender equality and literacy are essential to address in rural populations. Devising policies to protect the emotional, social and physical well-being of all children is the state’s responsibility. If families are unable to make ends meet and have to resort to assigning sibling caretaking responsibilities to the eldest child, mostly the girl, special initiatives should be undertaken to create awareness and provide solutions regarding these economic and social development issues (such as affordable, accessible childcare services). A look into the positives: the lasting positive impact of sibling bonding through sibling caretaking While it may seem a dismal state that children are subjected to the caretaking of younger siblings, the relationship could have a positive impact. If the parents invest time and energy in the education and upbringing of the eldest child, it could positively impact the well-being of the younger siblings. Sibling interaction could play an important role in socialization (Goodwin, 2017 ; Wikle, Jensen, & Hoagland, 2018 ). Dependability, trust and compassion among siblings could help in developing positive attitudes and building stronger family ties. Caring for others and showing a genuine concern for each other’s well-being is perhaps the most precious of human emotions (Hughes, McHarg, & White, 2018 ). However, such positive outcomes are possible only when all children are treated fairly and the parents ensure the emotional well-being, education and health of the entire family. The lasting negative impact on sibling bonding: what may be In the absence of care from parents, good nutrition, education and a good upbringing, sibling caretaking and sibling relationships could be severed or otherwise adversely affected. The elder child made responsible for caring for the young and not receiving care himself or herself may suffer from resentment, depression and a sense of deprivation, along with a loss of safety and security. Assisting parents in household chores and caring for siblings may have positive outcomes as just that – assisting. When the roles are reversed with permanent expectations, it will most likely be detrimental to the caregiving child’s development. The future: the public, practice and policy The effect the eldest child can have on younger siblings is a window of opportunity to change the social landscape in rural Pakistan. Investing in the eldest child is most likely to have a positive ripple effect within the family and society (UNICEF, 2017 ). This can be made possible only when the public is sensitized to understand and acknowledge the problem. The public affected should be made to realize the significant loss their actions could bring to the well-being, growth and development of their children and society as a whole. Even the public, who may not be affected by this problem should be made aware, to provide the necessary social support in advising parents, extending help and opportunities for families to learn and improve. In consonance, institutions and organizations in the public and private sectors should respond proactively to this problem. More evidence-based research is required in this area to fully understand the cause and effect of sibling caretaking. While keeping the positive aspects of sibling caretaking intact and ensuring the longevity of societal norms most positively, the national policy must ensure education for all, affordable quality healthcare, support to low-income earning families, programmes for awareness and education of the masses, with a genuine focus and political will of developing human capital. Conclusion There is evidence that sibling caregiving could have very positive outcomes in a child’s life, but only in the presence of a caring and responsible adult – preferably both parents. The negative impacts of sibling caretaking are detrimental to the healthy growth and development of children into adults with significant threat to their educational attainment and educational success, health and mental well-being, their relations and interactions with peers, opportunities to participate in social activities, employment opportunities and economic success, and general norms and behaviour. Pakistan is a developing country and needs to focus on the well-being of children in each household, regardless of socio-economic conditions, with comprehensive policies and programs for their protection, safety, and security to lead successful lives. The findings from this study regarding the prevalence and practices of children raising children can be implemented in the design and development of promotive and supportive childcare interventions for children and their families. Key Findings The phenomenon of sibling caretaking is prevalent in resource-constrained settings where parents/adult caregivers do not have sufficient systemic child caretaking support. Majority (73%) of parents assigned sibling caretaking responsibilities to their older daughters instead of their sons (27%). Most parents ask the older sibling to put the younger siblings to sleep, bathe, dress, guard, discipline, feed and play with their younger siblings while the parents are at work. Majority of parents (95%) view assigning sibling caretaking responsibilities to older children as the parents' personal choice, and most reported sibling caretaking as part of their cultural practice and tradition, but not necessarily a common practice in their family. Parental perceptions and practices regarding sibling caretaking may be influenced by several socioeconomic factors and cultural/personal beliefs. Comprehensive policies and programs are required to ensure the protection, safety and security of young children and their holistic development and well-being in Pakistan. Abbreviations CRC – Children Raising Children (H)DSS – Human Demographic Surveillance System LMIC – low and middle-income countries HIC – high-income countries SDG – Sustainable Development Goals Declarations Authors’ Contributions All authors contributed to the manuscript/study. SB, AA were principal investigators and designed the study protocol and ensured ethical conduct and research standards. SA, FU managed the data collection and supervised all field activities with SJ, KQ, NR. AR analysed the quantitative data and prepared the manuscript figures. SB and WM analysed the data and wrote the manuscript with input from all co-authors. Competing interests The authors have no competing interests to declare. Ethics approval and consent to participate ERC approval was obtained from Aga Khan University to ensure that all components of human bioethics research comply with this investigation. Informed consent from all the participants was sought. For children under 10, the parental informed consent/assent form was administered in the local language (Sindhi) to seek their consent. Availability of data and materials Deidentified study data and analyses, as well as data collection tools are available upon request from the corresponding author, [email protected] Funding This study did not receive any funding. References Ali, M., Shahab, S., Ushijima, H., & de Muynck, A. (2004). 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L., & Dancy, B. L. (2004). Dimensions of family functioning: Perspectives of low‐income African American single‐parent families. Journal of Marriage and Family, 66(3), 690-701. https://doi.org/10.1111/j.0022-2445.2004.00047.x Merten, S. (2016). Ambiguous care: siblings and the economies of HIV-related care in Zambia. AIDS care, 28(sup4) , 41-50. Morrow, V. (2008). Responsible children and children’s responsibilities? Sibling caretaking and babysitting by school-age children. Responsibility, law and the family , 105-124. Moyer, O. (2018). Female Education in Pakistan. Social Work: Student Scholarship & Creative Works, 4 . Available at https://jayscholar.etown.edu/cgi/viewcontent.cgi?article=1003&context=socwrkstu NPR. (2012, November). When Older Siblings Step Into Parents' Shoes . Retrieved from NPR Website: https://www.npr.org/2012/11/19/165494944/when-older-siblings-step-into-parents-shoes Pakistan Bureau of Statistics. (2016). Average household size and its composition by sex and quintiles (2015-16). Available at https://www.pbs.gov.pk/sites/default/files/pslm/publications/hies15-16/TABLE_01.pdf Purewal, N., & Hashmi, N. (2015). Between returns and respectability: parental attitudes towards girls’ education in rural Punjab, Pakistan. British Journal of Sociology of Education, 36(7), 977-995 , 977-995. Ruiz-Casares, M., Nazif-Muñoz, J. I., Iwo, R., & Oulhote, Y. (2018). Nonadult supervision of children in low-and middle-income countries: results from 61 national population-based surveys. International journal of environmental research and public health, 15(8) , 1564. Raza, A., & Sohaib, M.H. (2010). Gender gap in Pakistan: a socio-demographic analysis. International Journal of Social Economics, 37(7), 541-557 . Siddiqui, N. (2017). Socio-economic segregation of disadvantaged children between schools in Pakistan: comparing the state and private sector. Educational Studies, 43(4), 391-409 . Toor, I. A. (2005). Child Labor’s Link with Literacy and Poverty in Pakistan. Toor, S. (2001). Child labor in Pakistan: coming of age in the new world order. The Annals of the American Academy of Political and Social Science, 575 (1), 194-224. Toth, S. L., & Manly, J. T. (2019). Developmental consequences of child abuse and neglect: Implications for intervention. Child Development Perspectives, 13 (1), 59-64. https://doi.org/10.1111/cdep.12317 UNICEF. (2017). Situation Analysis of Children in Pakistan. UNICEF Pakistan. Weisner, T. S., Gallimore, R., Bacon, M. K., Barry III, H., Bell, C., Novaes, S. C., & Koel, A. (1977). My brother's keeper: Child and sibling caretaking [and comments and reply]. Current Anthropology, 18(2) , 169-190. Wikle, J. S., Jensen, A. C., & Hoagland, A. M. (2018). Adolescent caretaking of younger siblings. Social science research, 71 , 72-84. Wiysahnyuy, L. F. (2018). Sibling Care Giving Experiences among the Rural NSO Children of Cameroon. International Journal of Humanities Social Sciences and Education (IJHSSE) , 105-112. World Bank. (2019). Birth rate, crude (per 1,000 people)—Pakistan | Data . (n.d.). Retrieved 28 February 2022, from https://data.worldbank.org/indicator/SP.DYN.CBRT.IN?locations=PK World Health Organization & UNICEF. (2018). Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. Available at https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3498453","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":245836053,"identity":"d5d338ab-17e6-45d6-a286-614fce0c1ebb","order_by":0,"name":"Shelina 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University","correspondingAuthor":false,"prefix":"","firstName":"Najeeb","middleName":"","lastName":"Rehman","suffix":""},{"id":245836061,"identity":"1612d97d-7cf8-497d-b74a-92e13ada7ab8","order_by":8,"name":"Asad Ali","email":"","orcid":"","institution":"Aga Khan University","correspondingAuthor":false,"prefix":"","firstName":"Asad","middleName":"","lastName":"Ali","suffix":""}],"badges":[],"createdAt":"2023-10-27 09:29:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3498453/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3498453/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46051498,"identity":"df27ce5f-6eab-44d1-89e5-674355378d4a","added_by":"auto","created_at":"2023-11-08 00:04:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139746,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParents’ practices of sibling caregiving (n=150)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1Parentalpracticessiblingcaregiving.png","url":"https://assets-eu.researchsquare.com/files/rs-3498453/v1/c7f9576ec71beec8b2c602eb.png"},{"id":46051497,"identity":"39806be2-5ba6-4e18-826a-e537f0327723","added_by":"auto","created_at":"2023-11-08 00:04:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":94685,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParents’ Perceptions of Sibling Caregiving (n=150)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2Parentalperceptionssiblingcaregiving.png","url":"https://assets-eu.researchsquare.com/files/rs-3498453/v1/46a0df61b713bd52863f65e8.png"},{"id":55735958,"identity":"dbe1c9c3-312f-4015-8d06-94d92fb19694","added_by":"auto","created_at":"2024-05-02 12:25:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":851931,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3498453/v1/0f2507a6-bc73-426e-b3db-6a50a4056e70.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Children Raising Children: A cross-sectional survey of parental perceptions and practices regarding sibling caretaking in rural Pakistan","fulltext":[{"header":"Background","content":"\u003cp\u003ePakistan is the sixth most populous country in the world (UNDP, 2019), with approximately 27.84 births per 1000 people (World Bank, 2019). Most households in rural areas have an average of 5 children birthed by one mother (Pakistan Bureau of Statistics, 2016) and most children are born in poverty or resource-constrained settings, resulting in adversely affected developmental trajectories and unmet developmental potential (McCoy et al, 2016). The Nurturing Care Framework for Early Child Development (World Health Organization and UNICEF, 2018) guidelines identify a safe, secure, loving environment with appropriate nutrition, responsive care, and early learning activities as essential for optimal development and holistic well-being in a child\u0026rsquo;s life. This includes not just a healthy home environment, but also a safe, nurturing environment for childcare and early education. However, there is a dearth of affordable, accessible, quality services for childcare and development in resource-constrained settings such as Pakistan due to systemic challenges such as extreme poverty, limited funds, weak policies, and inadequate implementation (Kurji et al, 2016; Arshad \u0026amp; Zamir, 2018).\u003c/p\u003e\n\u003cp\u003eParents and caregivers who cannot afford early education or childcare for their young children may often rely on their older children for caretaking responsibilities while they are at work during the day. The phenomenon of children raising children, or older children caregiving for their younger siblings, has not been sufficiently investigated, particularly in the low- to middle-income country (LMIC) context. The question remains unanswered on how these practices emerged, how they impact the younger siblings and their development and how it influences the child caretaker. \u0026nbsp;This also raises questions regarding the impact of children raising children on various biomarkers, psychosocial factors, and their holistic well-being (cognitive, physical, and socio-emotional development).\u003c/p\u003e\n\u003cp\u003eThe phenomenon of children raising children in this study is operationalized as young children aged under ten years either supporting, co-parenting, or supporting their younger siblings 25% or more (4 or more hours) during their daily routine time. Inquisition regarding this phenomenon is rooted in the ground-level experiences and core observations of the researchers during different field activities whereby young children under the age of 10 years were seen taking care of their younger siblings in the remote villages of Pakistan. Formative research and field observations reflect that these practices are prevalent in low-income, resource-constrained, and rural settings. There is a lack of data regarding its prevalence or impact on children\u0026rsquo;s development and socioeconomic status in Pakistan. It is imperative to explore the existing perceptions and practices pertinent to children raising children or sibling caretaking in rural Pakistan, in order to design appropriate education, health, social services and welfare interventions for the developing population of the country.\u003c/p\u003e\n\u003cp\u003eIn theory, children raising children can have a multidimensional impact on young children and their families at large. The children responsible for the caretaking of their younger siblings or children in the neighbourhood may have compromised formal learning time, playtime, and time to engage in constructive early childhood development activities. Moreover, there could be multiple impacts of their caregiving on the younger children and their developmental milestones. In the long run, it may contribute to early marriages as the community might think that these children are prepared to be parents due to their experiences with their siblings. In Pakistan, such occurrences of children caring for children are seen as very common in both remote and urban contexts, but its prevalence seems to be much higher in areas with resource constraints and poverty (Ali et al, 2004). However, there is a lack of availability of literature regarding this phenomenon in the region and these associations require further exploration in the Pakistani context.\u003c/p\u003e\n\u003cp\u003eConsequently, it becomes fundamental to first conduct an exploratory mixed-methods study to understand the current prevalence, practices, and perceptions regarding sibling caretaking. Carrying this out on a national scale would be extremely time- and resource-intensive; hence, it is vital to focus on a subset of the population and conduct a province-wide statistical projections. Human experiences are universal. Social conditions could also be similar across cultures in different countries. Are children in rural Pakistan, particularly burdened with sibling caretaking or do other cultures and regions observe similar phenomena? Exploring the commonality of the phenomenon is essential to understand the impact sibling caretaking could have on the caregiving child, especially since research in Pakistan is non-existent on this topic.\u003c/p\u003e\n\u003cp\u003eOne study explored the burden on children\u0026rsquo;s personal and school success among Mexican American youth, revealing that excessive sibling caretaking could impact the caregiving child\u0026rsquo;s educational aspirations and prosocial tendencies, as there was a greater tendency for the caregiving youth to be absent from school (East \u0026amp; Hamill, 2013). While the experience could be a positive marker in the lives of some children, excessive caregiving that replaces the active role of parenting could have a negative impact and outcomes of the caregiving youth. It is important to note that this study too stated it lacked comprehensive evidence of the short- and long-term effects on caregiving children.\u003c/p\u003e\n\u003cp\u003eAcross the US, children as young as ten years old have assumed the roles of caregivers for their siblings; the situations and circumstances leading to each child\u0026rsquo;s role reversal as a caregiver stem from various issues such as deportation, absence of paternal and maternal roles (Allen, 2016), and poverty (NPR, 2012). Another study conducted in high-income countries highlights opportunities for research on the meaning and experiences of caregiving in young children\u0026rsquo;s lives\u0026nbsp;(East, 2010). Children\u0026rsquo;s involvement in caregiving is rising in the global north due to increased divorce rates, single-parent families and less participation of adults in parenting (Garey et al, 2002; Chappell \u0026amp; Johnson, 2005). This study also provided terminology for this study in understanding sibling caregiving: exclusive caretaking and secondary caretaking, each having a significant impact on children\u0026rsquo;s lives\u0026nbsp;(East, 2010). Compared with what is \u0026lsquo;visible\u0026rsquo; in the Pakistani context, sibling caretaking mostly assumes the greater responsibility, bordering on or immerses in exclusive caretaking including household chores and absence from school.\u003c/p\u003e\n\u003cp\u003eCaregiving and parenting are an adult\u0026rsquo;s responsibility (Evans, 2014). Caregiving children lose their childhood all too quickly due to poverty and household situations and circumstances. Where the youth demands education, companionship and interactions with similar age groups, sibling caregivers are rushing too soon into adulthood (Children Incorporated, 2018). The stresses of such a life could have a detrimental impact on children and young adults who miss out on a healthy transition from childhood to adolescence and adulthood. While some research reveals that caregiving could have a positive impact on children and youth to some extent (such as socio-emotional learning opportunities for the siblings involved), it could have a negative effect if the exclusive responsibility of caregiving rests mostly on a child\u0026nbsp;(East, 2010).\u003c/p\u003e\n\u003ch2\u003eResearch Questions\u003c/h2\u003e\n\u003cp\u003eThe following research questions were investigated in the formative phase of the study:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eWhat are the perceptions of parents towards sibling caretaking in resource-constrained settings of district Matiari, Pakistan?\u003c/li\u003e\n \u003cli\u003eWhat are the practices of parents towards sibling caretaking in resource-constrained settings of district Matiari, Pakistan?\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methodology","content":"\u003ch2\u003eDesign\u003c/h2\u003e\n\u003cp\u003eThis is a sub-study of a larger study exploring the phenomenon of children raising children. For the quantitative front, a cross-sectional study design was chosen to explore the perceptions and practices of parents pertinent to the same.\u003c/p\u003e\n\u003ch2\u003eResearch setting\u003c/h2\u003e\n\u003cp\u003eFour union councils of district Matiari were chosen as research sites. Matiari is a rural district of Sindh province, about 185 kilometers from Karachi, with a total population of 0.7 million as per the 2017-18 census and residing in 1,600 villages. Most of the adult population is engaged in agriculture-related activities. Matiari district is subdivided administratively into 18 Union Councils. Each union council has an average population of 35,000 and 5,000 households. The socio-economic demographics of the population in four union councils are comparable as stated below in Table 1. Matiari was selected as a rural site for this study as the Department of Paediatrics at the Aga Khan University has established a Demographic Surveillance System (DSS) and has been conducting multiple maternal and child health projects in the district for over a decade.\u003c/p\u003e\n\u003cp\u003eERC approval was obtained from Aga Khan University to ensure that all components of human bioethics research comply with this investigation. Informed consent from all the participants was sought. For children under 10, the parental informed consent/assent form was administered in the local language (Sindhi) to seek their consent.\u003c/p\u003e\n\u003ch2\u003eSampling\u003c/h2\u003e\n\u003cp\u003eTriangulation was done, and convenient and purposive sampling with a predefined inclusion criterion was chosen as a sampling strategy for this study. A total of 150 parents and children from four districts were chosen considering the below inclusion criteria. A total number of 5 parents from each of the union councils were selected to be a part of the qualitative in-depth interview who have sibling caretaking occurring in their houses, the sample for which was driven from the quantitative subset.\u003c/p\u003e\n\u003ch2\u003eInclusion Criteria for Parents\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003eHaving more than 3 children and one child must be under 6 years of age\u003c/li\u003e\n \u003cli\u003eAny work status i.e. Working or non-working\u003c/li\u003e\n \u003cli\u003eShould not be a widow or widower\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eInclusion Criteria for Children\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003ePrevalence of sibling caretaking, as reported by parents.\u003c/li\u003e\n \u003cli\u003e2 or more children in the household\u003c/li\u003e\n \u003cli\u003eChildren aged between 8 \u0026ndash; 14 years.\u003c/li\u003e\n \u003cli\u003eChildren, regardless of their parents working status i.e., Working or non-working parents.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eData collection tools and instrumentation\u003c/h2\u003e\n\u003cp\u003eA survey questionnaire composite of demographic variables and prevalence and practices to capture the sibling caretaking items were designed and piloted before data collection. All data collection instrumentation was designed in Sindhi, the local language of the participants. The translation was done and reviewed by a trained research specialist whose first language is Sindhi. For quantitative data collection, a survey tool consisting of a demographic section, parental practices section and parental perceptions section was used. Overall, the tool consisted of 45 items with different response categories such as \u0026ldquo;always, sometimes, never\u0026rdquo; and \u0026ldquo;strongly agree, agree, disagree, strongly disagree\u0026rdquo;. For the qualitative interview guide, a semi-structured key informant interview guide consisting of open questions with probes was used. Questions included \u0026ldquo;What are your thoughts on sibling caretaking/an elder sibling taking care of their younger sibling\u0026rdquo;, with probes such as \u0026ldquo;How did it start, what are your family practices, how often is sibling caretaking done\u0026rdquo; and \u0026ldquo;Which gender do you think is most fit for sibling caretaking, and why?\u0026rdquo;.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS 19.0 (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA). Frequency and percentage were computed for all categorical variables and responses of practice and perception of parents were assessed on the Likert scale in percentages. \u0026nbsp; Mean and standard deviation were computed for quantitative variables.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 150 parents was surveyed from a rural district of Sindh, Pakistan. Only parents whose children were involved in sibling caregiving activities were included in the final sample. The socio-economic demographics of participants are presented in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e78% of the respondents revealed their household size between 5 to 10 family members, followed by 1 to 5 family members (16%) and 6% had more than 10 family members in the household. Around 57% (86) of the respondents reported living in a concrete house (\u003cem\u003ePakki\u003c/em\u003e), while 43% (64) were living in \u003cem\u003eKatchi\u003c/em\u003e houses (mainly made of mud). Over half (80; 53%) did not own the house they were living in and were living in the house owned by the landowner, whereas 42% (63) of respondents resided in their own house. However, regardless of house status and type, all respondents reported living in small houses (i.e. having 1 to 3 rooms). Additionally, 66% of participants stated that they do not have toilet facilities inside the house and go outside for toilet purposes, whereas 34% reported the availability of toilet facilities inside their houses. Nearly 50% of the respondents reported their range of income as less than 10,000 Pakistani rupees (\u0026gt;US$35) per month, while a fraction of the respondents (N=10) mentioned an income of over PKR 15,000 per month. The monthly income of the remaining respondents (45%) was in the range of PKR 10,000 \u0026ndash; 15,000 (US$35-55) per month. The respondents further reported that they spend a monthly average of PKR1801 on their medical treatments and PKR1033 on the educational activities of their children/families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of the respondents have mobile phone access (85%) and electricity at home (83%), while 35% of them have a television in their house. Furthermore, a vast majority claimed the availability of toys for their children; in contrast, 93% reported the unavailability of non-academic books for their children at home. Overall, respondents \u0026ndash; both husband and wife \u0026ndash; were less or not educated, but there were considerably more uneducated females (82%) than uneducated males (52%). Only two female respondents had completed Matriculation/Intermediate level education, while only two male respondents recorded a Bachelor\u0026rsquo;s degree as the highest level of their education. Most of the male respondents (78%) were field workers/general labourers, whereas the rest were working as shopkeepers, mechanics or self-employed. On the other hand, more than half (58%) of female respondents reported doing manual labour in the fields or farms. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographics of participating parents\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency (percentage)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHouse type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eKatchi\u0026nbsp;\u003c/em\u003e(mud-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e64 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePakki\u0026nbsp;\u003c/em\u003e(concrete)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e86 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eHouse ownership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eOwned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e63 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eRented\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eJoint family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eLandowner\u0026rsquo;s property\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e80 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eNumber of rooms in the house\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003e1 \u0026ndash; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e150 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e3 \u0026ndash; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e6 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eHousehold income per month in Pakistani rupees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eBelow 5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e5000 \u0026ndash; 10000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e71 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e10000 \u0026ndash; 15000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e67 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e15000 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e10 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" valign=\"top\"\u003e\n \u003cp\u003eMedical expenses per month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eOn average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003eM=1801; S.D=1622 (Min.=200; Max. 10000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" valign=\"top\"\u003e\n \u003cp\u003eEducational expense per month\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eOn average\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003eM=1033; S.D=1549 (Min.=100; Max. 10000)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eToilet Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eOpen inside house\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e26 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eClosed inside house\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e26 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eOutside\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e98 (66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMobile Phones\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e127 (85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e23 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTelevision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e53 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e97 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eElectricity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e125 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e25 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eToys for children\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e138 (92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e12 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNon-academic books for kids\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e10 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e140 (93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eNumber of members in the household\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003e1 \u0026ndash; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e24 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e5 \u0026ndash; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e117 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003e10 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e9 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eFather\u0026rsquo;s highest level of education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eNo schooling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e78 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eBelow matric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e53 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eMatriculate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e5 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e12 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eGraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eGraduate and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eFather\u0026rsquo;s profession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eFieldworker/general labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e117 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eShop worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e21 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eMother\u0026rsquo;s highest level of education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eNo schooling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e122 (81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eBelow matric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e25 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eMatriculate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eIntermediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eGraduate\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eGraduate and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.101083032490976%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMother\u0026rsquo;s profession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.671480144404335%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.227436823104693%\"\u003e\n \u003cp\u003e6 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eFieldworker/general labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e87 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eShop worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.12994350282486%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.87005649717514%\"\u003e\n \u003cp\u003e57 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eParental Practices Regarding Sibling Caregiving\u003c/h2\u003e\n\u003cp\u003eResults presented in Figure 1 show parents\u0026rsquo; practices regarding sibling caregiving. Parents assigned sibling caretaking responsibility to their daughters (109;73%) more than the sons (41; 27%). Parents usually ask their eldest child to care for their younger siblings: a majority of parents (134; 89%) always ask their elder children to play with younger siblings, followed by 9% who rarely ask and 2% who never ask. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, 75% of participants reported that they always ask their elder children to feed younger siblings, while 22% ask occasionally for feeding young siblings. Around 60% of the parents always ask their children to bathe and dress younger siblings. However, many parents (20%) reported that they never ask their children to bathe younger siblings. A considerable percentage of parents reported that they also ask their children to guard (70%) and discipline (62%) their younger siblings when they go out. Moreover, 66% and 29% of parents stated that they always and sometimes ask their children to get younger siblings to sleep, respectively. \u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;When asked if the children\u0026rsquo;s school attendance is affected by caretaking, some parents were of the opinion that \u0026ldquo;\u003cem\u003eif my daughter is at home and not going to school, then [sibling caretaking] is right\u0026hellip; if she was going to school, then my mother or I or some other woman from the neighbourhood would take care of our children\u003c/em\u003e\u0026rdquo;, while others reported that the eldest female child in their family attends school during the day and takes care of her siblings after school and that her caregiving responsibilities also include teaching the younger siblings and helping them with their schoolwork.\u003c/p\u003e\n\u003ch2\u003eParental Perceptions of Sibling Caregiving\u003c/h2\u003e\n\u003cp\u003eThe results presented in Figure 2 demonstrate parents\u0026rsquo; perceptions of sibling caregiving. A vast majority of the respondents (95%) reported that they view assigning sibling caretaking responsibility to their elder children as their personal choice, while 75% of respondents reported that sibling caregiving is not a trend or common practice in their family. 79% of parents agreed that sibling caretaking is part of their cultural practice and tradition, with interview responses including \u0026ldquo;\u003cem\u003eThis has happened since [the time of] our elders \u0026hellip; if there is an older sister, she takes care of the younger brothers and sisters\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eBefore it was more common, now [sibling caregiving] time has decreased [in this generation]\u003c/em\u003e\u0026rdquo;. Most responses such as \u0026ldquo;\u003cem\u003eOur opinion is that if the elder girl doesn\u0026rsquo;t do it, she remains immature \u0026hellip; if there is no one else to take care [of the younger children], then she must do it\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003eIf the mother is busy with work, then our daughters do take care of our babies \u0026hellip; because they know more than boys do\u003c/em\u003e\u0026rdquo; indicated that girls are expected to care for their younger siblings more than their male counterparts are.\u003c/p\u003e\n\u003cp\u003eInterestingly, parental responses were equally distributed for the item \u0026lsquo;elder child caretaking is the right of the younger sibling\u0026rsquo;, where 50% agreed and 50% disagreed. Likewise, the same pattern was observed in response to sibling caretaking as the responsibility of elder children. 43% of the parents responded that assigning sibling caretaking responsibility is their right as parents. In contrast, a substantial number of respondents (89%) disagreed that sibling caregiving is related to any religious obligation. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The present study aimed to explore parental perceptions and practices regarding sibling care-taking in resource-constrained settings of district Matiari. Two research questions were posed to guide the investigation: What are the perceptions, and what are the practices of parents with regard to sibling caretaking in such settings? The findings provide valuable insights into the dynamics of sibling caretaking in a setting where resources are limited, and familial support is critical. This is one of the first studies in a developing region to explore parental perceptions and practices pertinent to sibling caregiving.\u003c/p\u003e \u003cp\u003e As for the parental perception, an overwhelming majority of respondents viewed assigning sibling caregiving responsibilities to their elder children as a personal choice, suggesting that parents may have a high degree of agency when it comes to determining their family's approach to childcare. Moreover, the finding that 79% of parents agreed that sibling caregiving is part of their cultural practices and tradition suggests that the expectations surrounding sibling caregiving may be deeply rooted in cultural norms and beliefs. The interviews revealed that girls are often expected to care for their younger siblings more than boys are, perpetuating gendered expectations and potentially limiting opportunities for girls to pursue other interests or activities. The finding that girls are expected to care for their younger siblings more than boys is consistent with previous research on gender caregiving expectations within families. These gendered expectations can have significant implications for girls' opportunities to pursue education and other lifestyle activities. These findings are also pertinent to research regarding girls and women taking up most roles in homemaking (Raza \u0026amp; Sohaib, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Moyer, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Human Rights Watch, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Another significant finding was concerning that 43% of parents believed that assigning sibling caregiving responsibilities is their right. This suggests that some parents may view their children's caregiving responsibilities as an obligation or duty that they are entitled to assign. Research has shown that child caregiving can have negative consequences for children's academic achievement and psychological well-being. Additionally, studies have found that children who provide caregiving are at increased risk for physical and emotional abuse, which can have long-term adverse implications for their well-being and development (Toth \u0026amp; Manly, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe second question was regarding parental practices; significant findings included that while they are at work during the day, parents usually ask their eldest children to take care of the younger sibling in terms of feeding, disciplining, guarding, playing with, dressing and bathing, and putting them to sleep. In rural Pakistan, the average family has 4 to 6 children (Pakistan Bureau of Statistics, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; World Bank, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The enhanced burden of poverty and constrained resources result in both parents working, with women/mothers usually engaged in manual agricultural labour in the family fields. This leads to the older sibling taking charge of caretaking for their younger siblings during the day, when they could alternatively be going to school, socializing with age-appropriate peers or engaging in other developmentally appropriate activities. An explanation for the phenomenon of children raising children could be the parents\u0026rsquo; personal beliefs and their cultural practices, wherein traditionally the parents, and their parents, have also been raised in similar circumstances. Additionally, there is a lack of formal outlets for play, socialization and education (parks, public libraries, daycare centers and quality schools) in rural areas such as Matiari, which results in children often staying home and helping their parents with manual labour in the fields, or tending to the younger children in the household, or assisting in other household errands/chores (Toor, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Toor, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The phenomenon of older children caretaking for their younger siblings is not limited to rural Pakistan. Children\u0026rsquo;s involvement in household chores and child caretaking have been documented in LMIC and HIC (Weisner et al, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1977\u003c/span\u003e; Morrow, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Merten, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ruiz-Casares et al \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In higher-income countries, older siblings may be accountable for sibling caretaking in low-income single-parent households (Wikle et al, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; McReary et al, 2004), whereas, in the rural Pakistani context, most families usually expect and ask children to support their parents in multiple daily caretaking and household activities. However, from most of the interview responses, this appears to be a personal and cultural choice stemming from tradition, rather than one based on religious beliefs, and therefore sibling caretaking by children is viewed as an organic cultural element, rooted in tradition, and not so much an imposition on children\u0026rsquo;s rights.\u003c/p\u003e \u003cp\u003eThe findings from this survey indicate that parental perceptions and practices regarding sibling caretaking have trends similarities. Similarly, household income level and family practices regarding sibling caretaking are correlated, indicating that families with higher incomes may be more likely to provide additional resources and support for sibling caretaking. These findings highlight the importance of examining familial and socioeconomic factors when considering the role of sibling caretaking in child development and family dynamics.\u003c/p\u003e \u003cp\u003eAs per our findings, sibling caretaking appears to be more often a girl\u0026rsquo;s responsibility, and the phenomenon is mostly a result of parents\u0026rsquo; personal choices and the wider cultural practices in Matiari. Older girls are seen as a natural substitute for their mothers who are working outside the home and therefore are assigned significant responsibilities including cooking, cleaning and caring for their siblings (Wiysahnyuy, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These domestic responsibilities prevent a significant proportion of female children from attending school and pursuing a formal education in rural Pakistan. However, from the descriptive data of this study, it is not possible to establish a causal relationship between sibling caregiving and low school attendance rates, particularly of girls, since the interview findings indicated that girls, when at home, are expected to take care of their siblings, but they may not be going to school for other reasons such as lack of infrastructure and transport options, as well as safety and security concerns. Parents in rural areas of Pakistan may not send their daughters to school for the fear of defamation of the girl or potential harassment during long-distance travel or in school (Ali \u0026amp; Cheema, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Furthermore, the investment in educating children is deemed more rewarding for a male child for want of gainful employment and family rearing (Purewal \u0026amp; Hashmi, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Moyer, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). It is generally believed that the girl child is better suited for this role of caregiving (Howe \u0026amp; Rinaldi, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) as she is to prepare for marriage and motherhood (Wiysahnyuy, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Pakistan, much work is required for a multi-sectoral level (academia, education and child-related policy), ranging from daycare facilities for working parents and their young children, to safe, accessible, quality educational facilities for children. Furthermore, gender equality and literacy are essential to address in rural populations. Devising policies to protect the emotional, social and physical well-being of all children is the state\u0026rsquo;s responsibility. If families are unable to make ends meet and have to resort to assigning sibling caretaking responsibilities to the eldest child, mostly the girl, special initiatives should be undertaken to create awareness and provide solutions regarding these economic and social development issues (such as affordable, accessible childcare services).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eA look into the positives: the lasting positive impact of sibling bonding through sibling caretaking\u003c/h2\u003e \u003cp\u003e While it may seem a dismal state that children are subjected to the caretaking of younger siblings, the relationship could have a positive impact. If the parents invest time and energy in the education and upbringing of the eldest child, it could positively impact the well-being of the younger siblings. Sibling interaction could play an important role in socialization (Goodwin, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wikle, Jensen, \u0026amp; Hoagland, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Dependability, trust and compassion among siblings could help in developing positive attitudes and building stronger family ties. Caring for others and showing a genuine concern for each other\u0026rsquo;s well-being is perhaps the most precious of human emotions (Hughes, McHarg, \u0026amp; White, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, such positive outcomes are possible only when all children are treated fairly and the parents ensure the emotional well-being, education and health of the entire family.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe lasting negative impact on sibling bonding: what may be\u003c/h2\u003e \u003cp\u003e In the absence of care from parents, good nutrition, education and a good upbringing, sibling caretaking and sibling relationships could be severed or otherwise adversely affected. The elder child made responsible for caring for the young and not receiving care himself or herself may suffer from resentment, depression and a sense of deprivation, along with a loss of safety and security. Assisting parents in household chores and caring for siblings may have positive outcomes as just that \u0026ndash; assisting. When the roles are reversed with permanent expectations, it will most likely be detrimental to the caregiving child\u0026rsquo;s development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe future: the public, practice and policy\u003c/h2\u003e \u003cp\u003eThe effect the eldest child can have on younger siblings is a window of opportunity to change the social landscape in rural Pakistan. Investing in the eldest child is most likely to have a positive ripple effect within the family and society (UNICEF, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This can be made possible only when the public is sensitized to understand and acknowledge the problem. The public affected should be made to realize the significant loss their actions could bring to the well-being, growth and development of their children and society as a whole. Even the public, who may not be affected by this problem should be made aware, to provide the necessary social support in advising parents, extending help and opportunities for families to learn and improve. In consonance, institutions and organizations in the public and private sectors should respond proactively to this problem. More evidence-based research is required in this area to fully understand the cause and effect of sibling caretaking. While keeping the positive aspects of sibling caretaking intact and ensuring the longevity of societal norms most positively, the national policy must ensure education for all, affordable quality healthcare, support to low-income earning families, programmes for awareness and education of the masses, with a genuine focus and political will of developing human capital.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e There is evidence that sibling caregiving could have very positive outcomes in a child\u0026rsquo;s life, but only in the presence of a caring and responsible adult \u0026ndash; preferably both parents. The negative impacts of sibling caretaking are detrimental to the healthy growth and development of children into adults with significant threat to their educational attainment and educational success, health and mental well-being, their relations and interactions with peers, opportunities to participate in social activities, employment opportunities and economic success, and general norms and behaviour. Pakistan is a developing country and needs to focus on the well-being of children in each household, regardless of socio-economic conditions, with comprehensive policies and programs for their protection, safety, and security to lead successful lives. The findings from this study regarding the prevalence and practices of children raising children can be implemented in the design and development of promotive and supportive childcare interventions for children and their families.\u003c/p\u003e"},{"header":"Key Findings","content":"\u003cul\u003e\n \u003cli\u003eThe phenomenon of sibling caretaking is prevalent in resource-constrained settings where parents/adult caregivers do not have sufficient systemic child caretaking support.\u003c/li\u003e\n \u003cli\u003eMajority (73%) of parents assigned sibling caretaking responsibilities to their older daughters instead of their sons (27%). Most parents ask the older sibling to put the younger siblings to sleep, bathe, dress, guard, discipline, feed and play with their younger siblings while the parents are at work.\u003c/li\u003e\n \u003cli\u003eMajority of parents (95%) view assigning sibling caretaking responsibilities to older children as the parents\u0026apos; personal choice, and most reported sibling caretaking as part of their cultural practice and tradition, but not necessarily a common practice in their family.\u003c/li\u003e\n \u003cli\u003eParental perceptions and practices regarding sibling caretaking may be influenced by several socioeconomic factors and cultural/personal beliefs.\u003c/li\u003e\n \u003cli\u003eComprehensive policies and programs are required to ensure the protection, safety and security of young children and their holistic development and well-being in Pakistan.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCRC \u0026ndash; Children Raising Children\u003c/p\u003e\n\u003cp\u003e(H)DSS \u0026ndash; Human Demographic Surveillance System\u003c/p\u003e\n\u003cp\u003eLMIC \u0026ndash; low and middle-income countries\u003c/p\u003e\n\u003cp\u003eHIC \u0026ndash; high-income countries\u003c/p\u003e\n\u003cp\u003eSDG \u0026ndash; Sustainable Development Goals\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthors\u0026rsquo; Contributions\u003c/h2\u003e\n\u003cp\u003eAll authors contributed to the manuscript/study. SB, AA were principal investigators and designed the study protocol and ensured ethical conduct and research standards. SA, FU managed the data collection and supervised all field activities with SJ, KQ, NR. AR analysed the quantitative data and prepared the manuscript figures. SB and WM analysed the data and wrote the manuscript with input from all co-authors.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eERC approval was obtained from Aga Khan University to ensure that all components of human bioethics research comply with this investigation. Informed consent from all the participants was sought. For children under 10, the parental informed consent/assent form was administered in the local language (Sindhi) to seek their consent.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eDeidentified study data and analyses, as well as data collection tools are available upon request from the corresponding author, [email protected]\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAli, M., Shahab, S., Ushijima, H., \u0026amp; de Muynck, A. (2004). Street children in Pakistan: A situational analysis of social conditions and nutritional status. \u003cem\u003eSocial Science \u0026amp; Medicine, 59(8), 1707-1717\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eAli, S., \u0026amp; Cheema, A. R. (2018). \u003cem\u003eExploring the many barriers to a girl\u0026rsquo;s education in Sindh, Pakistan\u003c/em\u003e. Retrieved from https://blogs.lse.ac.uk/southasia/2018/05/16/exploring-the-many-barriers-to-a-girls-education-in-sindh-pakistan/ \u003c/li\u003e\n\u003cli\u003eAllen, D. M. (2016, January). \u003cem\u003eNeglectful Parents and Eldest Siblings\u003c/em\u003e. Retrieved from Psychology Today Website: https://www.psychologytoday.com/us/blog/matter-personality/201601/neglectful-parents-and-eldest-siblings\u003c/li\u003e\n\u003cli\u003eArshad, M., \u0026amp; Zamir, S. (2018). Situational analysis of early childhood education in Pakistan: Challenges and solutions\u003cem\u003e. Journal of Early Childhood Care and Education, 2\u003c/em\u003e. http://dx.doi.org/10.30971/jecce.v2i0.146\u003c/li\u003e\n\u003cli\u003eChappell, N. P., \u0026amp; Johnson, M. L. 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Available at https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"siblings, caretaking, child-rearing, early child development, children raising children","lastPublishedDoi":"10.21203/rs.3.rs-3498453/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3498453/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe phenomenon of children raising children, or older children caretaking for younger children is under-investigated and can significantly impact child development and family wellbeing outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe perceptions and practices of 150 parents towards sibling caretaking in rural Pakistan were explored through mixed methods surveys and interviews.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e 73% of parents assign sibling caretaking responsibilities to their daughters primarily, and 89% ask the eldest child to care for younger siblings, while only 2% reported never assigning this responsibility to a child. Caretaking responsibilities include feeding, bathing, disciplining, and putting the younger siblings to sleep. 95% reported assigning these responsibilities to their eldest child as their personal choice; 79% reported sibling caretaking is aligned with traditional practices/beliefs, although 89% agreed it is unrelated to religious obligations.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e The findings hold implications for provision of nurturing care services for young children to support their health, education, childcare, social engagement in resource-constrained settings where children are expected to care for their siblings.\u003c/p\u003e","manuscriptTitle":"Children Raising Children: A cross-sectional survey of parental perceptions and practices regarding sibling caretaking in rural Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-08 00:04:17","doi":"10.21203/rs.3.rs-3498453/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2fe195fa-088d-4b29-ae8c-f4b3b7dd9743","owner":[],"postedDate":"November 8th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-02T12:17:09+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-08 00:04:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3498453","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3498453","identity":"rs-3498453","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}