In der Therapie orthopädischer Erkrankungen/Verletzungen gewann in den letzten Jahren das Training im Wasser als aktive Maßnahme an Bedeutung. Auf der Suche nach Möglichkeiten einer frühfunktionellen, aber schonenden Behandlung wurde das Bewegungstraining im Wasser wieder entdeckt (vgl. Froböse/ Nellessen/ Eckey 2003, 211-29). Innenmoser (2007) betonte, dass therapeutisches Aqua-Jogging geeignet bzw. notwendig ist für Menschen mit Schädigungen, chronischen Krankheiten und mit Beeinträchtigungen bzw. Gefährdungen vor allem der körperlichen Funktionen, aber auch bei Schwächen des Stütz- u. Bewegungsapparats und chronischen Erkrankungen wie Rheuma, Wirbelsäulenschäden und auch bei „Low-Back-Pain“-Patienten. Der Bewegungsraum Wasser bietet im Vergleich zu Bewegungen an Land, aufgrund seiner besonderen physikalischen Eigenschaften (vgl. hierzu alle zitiert in: Innenmoser 2001, 27: Aschoff 1971; Klauck 1977, 1998; Stegemann 1991; Stuart 2000 u.a.), eine weitestgehende Entlastung des Stütz- und Bewegungsapparates, insbesondere bei Teilnehmern mit stark verändertem Bewegungsbild. Für viele Menschen mit körperlichen Schädigungen sind bewegungstherapeutische Maßnahmen im Wasser die einzige Möglichkeit zur Erhaltung bzw. Steigerung ihrer Leistungsfähigkeit. 2 Ziele der vorliegenden Untersuchung Ziel der vorliegenden Untersuchung ist es, die möglichen Wirkungen der Aktiven Wassertherapie in Form des therapeutischen Aqua-Jogging nach dem Konzept Innenmoser (2001) bei „chronischen“ Rückenschmerz- Patienten nachzuweisen. Weil in sportwissenschaftlichen Studien die in klinischen Studien üblichen medizinischen Kontrollverfahren (Röntgendiagnostik, Oberflächen- EMG usw.) nicht zur Anwendung kommen können, wird in dieser Studie versucht, die Wirkungen der „ Bewegungstherapie im Wasser“ über den Weg eines indirekten Schließverfahrens zu ermitteln. Dieses beruht darauf, dass die Wirkungen der Aktiven Wassertherapie sich in einer verbesserten Bewegungsmöglichkeit bzw. einem höheren Bewegungsausmaß der Bewegungen des Rumpfes bzw. der unteren Wirbelsäule dann zeigen, wenn die Personen unmittelbar nach Verlassen des Wassers mit unserem ultraschallgestützten Prüfverfahren kontrolliert werden. Der Vergleich zwischen den Veränderungen der Messwerte bei ausgesuchten Bewegungsaufgaben / Tests im Bereich der Wirbelsäule vor Beginn des Aqua-Joggens und unmittelbar danach wird als Indikator für eine bessernde Wirkung der Bewegungen im Wasser angesehen. Dabei galt es nachzuweisen, dass tatsächlich die Kontrolle am Beckenrand deutlichere Zeichen einer Wirkung der Bewegungen im Wasser erbringen kann, als die zeitlich immer viel später liegenden Laboruntersuchungen. 3 Methodik und Design In einer kontrollierten prospektiven Studie wurden 11 Probanden im Alter zwischen 41 und 71 Lebensjahren mit chronischen Rückenschmerzen in der Lendenwirbelsäule (Dauer > 2 Jahre) in Rahmen einer Einzelfallstudie (ohne begleitende physiotherapeutische Behandlung) erfasst. Sie nahmen über die Dauer von 14 Wochen ein mal pro Woche an einem Aqua-Jogging-Programm von 60 min Dauer teil. Alle Probanden absolvierten das Trainingsprogramm ausschließlich im Wasser. Neben den Messungen von Mobilität und Schmerz wurden durch Prä-, Post-, Follow-up-Tests und die verlaufsdiagnostische Untersuchung mit Hilfe eines „Befindlichkeitsfragebogens“, auch die subjektiven Einschätzungen von Leistungsfähigkeit, Befinden und Schmerzempfinden ermittelt. Im Labor kamen als ergänzende Parameter die Ermittlung der statischen Körperhaltung und der anthropometrischen Date hinzu. Der alltäglich wechselnde Schmerzzustand der Probanden wurde anhand eines „Tagebuchs“ festgehalten. Die Lendenwirbelsäule-Mobilität wurde mit Hilfe der Bestimmung des „Schoberzeichens“ im Labor in die Analyse mit einbezogen. Die Schmerzvarianten der Personen wurde mit Hilfe einer Befragung (Fragebogen FSR), dem ein Schmerzregulationsmodell zugrunde liegt, am Anfang und am Ende des Aqua-Jogging-Programms und nach dessen Ende im Follow-Up Zeitraum gemessen. Wichtigste Aufgabe aber waren die Messungen der Bewegungsmöglichkeiten der Lendenwirbelsäule mit Hilfe des Ultraschallmessverfahrens System Zebris am Beckenrand vor und nach dem Aqua-Jogging und dessen Auswertung unter Berücksichtung jedes einzelnen Probanden. 4 Ergebnisse Die Auswertung der Veränderungen mit dem ultraschalltopografischen Messverfahren nach Zebris in den Verlaufsuntersuchungen ergab bei 8 Probanden eine Verbesserung der LWS Beweglichkeit. Bei 8 Probanden waren auch Verbesserungen im Follow-Up Test im Merkmal Flexion zu sehen. Diese fiel deutlich umfangreicher aus. Bei weiteren 6 Probanden ergaben sich Verbesserungen der Extension im Bereich der LWS. Ebenfalls 6 Probanden konnten die Lateralflexion nach links vergrößern. Nur bei 5 Probanden verbesserte sich die Lateralflexion nach rechts. Bei 5 Probanden war die Rotation nach links besser, während bei 8 Probanden die Rotation nach rechts besser gelang. 6 Probanden verbesserten ihre LWS Beweglichkeit in der Flexion, wenn man das Schoberzeichen als Kriterium heranzog. Nur 3 Probanden verbesserten ihre FSR- Kompetenz, während 5 Probanden eine geringere Schmerzintensität lt. FSR aufwiesen. 7 Probanden zeigten eine geringere Angst gemäß FSR und bei 7 Probanden verringerte sich die Neigung zu Depression, Die Effekte sind unabhängig von Geschlecht und Chronifizierungsausmaß. Verallgemeinernd gesehen waren mit Hilfe der ausgewählten Messkriterien eine Verbesserung der Beweglichkeit der Wirbelsäule, eine Linderung der Schmerzen und Steigerung der Lebensqualität zu beobachten. Trainingsbedingt zeigte sich teilweise eine kräftige Beschwerdereduktion (Linderung der Schmerzintensität) und eine relativ deutliche Steigerung der körperlichen Leistungsfähigkeit. Teilnehmer über 60 Jahre zeigen gegenüber jüngeren Teilnehmern einen höheren Beweglichkeitszuwachs der Flexion bei gleicher Schmerzreduktion. Es wurde eindeutig klar, dass die individuell unterschiedlichen Wirkungen des Aqua-Joggings auf Flexion, Extension, Lateralflexion links und rechts und Rotation links und rechts nur dann sicher erfasst werden können, wenn die Kontrolle tatsächlich am Beckenrand erfolgte. Diese akuten Wirkungen erklärten auch das fast stets gesteigerte Gefühl des Wohlbefindens bei den Probanden und ihre regelmäßig geäußerten Wünsche nach einer Fortsetzung der Trainingsmaßnahmen 5 Schlussfolgerungen Das Aqua-Jogging bestätigte sich als wirksame Maßnahme im Sinne einer Trainingstherapie. In der untersuchten Stichprobe wurden schon nach kurzer Zeit und im Verlauf der Studie bis zum Ende deutliche positive Veränderungen der Bewegungsmöglichkeiten der Lendenwirbelsäule festgestellt. Dass dies nicht bei allen Probanden bei allen Provokation einheitlich gleich war, lässt sich erklären durch die sehr unterschiedlichen Ausprägungen der Symptome, obwohl alle sicher zur Gruppe der „Low-Back-Pain“-Patienten zu zählen sind. Die Ergebnisse der Untersuchungen und die Durchführung des Trainings unter den festgelegten Bedingungen können weitere Erkenntnisse für effektive Therapiemaßnahmen für Rückenpatienten bringen. 6 Schlussthesen 6.1 Mit Hilfe des Ultraschall-Diagnoseverfahrens (System Zebris) am Beckenrand gelingt es, die unmittelbaren Auswirkungen des Aqua Joggings – repräsentiert durch eine verbesserte Beweglichkeit in Flexion, Extension, Lateralflexion und Rotation der LWS – nach jeder Therapieeinheit nachzuweisen. 6.2 Ein erhöhtes Niveau der Lendenwirbelsäulen–Bewegungsmöglichkeiten und eine Verbesserung der „Schmerzfaktoren“ kann durch ein spezifisches Aqua-Jogging Training erreicht werden. Eine längerfristige Wirksamkeit der Intervention in Form von geringeren Rückbildungsprozessen auf den alten Zustand vor Beginn des Programms konnte am Follow-up-Messzeitpunkt nur teilweise gezeigt werden. 6.3 Alle Teilnehmer der Studie reagierten beim Post Test im Vergleich mit dem Prä-Test – im Sinne der Schmerzreduktion – positiv auf die Teilnahme am Aqua-Jogging. Die Patienten fühlten sich nach dem Aqua Jogging wohler als vor dem Aqua-Jogging.

The purpose of this study was to assess the epidemiology of preventable risk factors for NCDs among the adult population in Tigray, Northern Ethiopia. A quantitative descriptive cross-sectional design was employed to describe the distribution of behavioural and biological risk factors for NCDs, assess the status of knowledge, perceptions, attitude and behaviour of the study participants for NCDs and their risk factors, and a matched case-control study to identify the determinants of hypertension. The data was collected using a structured questionnaire for the interview, physical measurements including weight and height scales, non-elastic measuring tape for waist and hip circumferences, Omron digital BP apparatus for blood pressure and heart rate; Accutrend Plus for measuring fasting blood glucose, cholesterol and triglycerides. For the descriptive cross-sectional study a total of 2347 participants were included, and for the matched case control study a total of 117 cases and 235 controls participated. Behavioural and biological risk factors were assessed. Only 0.8% of the study participants used optimal fruit serving per day. The prevalence of low level physical activity (<600 MET-minutes/week) was 44.8%. The magnitude of ever alcohol consumption was 66.8%. However, the magnitude of khat chewing and tobacco smoking among the study participants was not as high as the other risk factors i.e. 3.3% and 2.3% respectively. The magnitude of hypertension, central obesity, hyperglycaemia, hypercholesterolemia and hypertriglyceridemia was 9.9%, 22.2%, 3.5%, 30.3% and 32.2% respectively. Factors associated with the risks aforementioned were gender, age, place of residence, education, knowledge status on NCDs, mental stress and others. The status of knowledge on CVDs, breast and cervical cancers, diabetes and their potential risk factors was low and not comprehensive. Misconceptions on NCDs and body size and shape were pervasive. Risky behaviours underlying NCDs were rampant in the study population. Factors related to poor knowledge on NCDs were gender, age, place of residence, education and misconceptions on NCDs. The determinants of hypertension were physical inactivity, duration of alcohol intake, central obesity and mental stress. Awareness raising interventions on NCDs and their risk factors; improving socio-economic status and accessibility to health care settings have to be in place to curb these formidable problems. / Health Studies / D. Litt. et Phil. (Health Studies)

Background and aims: Despite living with a gluten-free diet (GFD) Swedish women with coeliac disease (CD) report a lower level of well-being than women without the disease and men with the disease. The all-embracing aim of the thesis was to study experiences of living with coeliac disease in remission and to discover whether a patient education intervention can influence the perceived health and daily life of women with coeliac disease. Methods: Studies I-IV were based on the same sample, a total population of 106 women, &gt; 20 years old, with confirmed CD, who had been treated with a GFD for a minimum of five years. From the total population of 106, 15 and 14 purposefully selected women were included in studies I and IV respectively, which had a phenomenological approach by which data was collected through recorded personal narrative interviews. The participants in studies II &amp; III, comprising the total sample of 106 women, were randomized to one of two groups: either to the intervention group (n=54) that underwent a ten-session patient education (PE) program with problem based learning (PBL), or to a control group (n=52) that received information regarding CD, which was sent to their home on a regular basis. Data was collected by self-administered questionnaires. Study V included 22 purposefully selected people (11 women and 11 men) with confirmed CD that had experienced any kind of residual discomfort despite treatment for at least five years with a GFD. Data was collected by recorded semistructured interviews. Well-being (II-III) was assessed at baseline and after 10 weeks in all patients and after six months in the intervention group using the Psychological General Well-Being index and the Gastrointestinal Symptom Rating Scale. The interviews (I &amp; IV), which were carried out before the start of the PE (I) and within two weeks of completion of the PE program and about three months after the first interview (IV), were analysed with descriptive phenomenology. The data from study V was analysed by content analysis. Results: In the results, the experience of living with CD in remission was described by participants as a constant quest for a normal life (I, V). Three constituents representing conditions necessary to achieve a normalised lifeworld were described (I) as: being secure, being in control, and being seen and included. The balance of thoughts in relation to these constituents proved to be crucial for the individual woman’s ability to experience a normal life, despite the disease. Participants described (V) conditions facilitating the opportunities to live a normal life, but also various barriers to reaching this goal. The results from the PE based on PBL (II-III) showed that the PE improved psychological well-being (II) and GI (III) in women with CD to some extent, but not sufficiently as the improvement reached normative values for women only at 10 weeks regarding PGWB mean total index, and at no point in time regarding GSRS mean total index. The effect had waned at the follow-up six months after the intervention was completed as regards the women’s psychological well-being. In coping with CD, it seems essential for women to interact with others with the same disease (IV). The interaction made women feel individually strengthened, and provided them with a broader perspective on life with CD. As a result, this strengthened their sense of self in relation to the disease. Knowledge given by other participants and experts could result in both relief and anxiety. The results from the PE based on PBL (II-III) showed that the PE improved psychological well-being (II) and GI (III) in women with CD to some extent, but not sufficiently as the improvement reached normative values for women only at 10 weeks regarding PGWB mean total index, and at no point in time regarding GSRS mean total index. The effect had waned at the follow-up six months after the intervention was completed as regards the women’s psychological well-being. In coping with CD, it seems essential for women to interact with others with the same disease (IV). The interaction made women feel individually strengthened, and provided them with a broader perspective on life with CD. As a result, this strengthened their sense of self in relation to the disease. Knowledge given by other participants and experts could result in both relief and anxiety.

Thesis (DPhil (Psychology))—University of Stellenbosch, 2009. / ABSTRACT: This study, within the fields of occupational therapy and occupational science, describes the occupations of isiXhosa-speaking individuals with longstanding histories of mental illness living in chronic poverty. Occupation refers to the daily tasks and purposeful activities which, in occupying people’s time, establish the patterns of their lives and give expression to their roles, identity, interests and abilities. The aim of this study was to describe how poor households and persons with psychiatric disability living in those households coped with their circumstances and how they viewed, orchestrated, drew meaning from and attributed purpose to the everyday things they did, in particular the self-identified, primary income generating occupation of the disabled person. The research questions elicited information about the genesis, characteristics, meanings and functions of occupation, in particular those occupations performed by the disabled member that contributed to the survival of the household. Using case study methodology, the research involved prolonged engagement with five households living in a peri-urban, informal settlement on the outskirts of Cape Town, South Africa. Qualitative data about occupation was derived through demographic screening, multiple interviews with key informants in each household, participant observation and focus group discussion. In addition, discussions were held with mental health professionals familiar with the context and the Xhosa culture. Four forms of data analysis and interpretation (Kavale, 1996; Stake,1995) were applied to develop substantive case studies: condensation (identification of major organising ideas); categorisation (thematic categorical aggregation); patterning (narrative structuring) and generalisation (naturalistic interpretation). In addition, discussions were held with mental health professionals familiar with the context and the Xhosa culture. Four forms of data analysis and interpretation (Kavale, 1996; Stake, 1995) were applied were applied to develop substantive case studies: condensation (identification of major organising ideas); categorisation (thematic categorical aggregation); patterning (narrative structuring) and generalisation (naturalistic interpretation). Thematic descriptions of the basics of occupation are used to illustrate the various ways participants negotiated the challenges of life at the margins of society through the ordinary things they did everyday. Cross case analysis provided insights into the financial and social costs of mental illness as well as the strategies, embedded in occupation, adopted by participants in dealing with their circumstances. The central thesis of this dissertation is that psychiatrically disabled people, as economic actors functioning in complex structural, social and occupational matrices, contribute in paradoxical ways to the survival of their households. While their illness behaviour may increase the vulnerability of the household from time to time, they nevertheless facilitate its functioning either as providers of a disability grant; as contributors of additional labour or as productive income generating agents. The individual, the social and the structural are co-constituted in what poor and disabled people are able to do everyday. The less resources that are available in the occupational form, the more effort is needed to perform occupations and the more reliance is placed on the informal relational economy. Relative mastery of constrained circumstances occurred by optimising the goodness of fit between occupational form and occupational performance through adaptive capacity, an under-recognised form of agency in the context of chronic poverty. Looking beyond the obscuring façade of psychiatric disability at the ordinary things people did everyday revealed their capacity to strategise practically and attitudinally in support of the household’s survival. The study heightens awareness of human experiences that have been overlooked in the occupational science and occupational therapy literature, in particular how the basics of occupation operate in resource constrained environments. This contribution to knowledge about human occupation will inform mental health occupational therapy practice and community based psychiatric services concerned with the inclusion of disabled people in promoting social development. / OPSOMMING: Hierdie studie val binne die gebied van arbeidsterapie en ‘occupational science’. Dit beskryf die ‘occupations’ van Xhosa-sprekende individue met ‘n geskiedenis van geestesongesteldheid wat in kroniese armoede in informele nedersettings aan die buitewyke van Kaapstad, Suid-Afrika woon. ‘Occupation’ verwys na die daaglikse take en doelgerigte aktiwiteite wat mense se tyd in beslag neem; die patrone en ritmes van hul lewens bevestig en wat uitdrukking gee aan hul verskeie rolle, identiteit, belangstellings en vermoëns. Die doel van die studie was om inligting te verkry oor die oorsprong, eienskappe, betekenis en funksies van ’occupation’ in die konteks van armoede en veral met betrekking tot die psigiatries gestremde lid se belewenis en bydrae tot die huishouding se oorlewing deur sy of haar self-geidentifiseerde, primêre winsgewende ‘occupation’. Verlengde verbintenis met vyf huishoudings en sleutel informante as gevalstudies het die verkryging van kwalitatiewe data oor ‘occupation’ deur onderhoude, waarneming en fokusgroepe moontlik gemaak. Onderhoude met geestesgesondheidspesialiste vertroud met die konteks en die Xhosakultuur is ook gevoer. Vier tipes data-analise en interpretasie (Kavale, 1996; Stake, 1995) is toegepas om die ontwikkeling van substantiewe gevallestudies moontlik te maak: kondensasie (identifisering en organisasie van belangrike idees); kategorisering (tematiese sorteering van eenhede van betekenis); motief (narratiewe strukturering) en veralgemening (naturalistiese interpretasie). Kruisgevalanalise is toegepas om inligting oor die finansiële en sosiale kostes van ‘n psigiatriese stoornis in die konteks van armoede te bekom asook die ‘occupational’ strategieë waarvan informante in die hantering van hul omstandighede gebruik gemaak het. Die slotsom van hierdie verhandeling is dat psigiatries gestremde persone wat in die konteks van kroniese armoede ‘n bestaan probeer voer, op paradoksale maniere ‘n bydrae tot die voortbestaan van hul huishoudings lewer. Terwyl hulle siektegedrag die kwesbaarheid van die huishouding van tyd tot tyd laat toeneem, maak hulle nieteenstaande die oorlewing van die huishouding moontlik deur ‘n kombinasie van die volgende bydraes: die verskaffing van bykomende arbeid; die beskikbaarstelling van ‘n ongeskiktheidstoelaag en die produktiewe uitvoering van winsgewende ‘occupations’ in die sogenaamde ‘tweede’ of informele ekonomie. Die individuele, die sosiale en die strukturele is aan mekaar verbonde en beinvloed sodanig wat arm en gestremde mense daagliks in staat is om te doen. Hoe minder materiele komponente en hulpbronne in die ‘occupational form’ beskikbaar is, hoe groter is die inspanning wat benodig word om ‘occupation’ uit te voer en hoe meer afhanklik word die gestremde persoon op die informele sosiale ekonomie. Die teenoorgestelde is ook waar. Die kapasiteit vir aanpasbaarheid, ‘n miskende vorm van agentskap in die konteks van kroniese armoede, maak die bemeestering van beperkte omstandighede moontlik. Die kapasiteit vir aanpasbaarheid is geleë in die vermoë om strategies, prakties en sielkundig te funksioneer. Die studie vergroot die bewustheid van menslike ervarings wat oor die hoof gesien is in die arbeidsterapie en ‘occupational science’ literatuur, veral hoe die basiese beginsels van ‘occupation’ funksioneer in omgewings wat gekenmerk word deur deprivasie en beperkte materiële besittings. Hierdie bydrae tot kennis oor ‘occupation’ sal arbeidsterapiepraktyk en gemeenskaps-gebaseerde psigiatriese dienste toelig asook die insluiting van psigiatries gestremde persone in maatskaplike ontwikkeling bevorder.

Thesis (PhD)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Despite the high prevalence of chronic kidney disease, renal narratives are under-reported. Much of what is written on kidney failure is written by health care professionals for health care professionals and about patients. While medical experts and health care practitioners have one type of knowledge, their patients have another type of knowledge acquired through their experience of their own condition. From within the disability and patients’ rights movements urgent calls have been made for the authentic voices of disabled people and patients to be heard without the mediation of professional lenses. In response to this my dissertation combines personal and academic writing to explore my own experience of end-stage renal disease, dialysis, transplantation and the life after transplant. I have used autoethnography as a methodology. Autoethnography is a relatively new, somewhat postmodern form of inquiry that developed from the reflexive turn in anthropology and narrative studies in the latter part of the twentieth century. It is very useful in writing about the experience of illness and reflecting on illness narratives because, in autoethnographic writing, the observer and observed, the narrator and narrated, insider and outsider are the same person. This allows scope for exploring the problematics of representation and for finding alternatives to already existing ways of telling certain stories. Engaging with autoethnography’s postmodern aspects has allowed me to conceptualize experiences that, until I undertook this research, I have never been able to articulate, because the traditional (static) illness narrative forms did not speak to my experience or my understanding of my condition. The central issue in my dissertation lies in the question: How do I tell the story of chronic illness once I have had an organ transplant? Flowing from this are a number of sub-issues: Can my story change? How do I describe myself: The well, the ill, the impaired, the disabled, the afflicted? Do I describe myself living in no man’s land? In my narrative, do I oscillate between being well and ill, or do I occupy another territory entirely? And if I do, what is it? My study shows that writing the story (or stories) of chronic kidney disease is complex, nuanced and dynamic and that, far from being an extended liminal experience, kidney disease is littoral. This distinction is important in coming to narrative terms with an identity that is not damaged so much as different. Through this I hope to demonstrate to both outsiders and insiders, who often submit to narratives that are forced on them, that more satisfying alternatives can be found. / AFRIKAANSE OPSOMMING: Ondanks die hoë voorkomssyfer van chroniese nierkwale word nierverhale nie genoeg aangemeld nie. Die meerderheid van dit wat oor nierversaking geskryf word, word deur gesondheidsorgdeskundiges vir gesondheidsorgdeskundiges en oor pasiënte geskryf. Terwyl mediese deskundiges en gesondheidsorgpraktisyns een soort kennis het, het hulle pasiënte ’n ander soort kennis op grond van hulle ervaring van hulle eie toestande. Van binne die gestremdheid en pasiënteregte-bewegings het ’n dringende oproep weerklink vir die outentieke stemme van mense met gestremdhede en pasiënte om gehoor te word sonder die tussenkoms van professionele perspektiewe. In reaksie hierop kombineer my verhandeling persoonlike en akademiese beskrywings om my eie ervaring van eindstadium- nierkwale, dialise, oorplanting en die lewe na oorplanting te verken. Ek het outo-etnografie as metodologie gebruik. Outo-etnografie is ’n relatief nuwe, ietwat postmoderne vorm van ondersoek wat in die tweede deel van die twintigste eeu uit die refleksiewe wending in antropologie en narratiewe studies ontwikkel het. Dit is baie bruikbaar wanneer oor die belewenis van siekte en besinning oor siekte-narratiewe geskryf word aangesien die waarnemer en die waargeneemde, die verteller en dit wat vertel word, die ingewyde en die buitestander in outo-etnografiese skryfwerk dieselfde persoon is. Dit laat meer ruimte vir verkenning van die problematiek van voorstelling en vir die opspoor van alternatiewe vir reeds bestaande wyses om sekere stories te vertel. My bemoeienis met postmoderne aspekte van outo-etnografie het dit vir my moontlik gemaak om ervaringe wat ek tot en met hierdie navorsing nooit kon artikuleer nie, te konseptualiseer, aangesien die tradisionele (statiese) vorme van siekte-narratiewe nie tot my ervaring of my begrip van my toestand gespreek het nie. ‘Hoe vertel ek die storie van chroniese siekte nadat ek ’n orgaanoorplanting gehad het?’ is ’n sentrale vraagstuk in my verhandeling. Hieruit spruit ’n aantal newevraagstukke voort: Kan my storie verander? Hoe beskryf ek myself: Die gesonde persoon, die sieke, die verswakte, die gestremde, die aangetaste? Hoe beskryf ek myself wat in ’n niemandsland woon? Fluktueer ek in my narratief tussen gesond wees en siek wees of betrek ek ’n geheel ander gebied? En indien wel, wat is dit? My studie toon dat, om die storie (of stories) van chroniese niersiekte te skryf, kompleks, genuanseerd en dinamies is en dat niersiekte glad nie ’n uitgebreide liminale ervaring is nie, maar eerder littoraal is. Dit is belangrik wanneer daar tot ’n narratiewe verstandhouding gekom moet word met ’n identiteit wat nie soseer beskadig is nie, maar eerder anders. Hierdeur hoop ek om aan beide buitestanders en ingewydes, wat dikwels voor narratiewe wat op hulle afgedwing word, moet buig, te wys dat daar meer bevredigende alternatiewe gekry kan word.

BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

In 2008, El Salvador registered the world's highest mortality rate from kidney failure, with more than 2500 deaths annually in Central America's smallest country. El Salvador is the ground zero of a new form of Chronic Kidney Disease (CKD) that has become an epidemic among otherwise healthy agricultural workers and rural residents in lowland Central America in the past three decades. While the epidemic is believed to stem from some combination of agro- chemical exposure and/or dehydration, research on the disease remains embroiled in controversy, policy changes few, and medical support for affected individuals challenging. Foucaultian theorizations of 'discursive materiality' provide insights into the ways in which–even as the science remains inconclusive–understandings, discussions, and research on CKD in El Salvador are having material effects on individuals' bodies and health statuses. Based on fieldwork in El Salvador in summer 2014, this thesis uses the lens of Salvadorian CKD to explore the workings of biopower in settings of industrial agricultural production. Focusing on the Bajo Lempa region of El Salvador, in particular, the thesis examines the discourses, materialities, and practices through which CKD has "come to matter" as a medical and political phenomenon in relation to the agriculture through which affected Salvadorians make their living. Thinking through the discursive materialities of CKD alongside the production of spaces of health and agriculture, this thesis provides insights for the growing field of the political ecology of health by investigating the wider socio-political and environmental processes that make CKD management such a challenge in a Central America.

Renal replacement therapy, in the form of dialysis or transplantation, is the cornerstone of management for end-stage renal disease. UK renal registry shows nearly half of those needing renal replacement therapy are treated by dialysis – predominantly by haemodialysis. Patients on renal replacement therapy have increased mortality risk compared to age matched general population. Moreover, some specific subgroups of patients on haemodialysis have increased risk of mortality than expected. The survival benefit seen in women in the general population is attenuated resulting in similar survival for men and women on haemodialysis therapy. In addition, obese individuals and those of non-Caucasian origin have better survival outcome. Though the underlying reason for these findings is not clear and is likely to be multi-factorial, it has been hypothesised that this paradox could be due to the current practice of normalising dialysis dose to total body water. A number of metabolic factors – body surface area, resting energy expenditure and total energy expenditure – have been proposed as alternative to total body water for scaling dialysis dose. There were two overarching aims of this work – one was to study the effect of declining renal function on resting and total energy expenditure and to study the influence of various energy expenditure measures on uraemic toxin generation. The second was to study the impact on survival outcome of using these alternate parameters for normalising dialysis dose and to derive dialysis dose adjustments based on these metabolic parameters. In order to study these aims, studies were designed to explore different aspects of energy expenditure measures along with a longitudinal study to examine the impact of these parameters on survival outcome. The relationship between energy metabolism, body composition and uraemic toxin generation was studied with a retrospective analysis of 166 haemodialysis patients in whom urea generation rate was used as surrogate marker of uraemic toxin generation. It was found that total energy expenditure and fat-free mass predicted uraemic toxin generation after adjustment for other relevant variables. This study provided the preliminary data which was useful in designing further studies for this work. The effect of renal function on resting and total energy expenditure was studied in 80 patients with varying stages of chronic kidney disease who were not on renal replacement therapy. Resting and total energy expenditures were measured directly using gold-standard methods. It was found that declining renal function did not have a significant influence on either of these measures. This supports the hypothesis that metabolic rate is the driving force for glomerular filtration rate and not vice-versa. The directly measured energy expenditure measures were also found to have a moderately strong relationship with urea generation rate in these patients not on renal replacement therapy. The impact of physical activity on uraemic toxin generation, and thereby dialysis requirement, was studied in a prospective cross-sectional study of 120 haemodialysis patients in whom the physical activity was measured by an accelerometer device. Results from the study showed physical activity level to be a significant predictor of uraemic toxin generation after adjustment for gender and body size differences. This study results stressed the importance of adjusting dialysis dose based on individual’s physical activity level. To study the impact of using metabolic factors as normalising parameter for scaling dialysis dose on survival outcome, a large-scale longitudinal study was conducted with 1500 maintenance haemodialysis patients recruited for the study. Dialysis dose-related parameters and survival outcomes were collected at baseline and at various time points during the follow-up period of 18 months. Study results were analysed in two parts - the theoretical basis for using these metabolic factors as scaling parameters was explored which showed that current minimum target dialysis dose risks under-dialysis in certain subgroups of patients and using these alternative parameters may provide a more equivalent dialysis dose across individuals of different body sizes and gender. With these results arguing for potential use of the alternative parameters, the impact on survival of using them were examined. It was found that all three parameters performed better than the current parameter (total body water) with regards to predicting mortality. Total energy expenditure was found to be the best parameter with the lowest hazard ratio for risk of death. The study data was also analysed to derive an algorithm for adjustment of minimum target dialysis dose based on body size and physical activity level. This newly derived minimum dose target was also shown to impact on survival with those underdialysed based on this criteria having poorer survival outcomes. To understand the impact of whole body protein turnover on resting energy expenditure and uraemic toxin generation, a cross-sectional study was conducted on 12 patients with advanced CKD – 6 each in pre-dialysis CKD and haemodialysis group. It was found that haemodialysis patients had higher rate of protein turnover compared to pre-dialysis patients. Whole body protein turnover was found to contribute significantly to resting energy expenditure and had a moderately strong relationship with urea generation rate. In the course of these studies, two questionnaire tools have been validated for use for clinical and research purposes – one is a self-report comorbidity questionnaire and the other, the Recent Physical Activity Questionnaire. The comorbidity questionnaire was developed as part of this work and was validated against Charlson Comorbidity Index. The Recent Physical Activity Questionnaire was validated for physical activity data collection and energy expenditure calculation against the gold-standard doubly labelled water method. In conclusion, it has been demonstrated that metabolic factors such as body surface area, resting energy expenditure and total energy expenditure are more closely related to uraemic toxin generation compared to total body water. It has also been demonstrated that physical activity contributes to metabolic waste production and may necessitate changes in dialysis requirement. It has been shown that these metabolic factors, when used as scaling parameter for dialysis dosing, may predict survival better than the current parameter in use. The algorithm for dialysis dose adjustment and the questionnaires validated in this work have provided novel tools for further research studies and clinical practice. The central hypothesis of this work is that some metabolic factors may be better markers of uraemic toxin generation compared to total body water. It is hypothesised that modifications in dialysis practice based on these factors may improve the quality of haemodialysis and favourably impact on survival outcome for patients with end-stage renal disease. The work presented here largely supports this hypothesis.

Enteric fever remains the most common febrile illness in urban Nepal. Some individuals may have recurrent infection and some may even progress to become long term chronic carriers. The aim of this thesis was to investigate the rate and factors leading to relapse with typhoid fever in patients who were enrolled in clinical treatment trials for acute enteric fever. The results show that relapses in enteric fever is a common complication and is more likely to be associated with the treatment antimicrobial, cefixime. Gallbladder carriage of invasive Salmonella is considered fundamental in sustaining enteric fever transmission as humans are the only known natural host. This thesis, therefore, also aimed to investigate the prevalence, characteristics, immunological responses, and mechanism of carriage of invasive Salmonella in the gallbladder by examining bile and tissue obtained from individuals who underwent cholecystectomy in Kathmandu. Data presented here demonstrate that S. Paratyphi A is almost as prevalent as S. Typhi in the gallbladder and that carriage may not be driven by antimicrobial resistance. Gallbladders that contained Salmonella were more likely to show evidence of acute inflammation with extensive neutrophil infiltrate. Chronic carriers were found to have dramatically elevated levels of IgG to O:2 and Vi antigens with high bactericidal activity yet low pro-inflammatory cytokine levels suggesting that Salmonella are stimulating a constant immunological response, in the form of antibody. S. Typhi may be controlling the inflammatory process through the expression of the Vi capsule in the gallbladder. Genome sequencing of S. Typhi isolated from chronic carriers were different from those S. Typhi causing acute disease. These data question the current dogmas surrounding the carriage of S. Typhi in gallbladder and predict a pivotal role of Vi capsule and gallstones in maintaining carriage. Therefore, prospectively identifying these individuals is paramount for rapid local and regional elimination. Furthermore, combining cytokine profiles and antibody levels may be a method of prospectively detecting carriers in the general population.

The tibialis anterior (TA) muscle plays a vital role in human movement such as walking and running. Overuse of TA during these movements leads to an increased susceptibility of injuries e.g. chronic exertional compartment syndrome. TA activation has been shown to be affected by increases in exercise, age, and the external environment (i.e. incline and footwear). Because activation parameters of TA change with condition, it leads to the interpretation that force changes occur too. However,activation is only an approximate indicator of force output of a muscle. Therefore, the overall aim of this thesis was to investigate the parameters affecting accurate measure of TA force, leading to development of a subject-specific EMG-driven model, which takes into consideration specific methodological issues. The first study investigated the reasons why the tendon excursion and geometric method differ so vastly in terms of estimation of TA moment arm. Tendon length changes during the tendon excursion method, and location of the TA line of action and irregularities between talus and foot rotations during the geometric method, were found to affect the accuracy of TA moment arm measurement. A novel, more valid, method was proposed. The second study investigated the errors associated with methods used to account for plantar flexor antagonist co-contraction. A new approach was presented and shown to be, at worse, equivalent to current methods, but allows for accounting throughout the complete range of motion. The final study utilised the outputs from studies one and two to directly measure TA force in vivo. This was used to develop, and validate, an EMG-driven TA force model. Less error was found in the accuracy of estimating TA force when the contractile component length changes were modelled using the ankle, as opposed to the muscle. Overall, these findings increase our understanding of not only the mechanics associated with TA and the ankle, but also improves our ability to accurately monitor these.