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M.A. (Clinical Psychology) / Family therapy offers an alternative to traditional psychotherapeutic ways of treatment. It becomes possible for the clinician to conceptualize the family as a system and to observe the patterns and interrelations in the family. Therapy is thus focused on the family as a whole and not on the individual in isolation. The family therapist sees maladaptive behaviour as functional for the family system in which it occurs, and aims therapeutic interventions at the family as a whole. The danger exists however, that because of his conceptualization, the family therapist can neglect the individual in therapy. The individual is seen mainly as a subsystem of the family and less attention is paid to the psychology of the individual. This can lead to a situation where the world of experience of the individual as well as the meaning of the symptomatology for the individual become neglected. This can lessen the effectiveness of family therapy and can lead to individuals feeling as if their experiences are not understood and their emotions not acknowledged. Through the integration of elements such as empathic understanding and unconditional acceptance from the traditions of individual therapy, it becomes possible for the clinician to attend more to the individual in family therapy.

This study evaluated the relationship between two supervision models (live or delayed) to structural family therapy outcome. Eighteen families participated in this study for a maximum of ten family therapy sessions. Two indices of change were measured before and after family treatment, resolution or non-resolution of the family's presenting problem, and changes in family structure as measured by the FIAT. The Family Interaction Apperception Technique was used as the pre- and post-treatment measure of family structure. Presenting problem resolution or non-resolution was determined by the family's report and demonstration within the counseling session that the presenting problem was no longer a family concern. Problem resolution was judged by the case supervisor and reported on the Session and Problem Checklist.

M.A. (Clinical Psychology) / As family therapy has gained acceptance as a treatment modality within the mental health field, increasing attention has been directed towards theory development. With the focus on theoretical issues, including that of epistemology, a division has arisen between strategic and ecosysternic approaches to family therapy. This study was undertaken in order to examine the nature of this debate. The work of Jay Haley was chosen as representative of the strategic approach, and that of Bradford Keeney as representative of the ecosystemic approach to family therapy. The study proceeded on the assumption that fundamental differences exist between the two approaches, which reflect the difference between a lineal and a non-lineal epistemology. In order to place the study in context, the historical development of the family therapy field was reviewed and the conclusion was reached that family therapy represents a method of conceptualising human behaviour, which isdiscontinuous with previous conceptualisations, and which parallels similar shifts in other disciplines. The concept of epistemology within the family therapy field was explored. The lack of clarity which continues to characterise the use of this term within the field, may be attributed, at least in part, to its confusing use by influential writers in the field. The underlying assumptions, central theoretical concepts and methodology of both Haley's strategic therapy and Keeney's cybernetic epistemology, were delineated and the two approaches were then compared along a number of critical dimensions. The investigation established significant conceptual differences between the two approaches and the conclusion was reached that these differences reflect essential epistemological differences. While Keeney's ecosystemic approach is consistent with a non-lineal epistemology, Haley's approach continues to reflect an underlying lineal epistemology

This thesis presents an analysis of two classical problems in the theory of optimal taxation: commodity tax reform and nonlinear income taxation. Economic behavior is modeled as arising out of a family decision making process rather than owing to individual utility maximization. The taxation authority is assumed to have no direct control over intra-family allocations of ^resources. In this way, family interactions change the nature of the second-best constraints the planner faces. The analysis focuses on the impact of these constraints on optimal policy choices. Attention is focused on families with two members, whom the planner can (in most situations that are modeled) tell apart. In the chapters dealing with commodity tax reform, behaviour is modeled as the Pareto-efficient outcome of a family decision process. Conditions for the existence of a feasible, Pareto-improving tax change are presented and contrasted with those that obtain in the individualistic case. The consequences of treating households as a single individual are also discussed. It is shown that treating families as if they were individuals can lead to misleading conclusions. An example is presented to demonstrate that the traditional analysis may go wrong even when families behave as if they are individuals. Moreover, it is shown that household budget data alone is insufficient to address this issue. The model is then put to use to address question of temporary inefficiencies in tax reform. I present how the circumstances under which temporary inefficiencies can arise vary with the structure of poll taxes. The problem faced by a planner choosing an income tax schedule for families is modeled as a multi-dimensional screening problem. Families are described by a two-dimensional vector of characteristics, interpreted as the labour productivities of their members. The planner cannot observe these characteristics directly. Furthermore, families are free to redistribute the after-tax incomes of their members. The planner must take this behaviour into account when choosing the tax schedule. A description of the possible Pareto-efficient mechanisms is given. The implications of a standard redistributive assumption on the sign of marginal tax rates are explored. In contrast to uni-dimensional taxation models, the redistributive assumption does not imply that marginal tax rates are everywhere non-negative. For much of the analysis, the usual assumption of quasi-linear preferences is jettisoned, allowing an exploration of the implications of this additional structure. The qualitative features of optimal tax- schedules are discussed. It is concluded that neither individual-based taxation nor taxation based solely on total family income is optimal. / Arts, Faculty of / Vancouver School of Economics / Graduate

This study was conducted in an effort to examine: (1) adolescents' concepts of their relationships with their families, (2) possible correlations between adolescents' percentile ranks indicated in family relationships with a limited number of other factors which appear to be associated with personal and social adjustment, and (3) any significant differences in responses of adolescent girls enrolled in homemaking education and those not currently enrolled in homemaking.

Includes bibliographical references. / The systematic review undertaken for this MPH dissertation examines the existing evidence for youth violence interventions involving substance abuse intervention programs. Part A is the review protocol which outlines the background and process of the review. Search strategies combined related terms for youth, violence and a broad combination of terms for the intervention. Inclusion criteria were broad enough to include a wide range of study designs, given the large heterogeneity of outcomes and the paucity of randomised controlled trials (RCTs). Abstracts were screened by two reviewers, as were selected full texts articles. These were evaluated using the EPHPP questionnaire, a quantitative study assessment tool to identify methodological issues.

Introduction: Human Immunodeficiency Virus remains as one of the largest pandemics in the world, with the prevalence of more than 70% of HIV-infected individual reside in Sub-Saharan Africa. Moreover, other sexually transmitted viral infection such as Human Papillomavirus and Herpes Simplex Virus also show a high prevalence in Sub-Saharan Africa. Recent studies show the presence of other viral STI in the genital region may have increased HIV shedding in the genital region. However, it not clearly known if the presence of ART or HIV may affect the shedding of other viral STI in the genital region and if the combination of other viral STI treatment and ART is necessary to treat an individual with multiple STI infection. Methods: This is a secondary data analysis study, based on analysing the data collected from a single-site, double-blinded randomized control study (2-IUD study). The research site was the Gugulethu Community Health Centre, Cape Town, South Africa and samples were collected between 2014 and 2018. Analysis was conducted on genital tract specimens of study participants obtained via the Menstrual Cup (MC) and Endocervical Swabs (ECS), collected at baseline, 3 and 6 months’ follow up visit from randomly selected 52 ART-Naïve participants and 56 age-matched women from the ART-Using group of the primary study. Logistic regression models were constructed to measure the associations between possible risk factors and viral STIs. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results: ART-Naïve women had higher rates of HIV shedding in the genital tract at each visit. However, more than half of women using ART, most of them virally suppressed, had detectable genital HIV at one or more visits. Most of the participants showed pre-exposure to HSV-2, but shedding of HSV-2 was substantially less common. HPV was detected in 72% of the participants, with no significant difference by ART status. Overall, 70.3% of samples had at least one viral pathogen detected - 60.4% among ART-Using women compared to 82.8% in ART-Naïve women (P<0.001). Compared to ART-Naïve women, ART-Using women were significantly less likely to have co-occurrence of viral shedding overall. However, ART-Using women with higher VL had levels of viral co-occurrence similar to those of ART-Naïve women. Conclusion: Our analysis demonstrated that the ART-Using women were less likely to shed HIV, HSV-2, HPV and viral STI co-infection in the genital tract compared to ART-Naïve women. This may be be driven by plasma VL levels where ART-Using women with lower VL are less likely to shed these viruses compared to women with elevated VL, including those not on ART.

Background: The tension between the increasing cost of healthcare provision and the need to provide a quality level of care to a rising number of people is a global phenomenon. A focus on one over the other could result in a rise in adverse patient outcomes, or a health system too costly to be sustainable. Clinical governance is an approach policymakers can use to walk the middle line of creating a healthcare service that meets quality of care standards in a cost-effective manner, as has been done in Australia, Burundi, Egypt, Spain, UK and Yemen (Goyet et al, 2019; Abd El Fatah et al, 2019, Mannion et al, 2015; Aguilar Martin et al, 2019). This study examines the practice of clinical governance in one LMIC setting that has been able to successfully do this balancing walk for 20 years. Understanding how this was done in the Western Cape province of South Africa helps inform how clinical governance can be used to continue adding value as the health system moves towards universal healthcare. In addition, this South African experience adds to the still small pool of relevant experience from low- and middle-income countries reported in the international literature. Methods: A mixed methods qualitative design was used for data collection and involved three phases: (1) a document review of all policies in the province to identify clinical governance structures; (2) observation of these structures in action, comparing lived to written experience of clinical governance; and (3) interviews with key stakeholders in the province to get their perspectives on past, present and future forms of clinical governance. The Donabedian model was used to frame analysis into three dimensions of care, viz. structure, process and outcome. Results: Beyond a comprehensive policy framework, collaborative structures and consultative leadership styles facilitated strengthened clinical governance in the Western Cape. For example, although corporate-governance-inspired structures, such as clinical audits and M&E events, may become punitive and corrosive, the potential negative impact on clinical governance outcomes and organisational culture was tempered by healthy communication and supportive relationships between colleagues. Family physicians have become the champions of clinical governance in a decentralized health system and when supported in this by policy and management, the quality of care in health systems thrive. Conclusions Clinical governance is an effective strategy or tool LMICs can use to ensure quality of care is maintained or improved upon, even in resource-challenged settings. But while some structures, processes and outcomes may be borrowed from other LMIC or HIC settings, these need to be contextualized to local conditions. Appropriate clinical governance champions need to be identified and given the appropriate mandate. Human relationships are key to the successful implementation of interventions of this nature and space needs to be created in policy for this to be cultivated.

Current international guidelines recommend that a cranial computed tomography (CT) be performed, on all HIV positive patients presenting with new onset seizures, before a lumbar puncture (LP) is performed. In the South African setting, however, this delay could be life threatening. This study sought to measure the number of cranial CTs that contraindicate an LP and to predict which clinical signs and symptoms are likely to pose an increased risk from LP. Methods: The study was performed at a district level hospital in the Western Cape. Data was collected retrospectively from October 2013 to October 2014. Associations between categorical variables were analysed using Pearson's Chi-squared test. Generalised linear regression was used to estimate prevalence ratios. Results 100 out of 132 patients were studied. Brain shift contraindicated an LP in 5% of patients. Patients with brain shift presented with: decreased level of consciousness, focal signs, head ache and neck stiffness. 25% of patients had a space occupying lesion (defined as a discreet lesion that has a measurable volume) or cerebral oedema. Multivariate analysis showed a CD4 count < 50 (p=0.033) to be a statistically significant predictor of patients with a space occupying lesion (SOL) and cerebral oedema. Univariate analysis showed focal signs (p=0.0001), neck stiffness (p=0.05), vomiting (p=0.018) and a GCS<15 (0.002) to be predictors of SOL and cerebral oedema.