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South African Journal of Education

On-line version ISSN 2076-3433
Print version ISSN 0256-0100

S. Afr. j. educ. vol.42 n.1 Pretoria Feb. 2022 



Vulnerable young adults' retrospective perceptions of school-based psychosocial support



Ann Lindsey NortjeI; Jace PillayII

IDepartment of Educational Psychology, Faculty of Education, University of Johannesburg, Soweto, South Africa
IISouth African Research Chair, Education and Care in Childhood, Faculty of Education, University of Johannesburg, Soweto, South Africa




In this article we describe the retrospective perceptions of vulnerable young adults on the psychosocial support they had been exposed to when they were in school. Qualitative data were collected through individual interviews, collages and a focus group discussion with 5 young adults (2 females and 3 males aged from 20 to 23) who resided at a foster home in Johannesburg. Thematic data analysis identified distinct psychological and social experiences which impacted on their ability to function independently as adults. The psychological experiences highlighted their sense of vulnerability, a lack of identity, emotional pain, and the need for career and guidance counselling. Their social experiences were characterised by social isolation and a lack of social skills. Adopting Erikson's theory of psychosocial development, we discuss what psychosocial support should be provided at schools so that vulnerable children could have a better life.

Keywords: independent; perceptions; psycho-social preparation; retrospective; skills acquisition; transition; vulnerable; young adults



Introduction and Background to Study

The aim of the study reported on here was to explore vulnerable, young adults' perceptions of the way in which their schools had prepared them psychosocially for life after school during their transition to adulthood. The participants in this study were raised in a foster home and were compelled to find residence elsewhere when they turned 18. Little is known, however, about whether they had received adequate school-based psychosocial preparation for life after school and their foster home. The central argument of the study is that psychosocial preparation while still at school would probably have contributed to the participants coping better in their lives.

In this study the term "vulnerable" refers to young adults who are more prone to psychosocial risks than their peers. Their vulnerability could have resulted from various forms of deprivation (food, education, and parental care), exploitation, abuse, neglect, violence, and human immunodeficiency syndrome (HIV) infection (Arora, Shah, Chaturvedi & Gupta, 2015). Orphans are particularly vulnerable to poor psychosocial outcomes, risk and danger since parents are the main shield against all forms of child abuse and exploitation. Pillay (2016:560) found that many children resided in foster homes as a result of "poverty, health issues, experiences of child abuse and neglect, discrimination, and domestic violence." Many orphans and vulnerable children (OVC) have poor outcomes with regard to education, food security, and morbidity (Arora et al., 2015).

The term "psychosocial" comprises both psychological and social experiences. The psychological experiences include personal thoughts, emotions and behaviour while the social experiences encompass relationships, social support, tradition and culture (United Nations Children's Fund [UNICEF], 2011). UNICEF (2011:10) identifies three domains of psychosocial aspects essential to an assessment of the lives of young people, namely, culturally relevant knowledge and life skills, emotional well-being (safety, trust in others, self-worth), and social well-being (relationship, sense of belonging, and access to socially appropriate roles). In the context of this study, psychosocial support refers to the care and support (including material, emotional, mental and spiritual support) that vulnerable young adults had received at a foster home while they were still at school and in preparation for a better life.

This study dealt with young people who were over the age of 18 and who, because of their life circumstances and inadequate support mechanisms at school, felt vulnerable (Atkinson, 2008; UNICEF, 2011). These young adults did not have the necessary life skills to "participate in society and to have faith for the future" (Richter, Foster & Sherr, 2006:15). In South Africa, the Children's Act (Act 38 of 2005) (Republic of South Africa [RSA], 2005) states that OVC, who live in places of safety for vulnerable children, are required to exit these places of care when they obtain legal maturity. When this happens, they are deprived of emotional and financial support. The trauma induced by this withdrawal of support can be minimised and their integration into society can be facilitated by the provision of a measure of psychosocial preparation (Haihambo, 2020; Mwoma & Pillay, 2015). Taking the above into consideration, the research questions in this study were: What are the retrospective perceptions of vulnerable young adults about psychosocial support they had received? What kind of psychosocial support is needed for OVC?

Literature Review

The plight of young adults leaving sheltered care has been identified as an international phenomenon. Atkinson (2008) found that OVC leaving foster care in the United States of America (USA) were often neglected in terms of psychosocial preparation as stipulated in the Foster Care Independence Act of 1999 (USA, 1999). Similarly, the retrospective narratives of vulnerable young adults in Australia echo the inadequacy of psychosocial education both in school and the extended social community (Murray, Murphy & Branigan, 2009). Narrowing down these retrospective narratives from vulnerable young adults to the South African context, the authors noted that similar studies were needed, prompting this particular study.

Over the past two decades the South African government promulgated several policies intended to provide psychosocial and educational support for all learners and, in particular, for those most vulnerable. Pillay (2020:42) identified some of the relevant policies and regulations as: (1) Quality of education for all: overcoming barriers to learning and development (Department of Education [DoE], 1997); (2) Education White Paper 6: Special education needs (DoE, 2001); (3) Conceptual and operational guidelines for the implementation of inclusive education: full-service schools (DoE, South Africa, 2005); (4) Guidelines for full-service schools (Department of Basic Education [DBE], RSA, 2009); and (5) the Policy on screening, assessment, identification, and support (DBE, RSA, 2014). The Children's Act (RSA, 2005) calls for changeover support for youths leaving care, but it does not stipulate who should provide that support (Maposa & Louw-Potgieter, 2012; Tanur, 2012). Pillay (2020) notes that all of the policies are based on an inclusive philosophy directed at providing psychosocial and educational support for all children. The policies endorse the DBE's conceptual framework for supporting OVC by desribing the role of school governing bodies (SGBs), teachers, and school-based support teams (SBSTs).

The cited policies are poorly implemented as is evident in the numerous psychosocial problems prevalent in South African families, schools, and communities (Donohue & Bornman, 2014). The lack of policy implementation and subsequent psychosocial problems have resulted in psychological problems such as depression, anxiety, stress, trauma, grief, and suicide (Babedi, 2018). Vulnerable youths are often victims, and sometimes perpetrators, of social problems that are characterised by crime, poverty, gender-based violence, violence in families and communities, school bullying, and the social stigma attached to HIV and acquired immunodeficiency syndrome (AIDS) (Donald & Clacherty, 2005; Maqoko & Dreyer, 2007), and more recently, coronavirus disease (COVID-19) (Lin, 2020). Several studies report that psychosocial support for schools that need it most is seriously lacking (Mwoma & Pillay, 2015). Inevitably, this is likely to have a deleterious effect on OVC since studies show that if children do not receive psychosocial support while they are young, they are prone to experience poor mental health and social and educational problems as they grow older (Mwoma & Pillay, 2015).

Cognisance must be taken of the fact the South African government has made several attempts to provide psychosocial services to schools. For example, the Going for the Goal (GOAL) life skills project for OVC in the Western Cape has produced good results (Forneris, Danish & Scott, 2006). SBSTs are expected to facilitate psychosocial support in public schools, but often they do not have the means or time to accomplish this. Life orientation teachers are often left with the responsibility of providing psychosocial support to children, but many of them are not adequately trained to do this (Molefe, 2014). On a positive note, Ferreira and Ebersöhn (2011) found that teachers were strategically placed to support vulnerable children and many of them are willing to do so, but for which they need training and support.

The Mamelane Projects (2010) is a philanthropic organisation in the Western Cape which works with the World Childhood Foundation to capacitate OVC and vulnerable young adults who have spent their childhoods in state care. The focus is to help them make the transition to independent living as young adults with healthier relationships, a more assured self-image, and greater resilience. Young adult participants in the Mamelane projects commonly expressed gratitude and appreciation for the support they had received from structures external to their schools (Mamelane Projects, 2010), but not from within their schools. Building psychosocial support for children in schools should be a strategic intervention of government, schools and communities, since research has shown that such support enhances resilience among young people (Theron, Theron & Malindi, 2013). With early intervention OVC may be helped to become functioning members of society.

Theoretical Framework

This study is underpinned by Erikson's (2005) psychosocial theory of development which states that individuals develop their personality through eight stages from infancy through to adulthood. The first five stages of psychosocial development were relevant to the participants of this study, commencing with trust versus mistrust (0 to 18 months), and progressing to identity versus role confusion (12 to 18 years). During the first five stages the individual learns the virtues of hope, will, purpose, competency, and fidelity (McLeod, 2018). The attainment of these virtues are compromised by psychosocial crises which create a conflict between the psychological needs of the person and the needs of the society (McLeod, 2018). During the first five stages children are dependent on their parents or caregivers for the development of the five virtues, becoming progressively independent as they move through subsequent stages.

A rigid application of Erikson's stages of development implies that participants in this study were likely to experience psychosocial problems because they were OVC. The lack of adequate support might have inhibited their development during adolescence and this may have influenced their perceptions of their experiences. According to Erikson's theory, self-organisation and self-mastery are important for the individual's sense of control and independence (McLeod, 2018) Therefore, from an educational perspective, classroom activities need to be directed at providing children with realistic choices and the opportunity to act on these.



Research Design

Qualitative phenomenological research was conducted to give the participants a voice to share their psychosocial experiences (Willig, 2013). Within a social constructivist paradigm, the participants were able to use language to describe and construct a sense of their own reality (Terre Blanche, Durrheim & Painter, 2006).


Participants were purposively selected on the basis of the following characteristics: they were accessible as they lived in a safe house for vulnerable young adults in Johannesburg; they agreed to participate, they could be labelled as vulnerable young adults; and they were older than 18. The study sample comprised five participants, two females and three males, treated as individual cases. All the participants came from a background of poverty and were from single parent families or had headed a household as a child. A profile of the participants is provided in Table 1.

Data Collection Methods

Data were collected through five individual interviews, a collage created by each participant, and a focus group discussion. The individual interviews were semi-structured to elicit detailed personal narratives (DiCicco-Bloom & Crabtree, 2006). Each participant was encouraged to produce a collage of their lived experiences and what they would have liked those experiences to have consisted of, and then encouraged to comment on their collages. Finally, a focus group discussion between the participants (King & Horrocks, 2010) was held to gain an understanding of their different experiences and expectations. Burr (2015) proposes that using a variety of methods to elicit information allows the individuals to express, through different ways, their impressions of their own life stories.

Ethical Considerations

Ethical clearance for the study was granted by the ethics committee of the faculty of education at the university where the authors were based. The head of the foster home gave consent for the research to be conducted at the facility and each research participant provided written, informed consent. Pseudonyms were used for the participants in order to protect their identities.


In order to ensure trustworthiness, one needs to establish dependability, transferability, and confirmability (Lincoln & Guba, 1985). To ensure transferability, a sample was purposefully selected from a group of vulnerable young adults. To establish credibility, we described the participants' experiences by using a triangulation of data collection methods. Dependability was established by clearly recording the steps of the process so that it could be replicated. Finally, confirmability was secured by making the original data and records accessible to confirm authenticity of the results.

Data Analysis Methods

All data collected were recorded and transcribed. Material was then analysed with the use of the steps proposed by Creswell (2013) in the identification of common themes and subthemes related to the experiences of the participants.



The participants' psychological and social perceptions of post-school psychosocial preparation were documented in the findings and presented verbatim. Their psychological experiences were denoted by a sense of vulnerability, the lack of a sense of personal identity, emotional pain, and the lack of career guidance. Their social experiences were characterised by social isolation and a lack of social preparation skills.

Psychological Experiences A sense of vulnerability

The research participants were cognisant of the way in which their vulnerability had contributed towards their unfulfilled hopes and dreams, as well as the state of their present reality.

When the participants described their notions of vulnerability, they tended to focus on their experiences of poverty and the lack of physical resources. One of the participants, Anna, described her vulnerability, saying: "Going through a lot, I think pain, poverty, you know, all those negative things would make one [vulnerable]." Similar feelings of vulnerability that resulted from a lack of resources were represented in the collages. In his collage, Letabo included images of a run-down area and the inside of a shack, which illustrated his perceptions of vulnerability. He included an image of a tastefully decorated room, explaining "why I made this picture is because uhm ... we never got this." Karabo corroborated this experience by including an image of a dilapidated, ruined building in his collage, and labelled it: "This is how I felt like my life looked."

When interviewed, some of the participants commented on their sense of vulnerability as experiencing a lack of emotional resources and support. Letabo explained that, while he was still a scholar, he was "jumping some other stages'" because he had to take care of his younger siblings without parental support. Since he had been forced into this role, he felt that he had lost a part of his own childhood and was left exposed and vulnerable in the absence of assistance, particularly from his school. Antonio's school experiences echoed this:

"I had a lot of needs that no-one is really sorting out for me." In the focus group, Lotabo expressed his vulnerability "Ja and feel so small, feel like no one cares about me at school. Ja, so, because I was confused." Similarly, Rose added: "So now it's even more isolation and you don't know where to start and who to ask help from." Karabo described his sense of isolation in the school environment as: "Ja there was really not anyone I could tell and even if I tell any teacher it wouldn't make a difference."

All of the participants spoke about how the loss of their parents had led them to feel even more vulnerable. Letabo stated: "Sho uh . it's a very challenging ... you need to fight your own battles. You need to stand up. And self-motivate yourself as well" Rose added that the absence of her father in her life made her realise "that most children that don't have fathers in their life, like ... they tend to go the wrong direction looking for love in the wrong places." In the focus group, Letabo said that he struggled to be a parent to his younger siblings when he needed parenting himself: "For me it . I felt like I'm a parent the same time . I feel like I wasn't ready for that... and I felt that it's unfair."

Lack of a sense of identity

The participants described their lack of a sense of personal identity in their confusion over assuming adult roles and the problems they had experienced as a result of peer pressure. Some of the participants felt that they were too young to take on responsibilities as adults when they still needed parental support themselves. In his interview, Karabo commented on the stress of having to be self-sufficient from the age of 12: "You're taking responsibility not because of you like, but because of the situation." In the focus group discussion, Letabo spoke about the stress of having to provide food and shelter for his younger sibling when he was also a vulnerable teenager:

I felt like I'm old at the same time. Things are happening before time. Ja, that now I have to think about someone as well and I'm not thinking for myself so there's people I couldn't just leave, I can'tpursue whatever I'm thinking its right, I can't get the guidance.

This sense of a lack of identity and vulnerability also manifested in the participants submitting to peer pressure and, in doing so, engaging in risky behaviour. Karabo admitted to abusing alcohol and marijuana "because the group was doing it", and "I had to fill the void that was never . nothing could fill it up." Similarly, Rose reflected on a tendency to "go in the wrong direction looking for love in all the wrong places. "

Emotional pain

The participants expressed emotional pain as a consequence of the lack of support from school, unsupportive adults, and most importantly, from family. Letabo's narrative reveals that he felt "exhausted" and "stressed", and he was "just overwhelmed."" He said that "at school there was no-one."" Karabo said that he had not received the kind of emotional support he wanted and needed: "I would say my entire school period I've never had a teacher speak to me about my personal development, my emotions, or my ... ambitions." Antonio expressed that being abandoned by his family and having to pursue his studies without their support "was rough."" Karabo included a dilapidated building in his collage, saying, "it spoke a lot about the brokenness I felt" and "no-one could see the pain... of the suffering." He felt that nobody in the school setting acknowledged his pain, let alone helped him. The same sentiments that emerged in the individual interviews were repeated by the participants in the focus group discussion. Karabo wished that teachers "got to know you and what you needed a little better" ; Letabo said that he had received no adult support and that he "had to find everything by myself. Working it out for myself"

Lack of career counselling and guidance The participants all commented on a distinct lack of career counselling guidance from both family and school. This was evident in their uncertainty about what they were studying at that stage and whether their chosen career path was right for them or not. This uncertainty was also evident in the confusion that some of the participants experienced with how to go about fulfilling their dreams.

In her interview, Rose reflected that her decision to go into nursing was influenced by her mother being a nurse, but she "didn't (really) know what to expect coming into nursing"" She mentioned that her school had provided generalised career counselling, but that the process had not included an assessment or any personal guidance. She said that she would have liked more individual counselling "(to) give me more direction in terms of what I really want to do, career wise and everything. Because even right now I'm still confused as to what I really want to be." Letabo stated that at school "I didn't have a certain plan ... what to do" and that there was nobody to assist him, "not really when I was at school." For Antonio, the lack of career guidance resulted in a series of career choices that changed dramatically over the space of 2 years: "I, uhm, when I was in Grade 10 my ... I wanted to be a scientist. And then it changed in Grade 11 to be a pilot. But then I first thought like science is the place to be since, it's crazier. But then I went back to piloting because I wanted to travel the world" In addition, in his collage, Antonio revealed a dream of becoming successful, but he had no idea of how he hoped to achieve this. In his collage, Letabo included the words "entrepreneur" and "live your dream", but he also had no idea of what that would entail.

In the focus group discussion, Letabo echoed the previously stated sentiments: "Because I was confused when I got to Matric what to do and what to decide regarding my career path . I mean, it's your future and no one is helping and I just felt like I'm there in the bush alone. I need to find my own way out by myself and I'm not ready for this. I'm still young and I need someone to guide me. " In Letabo' s case, he put his career ambitions on hold to care for a younger sibling.

Social Experiences

The second theme that emerged from the data was about social experiences and social isolation, particularly due to the lack of preparation at school to help the participants acquire the social skills that would assist them function as independent young adults.

Social isolation

All the research participants spoke about a sense of isolation and loneliness when they were at school and as young adults. They acknowledged, however, that much of their isolation was self-inflicted. Antonio said that "it (his situation) also caused me to isolate myself." Some of the other participants reflected on another aspect of isolation, that of feeling unloved and unnoticed. Anna said: "I was so used to feeling unloved and being lonely, that when I had people who loved me for me ... it just didn't feel right." Letabo added that he felt "exposed out there and I feel like I'm alone." Karabo echoed this: "After that I just stayed alone ... there was no one to tell, really."

The participants echoed these sentiments in their collages. Karabo represented his life as a maze where he "had to do that most part of my life by myself." Anna initially claimed that she did not want a relationship, but her personal dreams were different: "So for me, I never wanted to get married. I never wanted to be a wife." Letabo added a picture of a mother and child to his collage, and his reflection revealed his sense of isolation and loneliness. "Here's a picture of a mother and a kid in between. Why I made this picture is because uhm ... we never got this."

During the focus group discussion, the participants reiterated their sense of loneliness and isolation. Letabo said that he had to go through the process of growing up alone: "Working it out for myself." Letabo expressed his feelings of loneliness while at school: "Ja and feel so small, feel like no one cares about me at school." Rose also felt isolated when she left school and she had no emotional support from anyone: "So now it's even more isolation and you don't know where to start and who to ask help from."

Lack of social skills preparation The participants were unanimous in that they had been left to figure things out by themselves. They reflected that while at school they were not taught practical social skills to find shelter, employment opportunities, manage money, or even how to access fundamental health care benefits.

Karabo commented on this lack of assistance: "I had to do those things by myself ... that would have been very, very beneficial"" Antonio added "how hard life is when you 're done with school", and that he wished that he could have had someone to "sit us down and like prepare us"" Rose focused on how she wished someone had been available to assist her: "It does help when you see that people really wanna help you and that you don't have to really worry about the financial struggles of furthering your studies and things"" Karabo also commented on the lack of assistance in during his collage discussion: "I had to do the most part by myself."" In the focus group, Antonio stated that he would have liked his school to provide more practical support with independent living after school: "We would be more ready and prepared for everything. We wouldn't feel like you 're lost""



The participants' narratives showed a sense of vulnerability in the absence of significant adult relationships after leaving the safety net of the welfare and school systems (Cunningham & Diversi, 2013; Dewar & Goodman, 2014). The participants' perceptions are in line with studies that link the lack of parental support to a sense of vulnerability (Larimore, 2012; Osgood, Foster & Courtney, 2010). Feeling vulnerable, the young adult disengages from others, not only increasing the distance between them and people who could help, but resulting in poor social relationships (Erikson, 2005).

Erikson (2005) suggests that in the stage of identity versus role confusion, young adults experience vulnerability as a time of crisis that is settled through communication with, and support from, significant adults, as well as the exploration of relationships. In the absence of adult support, young adults experience a lack of direction and self-doubt (Woolfolk & Perry, 2012). This self-doubt and lack of focus were expressed in the participants' voices as a sense of vulnerability and isolation. When a vulnerable young adult is expected to take on adult roles too soon and where support is lacking, a sense of confusion about the self emerges (Erikson, 2005). Many of the participants in this study felt that the teachers at school could have provided them with the adult guidance and support that they needed.

The vulnerability that the participants referred to clearly emanated from childhood and continued through young adulthood and possibly adulthood.

In retrospect, it makes sense for psychosocial interventions to be implemented during the early years of schooling. Since children spend a considerable amount of time at school, it would be strategic to focus on school-based psychosocial interventions that target vulnerability. Psychological interventions should focus on building resilience among vulnerable children to provide them with the necessary knowledge and skills to help alleviate all forms of vulnerability. Interventions should assist in freeing them from a victim mentality and encourage them to rise above their vulnerability. Life orientation teachers and school counsellors could be instrumental in providing psychosocial support addressing vulnerability. Teachers could play a prominent role in this regard, for example, by explaining to vulnerable children that living in a shack should not define them. Enabling children to make wise choices during classroom activities is something that Erikson's theory endorses.

Emotional support is one of the key elements for OVC to make a successful transition to independent, adult life (Cunningham & Diversi, 2013). Erikson's (2005) theory also highlights the need for significant adults to act as role models. In the absence of parents it is even more important for other adults, such as elders and mentors in the community, to fulfil this role (Mampane, 2014; Nsamenang, 2006). In their narratives, the participants noted the absence of these elder figures and, as a result, they often felt as if they had to work things out for themselves and became increasingly isolated from their communities. Life orientation teachers could invite adults from the community to share their experiences of, for instance, recovery from addiction or crime to lead successful lives. Hearing how respected older people overcame the adversities they experienced could help to deter vulnerable young people from making the same mistakes. This aligns with Erikson's theory on using good role models in the community and schools to positively socialise children.

Erikson (2005) highlights the importance of a career-based identity as it provides a structure for identifying one's future direction. He links the identification of goals and career-objectives to healthy identity progression. When that career-focused identity is compromised, confusion for the future arises, as was presented in this study. Traditionally, parents engage in conversations about the future, tertiary education and possible career pathways (Cunningham & Diversi, 2013; Larimore, 2012) and when they are absent, teachers and schools need to fulfill that role. In South Africa, the life orientation programme in schools makes provision for discussing competencies, skills and possible career paths (DBE, RSA, 2011), but often this is handled in a cursory manner without the learners receiving individual guidance -something that the participants in this study had commented on. Hence, well-structured career guidance programmes should be integrated with the school curriculum. Linked to Erikson's theory, schools could assist children to make wise career choices directed at self-organisation.

Erikson's sixth stage of intimacy versus isolation describes a time when individuals should be secure in their views of self and are attempting to form intimate relationships (Erikson, 2005). Trust is one of the key elements in new relationships, but when an individual does not have a clear sense of personal identity, trust issues develop and, more importantly, individuals will experience a sense of isolation and social anxiety (Erikson, 2005). School activities should be directed at increasing positive social relations among children, teaching respect for different races, cultures, genders, sexual orientations, and people with disabilities.

The finding that social-skills training should be embedded within the school curriculum to prepare OVC for adult life confirms what other authors maintain (Atkinson, 2008; Cunningham & Diversi, 2013; Murray et al., 2009). Many vulnerable young adults, including the participants in this study, feel as though they do not have control of the transition process and are ill-equipped to access social aid, accommodation, financial assistance, and jobs (Forneris et al., 2006; Scannapieco, Cornell-Carrick & Painter, 2007). The school curriculum should include practical life skills programmes so that children learn what to do when confronted with situations that make them feel helpless.



In this study we highlighted the retrospective perceptions of vulnerable adults about the psychosocial support they had received while they were at school. The findings indicate that they would have preferred to receive support that addressed their vulnerability, sense of identity, emotional distress, career guidance, social isolation, and needs for social preparation. For the psychosocial needs of OVC to be addressed it is vital that once a child in need has been identified, the school should collaborate with the extended community on a suitable way of providing OVC with practical living assistance. This could also take the form of providing information about gaining access to relevant social services. In addition, schools could assist OVC by providing life-skills training and therapy that focuses on building resilience and self-esteem. Mentoring could be instituted in schools to provide the necessary adult guidance for OVC. This could be connected to a community-based intervention that would allow OVC to feel included and not isolated from the world around them. The DoE should adopt a formal psychosocial programme in all schools. The findings of this study have global value since OVC are prevalent in schools worldwide.



This study was supported by the South African Research Chairs Initiative of the Department of Science and Innovation and National Research Foundation of South Africa' and the South African Research Chair: Education and Care in Childhood: Faculty of Education: University of Johannesburg, South Africa. Grant Number: 87300.

Authors' Contributions

The article is based on the master's study of Ms Ann Lindsey Nortje. She collected all the data and wrote the first draft of the manuscript. Prof. Pillay supervised the study and the writing of the article. Ms Nortje was not available to address the revisions that were requested from the reviewers. Prof. Pillay addressed all comments and rewrote the parts of the article that needed revision.



i . Published under a Creative Commons Attribution Licence.



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Received: 6 February 2020
Revised: 12 April 2021
Accepted: 19 April 2021
Published: 28 February 2022

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