DOCSLIB.ORG

The Quality of Care Among Older Adults with Diabetes Comorbid with Other Chronic Conditions

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Quality of Care Among Older Adults with Diabetes Comorbid with Other Chronic Conditions The quality of care among older adults with diabetes comorbid with other chronic conditions by Yelena Petrosyan A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy (PhD) Institute of Health Policy, Management & Evaluation University of Toronto © Copyright by Yelena Petrosyan 2017 The quality of care among older adults with diabetes comorbid with other chronic conditions Yelena Petrosyan Doctor of Philosophy Institute of Health Policy, Management and Evaluation University of Toronto 2017 Abstract The management of people with multiple chronic conditions requires understanding the extent to which concurrent chronic conditions contribute and interact to affect the patient’s health status, as well as assessing the risk and benefits of various strategies for the treatment of complex needs in patients. A single condition focus in both clinical care and research remains and limits the assessment of care for people with multiple chronic conditions. The overall aim of this project was to evaluate the quality of overall care for older adults with selected disease combinations in ambulatory care settings. The first study aimed to identify a set of evidence-based and valid quality indicators for evaluating ambulatory care for older adults with selected chronic conditions, including diabetes, hypertension, chronic ischemic heart disease, major depression and osteoarthritis. The second study aimed to critically appraise the identified quality indicators and select a set of indicators for evaluating the quality of care for older adults with diabetes with comorbid concordant and discordant chronic conditions. The third study aimed to examine the difference in the quality of care between patients with 2 vs. 1 selected concordant vs. discordant comorbid conditions, and to examine associations of quality of care and hospitalizations among older adults with selected disease combinations. The study findings suggest that older adults with diabetes are at risk of suboptimal care with additional selected comorbid conditions, especially those with discordant comorbid ii conditions. The study findings also support the importance of continuity of care for older diabetes patients with comorbid chronic conditions. The study findings suggest that the likelihood of hospitalizations increases with the number of prescribed drugs among older adults with comorbidities. There is a need for a holistic approach in education and clinical care of older adults with diabetes taking into account concomitant conditions that affect patient’s health status. Future research is needed for measuring the quality of care in the larger diabetes population and reporting by different stratifications, including age, sex, primary care models to see if there are any patterns in certain groups and target the interventions towards improving practices for specific sub groups. iii Acknowledgments I would like to dedicate this work in memory of my mother, Hripsime Baghdasaryan. This work is also dedicated to my father, Rafael Petrosyan and brother, Armen Petrosyan for always supporting, helping, and encouraging me. Despite the fact that we have been living far apart during my graduate studies, their endless support and unconditional love have always been with me through all the ups and downs of this long journey. I would like to sincerely thank my supervisor, Dr. Walter Wodchis for his guidance and mentorship over the past four years. I am also grateful for all of the research opportunities that he exposed me to during past four years. I would like to express my appreciation to my thesis committee members, Dr. Jan Barnsley, Dr. Kerry Kuluski, and Dr. Barbara Liu for providing insightful comments and questions on my research as it developed. I would like to extend my sincere thanks to Yeva Sahakyan, who helped me to accomplish the systematic reviews. I would like to express thanks to Chris Bai and Andrew Calzavara, ICES UofT, for their continuous support. I would like to thank all of the health care providers/researchers who participated in this research. I would like to express sincere thanks to my colleagues and friends from the Toronto Health Economics and Technology Assessment (THETA) Collaborative, UofT, for nurturing environment and support over the past two years. I want to thank the Health System Performance Research Network (HSPRN) for providing me with financial support during my study years. iv Table of Contents Acknowledgments ......................................................................................................................... iv List of Tables ................................................................................................................................. ix List of Figures ............................................................................................................................... xii List of Appendices ....................................................................................................................... xiii CHAPTER 1: Introduction ............................................................................................................. 1 1.1 Chronic conditions, aging and multimorbidity ......................................................................... 1 1.2 Multimorbidity among patients with diabetes .......................................................................... 2 1.3 Multimorbiditiy’s issues/challenges ......................................................................................... 5 1.3.1 Multimorbidity: high health care utilization .............................................................. 5 1.3.2 Management of older adults with multiple chronic conditions ................................. 7 1.3.3 Multimorbidity: implications for primary care .......................................................... 9 1.3.4 Continuity of care .................................................................................................... 11 1.3.4 Quality indicators in health care .............................................................................. 13 1.4 Performance Measurement for People with Multimorbidity: Conceptual model ................... 15 1.5 Summary ................................................................................................................................. 19 1.6 Thesis project outline .............................................................................................................. 20 1.7 Broad project objectives ......................................................................................................... 21 CHAPTER 2: Systematic review of quality indicators for care for older adults with diabetes, hypertension, chronic ischemic heart disease, major depression and osteoarthritis ..................... 24 Abstract ......................................................................................................................................... 24 2.1 Introduction ............................................................................................................................. 26 2.2 Rationale for the study ............................................................................................................ 28 2.3 Study objectives ...................................................................................................................... 30 2.4 Methods .................................................................................................................................. 30 2.4.1 Search strategy ......................................................................................................... 30 2.4.2 Study selection ......................................................................................................... 32 2.4.3 Methodological assessment ..................................................................................... 34 2.4.4 Data extraction ......................................................................................................... 36 2.5 Results ..................................................................................................................................... 37 2.5.1 Systematic review of quality indicators for care for older adults with diabetes ...... 37 2.5.1.1 Search results ........................................................................................................ 37 v 2.5.1.2 Study characteristics ............................................................................................. 38 2.5.1.3 Methodological quality ......................................................................................... 40 2.5.1.4 Quality indicators .................................................................................................. 41 2.5.2 Systematic review of quality indicators for care for older adults with hypertension, and chronic ischemic heart disease ............................................................ 45 2.5.2.1 Search results ........................................................................................................ 45 2.5.2.2 Study characteristics ............................................................................................. 47 2.5.2.3 Methodological quality ......................................................................................... 49 2.5.2.4 Quality indicators .................................................................................................. 50 2.5.2.4.1 Quality
Load more

Recommended publications
  • Ever 2018 Eupo 2018
    European Association for Vision and Eye Research European University Professors of Ophthalmology EVER 2018 Annual Congress October 4-6, 2018 EUPO 2018 Course on Retina, Intraocular Inflammation & Uveitis October 3-4, 2018 Programme book Nice, France www.ever.be www.eupo.eu European Association for Vision and Eye Research EVER 20October 17-1919 in Nice, France www.ever.be 1 Table of contents Word from the president ....................................................................................................................................2 About EVER ..........................................................................................................................................................3 EVER Membership ...............................................................................................................................................4 Speakers’ affiliation to scientific sections .........................................................................................................5 Composition of the board 2018 .........................................................................................................................8 Venue ................................................................................................................................................................... 10 Congress information ....................................................................................................................................... 11 Programme information ....................................................................................................................................15
    [Show full text]
  • The Role of Disclosure and Resilience in Response to Stress and Trauma
    ResearchOnline@JCU This file is part of the following reference: Bowen, Alana (2011) The role of disclosure and resilience in response to stress and trauma. PhD thesis, James Cook University. Access to this file is available from: http://eprints.jcu.edu.au/23905/ The author has certified to JCU that they have made a reasonable effort to gain permission and acknowledge the owner of any third party copyright material included in this document. If you believe that this is not the case, please contact [email protected] and quote http://eprints.jcu.edu.au/23905/ i The role of disclosure and resilience in response to stress and trauma Alana Bowen Thesis submitted in fulfilment of the requirements for a Doctor of Philosophy Degree with James Cook University ii Statement of access I, the undersigned, the author of this thesis, understand that James Cook University will make it available for use within the University Library and, by microfilm or other photographic means, allow access to others in other approved libraries. All users consulting the thesis will have to sign the following statement: “In consulting this thesis I agree not to copy or closely paraphrase it in whole or in part without the written consent of the author; and to make proper written acknowledgment for any assistance which I have obtained from it.” Beyond this, I do not wish to place any restriction on access to this thesis. Users of this thesis are advised that the policy for preparation and acceptance of this thesis does not guarantee that they are entirely free of inappropriate analyses or conclusions.
    [Show full text]
  • Mental Health Among Young Women in Saudi Arabia: a Mixed Methods
    Mental Health Among Young Women In Saudi Arabia: A mixed Methods Approach Hissah Alzahrani A thesis submitted in partial fulfilment for the requirements for the award of Doctor of Philosophy University of Central Lancashire May, 2019 i Declaration I declare that while registered as a candidate for the research degree, I have not been a registered candidate or enrolled student for another award of the University or other academic or professional institution. I declare that that no material contained in the thesis has been used in any other submission for an academic award and is solely my own work. Signature of Candidate: Type of Award: Doctor of Philosophy School: School of Psychology ii Abstract This thesis aims to gain an understanding of the mental health of young women in Saudi Arabia. To achieve this broad aim, this thesis, which encompasses two studies, employs a mixed methods approach. Study 1 is a longitudinal quantitative study that aims to examine the trajectories of university students ’ mental health—via the change in their mental health and their ability to adjust—by assessing them over three time points during their first year at university. This study also examined whether theoretically relevant determinants, such as trait emotional intelligence (EI), emotional self-efficacy (ESE), social support and loneliness, affected the students’ mental health trajectories and adjustment to university life. The results show that the mean level of mental health problems was low and did not change significantly over time, while the adjustment level decreased over the first year of university. The results indicated that even in students with a high adjustment level in the beginning of their university year, the level decreased over time.
    [Show full text]
  • The Prevention of Trauma Reactions Tracey Varker Doctor of Philosophy
    The Prevention of Trauma Reactions Tracey Varker Doctor of Philosophy July 2009 Tracey Varker PhD Thesis Abstract Abstract Exposure to traumatic or stressful events has been linked to the development of trauma symptomatology in a minority of individuals for some time now. Although there have been many studies which have examined the nature and aetiology of trauma reactions, few researchers have examined whether it is possible to prevent reactions to trauma. This is somewhat surprising, given the impact that an adverse trauma reaction can have to both an individual and an organisation (if the individual is also an employee). One exception is the body of work which has been created by researchers who investigated the psychological intervention known as psychological debriefing. This intervention has been designed to be administered immediately after an individual experiences a traumatic event, and is said to mitigate an individual’s reaction to trauma. The scientific evidence for this intervention, however, has been equivocal. At the time that this thesis was being prepared, there were only two published randomised controlled trials of group debriefing. In addition, the impact of psychological debriefing upon an individual’s memory for a traumatic event had never before been examined. This is important to note, because in many instances an individual who is a witness to a crime, will receive psychological debriefing before they give a statement to police officers. For Study 1, a randomised controlled trial of group debriefing was conducted. The aim was to assess the effect of this intervention upon eyewitness memory for a stressful event and eyewitness stress reactions, with a sample drawn from the general community ( n = 61).
    [Show full text]
  • Framing in Design
    INTERNATIONAL CONFERENCE ON ENGINEERING DESIGN, ICED15 27-30 JULY 2015, POLITECNICO DI MILANO, ITALY FRAMING IN DESIGN: A FORMAL ANALYSIS AND FAILURE MODES Vermaas, Pieter (1); Dorst, Kees (2,3); Thurgood, Clementine (2) 1: Delft University of Technology, Netherlands; 2: University of Technology Sydney, Australia; 3: Eindhoven University of Technology, Netherlands Abstract This contribution presents a formal description of the design practice of framing and identifies two general modes in which framing can lead to failure in design projects. The first is called the goal reformulation failure mode and occurs when designers reformulate the goal of the client in a design task and give design solutions that solve the reformulated goal but not the original goal. The second is called the frame failure mode and occurs when designers propose a frame for the design task that cannot be accepted by the client. The analysis of framing and its failure modes is aimed at better understanding this design practice and provides a first step towards arriving at criteria that successful applications of framing should meet. The description and the failure modes are illustrated by critically considering an initially successful case of framing, namely the redesign of the Kings Cross entertainment district in Sydney. Keywords: Framing, Design Theory, Design methodology, Failure modes Contact: Dr. Pieter Vermaas TU Delft Netherlands, The [email protected] Please cite this paper as: Surnames, Initials: Title of paper. In: Proceedings of the 20th International Conference on Engineering Design (ICED15), Vol. nn: Title of Volume, Milan, Italy, 27.-30.07.2015 ICED15 1 1 INTRODUCTION One of the powerful practices in the toolkit of designers and design thinkers is the framing of a design task, that is, the creation of a new perspective on a design task.
    [Show full text]
  • CONTRIBUTORS Thank You to the Following Foundations, Businesses, and Individuals Who Made Contributions to Lifeworks in 2019
    CONTRIBUTORS Thank you to the following foundations, businesses, and individuals who made contributions to Lifeworks in 2019. It is because of your investment that we are able to fund the innovative and progressive programs that Lifeworks offers. Your support makes a profound difference in the lives of those we serve. LEADERSHIP CIRCLE $1,000-$4,999 ConvergeOne Innovative Office Solutions Donations of $500 or more 2019 Medtronic Foundation Ecolab, Inc. Lunds & Byerlys giving totals reflect received Rusty & Mary Jane Poepl Edmentum, Inc. Messerli & Kramer, P.A. donations as well as contributions Foundation Key Surgical Midwest Rubber Service and secured through multi-year pledges. The Bieber Family Foundation Marsden Building Maintenance, LLC Supply Co. Minnesota Bank & Trust Peace Coffee FOUNDATIONS $500-$999 Otter Tail Corporation Robert Half Management Resources The CarMax Foundation Prime Therapeutics Schwebel Goetz & Sieben PA $50,000-$75,000 Prudential Tapemark Otto Bremer Trust BUSINESSES RBA Inc. UCare The Bailey Group Wheels Inc. $10,000-$24,999 $50,000 or more Thomson Reuters Anonymous Atomic Data Uponor Ecolab Foundation The General Counsel, Ltd. Wells Fargo Securities F.R. Bigelow Foundation Fred C. and Katherine B. $25,000-$49,999 $1,000-$4,999 Andersen Foundation Ameriprise Financial American Durable, Inc. Lynne and Andrew Blue Cross and Blue Shield Anagram International Redleaf Foundation of Minnesota Andersen Corporation Richard M. Schulze Family Cargill Ballard Spahr Foundation Horton, Inc. Bercom International, LLC Saint Paul and Minnesota Securian Financial Community Association Foundation The Show Syndicate Group, LLC Securian Financial Foundation Creative Water Solutions, LLC Travelers Foundation $10,000-$24,999 CRESA Partners Allianz Life Insurance Company of Crystal D $5,000-$9,999 North America Custom Visual Services Andersen Corporate Foundation Intersection First Impression Group John and Denise Graves Fredrikson & Byron P.A.
    [Show full text]
  • How Mental Health, Sojourner Adjustment, and Drinking Motives Impact Alcohol-Related Consequences for College Students Studying Abroad
    Syracuse University SURFACE Dissertations - ALL SURFACE December 2015 HOW MENTAL HEALTH, SOJOURNER ADJUSTMENT, AND DRINKING MOTIVES IMPACT ALCOHOL-RELATED CONSEQUENCES FOR COLLEGE STUDENTS STUDYING ABROAD Laura Kay Thompson Syracuse University Follow this and additional works at: https://surface.syr.edu/etd Part of the Student Counseling and Personnel Services Commons Recommended Citation Thompson, Laura Kay, "HOW MENTAL HEALTH, SOJOURNER ADJUSTMENT, AND DRINKING MOTIVES IMPACT ALCOHOL-RELATED CONSEQUENCES FOR COLLEGE STUDENTS STUDYING ABROAD" (2015). Dissertations - ALL. 408. https://surface.syr.edu/etd/408 This Dissertation is brought to you for free and open access by the SURFACE at SURFACE. It has been accepted for inclusion in Dissertations - ALL by an authorized administrator of SURFACE. For more information, please contact [email protected]. Abstract The topic of college student drinking has been widely addressed in the literature. Traditional-aged college students are considered to be an at-risk population in terms of the problematic use of alcohol, putting them at risk for a wide range of negative consequences. College students who study abroad are a sub-group of students who may be vulnerable to increased alcohol-related consequences due to variables associated with being in an unfamiliar environment where alcohol is often more accessible. While previous studies have explored the impact that a range of factors has on alcohol-related consequences for students abroad, none has examined the impact that mental health has on consequences. The present study sought to address this gap in the literature by sampling college students (N = 157) who were participating in a study abroad program during Spring 2015.
    [Show full text]
  • Concessions for Free Transport on City Buses, Trolleybuses and Trams for All Holders of an Olympic Card Were Granted by the Municipal Transport Authority
    Concessions for free transport on City buses, trolleybuses and trams for all holders of an Olympic Card were granted by the Municipal transport authority. But the most difficult negotiations were those with the Ministry of Transport for the concession of a reduction on State Railways for travellers to Rome and from Rome to other sites of Olympic events. Unfortunately TABLE NO. 1. FREE TRIPS FOR OFFICIALS AND JOURNALISTS NUMBER OF GUESTS COUNTRIES TRIPS TOTAL 1958 1959 1960 France 2 10 10 20 Belgium 2 10 10 20 Spain 1 5 5 10 Greece 1 5 5 Austria 2 10 5 15 Tunisia 1 5 5 Holland 1 10 10 Switzerland 2 10 5 15 Kenya, Uganda, Tanganyika 1 10 10 U.S.A. 4 20 20 40 India 1 10 10 Israel 1 5 5 Germany 3 15 10 25 Ethiopia, Somalia, Sudan 1 10 10 Rhodesia 1 5 5 Brazil 1 10 10 Uruguay 1 5 5 Portugal 1 5 5 Canada 1 5 5 Venezuela 2 5 10 15 Argentine 1 10 10 Great Britain 2 20 20 Lebanon 1 5 5 Iran 1 5 5 South Africa 1 10 10 Libya 1 5 5 TOTALS 38 30 185 85 300 440 these negotiations were not wholly successful, although a reduction of 20%, valid for not more than two months within the period of 20th June-20th September, was granted to holders of the Olympic Card only. In this con- nection, mention must be made of reductions on the railways conceded by other Countries, i.e. Bulgaria 25 %, Portugal 20 %, Spain 25 %, and Turkey 25 %.
    [Show full text]
  • Anger and Violence Among Individuals with Substance Use
    Hurt people who hurt people: Anger and violence among individuals with substance use disorder and post traumatic stress disorder Emma L. Barrett B.Psych (Hons), M.Psych (Forensic) A thesis submitted in accordance with the requirements for admission to the degree of Doctor of Philosophy National Drug and Alcohol Research Centre School of Public Health and Community Medicine Faculty of Medicine University of New South Wales Sydney, Australia December, 2011 ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged’. Emma Barrett December 2011 ii COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights.
    [Show full text]
  • Blue Simple Minimal Corporate Annual Report
    FISCAL YEAR 2019 ANNUAL IMPACT REPORT MESSAGE FROM THE EXECUTIVE DIRECTOR & BOARD PRESIDENT Executive Director Renee Z. Dominguez, Ph.D. Director of Development Monica M. Garvey Dear Friends, BOARD OF DIRECTORS Peter Barrow As we reflect on the vital work accomplished this year, Family Thomas Forrester Service Center remains hopeful for the future. With your support, Fritz Freidinger our staff was able to provide crucial mental health care to Andrew Haak Keryl Klemm community members, many of whom would not otherwise be Mari Marrinan able to access or afford this care. Approximately 77% of FSC's Becky McLennan clients qualified for a reduced fee. James Neaylon III Chris Northwick Peggy O’Brien This report reflects FSC's increased services. Clinicians provided Melanie Peterson over 5,000 hours of therapy, completed 36 health and safety Noelle Pontarelli, Ph.D. assessments, and delivered fourteen presentations to over 800 Rodney Quainton people in the community. FSC also continued to develop Stefanie Rupp Pastor Kyle Severson collaborative relationships and to expand our formal outreach Marsha Tolchin and educational programming with local school districts, clubs, Louise Yao and places of worship. ADVISORY BOARD William Attea For fiscal year 2020, we look forward to continued collaborations Gilbert W. Bowen, D.Div with supportive individuals, foundations, corporate partners, Nancy Canafax school districts, inspirational leaders, community and civic Mark Damisch Ellen Fagerburg groups, and other social service agencies. Rev. Thomas E. Hickey Philip Janicak, M.D. We appreciate your continued commitment to mental health Joyce Knauff and your support of FSC's mission. Andrew Kuby III State Sen.
    [Show full text]
  • Annuario Annuario 2016 - 2017
    ROTARY INTERNATIONAL DISTRETTO 2072 INTERNATIONAL ROTARY Distretto 2072 ANNUARIO ANNUARIO 2016 - 2017 2016 - 2017 ROTARY INTERNATIONAL DISTRETTO 2072 (Emilia Romagna, Repubblica di San Marino) ANNUARIO DEI ROTARY CLUB Anno Rotariano 2016 - 2017 1 TEMA PRESIDENZIALE Il Rotary ha rappresentato molte cose, per Una delle tante lezioni apprese dalla nostra tante persone, negli ultimi 111 anni. Grazie al lotta alla polio, e una delle più importanti, è Rotary, i nostri soci hanno trovato amici, co- comunque una delle più semplici: se vogliamo munità e un senso di realizzazione; abbiamo spingere in avanti il Rotary tutti quanti dobbia- creato rapporti, migliorato le nostre carriere e mo muoverci nella stessa direzione. La conti- abbiamo avuto esperienze straordinarie, che nuità della leadership, a livello di club, distretto sarebbero state altrimenti impossibili. Ogni e RI, è l’unico modo per progredire e realizzare settimana, nei 34.000 club di tutto il mondo, il nostro pieno potenziale. Non basta semplice- i Rotariani si riuniscono per parlare, divertirsi mente trovare nuovi soci e creare nuovi club: il e scambiare idee. Ma soprattutto, ci riuniamo nostro obiettivo non è avere più Rotariani, ma per un unico obiettivo: metterci al servizio degli più Rotariani che possono realizzare più opere altri. di successo per il Rotary, che diventeranno i leader futuri del Rotary. Mettersi al servizio dell’umanità è la pietra an- golare del Rotary sin dalla sua nascita, ed è Alla fine della sua vita, riflettendo sul percor- rimasto il suo scopo principale fino ad oggi. Ri- so che lo aveva portato al Rotary, Paul Harris tengo che oggi non vi sia una via più significa- scrisse: “Gli sforzi individuali possono diventa- tiva per mettersi al servizio del mondo dell’affi- re esigenze individuali, ma gli sforzi condivisi liazione al Rotary.
    [Show full text]
  • The Development of a Counselling Intervention for People Living with Hivand Aids Experiencing Stress-Related Psychological Conditions in the Eastern Cape Province
    THE DEVELOPMENT OF A COUNSELLING INTERVENTION FOR PEOPLE LIVING WITH HIVAND AIDS EXPERIENCING STRESS-RELATED PSYCHOLOGICAL CONDITIONS IN THE EASTERN CAPE PROVINCE N.V. TWAISE 2016 THE DEVELOPMENT OF A COUNSELLING INTERVENTION FOR PEOPLE LIVING WITH HIVAND AIDS EXPERIENCING STRESS -RELATED PSYCHOLOGICAL CONDITIONS IN THE EASTERN CAPE PROVINCE NOMVULA VIRGINIA TWAISE Submitted in fulfilment of the requirements for the Doctor of Philosophy Degree (Psychology) in the Faculty of Health Sciences at the Nelson Mandela Metropolitan University DECEMBER 2016 SUPERVISOR: PROF T.V. MAYEKISO CO-SUPERVISOR: PROF D.S. ELKONIN ii DECLARATION I, NOMVULA VIRGINIA TWAISE, Student No. 21129181, hereby declare that the thesis for PhD (Psychology) to be awarded is my own work and that it has not previously been submitted for assessment or completion of any postgraduate qualification to another university or another qualification. …………………………….. Nomvula V. Twaise iii Acknowledgements I would like to express my sincere appreciation to the following people for making this research project possible; First and foremost, I give thanks to God Almighty for giving me strength, favour, courage and determination to complete this project. My ancestors for watching over me throughout this project. My Supervisors: Prof Thoko Mayekiso – for believing that I can do this and accommodate me in her hectic schedule and Prof Diane Elkonin – for her time, prompt responses, encouragement, guidance, patience, valuable advice and critical comments throughout this project. May you both continue to produce more academic leaders and help people like me to realize their potential. Colleagues- Prof G. Ekosse who saw potential in me when I could not see any and continued to check up on me even through my supervisors.
    [Show full text]