Context: Data, primarily from the United States, indicates that Black women experience delays in breast cancer treatment, receive non-standard care, and have a lower survival rate. Canada is not immune to racial disparities, but race-based health data is not routinely collected. Objectives: To understand the lived experiences of Black women in Canada living with breast cancer. Methods: One-on-one semi-structured qualitative interviews were conducted with 20 women living in Toronto, Ontario who identified as Black/African/Caribbean and who were currently undergoing or had previously undergone treatment for breast cancer. Data was analyzed using an inductive, constant comparative method to derive themes. Results: Several themes were identified including 1) the importance of social support and community; 2) importance of faith and spirituality; 3) cultural considerations; 4) mental health and psychosocial support; 5) body image and intimacy challenges; 6) importance of fertility preservation; 7) financial burden; 8) lack of representation; and 9) mistrust of the healthcare system. The overarching theme was a sense of feeling alone, unseen, and unrepresented. Recommendations include the importance of advocacy, the need for race-based cancer and health data and the need for racially concordant care. Conclusion: Invisibility and anti-Black racism in healthcare settings are unique concerns for Black women with breast cancer in Toronto. Understanding their needs can help to dismantle medical racism and colourblind healthcare. Further research is needed to develop tools to address these inequities and work towards culturally appropriate and safe approaches. / Thesis / Master of Public Health (MPH) / Little is known about the breast cancer experiences of Black women in Canada. The purpose of this study is to explore the lived experiences of Black women in Toronto, Ontario with breast cancer, in order to understand their cancer journey. In the United States, Black women are more likely to develop aggressive breast cancer and to die from their disease compared to white women. The information learned from this study will begin to address a gap in the literature about Black women living with breast cancer in Canada.

The purpose of this thesis is two-fold: it attempts to develop a feminist theory of health and health care of women and moves beyond the political economy theory of health and health care grounded in Marxist principles. Secondly, it attempts to apply these feminist theoretical principles, incorporating the methodology of historical materialism, to a specific historical situation - that of African women in Natal/Zululand in the nineteenth century. The thesis is divided into three parts. The first provides an overview of the political economy of health and the Marxist theory on which it is based. The second section deals specifically with feminist theoretical concerns: particularly the need to incorporate the concept of gender and the sexual division of labour into analysis of the position of women in society. In addition, it focusses on women's particular health needs and attempts to incorporate these into a feminist theory of health and health care. The third part examines the health and health care of African women in pre-colonial Natal/Zululand by focussing on their role in procreation and production, and changing health patterns and health care under colonial rule. / Thesis (M.A.)-University of Natal, Durban, 1990.

Problem to be addressed: Stillbirth is a major public health problem. The stillbirth burden is on a par with newborn deaths. The stillbirth rate measures not only a substantial portion of the global and national burden of mortality, but also equity and quality of care for women’s and children’s health. Reducing the numbers of these deaths requires an understanding of why they occur, yet approximately one-third of stillbirths are unexplained, even in settings with high-quality autopsy and placental examination, while deaths considered to be explained are usually ascribed to single, proximal causes. An important limiting factor for efforts to reduce the large and inequitable stillbirth burden has been insufficient research into conditions that could inform prevention strategies and reduce inequity.1 2 Substantial evidence exists for associations between structural racism, maternal stress, and adverse pregnancy outcomes, yet research focusing on stillbirth is sparse, particularly at the ends of the causal spectrum—macro-level structural conditions and mechanisms. Several studies have called for research on possible biological mechanisms by which racism, racism-related stress, and stillbirth may be associated, including epigenetic mechanisms.3-6 The most recent review of causes of racial disparities in stillbirth rates in the U.S. recommended that researchers take a multi-domain approach, considering not just individual-level risk factors, which have been relatively well-studied, but also upstream factors such as institutional racism, and biological mechanisms such as epigenetic modification. The objective of this dissertation was to explore evidence that could help to explain persistent racial disparities in stillbirth. The specific aims were: 1. To review the literature on racial disparity in stillbirth rates; 2. To assess whether structural racism can help to explain racial disparity in stillbirth rates in New York City; and 3. To assess whether maternal stress is associated with stillbirth, whether stress is associated with methylation of stress-related genes, whether methylation is associated with stillbirth, and whether there is evidence that methylation of stress-related genes mediates associations between stress and stillbirth. Materials and methods used: For Aim 1, we carried out a scoping review of the literature in five databases (PubMed, Scopus, Cinahl, Embase, PsycInfo) to identify all reports including stillbirth rates stratified by race in the U.S., mapping exposures and effect modifiers (“domains of analysis”) and authors’ comments on racial disparity in stillbirths (“domains of explanation”) into one of eight domains (race, genetic, fetal, maternal, family, community, healthcare system, and structural). We defined Stillbirth Disparity Ratios (SDRs) as the ratio of the stillbirth rate in a racial/ethnic minority group to the stillbirth rate in white individuals. Selected SDRs were extracted from each report, as were all SDRs for Black/white comparisons. For Aim 2, we modelled associations between four measures of structural racism and stillbirth in all non-Hispanic (NH) Black and white singleton births in New York City between 2009 and 2018. Exposures were four Public Use Microdata Area (PUMA)-level measures of structural racism (Indices of Dissimilarity, Isolation, and Concentration at the Extremes (ICE), and an Educational Inequity Ratio) constructed from U.S. Census American Community Survey data. Using multilevel logistic regression, we first tested for interaction between race and structural racism in relation to stillbirth. For structural racism measures that interacted with race, we estimated odds ratios for stillbirth separately in 221,925 NH Black and 325,058 NH white births. Race-specific models were further stratified by maternal age. For Aim 3, we assessed associations between maternal stressors and stillbirth in 183 non-anomalous full-term singleton births (63 stillbirths and 120 livebirths) from the U.S. Stillbirth Collaborative Research Network. Measuring maternal stress with two hypothesized stressors, an Index of Significant Life Events and an Index of Disadvantage, we assessed associations between maternal stressors and stillbirth in our sample, and then whether maternal stressors and stillbirth were associated with differential methylation of 1,191 CpGs on five stress-related genes (BDNF, FKBP5, HSD11B2, IGF2, and NR3C1). Finally, we assessed whether methylation mediates associations between stressors and stillbirth. Conclusions reached: For Aim 1, we found 95 reports presenting stillbirth rates stratified by race/ethnicity in the U.S. We found evidence of increased risk of stillbirth in Black as compared to white births in the majority of the 83 reports with the necessary data. Among the 1143 Black-white SDRs that we extracted, the median SDR was 1.67, with 74% of SDRs showing evidence of disparity. Family and community factors, healthcare system factors, and structural factors were commonly used as domains of explanation (20-38% of reports), but rarely (family/community, structural, 4-5%) or never (healthcare system) used in analysis. The most commonly used domains of analysis—fetal and maternal factors including gestational age, maternal age, education, and prenatal care—do not appear able to explain the observed racial disparities. Gaps in the literature include a paucity of studies examining the possible role of health system, community, and structural factors in Black-white disparity in stillbirth rates, and limited data on other types of racial disparities in stillbirth rates, including Hispanic and Native American births. For Aim 2, we found that structural racism as measured by ICE and Isolation was associated with stillbirth in NH Black but not NH white mothers. This would seem consistent with our hypothesis that structural racism may help to explain racial disparity in stillbirth rates; however, the associations we observed were not in the expected direction. Specifically, NH Black mothers living in PUMAs with a high concentration of privilege had 90% greater odds of stillbirth in comparison to those living in PUMAs with a high concentration of disadvantage (ICE quintile 5 vs 1), and NH Black mothers living in PUMAs that were the most isolated had 40% lower odds of stillbirth in comparison to those living in PUMAs that were the least isolated (Isolation tertile 3 vs 1). We suggest that while the measures we used (ICE and Isolation) do help to explain the Black-white disparity in stillbirth rates, our results raise questions about the way these measures operationalize structural racism, meriting further investigation. For Aim 3, we found that having two or more vs no items in the Index of Disadvantage (“Disadvantage”) was associated with more than fourfold greater odds of stillbirth (95% CI 1.58, 12.93). We found no association between the Index of Significant Life Events and stillbirth. We found that 32 out of 1,191 CpGs on five stress-related genes were differentially methylated with respect to stillbirth, and six CpGs were differentially methylated with respect to Disadvantage. Methylation at two CpGs on IGF2 and one on HSD11B2 (cg02097792, cg12283393, and cg19413291, respectively) mediated the association between Disadvantage and stillbirth. Research on causes is a critical component of stillbirth prevention and reducing the inequitable distribution of this public health burden. Limited understanding of causes at both “ends of the spectrum”, from upstream distal factors to mechanisms, has likely contributed to slow progress on prevention.7 8 This dissertation contributes to science and public health by providing researchers with data to support new lines of inquiry, e.g., into associations between structural racism and stillbirth, and for methylation as a mechanism of effect, that should help to improve our understanding of causes. Our research may also support health policy makers who now have additional data to illustrate the adverse health outcomes of structural racism in the U.S. Finally, it may help the parents and other family members of stillborn babies who continually seek to understand “why”.

The effects of a multifaceted weight loss program on the body weight, body composition, plasma variables, and nutrient intakes of 50 obese black women were investigated. Subjects were between 20 and 51 years of age, with an average BMI of 34.5 (range = 23.6 - 57.3). Subjects attended nutrition education/behavior modification classes once per week for three months. Thirty-five of the women attended 80% or more of the classes (NU). Twenty-eight women attended 30% or more of the low-impact aerobic exercise classes that were offered three days per week, for six months. An average 2.2 kg weight loss was observed for the whole study group, as body fat fell, and lean body mass increased by 2.1% of total body weight. Slightly greater changes were observed in the group that exercised consistently, as well as those who regularly attended nutrition classes, but not in either of the groups which more sporadically attended exercise or nutrition classes. Significant reductions in plasma total cholesterol, HDL-Cholesterol, HDL₂-Cholesterol, and insulin were observed for the group of 50 subjects. Significant reductions in plasma TC occurred in both the SE (attended between 30 to 70% of exercise sessions) and SN ( < 80% attendance of nutrition classes) groups. Plasma LDL-Cholesterol followed the same pattern as plasma total cholesterol but there were no significant differences. Exercise appeared to mitigate decreases in plasma HDL-C. Significant reductions in total Kcal, including CHO, protein, fat (including saturated, polyunsaturated, and monounsaturated fatty acids), dietary cholesterol, and sugar were noted for the study group. A weight-loss program which included diet, nutrition education, behavior modification, stress management and exercise was effective in producing favorable changes in body composition, plasma variables, and dietary components in obese black women over six months, with a high degree of variability in motivation and participation. / Master of Science

Existing research on health disparities in breast cancer is heavily focused on outcomes for poor or low-income women. Little is known about the experience of privately insured Black breast cancer patients that have moderate to high SES. As a result, the present study was conducted to learn more about their experiences. It examines differences in physician prescribing of two breast cancer pain treatments, peripheral nerve block (PNB) and opioids, for Black and White women with like levels of health insurance coverage and socioeconomic status (SES). Three specific questions are addressed: 1. What, if any, race-based disparities exist in usage of PNBs at time of total mastectomy? 2. What, if any, race based disparities exist in the prescription of opioids for postoperative pain following total mastectomy? 3. What, if any, changes have occurred in the frequency of orders placed for PNBs and prescription opioids over time, to treat postoperative pain resulting from mastectomy? A cross-sectional designed was used relying on an existing national dataset, Optum Clinformatics Data Mart. The study period was January 1, 2012, through December 31, 2019. Study results revealed that while moderate to higher SES Black women have equitable access to PNB and opioids - a kind of shield from long established physician bias against Black women – this protection is quite porous. They still do not have open and ready access to PNB as a more advanced pain treatment. Nor do they have assurance that they are protected from the overprescribing of opioids, a class of drugs with serious and well-known safety risks. Therefore, on the surface, it appears that equity and racial inclusion are hallmarks of physician prescribing of postoperative breast cancer pain treatment. However, further interrogation reveals that ‘separate and somewhat equal’ is a more accurate characterization of their prescribing practices, based both on race and SES.

This study addressed the long-standing crisis of Black severe maternal morbidity in the U.S., while the COVID-19 pandemic led to even worse outcomes. The purpose of the study was to identify significant predictors of the quality of patient-provider relationships during a birth hospitalization. The sample of Black women (N=182) gave moderate ratings for quality of patient provider relationships, and for level of trust, rapport, and communication with providers. Providers were rated as having a fair level of cultural sensitivity, competence, and humility—while 30.2% rated them as poor. For experiences of racism, discrimination and inequities in service delivery, combining categories of a “few times” and “many times,” 53.3% felt racially stereotyped or treated like a racial stereotype, 52.5% were treated with less respect than a White woman would have been, 39.7% were verbally abused or yelled at, 43.8% were scolded, ridiculed, mocked, and shamed, 47.2% felt belittled and put down, 42.7% felt threatened, coerced, lied to, and manipulated, and 46% felt their pain was not managed the same way as for a White woman. Women entered the hospital with risk factors of cardiovascular disease (20.3%), hypertension (23.6%), obesity (18.1%), and diabetes (13.7%). Further, 74.2% had COVID-19 in the past two years, 25.8% had long COVID-19, 34.1% had COVID-19 during their pregnancy, and 34.1% had COVID-19 at delivery. Medical events during their delivery hospitalization included hemorrhage (40.7%), blood clot (25.3%), and a hypertensive disorder of pregnancy (25.3%). Women had high rates (over 75%) of past year depression, anxiety, and trauma—with 68.1% receiving counseling; and higher rates (over 85%) the year post-partum—with 76.9% receiving counseling. Noteworthy significant predictors of a higher quality of patient-provider relationships were higher education, higher trust/ rapport/ communication with providers, and lower global racism/ discrimination/ inequities during service delivery—while entering the hospital with lower risk factors for pregnancy-related complications (69.8% of variance predicted). The study contributes to literature on the crisis of severe maternal morbidity for Black women in the U.S, as well as factors that need to be addressed to reduce it, while offering a cache of culturally appropriate measures for ongoing research.

M.A. / Because of the high incidence of hypertension amongst South African blacks, many hypothesis have been forwarded to account for the relative higher index of hypertension amongst South African blacks when compared to whites. Because of the virtue lack of endemic proportions of hypertension in South African blacks at the beginning of this century, the often - quoted genetic hypothesis that hypertension is genetically determined would seem not to hold for South African situation. However, this was not yet tested as one of the risk factors or precursors to hypertension, namely the higher indices of cardiovascular reactivity had not been compared in the South African group between white and black subjects. This study investigated the hypothesis that the offspring of black hypertensive parents would show greater cardiovascular reactivity than those of black non-hypertensive parents, and also show greater cardiovascular reactivity than the children of white hypertensive parents as well as the children of white non-hypertensive parents. These hypotheses were partially supported. As expected the children of black hypertensives did show greater indices of cardiovascular reactivity when compared to both children of white hypertensives and the children of black non-hypertensives. An interesting finding however, was that the children of white hypertensives had shown greater indices of the psychological construct of state anxiety than the children of black hypertensive and black non-hypertensive subjects. Whereas this study supported the hypothesis that an inherited cardiovascular reactivity would and could account for the greater index of hypertension amongst South African blacks, it is also possible that the non-psychological expression of tension or cardiovascular reactivity in the form of state anxiety could partially account for the results herein obtained.

M.Cur. / Community nurses have a very important role to play in the planning of health promotion programmes and implementation of the necessary interventions for patients and groups with obesity problems. Obesity is one of the health problems that requires signficant behavioural changes in one's lifestyle as part of such interventions. The research study sought to explore the perceptions of both the patients and the community nurses of the phenomenon of obesity as a health risk, and to identify any areas that could give rise to problems when health promotion actions were planned for obese people. It was specifically important to obtain the perceptions of the community nurse of obesity, since the level of knowledge of the health problem as well as her personal attitude towards this problem, will be crucial in the manner and quality of her interventions. The study explored patients' and nurses' perceptions about obesity as a health risk (Phase I and 2). Factors in the internal and external environments of the obese individual were identified and analysed into categories and subcategories. The study is qualitative and explorative in nature, data was collected through the use of semistructured interviews, and Giorgi's method of data analysis was used. Literature control was done to examine how existing literature compared with data obtained from semistructured interviews on the nature of obesity as a health problem. Obesity is clearly a health risk and affects the person's totality of life experiences as demonstrated by the resultant patterns of interactions between the internal and external environments of an obese person. Results of the data analysis and literature control gave rise to the need to structure recommendations to give the community nurse the capacity and support that was identified as necessary for her to be able to carry out her nursing intervention.

Thesis (MA)--University of Stellenbosch, 2002. / ENGLISH ABSTRACT: Many Black nurses who originally come from previously disadvantaged communities find themselves at present in relatively senior positions. The reality is, however, that many of these employees are still residing in residential areas where transformation and changes are still very limited and progress hardly noticeable. Such employees experience the stressful world of nursing on the one hand while on the other hand they also have to battle with the realities of the legacy of Apartheid. These may include aspects such as financial burdens, long distances from work, poor public transport, high crime rates in their communities and schools that are yet to improve standards. There are still Black South Africans, amongst them Black nursing sisters, who have to battle with these problems daily, in addition to having to cope with occupational stressors. One would assume then that they may be experiencing a large degree of strain and burnout. This research was therefore concerned with those nurses who remain productive and efficient in their work by overcoming constant occupational and non-occupational demands and stressors. Not all nurses, however, experience ill health due to stressors. There are nurses who do cope well. Two research questions were investigated with reference to the above: (a) Why some Black nursing sisters appear to cope better than others; and (b) What the role of Sense of Coherence (SOC) is as a coping resource. The study therefore investigated the statistical relationship between (a) SOC and well-being and (b) the effect that SOC has on the perception of a selected number of work characteristics. Significant Pearson Correlations were found between SOC and psychosomatic strain symptoms and burnout frequency. No significant relationship was found between SOC and burnout intensity. A significant relationship was found between SOC and work demands, as well as SOC and career rewards. Findings further indicate that no significant relationship was found between organisational climate, leadership relations, influence at work, time pressures and adverse factors in the work environment. Two-way ANOVAs indicate that no significant main effect exists in respect of SOC on psychosomatic strain symptoms. The study also indicates that a significant main effect exists for SOC on burnout frequency, whereas no significant main effect exists for SOC on burnout intensity. No significant interaction effect exists between SOC and age on psychosomatic strain symptoms, burnout frequency and burnout intensity. A significant interaction effect exists between SOC and education level on burnout intensity, while there is no significant interaction effect between SOC and educational level on psychosomatic strain symptoms and burnout frequency. A significant main effect exists for SOC on the perception of leadership relations, influence at work and career rewards. Findings further indicate that no significant main effect exists for SOC on the perception of: orgnisational climate, time pressures, work demands and adverse factors in the work environment. No significant interaction effect exists between SOC and age on the perception of organisational climate, influence at work, work demands, time pressures, career rewards, leadership relations and adverse factors in the work environment. Results indicate that no significant interaction effect exists between SOC and educational level on the perception of organisational climate, influence at work, work demands, time pressures, career rewards, leadership relations and adverse factors in the work environment. The results thus indicate that a positive correlation exists between SOC and wellbeing. / AFRIKAANSE OPSOMMING: Talle verpleegters uit voorheen benadeelde gebiede, bevind hulself huidiglik in relatiewe senior posisies. Die werklikheid is egter dat hierdie werknemers nog steeds onder andere in woongebiede bly waar transformasie en verandering gering is en algemene vordering nie waarneembaar is nie. Hierdie werknemers ondervind die stresvolle omstandighede van verpleging eendersyds en andersyds voer hulle 'n stryd teen die nalatenskap van apartheid. Dit kan aspekte soos finansiele probleme, lang afstande van hul werkplek, publieke vervoer, hoë misdaadsyfers in hul gemeenskappe asook skole waar die opvoedkundige standaarde nog aangespreek moet word, insluit. Daar is nog talle Swart Suid-Afrikaners, Swart verpleegsusters onder andere wat daagliks met hierdie probleme die stryd voer met 'n langsame veranderingsproses, terwyl hulle ook met talle stressors in hul beroepe te make het. Dit kan dus aanvaar word dat hierdie persone 'n groot mate van stres en uitbranding ondervind. Hierdie navorsing het te make met daardie groep verpleegsters wat produktief en bekwaam in hul werk bly funksioneer het, weens die feit dat hulle hierdie voordurende beroeps-en nie-beroeps vereistes en stressors suksesvol die hoof kan bied. Nie al die verpleegsters se geestegesondheid word dus deur genoemde stresfaktore benadeel nie en kan deurgaans effektief funksioneer. Twee navorsings-vraagstukke is met betrekking tot bogenoemde Suid-Afrikaanse realiteit ondersoek: (a) Waarom sommige Swart verpleegsusters die stressors in hul beroeps-en lewensomstandighede beter as ander hanteer en (b) Watter rol speel koherensiebelewing ("SOC") as enstreshantering meganisme. Die studie het (a) die verhouding tussen koherensiebelewing en werknemer welsyn en (b) die rol van koherensiebelewing ("SOC") as enmeganisme vir die hantering van stres, nagevors. Beduidende Pearson Korrelasies tussen koherensiebelewing, psigosomatiese stressimptome en die frekwensie van uitbranding is gevind. Geen beduidende verband is tussen koherensiebelewing, werkseise en loopbaanbelonings gevind nie. Die resultate dui verder aan dat daar geen beduidende verband tussen organisatoriese klimaat, leierskap verhoudings, invloed by die werk, tydsdruk, en nadelige faktore in die werksomgewing bestaan nie. Twee-rigting variansie ontledings dui egter aan dat daar geen beduidende hoof effek tussen koherensiebelewing en psigosomatiese stressimptome bestaan nie. Die studie dui ook op 'n beduidende hoof effek tussen koherensiebelewing en die frekwensie van uitbranding. Geen beduidende hoof effek is tussen koherensiebelewing en uitbranding intensiteit gevind. Geen beduidende interaksie effek bestaan tussen koherensiebelewing en ouderdom op psigomatiese stressimptome, frekwensie van uitbrandiqg en uitbrandings intensiteit nie. 'n Beduidende interaksie effek bestaan tussen koherensiebelewing en opvoedkundige kwalifikasie op uitbranding intensiteit, terwyl daar geen interaksie effek bestaan tussen psigomatiese stressimptome en frekwensie van uitbranding nie. 'n Beduidende hoof effek ten opsigte van koherensiebelewing op die persepsie van leierskap-verhoudings, invloede by die werk, en loopbaanbelonings is gevind. Die navorsing dui verder daarop dat geen betekenisvolle hoof effek bestaan ten opsigte van koherensiebelewing op die persepsie van organisatoriese klimaat, tydsdruk, werksvereistes en nadelige faktore in die werksomgewing nie. 'n Statisties beduidende hoof effek ten opsigte van koherensiebelewing op die persepsie van leierskap-verhoudings, invloede by die werk, en loopbaanbelonings, bestaan. Geen beduidende interaksie effek bestaan tussen koherensiebelewing en ouderdom op die persepsie van organisatoriese klimaat, invloed by die werk, werkseise, tydsdruk, loopbaanbelonings, leierskap-verhoudings en nadelige faktore in die werksomgewing nie. Resultate toon geen statisties beduidende interaksie effek tussen koherensiebelewing en opvoedkundige kwalifikasie op die persepsie van organisatoriese klimaat, invloede by die werk, werkseise, tydsdruk, loopbaanbelonings, leierskap-verhoudings en nadelige faktore by die werk nie. Die resultate dui derhalwe op 'n positiewe verband tussen koheresensiebelewing en werknemerwelstand.

This dissertation is an examination of salient factors that influence the health seeking behaviour of mothers/caregivers of pre-school children in Kwangwanase, KwaZuluNatal province, South Africa. Health seeking behaviour for pre-school children is poorly understood, and is influenced by an array of complex factors that inhibit full utilisation of available health services. Amongst other things, health-seeking behaviour is influenced by cultural beliefs about children's illnesses as well as the local availability of treatment options, and the perceived quality of care provided. This dissertation represents the findings of a combined qualitative and quantitative research approach using free listing, pile sorts, interview schedules, logbooks and observation to explore health-seeking behaviour. Research focussed on the local knowledge held in relation to childhood illnesses that affect children under age six, along with the explanatory models used to discern causation and shape decisions regarding treatment and care. Mothers and caregivers of Kwangwanase draw upon their existing knowledge of children's illnesses, including notions of disease causation, when making diagnoses and deciding between home treatments and professional consultation. Mothers and caregivers pay close attention to the well being of small children. They are constantly involved in the routine management of health and illness. Various treatment options are utilised in a pragmatic way, as mothers and caregivers pick and choose from all available health resources as and when they see fit. Cultural beliefs, accessibility, religious views and other factors influence their choice of health service. Depending on the quality of the care provided and the outcome of the therapeutic intervention, mothers and caregivers are likely to consult several different health care providers in a sequential manner. / Thesis (M.A.)-University of Natal, Durban, 2002.