People diagnosed with cancer or undergoing cancer treatment experience a wide range of symptoms. One of the most common symptoms experienced by cancer patients today is cancer-related fatigue. Cancer-related fatigue is a complex condition, recognised as a multidimensional construct and thought to be associated with a cluster of symptoms rather than occurring in isolation. Cancer-related fatigue is distressing and can persist beyond the treatment phase or the disease itself. Current understanding of cancer-related fatigue and its management is limited. Further developing our knowledge of cancer-related fatigue may lead to innovative means of improving the identification, prediction and management of this troublesome symptom. To this end, this thesis aims to: I) identify factors reported to have a relationship with cancer-related fatigue; II) examine the course of cancer-related fatigue during and after radiotherapy; III) determine a method of detecting clinically meaningful change in fatigue; IV) examine whether correlates of fatigue are consistent across all fatigue dimensions or whether each dimension has its own unique pattern of correlates; and, V) develop and trial a group-based educational intervention to target cancer-related fatigue. To address Aim I in this thesis, relevant literature was reviewed to identify factors which potentially influence cancer-related fatigue. Factors identified include underlying medical factors (biomedical mechanisms, disease-related factors, treatment-related factors and comorbid conditions); physical or behavioural factors (poor nutrition, decreased activity, sleep disturbance, pain); psychological factors (anxiety and depression); and sociodemographic factors (social support, employment and education). The range of inter-related factors identified makes cancer-related fatigue a challenging condition to manage. The factors associated with cancer-related fatigue were synthesized into the Fatigue Framework to provide a clinically useful format for health professionals working with people with cancer. The Fatigue Framework was used to guide the remainder of the research into cancer-related fatigue presented in this thesis. This research consists of two main studies; a prospective longitudinal cohort study (to address Aims II, III, IV) and a randomised controlled trial (to address Aim V). The first study in this research examined the factors and effects associated with cancer-related fatigue in a radiotherapy population (n=210). Patients undergoing radiotherapy were recruited for a single-centre prospective longitudinal cohort study. Participants were assessed using a battery of assessments at three time points, at the start of radiotherapy, the end of radiotherapy and six weeks after radiotherapy completion. The results of this study were used to address Aim II, to identify the pattern of fatigue over the course of radiotherapy. The level of fatigue reported was shown to significantly increase from start to the end of radiotherapy and then significantly decrease from the end of radiotherapy to six weeks post-treatment for each subscale of the MFI. The results of this study were also used to address Aim III, to determine a method of detecting clinically meaningful change in fatigue. Whilst there are many tools used to assess cancer-related fatigue, the Multidimensional Fatigue Inventory (MFI) was the assessment chosen for use in this research study and throughout this thesis. The MFI is one of the few fatigue assessments that takes the various clinical dimensions of fatigue into account and has established reliability and validity. However, unlike other fatigue assessments, there were no published minimal clinically important difference (MCID) criteria for its use in cancer populations. MCID criteria determine the smallest change in scores that can be regarded as important, allowing clinicians and researchers to interpret the meaning of changes in patients’ fatigue scores. Determination of the MCID was based on the relationship of MFI scores to four clinically relevant constructs: (1) treatment impact on fatigue, (2) health-related quality of life, (3) performance status and (4) occupational productivity. These constructs were used as external or anchor-based measures to determine a MCID for each sub-scale of the MFI. Multiple MCID criteria were identified through the first study, each from a different perspective based on the anchor-based construct used. However, a two-point reference for each MFI sub-scale was suggested as a generic MCID as it was most consistent across the anchors examined. The MCID criteria validated in this study allow better interpretation of changes in MFI sub-scale scores and allow effect size calculations for determining sample size in future studies. The MFI allows assessment of multiple dimensions of fatigue (general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue). Minimal previous research had considered the differential effect of symptom correlates on individual dimensions of fatigue. The data of the prospective cohort study were further utilised to address Aim IV, to determine whether correlates of fatigue were consistent across all dimensions or whether each fatigue dimension had its own unique pattern of correlates. Results indicated that each dimension of fatigue was associated with a different pattern of correlates supporting the concept of multiple dimensions of fatigue. This enhanced understanding of fatigue could be used to guide the development of individually tailored interventions to target specific correlates of fatigue in affected domains, or group interventions to address all relevant fatigue correlates. Because fatigue is associated with multiple symptom correlates, it requires multi-focused symptom management. Education is a commonly recommended fatigue management strategy which can be used to target multiple symptoms simultaneously. There is a lack of information about the content and format used in education programs and the effectiveness of education in managing fatigue. The second study in this thesis addressed Aim V, to develop and trial a group-based educational intervention to target cancer-related fatigue. The study examined a group-based educational intervention (CAN-FIT) targeting cancer-related fatigue in radiotherapy patients. A pilot study of the intervention’s feasibility and acceptability indicated the intervention was acceptable to participants and its operation was feasible. Small modifications to program components were made based on participant feedback. A randomised controlled trial was then conducted to examine effectiveness of the CAN-FIT program and to ascertain the most effective timing for such an educational intervention. The study employed a factorial design and recruited 110 participants. Assessments were conducted at three time points, the start of radiotherapy, the end of radiotherapy and six weeks after the completion of radiotherapy. Results of the randomised controlled trial of CAN-FIT did not show a significant effect of the program on cancer-related fatigue levels, however the pre-radiotherapy education sessions were associated with significant increases in physical activity participation. Furthermore, the study demonstrated the delivery of education prior to radiotherapy was more effective than delivery after radiotherapy. This thesis successfully addresses its stated aims and provides a greater understanding of the concept of cancer-related fatigue. The results more clearly describe the course and correlates of fatigue and their relationship with the dimensions of fatigue. The MCID criteria for the MFI can be used in future research to evaluate outcomes and determine sample size in power calculations. The intervention trialled can be used in clinical practice to provide a low-resource intervention to improve activity levels without any subsequent change in fatigue in radiotherapy patients. Together these studies build upon current knowledge and provide directions for future research to address this difficult symptom.

The future work force will be expected to transition from the familiarity of their school environment into an unfamiliar and unstable career world. Organisational changes have shifted the terms of employment from an employee practicing a life-long vocation to now becoming part of a contingent work force. This infers that employees may have to forfeit their reliance on the company to shape their identity development in lieu of self-management. The acknowledgement of these changes has created a ripple effect in the career counselling field as career practitioners increasingly begin to experience the limitations of traditional career approaches in addressing their clients’ evolving career needs. Subsequently, a post-modern framework to career counselling has been introduced to guide career counselling practices in the 21st century. My study focused on the use of two such approaches, namely life-design counselling and career adaptability. This study was based on a socio-constructivist paradigm, which had developed from an interpretivist worldview. The nature of my research study lent itself well to a collective case study, which involved the participation of five learners from an independent school context in a major South African city. Qualitative data collection, analysis and interpretation techniques were used to explore the effect of life-design counselling on the career adaptability of the afore-mentioned participants. Prior to attending eight group-based life-design counselling sessions, the participants were asked to attend an individual pre-interview. They were also asked to participate in a post-interview upon completion of the last-mentioned sessions. The identified themes generated from the qualitative data collected were as follows: responses related to career adaptability and the related sub-skills based on the Career Adapt-Abilities Scale (CAAS) (Savickas & Porfeli, 2012:357); family/significant others’ influences; financial and economic considerations; components related to emotional intelligence (Bar-On, 2007); adolescent development; school life; childhood dreams, and reflection on the process of life-design counselling. Findings suggest that the participants from my study appeared to benefit from the implementation of a life-design counselling intervention aimed at improving their career adaptability. With this study I aimed to contribute to the field of career counselling by highlighting the specific factors that were likely to influence the career trajectory of the five participants and to demonstrate the positive effect of life-design counselling on their career adaptability. Recommendations have also been made for further research and practice. / Thesis (PhD)--University of Pretoria, 2015. / Educational Psychology / Unrestricted

One of the main challenges experienced during adolescence is that of developing a coherent sense of self, or self-identity (Becht, 2016; Bester & Quinn, 2010; Erickson, 1977). This study used a parallel (or convergent) interactive multi-method design, embedded in an intervention, to explore the possible effects of group based life design counselling on the sense of self of female adolescent peer supporters. The possibility of assisting more individuals by using intervention techniques in groups was also explored. The research study is embedded in a constructivist paradigm and, working from an interpretive stance, the researcher collected, analysed and reported on quantitative and qualitative data to gained insight into the participants’ experiences surrounding narrative group life design techniques and their possible impact on enhancing the sense of self. The overall findings indicate that the intervention programme enhanced the sense of self of the participating peer supporters. The mixed-method research results from this study provide a clearer view of how groups of adolescents can be supported to become better equipped to negotiate transitions in their lives, by enhancing their sense of self. / Thesis (PhD)--University of Pretoria, 2017. / Educational Psychology / PhD / Unrestricted

Post-stroke fatigue is a common problem that may limit participation in everyday activities. Emerging evidence suggests that group-based training in fatigue management may be an efficient means of reducing the effects of post-stroke fatigue. This mixed methods, quasi-experimental study proposed to determine whether a group-based educational program could be successful in relieving post-stroke fatigue and improving participation in daily activities. A convenience sample of stroke survivors (n=20) from retirement communities in southeastern PA were invited to participate in the research. Participants were screened for depression, motor and cognitive recovery, and sleep quality. Fatigue was measured using the Fatigue Severity Scale (FSS) and activity participation was measured using the Physical Self-Maintenance Scale- Instrumental Activities of Daily Living (PSMS-IADL). The measures were administered in a double pre-test, double post-test format over three seven-week phases; a non-intervention period; a group-based intervention period, and a post-intervention period. Qualitative information was gathered using a self-made Intervention Satisfaction Survey. Data analysis involved measures of central tendency for the demographic information. Tabulations of the survey responses were completed to judge the effectiveness of the group-based program or its’ components from the participants’ perspectives. Results indicated a statistically significant reduction in reported fatigue post-intervention (p= .022), which continued for seven-weeks (p= .240). There was a strong effect size for the post-intervention reduction of fatigue (r= .69). There was a trend toward improved participation in daily activities. Distribution across groups for presence of social support, age, sex, and level of care was found to be equivalent after one-way chi square analysis. There was no significant influence of these variables on fatigue or participation when used as grouping variables in RM-ANOVA. Participants reported feeling most confident scheduling activity to include rest periods and least confident managing sleep problems. Limitations include small sample size, demographics not being representative of the general stroke population, use of self-report measures with possible ceiling effect of PSMS-IADL, instrumentation effect given multiple administrations, and history effects as groups occurred at different time of the year. Overall, the results indicate that participation in a group-based educational program was effective in reducing post-stroke fatigue in chronic stroke.