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This study opens in a critical paradigm and explores the previously unheard experiences of caregivers who have been trained in and who practice palliative care in a context of rural African, isolated, profoundly impoverished homes. Instead of a healthcare focus, the study used curriculum theory to provide a fresh look at and to better understand palliative care in context. Curriculum theory distinguishes a curriculum as preactive (espoused) or interactive (enacted), and preactive and interactive curricula for palliative care were compared and interrogated as exemplarity of a circumstance when a curriculum is transported into a context other than that where it originated. The study offers several contributions to health sciences, including a link between curriculum theory and palliative care, and provides deep insights into the experiences of those who practice palliative care with limited guidance and support from senior healthcare professionals. In the 1970s palliative care developed in a hospital context in the United Kingdom as a response to ideas which included that society is death-denying and that medicine and associated sophisticated technology act to render patients passive spectators in care decisions. An aim is to coordinate and plan care which includes a focus on empowering patients and their families by giving them choices around living with a life-shortening illness and dying as comfortably and peacefully as possible. A common theme is an intention to relieve or prevent suffering, and palliative care services have developed throughout the world. Palliative care is delivered by healthcare professionals acting within a multidisciplinary team who provide care at various sites including hospitals, homes and hospices. Palliative care has been introduced to post-apartheid South Africa relatively recently, and the preactive palliative care curriculum is largely based on notions of palliative care which developed in a European context while the interactive curriculum is enacted in rural African homes. Ideas around palliative care may not have a universal or rigid quality, but may represent an agreement among people in a certain context and the unexplored introduction of such ideas into another context may potentially give rise to a hegemonic flow of ideas. Systemic challenges around healthcare in Africa may preclude a patient from having choices in their healthcare. The agency of patients may be undermined by their material living conditions. The study site was rural KwaZulu-Natal in South Africa, where the incidence and prevalence of Human Immunodeficiency Virus are the highest in the world. Study questions revolved around a curriculum as a source of knowledge for practice and experiences of a context and practice. Data sources were twofold: firstly a palliative care curriculum text was scrutinized and analyzed in terms of who is cared for, place of care, work of caregivers and palliative care; and secondly data from participants (nurses and home-based care workers) were analyzed to produce deep insights into their experiences of practising in context. Data were generated using a visual technique of “photo-elicitation”, where participants were invited to discuss photographs they took to convey their experiences, and analyzed inductively using naturally emerging themes. Curriculum data indicated that patients should be offered palliative care when there is awareness that they face a life-limiting illness, and a focus was on home care. The espoused curriculum foregrounded physical care and placed less emphasis on aspects such as spiritual, cultural or psychosocial care; the curriculum was delivered at a site distant to caregivers’ practice. In South Africa the legacy of apartheid lingers, and data from caregivers revealed that physical conditions are harsh in that patients are starving, housed in makeshift shelters and face profound social challenges. Spiritual care and cultural care were highly valued, as patients map onto traditional beliefs and cultural practices Data revealed that caregivers were sometimes unsure, angry, felt powerless and could be placed in physical and emotional danger. Patients and their families valued some aspects of palliative care, such as preparing for death and bereavement support, but found challenges in understanding other aspects such as why caregivers did not appear to make attempts to cure disease. Juxtaposing study findings with published literature revealed that diametric worldviews of teachers and learners have an impact on curriculum delivery. The home could be a beneficial place for care but could also create challenges. The study theorizes beyond a palliative care curriculum, and in concluding the study I found that I must move from a critical to a post-structural paradigm. A critical paradigm seeks data around oppression and marginalization so that transformation may be enacted, and data indicated that aspects of the practice of palliative care were both empowering and disempowering for caregivers; they were empowered by being able to practice in an independent, autonomous way, but were also disempowered since the curriculum did not adequately consider context. The study unearthed no universal truth for a curriculum for palliative care; an African curriculum should take cognizance of an African context. I use the study findings to put forward a thesis around certainty in curriculum, and the study prompts understanding of certain curriculum in contexts that are uncertain. Key words: Certainty, curriculum, palliative care practice, context, rural homes / Thesis (Ph.D.)-University of KwaZulu-Natal, Edgewood, 2012.

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This single-case design study examined the effectiveness of adapting evidence-based treatments (EBTs) for children in a community clinic through a university-community partnership. Community clinic therapists treated eight youths (five males), ages 10 to 14, of whom four were Caucasian, two were Latino, one was African-American, and one was Caucasian/African-American. Youths presented with a primary diagnosis of a DSM-IV (American Psychiatric Association, 1994) internalizing disorder (plus multiple comorbidities). An adapted treatment combining multiple elements based on two primary treatment manuals: Coping Cat (Kendall et al., 1990) and PASCET (Weisz et al., 1999) was used. Youths with comorbid externalizing symptoms were also treated with elements from a parent-training manual (Barkley, 1997). Results of visual and clinical significance analysis demonstrated mixed support for the adapted treatment in a community clinic setting. The findings support further efforts to test the effectiveness of adapted EBTs in a community clinic setting and population.

The purpose of this research was to obtain information on the content of education within cardiac rehabilitation programs, methods of administering education, what the barriers are to providing education and which professionals administer education.To reach this goal, a questionnaire was modified from a previous study and a pilot study was undertaken to establish reliability of the questionnaire. The questionnaire was then sent to a sample of 100 directors of cardiac rehabilitation programs belonging to The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). The questionnaire focused on 13 established areas of education within cardiac rehabilitation programs.Once the questionnaires were completed, the information was transferred to a table format based upon the 13 content areas. The following conclusions were drawn from the research and the data gathered: 11 of the 13 content areas are offered at least 84% of the time, the major barriers for the 13 content areas were lack of time and lack of interest on the patient's behalf, the most frequent methods of education for all 13 content areas were individual education, print materials, and group education, and the primary educator overall for all 13 content areas was the nurse followed by the exercise physiologist and dietitian/nutritionist. / Department of Physiology and Health Science

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Nurses, midwives and clinical officers referred to as Mid-level Practioners (MLPs) play an important role in the health care system especially in rural Africa. With particular reference to rural Uganda, due to the large shortage of doctors, MLPs handle most of the duties usually meant for doctors, at health centre IV(s). From 2009 to 2011, two training interventions of MLPs were performed at 36 sites in Uganda by the Integrated Infectious Disease Capacity Building Evaluation (IDCAP). The two interventions were: Integrated Management of Infectious Diseases (IMID) and On-site Support Services (OSS) which aimed at improving MLPs’ case management for four diseases: HIV, TB, pneumonia and malaria. In this thesis, we have developed three mathematical models to investigate the effect of the two training interventions on these infectious diseases. All the models are formulated using systems of ordinary differential equations which are structured in three age groups: [0, 5), [5, 14) and [14, 50). We explored the effect of the two training interventions in the context of malaria-pneumonia, HIV-TB co-infections and the four diseases together. Our analysis shows that: i) For malaria-pneumonia, both IMID and the combination of IMID and OSS reduce the number of cases, deaths and prevalence of disease but have no effect on the incident episodes of disease. ii) Results from the HIVTB model propose that HIV and TB testing are important steps in quality of health care and are capable of offsetting slightly negative effects of reduction in ART enrollment and provision of treatment. iii) The HIV-TB-malaria-pneumonia (HTMP) model concurs with the results of the first two models and its results demonstrate that high coverage levels of the training interventions increase the positive effects that the interventions have on mortality and morbidity. Overall, our results suggest that training of MLPs is much more effective for the short term duration diseases such as malaria and pneumonia, where the baseline values for most of the performance indicators are ≥ 0.6, but not so much for long term duration diseases such as HIV and TB, whose baseline values for most of the performance indicators are < 0.6. The results further highlight that problems such as case detection and drug stock-outs need to be addressed in order for training to have substantial impact, especially in instances where the performance indicator proportions are low. / AFRIKAANSE OPSOMMING: Verpleegsters, vroedvroue en kliniese beamptes wat gesamentlik na verwys word as midvlak praktisyns (MVPs) , speel n belangrike rol in die gesondheidsorg sisteem, veral in landelike dele van Afrika. Met spesifieke verwysing na gesondheid sentrums in Uganda, waar daar te min dokters is, hanteer MVPs die meeste van die pligte wat eintlik deur dokters verrig moet word. Vanaf 2009 tot 2011 is twee opleidingsprogramme vir MVPs by 36 fasiliteite in Uganda deur die Integrated Infectious Disease Capacity Building Evaluation (IDCAP) organisasie aangebied. Die twee programme staan bekend as: Integrated Management of Infectious Diseases (IMID) and On-site Support Services (OSS). Beide die programme stel ten doel om die MVPs se pasint bestuur vir die siektes MIV, tuberkulose (TB), longontsteking en malaria te verbeter. Drie wiskundige modelle word in hierdie tesis ontwikkel om die effek van die opleidingsprogramme op hierdie oordraagbare siektes te ondersoek. Al die modelle word geformuleer deur gebruik te maak van stelsels van gewone differensiaal vergelykings wat gestruktureer is in drie ouderdomsgroepe: [0, 5), [5, 14) en [14, 50). Die effek van die opleidings programme word in die konteks van longontstekingmalaria mede-infeksie, MIV- TB mede-infeksie en al vier siektes gelyk, ondersoek. Die analise wys dat: i) Vir longontsteking-malaria mede-infeksie het beide IMID en die kombinasie van IMID en OSS die aantal siekte-gevalle, sterftes en die prevalensie van die siektes verminder, maar het geen effek op die insidensie van siekte-gevalle nie. ii) Resultate van die MIV-TB model dui aan dat MIV en TB toetsing n belangrike aspek van die gehalte van sorg is en dat dit die effense negatiewe effek van die afname in ART inskrywing en voorsiening van behandeling, teenstaan. iii) Die MIV-TB-longontsteking-malaria model (HTMP) stem ooreen met die resultate van die bogenoemde twee modelle en demonstreer dat ho dekking van die opleidingsprogramme die positiewe effek van die programme op mortaliteit en morbiditeit verhoog. In geheel stel die resultate van hierdie studie voor dat die opleiding van MVPs baie meer effektief is vir die korttermyn siektes soos malaria en longontsteking waarvoor die meeste van die beginwaardes van die prestasie-aanwysers ≥ 0.6 is, maar nie soveel vir lang-termyn siektes soos MIV en TB waarvoor die meeste van die beginwaarde van die prestasie-aanwysers < 0.6 is. Die resultate dui verder aan dat opleiding nie voldoende is wanneer die prestasie-aanwysers < 0.6 is nie en dat probleme soos die opsporing van siekte-gevalle en n gebrek aan medisyne by die klinieke aangespreek moet word vir opleiding om aansienlike impak te hê.